Every finding on record at Golden Acres Living and Rehabilitation Center

Based on record reviews and interviews, the facility failed to maintain the residents right to be free from verbal abuse for one of five residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally abuse Resident #1 by yelling and pointing in the resident's face very loudly and scolding the resident for incontinence, which was captured on a video recording dated 08/21/2026 time stamped 12:06:17 AM.This deficient practice could place residents at risk for decreased quality of life, depression, and psychosocial harm. Findings included:Record review of Resident #1's Quarterly MDS dated [DATE] indicated she was a [AGE] year-old female that was admitted on [DATE]. Resident #1's BIMS score was 01, indicating severe cognitive impairment. Section E behavioral symptoms Behavior of this type occurred 1 to 3 days. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, verbal/vocal symptoms like screaming, disruptive sounds) Significantly interfere with the resident's participation in activities or social interactions Set up and clean up for ADLS assistance for toileting and showering.Record review of Resident #1's revised care plan dated 08/17/2026 reflected she had Potential for a behavior problem (unexplained crying) r/t (Pseudobulbar affect- is a neurological condition that causes sudden, uncontrollable episodes of laughing, crying, or anger that do not match a person's actual mood or the social context.) Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet needs. Approach in a calm manner. Assist to develop more appropriate methods of coping and interacting Encourage to express feelings appropriately.Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. behaviors, and resident response to interventions. Noted with impaired cognitive function and dementia with impaired thought processes r/t alert to name only with diagnosis of dementia w/ agitation. Report to Nurse any changes in cognitive function, specifically changes in: decision making ability, memory, recall, awareness of surroundings and others, difficulty expressing self, difficulty understanding others, sleepiness/lethargy, confusion. Resident #1 uses Anti-psychotic medication use r/t Schizoaffective Disorder (a chronic mental health condition marked by a combination of psychotic symptoms (like schizophrenia) and mood disorder symptoms (like depression or bipolar disorder).no GDR at this time per psychiatrist - still labile and irritable.Document episodes of behavior.Document non-pharmacological interventions: back rub, speak to /approach in a calm manner, reposition, offer snacks/fluids, assess for pain, provide a quiet environment.Document side-effects: drowsiness, dry mouth, blurred vision, constipation, edema, extra pyramidal symptoms, urinary retention, stiff or tight muscles, tardive dyskinesia ( is a neurological movement disorder that causes uncontrollable body movement. CNA-C was not observed using any of the non-pharmacological task listed in the care plan during the review of the video recording. Review of the video footage dated 08/21/2026 time stamped 12:06:17 AM reflected Resident #1 was observed walking to the room entrance, attempting to exit the room. CNA-C told her No, go sit down this continued for 3 minutes while CNA-C continued to yell at the resident. Eventually the resident entered the restroom. CNA-C was observed opening the restroom door, yelling Sit down!!! the resident said no, and she continued yelling at the resident to pay attention, stop talking, I need to change you. Once the resident was seated, CNA-C got in her face pointing her finger in her face yelling at the resident that she boo-booed on herself and she needed to change her. Resident #1 told CNA-C you always hurt me. Record review of Resident #1's physician orders dated reflected non-pharmacological interventions: (non-pharmacological interventions are patient care methods and treatments that do not use medications to manage health conditions, symptoms.) 0=None, 1= Massage, 2= Toileted, 3 = Snacks, 4= Soft Music, 5=Dim Lights, 6=Other (pain Need to Be Completed) every evening and night shift. This review reflects that Resident #1's interventions for redirection. Note: In the video CNA-C was not observed using care plan interventions to de-escalate Resident #1 at the time of the incident on 08/21/2026.Record review of Resident #1's nursing progress notes dated 08/27/2026 1:54 PM reflected: Late Entry: Resident noted to have bruising/discoloration on the right side of the chin upon assessment. [CNA-A] reported that resident stated she hit her chin on the bathroom sink the previous day. [CNA-A] further reported that she informed nursing staff of the resident's statement at that time. Review of resident's condition from the previous day did not indicate visible bruising to the area. Bruising became apparent on assessment today. Resident assessed for additional injuries, with no other visible injuries noted at this time. Resident denies pain/discomfort (if applicable). Vital signs and further assessments completed per facility protocol Physician and responsible party notified of findings. Incident documented as a possible unwitnessed injury of unknown origin per facility policy. Resident to continue to be monitored for any changes in condition, increased bruising, pain, or additional signs of injury. Competed by LVN-E.Record review of Resident #1's nursing progress note dated 08/27/2026 11:40 AM reflected: Resident has a bruise on the right side of her chin. The [CNA-C] stated that the resident told her she hit her chin on the bathroom sink yesterday. But yesterday she didn't have a bruise, the [CNA-C] also stated that they reported it to the nurse yesterday. But the nurse was getting a report on another resident and was busy at the time. Completed by LVN-ERecord review of facility in-services dated 08/27/2026 time unknown was completed by RN, titled Abuse Policy and Reporting reflected: If a resident or another person reports any form of abuse, the [Administrator] must be notified immediately.Record review of CNA-C's facility in-service trainings reflected the following: Abuse and Neglect, and Exploitation and Abuse and Neglect dated 02/04/2024. Knowing the rights of Residents dated 09/02/2026. Obligations to report abuse and Staff, tips on managing Challenging Behaviors dated 09/04/2026.Record review of CNA-C's disciplinary note dated 08/27/2026 reflected suspension, pending investigation, subject to discharge. Allegations from [Resident #1's RP] that aide was physically and verbally abusive to the resident. Date of incident 08/22/26. Signed by CNA-C and Administrator. During an interview on 08/26/2026 at 9:20 AM with Resident #1's CRP stated that she monitored a 24-hour video recording of Resident #1 and the facility staff. While reviewing the footage on 08/26/2026 the CRP stated she observed an unidentified female staff member that was later confirmed to be [CNA-C], yelling directly into Resident s #1's face, pointing her finger, and harassing (any unwelcome behavior, action, or communication that annoys, threatens, alarms, or creates a hostile (aggressive), intimidating (feel less confident), or offensive (causing anger) environment for a person.) the resident. Resident #1 was heard on camera asking the CNA-C why are you always being mean to me? The CRP attempted to contact the facility Administrator to report concerns, however, he had not returned her call on 08/25/26.During an interview on 08/27/2026 at 10:00 AM, the Administrator reported calling Resident #1's RP multiple times on 08/23/26, and via email. He stated that he directed ADON-D to contact the RP to follow up. He stated that RP stated that she wanted to speak with the Administrator only. RP did not provide any information. His expectation of his staff included reporting abuse immediately to him to investigate the incident for findings. During an interview on 08/27/2026 at 10:20 AM, ADON D he stated he was advised by the Administrator to contact the RP of Resident #1 to inquire about concerns. He stated that he contacted the RP and she refused to provide information to him and requested that the Administrator return her call. He assessed Resident #1, there were no injuries, and she did not report any concerns. During a second interview on 08/27/2026 at 12:15 PM with ADON D he had no reports of staff yelling in residents face. ADON-D said the CNA's were expected to notify the charge nurse immediately, and the nurses were expected to immediately contact the Administrator, notify the MD, and family of any injuries, findings, and alleged abuse. He stated the nursing staff would immediately conduct a skin assessment to gain details of the injury from the residents. When residents were unable to provide details, staff will continue to assess and monitor for changes in conditions, behaviors, consciences, mental status, vitals and more to determine a baseline. He said that all staff members would be interviewed to determine the occurrence. He stated with reports of abuse, the resident will be kept safe and removed from the alleged perpetrator. ADON-D stated the perpetrator would be interviewed and suspended pending the outcome of the investigation. ADON-D stated that failing to report abuse could result in more abuse to residents. During an observation and interview on 08/27/26 at 10:20 AM, Resident #1 was observed in her room sitting in her wheelchair with an injury to the left side of her chin. When asked about the bruising to her chin, she stated that she did not remember hurting herself and could recall how the bruise happened. Resident #1 stated that the staff were nice, gentle, and polite. She stated she did not have history of being hit, pushed, yelled at, roughhoused, or mistreated by any staff at the facility. Resident #1 stated she had no concerns about her care.During an interview on 08/27/26 at 11:15 AM, LVN-E stated that as the charge nurse, she was responsible for reporting abuse and neglect to the Administrator immediately. LVN-E said failing to report abuse could result in more harm to the residents or continued abuse. LVN-E reported upon being notified no knowledge of CNA-C or staff on her shift verbally abusing Resident #1. She stated though the resident exhibits aggressive behaviors toward staff at times, she ensure the staff respond with interventions of redirecting the resident and notifying the ADON, MD, and family of continued concerns or injuries. LVN-E stated she was observing the bruise to Resident #1s chin 08/27/2026. She had not reported the injury to the ADON, MD, nor Family. During an interview on 08/27/2026 at 11:25 AM, CNA-A stated she observed a bruise on Resident #1's chin this morning (time unknown). She stated that resident abuse should be reported immediately to the administrator and changes in resident conditions, such as (refusing care, excessive wandering, behaviors of agitation) should be reported to the nurse for further clinical assessments. CNA-A said staff are responsible for reporting physical, verbal, and mental, abuse. Report injuries to the nurse immediately to ensure resident safety and care. CNA- stated failing to report abuse to the administrator could result in more resident abuse and emotional concerns. During an interview on 08/27/2206 at 11:50 AM, LVN-E stated she had not received any reports of abuse from staff or residents. LVN-E said it was the expectation of the staff to report abuse immediately to the Administrator. LVN-E said failing to respond timely could result in additional resident, resident not feeling safe, treatment, and reporting. During an interview on 08/27/2026 at 12:08 PM, ADON O stated the expectations for nursing staff including reporting the incident to the Administrator. Next, the nursing staff will assess the resident for injuries and changes. notify the MD, RP, ADON findings of the incident, and completed an incident report. Once reported and assessed, additional tasks to maintain resident safety would continue such as monitoring, supervision, new interventions, training of staff with information to prevent further incidents from occurring. During an interview on 08/27/2026 at 4:51 PM, the DON stated she was not in the building at the time of the incident. She stated she was informed of the incident by phone by the administrator this morning. She stated that Resident #1 was assessed for injuries this morning, and she had a bruise on her chin. The DON stated she expected the staff to report abuse immediately to the Administrator. The DON stated the risk to the resident when not reported could result in change in behaviors, additional abuse, and possible emotional changes. The DON stated that the staff are in serviced on verbal abuse. The DON stated CNA C was suspended today 08/27/2026 and will be terminated.During a second interview on 08/27/26 at 4:54 PM, the Administrator stated he expected all staff to report abuse immediately to him, to ensure resident safety. The Administrator stated the risk of verbal exchange could escalate or cause emotional or psychological damage. The Administrator stated CNA C was suspended today 08/27/2026 and would be terminated. Record review of the facility's Abuse Prevention of and Prohibition Against policy, dated October 2023 reflected: It is the policy of this Facility that each resident has the right to be free from verbal and mental abuse. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services .This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Purpose: . Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging (be-[NAME]) and derogatory (insults) terms to residents.within their hearing distance, regardless of their age, ability to comprehend, or disability. Training: The Facility will engage in training and orienting its new and existing nursing staff on Prohibiting and preventing all forms of abuse, identifying what constitutes abuse.Recognizing signs of abuse.Reporting abuse, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal.Procedures for reporting incidents.Dementia management/ Care of Cognitively Impaired.Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.aggressive and/or catastrophic reactions of residents.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 1 (Resident #1) of 7 residents reviewed for care plans.The facility failed to ensure Resident #1 was care planned for a mechanical soft diet.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. Findings included:Record review of Resident #1's Care Plan revised 01/29/26 reflected he was a [AGE] year-old male, admitted to the facility 01/25/25. Focus: he had a nutritional problem r/t malnutrition/diet restrictions/cognitive deficit dated 1/21/26 for altered nutritional status r/t chewing/swallowing difficulty requiring mechanical soft diet, reflected a revision date of 07/21/26. Goal: will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date, revised 1/20/26. Interventions: Diet as ordered by the physician. LCS/NAS/Regular Diet/Thin Liquids date initiated 01/29/26. Record review [SH1.1]of Resident #1's MDS assessment dated [DATE] reflected he had a BIMS score was 00 (Severe cognitive Impairment) ( . Nutritional Approaches reflected mechanically altered diet while a resident. He had diagnoses of malnutrition (a serious health condition caused by a deficiency, excess, or imbalance in a person's intake of energy and nutrients), and dysphagia (trouble swallowing). Record review of Resident #1's Speech Therapy evaluation plan of treatment dated 1/20/26 reflected, patient also requires skilled ST services for dysphagia management, including training in safe-swallow strategies, improving overall swallowing safety, reducing risk of aspiration or airway obstruction, preventing further weight loss, and maintaining adequate nutrition and hydration with safe PO intake.Record review of Resident #1's doctor order summary report dated 01/25/26 reflected, mechanical soft diet. During an interview with the DON on 07/21/26 at 7:30 p.m., she stated that she had no idea why the care plan that was revised on 1/21/26 still indicated a physician ordered regular diet. She stated the facility had a unit manager change during that time, and the fact that the unit where Resident #1 was residing did not have a manager at that time could have been the reason the changed was not made to the care plan. She stated the unit manager or the MDS nurse would have been the person responsible to ensure the changes were made to the care plan. She stated the care plan not having the correct information could place a resident at risk of not receiving the correct care. She stated changes to the care plan should be made timely to ensure the new orders were followed in a timely manner. She stated changes to a care plan should be made as soon as possible or within a couple of days. She stated they would start to review all new orders for diets during the stand-up meetings so they could make changes right away. She stated, in the future, the MDS nurses would be doing a follow-up check to ensure the care plans had the updated changes. During an interview with the MDS nurse on 07/21/26 at 7:54 p.m., she stated Resident #1's care plan was overlooked, to be updated, because there was no unit manager for that unit. She stated all updates to the care plan should be completed by the unit manager. She said the future care plans would be updated by the IDT as soon as possible. She stated the IDT included[SH2.1] the unit manager and all persons responsible for ensuring the resident received the proper care.During a telephone interview with the Dietitian on 07/27/26 at 12:58 p.m., she stated Resident #1's diet orders when placed into the facility electronic health records system would generate the correct meal ticket indicating what diet he should receive. She stated any changes to his diet would automatically be updated on the meal ticket generated by the dietary staff. She stated she did an audit on the kitchen service once a month to ensure the residents received their meals as ordered by the physician. She stated if the correct information was not entered, the resident would be at risk of not receiving the diet that the speech therapist had recommended, and the resident would not receive a safe diet. Record review of Appendix PP dated , reflected (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required

Based on interviews 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 safety.The facility failed to dispose of expired milk. This failure could place residents at risk of foodborne illness.Based on interviews 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 safety. The facility failed to dispose of expired milk. This failure could place residents at risk of foodborne illness.Findings included:During an observation on 05/14/26 at 8:30 AM, revealed the following:* 3- whole 8 fluid ounces (half-pint) milk and 1- 2% 8 fluid ounces (half-pint) milk that expired on 05/13/26. *2 -whole 128 fluid ounces (gallon) of milk that expired on 05/14/26.During an interview on 05/14/26 at 9:00 AM, the Dietary Manager stated the Dietary Aide was responsible for taking the expired milk out of the refrigerator last night.During an interview over the phone on 05/14/26 at 10:52 AM, the registered Dietitian stated residents could experience gastro (stomach or the digestive system) problems from drinking expired milk.During an interview over the phone on 05/14/26 at 2:35 PM, the Dietary Aide stated he used the milk first with the closest expiration date. The Dietary Aide stated he did not recognize that the milk expired this morning. The Dietary Aide stated residents could get sick from eating expired food.During an interview on 05/14/26 at 2:45 PM, the Dietary Manager stated Dietary Aide should have exposed the milk in the morning when he first came in. The Dietary Manager stated the Dietary Aide was training two other staff and was busy. The Dietary Manager stated some residents like milk for dinner. The Dietary Manager stated residents can get sick from consuming expired items.During an interview on 05/14/26 at 3:00 PM, the Administrator stated the facility did not have a policy for expired food. Residents who consumed expired milk could have a gastro (stomach or the digestive system) infection. The Administrator stated the facility followed the FDA regulations. Record review of the FDA, dated 2022, 2022 FDA Food Code - Print Version reflected,1` `a cv3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observations, interviews, and record reviews, 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 3 of 5 residents (Residents # 1, 2, and 3) reviewed for infection control in that:. The Speech Therapist touched her hair two times without using hand sanitizer while feeding Resident #1. The LVN-A touched her hair while feeding Resident #2, then she moved to assist Resident #3 with her meal, she did not sanitize her hands when she moved between the residents. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. Findings included: Resident #1Record review of Resident #1's Face Sheet, dated 03/09/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with major depressive disorder (a serious mental health condition and low self-esteem), type 2 diabetes (a chronic condition where the body resist insulin or fails to produce enough, causing high blood sugar levels), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), dysphagia (difficulty swallowing), and anxiety disorder (serious persistent mental health conditions characterized by excessive, uncontrollable worry and fear that interfere with daily life). Record review of Resident #1's Quarterly MDS Assessment, dated 02/07/2026, reflected the resident had severe impairment (more than a minimal restriction on a person's ability to engage in basic activities) in cognition with a BIMS score of 00. The Quarterly MDS Assessment did not have an eating or feeding assessment. Record review of Resident #1's Comprehensive Care Plan, dated 06/25/2025, reflected the resident had a focus for potential nutritional problems and functional decline secondary dysphagia. The goal was to maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition. The intervention was that diet be as ordered by the physician, honor resident rights to make personal dietary choices. Provide a calm, quiet setting at mealtimes with adequate eating time. Resident #2Record review of Resident #2's Face Sheet, dated 05/09/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving cells of oxygen and nutrients), dysphagia (difficulty swallowing), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms -such as hallucinations, delusions, and disorganized thinking).Record review of Resident #2's Quarterly MDS Assessment, dated 01/16/2026, reflected that the resident was rarely understood to determine the BIMS score. The Quarterly MDS Staff Assessment indicated that the resident was severely impaired. The Quarterly MDS Assessment indicated that the resident was dependent on staff for eating. Record review of Resident #2's Comprehensive Care Plan, dated 05/27/2025, reflected the focus was on ADL self-care performance deficit r/t cognitive and functional decline and confusion. The goal was to maintain current level of function in eating. Intervention was to require staff participation-substantial/maximal assistance.Resident #3Record review of the face sheet dated 03/09/26 for Resident #3 reflected she was an 89 -year-old-female admitted to the facility 04/30/25. She was diagnosed with Alzheimer's Disease (a progressive, incurable neurodegenerative disorder), cognitive communication deficit (difficulty with verbal or non-verbal communication caused by underlying cognitive deficits). Record review of Quarterly MDS dated [DATE] for Resident #3 She had a BIMS score of 00 indicating severe impairment.Record review of care plan dated 05/01/25 for Resident #3 reflected a focus that she had potential nutritional problems. The goal was to maintain nutritional status. Intervention was to provide diet as ordered by the physician, regular diet with thin liquids. Observation on 03/09/26 at 1:30 PM revealed the Speech Therapist was feeding Resident #1 and touching her hair. She continued to feed Resident #1 and did not use hand sanitizer. LVN was observed touching her hair while she fed Resident #2, and she did not use hand sanitizer prior to continuing to feed Resident #2. LVN then moved to another table to assist Resident #3 to eat her meal, she did not sanitize her hands between residents.In an interview on 03/09/26 at 2:38 PM the Speech Therapist stated she was not aware that she had touched her hair while she was feeding Resident #1. She stated that she should have used hand sanitizer after she touched her hair before she continued feeding Resident #1. She stated she had received in-service training on infection control, but she did not remember the date. She stated that Resident #1 was at risk of infection when she did not sanitize her hands after touching her hair. In an interview on 03/09/26 at 2:42 PM the DON stated the staff were expected not to touch their hair while they were in the dining room feeding residents. She stated the staff were expected to sanitize their hands between assisting residents. She stated both the Speech Therapist and the LVN should have known to practice infection control. She stated that residents were at risk of infection when the staff touched their hair while they fed the residents. She stated she did in-service on infection control yearly on the computer in October and she also tried to do them in person monthly. She stated that Resident #1, Resident #2 and Resident #3 were at risk of infection when the LVN did not sanitize her hands between residents. In an interview on 03/09/26 at 2:50 PM LVN-A stated she did not use hand sanitizer when she fed Resident #2. She stated that she was not aware that she touched her hair while she fed Resident #2. She stated that she had sanitizer gel available and she just did not use it. She stated that she should have sanitized her hands prior to assisting Resident #3 and prior to returning to Resident #2. She stated that her actions placed both residents at risk of infection. Record review of hand hygiene policy dated August 2024 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.4. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:p. Before and after assisting a resident with meals; and

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Resident #1 and Resident #2) of 5 residents reviewed for dignity.The facility failed to ensure Speech Therapist and LVN did not stand in front of Resident #1 and Resident #2 while feeding the residents during lunch meal on 03/09/26. These failures could place the residents at risk of not having the right to a dignified existence.Findings included: Resident #1Record review of Resident #1's Face Sheet, dated 03/09/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with major depressive disorder (a serious mental health condition and low self-esteem), type 2 diabetes (a chronic condition where the body resist insulin or fails to produce enough, causing high blood sugar levels), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), dysphagia (difficulty swallowing), and anxiety disorder (serious persistent mental health conditions characterized by excessive, uncontrollable worry and fear that interfere with daily life). Record review of Resident #1's Quarterly MDS Assessment, dated 02/07/2026, reflected the resident had severe impairment (more than a minimal restriction on a person's ability to engage in basic activities) in cognition with a BIMS score of 00. The Quarterly MDS Assessment did not have an eating or feeding assessment. Record review of Resident #1's Comprehensive Care Plan, dated 06/25/2025, reflected the resident had a focus for potential nutritional problems and functional decline secondary dysphagia. The goal was to maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition. The intervention was that diet be as ordered by the physician, honor resident rights to make personal dietary choices. Provide a calm, quiet setting at mealtimes with adequate eating time. Resident #2Record review of Resident #2's Face Sheet, dated 05/09/2026, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving cells of oxygen and nutrients), dysphagia (difficulty swallowing), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms -such as hallucinations, delusions, and disorganized thinking).Record review of Resident #2's Quarterly MDS Assessment, dated 01/16/2026, reflected that the resident was rarely understood to determine the BIMS score. The Quarterly MDS Staff Assessment indicated that the resident was severely impaired. The Quarterly MDS Assessment indicated that the resident was dependent on staff for eating. Record review of Resident #2's Comprehensive Care Plan, dated 05/27/2025, reflected the focus was on ADL self-care performance deficit r/t cognitive and functional decline and confusion. The goal was to maintain current level of function in eating. Intervention was to require staff participation-substantial/maximal assistance.Observation on 03/09/26 at 1:30 PM revealed the Speech Therapist was standing while she fed Resident #1 her entire meal. LVN-A was observed standing while she fed Resident #2 her entire meal.In an interview on 03/09/26 at 2:38 PM the Speech Therapist stated she had known for over one year that it was a dignity issue to stand and feed a resident. She stated that the dining room was full and Resident #1 would become disruptive if she was not given her lunch timely. She stated that she should have asked another staff member to get a chair for her to sit. She stated that Resident #1 was at risk of choking or she would have to lean down to ensure that she was swallowing properly, and dignity. In an interview on 03/09/26 at 2:42 PM the DON stated the staff were expected to sit at the same level as the residents when feeding. She stated that the Speech Therapist was conducting a swallowing evaluation when she was feeding Resident #1. She stated she did not know if the LVN knew that she should not be standing while feeding Resident #2. She stated that residents were at risk of choking and not having dignified experience during their meal. The DON stated the facility did not have a feeding policy. In an interview on 03/09/26 at 2:50 PM LVN-A stated was not aware that she should not stand while she fed Resident #2. She stated risk to the resident was that she could have choked or felt intimidated when she was standing over the resident.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 7 residents (Resident #3, Resident #54, Resident #65, Resident #69, Resident #103, Resident #134, Resident #169) of 12 residents reviewed for ADLs. The facility failed to ensure:1- Resident #3, Resident #54, Resident #69, Resident #134, and Resident #169 had their fingernails trimmed and cleaned.2- Resident #65 and Resident #103 had their fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk of loss of dignity, risk for infections and a decreased quality of life.Findings include:1.Record review of Resident #3's MDS assessment dated [DATE] reflected he was an [AGE] year-old male with an admission date of 10/25/2024. His diagnoses included unspecified Dementia (memory loss), cognitive communication deficit (difficulty in communicating). Resident #3 had a BIMS score of 0 indicating severe cognitive impairment. Resident #3 was dependent on ADL care for personnel and toileting hygiene.Record review of Resident #3's care plan with a revision date of 11/12/2024 reflected he was at risk for impaired cognitive function/dementia or impaired thought process, intervention: need assistance with all decision making, Resident #3 had an ADL selfcare performance deficit related to Dementia.Observation and interview on 01/20/2026 at 11:02 AM with Resident #3 revealed he was sitting in his wheelchair in the common area wearing a helmet. Resident #3 had approximately 0.25-0.3 centimeters long fingernails on both hands and dark residue under the fingernails, he stated he would like it to be trimmed and cleaned.2. Record review of Resident #54's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 4/17/2024. His diagnoses included unspecified Dementia (memory loss), cognitive communication deficit (difficulty in communicating). Resident #54 had a BIMS score of 3, indicating severe cognitive impairment. Resident #54 needed moderate assistance with ADL care for personal and toilet hygiene.Record review of Resident #54's care plan with a review date of 04/18/2024 reflected he was at risk for ADL selfcare performance deficit, intervention: staff assist with all ADLs. Observation and interview on 01/20/2026 at 11:14 AM revealed Resident #54 was sitting in his wheelchair in the common area, Resident #54 had approximately 0.2 -0.3 centimeters long fingernails on both hands and dark residue under the fingernails. Resident #54 stated he would like it to be trimmed and cleaned.3. Record review of Resident #65's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 10/06/2025. His diagnoses included unspecified Dementia (memory loss), cognitive communication deficit (difficulty in communicating). Resident #65 had a BIMS score of 3 indicating severe cognitive impairment. Resident #65 needed supervision with ADL care for toileting hygiene. Record review of Resident #65's care plan with a revision date of 10/14/2025 reflected he was at risk for impaired cognitive function/dementia or impaired thought process, intervention: need assistance with all decision making, Resident #65 had an ADL selfcare performance deficit related to Dementia. Observation and interview on 01/20/2026 at 11:00 AM revealed Resident #65 was sitting in his wheelchair in the common area. Resident #65 had approximately 0.25-0.3 centimeters long fingernails on both hands. He stated he liked it to be trimmed. 4. Review of Resident #69's Quarterly MDS assessment dated [DATE] reflected, Resident #69 was an [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included the following: Dementia, Psychotic disorder, Depression, Respiratory failure (lungs cannot oxygenate blood or remove carbon dioxide effectively), Cognitive communication deficit (difficulty with talking, listening, reading, or writing), generalized muscle weakness. Her BIMS score was 3, which indicated Resident# 69 had severe cognitive impairment. Resident #69 required moderate assistance with personal hygiene.Review of Resident #69's Comprehensive Care Plan, revised 7/27/25 reflected, Focus:[Resident #69 had] ADL Self Care Performance Deficit related to Impaired balance, Dementia. Interventions.Personal Hygiene Routine: Requires [one] staff assistance.In an observation and interview on 01/20/2026 at 11:10 AM with Resident #69 revealed , she had long, dirty fingernails on both hands. The nails on both hands were approximately 0.25-0.3 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #69 stated she would like her nails to be cleaned.5. Review of Resident #103's Quarterly MDS assessment dated [DATE] reflected, Resident #103 was an [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included the following: Alzheimer's disease ( a progressive brain disorder causing gradual decline in memory), Depression, Anxiety, Dementia. Her BIMS score was 0, which indicated Resident# 103 had severe cognitive impairment. Resident #103 was dependent on staff for her personal hygiene.Review of Resident #103 's Comprehensive Care Plan, revised 5/14/2025 reflected, Focus: [Resident #103 had] ADL Self Care Performance Deficit related to Dementia. Interventions: . Encourage to participate to the fullest extent possible with each interaction.Observation and Interview on 1/20/2026 at 11:26 AM with Resident #103 revealed Resident #103 had long nails, about 0.2-0.3 centimeters long and jagged. Resident #103 was not interviewable. LVN A stated that Resident #103 had long nails and will try to clip them after some time.6. Record review of Resident #134's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 11/19/2024. His diagnoses included unspecified Dementia (memory loss), cognitive communication deficit (difficulty in communicating). Resident #134 had a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident #134's care plan with a revision date of 11/21/2024 reflected that he was at risk for impaired cognitive function/dementia or impaired thought process related to encephalopathy, ADL selfcare deficit related to epilepsy and dementia. Observation and interview on 01/20/2026 at 11:38 AM revealed Resident #134 was walking through the hallway. Resident #134 had approximately 1-1.5 centimeters long fingernails on both hands. The nails were discolored tan and the underside had dark brown colored residue. Resident #134 stated he would like it to be trimmed and cleaned. 7. Record review of Resident #169's MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of 11/26/2025. His diagnoses included Other cerebral infraction due to occlusion or stenosis of small artery (Stroke), Dementia in other diseases classified elsewhere (memory loss). Resident #169 had a BIMS score of 0 indicating severe cognitive impairment. Resident #169 needed substantial assistance with ADL care for toileting hygiene. Record review of Resident #169's care plan with a revision date of 12/05/2025 reflected he was at risk for impaired cognitive function/dementia or impaired thought process. ADL selfcare performance deficit due to Dementia. Observation and interview on 01/20/2026 at 11:28 AM revealed Resident #169 was sitting in his wheelchair in the common area. Resident #169 had long fingernails on both hands and dark residue under the fingernails. Resident #169 stated he would like it to be trimmed and cleaned.Interview on 01/20/2026 at 11:28 AM with LVN A stated that Nurses and CNAs were responsible for clipping and cleaning nails. He stated that for diabetic residents, nails should be clipped by nurses. He stated that CNAs performed nail care on residents on shower days and as needed. He added that he had not heard about any refusals for nail care on Resident #103 or Resident #69. LVN A stated he will offer nail care to both residents after the interview. He stated the risk of long and dirty nails were lapses in infection control.Interview on 01/20/2026 at 11:41 AM with CNA B stated that CNAs were responsible for nail care including trimming and cleaning them, unless the resident had diabetes. She stated that nailcare was provided on shower days and as needed. She stated that Resident #103 and Resident #69 both had dementia but were not resistive to care. She stated that risk of dirty, long nails increased risk of infection.Observation on 1/20/2026 at 12:15 PM with Resident #103, revealed resident fingernails were clipped and filed on both hands.In an interview on 01/20/2026 at 11:41 AM with CNA G revealed Nurses and CNAs were responsible to provide nailcare on shower days and as needed, nurses cut the nails for diabetic residents. She stated all the residents in the memory care unit agreed to cut nails, even if they refused during the first attempt. She stated residents were at risk for skin tears and infections if they had long/dirty fingernails.In an interview on 01/20/2026 at 11:52 AM with LPN J revealed he was the charge nurse, CNAs and nurses were responsible to provide nailcare on shower days and as needed, nurses cut the nails for diabetic residents. He stated residents were at risk for skin tears and infections if they had long/dirty fingernails. He stated if a resident refused nail care, it was care planned and none of the residents identified were known to refuse nail care. He stated he will make sure all residents with long fingernails will be trimmed as soon as possible.In an interview on 01/20/2026 at 12:04 AM with CNA H revealed CNAs and nurses were responsible to provide nailcare on shower days and as needed, nurses cut the nails for diabetic residents. She stated residents were at risk of skin tears and infections if they had long/dirty fingernails. She stated all the residents in the memory care unit agreed to cut nails, even if they refused during the first attempt.In an interview on 01/20/2026 at 02:43 PM with LVN K revealed all nursing staff were responsible for providing nailcare on shower days and as needed, nurses cut the nails for diabetic residents. She stated residents were at risk of skin tears and infections if they had long/dirty fingernails. She stated all the residents in the memory care unit agreed to cut nails, even if they refused during the first attempt.In an interview on 01/20/2026 at 03:11 PM with CNA I revealed all CNAs and LVNs were responsible for providing nailcare on shower days and as needed, nurses cut the nails for diabetic residents. She stated residents were at risk of skin tears and infections if they had long/dirty fingernails. She stated all the residents in the memory care unit agreed to cut nails, even if they refused during the first attempt.In an interview on 1/22/26 at 10:20 AM with ADON C revealed her expectation was that Nurses and CNAs provided nailcare on shower day and as needed. She added that nurses should cut nails for diabetic residents. She stated that as a ADON in the facility, all nursing Mangers, including the DON conducted daily rounds on their residents. She added that the risk of long, dirty nails was skin issues related to scratching and increased infection control. In an interview on 01/22/2026 at 9:49 AM with the DON revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. She stated the charge nurses were supposed to monitor. She stated that if a resident refuses, CNAs should inform charge nurses. If resident continues ADL care denials, Nurses notify family members for the resident. The DON stated residents having long and dirty fingernails could be an infection control issue, dignity, and skin issues. The DON stated that in order to maintain quality of life in the facility, she and Nursing management staff conducted daily rounds on all residents and any changes in condition or care refusals, if any were discussed in the clinical meeting. She stated that risk of long, dirty fingernails was skin integrity concerns.In a follow-up interview on 01/22/2026 at 10:31 AM with the DON, she stated that the facility did not have any specific policy on fingernails.Record review of the facility policy titled ADL, Services to carry out, revised 07/2015 revealed It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.2. If a resident is unable to carry out activities of daily living, the necessary services to maintain. grooming, and personal hygiene will be provided by qualified staff .

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 3 medication cart (Medication nurse cart [NAME] Hall, medication aide cart Hall [NAME] Tower 1, and Medication Nurse cart Hall [NAME] Tower2) of 7 medication carts reviewed for pharmacy services and 2 Medication room (Medication room for [NAME] Hall, and the medication room for Hall [NAME] 1 Tower) of 4 medications rooms. The facility failed to ensure medications in unsecure containers were immediately removed from stock. The facility failed to ensure expired medication (two antibiotic solution bags) were not in the refrigeration. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.Findings included: Record review on 01/20/26 of order summary dated 01/02/26 for Resident#174 revealed Ertapenem Sodium Injection solution Reconstituted use 500 mg intravenously one time a day for surgical wound 500 mg/100 ml to run over 30 minutes, and order summary dated 01/12/26 for Resident#174 revealed Ertapenem Sodium Injection solution Reconstituted use 1 gm intravenously one time a day for surgical wound 1gm 9gram)/100 ml (milliliter) to run over 30 minutes Observation and interview on 01/20/26 at 09:46 AM revealed Resident #174's two bags of antibiotic solution (Ertapenem Sodium Injection solution Reconstituted use 500 mg intravenously) were in the refrigerator in Medication room for [NAME] Hall, both dated 01/03/26 with a red label do not use after: 01/05/26. RN R stated she did not know that the antibiotic expired, and she would take the two bags of antibiotic medications and dispose of them. She stated the nurses were responsible to check the refrigerator daily and get rid of expired medications according to facility policy. RN R stated Resident #174's antibiotic medication order was changed, and someone could give him the wrong dose and expired medication. Observation on 01/20/26 at 09:56 AM of the Medication Nurse Cart Hall [NAME] revealed the blister pack for Resident #15's Tramadol 50 mg (milligrams) tablet (controlled medication used for anxiety) had 2 blisters (blister#16 and blister#25) seal broken and the pills were still inside the broken blisters. In an observation and interview on 01/20/26 at 9:58 AM, of the Medication Nurse Cart Hall [NAME] RN R stated the night shift nurse pulled the medication from the blister#25 to give it to Resident#15, but the resident left for dialysis, and the nurse put the pill back in the blister to be given to Resident when she was back from dialysis. RN R was unaware when the blister#16 pack seal was broken, and she was not aware of who might have damaged the blisters. She stated the risk of a damaged blister and medications left in it would be potential for drug diversion. She stated the nurses and medication aides were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, two nurses should discard the medication. An observation on 01/20/26 at 10:13 AM of the Medication Aide Cart Hall [NAME] 1 tower revealed the blister pack for Resident #120's Tramadol 50 mg (milligrams) tablet (controlled medication used for anxiety) had 1 blister (blister#1) seal broken and the pill was still inside the broken blister. The blister pack for Resident #132's Lorazepam 1 mg tablet (controlled medication used for anxiety) had 1 blister (blister#8) seal broken and the pill was still inside the broken blister. The blister pack for Resident #135's Zolpidem 6.25 mg tablet (controlled medication used for sleep aide) had 1 blister (blister#13) seal broken and the pill was still inside the broken blister. In an observation and interview on 01/20/26 at 10:17 AM, of the Medication Aide Cart Hall [NAME] 1 tower with MA Q revealed she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk of a damaged blister would be drug diversion. She stated the nurses and medication aides were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, two nurses should discard the medication. An observation on 01/21/26 at 1:20 PM of the Medication Nurse Cart Hall [NAME] 2 tower revealed the blister pack for Resident #2's Lorazepam 0.5 mg (milligrams) tablet (controlled medication used for anxiety) had 1 blister (blister#14) seal broken and the pill was still inside the broken blister. In an observation and interview on 01/21/26 at 1:22 PM, of the Medication Nurse Cart Hall [NAME] 2 Tower with LVN T revealed she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk of a damaged blister would be drug diversion, residents not getting the proper medication and allergic reaction. She stated the nurses and medication aides were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, two nurses should discard the medication. Interview on 01/22/26 at 12:55 PM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken, infection control. The DON stated the nurses were responsible for checking the refrigerator and medication carts for expired medication and removed it. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the cart randomly. The DON stated they did in-services for the MAs and nurses on medication storage including no expired medications in the refrigerator, and the locked boxes for the controlled substance medication in the refrigerator were supposed to be anchored to the refrigerator for safety and no one would walk away with the box. Record review of the facility's policy Medication Access and Storage/Drug Destruction, revised July 2007 reflected the following: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exist.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance:The facility failed to provide food that was palatable and served at an appetizing temperature to residents, during lunch on 1/21/2026.This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.Findings included:In an interview on 1/20/26 at 10:25 AM, Resident #24 stated that food was served cold sometimes. She stated that she still eats the food but cold food was not palatable. In an interview on 1/20/26 at 11:47 AM, Resident #58 stated that food was not tasting good. Food was cold at times.In an interview on 1/20/26 at 11:58 AM Resident #156 stated the food was cold and did not taste good.In an interview on 1/20/26 at 12:13 PM, Resident #39 stated the food was not always hot.In an observation on 1/21/26 at 11:35 AM of the [NAME] A taking food temperatures at the steam table before serving food revealed the temperature of lunch menu entree Penne [NAME] pasta was 145-degree Fahrenheit.In an Observation and Interview on 1/21/26 at 1:33 PM, a lunch test tray was sampled by [NAME] D and four surveyors. The sample tray consisted of 1 piece of garlic roasted chicken, penne alfredo pasta, 3/4 bowl of parsley carrots, 1 bread roll and 1 piece of banana foster cake. [NAME] D stated that pasta could be warmer, for it to taste better. The carrots and Garlic chicken were lukewarm to taste. [NAME] D measured the temperature of the pasta and it was 98-degree Fahrenheit.In a confidential group interview conducted on 1/21/26 at 2:00 PM, seven residents attending the group interview stated that the food was served cold. In an interview on 1/21/2026 at 1:48 PM with the Facility Dietitian, she stated that she was aware that residents in the facility had been complaining of cold food. She stated that the facility had obtained new plate warmer equipment last week. She stated food temperature was checked before service each meal. She stated that she had checked the pallet warmers that remained warm as well as steam tables were temping at appropriate temperature. She stated that the risk to residents for serving cold food was decreased palatability and possible poor food intake. She stated that all residents who complained of cold food were reviewed for weight loss. No residents met criteria requiring follow up for weight loss.In an interview on 1/21/2026 at 1:53 PM with the Administrator stated that he was aware of residents complaining of cold food. He stated that he put interventions in place such as changing the dietary manager in October of 2025 to supervise the efficiency of the kitchen service and buying new plate warmers for the kitchen last week to keep the food warm. He stated the new dietary manager was on leave for personal reasons and [NAME] D was the acting dietary manager. He also stated that he had hired new staff for the kitchen. He stated that risk of serving cold food was decreased food palatability. In an interview on 1/21/26 at 2:35 PM with [NAME] D revealed the kitchen received a new plate warmer equipment last week, however they equipment was not working well, it did not push the plates down enough when stacked up, as a result the plates remained stack up and did not heat up enough. She stated she had asked the maintenance tech to take out some springs at the bottom; however, the plates continue to stack up and do not go all the way down to keep the plates warm. She stated she had informed the maintenance personnel about the same, but no one had come to fix it. She added that food temperatures were taken before meal service. She stated the risk of serving cold food was food was not palatable and the residents would not eat as much.In an observation and interview on 1/21/26 at 2:49 PM with Facility Dietitian and Dietary Aide F, the new plate warmer unit did not stack up the plates all the way down to the bottom near the heating coil. Dietary Aide F stated that plates remain stacked up and do not collapse down near the base of the equipment to remain warm. The Facility Dietitian stated that if the plate stacked up, it would result in plates not being warmed enough for meal service.In an interview on 01/21/2026 at 3:08 PM with Maintenance Tech stated that the New Plate warming equipment was bought to the facility on 1/16/26. He stated that he came to the kitchen on 1/16/26 to remove a few coils from the warming unit, since the equipment was new and it was hard to push the plates down because of tight coils. He stated that he was not aware until the time of this interview that the plates continued to stack up on the top and did not go all the way down to warm up enough. He stated that if the plates stacked up on the top, the plates would not be warmed up as needed.In follow-up interview on 1/22/2026 at 12:39 PM with the Administrator, he stated that there was no facility policy regarding serving temperature of food but expected that staff followed state and federal guidelines of food safety and ensured residents were served palatable food.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food item in the facility walk-in refrigerator were labeled and dated on 1/20/26. 2. The facility failed to ensure food items in the facility walk-in refrigerator were stored in sanitary condition on 1/20/26.These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Observation of the facility walk-in refrigerator on 1/20/2026 at 9:33 AM revealed 3 slices of turkey lunch meat were wrapped in plastic bag and did not have a use-by date and were not labeled.Observation of the facility walk-in refrigerator on 1/20/2026 at 9:35 AM revealed a cardboard box having about 10-12 raw sweet potatoes were moldy and white fungus growing on them. It also revealed 2 cabbage heads with rotten leaves with black discoloration on them lying in a cardboard box. In an interview on 1/20/2026 at 9:40 AM with [NAME] D, she stated that she was the morning cook and acting food service manager since the facility's Dietary Manager was out for extended leave. She stated that she would throw out the turkey meat and spoiled sweet potatoes and cabbage immediately after the interview. In an interview on 01/21/2026 at 1:48 PM with facility Dietitian revealed her expectation was all the food items should be labeled and dated. She stated that once the package is opened, they should be adding use-by date on the package and label the food contents. She stated that her expectation was all fresh produce should be checked for freshness and if the produce was moldy or spoiled, should be discarded immediately. She stated that she conducted sanitation audits once a month for the facility. Sanitation audits included ensuring foods were labeled/dated, food temperatures were adequately taken and recorded, ensuring all the equipment was in working condition, and ensuring food temperatures for freezers and refrigerators. She stated that the risk of not labeling and dating food items or storing spoiled produce was possible infection control concerns and food borne illness in residents. She revealed that the facility did not have a specific policy for Food storage and utilized either Texas Food Establishment Rules from the Texas Administrative Code or Food and Drug Administration (FDA) food code as guidelines for food storage and food safety.In a follow-up interview on 1/21/2026 at 2:35 PM with [NAME] D revealed everyone in the kitchen was responsible for dating and labeling food items in the kitchen. She stated that she was not aware who left the turkey slices in the refrigerator but should label it and put an use-by date on it. She stated that the fresh produce should be checked daily and the sweet potatoes and cabbage, that were spoiled, were discarded promptly on 1/20/26. She stated that fresh produce should be stored in sanitary condition in the walk-in refrigerator to ensure they do not spoil. She added that the risk of not dating or labeling food items as well as not storing produce appropriately can lead to food borne illness in residents.In an interview on 1/21/26 at 2:44 PM with Dietary Aide E revealed everyone working in the kitchen was responsible for dating, labeling food items. She stated that fresh produce should be stored appropriately to minimize their spoilage. She stated that all spoiled produce should be thrown away immediately and not used for cooking. She stated that risk of not dating or labeling food items as well as not storing produce appropriately can lead to residents getting sick.Review of the Food and Drug Administration (FDA) Food Code, dated 2022, reflected, .3-305 Preventing contamination from the premise3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 Residents (Resident #157, Resident #13 and Resident #127) observed for infection control. 1.The facility failed to ensure CNA M and CNA L utilized Enhanced Barrier Precautions and performed hand hygiene during a mechanical lift transfer for Resident #157 and performed hand hygiene prior to leaving Resident #157's room on 01/20/26. 2.The facility failed to ensure CNA L performed hand hygiene during incontinence care for Resident # 13 and performed hand hygiene prior to leaving Resident #13's room on 01/20/26. 3. The facility failed to ensure Treatment Nurse P utilized Enhanced Barrier Precautions while performing wound care on Resident #127 on 01/21/26. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record Review of Resident #157's Face Sheet dated 01/22/26 reflected a [AGE] year-old female with an admission date of 11/12/24. Her diagnoses included Extended Spectrum Beta Lactamase (ESBL) (Type of enzyme produced by certain bacteria that makes them resistant to many common antibiotics, making infections harder to treat, often affecting the urinary tract, bloodstream and lungs). Record review of Resident #157's care plan with a revision date did not address the reason for Enhanced Barrier Precautions. In an observation on 01/20/26 at 10:40 a.m. a sign was observed posted on Resident #157's door, which indicated she was in enhanced barrier precautions. Upon entering the room CNA M stated she had just finished changing the resident and was going to get the mechanical lift and assistance to the get the resident up. CNA M left the room and within a few minutes returned with the mechanical lift and CNA L. Both CNAs put on gloves without performing hand hygiene and no gown. The CNAs proceeded to the hook the lift to the sling which had already been placed under the resident and transfer her to her wheelchair. CNA L guided the resident back into the wheelchair while CNA M lowered the mechanical lift. CNA L then removed her gloves and left the room with the lift without performing hand hygiene. CNA M finished adjusting the resident and then removed her gloves and left the room without performing hand hygiene. In an interview with LVN O on 01/20/26 at 11:00 a.m. she stated Resident #157 was in enhanced barrier precautions due to colonized ESBL in her urine. She stated the staff should be wearing PPE to perform high contact care, which included transfers. She stated she had been in enhanced barrier precautions for several months. In an interview on 01/20/26 at 11:15 a.m. with CNA M stated she did not notice the sign on the Resident #157's door and stated she worked yesterday and stated there was no sign on her door. She stated she should have noticed the sign and followed the protocols due to the risk of infection. She stated she had been in-serviced on enhanced barrier precautions and knew she was supposed to wear a gown during care of the resident, including transfers. In an interview on 01/20/26 at 1:15 p.m. with CNA L she stated she did not notice the sign on Resident #157's door and stated she was just helping with the transfer. She stated she guessed she should have worn the gown. She stated she had trained on enhanced barrier precautions and knew they were supposed to wear the gown and gloves when they provided incontinence care. She stated she was also supposed to perform hand hygiene when entering the room and before leaving and had failed to do that. 2. Record review of Resident #13's Face Sheet dated 01/22/2026, reflected an [AGE] year-old female with an admission date of 01/08/26. Her diagnoses included chronic obstructive pulmonary disease with exacerbation (progressive lung condition causing airflow blockage and breathing difficulties) In an observation on 01/20/2026 at 12:45 p.m. CNA L entered Resident #13's room to provide incontinence care. CNA L put on gloves without performing hand hygiene. CNA L opened the resident's brief and had her roll on her left side revealing she had a large loose bowel movement. CNA L wiped from front to back and changed and wiped multiple times but did not perform hand hygiene between glove changes. CNA L assisted the resident onto her other side to finish cleaning the resident, removed the soiled brief and under pad and the removed her gloves and put on clean gloves without performing hand hygiene. CNA L then applied barrier cream to the residents' buttocks and placed a clean brief under the resident and fastened the brief. CNA L gathered the trash and dirty linens, removed her gloves and left the room without performing hand hygiene. In an interview on 01/20/2026 at 12:55 p.m. with CNA L she stated she was supposed to perform hand hygiene before and after care and after gloves changes and stated she realized she had forgotten that. She stated the risk of not performing hand hygiene was the spread of infection to other residents. 3. Record review of Resident #127's Face Sheet dated 01/22/2026, reflected a [AGE] year-old female with an admission date of 01/18/26. Her diagnoses included diabetes and transmetatarsal amputation (removal of the fore foot just behind the toe). Record review of Resident #127's care plan with a revision date of 10/10/2025 reflected, Has wound.right foot.Interventions.Use Enhanced Barrier Precautions. An observation on 01/22/2026 at 11:35 a.m. revealed Treatment Nurse P outside of Resident #127's room preparing her wound care supplies. An EBP sign was posted on the door. Treatment Nurse P entered the room to assess the resident for pain and Resident #127 gave the okay for wound care to proceed. Treatment Nurse P returned to the medication cart, cleaned her bedside table and placed wax paper down. Treatment Nurse P then entered Resident #127's room, washed her hands and put on gloves, but no gown. She removed the old dressing from Resident #127's right foot and discarded it into a biohazard bag, removed her gloves and performed hand hygiene. Treatment Nurse P then cleansed the wound with saline gauze, removed her gloves, performed hand hygiene and put on clean gloves and placed the Dakin's (topical antiseptic used for disinfecting wounds) soaked gauze over the incision and covered with a dry dressing. Treatment Nurse P gathered the trash, removed her gloves and performed hand hygiene and left the room. In an interview on 01/21/2026 at 11:45 a.m. Treatment Nurse P stated any resident who had a wound required EBP and she stated, Oh my goodness, I did not wear a gown. She stated she had gowns on her cart and there were gowns in the resident's room. She stated she just simply forgot. She stated the reason for EBP was to prevent the spread of drug-resistant organisms from patient to patient. In an interview with the DON on 01/22/26 at 11:35 a.m. she stated staff were to change their gloves and perform hand hygiene before going form dirty to clean, before entering a resident's room and before leaving a resident's room. She stated all residents who were in Enhanced Barrier Precautions had signs posted on their doors and the staff was expected to follow those protocols. She stated they train and do in-services constantly on infection control. She stated that failing to follow those protocol places residents at a higher risk of infections. She stated they do monthly training on the use of PPE, how to appropriately don and doff, as well as annual skills checks. She stated all the staff knew the expectations. Record review of the facility's policy titled, Infection Prevention and Control, revised on May 2025, reflected, The facility will provide necessary Enhanced Barrier Precautions for resident care as needed.Facility management will post EBP signs and necessary PPE at the entrance of any room that contains a resident who had care appropriate for EBP. Facility staff will use necessary PPE to perform any care requiring the physical touch of a resident including but not limited to gowns and gloves. Record review of the facility policy titled, Hand Washing, revised May 2007, reflected, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, health environment for residents and staff.

Based on observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #162) of 2 residents reviewed for catheter care. The facility failed to ensure Resident #162's urine drainage catheter bag was kept below the level of the bladder when the resident was up in his wheelchair. This failure could place residents at risk for urinary tract infections.Findings included:Record review of Resident #162's Quarterly MDS assessment, dated 01/01/26, reflected an admission date of 09/25/22. Resident #162 had a BIMS score of 09, meaning his cognition was moderately impaired. He coded section H bowel and bladder: indwelling foley catheter. Resident #162's active diagnoses included obstructive uropathy (condition where urine flows backward from the bladder into the ureters and sometimes the kidneys), hypertension (elevated blood pressure, diabetes mellitus (elevated blood sugar), Cerebrovascular accident (happens when blood flow to a part of the brain is blocked or a blood vessel ruptures, causing brain cells to die from lack of oxygen, leading to sudden disability or death) and None Alzheimer's dementia (progressive brain disorders). Record review of Resident #162's care plan, dated 12/16/25, reflected . [Resident#162] has indwelling catheter . Goal: will show no sign/symptoms of urinary infection . Interventions included .Position catheter bag and tubing below the level of the bladder and away from entrance room door . Observation on 01/22/26 at 11:08 AM revealed Resident#162 was up in wheelchair in his room, watching TV. Resident#162's foley catheter tubing was coming out of his pants going to the right side of his body at the level of his waist and looping to the back to the drainage bag inside a cloth holding bag hanging at the back of the Resident wheelchair. Urine was observed backing up in the tubing back toward the resident's bladder. In an interview and observation on 01/22/26 at 11:10 AM, LVN S looked at Resident#162 and stated it looks like the tubing was not strapped to the resident's thigh, and the urinary drainage bag was to be always kept below the resident's bladder. LVN S stated she would get a strap for the resident tubing, and make sure the drainage was hanging beneath the wheelchair seat to keep it below the Resident#162 bladder. She stated the tubing should be strapped to the resident tight to prevent them from pulling, and that by failing to keep the bag under the bladder level it would put the resident at risk for urinary tract infections. In an interview with the DON on 01/22/26 at 12:55 PM she stated the catheter was to be maintained below the level of the bladder. She stated having the drainage bag on holding bag behind the resident wheelchair was not maintaining it below the bladder. She stated by not keeping it below the bladder urine could back up into the bladder and increase the risk of urinary tract infections. She stated she would do skills check on nursing staff and the ADON would do random checks to monitor staff. Record review of the facility's policy titled, Incontinent care and Foley Care, revealed no documentation of ensuring the urinary collection bag was below the bladder. Review of the CDC, Guidelines for Preventions of Catheter- Associated Urinary Tract Infections, dated March 25, 2024, .III. B. 2 Keep the collecting bag below the level of the bladder at all times

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls for 2 Medication room (Medication room for [NAME] Hall, and the medication room for Hall [NAME] 1 Tower) of 4 medications rooms. The facility failed to ensure controlled substance medication safety box was anchored inside the refrigerated, and not removable. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.Findings included:In an observation and interview on 01/20/26 at 10:29 AM the refrigerator in the medication room for Hall [NAME] 1 Tower had a locked clear see through plastic box with two boxes of Lorazepam oral concentration 2 mg/ml (controlled medication used for anxiety). The Plastic box was not anchored to the refrigerator. LVN U stated she did not know how long the controlled substance box had been in the refrigerator not anchored. She stated anyone could take the controlled substance box from the refrigerator. LVN U stated no anchored controlled substance box could lead to drug been lost or stolen, drug diversion, and residents not having their medication ready for use whenever they needed it. Interview on 01/22/26 at 12:55 PM, the DON stated the nurses were responsible for checking the refrigerator and medication carts for expired medication and removed it. The DON stated the ADON, and the DON were supposed to check the cart randomly. The DON stated they did in-services for the MAs and nurses on medication storage including no expired medications in the refrigerator, and the locked boxes for the controlled substance medication in the refrigerator were supposed to be anchored to the refrigerator for safety and no one would walk away with the box. Record review of the facility's policy Medication Access and Storage/Drug Destruction, revised July 2007 reflected the following: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exist.

Based on observation, interview and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 7 residents (Resident# 67) reviewed for residents' call system. The facility failed on 01/20/2026 to ensure the call light system was working and available to Resident #67 These failures could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.Record review of Resident #67's MDS assessment dated [DATE] reflected he was a [AGE] year old male with an admission date of 12/05/2024. His diagnoses included Alzheimer's disease with early onset (a brain disorder that destroys memory, thinking, and reasoning skills), spinal stenosis (narrowing of the spinal canal which causes pain), thrombocytopenia (low number of platelets in blood which can cause bleeding). Record review of Resident #67's care plan dated 12/17/2024 revealed he had alteration in musculoskeletal status related to fracture of the L olecranon. goal: will remain free of injuries. interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. ADL self-care performance deficit related to limited mobility, Dementia dated 12/10/2024, Goal: will maintain current level of function in. toilet use and personal hygiene, Interventions: . Toilet use. requires staff assistance x 1-2 to use toilet. Observation and interview on 01/20/2026 at 10:31 AM revealed Resident #67 was sitting in his bed, his call light device cord was tied around a monitoring device on the wall. Resident #67 stated his call light was not working for a few days, and he had no means to call for assistance other than yell. An interview on 01/26/2026 at 11:41 AM with CNA G revealed she was not aware that Resident #67's call light device was not working. She stated all the employees were responsible for making sure resident call lights were always working and within reach of the resident. She said the maintenance director was ultimately responsible for repairing and maintaining working call lights for all residents. She stated residents were at risk for falls, injury, delay in care if they did not have a working call light device. She stated they had an online system to report any maintenance issue to the maintenance director. An interview and observation on 01/26/2026 at 11:52 AM with LPN J revealed he was the charge nurse, he did not know Resident #67's call light device was not working. Observation revealed LPN J checking Resident #67's call light which was wrapped around a monitoring device on the wall, and he stated it was not working. He stated it was the responsibility of all the employees to ensure the call light was within reach of the resident and always working, notifying the maintenance if the device was not working. He stated the maintenance director was responsible for repairing and maintaining all the call light devices. He stated residents were at risk for falls, injury, delay in care if they did not have a working call light device. He stated he would give the resident a bell to call for help, if he knew the call light was not working. An interview on 01/20/2026 at 12:04 PM with CNA H revealed she was not aware that Resident #67's call light device was not working. She stated all the employees were responsible for making sure resident call lights were always working and within reach of the resident. She said the maintenance director was ultimately responsible for repairing and maintaining working call lights for all residents. She stated residents were at risk for falls, injury, delay in care if they did not have a working call light device. She stated they had an online system to report any maintenance issue to the maintenance director. An interview 01/20/2026 at 2:43 PM with LVN K revealed she was the charge nurse, she did not know Resident #67's call light device was not working. She stated it was the responsibility of all the employees to ensure the call light was within reach of the resident and always working, notifying the maintenance if the device was not working. She stated the maintenance director was responsible for repairing and maintaining all the call light devices. She stated residents were at risk for falls, injury, delay in care if they did not have a working call light device. An interview on 01/20/2026 at 3:11 PM with CNA I revealed he was not aware that Resident #67's call light device was not working. He stated it was the responsibility of all the employees to ensure the call light was within reach of the resident and always working, notifying the maintenance if the device was not working. He stated the maintenance director was responsible for repairing and maintaining all the call light devices. He stated residents were at risk for falls, injury, delay in care if they did not have a working call light device. An interview with the Maintenance director on 01/21/2026 at 02:21 PM revealed he came to know during a routine call light device check last Thursday that Resident #67's call light device was not working, and he had given a bell to the nurse on the same day to give it to Resident #67 to temporarily use until the call light device was repaired. He stated he had contacted the alarm company the same day and placed a work order, they came and looked at it on Friday and awaiting a part to complete the repairs. On 01/21/2026 at 01:40 PM, it was observed that Resident #67 had a bell next to his bed to call for assistance. An interview on 01/22/2026 at 12:10 PM with the DON revealed she expected all employees to make sure the residents had a working call light device at all times, report immediately to the charge nurse, maintenance director if a call light device was not working, and provide a temporary bell to the resident until the call light device was repaired. She stated residents were at risk for falls, injury and delay in care if they did not have a working call light device within reach. An interview with the Administrator on 01/22/2026 at 12:22 PM revealed he expected the residents to always have a working call light device, and it was the responsibility of all the employees to report to the maintenance director if a call light was not working. He stated residents were at risk for falls, injury and delay in care if they did not have a working call light device. He stated the maintenance director was responsible for repair and maintenance of call light devices. Record review of facility policy titled policy/procedure-nursing clinical, section: routine procedure, Subject: call light/bell, policy number: NCRP19 dated 05/2020 reflected it is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: . 5. Place the call device within resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 residents (Resident #35, Resident #44, and Resident#45) of 8 residents observed for infection control. The facility failed to ensure: 1- CNA I performed hand hygiene between change of gloves during incontinent care for Resident #44. 2- CMA F disinfected the blood pressure cuff in between blood pressure checks for the Resident #35 and Resident #45 These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: 1-Record review of Resident #44's Quarterly MDS assessment dated [DATE] reflected Resident #44 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included reduced mobility, muscle weakness, and cognitive communication deficit. Resident #44 had a BIMS score of 09, which indicated Resident #44's cognition was moderately impaired. The MDS assessment indicated Resident #44 was always incontinent of bladder and bowel. Record review of Resident #44's Care Plan dated 01/04/23, reflected the following: Focus: Has bowel/bladder incontinence . Goal: Will decrease frequency of urinary incontinence . Interventions: Check as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes . Observation on 10/30/24 at 9:03 AM revealed CNA I and CNA J entered Resident #44's room to provide incontinence care. Both CNAs washed hands and donned gloves, CNA H unfastened Resident #44's brief and cleaned the front pubic area. CNA J assisted the resident onto her side revealing she had a small bowel movement. CNA H discarded the dirty gloves, without hand hygiene she donned clean gloves. She cleaned the resident's buttocks area using several wipes. CNA H removed and discarded the dirty gloves, without hand hygiene, she donned clean gloves. She placed a clean brief under resident buttocks. Both CNAs fastened the brief. CNA J covered the resident in the bed. CNA H gathered the dirty clothes and trash. Both CNAs removed their gloves, washed their hands, and left the room. In an interview on 10/30/24 at 9:22 AM, CNA H stated she was supposed to perform hand hygiene between change of gloves and acknowledged she did not do that because she was nervous, and she did not have sanitizer on her. CNA H stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA H stated failing to provide proper care exposed the resident to infections. 2- Review of Resident #35's Comprehensive MDS dated [DATE] reflect Resident#34 was an [AGE] year-old female with a BIMS score 9 of 15 indicating moderate cognitive impairment. Resident#35 was admitted to the facility on [DATE] with the diagnoses of hypertension (elevated blood pressure) and cerebrovascular accident (type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain). Review of Resident #35's Care Plan dated 08/26/24 reflected the following: .Focus: Has hypertension Goal: Will remain free from sign/symptoms of hypertension through review date. Interventions: . Give anti-hypertensive medications as ordered Review of Resident#35's provider orders dated 09/18/20 reflected the following Lisinopril Tablet 40 MG Give 1 tablet by mouth one time a day for hypertension, Hold if SBP less than 100, DBP less than 60. Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for hypertension, Hold if SBP less than 100, DBP less than 60. Review of Resident #45's Comprehensive MDS dated [DATE] reflect Resident#45 was a [AGE] year-old female no BIMS score indicated. Resident#45 was admitted to the facility on [DATE] with diagnoses of hypertension (elevated blood pressure), aphagia, cerebrovascular accident, and dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Review of Resident #45's Care Plan initiated 07/02/15 reflected the following: .Focus: Resident#45 has hypertension. Goal: Will remain free of complication related to hypertension through review date. Interventions: . Give anti-hypertensive medications as ordered Review of Resident #45's provider order dated 08/26/23 reflected the following HydrALAZINE HCL Tablet 10 MG Give 1 tablet by mouth every 24 hours as needed for HTN give for SBP greater than 150. Observation on 10/29/24 at 08:20 AM reveled: CMA F checked Resident#35's blood pressure then put the blood pressure device, on the top of the medication cart, and sanitized hands. CMA F gave Resident#35's her medications; exited the room, and sanitized hands. CMA F moved his medication cart in front of Resident#45's room, took the blood pressure cuff without sanitizing it, and checked Resident#45's blood pressure, and then put the blood pressure cuff on top of the medication cart without sanitization. CMA F sanitize hands, then proceeded to prepare and administer medications to Resident#45. Interview on 10/29/24 at 08:33 AM, CMA F checked his medication cart, and stated he did not have the wipes. He stated the risk to residents were a transfer of germs. CMA F further stated just started two weeks ago, and he got training at school. In an interview on 10/30/24 at 2:30 PM, the DON stated she expected the staff to complete hand hygiene before and after care. The DON also stated in between care, the CNA's were to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection and cross contamination. The DON stated she would have the ADON do random checks to monitor. The DON stated to in order to prevent infection development for residents, the staff should sanitize the equipment like the blood pressure cuff and the blood sugar machine with each use. The DON stated to risk to residents development of infection . The DON further stated she was the IP for the facility, and in service was done quarterly and as needed. Record review of the facility's policy, Hand Hygiene, dated August 2014, reflected, .7. Use an alcohol-based hand rub ., or alternatively, soap and water for the following situations: . m. After removing gloves . Review of the facility's Policy Titled Infection Prevention and Control Program last revised in December 2023, reflected: .2. Process Surveillance is the review of practices by staff directly related to resident care. Some considerations for this process may include, but are not limited to .g. Cleaning and disinfection production and procedure for environment surface and equipment . 47690

48560 Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 Residents (Resident #27, Resident #133, Resident #41) reviewed for respiratory care. 1-The facility failed to ensure Oxygen (O2 ) in use signage was on Resident #133's doorway. 2-The facility failed to ensure Resident #27's nasal cannula tubing was changed in a timely manner. 3-The facility failed to ensure Resident #41 nasal cannula tubing was labeled or dated. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: 1- Resident #133 Record Review of Resident#133's Quarterly MDS assessment dated [DATE] reflected, Resident #133 was an [AGE] year-old-male admitted to the facility on [DATE]. His relevant diagnoses included: anemia (low red blood cell count), heart failure (heart is unable to pump enough blood for bodily needs), chronic obstructive lung disease (lung condition that makes it difficult to breathe), asthma, anxiety, and paraplegia (loss of muscle function). It also reflected, Resident #133 had BIMS of 15, which indicated he had intact cognition. Quarterly MDS also reflected Resident #133 was on Oxygen therapy. Record review of Resident #133's physician orders dated 8/23/2024 reflected, Oxygen at 3 liter per minute continuous per nasal cannula every shift related to Asthma. Record Review of Resident #133's Care plan, created on 9/11/24 reflected, Focus: [Resident #133] has oxygen therapy continuous related to Shortness of breath, Labored breathing. Goal: [Resident #133] Will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Monitor for signs and symptoms of respiratory distress and report to [physician] as needed. In an observation and interview on 10/28/24 at 11:11 AM Resident #133 stated he was on oxygen therapy. Observed that the resident room doorway did not have signage for Oxygen in use outside the door. In an interview and observation with CNA B at 10/28/24 at 11:13 AM stated Resident #133 was on Oxygen therapy. She stated she did not see the Oxygen in use sign on Resident #133's room door. She stated every resident on oxygen therapy should have the sign to ensure safety if flammable objects were bought to the room. She stated that it could also alert staff in case of any emergency or evacuation. She stated she has worked in other units within the facility and had seen the oxygen in use signage used for residents on oxygen therapy. In an interview on 10/29/24 at 09:30 AM RN D stated she was new to the facility and had started working about 2 weeks ago. She stated that Resident #133 was on continuous oxygen therapy and needed to have oxygen in use signage outside his room door. She stated the risk of not having appropriate signage was failure to alert staff members regarding resident's need for oxygen in case of emergencies or evacuation. She stated failure to have appropriate signage can lead to decreased quality of care by not meeting resident's care needs. 2- Resident #27 Record Review of Resident#27's Quarterly MDS assessment dated [DATE] reflected, Resident #27 was an [AGE] year-old-female admitted to the facility on [DATE]. Her relevant diagnoses included: Stroke (blood flow to the brain is interrupted resulting in death of brain cells), hypertension (high blood pressure), cognitive communication deficit (difficulty in communication caused by disruption in cognition), and aphasia (loss of ability to express speech). It also reflected, Resident #27 had BIMS of 8, which indicated she had moderate cognitive impairment. Record review of Resident #27's physician orders dated 5/28/2024 reflected, Oxygen at 2 liter per minute via nasal cannula. May titrate up to 5 liter per minute to keep oxygen saturation more than 92 percent. Record review of Resident #27's physician orders dated 2/1/2024 reflected, Change Oxygen Tubing and Humidifier Bottle every night shift every Wednesday. Record Review of Resident #27's Care plan, created on 9/10/24 reflected, Focus: [Resident# 27] has Oxygen Therapy related to Shortness of Breath. Goal: [Resident #27] Will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Monitor for signs and symptoms of respiratory distress and report to MD as needed. In an observation on 10/28/24 at 02:13 PM with Resident #27 revealed she was in bed and receiving oxygen via nasal cannula at 4 liters per minute. The date on the humidity bottle was marked as 10/17 and the date on the tubing was 10/18. In an observation and interview on 10/28/24 at 2:24 PM with LVN C revealed the date on the nasal cannula tubing was 10/18/24, which was 10 days ago and the date on the humidity bottle was 10/17/24 which was 11 days ago. LVN B stated that nasal cannula tubing and humidity bottle should be changed weekly and was done by the night shift nurses. She stated that failure to change nasal cannula tubing and humidity bottle in a timely manner could cause breathing problems and possibly infection control lapses in residents. 3- Resident #41 Record review of Resident # 41's Quarterly MDS assessment dated [DATE] reflected Resident #41 was an [AGE] year-old male readmitted to the facility on [DATE]. Diagnoses included, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and chronic respiratory failure (a long-term condition that occurs when the lungs can't exchange oxygen and carbon dioxide properly.) Resident had a BIMS Score of 15, meaning his cognition was intact. Record review of Resident #41's care plan revised 02/19/2024 reflected, Focus: has oxygen therapy related to chronic obstructive pulmonary disease/chronic respiratory failure . Goal: Will have no sign/symptoms of poor oxygen absorption . Interventions: Provide oxygen as ordered . Record review of Resident #41's Physician order dated October 2024, revealed Oxygen at 2l/min via nasal cannula every shift . with a start date of 08/10/2023. Record review of Resident #41's Physician order dated October 2024, revealed Change oxygen tubing a humidifier bottle every night shift every Wednesday. Observation on 10/29/24 at 8:52 AM revealed Resident #41 was sleeping in his bed. Oxygen concentrator was running at 2L/min and there was no date or label on the nasal cannula tubing. In an interview on 10/29/24 at 9:00 AM Resident #41 stated that he had been on continuous oxygen therapy because of his shortness of breath. Resident did not remember when the oxygen tubing was changed. In an observation and interview on 10/29/2024 at 9:23 AM, LVN H stated nurses were responsible for changing and dating nasal cannula tubing and it was done on weekly basis and as needed. She stated if oxygen supplies were not dated, it could lead to increased risk of infection. She stated she did not check the tubing for the date because she assumed the tubing was dated by the nurse who changed it. LVN H proceeded to change the tubing. In an interview on 10/28/24 01:39 PM with the DON, she stated her expectation was if the resident was on oxygen therapy, then signage for oxygen in use should be on the door. She stated her expectation was the nasal cannula tubing and humidity bottle should be changed weekly or as needed, if soiled or damaged. She stated that night shift floor nurses were responsible for putting up the sign and dating/labeling oxygen equipment weekly. She stated the facility was a non-smoking facility and oxygen in use sign was placed to warn people not to have flammable objects when oxygen was in use. She also stated that the risk of not having appropriate signage on the door was that staff may not be aware that residents were dependent on oxygen therapy. She stated that the risk of not dating the tubing / humidity bottle or not changing it in a timely manner could lead to infection control lapses and decreased quality of care. She stated as a DON of the facility, she or her designee conducted daily resident rounds. She stated that skill checks for nurses were done on a quarterly basis. She also stated that there was no facility policy for oxygen in use signage, however it was a part of standard nursing protocol. Record review of facility policy titled Policy / Procedure - Nursing Clinical: Oxygen Equipment revised 5/2017 reflected, . 3. Cannulas should be replaced every week .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to ensure food items in the facility walk-in freezer were labeled and dated. 2. [NAME] A failed to ensure to use appropriate hand hygiene during meal prep. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on [DATE] at 10:21 AM in the facility's walk-in freezer revealed 3 big bags of unidentified food items that did not have a date or label on it. Interview on [DATE] at 10:22 AM with the Dietary Manager revealed the unidentified food items were frozen popcorn shrimp. Observation on [DATE] at 10:26 AM along with the Dietary Manager, revealed [NAME] A was prepping for chicken salad sandwiches in the facility kitchen prep room. [NAME] A had donned gloves while mixing the chicken salad ingredients with his hands. Observed Cook's A personal phone placed on a cart in the prep area. [NAME] A reached out for the phone, picked it up, and placed it in his pocket. He then continued to mix the chicken salad mixture with the same gloves without performing adequate hand hygiene or hanging his gloves between the activities. In an interview on [DATE] at 02:05 PM the Dietary Manager stated that the facility cooks were responsible for dating and labeling all food items in the kitchen. He stated that his expectation was all food items in the kitchen should be marked with received date once they arrive at the facility. He stated that if the box was open, he expected the cooks to individually date each bag with a received date and use by date as well as label it appropriately. He also stated it was his expectation that all kitchen employees follow appropriate hand hygiene in the kitchen that included proper hand washing technique, sanitizing, and changing gloves after and between each task. He stated [NAME] A was an old employee with the facility and should have known the importance of changing gloves and performing adequate hand hygiene while cooking or prepping for meals. He stated that he had [NAME] A throw out the sandwich mixture and asked him to remake it using appropriate hand hygiene technique. He also stated that kitchen employees should not use phones or headphones while in the kitchen area but can utilize it in the break room. He stated the risk of not dating, labeling food items with use by date, and not following adequate hand hygiene while prepping food can cause cross contamination resulting in food borne illness. In an interview on [DATE] at 11:57 AM [NAME] A stated that he had worked in the facility for the last [AGE] years. He stated that cooks were responsible for dating and labeling food items. He stated he did not know about the frozen popcorn shrimp bags that were not dated or labeled. He stated that, all food items were dated with received date for boxed items and use by date for any open items. He stated it was important to date and label each food item to follow the first in first out rule and to prevent residents from getting sick by consuming expired foods. He also stated that he knew to change gloves and wash/ sanitize hands between kitchen tasks. He stated that it was an error to touch the chicken salad with the same gloves after touching his phone. He added the risk of not performing adequate hand hygiene during meal prep was residents could get sick because of infection or cross contamination. Record Review of the facility policy titled Infection Control policy food Service/Procedure revised ,d+[DATE] reflected, It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness .4. D. 1. Wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning, after using the bathroom, after coughing, sneezing, or blowing the nose, after touching the hair, mouth, or cigarettes, after handling raw unwashed food and dirty dishes; before touching food, clean dishes, and silverware. Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE] Preventing contamination from the premise,d+[DATE].11 Food Storage (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Review of the Food and Drug Administration Food Code, dated 2022, reflected ,d+[DATE].11 Clean Condition. The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. Even seemingly healthy employees may serve as reservoirs for pathogenic microorganisms that are transmissible through food. Staphylococci, for example, can be found on the skin and in the mouth, throat, and nose of many employees. The hands of employees can be contaminated by touching their nose or other body parts. ,d+[DATE].12 Cleaning Procedure. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE food as well as other pathogens that can be transmitted from environmental sources. Many employees fail to wash their hands as often as necessary and even those who do may use flawed techniques. In the case of a food worker with one hand or a hand-like prosthesis, the Equal Employment Opportunity Commission has agreed that this requirement for thorough handwashing can be met through reasonable accommodation in accordance with the Americans with Disabilities Act. Devices are available which can be attached to a lavatory to enable the food worker with one hand to adequately generate the necessary friction to achieve the intent of this requirement .

Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #17, Resident #28, Resident #91, and Resident #255) of 16 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #17 had his fingernails cleaned and trimmed. 2- Resident #91 had his fingernails trimmed. 3- Resident #28 had his fingernails cleaned and trimmed. 4- Resident #255 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1- Resident #17 Review of Resident #17's Quarterly MDS assessment dated [DATE] reflected Resident #17 was an [AGE] year-old male with initial admitted to the facility on [DATE]. His diagnoses included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue), hemiplegia (paralysis of one side of the body) affecting left side, diabetes mellitus (high blood glucose levels), and cognitive communication deficit. Resident #17 had a BIMS score of 12 which indicated he had moderate cognitive impairment. Resident #17 required maximal assistance with personal hygiene. Review of Resident #17's Comprehensive Care Plan, revised 07/09/24, reflected the following: Focus: [Resident #17] at risk for an ADL self-care performance deficit. Goal: [Resident #17] will maintain current level of function in . personal hygiene. Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. An observation and Interview on 11/28/24 at 10:37 AM revealed Resident #17 was sitting in his wheelchair. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #17 stated he did not like his nails long and dirty. He stated he did not tell anybody about his nails. 2- Resident #91 A record review of Resident #91's Quarterly MDS assessment dated [DATE] reflected Resident #91 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue), hemiplegia (paralysis of one side of the body) affecting left side of the body, and cognitive communication deficit. Resident #91 had a BIMS score of 15 which indicated Resident #91's cognition was intact. He required extensive assistance with personal hygiene. A record review of Resident #91's Comprehensive Care Plan, revised 04/29/24, reflected the following: Focus: ADL self-care performance deficit related to hemiplegia. Goal: Will maintain current level of function or improve in . personal hygiene An observation and interview on 10/28/24 at 10:45 AM revealed Resident #91 was laying in his bed. The nails on the right hand were approximately 0.4 centimeter in length extending from the tip of his fingers. Resident#91's left hand contracted, fingernails were approximately 0.4 cm. 4 of the fingernails pressing on the resident's palm of hand. No injury noticed. Resident#91 stated he would like his fingernails taken care of and he stated he would ask the nurse. In an interview with LVN H on 10/29/24 at 11:30 AM, she stated that she had not offered nailcare to Resident#17 and #91 recently. She stated that nailcare should be provided by the nursing staff as needed. She stated Resident #17's fingernails were long and dirty, and she offered to clean them after the interview. She stated she would trim resident #91's nails. She stated the risk of not providing adequate nail care was increased infections and skin break down issues. 3- Resident #28 A record review of Resident #28's annually MDS assessment dated [DATE] reflected Resident #28 was a [AGE] year-old male with a BIMS score 01 of 15, indicating severe cognitive impairment. Resident#28 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of diabetes mellitus (elevated blood sugar), anxiety, depression, cerebrovascular accident, and muscle weakness. The review further reflected the resident was totally dependent on staff for ADL's (activity of daily living). A record review of Resident #28's Comprehensive Care Plan dated 10/08/24 reflected Problem: (Resident #28). ADL Self-care Performance deficit r/t CVA Goal: (Resident#28) will maintain current level of function in .Grooming ., Personal Hygiene . An observation on 10/28/24 at 11:25 AM revealed Resident#28 up in wheelchair in his room, wearing daytime attire. Resident#28's right hand with fingernails approximately 0.4 centimeter in length extending from the tip of his fingers and dirty. Resident#28's left hand severely contracted, the first, second, 3rd, and 5th fingernails approximately 0.4 centimeter in length extending from the tip of his fingers, with dirty matter underneath the 1st, 2nd, 3rd, and 5th fingernail. Resident#28's 4th finger hiding under the 3rd and 5th fingers. Some of the fingernails were chipped in both hands. Resident#28 denied pain in the left hand. Resident#28 stated he would like his fingernails trimmed and cleaned. Interview and observation on 10/28/24 at 11:49 with LVN E revealed, LVN E looked at Resident#28's fingernails and stated the fingernails were long and needed to be cleaned. LVN E stated he would clean, and trim Resident#28's fingernails. LVN E stated the risk to the resident was he could cut himself, and development of infection. LVN E further stated it was the responsibility of the unit charge nurse to check, and make sure residents' fingernails were cleaned and trimmed all the time. 4- Resident #255 A record review of Resident #255's MDS assessment dated [DATE] reflected Resident #255 was a [AGE] year-old male with a BIMS score 03 of 15, indicating severe cognitive impairment. Resident#255 was admitted to the facility on [DATE] with the diagnosis of Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), seizer disorder, and depression. The review further reflected the resident was totally dependent on staff for ADL's (activity of daily living). A record review of Resident #255's Comprehensive Care Plan dated 10/28/24 reflected Problem: (Resident #255). ADL Self-care Performance deficit r/t dementia, history of CVA . Goal: (Resident#255) will maintain current level of function in .Grooming ., Personal Hygiene; ADL score through the review date. Interventions: Bathing (Shower/Bathe self): The Resident#255 x1-2 assistance with .prefers hands wash. An observation on 10/28/24 at 11:39 AM revealed Resident #255 was lying in bed wearing appropriate attire. Both hands fingernails were short with brown matter underneath. Resident#255 was unable to participate in interview. Interview and observation on 10/28/24 at 11:47 with LVN E revealed, he looked at Resident#255 fingernails and stated fingernails had some dirt underneath, and he would clean them. LVN E stated the risk to the resident could be development of infection, other than that hygiene. LVN E further stated it was the responsibility of the unit charge nurse to check, and make sure residents' fingernails were cleaned and trimmed all the time. In an interview with the DON on 10/30/24 at 2:11 PM revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. She stated the charge nurses were supposed to monitor. The DON stated residents having long and dirty fingernails could be an infection control issue, dignity, and skin issues. She stated in-service on resident's ADLS were done as needed and once a year. Record review of the facility policy titled ADL, Services to carry out, revised 07/2015 revealed It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care .2. If a resident is unable to carry out activities of daily living, the necessary services to maintain . grooming, and personal hygiene will be provided by qualified staff . 47690

Based on observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #104) of 2 residents reviewed for catheter care. The facility failed to ensure CNA B kept Resident #104's urine catheter bag below the level of the bladder during incontinent care. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #104's Quarterly MDS assessment, dated 10/09/24, reflected an admitted [DATE]. Resident #104 had a BIMS score of 09, meaning her cognition was moderately impaired. She required maximal assist with ADLs. Resident #104's active diagnoses included reflux uropathy (condition where urine flows backward from the bladder into the ureters and sometimes the kidneys), diabetes mellitus, and Alzheimer's disease. Record review of Resident #104's care plan, dated 06/22/23, reflected . [Resident#104] has indwelling catheter . Goal: will show no sign/symptoms of urinary infection . Interventions included .Position catheter bag and tubing below the level of the bladder and away from entrance room door . Review of Resident #104's Physician Orders Report dated 10/30/24 reflected, . Change foley catheter monthly on 15 day of each month . every shift starting on the 15th and ending on the 15th every month. With start date of 08/15/24. Observation on 10/30/24 at 11:08 AM revealed CNA B , and CNA G entered Resident #104's room. Both staff performed hand hygiene, and donned gowns and gloves. CNA G uncovered Resident #104 and unfastened the resident's brief. CNA B cleaned Resident #104's front pubic area with wipes, using one wipe per stroke. CNA B placed Resident #104's urinary catheter drainage bag on the bed by the resident's feet. Both CNAs assisted the resident to turn on her right side. CNA B cleaned the resident's buttocks using peri-wipes, she removed and discarded the dirty brief, and she put a clean brief under the resident. Both CNAs assisted Resident #104 back on her back. Urine was observed backing up in the tubing back toward the resident's bladder. Both CNAs fastened the brief. CNA B hooked the urinary catheter drainage bag, back on the right side of the bed. CNA G covered Resident #104. Both CNA removed gloves and gowns, washed hands, and left the room. In an interview on 10/30/24 at 12:06 PM, CNA B stated the urinary drainage bag was to be always kept below the resident's bladder. CNA B stated she knew better but she worried to pull the tubing. She stated by failing to keep the bag under the bladder level it would put the resident at risk for urinary tract infections. In an interview with the DON on 10/30/24 at 02:30 PM she stated the catheter was to be maintained below the level of the bladder. She stated placing the drainage bag on the bed was not maintaining it below the bladder. She stated by not keeping it below the bladder urine could back up into the bladder and increase the risk of urinary tract infections. She stated she would do skills check on nursing staff and the ADON would do random checks to monitor staff. Record review of CNA B's skills verification checklist dated 09/04/24 reflected she was competent in Peri-care-Foley catheter tubing care. Record review of the facility's policy titled, Catheter Care, Indwelling, revised May 2017, reflected, .Purpose: To promote hygiene, comfort, and decrease risk of infection for catheterized residents . Procedure . 12. Keep tubing below level of bladder .

Based on observations, interviews and record review, the facility failed to ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 7 Residents (Resident#10, Resident#13, Resident#30, Resident#64, Resident#75, Resident#96, and Resident#134) of 30 residents reviewed for residents' call systems. The facility failed to ensure the call light system was accessible to a resident, lying on the floor in the residents' toilets, located between two adjacent rooms in all female secured unit: . Resident#30 . Resident#75 . Resident#96 . Resident#134 . Resident#64 . Resident#13 . Resident#10 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: Resident#30 -Observation on 10/28/24 at 09:55 AM resident toilet call light pull string was hanging over the toilet paper dispenser. The dispenser was fixed to the wall six feet from the floor. Resident#75/Resident#96 -Observation on 10/28/24 at 09:56 AM Residents shared toilet in the two adjacent rooms call light pull string was hanging over the toilet paper dispenser. The dispenser was fixed to the wall six feet from the floor. Resident#134/Resident#64 -Observation on 10/28/24 at 09:57 AM Residents shared toilet in the two adjacent rooms call light pull string was intertwined on the straight grab bar fixed vertical to the wall in the right side of the toilet. The straight grab bar was two and half feet from the floor. Resident#13/Resident#10 - Observation on 10/28/24 at 09:58 AM Residents shared toilet in the two adjacent rooms call light pull string was hanging over the toilet paper dispenser. The dispenser was fixed on the wall six feet from the floor. Interview and observation on 10/30/24 at 09:30 AM the Maintenance Supervisor revealed, he took the call light pull string from the toilet paper dispenser and let it go. The call light pull string ended up laying on the floor, because it was too long, about six feet long. The Maintenance Supervisor stated he would fix it. The Maintenance Supervisor took the call light pull string from the floor, proceeded to adjust it to be going from the wall outlet down, not touching the floor, and cut the extra string. He stated the way it was, the call light could cause a serious problem to residents and declined to elaborate more. Interview on 10/30/2024 at 2:11 PM the DON stated all call lights needed to be always within reach of the resident. The DON stated the call light in the resident's bathroom should be next to the toilet and within resident use, even if the resident was lying in the floor. The DON stated the call light pull string should be going straight from the wall outlet down, and not hanging or intertwined on the fixtures. The DON stated the risk to the residents, if they cannot reach the call light, they could not call for help, and they will not get the help they needed. Interview on 10/30/24 at 3:44 PM the Administrator stated all the call light pull strings in the secured unit had been fixed, and they were no longer too long and dragging on the floor. He stated the staff had been reeducated to report any issue with the call light system to the Maintenance Supervisor. The Administrator stated the risk to residents, if the call light was not within resident reach or did not work properly, the residents could not call for help. Review of the facility policy titled policy/Procedure-Nursing services. Section: Routine Procedures- Subject: Call Light/Bell, revised 05/2007 revealed It is the policy of (to provide the resident a means of communication with nursing staff . 5. Place the call device within resident's reach before leaving room. If call light/bell defective, immediately report this information to the unit supervisor.

Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with accommodation of resident needs and preferences for 1 of 30 residents (Resident #255) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #255 lying in bed. This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers. Findings included: A record review of Resident #255's MDS assessment dated [DATE] reflected Resident #255 was a [AGE] year-old male with a BIMS score 03 of 15, indicating severe cognitive impairment. Resident #255 was admitted to the facility on [DATE] with the diagnoses of Dementia (a progressive loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), seizures disorder, and depression. The review further reflected the resident was totally dependent on staff for the ADL's (activity of daily living). A record review of Resident #255's Comprehensive Care Plan dated 10/28/24 reflected Focus. At risk for falls r/t dementia, seizures, and history of CVA. Goal. Will not sustain serious injury through the review date. Interventions. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Observation on 10/28/24 at 11:39 AM Resident#255 was lying in bed and trying to get up. Resident#255 stated he wanted to pee. Resident#255's call light was on top of the nightstand. Resident#255 could not reach the call light, this state surveyor pressed the resident call light, and LVN E entered the room to answer the call light. This state surveyor pointed to the call light on the nightstand. LVN E stated the call light was not within reach of Resident#255 and took the call light from the nightstand and placed it next to Resident#255 in the bed. LVN E called an aide to take Resident#255 to use the bathroom. Interview on 10/28/24 at 11:41 AM LVN E stated the call light was not within reach of the Resident#255. LVN E stated the call light should be within residents reach at all times, and risk to the resident not getting help on time could be a fall and possible injury. LVN E stated it was the responsibility of all the staff to make sure the call light was within resident reach before exiting the room. Interview on 10/30/2024 at 2:11 PM the DON stated all call lights needed to be always within reach of the resident. The DON stated the call light in the resident's bathroom should be next to the toilet and within resident use, even if the resident was lying in the floor. The DON stated the call light pull string should be going straight from the wall outlet down, and not hanging or intertwined on the fixtures. The DON stated the risk to the residents, if they cannot reach the call light, they could not call for help, and they will not get the help they needed. Interview on 10/30/24 at 3:44 PM the Administrator stated all the call light pull strings in the secured unit had been fixed, and they were no longer too long and dragging on the floor. He stated the staff had been reeducated to report any issue with the call light system to the Maintenance Supervisor. The Administrator stated the risk to residents, if the call light was not within resident reach or did not work properly, the residents could not call for help. Review of the facility policy titled policy/Procedure-Nursing services. Section: Routine Procedures- Subject: Call Light/Bell, revised 05/2007 revealed It is the policy of(to provide the resident a means of communication with nursing staff . 5. Place the call device within resident's reach before leaving room. If call light/bell defective, immediately report this information to the unit supervisor.

Based on observations, interviews, record reviews, facility policy reviews, and review of the Centers for Disease Control's (CDC's) Preparing for COVID-19 in Nursing Homes, the facility failed to transfer residents off of the quarantine unit who had completed a 14-day quarantine and failed to ensure staff followed transmission-based precautions requiring the use of full Personal Protective Equipment (PPE) (gloves, gowns, face mask, goggles or face shield) while providing care to Persons Under Investigation (PUI) resulting in the potential for those residents to be re-exposed to COVID-19. Potentially re-exposed residents were receiving therapy in the therapy department with the general population of the facility. The facility's failures increased the risk of COVID-19 transmission to all 158 residents who resided at the facility. On 10/29/20 at 2:53 PM, the Administrator, Administrator in Training (AIT), and the Director of Nursing (DON) were notified of the Immediate Jeopardy at F880 (Infection Control) related to the facility's failure of placing residents at an increased risk of exposure to COVID-19. The facility presented an acceptable removal plan for the Immediate Jeopardy at F880 on 10/30/20 at 2:35 PM. The removal plan included to make the Fast Track Unit an entirely quarantined unit. Residents who had completed their 14-day quarantine and were potentially exposed to COVID-19, were placed on a new 14-day quarantine period. The removal plan indicated facility staff had been educated on transmission-based precautions and the proper use of PPE. The removal plan was validated through observations, interviews, and record reviews. The facility was notified that the Immediate Jeopardy was removed on 10/30/20 at 3:05 PM. Findings include: Per Centers for Disease Control (CDC), Preparing for COVID-19 in Nursing Homes, dated 06/25/20, indicated, .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown.Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Health Care Professionals) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. During the entrance conference on 10/28/20 at 8:35 AM, the Director of Nursing (DON) stated the facility had a designated unit for new admissions and readmission called Fast Track. The DON stated staff on the Fast Track unit, staff were to follow contact and droplet precautions. The DON further stated staff were to don (put on) gown, gloves, face shield and a face mask prior to entering a PUI resident's room and doff (remove) the gown and sanitize the face shield prior to entering another resident's room. Review of a facility policy titled, Infection Control and Prevention Policy Emerging Infectious Disease (EID): Coronavirus Disease 2019 (COVID-19), dated as revised 09/27/20, indicated, .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown.Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Health Care Personnel) should wear a KN95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that coves the front and sides of the face), gloves, and a gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected . Review of a paper document provided by the DON, revealed per Texas Government Code titled, .Title 40 Part 1 Chapter 19 Social Services and Assistance Department of Aging and Disability Services Nursing Facility Requirements for Licensure and Medicaid Certification. §19.2802. Nursing Facility COVID-19 Response. undated, indicated Isolation-The separation of people who are COVID-19 positive from those who are COVID-19 negative and those whose COVID-19 status is unknown.PPE-Personal protective equipment. Specialized clothing or equipment worn by nursing facility staff for protection against transmission or infectious diseases such as COVID-19, including masks, goggles, face shields, gloves and disposable gowns.Quarantine-The separation of a person with unknown COVID-19 status from those who are COVID-19 positive and those who are COVID-19 negative.Unknown COVID-19 status-A person who is a new admission, readmission, has spent one or two nights from the facility. Review of a facility document, titled, Emerging Infectious Disease (EID) Emergency Plan Coronavirus 2019 (COVID-19), dated as issued 03/20, failed to address new admissions/readmissions as PUI. 1. Review of the Electronic Medical Records (EMR), Admission Record, indicated Resident (R) 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted to the long hall on the Fast Track Unit (quarantined area). Review of the resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/20 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. During an interview on 10/28/20 at 11:30 AM, R1 stated he was a new admission and stated staff only wear wore a simple face mask and no goggles or face shield when they entered his room. The resident also stated staff would sometimes wear a gown. The resident was on the outside of his room during this interview. The resident stated staff have not informed him to remain in his room while under quarantine. Review of the EMR Admission Record, indicated R2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted to the long hall of the Fast Track Unit (quarantined area). Review of the EMR Admission Record, indicated R10 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident was admitted to the long hall of the Fast Track Unit (quarantined area). Per review of the EMR nursing Progress Notes dated 10/16/20, R10 had a change in her condition and was sent to the local emergency room for evaluation and treatment. The resident was eventually admitted to the hospital. On 10/21/20 the resident was readmitted to the facility to the long hall of the Fast Track Unit. Review of the EMR, Admission Record, indicated R3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the EMR, Admission Record, indicated R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the long hall of the Fast Track Unit (quarantined area). Review of a paper document provided by the facility, titled, Room Relocation Form, dated 10/28/20 verified R4 was transferred from the long hall (quarantined area) to the short hall (non-quarantined area) on this date. During an interview on 10/28/20 at 11:45, LVN/Nurse Manager 8 stated the reason why the residents who had passed their 14-day quarantine were not transferred off of the long hall (quarantined area) to the short hall (non-quarantined area) was due to COVID-19 tests were conducted today. She said the facility wanted those residents negative before they were transferred off the long hall (quarantined area). LVN/Nurse Manager 8 stated staff were to wear a KN95 face mask, face shield, gown, and gloves prior to entering a resident's rooms. The staff were then to doff the gown and hang it on the inside of the door facing the inside of the resident's room before exiting. The staff member confirmed the facility used reusable gowns. She stated the gowns were not to be worn between residents. She continued and stated, therapy provides services in the rooms of the residents who are under quarantine. The staff member stated housekeeping was to follow the same process and change gowns between resident use. During an interview on 10/28/20 at 1:22 PM, Therapy Technician (Tech) stated residents who were quarantined would be provided therapy in their room until they had completed their 14-day quarantine and then the residents could come to the therapy gym. The Therapy Tech also stated R4 had received therapy in the therapy gym last week. Review of the EMR, Admission Record, indicated R6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a paper document titled, Room Relocation Form, dated 10/28/20 verified R6 was transferred from the long hall (quarantined area) to the short hall (non-quarantined area) on this date. Review of the EMR, Admission Record, indicated R8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident was admitted to the long hall of the Fast Track Unit (quarantined area). 2. Observation on 10/28/20 at 9:40 AM, Housekeeper 6 had a face mask on and no other PPE, such as a gown and face shield. The staff member was on the long hall of the quarantined unit. An interview was conducted after this observation. Housekeeper 6 confirmed she did not wear a gown or a face shield in the resident's room. Immediately after this interview, the Admissions Director was observed to enter room [ROOM NUMBER], due to the resident calling out. The Admissions Director did not have a gown or a face shield on upon entrance to the resident's room. When asked why she did not don a gown or a face shield prior to enter room [ROOM NUMBER], the Admissions Director stated she did not come up to the units much since the COVID-19 outbreak. During an observation on 10/28/20 at 9:42 AM, Licensed Vocational Nurse (LVN) 7 had a blue cloth gown on, face mask and a face shield on. LVN 7 was standing by a medication cart located in the front of room [ROOM NUMBER]. LVN 7 entered the resident room. The staff member came back out of the room a few seconds later and then entered room [ROOM NUMBER]. LVN 7 was not observed to doff (remove) her gown between entering resident rooms. LVN 7 then walked down to the nursing station, located at the opposite end of the hallway, again without doffing her gown prior to walking down the hall. An interview was conducted immediately after this observation and LVN 7 confirmed she did not change her gown between resident contacts. During an observation on 10/28/20 at 9:43 AM, Certified Nursing Assistant (CNA) 11 was observed in room [ROOM NUMBER] and after a few seconds left the room. CNA had a gown and a face mask on. The staff member failed to doff her gown prior to exiting room [ROOM NUMBER]. CNA11 then entered the room of 319 and again spent a few seconds in this room. The staff member failed to doff her gown prior to exiting this room. CNA11 then entered room [ROOM NUMBER] and gathered a completed breakfast tray then exited and failed to doff her gown. The staff member then took the food cart down the hallway next to the nursing station. During an interview on 10/29/20 at 9:40 AM, CNA11 confirmed she did not change her gown when going from room to room, gathering the completed breakfast trays. She stated this was not her normal practice. She said that she was to wear a face mask, face shield, gloves, and to change her gown before entering a resident room. The CNA stated she washed her hands and it should have been for at least 30 seconds. The agency staff member stated it was her first day on the Fast Track unit and was unaware the long hall was a quarantined area. During an interview on 10/28/20 at 10:15 AM, the DON stated all new admissions were placed on the Fast Track unit. The DON stated rooms (301-310) on the short hall of Fast Track Unit were not under quarantine. The DON stated the resident rooms (311-330) on the long hall of the Fast Track Unit were considered presumptive positive with COVID-19 and were to remain in their rooms, under quarantine for 14-days. The DON further stated facility staff were to change gowns each time they entered a resident room. Observation on the long hall of the Fast Track Unit, on 10/28/20 at 11:40 AM, revealed a sign posted at the end of the hallway, away from the nursing station, which stated, Fast Track room [ROOM NUMBER]-330 under quarantine must wear full PPE with a KN95 mask before entering the unit. The Medical Director was interviewed on 10/28/20 at 12:45 PM and stated there was minimal risk for exposure to COVID between the new admission residents and the residents who had been on the unit past the 14-day quarantine and were still on the unit. During an interview with the Administrator, DON, Administrator in Training (AIT) on 10/28/20 at 12:59 AM, they stated they the facility did not have policies and procedures on admissions/readmissions on how to handle PUI residents. They stated they follow Texas statutes, the State Agency guidelines, and the CDC recommendations on cohorting residents who are new admissions/readmissions. The Administrator apologized and said he had concerns with the residents still on the on the PUI unit based on the questions being asked with staff. The Administrator stated he was transferring the residents off the quarantined unit to a non-quarantined unit, but on the same floor. During an interview on 10/28/20 at 1:26 PM, the Director of Rehabilitation confirmed the residents on the long hall of the Fast Track Unit were quarantined for 14-days and therapy was provided in their rooms. The Director of Rehabilitation confirmed R10, R4, R5, and R6 were still on the long hall (quarantined area) of the Fast Track Unit; however, the residents had recently received therapy in the therapy gym. Observation on 10/28/20 at 3:10 PM, residents R10, R4, R6 were moved off the long hall to the short hall of the Fast Track Unit. During an interview with LVN7 on 10/28/20 at 3:11 PM, she stated residents who remained on the Fast Track Unit received rehabilitation (therapy). The staff member confirmed the residents who were on the short hall (non-quarantined area) could go to the therapy gym. The staff member stated those residents located on the long hall (quarantined area), were to remain in their rooms for therapy services. 3. Per review of the EMR, Admission Record, located under the Admissions tab, indicated R7 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Observation on 10/28/20 at 3:25 PM, Certified Nursing Assistant (CNA) 9 took R7 (from short hall) into the shower room, located by the nursing station. CNA 9 was observed with a face mask on and no face shield or gown. At 3:46 PM, CNA 9 was observed to take R7 out from the shower room and took the resident back to her room located on the Short Hall. The staff member did not have a face shield on. During an interview on 10/28/20 at 3:45 PM, NM8 confirmed the residents who had passed their 14-day quarantine were moved today onto the short hall (non-quarantined area). An interview was conducted with the DON on 10/28/20 at 4:09 PM; she confirmed the long hall of the Fast Track Unit was for the quarantined residents and short hall of the Fast Track Unit was the non-quarantined hall. The DON stated there was a plan to move R10, R4, and R6 and it never got done. Observation on 10/28/20 at 6:15 PM, CNA10 walked down the long hall of the Fast Track Unit away from the nursing station. The staff member entered room [ROOM NUMBER]. CNA10 failed to don a gown, nor did she have a face shield on. An interview was conducted after this observation. The staff member stated she was to wear a gown and a face shield and had been in the resident's room with those PPEs donned. The staff member pointed to her gown hanging on the door facing the inside of the resident's room. CNA10 stated her face shield was in the storage area behind the nursing station. The staff member stated the resident called to her after she had just left the room and the face shield was impossible to retrieve. The staff member stated she was in the room for only a few minutes. During an interview on 10/28/20 at 6:20 PM, LVN12 stated any staff who entered the long hall (quarantined area) of the Fast Track Unit and entered a resident's room, were to don a gown, face mask, face shield, and gloves. LVN12 stated the residents on the short hall of the Fast Track Unit (non-quarantined area), staff were to wear a face mask only. During an interview with the Medical Director, on 10/29/20 at 9:55 AM and she stated her source from her comment made from her interview on 10/28/20, were from multiple medical articles that she reads daily. The Medical Director stated she had not found evidence on transmission of new admissions/readmissions to other residents who have been in the facility for a while. She stated the facility's intentions were good and they had controlled an outbreak of COVID-19 since September 2020. During an interview with the Director of Rehabilitation on 10/29/20 at 10:21 AM, confirmed R10, R4, and R6 had completed the 14-days of quarantine and were taken to the therapy gym to complete therapy while the residents were still residing on the long hall. She stated the residents who were on 14-day quarantine had therapy in their rooms. During an interview on 10/29/20 at 10:32 AM, with DON, stated she did not integrate the new admissions/readmissions since information was changing all the time. The DON stated it was difficult to have policies and procedures since information changed day by day. The DON continued and stated the facility followed the guidelines that were in place until the facility could control the COVID-19 virus. During an interview on 10/30/20 at 12:55 PM on 10/30/20, with the Administrator, the AIT and the Clinical Director revealed there had been contrasting direction from the CDC, CMS, State Agency, and the local health department.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 3 residents reviewed for neglect. CNA D neglected to stay with Resident #1 when she knew the resident wanted her to stay during toileting and needed help with toileting and ambulation. After CNA D left Resident #1 alone in the bathroom, Resident #1 got up from the toilet, ambulated by herself and fell , resulting in fractures in her back. These failures could affect the 18 residents who required staff supervision on the secured memory care unit by placing them at risk to experience serious adverse consequences and a decreased quality of life. Findings included: Resident #1's MDS assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. She was usually understood, had impaired vision, long and short term memory problems, severely impaired decision making skills and no [MEDICAL CONDITION] or behavioral issues. She did not have any rejection of care issues. She required extensive physical assistance of one staff for bed mobility, transfers, toilet use, dressing and personal hygiene. She was not steady but able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive device, turning around, moving off the toilet and surface to surface transfers. She normally used a walker for mobility. She required supervision when walking between locations within her room by one staff. She was frequently incontinent of bowel and bladder and a toileting program had not been initiated since her admission. She had a fall since the prior to the MDS assessment that resulted in no injury. Resident #1's care plan dated 02/07/17 revealed Resident #1 fell on [DATE], 04/07/16, 06/24/16, 12/20/16 and 04/07/17. All falls prior to 04/07/17 resulted in no injuries and were unwitnessed. The fall on 04/07/17 was also unwitnessed and resulted in a [MEDICAL CONDITION] and L5 spine. Interventions in place prior to 04/07/17's fall were to check range of motion, collect UA, neurochecks as ordered, non-skid socks and to provide activities that promoted exercise and strength building when possible. After the fall on 04/07/17, new interventions documented were, Bed alarm which resident is noncompliant and turns off, sent to ER, educate staff and PMR consult. Resident #1's care plan identified her as at risk for ADL self-care deficit and required 1-2 staff participation to use the toilet, transfers, bed mobility and dressing. The care plan identified Resident #1 as a fall risk related to gait and balance problems since 06/29/15. Resident #1's incident report dated 04/07/17 reflected the resident was found on the floor at 1:30 PM while attempting to transfer back to bed without CNA assistance. Her mobility was assessed as ambulatory without assistance. Her pre-dispositioned physiological factors were confusion, gait imbalance, impaired memory, recent illness and recent change in medications. Resident #1's nursing progress note dated 04/07/17 reflected the resident attempted to transfer back to bed without CNA assistance. Her gait was very unsteady. Resident #1was noted on floor in supine position with roller walker by AC unit. Resident complained of pain to back area 7/10 on pain scale. No visible bruising to area or rest of skin integrity. Discoloration remained to left rib/side area from unknown injury two days prior. Initiated x-ray to back T-spine and L-spine and bilateral hip. Resident re-educated to use call light for assistance. Interview with the ADM and LVN A on 4/13/17 at 3:38 PM revealed LVN A was in the process of updating Resident #1's care plan after the fall. LVN A said the MDS assessment may have reflected Resident #1 needed extensive physical assistance with toileting by one person, but it probably meant that when she had an incontinent episode, only one staff would be needed to change her. She said prior to the fall, Resident #1 did not need any supervision in the bathroom prior to the fall on 04/07/17. She said the resident would at times make the staff leave her room, but she did not know if the resident had ever told staff to leave her alone while in the bathroom. LVN A looked at the care plan and verified no other updates were documented after the fall with the exception of ER visit and educate the staff. She said resident could follow simple commands so she would be able to participate in rehab or restorative therapy. Interview with LVN A on 04/13/17 at 1:25 PM revealed Resident #1 used to go to the bathroom by herself but since her injuries and fall, staff was assisting her. She said staff tried to educate Resident #1 on using the call light, but she was forgetful, so staff checked on her frequently. She had a bed alarm in place and she ambulated with a walker. Prior to the fall, she would take herself to and from the bathroom. Now, staff had to make sure someone was there to assist her. Interview with LVN B on 04/13/17 at 1:32 PM revealed Resident #1 could ambulate but was unsteady so she needed supervision when using her rolling walker. She could use the bathroom but she needed assistance to help with her gait safety. She could get off the toilet but needed staff to help her. LVN B said staff were not supposed to leave her because of safety precautions. Resident #1 would not remember to use the bathroom call light when she was finished using the bathroom. LVN B said, I don't think she would remember to wait for staff; the staff really have to stay close by. When Resident #1 fell on [DATE], LVN B said she was on her lunch break and CNA D notified her Resident #1 was on the floor. LVN B thought CNA D had taken Resident #1 to the bathroom and asked her to pull the light when she was done, but Resident #1 attempted to go back to her bed without assistance and fell in the bedroom. LVN B stated, (CNA D) should have stayed with her. CNA D told LVN B she gave the resident the call light to put on for assistance when she was done. Interview with CNA D on 04/13/17 at 1:43 PM revealed Resident #1 was a one-person transfer and she was not compliant with using the call light. CNA D said, You can give it to her, put it in her hand, clip it to her and she still will not use it. She said presently, Resident #1 needed assistance with toileting. CNA D said on 04/07/17, Resident #1 was at the dining room table in a wheelchair during lunch and said she needed to go to bathroom. Once in the bathroom, she told CNA D, Stay with me! Stay with me! Stay with me! CNA D put the call light in Resident #1's hand and told her to call her. Resident #1 responded, okay. As CNA D picked up meal trays in the dining room, she heard Resident #1 scream. CNA D went in and saw that Resident #1 was on the floor in her bedroom with her clothes pulled up. She asked Resident #1, What happened? I asked you to push your call light. Resident #1 told her she forgot and said, Get me up, get me up! CNA D told her she had to get the nurse first. CNA D said she was not Resident #1's aide that day but had helped because her aide for the day was busy. CNA D said Resident #1 was not interviewable, and her answer for everything was, I don't know. CNA D said Resident #1 had always been able to use the toilet independently, but since she got hurt, the staff had been taking her. She said staff had to stay with her now, and she would stand outside with the door cracked and her back to it until Resident #1 would tell her she was done. She said Resident #1 would not use the call light and she could not recall her using it in the past week. CNA D was asked how she learned what each resident's specific care needs were. She responded there was nothing special telling CNAs about each of the resident's individual needs. When a new CNA started, they had to rely on the training seasoned CNAs gave them about the residents to know what to do. CNA D said she had made her own paper for herself to use on each of the residents to help her. Observation and interview of Resident #1 on 04/13/17 at 2:35 PM revealed she resided in a secured memory care unit in the facility. She had a low bed and a functioning bed alarm in place. She did not remember the extent of her injuries or the fall she had on 04/07/17. Although she was conversational, she was alert to person only. Resident #1 said she thought she was able to walk and use the bathroom without any help. She said she did not know what the call light was or how to use it. The call light was pointed out to her; it was next to her head on the pillow. She did not know what it was. Resident #1's bathroom was checked for emergency call light functioning. The call light did not work when it was pulled. No call light was observed to come on in the bathroom or outside the room. Five minutes passed and the emergency call light remained unanswered. Interview with LVN A on 04/13/17 at 2:42 PM at the nurses' station revealed staff would know if a resident's emergency call light was on in the bathroom because the alarm would sound at the nurses' station. She was asked to check the panel and said no ones' call light was alarming. She went and checked Resident #1's room and verified the bathroom call light was not functioning. She said she would contact maintenance to have it fixed. She did not know how long the call light had not been working. Interview with ADM on 04/13/17 at 3:45PM revealed he had contacted the facility social worker to assist in providing any evidence Resident #1 was independent in using the bathroom prior to the fall. The social worker told him to refer to the care plan meeting notes. He brought in a care plan meeting note dated 02/16/17 that reflected Resident #1 had significant memory loss and was apt to tell staff to leave her alone and stayed in bed. He said he got information from the DON, who was currently out sick, that Resident #1 was able to use the call light so he was getting conflicting stories now from the staff. He said he would check to see if a therapy referral was made after it was updated as an intervention on the care plan. Interview with CNA E on 04/13/17 at 4:03 PM revealed Resident #1 was total care since the fall and staff did everything for her, like assistance with the bedside commode or going to the bathroom. She was sometimes incontinent of bladder. Staff also helped her with showers and bathing. Presently, CNA E said she had to put Resident #1 in the wheelchair and push her to the toilet, then transfer and let her sit down while she waited for her. CNA E said Resident #1 was a one person transfer. She said, With the way she is right now, if you leave her on the toilet, she won't remember to call, so I will stand there and let her finish. CNA E said Resident #1 had not ever asked CNA E to leave her alone. CNA E said, Most of the time, she'll say don't leave me, don't leave me. She said Resident #1 did not know how to use the call light. Resident #1 would not remember most things. Before her most recent fall, CNA E said Resident #1 was able to walk to the bathroom with a walker and use the toilet with one staff. However, even before she had a fall, CNA E said staff still had to watch her during toileting. She said the normal routine prior to the fall was to ask Resident #1 if she wanted to use the restroom, and if she said yes, CNA E would take her and stay next to the crack in the door to give her privacy, but still watch her still for safety. Interview with the ADM on 04/13/17 at 4:08PM revealed he received an email dated 04/13/17 at 3:17 PM from the assistant director of rehab to indicate Resident #1 would be screened by therapy on 04/13/17. Additionally, the ADM provided a transcript of a phone conversation he had just conducted with CNA D. She told the ADM when she took Resident #1 to the bathroom on 04/07/17; she locked the wheelchair and placed her walker in the bathroom. The resident then stood up and transferred without any assistance. CNA D pulled her pants down and the resident sat on the toilet without any assistance. CNA D told her before she got up, to pull the call light. Resident #1 responded okay. CNA D then said she stood outside Resident #1's bathroom door and did not close it all the way and did not leave the room. After approximately five to six minutes, CNA D asked Resident #1 if she was ready, and the resident told her no, and to leave her alone. CNA D then told her not to stand up and she'd be right back. Resident #1 responded okay. A couple of minutes later, CNA D heard the resident screaming and went to her room to find her by her bed with the walker next to the bed with her clothes pulled up. Review of the facility's Abuse Prevention Policy dated 11/28/16 and provided by the ADM on 04/13/17 reflected, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation; ., Prevention- Employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: staff has knowledge of the individual residents' care needs; ., Definition- Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The resident roster dated 04/13/17 provided by the ADM reflected 18 residents who required staff supervision on the secured memory care unit.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent an accident for one (Residents #1) of 3 residents reviewed for falls. CNA D failed to provide supervision or physical assistance to Resident #1 when she went to the bathroom on 04/07/16. Resident #1 attempted to ambulate from the bathroom by herself after toileting and fell in her bedroom, resulting in fractures of the L3 and L5 lumbar spine. These failures had the potential to affect the 18 residents who required staff supervision on the secured memory care unit by placing them at risk for injuries including fractures, skin tears, pain and decreased quality of life. Findings included: Resident #1's MDS assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. She was usually understood, had impaired vision, long and short term memory problems, severely impaired decision making skills and no psychosis or behavioral issues. She did not have any rejection of care issues. She required extensive physical assistance of one staff for bed mobility, transfers, toilet use, dressing and personal hygiene. She was not steady but able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive device, turning around, moving off the toilet and surface to surface transfers. She normally used a walker for mobility. She required supervision when walking between locations within her room by one staff. She was frequently incontinent of bowel and bladder and a toileting program had not been initiated since her admission. She had a fall since the prior to the MDS assessment that resulted in no injury. Resident #1's care plan dated 02/07/17 she was at risk for falls related to gait and balance problems. Interventions were to check range of motion, collect UA, neurochecks as ordered, non-skid socks and to provide activities that promoted exercise and strength building when possible. Resident #1's incident report dated 04/07/17 reflected the resident was found on the floor at 1:30 PM while attempting to transfer back to bed without CNA assistance. Her mobility was assessed as ambulatory without assistance. Her pre-dispositioned physiological factors were confusion, gait imbalance, impaired memory, recent illness and recent change in medications. Resident #1's nursing progress note dated 04/07/17 reflected the resident attempted to transfer back to bed without CNA assistance. Her gait was very unsteady. Resident #1was noted on floor in supine position with roller walker by AC unit. Resident complained of pain to back area 7/10 on pain scale. No visible bruising to area or rest of skin integrity. Discoloration remained to left rib/side area from unknown injury two days prior. Initiated x-ray to back T-spine and L-spine and bilateral hip. Resident re-educated to use call light for assistance. Interview with the ADM and LVN A on 4/13/17 at 3:38 PM revealed LVN A was in the process of updating Resident #1's care plan after the fall. LVN A said the MDS assessment may have reflected Resident #1 needed extensive physical assistance with toileting by one person, but it probably meant that when she had an incontinent episode, only one staff would be needed to change her. She said prior to the fall, Resident #1 did not need any supervision in the bathroom prior to the fall on 04/07/17. She said the resident would at times make the staff leave her room, but she did not know if the resident had ever told staff to leave her alone while in the bathroom. LVN A looked at the care plan and verified no other updates were documented after the fall with the exception of ER visit and educate the staff. She said resident could follow simple commands so she would be able to participate in rehab or restorative therapy. Interview with LVN A on 04/13/17 at 1:25 PM revealed Resident #1 used to go to the bathroom by herself but since her injuries and fall, staff was assisting her. She said staff tried to educate Resident #1 on using the call light, but she was forgetful, so staff checked on her frequently. She had a bed alarm in place and she ambulated with a walker. Prior to the fall, she would take herself to and from the bathroom. Now, staff had to make sure someone was there to assist her. Interview with LVN B on 04/13/17 at 1:32 PM revealed Resident #1 could ambulate but was unsteady so she needed supervision when using her rolling walker. She could use the bathroom but she needed assistance to help with her gait safety. She could get off the toilet but needed staff to help her. LVN B said staff were not supposed to leave her because of safety precautions. Resident #1 would not remember to use the bathroom call light when she was finished using the bathroom. LVN B said, I don't think she would remember to wait for staff; the staff really have to stay close by. When Resident #1 fell on [DATE], LVN B said she was on her lunch break and CNA D notified her Resident #1 was on the floor. LVN B thought CNA D had taken Resident #1 to the bathroom and asked her to pull the light when she was done, but Resident #1 attempted to go back to her bed without assistance and fell in the bedroom. LVN B stated, (CNA D) should have stayed with her. CNA D told LVN B she gave the resident the call light to put on for assistance when she was done. Interview with CNA D on 04/13/17 at 1:43 PM revealed Resident #1 was a one-person transfer and she was not compliant with using the call light. CNA D said, You can give it to her, put it in her hand, clip it to her and she still will not use it. She said presently, Resident #1 needed assistance with toileting. CNA D said on 04/07/17, Resident #1 was at the dining room table in a wheelchair during lunch and said she needed to go to bathroom. Once in the bathroom, she told CNA D, Stay with me! Stay with me! Stay with me! CNA D put the call light in Resident #1's hand and told her to call her. Resident #1 responded, okay. As CNA D picked up meal trays in the dining room, she heard Resident #1 scream. CNA D went in and saw that Resident #1 was on the floor in her bedroom with her clothes pulled up. She asked Resident #1, What happened? I asked you to push your call light. Resident #1 told her she forgot and said, Get me up, get me up! CNA D told her she had to get the nurse first. CNA D said she was not Resident #1's aide that day but had helped because her aide for the day was busy. CNA D said Resident #1 was not interviewable, and her answer for everything was, I don't know. CNA D said Resident #1 had always been able to use the toilet independently, but since she got hurt, the staff had been taking her. She said staff had to stay with her now, and she would stand outside with the door cracked and her back to it until Resident #1 would tell her she was done. She said Resident #1 would not use the call light and she could not recall her using it in the past week. CNA D was asked how she learned what each resident's specific care needs were. She responded there was nothing special telling CNAs about each of the resident's individual needs. When a new CNA started, they had to rely on the training seasoned CNAs gave them about the residents to know what to do. CNA D said she had made her own paper for herself to use on each of the residents to help her. Observation and interview of Resident #1 on 04/13/17 at 2:35 PM revealed she resided in a secured memory care unit in the facility. She had a low bed and a functioning bed alarm in place. She did not remember the extent of her injuries or the fall she had on 04/07/17. Although she was conversational, she was alert to person only. Resident #1 said she thought she was able to walk and use the bathroom without any help. She said she did not know what the call light was or how to use it. The call light was pointed out to her; it was next to her head on the pillow. She did not know what it was. Resident #1's bathroom was checked for emergency call light functioning. The call light did not work when it was pulled. No call light was observed to come on in the bathroom or outside the room. Five minutes passed and the emergency call light remained unanswered. Interview with LVN A on 04/13/17 at 2:42 PM at the nurses' station revealed staff would know if a resident's emergency call light was on in the bathroom because the alarm would sound at the nurses' station. She was asked to check the panel and said no ones' call light was alarming. She went and checked Resident #1's room and verified the bathroom call light was not functioning. She said she would contact maintenance to have it fixed. She did not know how long the call light had not been working. Interview with ADM on 04/13/17 at 3:45PM revealed he had contacted the facility social worker to assist in providing any evidence Resident #1 was independent in using the bathroom prior to the fall. The social worker told him to refer to the care plan meeting notes. He brought in a care plan meeting note dated 02/16/17 that reflected Resident #1 had significant memory loss and was apt to tell staff to leave her alone and stayed in bed. He said he got information from the DON, who was currently out sick, that Resident #1 was able to use the call light so he was getting conflicting stories now from the staff. He said he would check to see if a therapy referral was made after it was updated as an intervention on the care plan. Interview with CNA E on 04/13/17 at 4:03 PM revealed Resident #1 was total care since the fall and staff did everything for her, like assistance with the bedside commode or going to the bathroom. She was sometimes incontinent of bladder. Staff also helped her with showers and bathing. Presently, CNA E said she had to put Resident #1 in the wheelchair and push her to the toilet, then transfer and let her sit down while she waited for her. CNA E said Resident #1 was a one person transfer. She said, With the way she is right now, if you leave her on the toilet, she won't remember to call, so I will stand there and let her finish. CNA E said Resident #1 had not ever asked CNA E to leave her alone. CNA E said, Most of the time, she'll say don't leave me, don't leave me. She said Resident #1 did not know how to use the call light. Resident #1 would not remember most things. Before her most recent fall, CNA E said Resident #1 was able to walk to the bathroom with a walker and use the toilet with one staff. However, even before she had a fall, CNA E said staff still had to watch her during toileting. She said the normal routine prior to the fall was to ask Resident #1 if she wanted to use the restroom, and if she said yes, CNA E would take her and stay next to the crack in the door to give her privacy, but still watch her still for safety. Interview with the ADM on 04/13/17 at 4:08PM revealed he received an email dated 04/13/17 at 3:17 PM from the assistant director of rehab to indicate Resident #1 would be screened by therapy on 04/13/17. Additionally, the ADM provided a transcript of a phone conversation he had just conducted with CNA D. She told the ADM when she took Resident #1 to the bathroom on 04/07/17; she locked the wheelchair and placed her walker in the bathroom. The resident then stood up and transferred without any assistance. CNA D pulled her pants down and the resident sat on the toilet without any assistance. CNA D told her before she got up, to pull the call light. Resident #1 responded okay. CNA D then said she stood outside Resident #1's bathroom door and did not close it all the way and did not leave the room. After approximately five to six minutes, CNA D asked Resident #1 if she was ready, and the resident told her no, and to leave her alone. CNA D then told her not to stand up and she'd be right back. Resident #1 responded okay. A couple of minutes later, CNA D heard the resident screaming and went to her room to find her by her bed with the walker next to the bed with her clothes pulled up. Review of the facility's Falls Prevention Policy/Procedure dated May 2007 and provided by the ADM on 04/13/17 reflected, Care plans will be revised and/or updated to reflect changes in intervention. The resident roster dated 04/13/17 provided by the ADM reflected 18 residents who required staff supervision on the secured memory care unit.

Based on observation, interview and record review, the facility failed to develop and implement their written policies and procedures to prohibit neglect for one (Resident #1) of 3 residents reviewed for neglect. CNA D neglected to stay with Resident #1 when she knew the resident wanted her to stay during toileting and needed help with toileting and ambulation. After CNA D left Resident #1 alone in the bathroom, Resident #1 got up from the toilet, ambulated by herself and fell , resulting in fractures in her back. This failure could place the 18 residents who required staff supervision on the secured memory care unit by placing them at risk of injury. Findings included: Review of the facility's Abuse Prevention Policy dated 11/28/16 and provided by the ADM on 04/13/17 reflected, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation; ., Prevention- Employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: staff has knowledge of the individual residents' care needs; ., Definition- Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #1's MDS assessment dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. She was usually understood, had impaired vision, long and short term memory problems, severely impaired decision making skills and no [MEDICAL CONDITION] or behavioral issues. She did not have any rejection of care issues. She required extensive physical assistance of one staff for bed mobility, transfers, toilet use, dressing and personal hygiene. She was not steady but able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive device, turning around, moving off the toilet and surface to surface transfers. She normally used a walker for mobility. She required supervision when walking between locations within her room by one staff. She was frequently incontinent of bowel and bladder and a toileting program had not been initiated since her admission. She had a fall since the prior to the MDS assessment that resulted in no injury. Resident #1's care plan dated 02/07/17 revealed Resident #1 fell on [DATE], 04/07/16, 06/24/16, 12/20/16 and 04/07/17. All falls prior to 04/07/17 resulted in no injuries and were unwitnessed. The fall on 04/07/17 was also unwitnessed and resulted in a [MEDICAL CONDITION] and L5 spine. Interventions in place prior to 04/07/17's fall were to check range of motion, collect UA, neurochecks as ordered, non-skid socks and to provide activities that promoted exercise and strength building when possible. After the fall on 04/07/17, new interventions documented were, Bed alarm which resident is noncompliant and turns off, sent to ER, educate staff and PMR consult. Resident #1's care plan identified her as at risk for ADL self-care deficit and required 1-2 staff participation to use the toilet, transfers, bed mobility and dressing. The care plan identified Resident #1 as a fall risk related to gait and balance problems since 06/29/15. Resident #1's incident report dated 04/07/17 reflected the resident was found on the floor at 1:30 PM while attempting to transfer back to bed without CNA assistance. Her mobility was assessed as ambulatory without assistance. Her pre-dispositioned physiological factors were confusion, gait imbalance, impaired memory, recent illness and recent change in medications. Resident #1's nursing progress note dated 04/07/17 reflected the resident attempted to transfer back to bed without CNA assistance. Her gait was very unsteady. Resident #1was noted on floor in supine position with roller walker by AC unit. Resident complained of pain to back area 7/10 on pain scale. No visible bruising to area or rest of skin integrity. Discoloration remained to left rib/side area from unknown injury two days prior. Initiated x-ray to back T-spine and L-spine and bilateral hip. Resident re-educated to use call light for assistance. Interview with the ADM and LVN A on 4/13/17 at 3:38 PM revealed LVN A was in the process of updating Resident #1's care plan after the fall. LVN A said the MDS assessment may have reflected Resident #1 needed extensive physical assistance with toileting by one person, but it probably meant that when she had an incontinent episode, only one staff would be needed to change her. She said prior to the fall, Resident #1 did not need any supervision in the bathroom prior to the fall on 04/07/17. She said the resident would at times make the staff leave her room, but she did not know if the resident had ever told staff to leave her alone while in the bathroom. LVN A looked at the care plan and verified no other updates were documented after the fall with the exception of ER visit and educate the staff. She said resident could follow simple commands so she would be able to participate in rehab or restorative therapy. Interview with LVN A on 04/13/17 at 1:25 PM revealed Resident #1 used to go to the bathroom by herself but since her injuries and fall, staff was assisting her. She said staff tried to educate Resident #1 on using the call light, but she was forgetful, so staff checked on her frequently. She had a bed alarm in place and she ambulated with a walker. Prior to the fall, she would take herself to and from the bathroom. Now, staff had to make sure someone was there to assist her. Interview with LVN B on 04/13/17 at 1:32 PM revealed Resident #1 could ambulate but was unsteady so she needed supervision when using her rolling walker. She could use the bathroom but she needed assistance to help with her gait safety. She could get off the toilet but needed staff to help her. LVN B said staff were not supposed to leave her because of safety precautions. Resident #1 would not remember to use the bathroom call light when she was finished using the bathroom. LVN B said, I don't think she would remember to wait for staff; the staff really have to stay close by. When Resident #1 fell on [DATE], LVN B said she was on her lunch break and CNA D notified her Resident #1 was on the floor. LVN B thought CNA D had taken Resident #1 to the bathroom and asked her to pull the light when she was done, but Resident #1 attempted to go back to her bed without assistance and fell in the bedroom. LVN B stated, (CNA D) should have stayed with her. CNA D told LVN B she gave the resident the call light to put on for assistance when she was done. Interview with CNA D on 04/13/17 at 1:43 PM revealed Resident #1 was a one-person transfer and she was not compliant with using the call light. CNA D said, You can give it to her, put it in her hand, clip it to her and she still will not use it. She said presently, Resident #1 needed assistance with toileting. CNA D said on 04/07/17, Resident #1 was at the dining room table in a wheelchair during lunch and said she needed to go to bathroom. Once in the bathroom, she told CNA D, Stay with me! Stay with me! Stay with me! CNA D put the call light in Resident #1's hand and told her to call her. Resident #1 responded, okay. As CNA D picked up meal trays in the dining room, she heard Resident #1 scream. CNA D went in and saw that Resident #1 was on the floor in her bedroom with her clothes pulled up. She asked Resident #1, What happened? I asked you to push your call light. Resident #1 told her she forgot and said, Get me up, get me up! CNA D told her she had to get the nurse first. CNA D said she was not Resident #1's aide that day but had helped because her aide for the day was busy. CNA D said Resident #1 was not interviewable, and her answer for everything was, I don't know. CNA D said Resident #1 had always been able to use the toilet independently, but since she got hurt, the staff had been taking her. She said staff had to stay with her now, and she would stand outside with the door cracked and her back to it until Resident #1 would tell her she was done. She said Resident #1 would not use the call light and she could not recall her using it in the past week. CNA D was asked how she learned what each resident's specific care needs were. She responded there was nothing special telling CNAs about each of the resident's individual needs. When a new CNA started, they had to rely on the training seasoned CNAs gave them about the residents to know what to do. CNA D said she had made her own paper for herself to use on each of the residents to help her. Observation and interview of Resident #1 on 04/13/17 at 2:35 PM revealed she resided in a secured memory care unit in the facility. She had a low bed and a functioning bed alarm in place. She did not remember the extent of her injuries or the fall she had on 04/07/17. Although she was conversational, she was alert to person only. Resident #1 said she thought she was able to walk and use the bathroom without any help. She said she did not know what the call light was or how to use it. The call light was pointed out to her; it was next to her head on the pillow. She did not know what it was. Resident #1's bathroom was checked for emergency call light functioning. The call light did not work when it was pulled. No call light was observed to come on in the bathroom or outside the room. Five minutes passed and the emergency call light remained unanswered. Interview with LVN A on 04/13/17 at 2:42 PM at the nurses' station revealed staff would know if a resident's emergency call light was on in the bathroom because the alarm would sound at the nurses' station. She was asked to check the panel and said no ones' call light was alarming. She went and checked Resident #1's room and verified the bathroom call light was not functioning. She said she would contact maintenance to have it fixed. She did not know how long the call light had not been working. Interview with ADM on 04/13/17 at 3:45PM revealed he had contacted the facility social worker to assist in providing any evidence Resident #1 was independent in using the bathroom prior to the fall. The social worker told him to refer to the care plan meeting notes. He brought in a care plan meeting note dated 02/16/17 that reflected Resident #1 had significant memory loss and was apt to tell staff to leave her alone and stayed in bed. He said he got information from the DON, who was currently out sick, that Resident #1 was able to use the call light so he was getting conflicting stories now from the staff. He said he would check to see if a therapy referral was made after it was updated as an intervention on the care plan. Interview with CNA E on 04/13/17 at 4:03 PM revealed Resident #1 was total care since the fall and staff did everything for her, like assistance with the bedside commode or going to the bathroom. She was sometimes incontinent of bladder. Staff also helped her with showers and bathing. Presently, CNA E said she had to put Resident #1 in the wheelchair and push her to the toilet, then transfer and let her sit down while she waited for her. CNA E said Resident #1 was a one person transfer. She said, With the way she is right now, if you leave her on the toilet, she won't remember to call, so I will stand there and let her finish. CNA E said Resident #1 had not ever asked CNA E to leave her alone. CNA E said, Most of the time, she'll say don't leave me, don't leave me. She said Resident #1 did not know how to use the call light. Resident #1 would not remember most things. Before her most recent fall, CNA E said Resident #1 was able to walk to the bathroom with a walker and use the toilet with one staff. However, even before she had a fall, CNA E said staff still had to watch her during toileting. She said the normal routine prior to the fall was to ask Resident #1 if she wanted to use the restroom, and if she said yes, CNA E would take her and stay next to the crack in the door to give her privacy, but still watch her still for safety. Interview with the ADM on 04/13/17 at 4:08PM revealed he received an email dated 04/13/17 at 3:17 PM from the assistant director of rehab to indicate Resident #1 would be screened by therapy on 04/13/17. Additionally, the ADM provided a transcript of a phone conversation he had just conducted with CNA D. She told the ADM when she took Resident #1 to the bathroom on 04/07/17; she locked the wheelchair and placed her walker in the bathroom. The resident then stood up and transferred without any assistance. CNA D pulled her pants down and the resident sat on the toilet without any assistance. CNA D told her before she got up, to pull the call light. Resident #1 responded okay. CNA D then said she stood outside Resident #1's bathroom door and did not close it all the way and did not leave the room. After approximately five to six minutes, CNA D asked Resident #1 if she was ready, and the resident told her no, and to leave her alone. CNA D then told her not to stand up and she'd be right back. Resident #1 responded okay. A couple of minutes later, CNA D heard the resident screaming and went to her room to find her by her bed with the walker next to the bed with her clothes pulled up. The resident roster dated 04/13/17 provided by the ADM reflected 18 residents who required staff supervision on the secured memory care unit.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibited neglect for one (Resident #16) of 12 residents reviewed for neglect. 1. CNA G and CNA H failed to listen to or recognize Resident #16's complaints of shortness of breath and failed to notify the charge nurse promptly of the resident's complaint. CNA H left the room and did not notify the charge nurse. These failures resulted in Resident #16 developing a worsening of her respiratory status and a dropping of her oxygen saturation level to unsafe levels of 56%. Resident #16 was diagnosed at the hospital with Acute on Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and hypercapnia. An Immediate Jeopardy (IJ) was identified on 04/07/16. While the IJ was removed on 04/08/16, the facility remained out of compliance at a scope of, pattern and a severity level of actual harm with potential for more than minimal harm, that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect 17 residents by placing them at risk for serious injury, harm and/ or death related to staff not listening to resident concerns regarding health and reporting any changes in condition which endangers the resident's health to the appropriate healthcare professional. Review of local Hospital History and Physical dated 02/28/16 reflected Resident #16 complained of shortness of breath (SOB) since earlier in the morning. The final assessment was HCAP (healthcare-associated pneumonia). And the plan was to monitor the resident, and check cultures and keep the renal physicians informed. MDS assessment dated [DATE] reflected Resident #16 was a [AGE] year old female originally admitted to the facility on [DATE] and recently re-admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #16 was cognitively impaired however she was able to understand others and make herself understood. Resident #16 was dependent on the staff for all care and required extensive assistance of at least two staff members for bathing, dressing, grooming, and incontinent care. Transferring only occurs twice a week with extensive assistance of two or more staff. Resident #16 has limited range of motion of all extremities. Review of Medication Review Report (Physicians orders) dated 04/07/16 reflected the following: Ordered 02/06/16, Oxygen saturation is to be checked every shift. Ordered 02/06/16, O2 (oxygen) at 2 LPM continuous per nasal cannula every shift. Ordered 03/03/16, Duo Neb Solution 0.5-2.5 (3) mg/ml ([MEDICATION NAME]- [MEDICATION NAME]), 1 inhalation orally every 6 hours for shortness of breath while awake. Review of Oxygen Saturation Summary dated 04/07/16 with saturation levels taken intermittently from 07/17/13 through 02/06/16 and the levels noted to be between 95% and 99% which is within the normal acceptable range. The oxygen saturation levels starting on 02/07/16 through 04/03/16 ran between 94 % and 100% and this is also in the acceptable range. On 04/25/17 the following article to define low blood oxygen levels. www.mayoclinic.org/Symptoms/hypovolemia Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath. Hypoxemia is determined by measuring the oxygen level in a blood sample taken from an artery (arterial blood gas). It can also be estimated by measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger. Normal arterial oxygen is approximately 75 to 100 millimeters of mercury (mm Hg). Values under 60 mm Hg usually indicate the need for supplemental oxygen. Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. The Care Plan dated 03/17/16 to address Resident # 16's usage of oxygen therapy, stating the resident would have no signs or symptoms of poor oxygen absorption.jInterventions included Monitor for signs and symptoms of respiratory distress and report to MD PRN, Respirations, Pulseoximetry,, increased heart rate ([MEDICAL CONDITION] Restlessness, Diaphoresis, Headaches, lethragy, Confusion, Atelectasis, Hemoptysis, Cough, Plueritic pain, Accessory muscle usage, skin color. Review of Oxygen Administration training by RRT undated. When to use oxygen therapy: Evidence of Hypoxemia, PaO2 of< 60mm Hg., SPO2 of less than 90%, Severe trauma, [MEDICAL CONDITION] dyspnea, Cyanosis, diaphoresis, Chest Pain, Known or suspected MI ([MEDICAL CONDITION] Infarction) Resident #16 was observed on 04/05/16 at 10:12 AM in her room. She was identified by RN F, (her nurse) who revealed Resident # 16 was alert and oriented to person and place, however would be forgetful. Resident #16 required extensive assistance of two or more staff, incontinent of bowel and bladder and required two or more staff to lift resident with an assistive device. Resident #16 was also on continuous oxygen via nasal cannula at 3 LPM (liters per minute). Resident # 16 also used [MEDICAL CONDITION] at night to assist with her breathing. Review of Resident #16's Medication Review Report dated 04/07/16 reflected additional Diagnoses: [REDACTED]. On 04/06/16 at 8:50 AM during an observation of Resident #16 during breakfast, she was pleasant, calm, and drinking coffee. Resident #16 had oxygen on. The head of the bed (HOB) was elevated at approximately 45 degrees and the resident was tilted to the right. Observation of Resident #16 on 04/06/16 at 10:00 AM revealed she was lying in bed with the head of the bed elevated to 45 degrees, her oxygen was on at 3 LPM, and she was slightly tilted to the right. On 04/06/16 at 10:07 AM CNA G entered Resident #16's room and placed a brief on the dresser. CNA G stated she was going to provide care and needed help, so she left the room. On 04/06/16 at 10:16 AM CNA G returned to Resident #16's room. Observation of CNA H on 04/06/16 at 10:17 AM entered the resident's room, went into the bathroom, washed her hands, came into the room, donned a pair of gloves, grabbed the curtain and pulled it around the bed, the HOB (Head of the bed) lowered residents bed to approximately 15 degrees. CNA G and CNA H removed the blanket covering the resident, undid the brief, and proceeded to do incontinent care. On 04/06/16 at 10:25 AM observed CNA G and CNA H assisted Resident #16 to turn to her left side, to cleanse the buttocks area. CNA H began to cleanse the buttocks area, as she was cleaning the area she wiped feces multiple times. Resident #16 told the CNA's to hurry up, hurry up, I can't breathe. CNA H continued to wipe the feces and told CNA G whenever she wiped the resident kept having more BM (bowel movement). The CNA's continued with the incontinence care and did not acknowlege that Resident #16 was short of breathe. CNA H then placed a brief on Resident #16 and they turned Resident # 16 on her back. Resident #16 continued to complain of shortness of breath. CNA H left the room after assisting positioning the resident. At no time was Resident #16's complaint of shortness of breath reported. On 04/06/16 at 10:28 AM after Resident #16 was placed on her back, she complained of shortness of breath, started pulling at her gown trying to remove her clothes, complained of being hot, the resident also raised her legs off the bed and began to shake her legs. Resident #16 continued to exibit shortness of breathe and asked for air. Resident #16 still laboring and using adomonal muscle to aid in breathing told CNA G to turn the fan on. CNA G pulled the fan closer, but stood in front of the fan on the bedside table not allowing Resident #16 to feel the air. While standing there, CNA G told the resident You know me, you trust me? Resident #16 nodded in agreement while being short of breathe. Resident #16 again asked for air from the fan, CNA G pulled the bedside table closer, but the resident still could not feel the fan. Resident #16 looked in the direction of the fan. The resident again asked for the fan and CNA G moved the fan on the over bed table closer to the resident and CNA G asked if that was better and Resident #16 replied yes. Resident #16 continued to have labored respirations and used her abdominal muscles to breathe. Resident #16 then asked CNA G to pray for her. CNA G responded You go ahead and pray. Resident #16 said Sweet Jesus over and over taking shallow breathes. CNA G made no verbal efforts to calm the resident other than stand there and hold her hand. The resident reached for the surveyor's hand and the surveyor held her hand as Resident #16 kept saying Sweet Jesus, Sweet Jesus repeatedly with shallow breathes. CNA G didn't say anything to Resident #16 which might be comforting or reassuring, CNA G held her hand and looked at the resident. On 04/06/16 at 10:30 AM Resident #16 took shallow breathes attempting to breathe and stated with weary voice I feel like I'm going. Resident #16 closed her eyes, her skin color got lighter and her lips became pale in color. Resident #16 was using her accessory muscles to assist with her breathing. The Resident continued to say in a soft voice I can't breathe and continued to say Oh sweet Jesus. On 04/06/16 at 10:32 AM the surveyor intervened and told CNA G she should get the charge nurse. CNA G left the room came back and asked if the surveyor was going to remain in the room, the surveyor responded Yes. On 04/06/16 at 10:34 AM RN F entered the room with a blood pressure cuff, and stethoscope, and pulse oximeter (measures pulse rate and oxygen level in the blood). RN F tried to raise the (HOB) for Resident #16 and explain why but Resident #16 did not want the HOB elevated. RN F then assessed the resident's oxygen level which was fluctuating between 56% and 59 %( percent) with 4 LPM of oxygen flowing via a nasal cannula. RN F left the room to get the crash cart, returned, placed an oxygen mask on the resident and connected the E-tank (portable oxygen) to the oxygen tubing and started the oxygen flow at 15 LPM. RN F did not have a watch on in order to time the Resident #16's respiration rate or to assess the residents pulse rate. The paramedics arrived at Resident 16's room on 04/06/16 at 10:46 AM and assessed the resident her oxygen levels were up to 73% with blood pressure at 150/74 and pulse at 88. Resident #16 breathed calmer and did not use her abdominal accessory muscles to breathe. On 04/06/16 at 3:25 PM interview with RN F revealed the incident with Resident #16 happended because CNAs did not tell her soon enough residents was having problems. Telephone interview with CNA G on 04/07/16 at 2:35 PM, Surveyor asked CNA G to explain what is shortness of breathe and she stated When you can't hardly breathe. When asked what would she do if a resident was short of breathe, CNA G stated Go get the nurse, but she (Resident #16) said she was ok, I was talking to her and she was ok. Telephone interview with CNA H on 04/07/16 at 2:45 PM, revealed she was not able to tell the number of times she cared for Resident # 16, but, she had not seen her exhibit any signs of distress. CNA H stated if she exibited distress they would get the nurse. CNA H stated I felt yesterday (04/06/16) she was not having distress. When asked about the resident complaining of shortness of breath, CNA H revealed No I saw nothing different. Interview with RN F on 04/06/16 at 4:14 PM, RN F stated the CNA's should have listened to the resident and told the her. She stated CNA G told her that Resident #16 did become short of breath and anxious at times, she (CNA G) tried to calm her down. RN F revealed CNA G agreed she should have come and told her (RN F). Interview with LVN M on 04/06/16 at 3:35 PM, revealed, regarding Resident #16 and her behaviors during care and if she exhibits any anxiety. LVN M revealed the Resident #16 would get a little anxious at times and have the staff come to her room. He stated Resident #16 never got anxious when she was turned on her sides. LVN M stated on [MEDICAL TREATMENT] days she generally helped the staff get the residetn ready. Interview with CNA L on 04/06/16 at 3:42 PM, revealed Resident #16 sometimes screams and yells because she wants you to stay with her. CNA L stated I have no problems when the resident is turned on her side to give incontinent care. CNA L stated if they gave care and the oxygen tubing moved a little, they they have to be careful and then tell the nurse. Interview with CNA N on 04/06/16 at 3:46 PM and she revealed if you talk to Resident #16 she will roll over and grab the bed rails. When asked about behaviors especially not being able to breathe, CNA N stated Resident #16 will holler when something hurt, but she had never complained of not being able to not breathe. Interview on 04/06/16 at 3:50 PM with LVN M, he revealed he would expected his staff to report to him if there was a change in condition or if a resident had a problem. He said his staff was good at reporting changes. Interview on 04/06/16 at 3:52 PM with LVN N she revealed she expected the staff to report to her or the charge nurse immediately if there was a change in condition in a resident. She stated the CNA's taking care of Resident #16 did not do the right thing earlier that day. As soon as she complained of being short of breath they should have stopped what they were doing and come and reported it to her or the charge nurse. She stated the CNA's did not give her a reason for not telling the charge nurse. LVN N revealed they told her the resident had gotten that way before and she calmed down. I am not aware of Resident #16 getting short of breath during care, but she knew the resident got anxious during ADL' s and yells. Interview on 04/07/16 at 1:58 PM with CNA Q, she revealed Resident #16 was nice and she had no problems with her. If Resident #16's head got to low she would say she could not breathe, but we would put her head back up and she would calm down. She stated the resident did not have problems breathing on her side. Interview on 04/07/16 at 2:21 PM with CNA R revealed she only takes care of Resident #16 once and a while. She stated during incontinent care the resident would say Oh I can't breathe, and I would go get the nurses. CNA R revealed it didn not happen every time she worked with Resident #16. She stated she would have to raise Resident #16's head up when Resident could not breathe. Interview on 04/07/16 at 2:25 PM with CNA S revealed she cares for Resident #16 once or twice a week and she is a nice person. CNA S also revealed Resident #16 can get mad and has a lot of anxiety. When you turn her to her side she wants to be turned back. Most of her anxiety she calls for her dad. Resident #16 did not get short of breath, if she did they would have to stop and go get the nurse. Review of the facility's neglect policy, revised 10/2013, revealed the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's signicant change of condition policy, revised 05/2007 revealed the following: 1. If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the Nurse Supervisor should be made aware of and he/she will monitor. This was determined to be an Immediate Jeopardy and on 04/06/16 at 4:50 PM the Administrator and the Director of Nursing were advised of the Immediate Jeopardy a plan of correction was requested at that time. On 04/07/15 a 1:45 PM The DON was interview regarding the cause of the Immediate Jeopardy. The DON revealed the CNA's did not immediately notify the nurse that the resident was in respiratory distress. When asked why the CNA's did not report the change in the resident, she revealed: they have known the resident a long time and she does this all the time. Even though the resident has calmed down they should have reported the incident to the nurse. The resident (Resident #16) always ended up in the hospital. The DON was asked what plans she planned to implement to ensure this did not occur again. The DON revealed she planned to have the staff: identify changes in conditions in all of the residents, CNA's immediately notify the charge nurses of a change in condition in a resident, and the charge nurses need to follow up and notify the responsible party and the physician. Record reviews of hospital records dated 04/2016 reflected Resident #16 was in the hospital in January 2016 and was intubated for her [MEDICAL CONDITION]. The Resident was also in the hospital in February 2016 for Pneumonia. An interview on 04/07/2016 at approximately 3:00 PM with the Administrator revealed the IJ was called because the CNA's were not timely in notifying the nurse when the resident was experincing problems. When asked what What type of procedures were there to make sure the needs of the residents were met, he stated development of structure with the Unit Managers to determine the needs of the residents, competency of the staff, and an open door policy to deal with grievances process. How do you monitor staff (DON) to ensure systems they monitor are being DON sufficiently? We have a Quality Assurance to tract and trend data, Weekly meetings to address what nursing is over to ensure the systems are working. Finally the Administrator was asked if he was confident that this failure was going to be followed up on. The Administrator was confident this issue would be followed up on. The facility's plan of removal, accepted on 04/07/16 at 4:02PM reflected IMMEDIATE ACTION TAKEN: - At approximately 11am on 4/6/2016, prior to Immediate Jeopardy being called by the survey team, in-servicing was initiated by ______/LVN/Staff Developer; education was provided to all CNAs working 6am-2pm on ________ unit. This in-servicing was initiated prior to the Immediate Jeopardy being called because the facility's Director of Nursing, _______ (RN), was made aware by the Unit Manager, _______/LVN, that the surveyor,________, had some concerns about how the change of condition was handled by the facility regarding ________. It is the practice of the facility, whenever patient care concerns are brought up by surveyors, to initiate staff in-servicing. o Trainer: ______, LVN, Staff Developer o Audience: 6-2 CNAs on Resident ' s unit o Initiated: 4/6/2016 o Completed: 4/6/2016 o Topics: § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation § Timely nurse notification - At approximately 11am on 4/6/2016, ________ Responsible Party, _______, was notified of _________ change of condition by Princess Gbor, RN, and transferred to the Hospital. - On 4/6/2016, at roughly 6pm, the Resident's attending physician______ was notified by ________/LVN/Unit Manager, of _______ change of condition and transfer to the Hospital. - At approximately 11am on 4/6/2016, one-on-one in-servicing was completed as follows: o Trainer: _____, RN, DON o Employee: Irish Rogers (this in-service was completed prior to Irish ' s suspension) o Initiated: 4/6/2016 o Completed: 4/6/2016 o Topics: § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation § Timely nurse notification - On 4/6/2016, CNAs _____ and ____ were suspended for allegation of neglect which was brought to the attention of the Administrator,_______, and the Director of Nursing, _______, RN, by the survey team at roughly 5pm on 4/6/2016. - On 4/6/2016, all residents (16) on continuous oxygen were assessed by Unit Managers, ________/LVN, _______/LVN, _________/LVN, and ______/LVN to ensure that all oxygen was being administered properly and that the Residents were comfortable and receiving the benefits of the intervention. No negative findings were identified in connection with this assessment process (see Attachment A). - The following in-services were provided (which were followed by a post-test to assess and confirm competency): o Trainer: Unit Managers, _______/LVN, _______/LVN, ______/LVN, and _______/LVN, Staff Developer _______/LVN. or designee. o Audience: All CNAs o Initiated: 4/6/2016 o Completion Date: All available staff will be in-serviced by the end of the business day on 4/8/16 and post-tests will be completed by 4/8/16. All staff currently away from the Facility for reasons of vacation, illness, PRN status, or approved leave, will be in-serviced by Tonya Bradford, LVN, Staff Developer, or her designee prior to their return to work. o Topics § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation · Timely nurse notification § Proper respiratory assessment for residents of differing skin colors - The following in-services were provided (which were followed by a post-test to assess and confirm competency): o Trainer: ________, RCP (Licensed Respiratory Therapist) o Audience: All licensed nurses (LVN and RN) o Initiated: 4/7/2016 o Completion Date: All available staff will be in-serviced by the end of the business day on 4/8/16 and post-tests will be completed by 4/8/16. All staff currently away from the Facility for reasons of vacation, illness, PRN status, or approved leave, will be in-serviced by _______, LVN, Staff Developer, or her designee prior to their return to work. o Topics § Proper respiratory assessment for residents of differing skin colors § Proper oxygen administration to include: · When to use different equipment types · O2 limits § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation · Timely notification - On 4/6/2016, at roughly 6:30pm, ________/LVN/Unit Manager, contacted the hospital and was informed that _______ was in stable condition on the med/surg floor. Her admitting [DIAGNOSES REDACTED]. - On 4/7/2016, at roughly 8:30am, _______/DON/RN, contacted the hospital and was informed that ________ was once again in stable condition on the med/surg floor. SYSTEMIC CHANGE TO PREVENT RECURRENCE: - Starting on 4/6/16 and continuing for the next 90 days, Unit Managers (______ /LVN, _______/LVN, _______/LVN, and ______/LVN) or designees will, on a weekly basis, randomly select ten (10) CNAs to assess and validate their understanding and response, by way of one-on-one interviews and group interviews, (including notification of the Charge Nurse or a Nursing Supervisor) to an observed change in the Resident ' s condition. o Results from these interviews, including the responses of the CNAs to the assessment and validation process, will be recorded. o Those CNAs who are not able to properly recognize and respond to a change in the Resident ' s condition relative to this assessment and validation will not be permitted to work on the unit. Likewise, they will not be allowed to return to work until such time as their competence in this area is appropriately demonstrated. - The orientation of new hires will include training on circumstances which constitute a change in the Resident ' s condition, and new hires will receive instruction on nursing notification in the event of such a change. For the facility ' s policy on Significant Change of Condition, please refer to Attachment B. MONITORING TO ENSURE ONGOING COMPLIANCE: - The Administrator (________)/Designee and Director of Nursing (______, RN)/Designee will audit the results of the weekly interviews, on a semi-monthly basis, to ensure compliance as described above. - A summary of these results will be shared with the QA & A committee for review and follow-up (as necessary) over the next ninety (90) days. The Facility welcomes and questions or comments the Department may have regarding the above, or any other matter. Thank you for your attention to these important issues. After the facility's Plan of Removal was accepted on 04/07/16, on-site monitoring was started. The interviews were conducted on 04/07/16 and 04/08/16. The interviews conducted during the on-site monitoring included staff from all shifts including weekend and prn staff. There was a total of 47 staff interviewed which included 20 nurses and 27 nurse aides. There were four nurses and 12 nurse aides interviewed who worked the 6:00 AM to 2:00 PM shift. There were eight nurses and eight nurse aides interviewed who worked the 2:00 PM to 10:00 PM shift. There were three nurses and one nurse aide interviewed who worked the 10:00 PM to 6:00 AM shift. There were four nurses and three nurse aides interviewed who worked weekend shifts. There was one nurse and three nurse aides interviewed who worked PRN . All nurses interviewed who were interviewed confirmed that they had received the in-service training. They were all knowledgeable in what to do when a resident experienced a change in condition; how to assess the resident, especially respiratory distress and how to properly administer oxygen. All nurse aides interviewed confirmed they had received the in-service training. They were all knowledgeable in what kind of changes in conditions, especially respiratory distress, of the residents. They were aware that they were to report to the nurses immediately if the residents were experiencing shortness of breath. The facility provided a list on 04/07/16 with12 residents including Resident #16. On 04/08/2016 at 4:10 PM, The Administrator was notified the IJ was removed. While the IJ was removed on 04/08/2016, the facility remained out of compliance at a severity level of no actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan. CMS 672 dated 04/05/16 revealed there were 12 residents receiving respiratory treatments and the census was 203.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident # 16) of 12 residents reviewed for neglect. 1. CNA G and CNA H failed to listen to or recognize Resident #16's complaints of shortness of breath and failed to notify the charge nurse promptly of the resident's complaint. CNA H left the room and did not notify the charge nurse. These failures resulted in Resident #16 developing a worsening of her respiratory status and a dropping of her oxygen saturation level to unsafe levels of 56%. Resident #16 was diagnosed at the hospital with Acute on Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and hypercapnia. An Immediate Jeopardy (IJ) was identified on 04/07/16. While the IJ was removed on 04/08/16, the facility remained out of compliance at a scope of, pattern and a severity level of actual harm with potential for more than minimal harm, that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect 17 residents by placing them at risk for serious injury, harm and/ or death related to staff not listening to resident concerns regarding health and reporting any changes in condition which endangers the resident's health to the appropriate healthcare professional. Findings included: Review of local Hospital History and Physical dated 02/28/16 reflected Resident #16 complained of shortness of breath (SOB) since earlier in the morning. The final assessment was HCAP (healthcare-associated pneumonia). And the plan was to monitor the resident, and check cultures and keep the renal physicians informed. MDS assessment dated [DATE] reflected Resident #16 was a [AGE] year old female originally admitted to the facility on [DATE] and recently re-admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #16 was cognitively impaired however she was able to understand others and make herself understood. Resident #16 was dependent on the staff for all care and required extensive assistance of at least two staff members for bathing, dressing, grooming, and incontinent care. Transferring only occurs twice a week with extensive assistance of two or more staff. Resident #16 has limited range of motion of all extremities. Review of Medication Review Report (Physicians orders) dated 04/07/16 reflected the following: Ordered 02/06/16, Oxygen saturation is to be checked every shift. Ordered 02/06/16, O2 (oxygen) at 2 LPM continuous per nasal cannula every shift. Ordered 03/03/16, Duo Neb Solution 0.5-2.5 (3) mg/ml ([MEDICATION NAME]- [MEDICATION NAME]), 1 inhalation orally every 6 hours for shortness of breath while awake. Review of Oxygen Saturation Summary dated 04/07/16 with saturation levels taken intermittently from 07/17/13 through 02/06/16 and the levels noted to be between 95% and 99% which is within the normal acceptable range. The oxygen saturation levels starting on 02/07/16 through 04/03/16 ran between 94 % and 100% and this is also in the acceptable range. On 04/25/17 the following article to define low blood oxygen levels. www.mayoclinic.org/Symptoms/hypovolemia Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath. Hypoxemia is determined by measuring the oxygen level in a blood sample taken from an artery (arterial blood gas). It can also be estimated by measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger. Normal arterial oxygen is approximately 75 to 100 millimeters of mercury (mm Hg). Values under 60 mm Hg usually indicate the need for supplemental oxygen. Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. The Care Plan dated 03/17/16 to address Resident # 16's usage of oxygen therapy, stating the resident would have no signs or symptoms of poor oxygen absorption.jInterventions included Monitor for signs and symptoms of respiratory distress and report to MD PRN, Respirations, Pulseoximetry,, increased heart rate ([MEDICAL CONDITION] Restlessness, Diaphoresis, Headaches, lethragy, Confusion, Atelectasis, Hemoptysis, Cough, Plueritic pain, Accessory muscle usage, skin color. Review of Oxygen Administration training by RRT undated. When to use oxygen therapy: Evidence of Hypoxemia, PaO2 of< 60mm Hg., SPO2 of less than 90%, Severe trauma, [MEDICAL CONDITION] dyspnea, Cyanosis, diaphoresis, Chest Pain, Known or suspected MI ([MEDICAL CONDITION] Infarction) Resident #16 was observed on 04/05/16 at 10:12 AM in her room. She was identified by RN F, (her nurse) who revealed Resident # 16 was alert and oriented to person and place, however would be forgetful. Resident #16 required extensive assistance of two or more staff, incontinent of bowel and bladder and required two or more staff to lift resident with an assistive device. Resident #16 was also on continuous oxygen via nasal cannula at 3 LPM (liters per minute). Resident # 16 also used [MEDICAL CONDITION] at night to assist with her breathing. Review of Resident #16's Medication Review Report dated 04/07/16 reflected additional Diagnoses: [REDACTED]. On 04/06/16 at 8:50 AM during an observation of Resident #16 during breakfast, she was pleasant, calm, and drinking coffee. Resident #16 had oxygen on. The head of the bed (HOB) was elevated at approximately 45 degrees and the resident was tilted to the right. Observation of Resident #16 on 04/06/16 at 10:00 AM revealed she was lying in bed with the head of the bed elevated to 45 degrees, her oxygen was on at 3 LPM, and she was slightly tilted to the right. On 04/06/16 at 10:07 AM CNA G entered Resident #16's room and placed a brief on the dresser. CNA G stated she was going to provide care and needed help, so she left the room. On 04/06/16 at 10:16 AM CNA G returned to Resident #16's room. Observation of CNA H on 04/06/16 at 10:17 AM entered the resident's room, went into the bathroom, washed her hands, came into the room, donned a pair of gloves, grabbed the curtain and pulled it around the bed, the HOB (Head of the bed) lowered residents bed to approximately 15 degrees. CNA G and CNA H removed the blanket covering the resident, undid the brief, and proceeded to do incontinent care. On 04/06/16 at 10:25 AM observed CNA G and CNA H assisted Resident #16 to turn to her left side, to cleanse the buttocks area. CNA H began to cleanse the buttocks area, as she was cleaning the area she wiped feces multiple times. Resident #16 told the CNA's to hurry up, hurry up, I can't breathe. CNA H continued to wipe the feces and told CNA G whenever she wiped the resident kept having more BM (bowel movement). The CNA's continued with the incontinence care and did not acknowlege that Resident #16 was short of breathe. CNA H then placed a brief on Resident #16 and they turned Resident # 16 on her back. Resident #16 continued to complain of shortness of breath. CNA H left the room after assisting positioning the resident. At no time was Resident #16's complaint of shortness of breath reported. On 04/06/16 at 10:28 AM after Resident #16 was placed on her back, she complained of shortness of breath, started pulling at her gown trying to remove her clothes, complained of being hot, the resident also raised her legs off the bed and began to shake her legs. Resident #16 continued to exibit shortness of breathe and asked for air. Resident #16 still laboring and using adomonal muscle to aid in breathing told CNA G to turn the fan on. CNA G pulled the fan closer, but stood in front of the fan on the bedside table not allowing Resident #16 to feel the air. While standing there, CNA G told the resident You know me, you trust me? Resident #16 nodded in agreement while being short of breathe. Resident #16 again asked for air from the fan, CNA G pulled the bedside table closer, but the resident still could not feel the fan. Resident #16 looked in the direction of the fan. The resident again asked for the fan and CNA G moved the fan on the over bed table closer to the resident and CNA G asked if that was better and Resident #16 replied yes. Resident #16 continued to have labored respirations and used her abdominal muscles to breathe. Resident #16 then asked CNA G to pray for her. CNA G responded You go ahead and pray. Resident #16 said Sweet Jesus over and over taking shallow breathes. CNA G made no verbal efforts to calm the resident other than stand there and hold her hand. The resident reached for the surveyor's hand and the surveyor held her hand as Resident #16 kept saying Sweet Jesus, Sweet Jesus repeatedly with shallow breathes. CNA G didn't say anything to Resident #16 which might be comforting or reassuring, CNA G held her hand and looked at the resident. On 04/06/16 at 10:30 AM Resident #16 took shallow breathes attempting to breathe and stated with weary voice I feel like I'm going. Resident #16 closed her eyes, her skin color got lighter and her lips became pale in color. Resident #16 was using her accessory muscles to assist with her breathing. The Resident continued to say in a soft voice I can't breathe and continued to say Oh sweet Jesus. On 04/06/16 at 10:32 AM the surveyor intervened and told CNA G she should get the charge nurse. CNA G left the room came back and asked if the surveyor was going to remain in the room, the surveyor responded Yes. On 04/06/16 at 10:34 AM RN F entered the room with a blood pressure cuff, and stethoscope, and pulse oximeter (measures pulse rate and oxygen level in the blood). RN F tried to raise the (HOB) for Resident #16 and explain why but Resident #16 did not want the HOB elevated. RN F then assessed the resident's oxygen level which was fluctuating between 56% and 59 %( percent) with 4 LPM of oxygen flowing via a nasal cannula. RN F left the room to get the crash cart, returned, placed an oxygen mask on the resident and connected the E-tank (portable oxygen) to the oxygen tubing and started the oxygen flow at 15 LPM. RN F did not have a watch on in order to time the Resident #16's respiration rate or to assess the residents pulse rate. The paramedics arrived at Resident 16's room on 04/06/16 at 10:46 AM and assessed the resident her oxygen levels were up to 73% with blood pressure at 150/74 and pulse at 88. Resident #16 breathed calmer and did not use her abdominal accessory muscles to breathe. On 04/06/16 at 3:25 PM interview with RN F revealed the incident with Resident #16 happended because CNAs did not tell her soon enough residents was having problems. Telephone interview with CNA G on 04/07/16 at 2:35 PM, Surveyor asked CNA G to explain what is shortness of breathe and she stated When you can't hardly breathe. When asked what would she do if a resident was short of breathe, CNA G stated Go get the nurse, but she (Resident #16) said she was ok, I was talking to her and she was ok. Telephone interview with CNA H on 04/07/16 at 2:45 PM, revealed she was not able to tell the number of times she cared for Resident # 16, but, she had not seen her exhibit any signs of distress. CNA H stated if she exibited distress they would get the nurse. CNA H stated I felt yesterday (04/06/16) she was not having distress. When asked about the resident complaining of shortness of breath, CNA H revealed No I saw nothing different. Interview with RN F on 04/06/16 at 4:14 PM, RN F stated the CNA's should have listened to the resident and told the her. She stated CNA G told her that Resident #16 did become short of breath and anxious at times, she (CNA G) tried to calm her down. RN F revealed CNA G agreed she should have come and told her (RN F). Interview with LVN M on 04/06/16 at 3:35 PM, revealed, regarding Resident #16 and her behaviors during care and if she exhibits any anxiety. LVN M revealed the Resident #16 would get a little anxious at times and have the staff come to her room. He stated Resident #16 never got anxious when she was turned on her sides. LVN M stated on [MEDICAL TREATMENT] days she generally helped the staff get the residetn ready. Interview with CNA L on 04/06/16 at 3:42 PM, revealed Resident #16 sometimes screams and yells because she wants you to stay with her. CNA L stated I have no problems when the resident is turned on her side to give incontinent care. CNA L stated if they gave care and the oxygen tubing moved a little, they they have to be careful and then tell the nurse. Interview with CNA N on 04/06/16 at 3:46 PM and she revealed if you talk to Resident #16 she will roll over and grab the bed rails. When asked about behaviors especially not being able to breathe, CNA N stated Resident #16 will holler when something hurt, but she had never complained of not being able to not breathe. Interview on 04/06/16 at 3:50 PM with LVN M, he revealed he would expected his staff to report to him if there was a change in condition or if a resident had a problem. He said his staff was good at reporting changes. Interview on 04/06/16 at 3:52 PM with LVN N she revealed she expected the staff to report to her or the charge nurse immediately if there was a change in condition in a resident. She stated the CNA's taking care of Resident #16 did not do the right thing earlier that day. As soon as she complained of being short of breath they should have stopped what they were doing and come and reported it to her or the charge nurse. She stated the CNA's did not give her a reason for not telling the charge nurse. LVN N revealed they told her the resident had gotten that way before and she calmed down. I am not aware of Resident #16 getting short of breath during care, but she knew the resident got anxious during ADL' s and yells. Interview on 04/07/16 at 1:58 PM with CNA Q, she revealed Resident #16 was nice and she had no problems with her. If Resident #16's head got to low she would say she could not breathe, but we would put her head back up and she would calm down. She stated the resident did not have problems breathing on her side. Interview on 04/07/16 at 2:21 PM with CNA R revealed she only takes care of Resident #16 once and a while. She stated during incontinent care the resident would say Oh I can't breathe, and I would go get the nurses. CNA R revealed it didn not happen every time she worked with Resident #16. She stated she would have to raise Resident #16's head up when Resident could not breathe. Interview on 04/07/16 at 2:25 PM with CNA S revealed she cares for Resident #16 once or twice a week and she is a nice person. CNA S also revealed Resident #16 can get mad and has a lot of anxiety. When you turn her to her side she wants to be turned back. Most of her anxiety she calls for her dad. Resident #16 did not get short of breath, if she did they would have to stop and go get the nurse. Review of the facility's neglect policy, revised 10/2013, revealed the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's signicant change of condition policy, revised 05/2007 revealed the following: This was determined to be an Immediate Jeopardy and on 04/06/16 at 4:50 PM the Administrator and the Director of Nursing were advised of the Immediate Jeopardy a plan of correction was requested at that time. On 04/07/15 a 1:45 PM The DON was interview regarding the cause of the Immediate Jeopardy. The DON revealed the CNA's did not immediately notify the nurse that the resident was in respiratory distress. When asked why the CNA's did not report the change in the resident, she revealed: they have known the resident a long time and she does this all the time. Even though the resident has calmed down they should have reported the incident to the nurse. The resident (Resident #16) always ended up in the hospital. The DON was asked what plans she planned to implement to ensure this did not occur again. The DON revealed she planned to have the staff: identify changes in conditions in all of the residents, CNA's immediately notify the charge nurses of a change in condition in a resident, and the charge nurses need to follow up and notify the responsible party and the physician. Record reviews of hospital records dated 04/2016 reflected Resident #16 was in the hospital in January 2016 and was intubated for her [MEDICAL CONDITION]. The Resident was also in the hospital in February 2016 for Pneumonia. An interview on 04/07/2016 at approximately 3:00 PM with the Administrator revealed the IJ was called because the CNA's were not timely in notifying the nurse when the resident was experincing problems. When asked what What type of procedures were there to make sure the needs of the residents were met, he stated development of structure with the Unit Managers to determine the needs of the residents, competency of the staff, and an open door policy to deal with grievances process. How do you monitor staff (DON) to ensure systems they monitor are being DON sufficiently? We have a Quality Assurance to tract and trend data, Weekly meetings to address what nursing is over to ensure the systems are working. Finally the Administrator was asked if he was confident that this failure was going to be followed up on. The Administrator was confident this issue would be followed up on. The facility's plan of removal, accepted on 04/07/16 at 4:02PM reflected IMMEDIATE ACTION TAKEN: - At approximately 11am on 4/6/2016, prior to Immediate Jeopardy being called by the survey team, in-servicing was initiated by ______/LVN/Staff Developer; education was provided to all CNAs working 6am-2pm on ________ unit. This in-servicing was initiated prior to the Immediate Jeopardy being called because the facility's Director of Nursing, _______ (RN), was made aware by the Unit Manager, _______/LVN, that the surveyor,________, had some concerns about how the change of condition was handled by the facility regarding ________. It is the practice of the facility, whenever patient care concerns are brought up by surveyors, to initiate staff in-servicing. o Trainer: ______, LVN, Staff Developer o Audience: 6-2 CNAs on Resident ' s unit o Initiated: 4/6/2016 o Completed: 4/6/2016 o Topics: § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation § Timely nurse notification - At approximately 11am on 4/6/2016, ________ Responsible Party, _______, was notified of _________ change of condition by Princess Gbor, RN, and transferred to the Hospital. - On 4/6/2016, at roughly 6pm, the Resident's attending physician______ was notified by ________/LVN/Unit Manager, of _______ change of condition and transfer to the Hospital. - At approximately 11am on 4/6/2016, one-on-one in-servicing was completed as follows: o Trainer: _____, RN, DON o Employee: ______ (this in-service was completed prior to _____suspension) o Initiated: 4/6/2016 o Completed: 4/6/2016 o Topics: § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation § Timely nurse notification - On 4/6/2016, CNAs _____ and ____ were suspended for allegation of neglect which was brought to the attention of the Administrator,_______, and the Director of Nursing, _______, RN, by the survey team at roughly 5pm on 4/6/2016. - On 4/6/2016, all residents (16) on continuous oxygen were assessed by Unit Managers, ________/LVN, _______/LVN, _________/LVN, and ______/LVN to ensure that all oxygen was being administered properly and that the Residents were comfortable and receiving the benefits of the intervention. No negative findings were identified in connection with this assessment process (see Attachment A). - The following in-services were provided (which were followed by a post-test to assess and confirm competency): o Trainer: Unit Managers, _______/LVN, _______/LVN, ______/LVN, and _______/LVN, Staff Developer _______/LVN. or designee. o Audience: All CNAs o Initiated: 4/6/2016 o Completion Date: All available staff will be in-serviced by the end of the business day on 4/8/16 and post-tests will be completed by 4/8/16. All staff currently away from the Facility for reasons of vacation, illness, PRN status, or approved leave, will be in-serviced by ______, LVN, Staff Developer, or her designee prior to their return to work. o Topics § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation · Timely nurse notification § Proper respiratory assessment for residents of differing skin colors - The following in-services were provided (which were followed by a post-test to assess and confirm competency): o Trainer: ________, RCP (Licensed Respiratory Therapist) o Audience: All licensed nurses (LVN and RN) o Initiated: 4/7/2016 o Completion Date: All available staff will be in-serviced by the end of the business day on 4/8/16 and post-tests will be completed by 4/8/16. All staff currently away from the Facility for reasons of vacation, illness, PRN status, or approved leave, will be in-serviced by _______, LVN, Staff Developer, or her designee prior to their return to work. o Topics § Proper respiratory assessment for residents of differing skin colors § Proper oxygen administration to include: · When to use different equipment types · O2 limits § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation · Timely notification - On 4/6/2016, at roughly 6:30pm, ________/LVN/Unit Manager, contacted the hospital and was informed that _______ was in stable condition on the med/surg floor. Her admitting [DIAGNOSES REDACTED]. - On 4/7/2016, at roughly 8:30am, _______/DON/RN, contacted the hospital and was informed that ________ was once again in stable condition on the med/surg floor. SYSTEMIC CHANGE TO PREVENT RECURRENCE: - Starting on 4/6/16 and continuing for the next 90 days, Unit Managers (______ /LVN, _______/LVN, _______/LVN, and ______/LVN) or designees will, on a weekly basis, randomly select ten (10) CNAs to assess and validate their understanding and response, by way of one-on-one interviews and group interviews, (including notification of the Charge Nurse or a Nursing Supervisor) to an observed change in the Resident ' s condition. o Results from these interviews, including the responses of the CNAs to the assessment and validation process, will be recorded. o Those CNAs who are not able to properly recognize and respond to a change in the Resident ' s condition relative to this assessment and validation will not be permitted to work on the unit. Likewise, they will not be allowed to return to work until such time as their competence in this area is appropriately demonstrated. - The orientation of new hires will include training on circumstances which constitute a change in the Resident ' s condition, and new hires will receive instruction on nursing notification in the event of such a change. For the facility ' s policy on Significant Change of Condition, please refer to Attachment B. MONITORING TO ENSURE ONGOING COMPLIANCE: - The Administrator (________)/Designee and Director of Nursing (______, RN)/Designee will audit the results of the weekly interviews, on a semi-monthly basis, to ensure compliance as described above. - A summary of these results will be shared with the QA & A committee for review and follow-up (as necessary) over the next ninety (90) days. The Facility welcomes and questions or comments the Department may have regarding the above, or any other matter. Thank you for your attention to these important issues. After the facility's Plan of Removal was accepted on 04/07/16, on-site monitoring was started. The interviews were conducted on 04/07/16 and 04/08/16. The interviews conducted during the on-site monitoring included staff from all shifts including weekend and prn staff. There was a total of 47 staff interviewed which included 20 nurses and 27 nurse aides. There were four nurses and 12 nurse aides interviewed who worked the 6:00 AM to 2:00 PM shift. There were eight nurses and eight nurse aides interviewed who worked the 2:00 PM to 10:00 PM shift. There were three nurses and one nurse aide interviewed who worked the 10:00 PM to 6:00 AM shift. There were four nurses and three nurse aides interviewed who worked weekend shifts. There was one nurse and three nurse aides interviewed who worked PRN . All nurses interviewed who were interviewed confirmed that they had received the in-service training. They were all knowledgeable in what to do when a resident experienced a change in condition; how to assess the resident, especially respiratory distress and how to properly administer oxygen. All nurse aides interviewed confirmed they had received the in-service training. They were all knowledgeable in what kind of changes in conditions, especially respiratory distress, of the residents. They were aware that they were to report to the nurses immediately if the residents were experiencing shortness of breath. The facility provided a list on 04/07/16 with 12 residents including Resident #16. On 04/08/2016 at 4:10 PM, The Administrator was notified the IJ was removed. While the IJ was removed on 04/08/2016, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan. CMS 672 dated 04/05/16 revealed there were 12 residents receiving respiratory treatments and the census was 203.

Based on observation, interview and record review it was determined the facility failed to implement written policies and procedures that prohibited neglect for one (Resident #16) of 12 residents reviewed for neglect. 1. CNA G and CNA H failed to listen to or recognize Resident #16's complaints of shortness of breath and failed to notify the charge nurse promptly of the resident's complaint. CNA H left the room and did not notify the charge nurse. These failures resulted in Resident #16 developing a worsening of her respiratory status and a dropping of her oxygen saturation level to unsafe levels of 56%. Resident #16 was diagnosed at the hospital with Acute on Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and hypercapnia. An Immediate Jeopardy (IJ) was identified on 04/07/16. While the IJ was removed on 04/08/16, the facility remained out of compliance at a scope of, pattern and a severity level of actual harm with potential for more than minimal harm, that is not immediate jeopardy, because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect 17 residents by placing them at risk for serious injury, harm and/ or death related to staff not listening to resident concerns regarding health and reporting any changes in condition which endangers the resident's health to the appropriate healthcare professional. Findings included: Review of local Hospital History and Physical dated 02/28/16 reflected Resident #16 complained of shortness of breath (SOB) since earlier in the morning. The final assessment was HCAP (healthcare-associated pneumonia). And the plan was to monitor the resident, and check cultures and keep the renal physicians informed. MDS assessment dated [DATE] reflected Resident #16 was a [AGE] year old female originally admitted to the facility on [DATE] and recently re-admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #16 was cognitively impaired however she was able to understand others and make herself understood. Resident #16 was dependent on the staff for all care and required extensive assistance of at least two staff members for bathing, dressing, grooming, and incontinent care. Transferring only occurs twice a week with extensive assistance of two or more staff. Resident #16 has limited range of motion of all extremities. Review of Medication Review Report (Physicians orders) dated 04/07/16 reflected the following: Ordered 02/06/16, Oxygen saturation is to be checked every shift. Ordered 02/06/16, O2 (oxygen) at 2 LPM continuous per nasal cannula every shift. Ordered 03/03/16, Duo Neb Solution 0.5-2.5 (3) mg/ml ([MEDICATION NAME]- [MEDICATION NAME]), 1 inhalation orally every 6 hours for shortness of breath while awake. Review of Oxygen Saturation Summary dated 04/07/16 with saturation levels taken intermittently from 07/17/13 through 02/06/16 and the levels noted to be between 95% and 99% which is within the normal acceptable range. The oxygen saturation levels starting on 02/07/16 through 04/03/16 ran between 94 % and 100% and this is also in the acceptable range. On 04/25/17 the following article to define low blood oxygen levels. www.mayoclinic.org/Symptoms/hypovolemia Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath. Hypoxemia is determined by measuring the oxygen level in a blood sample taken from an artery (arterial blood gas). It can also be estimated by measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger. Normal arterial oxygen is approximately 75 to 100 millimeters of mercury (mm Hg). Values under 60 mm Hg usually indicate the need for supplemental oxygen. Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. The Care Plan dated 03/17/16 to address Resident # 16's usage of oxygen therapy, stating the resident would have no signs or symptoms of poor oxygen absorption.jInterventions included Monitor for signs and symptoms of respiratory distress and report to MD PRN, Respirations, Pulseoximetry,, increased heart rate ([MEDICAL CONDITION] Restlessness, Diaphoresis, Headaches, lethragy, Confusion, Atelectasis, Hemoptysis, Cough, Plueritic pain, Accessory muscle usage, skin color. Review of Oxygen Administration training by RRT undated. When to use oxygen therapy: Evidence of Hypoxemia, PaO2 of< 60mm Hg., SPO2 of less than 90%, Severe trauma, [MEDICAL CONDITION] dyspnea, Cyanosis, diaphoresis, Chest Pain, Known or suspected MI ([MEDICAL CONDITION] Infarction) Resident #16 was observed on 04/05/16 at 10:12 AM in her room. She was identified by RN F, (her nurse) who revealed Resident # 16 was alert and oriented to person and place, however would be forgetful. Resident #16 required extensive assistance of two or more staff, incontinent of bowel and bladder and required two or more staff to lift resident with an assistive device. Resident #16 was also on continuous oxygen via nasal cannula at 3 LPM (liters per minute). Resident # 16 also used [MEDICAL CONDITION] at night to assist with her breathing. Review of Resident #16's Medication Review Report dated 04/07/16 reflected additional Diagnoses: [REDACTED]. On 04/06/16 at 8:50 AM during an observation of Resident #16 during breakfast, she was pleasant, calm, and drinking coffee. Resident #16 had oxygen on. The head of the bed (HOB) was elevated at approximately 45 degrees and the resident was tilted to the right. Observation of Resident #16 on 04/06/16 at 10:00 AM revealed she was lying in bed with the head of the bed elevated to 45 degrees, her oxygen was on at 3 LPM, and she was slightly tilted to the right. On 04/06/16 at 10:07 AM CNA G entered Resident #16's room and placed a brief on the dresser. CNA G stated she was going to provide care and needed help, so she left the room. On 04/06/16 at 10:16 AM CNA G returned to Resident #16's room. Observation of CNA H on 04/06/16 at 10:17 AM entered the resident's room, went into the bathroom, washed her hands, came into the room, donned a pair of gloves, grabbed the curtain and pulled it around the bed, the HOB (Head of the bed) lowered residents bed to approximately 15 degrees. CNA G and CNA H removed the blanket covering the resident, undid the brief, and proceeded to do incontinent care. On 04/06/16 at 10:25 AM observed CNA G and CNA H assisted Resident #16 to turn to her left side, to cleanse the buttocks area. CNA H began to cleanse the buttocks area, as she was cleaning the area she wiped feces multiple times. Resident #16 told the CNA's to hurry up, hurry up, I can't breathe. CNA H continued to wipe the feces and told CNA G whenever she wiped the resident kept having more BM (bowel movement). The CNA's continued with the incontinence care and did not acknowlege that Resident #16 was short of breathe. CNA H then placed a brief on Resident #16 and they turned Resident # 16 on her back. Resident #16 continued to complain of shortness of breath. CNA H left the room after assisting positioning the resident. At no time was Resident #16's complaint of shortness of breath reported. On 04/06/16 at 10:28 AM after Resident #16 was placed on her back, she complained of shortness of breath, started pulling at her gown trying to remove her clothes, complained of being hot, the resident also raised her legs off the bed and began to shake her legs. Resident #16 continued to exibit shortness of breathe and asked for air. Resident #16 still laboring and using adomonal muscle to aid in breathing told CNA G to turn the fan on. CNA G pulled the fan closer, but stood in front of the fan on the bedside table not allowing Resident #16 to feel the air. While standing there, CNA G told the resident You know me, you trust me? Resident #16 nodded in agreement while being short of breathe. Resident #16 again asked for air from the fan, CNA G pulled the bedside table closer, but the resident still could not feel the fan. Resident #16 looked in the direction of the fan. The resident again asked for the fan and CNA G moved the fan on the over bed table closer to the resident and CNA G asked if that was better and Resident #16 replied yes. Resident #16 continued to have labored respirations and used her abdominal muscles to breathe. Resident #16 then asked CNA G to pray for her. CNA G responded You go ahead and pray. Resident #16 said Sweet Jesus over and over taking shallow breathes. CNA G made no verbal efforts to calm the resident other than stand there and hold her hand. The resident reached for the surveyor's hand and the surveyor held her hand as Resident #16 kept saying Sweet Jesus, Sweet Jesus repeatedly with shallow breathes. CNA G didn't say anything to Resident #16 which might be comforting or reassuring, CNA G held her hand and looked at the resident. On 04/06/16 at 10:30 AM Resident #16 took shallow breathes attempting to breathe and stated with weary voice I feel like I'm going. Resident #16 closed her eyes, her skin color got lighter and her lips became pale in color. Resident #16 was using her accessory muscles to assist with her breathing. The Resident continued to say in a soft voice I can't breathe and continued to say Oh sweet Jesus. On 04/06/16 at 10:32 AM the surveyor intervened and told CNA G she should get the charge nurse. CNA G left the room came back and asked if the surveyor was going to remain in the room, the surveyor responded Yes. On 04/06/16 at 10:34 AM RN F entered the room with a blood pressure cuff, and stethoscope, and pulse oximeter (measures pulse rate and oxygen level in the blood). RN F tried to raise the (HOB) for Resident #16 and explain why but Resident #16 did not want the HOB elevated. RN F then assessed the resident's oxygen level which was fluctuating between 56% and 59 %( percent) with 4 LPM of oxygen flowing via a nasal cannula. RN F left the room to get the crash cart, returned, placed an oxygen mask on the resident and connected the E-tank (portable oxygen) to the oxygen tubing and started the oxygen flow at 15 LPM. RN F did not have a watch on in order to time the Resident #16's respiration rate or to assess the residents pulse rate. The paramedics arrived at Resident 16's room on 04/06/16 at 10:46 AM and assessed the resident her oxygen levels were up to 73% with blood pressure at 150/74 and pulse at 88. Resident #16 breathed calmer and did not use her abdominal accessory muscles to breathe. On 04/06/16 at 3:25 PM interview with RN F revealed the incident with Resident #16 happended because CNAs did not tell her soon enough residents was having problems. Telephone interview with CNA G on 04/07/16 at 2:35 PM, Surveyor asked CNA G to explain what is shortness of breathe and she stated When you can't hardly breathe. When asked what would she do if a resident was short of breathe, CNA G stated Go get the nurse, but she (Resident #16) said she was ok, I was talking to her and she was ok. Telephone interview with CNA H on 04/07/16 at 2:45 PM, revealed she was not able to tell the number of times she cared for Resident # 16, but, she had not seen her exhibit any signs of distress. CNA H stated if she exibited distress they would get the nurse. CNA H stated I felt yesterday (04/06/16) she was not having distress. When asked about the resident complaining of shortness of breath, CNA H revealed No I saw nothing different. Interview with RN F on 04/06/16 at 4:14 PM, RN F stated the CNA's should have listened to the resident and told the her. She stated CNA G told her that Resident #16 did become short of breath and anxious at times, she (CNA G) tried to calm her down. RN F revealed CNA G agreed she should have come and told her (RN F). Interview with LVN M on 04/06/16 at 3:35 PM, revealed, regarding Resident #16 and her behaviors during care and if she exhibits any anxiety. LVN M revealed the Resident #16 would get a little anxious at times and have the staff come to her room. He stated Resident #16 never got anxious when she was turned on her sides. LVN M stated on [MEDICAL TREATMENT] days she generally helped the staff get the residetn ready. Interview with CNA L on 04/06/16 at 3:42 PM, revealed Resident #16 sometimes screams and yells because she wants you to stay with her. CNA L stated I have no problems when the resident is turned on her side to give incontinent care. CNA L stated if they gave care and the oxygen tubing moved a little, they they have to be careful and then tell the nurse. Interview with CNA N on 04/06/16 at 3:46 PM and she revealed if you talk to Resident #16 she will roll over and grab the bed rails. When asked about behaviors especially not being able to breathe, CNA N stated Resident #16 will holler when something hurt, but she had never complained of not being able to not breathe. Interview on 04/06/16 at 3:50 PM with LVN M, he revealed he would expected his staff to report to him if there was a change in condition or if a resident had a problem. He said his staff was good at reporting changes. Interview on 04/06/16 at 3:52 PM with LVN N she revealed she expected the staff to report to her or the charge nurse immediately if there was a change in condition in a resident. She stated the CNA's taking care of Resident #16 did not do the right thing earlier that day. As soon as she complained of being short of breath they should have stopped what they were doing and come and reported it to her or the charge nurse. She stated the CNA's did not give her a reason for not telling the charge nurse. LVN N revealed they told her the resident had gotten that way before and she calmed down. I am not aware of Resident #16 getting short of breath during care, but she knew the resident got anxious during ADL' s and yells. Interview on 04/07/16 at 1:58 PM with CNA Q, she revealed Resident #16 was nice and she had no problems with her. If Resident #16's head got to low she would say she could not breathe, but we would put her head back up and she would calm down. She stated the resident did not have problems breathing on her side. Interview on 04/07/16 at 2:21 PM with CNA R revealed she only takes care of Resident #16 once and a while. She stated during incontinent care the resident would say Oh I can't breathe, and I would go get the nurses. CNA R revealed it didn not happen every time she worked with Resident #16. She stated she would have to raise Resident #16's head up when Resident could not breathe. Interview on 04/07/16 at 2:25 PM with CNA S revealed she cares for Resident #16 once or twice a week and she is a nice person. CNA S also revealed Resident #16 can get mad and has a lot of anxiety. When you turn her to her side she wants to be turned back. Most of her anxiety she calls for her dad. Resident #16 did not get short of breath, if she did they would have to stop and go get the nurse. Review of the facility's neglect policy, revised 10/2013, revealed the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's signicant change of condition policy, revised 05/2007 revealed the following: This was determined to be an Immediate Jeopardy and on 04/06/16 at 4:50 PM the Administrator and the Director of Nursing were advised of the Immediate Jeopardy a plan of correction was requested at that time. On 04/07/15 a 1:45 PM The DON was interview regarding the cause of the Immediate Jeopardy. The DON revealed the CNA's did not immediately notify the nurse that the resident was in respiratory distress. When asked why the CNA's did not report the change in the resident, she revealed: they have known the resident a long time and she does this all the time. Even though the resident has calmed down they should have reported the incident to the nurse. The resident (Resident #16) always ended up in the hospital. The DON was asked what plans she planned to implement to ensure this did not occur again. The DON revealed she planned to have the staff: identify changes in conditions in all of the residents, CNA's immediately notify the charge nurses of a change in condition in a resident, and the charge nurses need to follow up and notify the responsible party and the physician. Record reviews of hospital records dated 04/2016 reflected Resident #16 was in the hospital in January 2016 and was intubated for her [MEDICAL CONDITION]. The Resident was also in the hospital in February 2016 for Pneumonia. An interview on 04/07/2016 at approximately 3:00 PM with the Administrator revealed the IJ was called because the CNA's were not timely in notifying the nurse when the resident was experincing problems. When asked what What type of procedures were there to make sure the needs of the residents were met, he stated development of structure with the Unit Managers to determine the needs of the residents, competency of the staff, and an open door policy to deal with grievances process. How do you monitor staff (DON) to ensure systems they monitor are being DON sufficiently? We have a Quality Assurance to tract and trend data, Weekly meetings to address what nursing is over to ensure the systems are working. Finally the Administrator was asked if he was confident that this failure was going to be followed up on. The Administrator was confident this issue would be followed up on. The facility's plan of removal, accepted on 04/07/16 at 4:02PM reflected IMMEDIATE ACTION TAKEN: - At approximately 11am on 4/6/2016, prior to Immediate Jeopardy being called by the survey team, in-servicing was initiated by ______/LVN/Staff Developer; education was provided to all CNAs working 6am-2pm on ________ unit. This in-servicing was initiated prior to the Immediate Jeopardy being called because the facility's Director of Nursing, _______ (RN), was made aware by the Unit Manager, _______/LVN, that the surveyor,________, had some concerns about how the change of condition was handled by the facility regarding ________. It is the practice of the facility, whenever patient care concerns are brought up by surveyors, to initiate staff in-servicing. o Trainer: ______, LVN, Staff Developer o Audience: 6-2 CNAs on Resident ' s unit o Initiated: 4/6/2016 o Completed: 4/6/2016 o Topics: § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation § Timely nurse notification - At approximately 11am on 4/6/2016, ________ Responsible Party, _______, was notified of _________ change of condition by Princess Gbor, RN, and transferred to the Hospital. - On 4/6/2016, at roughly 6pm, the Resident's attending physician______ was notified by ________/LVN/Unit Manager, of _______ change of condition and transfer to the Hospital. - At approximately 11am on 4/6/2016, one-on-one in-servicing was completed as follows: o Trainer: _____, RN, DON o Employee: ______ (this in-service was completed prior to _____suspension) o Initiated: 4/6/2016 o Completed: 4/6/2016 o Topics: § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation § Timely nurse notification - On 4/6/2016, CNAs _____ and ____ were suspended for allegation of neglect which was brought to the attention of the Administrator,_______, and the Director of Nursing, _______, RN, by the survey team at roughly 5pm on 4/6/2016. - On 4/6/2016, all residents (16) on continuous oxygen were assessed by Unit Managers, ________/LVN, _______/LVN, _________/LVN, and ______/LVN to ensure that all oxygen was being administered properly and that the Residents were comfortable and receiving the benefits of the intervention. No negative findings were identified in connection with this assessment process (see Attachment A). - The following in-services were provided (which were followed by a post-test to assess and confirm competency): o Trainer: Unit Managers, _______/LVN, _______/LVN, ______/LVN, and _______/LVN, Staff Developer _______/LVN. or designee. o Audience: All CNAs o Initiated: 4/6/2016 o Completion Date: All available staff will be in-serviced by the end of the business day on 4/8/16 and post-tests will be completed by 4/8/16. All staff currently away from the Facility for reasons of vacation, illness, PRN status, or approved leave, will be in-serviced by ______, LVN, Staff Developer, or her designee prior to their return to work. o Topics § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation · Timely nurse notification § Proper respiratory assessment for residents of differing skin colors - The following in-services were provided (which were followed by a post-test to assess and confirm competency): o Trainer: ________, RCP (Licensed Respiratory Therapist) o Audience: All licensed nurses (LVN and RN) o Initiated: 4/7/2016 o Completion Date: All available staff will be in-serviced by the end of the business day on 4/8/16 and post-tests will be completed by 4/8/16. All staff currently away from the Facility for reasons of vacation, illness, PRN status, or approved leave, will be in-serviced by _______, LVN, Staff Developer, or her designee prior to their return to work. o Topics § Proper respiratory assessment for residents of differing skin colors § Proper oxygen administration to include: · When to use different equipment types · O2 limits § Change of condition types · Shortness of breath · Weakness · Falls · Change in appetite · Change in demeanor · Change in vitals · Complaints of pain · Confusion or agitation · Timely notification - On 4/6/2016, at roughly 6:30pm, ________/LVN/Unit Manager, contacted the hospital and was informed that _______ was in stable condition on the med/surg floor. Her admitting [DIAGNOSES REDACTED]. - On 4/7/2016, at roughly 8:30am, _______/DON/RN, contacted the hospital and was informed that ________ was once again in stable condition on the med/surg floor. SYSTEMIC CHANGE TO PREVENT RECURRENCE: - Starting on 4/6/16 and continuing for the next 90 days, Unit Managers (______ /LVN, _______/LVN, _______/LVN, and ______/LVN) or designees will, on a weekly basis, randomly select ten (10) CNAs to assess and validate their understanding and response, by way of one-on-one interviews and group interviews, (including notification of the Charge Nurse or a Nursing Supervisor) to an observed change in the Resident ' s condition. o Results from these interviews, including the responses of the CNAs to the assessment and validation process, will be recorded. o Those CNAs who are not able to properly recognize and respond to a change in the Resident ' s condition relative to this assessment and validation will not be permitted to work on the unit. Likewise, they will not be allowed to return to work until such time as their competence in this area is appropriately demonstrated. - The orientation of new hires will include training on circumstances which constitute a change in the Resident ' s condition, and new hires will receive instruction on nursing notification in the event of such a change. For the facility ' s policy on Significant Change of Condition, please refer to Attachment B. MONITORING TO ENSURE ONGOING COMPLIANCE: - The Administrator (________)/Designee and Director of Nursing (______, RN)/Designee will audit the results of the weekly interviews, on a semi-monthly basis, to ensure compliance as described above. - A summary of these results will be shared with the QA & A committee for review and follow-up (as necessary) over the next ninety (90) days. The Facility welcomes and questions or comments the Department may have regarding the above, or any other matter. Thank you for your attention to these important issues. After the facility's Plan of Removal was accepted on 04/07/16, on-site monitoring was started. The interviews were conducted on 04/07/16 and 04/08/16. The interviews conducted during the on-site monitoring included staff from all shifts including weekend and prn staff. There was a total of 47 staff interviewed which included 20 nurses and 27 nurse aides. There were four nurses and 12 nurse aides interviewed who worked the 6:00 AM to 2:00 PM shift. There were eight nurses and eight nurse aides interviewed who worked the 2:00 PM to 10:00 PM shift. There were three nurses and one nurse aide interviewed who worked the 10:00 PM to 6:00 AM shift. There were four nurses and three nurse aides interviewed who worked weekend shifts. There was one nurse and three nurse aides interviewed who worked PRN . All nurses interviewed who were interviewed confirmed that they had received the in-service training. They were all knowledgeable in what to do when a resident experienced a change in condition; how to assess the resident, especially respiratory distress and how to properly administer oxygen. All nurse aides interviewed confirmed they had received the in-service training. They were all knowledgeable in what kind of changes in conditions, especially respiratory distress, of the residents. They were aware that they were to report to the nurses immediately if the residents were experiencing shortness of breath. The facility provided a list on 04/07/16 with12 residents including Resident #16. On 04/08/2016 at 4:10 PM, The Administrator was notified the IJ was removed. While the IJ was removed on 04/08/2016, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan. CMS 672 dated 04/05/16 revealed there were 12 residents receiving respiratory treatments and the census was 203.

Based on observation, interview and record review, it was determined the facility failed to ensure two (Resident #5 and #27 were free of any significant medication errors for two of nine observed during the medication pass conducted on 03/23/15 and 03/24/15. 1) LVN C administered the long acting insulin, [MEDICATION NAME] to cover Resident #5's elevated blood glucose instead of the short acting insulin [MEDICATION NAME] as ordered by the physician. An IJ was identified on 03/24/15. The Administrator and DON, were notified on 03/24/15 at 7:48 p.m. of the IJ and a Plan of Removal was requested at that time. 2) Facility nursing staff failed to administer insulin to Resident #27 before meals according to physician's orders [REDACTED]. These failures created the potential for residents to have severe [DIAGNOSES REDACTED] (low blood glucose), [MEDICAL CONDITION] (high blood glucose) and experience diabetic complications including coma, kidney failure and death. These failures could affect the 48 residents identified by the facility who received routine insulin and the 57 residents identified by the facility who received insulin according to a sliding scale (Sliding scale insulin-a set of instructions for administering insulin dosages based on specific blood glucose readings). Findings included: (1) Review of Resident #5's current Minimum Data Set assessment dated [DATE] revealed the resident was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 was initially observed during rounds on 03/22/15 at 3:53 p.m. with LVN L. The resident was sitting in a Geri-chair in the dayroom. LVN L stated the resident was incontinent of bowel/bladder, cognitively impaired and required total care for all activities of daily living. Unit NCH 2- On 03/24/15 at 4:25 p.m. LVN C was observed to obtain a finger stick blood sample from Resident #5. The resident's blood glucose result was 213 milligrams per deciliter mg/dL. LVN C then administered 4 units of [MEDICATION NAME]subcutaneously into the right side of the resident's abdomen. ([MEDICATION NAME]is long-acting insulin used to treat diabetes). LVN C was queried if he was going to administer any insulin to cover the resident's elevated blood glucose. LVN C stated Resident #5 was ordered to receive [MEDICATION NAME] (Rapid acting insulin used to treat diabetes) insulin but there was none available for the resident. LVN C stated, "She is out." LVN C was queried about the differences between the [MEDICATION NAME]he had administered incorrectly and the [MEDICATION NAME]that was ordered to be administered for the sliding scale blood glucose of 213 mg/dL. The nurse stated [MEDICATION NAME]was long acting insulin and [MEDICATION NAME] was short acting insulin. When queried why he administered the incorrect insulin the nurse stated he wanted to make sure the resident had "something" to treat her elevated blood glucose. LVN C stated he was aware the [MEDICATION NAME]was long acting and would not be effective in lowering the resident's elevated blood glucose quickly. LVN C further stated the [MEDICATION NAME] was ordered on the previous shift by the previous nurse but had not arrived. When queried if there was any [MEDICATION NAME] available in the facility's emergency medication kit, LVN C stated he did not know. Additionally, LVN C stated the resident had only been out of the insulin for his shift (evening) on 03/24/15. Resident #5's consolidated monthly physician's orders [REDACTED]. The orders reflected the resident was ordered to receive [MEDICATION NAME]according to a sliding scale before meals and at bedtime. The resident should have received 4 units of [MEDICATION NAME]instead of the [MEDICATION NAME]. The orders further reflected 4 units of [MEDICATION NAME]were ordered for a blood glucose level of 201 to 250 mg/dL. Resident #5's glucose result was 213 mg/dL. Additionally, the orders reflected 15 units of [MEDICATION NAME]was ordered to be administered at bedtime (8:00 p.m.) On 03/24/15 at 8:00 p.m. the resident would have received the 15 units of routinely scheduled [MEDICATION NAME] resulting in 19 units of [MEDICATION NAME]being administered when only 15 units were ordered by the physician. On 03/24/15 at 5:10 p.m. Unit Manager F (UM) was informed of the medication error. UM F stated insulin should have been ordered every 28 days regardless if the bottle was empty or not. On 03/24/15 at 5:20 p.m. UM F was observed to phone the pharmacy. UM F stated the pharmacy informed her the last time [MEDICATION NAME]for Resident #5 was delivered to the facility was 01/03/15. During the communication with the pharmacy UM F ordered the [MEDICATION NAME]for Resident #5. An interview with LVN N on 03/25/15 at 12:50 p.m. revealed he was the day shift charge nurse on 03/24/15. LVN N stated he was not aware the [MEDICATION NAME]for Resident #5 was not available. He further stated he only used it a few times, was unable to recall when he had used it last but the last time he used it there was insulin left. Additionally, LVN N stated he did not know what had happened to the [MEDICATION NAME] insulin. According to DiabetesNet.com viewed on 04/13/15, [MEDICATION NAME]starts to work about 20 minutes after taken, with a gradual rise (peak) in action over the next 1.75 to 2.25 hours. Action ends in 4.5 to 6 hours. [MEDICATION NAME]starts to work1 to 3 hours after taken and peaks in 8 to 10 hours. The action ends in 18 to 26 hours. According to the [MEDICATION NAME] package insert and label information viewed on DrugInserts.com on 04/13/15, the dose of [MEDICATION NAME]must be individualized based on clinical response. Blood glucose monitoring is essential in all patients receiving insulin therapy. The dosage of [MEDICATION NAME] is based on a medical conditions and response to treatment. Measure each dose very carefully because even small changes in the amount of insulin may have a large effect on blood sugar levels. [DIAGNOSES REDACTED] is the most common adverse reaction of insulin therapy, including [MEDICATION NAME]. Severe [DIAGNOSES REDACTED] can lead to unconsciousness or convulsions and may result in temporary or permanent impairment of brain function or death. (2) Review of Resident #27's current Minimum Data Set assessment dated [DATE] revealed the resident was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #27 was initially observed during rounds on 03/22/15 at 2:30 p.m. with LVN D. The resident was sitting in a reclining chair in her room. The nurse stated the resident was incontinent of bowel/bladder, cognitively impaired and required total care for all activities of daily living. On 03/23/15 at 11:30 a.m. LVN A was observed to obtain a finger stick blood sample from Resident #27. The resident's blood glucose result was 224 milligrams per deciliter (mg/dL). LVN A stated the resident was ordered to receive 25 units of regular insulin routinely before the lunch meal daily. LVN A stated she was holding the insulin because she (the nurse) was concerned Resident #27 would not eat well at lunch. LVN A stated recently she had frequently held the resident's insulin because the resident had not been eating well. According to LVN A there was an order to hold the routine insulin if the resident did not eat "well." LVN A was queried about how much of the lunch meal Resident #27 had to eat to be considered well. The nurse stated "50 percent." On 03/23/15 LVN A was observed to administer 25 units of [MEDICATION NAME] Regular insulin into Resident #27's upper left arm at 12:50 p.m. after the resident had completed the lunch meal. Resident #27's consolidated monthly physician's orders [REDACTED]. There were no parameters related to holding Resident #27's insulin. Review of Resident #27's entire clinical record on 03/23/15 revealed there were no orders related to holding the resident's insulin or any documentation the physician had been involved in the decision to hold the insulin. According to the American Diabetes Association's web site viewed on 03/31/15 it is important to treat symptoms of high blood sugar right away to help prevent complications. The American Diabetes Association recommends a fasting (before a meal) blood glucose level of 70-130 mg/dL and after meals less than 180 mg/dL. Review of the resident's medication administration records (MARs) dated March 2015 reflected the [MEDICATION NAME] Regular and the [MEDICATION NAME] had been held (not administered) on the following days: MAR dated March 2015-[MEDICATION NAME]-on 03/03/15 ordered to be administered before dinner. The resident's finger stick blood glucose result was 99 mg/dL. The explanation documented on the back of the MAR indicated [REDACTED]. MAR dated March 2015-[MEDICATION NAME]-on 03/09/15 ordered to be administered before dinner. The resident's finger stick blood glucose result was 72 mg/dL. The explanation documented on the back of the MAR indicated [REDACTED]. An interview with LVN E on 03/26/15 at 10:10 p.m. revealed she was the charge nurse on duty on 03/03/15 and 03/09/15 and had held the insulin for Resident #27. The nurse stated she felt the resident's blood glucose was too low at 99 mg/dL. She further stated a normal blood glucose range was 80 to 120 mg/dL. According to LVN E there was a time in the past when the facility's Nurse Practitioner (NP) told nursing staff to hold Resident #27's insulin when the blood glucose was below 100 mg/dL. The nurse stated the NP provided no specific parameters for holding the insulin other than below 100 mg/dL. According to LVN E she had not observed the resident with any signs/symptoms of [DIAGNOSES REDACTED] (low blood glucose). Additionally, LVN E stated she did not notify the physician, NP or receive any orders related to holding the resident's insulin. The nurse was unable to recall where the information related to holding the resident's [MEDICATION NAME] had originated. LVN E stated she believed another nurse told her and holding the resident's insulin had been occurring since February 2015. MAR dated March 2015-[MEDICATION NAME] Regular-on 03/10/15 ordered to be administered before lunch. The resident's finger stick blood glucose result was 219 mg/dL. The explanation documented on the back of the MAR indicated [REDACTED]. MAR dated March 2015-[MEDICATION NAME] Regular-on 03/12/15 ordered to be administered before lunch. The resident's finger stick blood glucose result was 170. The explanation documented on the back of the MAR indicated [REDACTED]. MAR dated March 2015-[MEDICATION NAME] Regular-on 03/18/15 ordered to be administered before lunch. The resident's finger stick blood glucose result was 187. The explanation documented on the back of the MAR indicated [REDACTED]. MAR dated March 2015-[MEDICATION NAME] Regular-on 03/20/15 ordered to be administered before lunch. The resident's finger stick blood glucose result was 174. The explanation documented on the back of the MAR indicated [REDACTED]. Record review of Resident #27's documented meal intake for 03/10/15 reflected there was no documented intake for the entire day. On 03/12/15 the documented meal intake for lunch was 100 percent, on 03/18/15 it was 25 percent and on 03/20/15 it was 100 percent. MAR dated March 2015-[MEDICATION NAME]-on 03/22/15 ordered to be administered before breakfast. The resident's finger stick blood glucose result was 74 mg/dL. The explanation documented on the back of the MAR indicated [REDACTED]. MAR dated March 2015-[MEDICATION NAME]-on 03/23/15 ordered to be administered before breakfast. The resident's finger stick blood glucose result was 100 mg/dL. The explanation documented on the back of the MAR indicated [REDACTED]. Record review of Resident #27's documented meal intake for 03/23/15 reflected the resident consumed 100 percent of the breakfast meal. An interview with LVN D on 03/26/15 at 5:20 p.m. revealed she was the charge nurse on duty on 03/22/15 and 03/23/15 and had held the insulin for Resident #27. LVN D stated she held the resident's insulin because the resident's blood glucose was below 100 mg/dL. LVN D further stated normal blood glucose ranged from 70 to 100 mg/dL and she had used her nursing judgment to hold the insulin. Additionally, LVN D stated she had informed the NP later in the day of the resident's blood glucose results and of holding the insulin. LVN D further stated she did not recall what the NP said after he was informed but she did not receive any new orders and forgot to document the conversation. Review of nurse's notes for the month of March 2015 revealed there was no documentation the resident's physician had been notified of the nurses holding Resident #27's insulin. On 03/25/15 the facility's policy/procedures related to sliding scale insulin and blood glucose parameters was requested from the Corporate Nurse. On 03/25/15 at 5:05 p.m. the Corporate Nurse stated there was no specific policy/procedure related to sliding scale insulin administration or blood glucose parameters. She further stated nurses should follow physician's orders [REDACTED]. On 03/27/15 at 8:50 a.m. RN MM provided the facility's drug reference book, "Nursing2014 Drug Handbook 34th edition" and identified it as the facility's current drug reference. According to page 748, [MEDICATION NAME]should be administered 5-10 minutes before a meal. An interview was conducted with the Director of Nurses (DON) on 03/27/15 at 11:23 a.m. The DON was queried about what she expected nursing staff to do if insulin was held. The DON stated she expected nurses to call the physician for instructions. The DON was queried about the facility's policies and procedures related to parameters for holding insulin. The DON stated there were no policies/procedures but she planned to involve the physicians in the development of polices/procedures. When queried if she was aware nurses were indiscriminately holding insulin for Resident #27, the DON replied not until it had been identified by the surveyor. During the interview the DON was queried about what training had been provided to nursing staff to ensure they were competent in caring for resident's diagnosed with [REDACTED]. When queried about any specific in-services related to care of residents diagnosed with [REDACTED]. She further stated she was unsure of what had been provided prior to her employment at the facility. The DON stated she believed LVN N "panicked" and failed to notify the physician when he realized there was no [MEDICATION NAME]available for Resident #5. The website www.[MEDICATION NAME].com <http://www.[MEDICATION NAME].com> was viewed on 03/31/15 and the section related to warnings and precautions reflected, "Any change of insulin dose should be made cautiously and only under medical supervision. Changing from one insulin product to another or changing the insulin strength may result in the need for a change in dosage." The facility's Plan of Removal, dated 03/25/15, was accepted on 03/26/15 and reflected, "On 3/24/2015 at roughly 5:30 p.m. the facility determined that there was no [MEDICATION NAME]in the medication cart for Resident #5 nor was there any [MEDICATION NAME] in the facility's emergency medication kit." The pharmacy was notified of the need to refill the [MEDICATION NAME]and the insulin arrived at the facility on 03/24/15 at 7:45 p.m. All medication carts in the facility were inspected to ensure insulin was present for residents with orders for insulin. LVN C was suspended on 03/24/15. Starting on 3/25/2015, the pharmacy will stock [MEDICATION NAME]in all facility emergency medication kits. In-services were provided to nursing staff as follows: a) Insulin administration, physician orders, validation of physician orders [REDACTED]. b) Proper labeling of insulin bottles, proper amount/dosage, labels matching MAR. c) The six rights of medication administration (the right patient, right medication, right dose, right time, right route and right documentation). d) Verbal orders for drugs and treatments shall be received only by licensed nurses. Verbal orders must be properly recorded immediately. e) Medication refills need to be ordered no less than three (3) days prior to the last dosage being administered. The plan of removal further reflected post-test were being administered to all available nursing staff. Unavailable nursing staff would be tested prior to them working on units. On 3/25/2015 and continuing for the next 90 days, Unit Managers or designees would make bi-weekly audits for insulin availability. On 3/24/2015 and continuing for the next 90 days, the night nurse or designee would verify insulin availability per physician orders [REDACTED]. The orientation of new hires would include training on proper verification of insulin availability per physician orders. Unit Managers or designee will conduct bi-weekly audits of MARS to ensure there have been no incidents of nurses holding scheduled insulin. The orientation of new hires will include training on proper insulin administration and documentation for holding insulin per physician orders. The Administrator/Designee and Director of Nursing/Designee will inspect the results of the bi-weekly audits and the insulin availability verification form during the weekly Standards of Care meeting. Bi-monthly and for the next 90 days the Pharmacy Consultant will observe medication administration to ensure insulin is being properly administered. The Director of Nursing/Designee will meet with Unit Managers and review the results of the bi-weekly audits of MARs during the weekly Standards of Care meeting. Interviews were conducted with nursing staff representing all three shifts, weekends and PRN (as needed) as follows: Interviews were conducted on 03/26/15 between from 10:50 a.m. to 5:20 p.m. with the following nurses, LVN D, H, U, V, W, X, Y, AA, CC, DD, EE, FF, GG, HH, II, JJ, and LL. RN E, RN BB, RN MM and RN Z. On 03/27/15 interviews were conducted with LVN NN and LVN KK at 12:10 a.m. and 1:00 a.m. respectfully. All nurses interviewed stated they had received the above in-service training and post-test. The nurses were knowledgeable in the different types of insulin and the rate of action different types of insulin. The nurses verbalized they were aware to only administer insulin according to physician orders [REDACTED]. All nurses were aware of the availability and location of insulin in the emergency medication kits. Observation of facility emergency medication kits were conducted on 03/27/15 on the Schepps Unit at 10:00 a.m., the NCH-1 Unit at 10:12 a.m., and the NCH-3 Unit at 10:20 a.m. All three units had specific kits containing various types of insulin for use in case of an emergency. On 03/27/15 the IJ was removed. On 03/27/15 at 1:40 p.m., the Administrator, and DON were informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. A list provided by the DON on 03/25/15 reflected there were 57 residents in the facility who received insulin according to a sliding scale and 48 residents who received routine insulin.

Based on observation, interview, and record review, it was determined the Administrator and DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (Resident #5, #6 and #27) of 27 residents reviewed for quality of care. 1) The ADM failed to monitor the DON to ensure she carried out her responsibilities to ensure Resident #5's, #6's and #27's needs were met by the nursing staff to include [DEVICE] feeding and insulin administration. Resident #6 ' s liquid nutritional feedings were being administered by the nursing staff by mouth prior to attempting bolus feeds and were not being thickened to a nectar thick consistency per doctor orders to prevent silent aspiration. An Immediate Jeopardy (IJ) was identified on 03/24/15. While the IJ was removed on 03/27/15, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" , due to the facility was still monitoring the effectiveness of the Plan Removal. This deficient practice could affect the fifteen residents with gastrostomy tubes and could result in complications relating to aspiration, which could place the residents as risk for damage to their lungs, pneumonia, repeated episodes of choking and frequent colds, vomiting, and a decreased quality of life. These failures could affect the 48 residents identified by the facility who received routine insulin and the 57 residents identified by the facility who received insulin according to a sliding scale (Sliding scale insulin-a set of instructions for administering insulin dosages based on specific blood glucose readings) and created the potential for residents to have severe [MEDICAL CONDITION] (high blood glucose) and to experience diabetic complications including amputations, [MEDICAL CONDITIONS] and kidney disease and death. Findings included: 1) Resident #6 ' s annual MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was assessed as severely cognitively impaired for daily decision making. Resident #6 required extensive assistance by one staff for eating, required the use of a feeding tube and a mechanically altered diet. Resident #6's received 51 percent or more of his nutritional via [DEVICE]. A [DEVICE] is a tube inserted through the abdomen into the stomach for the purpose of administering water, liquid nutrition and medications. Resident #6 was initially observed during rounds on 03/22/2015 at 2:17 PM sitting front of the nurses' station. During this observation, the weekend charge nurse, LVN L, described the resident as totally dependent on staff for all ADLs, alert and oriented to person only, incontinent, confused and forgetful, and wearing an abdominal binder because he had pulled out his [DEVICE] within the past week. LVN L said Resident #6 did not speak English and only said a few words. Resident #6's care plan dated 08/21/14 reflected he had the potential for a nutritional problem related to his [DEVICE] diet restriction. The goal was he would receive pleasure feedings of a pureed diet if he could be fed by staff and would receive bolus feedings five times a day. Speech Therapy Plan of Care Form with a baseline date of 10/13/14 reflected an evaluation was completed and Resident #6 had severe oropharyngeal dysphagia with mechanical soft food and thin liquids. "Oropharyngeal dysphagia occurs when certain conditions weaken throat muscles, making it difficult to move food from the mouth into the throat and esophagus when swallowing is initiated. This could result in a person choking, gagging or coughing when trying to swallow, or have the sensation of food or fluids going down the windpipe (trachea) or up the nose. This may lead to pneumonia (http://www.mayoclinic.org/diseases-conditions/dysphagia/basics/causes/con- 444, 04/09/15). " The SLP changed the diet to pureed food, nectar thick liquids after the evaluation was completed because, "The resident ran a runny nose, was coughing, and sneezing during PO intake, decreased oral/pharyngeal function and increased risk for airway obstruction and aspiration." An interview on 03/24/15 at 1:00 PM with the SLP revealed she worked with Resident #6 in the past and he had admitted into the facility with orders for nothing by mouth. She stated she worked very slowly with tactile stimulation on his lips because he was very apprehensive to have anything touch his mouth. She stated after a while, he began to accept lip stimulation, then sugar free flavored sprays, then eventually mechanical soft food with honey thick liquids. The SLP thought Resident #6 admitted with a bolus for feedings and had it the whole time he had been a resident. She stated he went to the hospital recently and his diet was downgraded to pureed pleasure feeds and bolus feedings. The SLP said Resident #6's bolus feeds were to be done via his [DEVICE], not his mouth, because the nutritional supplement was not a thickened liquid. She stated bolus feedings were when the supplement/nutrition was delivered via his [DEVICE]. March 2015 Physicians Orders reflected Resident #6 had a diet order for pureed texture, nectar thick consistency, with resident being able to have pleasure feeds with trained staff only. The order was for [MEDICATION NAME] 2.0 one can two times a day for enteral feed and 1 ½ can of [MEDICATION NAME] two times a day. The Physicians Order did not reflect what to do if the resident refused his [DEVICE] feedings. A Dysphagia Evaluation dated 10/28/14 reflected the reason for the assessment was because Resident #6 had symptoms of coughing and choking with oral intake, a runny nose and weight loss. The evaluation determined that nectar thick liquids were recommended at that time. The resident was documented at being risk for silent aspiration and the diet order recommendation remained a pureed diet with nectar thick liquids. Silent aspiration is when there is no outward signs of swallowing difficulty; therefore, secretions, food, or liquid enter into the airway, past the vocal folds, and no cough, throat clear or distress occurs (http://www.everythingspeech.com/articles/silent-aspiration, 04/01/15). A Safe Swallow Strategies form dated 12/02/14 reflected: 1. Current Diet: Pureed/Nectar thick 2. Thicken all liquids to Nectar consistency. Thicken all liquids using thickening powder. All liquids include water, milk, juice, coffee, soda, ice cream, milkshakes, cream soups, clear broths~ anything that can be eaten. 3. Recommend assistance and supervision with feeding. A physician ' s progress note dated 01/14/15 reflected Resident #6 was seen at the request of staff due to a fever and a cough. Staff reported multiple residents on the secured unit were having upper respiratory symptoms. Resident was on [MEDICATION NAME] due to symptoms of the flu and was started on a Z-Pak (antibiotic) due to an increased risk of secondary bacterial infection. An interview with LVN N on 03/23/15 at 11:50 AM revealed he fed Resident #6 the nutritional supplement through his mouth rather than through his [DEVICE]. He stated the resident trusted him more now than when he first started working on the unit and that was why he did it. He stated he tried to thicken the nutritional supplement in the past, but the consistency never seemed right and was too thick, so he now administered it at regular consistency. The care plan did not reflect the resident could be fed his nutritional supplement through his mouth if he refused his bolus feeds, nor did the care plan reflect the nutritional supplement had to be thickened to a certain consistency prior to being administered by mouth. An interview with LVN N on 03/24/15 at 1:15 PM with the SLP revealed when the SLP asked LVN N how he administered Resident #6's bolus feedings. He replied that he always just gave it by mouth, about 2 ½ cups worth. The SLP asked him how he got it to nectar thick consistency and he replied he had tried a few times to add a spoon of thickener but it made it too thick. She said he should have tried a half spoon of thickener instead. He did not reply. LVN N stated that the 2:00 PM bolus feeding was given to the resident before lunch. When queried why he had given it three hours early, he said when he tried to give the resident his bolus at 2:00 PM, he often would not accept it, so he gave it to him earlier. LVN N stated he also gave Resident #6 his 10:00 AM bolus feeding and 11:00 AM bolus feeding. He revealed the resident was administered approximately five cups of nutritional supplement orally within a one hour time frame. An interview with LVN C on 03/24/15 at 4:05 PM revealed he had been working on the secured unit for three weeks. He stated Resident #6 got his next bolus feeding at 6:00 PM that evening. He stated when he administered the resident's nutritional supplement, the resident would sometimes swat at his head to indicate he did not want the nurse to give him food via his bolus, so he would give it by mouth. LVN C stated he did not thicken the supplement and it was about the consistency of thin milk. An observation on 03/24/15 at 5:12 PM revealed LVN C and MA T in Resident #6 ' s room. LVN C flushed 60 cc of water into his [DEVICE] via a plunger on the syringe. LVN C did not check the [DEVICE] for placement or residuals prior to the water flush. The resident screamed out when the water was plunged into his [DEVICE] and was visibly agitated, grimacing and moving his arms in a defensive position. MA T tried to calm the resident down by talking to him. LVN C poured the [MEDICATION NAME] 2.0 supplement directly into a cup and attempted to pour it twice into the resident's [DEVICE]. LVN C did not thicken the [MEDICATION NAME] prior to putting it in his [DEVICE]. When he tried to pour it into the [DEVICE], the resident swiped at his hand and most of the [MEDICATION NAME] spilled on the floor. The LVN stated, "See! This is why I have to give it to him by mouth. " MA T told LVN C to try and put some music on for Resident #6 to help distract him but the nurse did not put on any music. He got another container of [MEDICATION NAME] 2.0, poured it into a cup, did not thicken it, and tried to give it orally to Resident #6. The resident resisted. LVN C gave the resident the cup of formula but he did not drink it initially. MA T said, "Maybe you should just start pouring it into his mouth ", LVN C proceeded to administer it orally. Resident #6 attempted to take the cup from LVN C several times. LVN C let the resident take the cup a couple of times and drink from the cup with him standing by watching; sometimes he held the cup with the resident holding it at the same time. The resident had jerky arm movements and his ability to drink from the cup unassisted appeared difficult. LVN C stopped giving [MEDICATION NAME] 2.0 after about a minute passed and measured about 35 cc of [MEDICATION NAME] left it the cup. He said he was throwing it out because the resident drooled and there was too much of the resident's saliva in it. LVN C got another cup and poured the rest of the [MEDICATION NAME] from the original container in it. The resident refused to drink it after a few sips. LVN C said he would try again later. There were 60 cc remaining in the cup. MA T stated the [MEDICATION NAME] 2.0 came in a 250ml container. LVN C was queried during the oral administration of the [MEDICATION NAME] if it was dangerous to give it to the resident. He replied, "No. " He said he had never seen Resident #6 choke or aspirate before while giving it to him. According to the liquid measurements of [MEDICATION NAME] that remained, Resident #6 was given 155ml of his 250 ml of enteral feeding. An Immediate Jeopardy (IJ) was identified on 03/24/15 at 7:40 PM. On 03/24/15 at 7:40 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time.While the IJ was removed on 03/27/15 at 2:00 PM, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern", due to the facility was still monitoring the effectiveness of the Plan Removal. Immediate action taken by the facility after the IJ notification included: - On 3/24/2015, LVN C was removed from the unit and suspended from work at approximately 6pm for failure to follow physician orders [REDACTED]. On 3/25/15 at 9:30 AM, LVN C was interviewed regarding occurrences on 3/24/15 and Joseph offered no explanation as to his actions so he was terminated at this time. - LVN N was in-serviced on insulin administration and suspended on 03/26/15. The DON stated that when interviewed, LVN told them he always thickened the resident ' s formula when administered orally. - The resident was assessed on 3/24/2015 by LVN M, for signs and symptoms of aspiration related to receiving thin liquids. No signs/symptoms were noted. (Attachment #3) - On 3/24/2015, the NP was notified regarding the incident. - On 3/25/2015, the resident ' s responsible party was notified regarding the incident. - On 3/24/2015, the order for administration of [MEDICATION NAME] 2.0 was clarified by Medicare Nurse GGG to show route and thickening consistency of nectar and updated MAR given to 3/24/15 charge nurse on 10-6 shift. - On 3/24/2015, a stat X-ray of the lungs was ordered to rule out aspiration. Results received 3/25/15 and copy of x-ray attached was provided. - On 3/25/2015, a new order was ordered by MD for a Modified [MEDICATION NAME] Swallow Study. MBSS to be completed on 3/26/15. (Attachments #4 and #5) - On 3/25/2015 the resident ' s care plan was reviewed and updated by Medicare Nurse GGG to reflect clarified physician orders. - On 3/25/2015, 33 residents were identified with physician's order [REDACTED]. On 3/25/15 all residents with thickened liquid doctor ' s orders were audited. (Attachment #6) The facility's Plan of Removal, dated 03/25/15, reflected, " ...The following in-services were provided on March 25, 2015, in-service for all nursing staff (RNs, LVNs, CNAs, and RNAs): 1. Title: Thickening Liquids-Proper nectar consistency, Proper honey consistency, Proper pudding consistency, and Proper stirring instructions 2. Title: Enteral Feeding Administration- Proper formula delivery, Proper use of enteral equipment, Verification of physician order, Proper procedures for enteral tube flushing, Proper syringe administration to end of feeding tube, Gravity method techniques, Never push feeding with plunger or syringe, When to discontinue feedings. 3. Title: Interventions for dealing [MEDICAL CONDITION] (TBI) residents, dementia residents, and difficult or combative residents. A post-test will be administered by the (RN, DON) or designee for the above mentioned in-services to ensure competency. Completion Date: All available staff will complete post-test by end of business 3/26/15. The Plan of Removal's systemic change to prevent reoccurrence included, " 1) Starting 3/25/2015 and continuing for 90 days, the DON or designee will conduct observation rounds at resident bedside of enteral nutrition administration and review documentation for residents with enteral feedings twice weekly to ensure proper administration of enteral feeding/bolus feeding and that the administration is consistent with physician's orders [REDACTED]. 2) Starting 3/25/2015 and continuing for 90 days, the DON or designee will conduct observation rounds in resident dining areas twice weekly for residents with physician's order [REDACTED]. From 03/24/14-03/27/14, 26 nursing staff members completed in-services and a post-test to ensure competency regarding enteral [DEVICE] feedings. Interviews were conducted with the following: · 6:00 AM- 2:00 PM Staff: LVN V, LVN X, LVN Y, UM F, RN Z, RN BB, LVN H, LVN FF, LVN GG, LVN LL, LVN MM, LVN M · 2:00 PM-10:00 PM: LVN W, LVN CC, LVN DD, LVN EE, LVN HH, RN NN · 10:00 PM- 6:00 PM: LVN AA, LVN II, LVN JJ, LVN KK, LVN D, LVN NN · PRN and Weekends: LVN J, LVN U An observation and interview on 03/25/15 at 9:13 AM revealed the SLP was in the dining room stirring thickener into Resident #6 ' s [MEDICATION NAME] 2.0 with LVN N, the DON and the RD present. The SLP said she was making sure it was nectar thick and was thickening it herself. She stood next to LVN N while he orally administered it to the resident. LVN N was asked how Resident #6 ' s medications were administered and he stated via the [DEVICE] if the resident let him, or else he administered them by mouth. He stated the [DEVICE] was small and could take a long time for medications and formula to get down. An interview with the SLP on 03/25/15 at 9:20 AM revealed that a swallow study was in the process of being scheduled and the resident was not at risk for silent aspiration. The SLP said silent aspiration was when a resident drank or ate something, started choking, but was not making any sounds. She said the resident was capable of coughing but did not cough very often. SLP was queried where she got her information that Resident #6 was not at risk of silent aspiration. She replied from his Dysphagia Evaluation swallow study; that he had three of them in the past. SLP was showed the most recent swallow study from October 2014 where it indicated the resident was at risk for silent aspiration. She responded that she did not notice that one and she must have been thinking about one previously from July 2014. An interview with the DON occurred on 03/27/15 at 10:32 AM regarding the Immediate Jeopardy. She stated all the nurses were trained upon hire, received on the floor training and in-services. She stated [DEVICE] and enteral feedings were discussed only upon hire. She said the Staffing Development Nurse did all the initial training. The DON stated the facility did a general competency test and a general orientation with the nurses but did not know if there was a specific question related to enteral [DEVICE] feedings on it. The DON was queried what type of plan was in place to monitor enteral [DEVICE] feedings on the floor prior to the immediate jeopardy. She replied there was no monitoring being done on the floor; no routine checks. She said it was a general competency that nurses should have. The DON did not know if there had been any in-services completed related to enteral [DEVICE] feedings because she had only worked at the facility for two months. When asked how she thought the IJ occurred, she replied it was a breakdown in the thickening of the liquid and the staff were not verifying the doctor orders or the resident ' s diet. The DON did not recall the QA process addressing any areas of concern related to enteral [DEVICE] feedings and diet orders. Immediate action taken by the facility after the IJ notification included: - On 3/24/2015, LVN C was removed from the unit and suspended from work at approximately 6pm for failure to follow physician orders [REDACTED]. On 3/25/15 at 9:30 AM, LVN C was interviewed regarding occurrences on 3/24/15 and Joseph offered no explanation as to his actions so he was terminated at this time. - - LVN N was in-serviced on insulin administration and suspended on 03/26/15. The DON stated that when interviewed, LVN told them he always thickened the resident ' s formula when administered orally. - - The resident was assessed on 3/24/2015 by LVN M, for signs and symptoms of aspiration related to receiving thin liquids. No signs/symptoms were noted. (Attachment #3) - On 3/24/2015, the NP was notified regarding the incident. - On 3/25/2015, the resident ' s responsible party was notified regarding the incident. - On 3/24/2015, the order for administration of [MEDICATION NAME] 2.0 was clarified by Medicare Nurse GGG to show route and thickening consistency of nectar and updated MAR given to 3/24/15 charge nurse on 10-6 shift. - On 3/24/2015, a stat X-ray of the lungs was ordered to rule out aspiration. Results received 3/25/15 and copy of x-ray attached was provided. - On 3/25/2015, a new order was ordered by MD for a Modified [MEDICATION NAME] Swallow Study. MBSS to be completed on 3/26/15. (Attachments #4 and #5) - On 3/25/2015 the resident ' s care plan was reviewed and updated by Medicare Nurse GGG to reflect clarified physician orders. - On 3/25/2015, 33 residents were identified with physician's order [REDACTED]. On 3/25/15 all residents with thickened liquid doctor ' s orders were audited. (Attachment #6) The facility's Plan of Removal, dated 03/25/15, reflected, " ...The following in-services were provided on March 25, 2015, in-service for all nursing staff (RNs, LVNs, CNAs, and RNAs): 1. Title: Thickening Liquids-Proper nectar consistency, Proper honey consistency, Proper pudding consistency, and Proper stirring instructions 2. Title: Enteral Feeding Administration- Proper formula delivery, Proper use of enteral equipment, Verification of physician order, Proper procedures for enteral tube flushing, Proper syringe administration to end of feeding tube, Gravity method techniques, Never push feeding with plunger or syringe, When to discontinue feedings. 3. Title: Interventions for dealing [MEDICAL CONDITION] (TBI) residents, dementia residents, and difficult or combative residents. The Plan of Removal's systemic change to prevent reoccurrence included, " 1) Starting 3/25/2015 and continuing for 90 days, the DON or designee will conduct observation rounds at resident bedside of enteral nutrition administration and review documentation for residents with enteral feedings twice weekly to ensure proper administration of enteral feeding/bolus feeding and that the administration is consistent with physician's orders [REDACTED]. 2) Starting 3/25/2015 and continuing for 90 days, the DON or designee will conduct observation rounds in resident dining areas twice weekly for residents with physician's order [REDACTED]. After the Plan of Removal was accepted, and an interview with the ADM on 03/27/15 at 10:59 AM revealed he had daily stand-up meetings with all disciplines. During those meetings, staff brought up concerns and the 24-hour report was covered. The ADM stated he had standard of care meetings weekly where topics such as weights and psychoactive medication were discussed. He also stated there was a daily meeting regarding any falls that had occurred. The ADM stated all the areas of concern are brought to the monthly Quality Assurance meetings, tracked and trended. The ADM stated when there were certain concerns, the facility would complete an audit and tracking depended on the area of concern by the ADM, DON and Unit Managers and brought back to the Quality Assurance Meetings. If an area of concern did not improve, the ADM stated he would discuss it as a team and change it, and try to find the root cause of the problem. After a concern was identified, the ADM would address it by completing a plan of action, assigning someone to track and trend it. Regarding bolus feedings, the ADM stated there needed to be continual training to the staff members specific to those things, chart audits related to physician orders [REDACTED]. He stated that maybe the sample size audited needed to be increased. The ADM stated the QA process had not identified any enteral feeding issues since he had been working at the facility, which was two months. A list of personnel provided by the HR director on 03/23/15 reflected the Administrator was hired on 08/08/14 and the DON was hired on 01/01/15. The ADM ' s job description, reflected, " PURPOSE of YOUR JOB POSITION: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality of care can be provided to our residents at all times, ..., DUTIES and RESPONSIBILITIES: · Plan, organize, implement, evaluate and direct the facility ' s programs and activities. · Develop and maintain written policies and procedures that govern the operation of the facility. · Make routine inspections of the facility to make assure the established policies and procedures are being met and followed. · Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. · Review and check competence of work force and make necessary adjustments/corrections as required. 2) "On 3/24/2015 at roughly 5:30 p.m. the facility determined that there was no [MEDICATION NAME]in the medication cart for Resident #5 nor was there any [MEDICATION NAME] in the facility's emergency medication kit." The pharmacy was notified of the need to refill the [MEDICATION NAME]and the insulin arrived at the facility on 03/24/15 at 7:45 p.m. All medication carts in the facility were inspected to ensure insulin was present for residents with orders for insulin. LVN C was suspended on 03/24/15. Starting on 3/25/15, the pharmacy will stock [MEDICATION NAME]in all facility emergency medication kits. In-services were provided to nursing staff as follows: a) Insulin administration, physician orders, validation of physician orders [REDACTED]. b) Proper labeling of insulin bottles, proper amount/dosage, labels matching MAR. c) The six rights of medication administration (the right patient, right medication, right dose, right time, right route and right documentation). d) Verbal orders for drugs and treatments shall be received only by licensed nurses. Verbal orders must be properly recorded immediately. e) Medication refills need to be ordered no less than three (3) days prior to the last dosage being administered. The plan of removal further reflected post test were being administered to all available nursing staff. Unavailable nursing staff would be tested prior to them working on units. On 3/25/2015 and continuing for the next 90 days, Unit Managers or designees would make bi-weekly audits for insulin availability. On 3/24/2015 and continuing for the next 90 days, the night nurse or designee would verify insulin availability per physician orders [REDACTED]. The orientation of new hires would include training on proper verification of insulin availability per physician orders. Unit Managers or designee will conduct bi-weekly audits of MARS to ensure there have been no incidents of nurses holding scheduled insulin. The orientation of new hires will include training on proper insulin administration and documentation for holding insulin per physician orders. The Administrator/Designee and Director of Nursing/Designee will inspect the results of the bi-weekly audits and the insulin availability verification form during the weekly Standards of Care meeting. Bi-monthly and for the next 90 days the Pharmacy Consultant will observe medication administration to ensure insulin is being properly administered. The Director of Nursing/Designee will meet with Unit Managers and review the results of the bi-weekly audits of MARs during the weekly Standards of Care meeting. Interviews were conducted with nursing staff representing all three shifts, weekends and PRN (as needed) as follows: Interviews were conducted on 03/26/15 between from 10:50 a.m. to 5:20 p.m. with the following nurses, LVN D, H, U, V, W, X, Y, AA, CC, DD, EE, FF, GG, HH, II, JJ, and LL. RN E, RN BB, RN MM and RN Z. On 03/27/15 interviews were conducted with LVN NN and LVN KK at 12:10 a.m. and 1:00 a.m. respectfully. All nurses interviewed stated they had received the above in-service training and post-test. The nurses were knowledgeable in the different types of insulin and the rate of action different types of insulin. The nurses verbalized they were aware to only administer insulin according to physician orders [REDACTED]. All nurses were aware of the availability and location of insulin in the emergency medication kits. Observation of facility emergency medication kits were conducted on 03/27/15 on the Schepps Unit at 10:00 a.m., the NCH-1 Unit at 10:12 a.m., and the NCH-3 Unit at 10:20 a.m. All three units had specific kits containing various types of insulin for use in case of an emergency. An interview was conducted with the Director of Nurses (DON) on 03/27/15 at 11:23 a.m. The DON was queried about what she expected nursing staff to do if insulin was held. The DON stated she expected nurses to call the physician for instructions. The DON was queried about the facility's policies and procedures related to parameters for holding insulin. The DON stated there were no policies/procedures but she planned to involve the physicians in the development of polices/procedures. When queried if she was aware nurses were indiscriminately holding insulin for Resident #27, the DON replied not until it had been identified by the surveyor. During the interview the DON was queried what training had been provided to nursing staff to ensure they were competent in caring for resident's diagnosed with [REDACTED]. MORE THAN LVN A WHAT? When queried about any specific in-services related to care of residents diagnosed with [REDACTED]. She stated she was unsure of what had been provided prior to her employment at the facility. The DON stated she believed LVN N "panicked" and failed to notify the physician when he realized there was no [MEDICATION NAME]available for Resident #5. CMS form 672, Resident Census and Conditions of Residents, signed by the DON on 03/22/15, reflected 15 residents with [DEVICE]s and per the interview with the DON, there were four residents including Resident #6 who LVN C and LVN N were responsible for administering medications via their [DEVICE]s. A list provided by the DON on 03/25/15 reflected there were 57 residents in the facility who received insulin according to a sliding scale and 48 residents who received routine insulin.

Based on observation, interview and record review, it was determined the facility failed to ensure the medication error rate was less than 5 percent. Thirty opportunities were observed with a total of three errors, resulting in a ten percent error rate for four residents (Resident #5, #27 and #31). A total of nine residents were observed during the medication pass on 03/23/15 and 03/24/15. 1) LVN C administered the long acting insulin, [MEDICATION NAME] to cover Resident #5's elevated blood glucose instead of the short acting insulin [MEDICATION NAME] as ordered by the physician. An IJ was identified on 03/24/15. The Administrator and DON were notified on 03/24/15 at 7:48 p.m. of the IJ and a Plan of Removal was requested at that time. 2) Licensed Vocational Nurse (LVN) A failed to administer insulin to Resident #27 before lunch according to physician's orders [REDACTED]. 3) Medication Aide (MA) B failed to administer [MEDICATION NAME] before meals according to manufactures specifications. These failures created the potential for residents to have severe [DIAGNOSES REDACTED] (low blood glucose), [MEDICAL CONDITION] (high blood glucose) and experience diabetic complications including coma, kidney failure and death. These failures could affect the 23 residents MA B was assigned to administer oral medications to, the seven residents with a [DIAGNOSES REDACTED]. Findings included: (1) Review of Resident #5's current Minimum Data Set assessment dated [DATE] revealed the resident was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5 was initially observed during rounds on 03/22/15 at 3:53 p.m. with LVN L. The resident was sitting in a Geri-chair in the dayroom. LVN L stated the resident was incontinent of bowel/bladder, cognitively impaired and required total care for all activities of daily living. Unit NCH 2- On 03/24/15 at 4:25 p.m. LVN C was observed to obtain a finger stick blood sample from Resident #5. The resident's blood glucose result was 213 milligrams per deciliter mg/dL. LVN C then administered 4 units of [MEDICATION NAME]subcutaneously into the right side of the resident's abdomen. ([MEDICATION NAME]is long-acting insulin used to treat diabetes.) LVN C was queried if he was going to administer any insulin to cover the resident's elevated blood glucose. LVN C stated Resident #5 was ordered to receive [MEDICATION NAME] (Rapid acting insulin used to treat diabetes) insulin but there was none available for the resident. LVN C stated, "She is out." LVN C was queried about the differences between the [MEDICATION NAME]he had administered incorrectly and the [MEDICATION NAME]that was ordered to be administered for the sliding scale blood glucose of 213 mg/dL. The nurse stated [MEDICATION NAME]was long acting insulin and [MEDICATION NAME] was short acting insulin. When queried why he administered the incorrect insulin the nurse stated he wanted to make sure the resident had "something" to treat her elevated blood glucose. LVN C stated he was aware the [MEDICATION NAME]was long acting and would not be effective in lowering the resident's elevated blood glucose quickly. LVN C further stated the [MEDICATION NAME] was ordered on the previous shift by the previous nurse but had not arrived. When queried if there was any [MEDICATION NAME] available in the facility's emergency medication kit, LVN C stated he did not know. Additionally, LVN C stated the resident had only been out of the insulin for his shift (evening) on 03/24/15. Resident #5's consolidated monthly physician's orders [REDACTED]. The orders reflected the resident was ordered to receive [MEDICATION NAME]according to a sliding scale before meals and at bedtime. The resident should have received 4 units of [MEDICATION NAME]instead of the [MEDICATION NAME]. The orders further reflected 4 units of [MEDICATION NAME]were ordered for a blood glucose level of 201 to 250 mg/dL. Resident #5's glucose result was 213 mg/dL. Additionally, the orders reflected 15 units of [MEDICATION NAME]was ordered to be administered at bedtime (8:00 p.m.) On 03/24/15 at 8:00 p.m. the resident would have received the 15 units of routinely scheduled [MEDICATION NAME] resulting in 19 units of [MEDICATION NAME]being administered when only 15 units were ordered by the physician. On 03/24/15 at 5:10 p.m. Unit Manager F (UM) was informed of the medication error. UM F stated insulin should have been ordered every 28 days regardless if the bottle was empty or not. On 03/24/15 at 5:20 p.m. UM F was observed to phone the pharmacy. UM F stated the pharmacy informed her the last time [MEDICATION NAME]for Resident #5 was delivered to the facility was 01/03/15. During the communication with the pharmacy UM F ordered the [MEDICATION NAME]for Resident #5. An interview with LVN N on 03/25/15 at 12:50 p.m. revealed he was the day shift charge nurse on 03/24/15. LVN N stated he was not aware the [MEDICATION NAME]for Resident #5 was not available. He further stated he only used it a few times, was unable to recall when he had used it last but the last time he used it there was insulin left. Additionally, LVN N stated he did not know what had happened to the [MEDICATION NAME] insulin. According to DiabetesNet.com viewed on 04/13/15, [MEDICATION NAME]starts to work about 20 minutes after taken, with a gradual rise (peak) in action over the next 1.75 to 2.25 hours. Action ends in 4.5 to 6 hours. [MEDICATION NAME]starts to work1 to 3 hours after taken and peaks in 8 to 10 hours. The action ends in 18 to 26 hours. According to the [MEDICATION NAME] package insert and label information viewed on DrugInserts.com on 04/13/15, the dose of [MEDICATION NAME]must be individualized based on clinical response. Blood glucose monitoring is essential in all patients receiving insulin therapy. The dosage of [MEDICATION NAME] is based on a medical conditions and response to treatment. Measure each dose very carefully because even small changes in the amount of insulin may have a large effect on blood sugar levels. [DIAGNOSES REDACTED] is the most common adverse reaction of insulin therapy, including [MEDICATION NAME]. Severe [DIAGNOSES REDACTED] can lead to unconsciousness or convulsions and may result in temporary or permanent impairment of brain function or death. On 03/27/15 at 8:50 a.m. RN MM provided the facility's drug reference book, "Nursing2014 Drug Handbook 34th edition" and identified it as the facility's current drug reference. According to page 748, [MEDICATION NAME]should be administered 5-10 minutes before a meal. (2) Unit Levy 3- On 03/23/15 at 11:30 a.m. LVN A was observed to obtain a finger stick blood sample from Resident #27. The resident's blood glucose result was 224 milligrams per deciliter (mg/dL). LVN A stated the resident was ordered to receive 25 units of regular insulin routinely before the lunch meal daily. LVN A stated she was holding the insulin because she (the nurse) was concerned Resident #27 would not eat well at lunch. LVN A stated recently she had frequently held the resident's insulin because the resident had not been eating well. According to LVN A there was an order to hold the routine insulin if the resident did not eat "well." LVN A was queried about how much of the lunch meal Resident #27 had to eat to be considered well. The nurse stated "50 percent." On 03/23/15 at 12:50 p.m. LVN A was observed to administer 25 units of [MEDICATION NAME] Regular insulin into Resident #27's upper left arm at 12:50 p.m. after the resident had completed the lunch meal. Resident #27's consolidated monthly physician's orders [REDACTED]. There were no parameters related to holding Resident #27's insulin. Review of Resident #27's entire clinical record on 03/23/15 revealed there were no orders related to holding the resident's insulin or any documentation the physician had been involved in the decision to hold the insulin. On 03/25/15 the facility's policy/procedures related to sliding scale insulin and blood glucose parameters was requested from the Corporate Nurse. On 03/25/15 at 5:05 p.m. the Corporate Nurse stated there was no specific policy/procedure related to sliding scale insulin administration or blood glucose parameters. She further stated nurses should follow physician's orders [REDACTED]. (3) Unit Levy 2- On 03/24/15 at 9:30 a.m. MA B was observed to prepare and administer medications to Resident #31. Medications included a 20 milligram capsule of [MEDICATION NAME] delayed release (reduces gastric secretions). Resident #31's consolidated monthly physician's orders [REDACTED]. According to the medication administration records the resident was to receive the medication at 7:30 a.m. daily. An interview with MA B on 03/24/15 at 10:00 a.m. revealed she did not administer the medication before the resident's breakfast meal because she had been administering medications downstairs on another floor. MA B stated Resident #31 had completed breakfast. MA B further stated she was responsible for passing oral medications on Unit Levy 1 (rooms 95 to 104) and on Unit Levy 2 (rooms 212 to 223). On 03/24/15 at 10:15 a.m. LVN H provided the facility's drug reference book, "Nursing2014 Drug Handbook 34th edition" and identified it as the facility's current drug reference. According to page 1026 the medication [MEDICATION NAME] delayed release should have taken one hour before meals. An interview was conducted with the Director of Nurses (DON) on 03/27/15 at 11:23 a.m. The DON was queried about what she expected nursing staff to do if insulin was held. The DON stated she expected nurses to call the physician for instructions. The DON was queried about the facility's policies and procedures related to parameters for holding insulin. The DON stated there were no policies/procedures but she planned to involve the physicians in the development of polices/procedures. When queried if she was aware nurses were indiscriminately holding insulin for Resident #27, the DON replied not until it had been identified by the surveyor. During the interview the DON was queried what training had been provided to nursing staff to ensure they were competent in caring for resident's diagnosed with [REDACTED]. When queried about any specific in-services related to care of residents diagnosed with [REDACTED]. She stated she was unsure of what had been provided prior to her employment at the facility. The DON stated she believed LVN N "panicked" and failed to notify the physician when he realized there was no [MEDICATION NAME]available for Resident #5. According to the American Diabetes Association's web site viewed on 03/31/15 it is important to treat symptoms of high blood sugar right away to help prevent complications. The American Diabetes Association recommends a fasting (before a meal) blood glucose level of 70-130 mg/dL and after meals less than 180 mg/dL. The facility's Plan of Removal was accepted on 03/26/15 and reflected, "On 3/24/2015 at roughly 5:30 p.m. the facility determined that there was no [MEDICATION NAME]in the medication cart for (Resident #5)nor was there any [MEDICATION NAME] in the facility's emergency medication kit." The pharmacy was notified of the need to refill the [MEDICATION NAME]and the insulin arrived at the facility on 03/24/15 at 7:45 p.m. All medication carts in the facility were inspected to ensure insulin was present for residents with orders for insulin. LVN C was suspended on 03/24/15. Starting on 3/25/2015, the pharmacy will stock [MEDICATION NAME]in all facility emergency medication kits. In-services were provided to nursing staff as follows: a) Insulin administration, physician orders, validation of physician orders [REDACTED]. b) Proper labeling of insulin bottles, proper amount/dosage, labels matching MAR. c) The six rights of medication administration (the right patient, right medication, right dose, right time, right route and right documentation). d) Verbal orders for drugs and treatments shall be received only by licensed nurses. Verbal orders must be properly recorded immediately. e) Medication refills need to be ordered no less than three (3) days prior to the last dosage being administered. The plan of removal further reflected post-test were being administered to all available nursing staff. Unavailable nursing staff would be tested prior to them working on units. On 3/25/2015 and continuing for the next 90 days, Unit Managers or designees would make bi-weekly audits for insulin availability. On 3/24/2015 and continuing for the next 90 days, the night nurse or designee would verify insulin availability per physician orders [REDACTED]. The orientation of new hires would include training on proper verification of insulin availability per physician orders. Unit Managers or designee will conduct bi-weekly audits of MARS to ensure there have been no incidents of nurses holding scheduled insulin. The orientation of new hires will include training on proper insulin administration and documentation for holding insulin per physician orders. The Administrator/Designee and Director of Nursing/Designee will inspect the results of the bi-weekly audits and the insulin availability verification form during the weekly Standards of Care meeting. Bi-monthly and for the next 90 days the Pharmacy Consultant will observe medication administration to ensure insulin is being properly administered. The Director of Nursing/Designee will meet with Unit Managers and review the results of the bi-weekly audits of MARs during the weekly Standards of Care meeting. Interviews were conducted with nursing staff representing all three shifts, weekends and PRN (as needed) as follows: Interviews were conducted on 03/26/15 between from 10:50 a.m. to 5:20 p.m. with the following nurses, LVN D, H, U, V, W, X, Y, AA, CC, DD, EE, FF, GG, HH, II, JJ, and LL. RN E, RN BB, RN MM and RN Z. On 03/27/15 interviews were conducted with LVN NN and LVN KK at 12:10 a.m. and 1:00 a.m. respectfully. All nurses interviewed stated they had received the above in-service training and post-test. The nurses verbalized they were knew to only administer insulin according to physician orders [REDACTED]. All nurses were aware of the availability and location of insulin in the emergency medication kits. Observation of facility emergency medication kits were conducted on 03/27/15 on the Schepps Unit at 10:00 a.m., the NCH-1 Unit at 10:12 a.m., and the NCH-3 Unit at 10:20 a.m. All three units had specific kits containing various types of insulin for use in case of an emergency. On 03/27/15 the IJ was removed and the Administrato and DON were informed on 03/27/15 at 1:40 p.m. the IJ was removed. While the IJ was removed on 03/27/15, the facility remained out of compliance at scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. A list provided by the DON on 03/25/15 reflected there were seven residents on Unit L3 and nine residents on Unit N2 with a [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to ensure a resident who was fed by a gastrostomy tube received appropriate treatment and services for two (Resident #6 and Resident #4) of three residents reviewed for gastrostomy tubes to prevent aspiration, aspiration pneumonia, dehydration, vomiting, a decreased quality of life and/or possible death. 1) Resident #6's liquid nutritional feedings were being administered by the nursing staff by mouth prior to attempting [DEVICE] feeds and were not being thickened to a nectar thick consistency per doctor orders to prevent silent aspiration. An Immediate Jeopardy (IJ) was identified on 03/24/15. While the IJ was removed on 03/27/15, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern", due to the facility still monitoring the effectiveness of the Plan Removal. 2) Resident #4 was disconnected from the feeding pump at times that were not ordered by the physician. This failure could result in potential weight loss. This deficient practice could affect the fifteen residents with gastrostomy tubes and could result in immediate choking and gagging, fluid going into the lung causing aspiration, damage to lungs, pneumonia, repeated episodes of choking and frequent colds, vomiting, a decreased quality of life and death. Findings included: 1) Resident #6's annual MDS assessment dated [DATE] reflected he was a [AGE] year-old male with an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was assessed as severely cognitively impaired for daily decision making. Resident #6 required extensive assistance by one staff for eating, required the use of a feeding tube and a mechanically altered diet. Resident #6's received 51 percent or more of his nutritional via [DEVICE]. A [DEVICE] is a tube inserted through the abdomen into the stomach for the purpose of administering water, liquid nutrition and medications. Resident #6 was initially observed during rounds on 03/22/2015 at 2:17 PM sitting front of the nurses' station. During this observation, the weekend charge nurse, LVN L, described the resident as totally dependent on staff for all ADLs, alert and oriented to person only, incontinent, confused and forgetful, and wearing an abdominal binder because he had pulled out his [DEVICE] within the past week. LVN L said Resident #6 did not speak English and only said a few words. Resident #6's care plan dated 08/21/14 reflected he had the potential for a nutritional problem related to his [DEVICE] diet. The goal was that he would receive pleasure feedings of a pureed diet if he could be fed by staff and would receive bolus feedings ([DEVICE] feedings) five times a day. A Speech Therapy Plan of Care Form with a baseline date of 10/13/14 reflected an evaluation was completed and Resident #6 had severe oropharyngeal dysphagia with mechanical soft food and thin liquids. "Oropharyngeal dysphagia occurs when certain conditions weaken throat muscles, making it difficult to move food from the mouth into the throat and esophagus when swallowing is initiated. This could result in a person choking, gagging or coughing when trying to swallow, or have the sensation of food or fluids going down the windpipe (trachea) or up the nose. This may lead to pneumonia (http://www.mayoclinic.org/diseases-conditions/dysphagia/basics/causes/con- 444, 04/09/15). " The SLP changed the diet to nectar thick liquids after the evaluation was completed because, "The resident ran a runny nose, was coughing, and sneezing during PO intake, decreased oral/pharyngeal function and increased risk for airway obstruction and aspiration." An interview on 03/24/15 at 1:00 PM with the SLP revealed she worked with Resident #6 in the past and he had admitted into the facility with orders for nothing by mouth. She stated she worked very slowly with tactile stimulation on his lips because he was very apprehensive to have anything touch his mouth. She stated after a while, he began to accept lip stimulation, then sugar free flavored sprays, then eventually mechanical soft food with honey thick liquids. The SLP thought Resident #6 admitted with a bolus for feedings and had it the whole time he had been a resident. She stated he went to the hospital recently and his diet was downgraded to pureed pleasure feeds and bolus feedings. The SLP said Resident #6's bolus feeds were to be done via his [DEVICE], not his mouth, because the nutritional supplement was not a thickened liquid. She stated bolus feedings were when the supplement/nutrition was delivered via his [DEVICE]. A Physician order [REDACTED].#6 reflect, "May give medications and bolus feedings PO of resident is able to tolerate". A Dysphagia Evaluation dated 10/28/14 reflected the reason for the assessment was because Resident #6 had symptoms of coughing and choking with oral intake, a runny nose and weight loss. The evaluation determined that nectar thick liquids were recommended at that time. The resident was documented at being risk for silent aspiration and the diet order recommendation remained a pureed diet with nectar thick liquids. Silent aspiration is when there is no outward signs of swallowing difficulty; therefore, secretions, food, or liquid enter into the airway, past the vocal folds, and no cough, throat clear or distress occurs (http://www.everythingspeech.com/articles/silent-aspiration, 04/01/15). A Safe Swallow Strategies form for Resident #6 dated 12/02/14 reflected: 1. Current Diet: Pureed/Nectar thick 2. Thicken all liquids to Nectar consistency. Thicken all liquids using thickening powder. All liquids include water, milk, juice, coffee, soda, ice cream, milkshakes, cream soups, clear broths~ anything that can be eaten. 3. Recommend assistance and supervision with feeding. March 2015 Physicians Orders reflected Resident #6 had a diet order for pureed texture, nectar thick consistency, with resident being able to have pleasure feeds with trained staff only. The start date for the order was 09/12/14. The order was for [MEDICATION NAME] 2.0 one can BID and 1 ½ cans BID. The March 2015 Physicians Order did not that any medications or [DEVICE] feedings could be given orally. An interview with LVN N on 03/23/15 at 11:50 AM revealed he fed Resident #6 the nutritional supplement through his mouth rather than through his [DEVICE]. He stated the resident trusted him more now than when he first started working on the unit and that was why he did it. He stated he tried to thicken the nutritional supplement in the past, but the consistency never seemed right and was too thick, so he now administered it at regular consistency. The care plan did not reflect the resident could be fed his nutritional supplement through his mouth if he refused his bolus feeds, nor did the care plan reflect the nutritional supplement had to be thickened to a certain consistency prior to being administered by mouth. An interview with LVN N and SLP occurred on 03/24/15 at 1:15 PM in the dining room. The SLP asked LVN N how he administered Resident #6's bolus feedings. He replied that he always just gave it by mouth, about 2 ½ cups worth. The SLP asked him how he got it to nectar thick consistency and he replied he had tried a few times to add a spoon of thickener but it made it too thick. She said he should have tried a half spoon of thickener instead. He did not reply to her. LVN N stated that the 2:00 PM bolus feeding was given to the resident before lunch around 11:00 AM. When queried why he had given it three hours early, he said when he tried to give the resident his bolus at 2:00 PM in the past, he often would not accept it, so he gave it to him earlier. LVN N stated he also gave Resident #6 his 10:00 AM bolus feeding as well that morning. He revealed the resident was administered approximately five cups of nutritional supplement orally within a one hour time frame. An interview with LVN C on 03/24/15 at 4:05 PM revealed he had been working on the secured unit for three weeks. He stated Resident #6 got his next bolus feeding at 6:00 PM that evening. He stated when he administered the resident's nutritional supplement, the resident would sometimes swat at his head to indicate he did not want the nurse to give him food via his bolus, so he would give it by mouth. LVN C stated he did not thicken the supplement and it was about the consistency of thin milk. An observation on 03/24/15 at 5:12 PM revealed LVN C and MA T in Resident #6's room. LVN C flushed 60 cc of water into his [DEVICE] via a plunger on the syringe. LVN C did not check the [DEVICE] for placement or residuals prior to the water flush. The resident screamed out when the water was plunged into his [DEVICE] and was visibly agitated, grimacing and moving his arms in a defensive position. MA T tried to calm the resident down by talking to him. LVN C poured the [MEDICATION NAME] 2.0 supplement directly into a cup and attempted to pour it twice into the resident's [DEVICE]. When he tried to pour it into the [DEVICE], the resident swiped at his hand and most of the [MEDICATION NAME] spilled on the floor. The LVN stated, "See! This is why I have to give it to him by mouth. " MA T told LVN C to try and put some music on for Resident #6 to help distract him but the nurse did not put on any music. He got another container of [MEDICATION NAME] 2.0, poured it into a cup, did not thicken it, and tried to give it orally to Resident #6. The resident resisted. LVN C gave the resident the cup of formula but he did not drink it initially. MA T said, "Maybe you should just start pouring it into his mouth ", LVN C proceeded to administer it orally. Resident #6 attempted to take the cup from LVN C several times. LVN C let the resident take the cup a couple of times and drink from the cup with him standing by watching; sometimes he held the cup with the resident holding it at the same time. The resident had jerky arm movements and his ability to drink from the cup unassisted appeared difficult. LVN C stopped giving [MEDICATION NAME] 2.0 after about a minute passed and measured about 35 cc of [MEDICATION NAME] left in the cup. He said he was throwing it out because the resident drooled and there was too much of the resident's saliva in it. LVN C got another cup and poured the rest of the [MEDICATION NAME] from the original container in it. The resident refused to drink it after a few sips. LVN C said he would try again later. There were 60 cc remaining in the cup. MA T stated the [MEDICATION NAME] 2.0 came in a 250ml container. LVN C was queried during the oral administration of the [MEDICATION NAME] if it was dangerous to give it to the resident. He replied, "No." He said he had never seen Resident #6 choke or aspirate before while giving it to him. According to the liquid measurements of [MEDICATION NAME] that remained, Resident #6 was given 155ml of his 250 ml of enteral feeding. An IJ was identified on 03/24/15. On 03/24/15 at 7:40 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Immediate action taken by the facility after the IJ notification included: - On 3/24/2015, LVN C was removed from the unit and suspended from work at approximately 6:00pm for failure to follow physician orders [REDACTED]. On 3/25/15 at 9:30 AM, LVN C was interviewed regarding occurrences on 3/24/15 and LVN C offered no explanation as to his actions so he was terminated at this time. - - LVN N was in-serviced on insulin administration and suspended on 03/26/15. The DON stated that when interviewed, LVN told them he always thickened the resident's formula when administered orally. - - The resident was assessed on 3/24/2015 by LVN M, for signs and symptoms of aspiration related to receiving thin liquids. No signs/symptoms were noted. (Attachment #3) - On 3/24/2015, the NP was notified regarding the incident. - On 3/25/2015, the resident's responsible party was notified regarding the incident. - On 3/24/2015, the order for administration of [MEDICATION NAME] 2.0 was clarified by Medicare Nurse GGG to show route and thickening consistency of nectar and updated MAR given to 3/24/15 charge nurse on 10-6 shift. - On 3/24/2015, a stat X-ray of the lungs was ordered to rule out aspiration. Results received 3/25/15 and copy of x-ray attached was provided. - On 3/25/2015, a new order was ordered by MD for a Modified [MEDICATION NAME] Swallow Study. MBSS to be completed on 3/26/15. (Attachments #4 and #5) - On 3/25/2015 the resident ' s care plan was reviewed and updated by Medicare Nurse GGG to reflect clarified physician orders. - On 3/25/2015, 33 residents were identified with physician's order [REDACTED]. On 3/25/15 all residents with thickened liquid doctor ' s orders were audited. (Attachment #6) The facility's Plan of Removal, dated 03/25/15, reflected, " ...The following in-services were provided on March 25, 2015, in-service for all nursing staff (RNs, LVNs, CNAs, and RNAs): 1. Title: Thickening Liquids-Proper nectar consistency, Proper honey consistency, Proper pudding consistency, and Proper stirring instructions 2. Title: Enteral Feeding Administration- Proper formula delivery, Proper use of enteral equipment, Verification of physician order, Proper procedures for enteral tube flushing, Proper syringe administration to end of feeding tube, Gravity method techniques, Never push feeding with plunger or syringe, When to discontinue feedings. 3. Title: Interventions for dealing [MEDICAL CONDITION] (TBI) residents, dementia residents, and difficult or combative residents. A post-test will be administered by the (RN, DON) or designee for the above mentioned in-services to ensure competency. Completion Date: All available staff will complete post-test by end of business 3/26/15. The Plan of Removal's systemic change to prevent reoccurrence included, " 1) Starting 3/25/2015 and continuing for 90 days, the DON or designee will conduct observation rounds at resident bedside of enteral nutrition administration and review documentation for residents with enteral feedings twice weekly to ensure proper administration of enteral feeding/bolus feeding and that the administration is consistent with physician's orders [REDACTED]. 2) Starting 3/25/2015 and continuing for 90 days, the DON or designee will conduct observation rounds in resident dining areas twice weekly for residents with physician's order [REDACTED]. From 03/24/14-03/27/14, 26 nursing staff members completed in-services and a post-test to ensure competency regarding enteral [DEVICE] feedings. Interviews were conducted with the following: · 6:00 AM- 2:00 PM Staff: LVN V, LVN X, LVN Y, UM F, RN Z, RN BB, LVN H, LVN FF, LVN GG, LVN LL, LVN MM, LVN M · 2:00 PM-10:00 PM: LVN W, LVN CC, LVN DD, LVN EE, LVN HH, RN NN · 10:00 PM- 6:00 PM: LVN AA, LVN II, LVN JJ, LVN KK, LVN D, LVN NN · PRN and Weekends: LVN J, LVN U An observation and interview on 03/25/15 at 9:13 AM revealed the SLP was in the dining room stirring thickener into Resident #6 ' s [MEDICATION NAME] 2.0 with LVN N, the DON and the RD present. The SLP said she was making sure it was nectar thick and was thickening it herself. She stood next to LVN N while he orally administered it to the resident. LVN N was asked how Resident #6 ' s medications were administered and he stated via the [DEVICE] if the resident let him, or else he administered them by mouth. He stated the [DEVICE] was small and could take a long time for medications and formula to get down. An observation was made on 03/27/15 of the revised nursing TARs which reflected a place for the nurse to initial when the resident refused his [DEVICE] feedings and indicated if the [MEDICATION NAME] was administered orally and thickened. An interview with the SLP on 03/25/15 at 9:20 AM revealed that a swallow study was in the process of being scheduled and the resident was not at risk for silent aspiration. The SLP said silent aspiration was when a resident drank or ate something, started choking, but was not making any sounds. She said the resident was capable of coughing but did not cough very often. SLP was queried where she got her information that Resident #6 was not at risk of silent aspiration. She replied from his Dysphagia Evaluation swallow study; that he had three of them in the past. SLP was showed the most recent swallow study from October 2014 where it indicated the resident was at risk for silent aspiration. She responded that she did not notice that one and she must have been thinking about one previously from July 2014. An interview with the DON occurred on 03/27/15 at 10:32 AM regarding the Immediate Jeopardy. She stated all the nurses were trained upon hire, received on the floor training and in-services. She stated [DEVICE] and enteral feedings were discussed only upon hire. She said the Staffing Development Nurse did all the initial training. The DON stated the facility did a general competency test and a general orientation with the nurses but did not know if there was a specific question related to enteral [DEVICE] feedings on it. The DON was queried what type of plan was in place to monitor enteral [DEVICE] feedings on the floor prior to the immediate jeopardy. She replied there was no monitoring being done on the floor; no routine checks. She said it was a general competency that nurses should have. The DON did not know if there had been any in-services completed related to enteral [DEVICE] feedings because she had only worked at the facility for two months. When asked how she thought the IJ occurred, she replied it was a breakdown in the thickening of the liquid and the staff were not verifying the doctor orders or the resident ' s diet. The DON did not recall the QA process addressing any areas of concern related to enteral [DEVICE] feedings and diet orders. The IJ was removed on 03/27/15. The ADM and DON were informed of the IJ removal on 03/27/15 at 2:00PM. While the IJ was removed on 03/27/15, the facility remained out of compliance at a severity level of "potential for more than minimal harm that is not immediate jeopardy" and a scope of "pattern" , due to the facility was still monitoring the effectiveness of the Plan Removal. 2)Resident #4's MDS assessment, dated 02/04/15,reflected the resident was a [AGE] year-old female who had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected Resident #4 had unclear speech, rarely could she understand others and rarely staff can understand her, and she had both short-term and long-term memory loss and she was severely cognitively impaired. Resident #4 was totally dependent on two staff for eating, toilet use transfers. She was non-ambulatory. She required extensive assistance of one staff for locomotion around the unit, personal hygiene and bathing. She required dressing with assistance of two staff. She was incontinent of both bowel and bladder. The MDS assessment also reflected Resident #4 received all nutrition from a gastrostomy tube. Resident #4's current computer-generated Physician order [REDACTED]. X 20 hours=1800cal each shift," and hand written over the computer generated order for "[DEVICE] FEEDING DOWN TIME 4 HOURS PER DAY FROM 8AM - 12 noon." Review of Resident #4's March 2015 MAR indicated [REDACTED]. X 20 hours=1800cal each shift " and " [DEVICE] FEEDING DOWN TIME 4 HOURS PER DAY FROM 8AM - 12 noon." Review of Resident #4's revised computer generated Physician order [REDACTED]. X 20 hours=1800cal each shift, " and " [DEVICE] FEEDING DOWN TIME 4 HOURS DAILY BETWEEN 1100-1500 (11:00 AM- 3:00 PM). One time a day Order changed by NP d/t Therapy sessions for resident between this time and resident being a diabetic to prevent [DIAGNOSES REDACTED]. " Review of Resident #4's revised March 2015 MAR indicated [REDACTED]. X 20 hours=1800cal each shift " and " [DEVICE] FEEDING DOWN TIME 4 HOURS PER DAY FROM 1100-1500 (11:00 AM- 3:00 PM)." At 3:26 PM on 03/23/15, Resident #4 was observed in the lobby not connected to feeding pump. Observation of the [MEDICATION NAME] 1.5 bag revealed 500 mL remaining inside the bag. The bag was hung on 03/23/15 at 0045 AM. At 9:30 AM on 03/24/15 Resident #4 was observed in bed asleep with pump off. The [MEDICATION NAME] 1.5 cal was hung at 430 AM on 03/24/15 with ~800 ml. At 12:00 PM Resident #4 was observed disconnected from her pump and was sitting in the hallway awaiting therapy. At 1:43 PM Resident #4 was not in her room and her pump was off with ~800 ml remaining from the 9:30 observation. At 1:53 PM on 03/24/15 Resident #4 was observed getting off the elevator with Therapist Tech XX. Interview with Therapist Tech XX stated " I usually get (Resident #4) after my lunch around 12:30 PM daily for therapy. " At 3:54 PM on 03/24/15 Resident #4 was observed sitting in the lobby without her pump. Observation of her pump in her room revealed the [MEDICATION NAME] bag was hung at 0430 AM on 03/24/15 with ~800 ml remaining. The same amount from the observation at 9:30 AM on 03/24/15. In an interview with CNA YY on 03/24/15 at 4:15 PM stated " I get her at 2 PM and therapy is just getting through with Resident #4. I was told by therapy not to put (Resident #4) in bed until her therapy session is done with. " In an interview with OT K on 03/24/15 at 5:11 PM stated " I get Resident #4 for therapy after lunch at 12:30PM. " In an interview with the DON on 03/25/15 at 9:20 AM stated " I don't know how long therapy has been coming late to get Resident #4 for therapy but currently therapy will get Resident #4 on her downtime. " In an interview with the DON on 03/25/15 at 11:51 AM stated " I was unaware of the hand written down time on the MAR. The MAR indicated [REDACTED]. " In an interview with the Administrator on 03/25/15 at 11:51 AM stated " It is not acceptable for a staff member to change the times of downtime on the MAR indicated [REDACTED] An observation on 03/25/15 at 12:28 PM revealed Resident #4 in bed with pump infusing at 60 ml/hr. There was 28ml fed and ~800 ml remaining. The [MEDICATION NAME] was hung at 5:30 AM on 03/25/15. In an interview with the RD/LD on 03/25/15 at 4:05 PM stated " I was not aware of the resident not on the pump during up time. No one informed me. " Review of the Progress Note dated 01/28/15 at 18:04 noted Type: Nursing Note Text: Received call from the Dietician. noted [MEDICATION NAME] 1.5 60 ml q hr. x 20 hrs downtime at 8am to 12noon, H20 45cc q hrs. X 20hrs. flush 30cc before and after med administrations. POA was notified. Author: LVN W At the times mentioned below were evidence from the progress notes that Resident #4 was not recieving scheduled feedings on the up time as prescribed by the Physician. Review of Progress Note dated 02/05/15 at 14:17 (2:17 PM) noted: Resident #4 sitting up at the nurses lobby at this time just back from therapy. Author: LVN BBB Review of Progress Note dated 02/11/15 at 14:37 (2:37 PM) noted Resident at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 02/12/15 at 13:25 (1:25 PM) noted Resident at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 02/13/15 at 14:25 (2:25 PM) noted Resident#4 just back from therapy sessions. Author: LVN BBB Review of Progress Note dated 02/16/15 at 13:57 (1:57 PM) noted Resident #4 at therapy sessions at this time Author: LVN BBB Review of Progress Note dated 02/17/15 at 13:31 (1:31 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 02/24/15 at 14:02 (2:02 PM) noted Resident #4 left for therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/02/15 at 13:38 (1:38 PM)noted Resident #4 left for therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/03/15 at 13:40 (1:40 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/09/15 at 14:05 (2:05 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/10/15 at 13:51 (1:51 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/12/15 at 13:19 (1:19 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/16/15 at 12:45PM noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/17/15 at 14:13 (2:13 PM)noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/18/15 at 14:03 (2:03 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/19/15 at 14:07 (2:07 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/23/15 at 13:40 (1:40 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/24/15 at 13:44 (1:44 PM) noted Resident #4 at therapy sessions at this time. Author: LVN BBB Review of Progress Note dated 03/24/15 at 13:54 (1:54 PM) noted Resident #4 back from therapy sessions at this time. Author: LVN BBB The CMS form 672, Resident Census and Conditions of Residents, signed by the DON on 03/22/15, reflected 15 residents with [DEVICE]s and per the interview with the DON, there were four residents including Resident #6 who LVN C and LVN N were responsible for administering medications via their [DEVICE]s.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #9)of 18 residents reviewed for accident hazards received adequate supervision to prevent accidents. 1) LVN C failed to transfer Resident #9, who was assessed as a two person transfer, with assistance. 2) The facility failed to have a Care Plan in place for Resident #9 to direct caregivers she was assessed as a two person transfer. Resident #9 sustained a fractured tibia. These failures could affect the other182 residents, who needed one or two staff for transfers, and the 23 residents, who were dependent on staff for transfers, by placing them at risk for significant injuries and falls. Findings included: 1)Resident #9's MDS assessment, dated 01/02/14, reflected: She was admitted to the facility on [DATE], and required extensive assistance with the physical assistance of two or more persons for bed mobility and transfer activities and required extensive assistance with the physical assistance of one person to complete locomotion, dressing, eating, toileting, and personal hygiene activities. Resident #9 was not steady and was only able to stabilize with staff assistance when moving from a seated to standing position, walking, moving on and off the toilet and during surface to surface transfers. Resident #9's History and Physical, dated 02/05/14, reflected she had [DIAGNOSES REDACTED]. Review of a Physical Therapy Progress Report for 02/09/14 through 02/15/14, revealed: Resident #9 required maximum assistance with two staff for sit to stand activities on 12/17/13, and had progressed to moderate assistance with two staff by 02/08/14. Review of the X-ray of Resident #9's right ankle on 02/13/14, revealed a "nondisplaced spiral fracture of the distal tibia." Review of Resident #9's entire electronic health record revealed under the Care Plan: "Alteration in musculoskeletal status r/t (related to) Fracture of right distal tibia. Date initiated 2/13/2014." This entry was made by Unit Manager J. This was the only care plan entry found for Resident #9. An interview on 03/05/14 at 8:58 AM with Unit Manager J revealed when she learned of Resident #9's fracture, she "updated" the careplan. When asked where the careplan was she updated, Unit Manager J stated there was no careplan for Resident #9 as it had not yet been completed. Unit Manager J confirmed the only careplan entry for Resident #9 was the one she entered on 02/13/14, 48 days, post-admission. When asked why a careplan had not been completed for Resident #9, Unit Manager J replied she did not know, but there had been a problem with MDS assessments and careplans being conducted. Resident #9 was observed in bed, sleeping, during the initial tour on 03/04/14 at 8:41 AM. LVN D stated Resident #9 was alert and oriented to time, place and person; came in with a sacral wound, and sustained a fractured tibia. When asked how the fracture occurred, LVN D replied, she was transferred by one person, LVN C, when she required two staff for transfers. LVN D stated, Resident #9's right tibia was fractured during this transfer and she now required a mechanical lift as she was non-weight bearing. Prior to this, LVN D stated she was able to bear weight and pivot during transfers. LVN D was interviewed again on 03/05/14 at 6:22 AM, and stated on 02/13/14, she was the charge nurse for Resident #9; however, she was busy with another resident when Resident #9 activated her call light. LVN C responded to the light and Resident #9 wanted to go back to bed. LVN C transferred Resident #9 by herself and after the transfer, informed LVN D that Resident #9 was complaining of pain. LVN D stated she did not think anything of it because Resident #9 complained often of shoulder pain, but went in to make an assessment. LVN D stated that is when Resident #9 told me, "(LVN D), I think my foot is broke." Resident #9 stated during the transfer her leg got tangled up. LVN D stated she then went and asked LVN C more questions and was told LVN C stated she heard a "pop" when she transferred Resident #9. LVN D stated it was then she contacted and informed Unit Manager J, the physician, and the Administrator. Unit Manager J also stated LVN D contacted her on 02/13/14, and told her another nurse transferred Resident #9 and heard a "pop," and they thought the leg was fractured. Unit Manager J stated she reviewed the documentation for Resident #9 and discovered two staff should have transferred her. Resident #9 was interviewed on 03/05/14 at 12:00 PM and stated before she fractured her leg, two aides would transfer her to and from bed by standing on her sides, and holding on to her and helping her turn. Resident #9 stated she could bear some weight and twist her body during these transfers. Resident #9 said that on the day she sustained the fracture she needed to go back to bed and turned on a light. A nurse came in she had never seen before and stated, "I think I can handle this by myself." Resident #9 stated she did not tell the nurse anything different and the nurse transferred her and her leg got tangled up with the nurse's leg, twisted, and popped. "It hurt so bad." They got an X-ray and it showed a fracture. Resident #9 stated she was sent me to the hospital and they applied a brace. Resident #9 added, it was the "one and only time one person tried by themselves." Resident #9 added she did not tell the nurse anything because, "she was a nurse." LVN C was interviewed on 03/05/14 at 1:33 PM and stated the day of the incident, 02/13/14, was her first day working for the facility since she quit last year. LVN C stated it was around 12:00 PM or 12:30 PM and lunch trays were being served. The CNAs were all busy when Resident #9 put on her light and said she needed to go back to bed to get cleaned up for therapy. LVN C stated all the aides were busy but she felt she could transfer Resident #9 by herself. LVN C stated when she stood Resident #9 up and went to pivot her, Resident #9's right foot remained planted and did not pivot. LVN C stated she heard a pop and Resident #9 complained of her ankle hurting. LVN C stated she immediately reported the incident to LVN D. LVN C also stated it was the first time she had ever worked with Resident #9 and she did not ask or look up how many people it took to transfer her. LVN C added, "I just thought I could do it by myself." On 03/05/14 at 9:24 AM, it was confirmed by Human Resources, LVN C had worked for the facility from 01/17/12 through 08/20/13; and was re-hired on 02/13/14, the day of Resident #9's incident. The facility's Form CMS- 672, Resident Census and Conditions of Residents, completed by the DON on 03/07/14, reflected 183 needed the assistance of one or staff for transfers and 23 residents were dependent on staff for transfers.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical and nursing need and described the services that were to be furnished to attain or maintain the resident's highest practicable physical well-being for one (Resident #1) of 24 residents reviewed for skin/wound care and/or pacemakers. Staff failed to develop and implement a Care Plan, including interventions, for Resident #1's new pacemaker and care of the pacemaker surgical wound site. Resident #1 was admitted to the hospital and received an intravenous antibiotic. An Immediate Jeopardy (IJ) was identified on 10/16/13. While the IJ was removed on 10/21/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could also affect the 27 residents, who were cared for by LVN B, by placing them at risk for delayed medical care and treatment, increased infection, wound deterioration and/or death. Findings included: Resident #1's Admission Record, dated 08/22/13, reflected he was originally admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 08/29/13, reflected the resident was a [AGE] year-old male with [DIAGNOSES REDACTED]. The functional status indicated resident required set up assistance only for all activities of daily living. Resident was continent of bowel and bladder. The section on the MDS assessment regarding cognition was blank. Resident #1's Care Plan, dated 07/31/13, reflected only problems of falls and fall potential. On 10/16/13 at 3:30 PM, an interview with the DON revealed the MDS Coordinator responsible for care plans was on medical leave. Resident #1's Nursing Progress Note, dated 08/16/13 reflected the resident's pacemaker was being removed and a new one was to be implanted. Resident #1 was sent to the hospital via non- emergency transport for the procedure. Resident #1's Nursing Progress Note, dated 08/16/13 at 11:27 AM reflected he was not able to shower for one week, lift his left arm above his shoulder, or lift more than 10 pounds with his left arm. The Note also reflected not to remove the steri-strips on the wound for one week, and the physician would continue to monitor. An interview with LVN WW on 10/16/13 at 5:20 PM revealed she received Resident #1 back from getting the new pacemaker. She did not remember what documentation was sent back with the resident. LVN WW stated she did not transcribe the above information onto a Physician's Telephone Order because she did not think they were actually physician's orders [REDACTED]. Resident #1's Care Plan, dated 07/31/13, did not reflect an update and/or review regarding his new pacemaker, surgical wound site, or surgical wound site care. All of Resident #1's physician's orders [REDACTED]. Resident #1's Physician's Note from the Cardiologist, dated 09/26/13, reflected the resident saw the Cardiologist that day. Interview with Resident #1's family member on 10/16/13 at 11:30 AM revealed he/she took the resident to the doctor on 09/26/13 for a check-up following the visit of 08/16/13. The family member stated the doctor pulled the dressing back and told the him/her the pacemaker site looked good and to keep it covered. Interview on 10/14/13 at 3:40 PM with LVN MM, who worked the second shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1. She stated there was no evidence of swelling or infection at the site. Interview on 10/14/13 at 3:50 PM with LVN E, who worked the second shift on Resident #1's unit, revealed she had not seen a wound, dressing or drainage on Resident #1's chest. Interview with CNA NNN, who worked the second shift on Resident #1's unit, on 10/14/13 at 3:55 PM revealed she had not seen a dressing on Resident #1's chest. Interview on 10/18/13 at 5:30 AM with LVN I, who worked the third shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1's chest. Interview with CNA Q, who worked the third shift on Resident #1's unit, on 10/18/13 at 5:40 AM revealed she changed Resident #1's tee shirt one day last week (week of 10/06/13 through 10/12/13) and there was not a dressing or anything unusual about his chest. Interview with LVN B on 10/15/13 at 3:05 PM revealed he changed Resident #1's dressing on 10/11/13 because it was soiled. LVN B stated the wound was opened and he could see the pacemaker. He revealed he thought the treatment nurse was taking care of the wound. LVN B stated there was no drainage. Interview with LVN A, the treatment nurse for the entire facility, on 10/15/13 at 2:00 PM revealed she had no information regarding a wound or wound care for Resident #1. Another interview with LVN B, on 10/16/13 at 12:15 PM with the DON present, revealed Resident #1's surgical site was never red or swollen and 10/11/13 was the first time he saw a dressing on the wound. LVN B stated again he thought the treatment nurse was taking care of it because there were no orders on Resident #1's Treatment Administration Record. He revealed he did not contact Resident #1's physician when he saw the opened wound on the resident's chest with his pacemaker exposed. When asked if he told the treatment nurse about the resident's opened wound, LVN B replied, "No." Interview with the DON and Administrator on 10/15/13 at 3:30 PM revealed they did not have any knowledge that LVN B was aware the resident's wound had opened and his pacemaker was exposed, and LVN B covered the site with a dressing. The DON stated she was contacted by the ER regarding the information they received from LVN C on 10/13/13. She also stated the weekend supervisor told her about the wound after the arrival of the surveyors. The DON and Administrator revealed they had started an investigation. The DON stated, on 10/16/13 at approximately 2:00 PM, LVN B was suspended pending investigation. Interview with CNA M, who worked the first shift on Resident #1's unit, on 10/16/13 at 8:10 AM revealed she frequently cared for him. She stated on 10/13/13 she notified LVN C there was drainage on Resident #1's dressing. CNA M revealed Resident #1 usually would not take off his tee shirt except in the shower. CNA M stated there had not been a dressing on the site until Resident #1 fell on [DATE]. Interview with LVN E, who worked the second shift on Resident #1's unit, on 10/16/13 at 5:10 PM revealed she had not seen a wound, dressing or drainage on Resident #1's chest. She stated there was not a dressing on the resident after his fall on 10/07/13. Resident #1's Nurse's Note, dated 10/13/13 at 10:52 AM, reflected "incision site is open with purulent drainage." The physician and family were notified and the resident was sent to the ER. Interview with LVN C on 10/19/13 at 11:00 AM revealed on 10/13/13 when he saw the wound, he called the supervisor and treatment nurse to check the wound as well as notifying the physician and family. LVN C did not recall Resident #1 having a dressing previously, nor did LVN C identify anytime he had an occasion to check Resident #1's chest. A telephone interview with Resident #1's physician on 10/16/13 at 3:10 PM revealed he was not aware of the wound until 10/13/13. Resident #1's emergency room Physician's entry, dated 10/13/13 at 2:40 PM, reflected he came to the ER with a wound infection, and there was a left chest wound dehiscence (opening at a surgical site) of a pacemaker device. The opening measured two inches by one inch with purulent (containing pus) drainage. Resident #1 was admitted to the hospital and treated with intravenous antibiotics. Resident #1's Hospital physician progress notes [REDACTED]." Resident #1's physician's orders [REDACTED]. The Order also reflected to monitor for a change in condition. Observation of Resident #1 on 10/15/13 at 10:00 AM revealed he was alert and oriented to time, place and person. He had difficulty answering questions due to his severe hearing loss. An observation on 10/15/13 at 3:15 PM of Resident #1's wound care revealed an opened area approximately two inches by one inch in his left chest with his pacemaker clearly visible. The chest wall behind the pacemaker was also visible. The wound was clean and free of drainage. An Immediate Jeopardy was identified on 10/16/13. The Administrator and DON were notified on 10/16/13 at 1:56 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 10/18/13 at 1:45 PM and reflected the following: LVN B was terminated and his license was referred to the Texas State Board of Nursing. Nursing administrative staff in-serviced all clinical staff including six RNs, 50 LVNs, five Restorative Aides, 20 MAs, and 108 CNAs. In-service began on 10/18/13 and was scheduled to be completed by 10/23/13. Staff were not scheduled to work until the in-service was completed. Training included hand-outs and a post competency test. In-service for RNs, LVNs and MAs included: Detailed care plan Management and monitoring of the wound care program along with other major changes would be accomplished by nursing administration. Interviews conducted beginning on 10/18/13 at 3:30 PM through 10/21/13 at 6:00 AM, with LVN MM, LVN H, LVN E, ADON LVN E, LVN U, LVN A, RN W, LVN D, RN AA, LVN C, RN V, LVN OO, LVN F, LVN PP, LVN I, RN W, LVN QQ, LVN RR, LVN HHH, LVN III, LVN SS, LVN TT, LVN VV, LVN WW, RN UU, CNA R, CNA Q, CNA YY, CNA FF, CNA ZZ, CNA N, CNA O, CNA M, CNA P, CNA AAA, CNA BBB, MA CCC, CNA DDD, CNA EEE, CNA FFF, CNA GGG, CNA L, CNA JJJ, CNA KKK, MA S, CNA LLL, CNA KK, CNA MM, CNA MMM, revealed they attended the in-service, except for one CNA who was scheduled to go the day of interview. All of those who attended were able to identify the content of the in-service and understood the significance of the content. On 10/21/13 the IJ was removed. On 10/21/13 at 2:45 PM , the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's roster provided on 10/14/13 reflected 27 residents resided on the unit where Resident #1 resided and where LVN B worked.

Based on observation, interview and record review, it was determined the facility failed to follow its policies and procedures that prohibit neglect of residents for one (Resident #1) of 27 residents reviewed for skin/wound care and/or pacemakers. 1. LVN B failed to notify Resident #1's physician when he saw the resident's surgical wound had opened and the pacemaker was clearly visible. 2. Staff failed to develop and implement a Care Plan, including interventions, for Resident #1's new pacemaker and care of the pacemaker surgical wound site. 3. LVN WW failed to clarify and write physician's orders [REDACTED]. 4. LVN B placed a dressing on Resident #1's opened surgical wound without a physician's orders [REDACTED]. 5. Staff failed to accurately assess Resident #1's skin related to his surgical wound pacemaker site. Resident #1 was admitted to the hospital and received an intravenous antibiotic. An Immediate Jeopardy (IJ) was identified on 10/16/13. While the IJ was removed on 10/21/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could also affect the 27 residents, who were cared for by LVN B, by placing them at risk for delayed medical care and treatment, increased infection, wound deterioration and/or death. Findings included: The facility's current policy, Abuse Prevention, dated February 2010 reflected staff of the facility would take action to protect and prevent neglect from occurring within the facility. The policy also reflected neglect was defined as the failure to provide goods and services necessary to avoid physical harm. Resident #1's Admission Record, dated 08/22/13, reflected he was originally admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 08/29/13, reflected the resident was a [AGE] year-old male with [DIAGNOSES REDACTED]. The functional status indicated resident required set up assistance only for all activities of daily living. Resident was continent of bowel and bladder. The section on the MDS assessment regarding cognition was blank. Resident #1's Care Plan, dated 07/31/13, reflected only problems of falls and fall potential. On 10/16/13 at 3:30 PM, an interview with the DON revealed the MDS Coordinator responsible for care plans was on medical leave. Resident #1's Nursing Progress Note, dated 08/16/13 reflected the resident's pacemaker was being removed and a new one was to be implanted. Resident #1 was sent to the hospital via non- emergency transport for the procedure. Resident #1's Nursing Progress Note, dated 08/16/13 at 11:27 AM reflected he was not able to shower for one week, lift his left arm above his shoulder, or lift more than 10 pounds with his left arm. The Note also reflected not to remove the steri-strips on the wound for one week, and the physician would continue to monitor. An interview with LVN WW on 10/16/13 at 5:20 PM revealed she received Resident #1 back from getting the new pacemaker. She did not remember what documentation was sent back with the resident. LVN WW stated she did not transcribe the above information onto a Physician's Telephone Order because she did not think they were actually physician's orders [REDACTED]. Resident #1's Care Plan, dated 07/31/13, did not reflect an update and/or review regarding his new pacemaker, surgical wound site, or surgical wound site care. All of Resident #1's physician's orders [REDACTED]. Resident #1's Nursing Progress Notes from 08/18/13 through 10/13/13 did not reflect assessment of his surgical site. Resident #1's Skin Assessment, dated 08/19/13, did not reflect his new surgical site wound. Resident #1's Physician's Note from the Cardiologist, dated 09/26/13, reflected the resident saw the Cardiologist that day. Interview with Resident #1's family member on 10/16/13 at 11:30 AM revealed he/she took the resident to the doctor on 09/26/13 for a check-up following the visit of 08/16/13. The family member stated the doctor pulled the dressing back and told the him/her the pacemaker site looked good and to keep it covered. Resident #1's Hospice Visit Note Report, dated 09/30/13, reflected the facility was providing wound care. The Note reflected he had an abrasion to his forehead and a skin tear to his right arm following a fall, but there was no mention of a dressing to his chest. There were no other hospice notes regarding skin assessment, wounds or wound care. Interview on 10/15/13 at 2:35 PM with the Hospice DON, Hospice RN and Hospice CNA revealed the Hospice RN did not check the resident's wounds, but there was a dressing. The Hospice CNA stated there was a dressing, which he covered with a towel when showered Resident #1. They stated Resident #1 enrolled in hospice on 09/06/13. Interview on 10/14/13 at 3:40 PM with LVN MM, who worked the second shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1. She stated there was no evidence of swelling or infection at the site. Interview on 10/14/13 at 3:50 PM with LVN E, who worked the second shift on Resident #1's unit, revealed she had not seen a wound, dressing or drainage on Resident #1's chest. Interview with CNA NNN, who worked the second shift on Resident #1's unit, on 10/14/13 at 3:55 PM revealed she had not seen a dressing on Resident #1's chest. Interview on 10/18/13 at 5:30 AM with LVN I, who worked the third shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1's chest. Interview with CNA Q, who worked the third shift on Resident #1's unit, on 10/18/13 at 5:40 AM revealed she changed Resident #1's tee shirt one day last week (week of 10/06/13 through 10/12/13) and there was not a dressing or anything unusual about his chest. Interview with LVN B on 10/15/13 at 3:05 PM revealed he changed Resident #1's dressing on 10/11/13 because it was soiled. LVN B stated the wound was opened and he could see the pacemaker. He revealed he thought the treatment nurse was taking care of the wound. LVN B stated there was no drainage. Interview with LVN A, the treatment nurse for the entire facility, on 10/15/13 at 2:00 PM revealed she had no information regarding a wound or wound care for Resident #1. Another interview with LVN B, on 10/16/13 at 12:15 PM with the DON present, revealed Resident #1's surgical site was never red or swollen and 10/11/13 was the first time he saw a dressing on the wound. LVN B stated again he thought the treatment nurse was taking care of it because there were no orders on Resident #1's Treatment Administration Record. He revealed he did not contact Resident #1's physician when he saw the opened wound on the resident's chest with his pacemaker exposed. When asked if he told the treatment nurse about the resident's opened wound, LVN B replied, "No." Interview with the DON and Administrator on 10/15/13 at 3:30 PM revealed they did not have any knowledge that LVN B was aware the resident's wound had opened and his pacemaker was exposed and LVN B placed a dressing over the site. The DON stated she was contacted by the ER regarding the information they received from LVN C on 10/13/13. She also stated the weekend supervisor told her about the wound after the arrival of the surveyors. The DON and Administrator revealed they had started an investigation. The DON stated, on 10/16/13 at approximately 2:00 PM, LVN B was suspended pending investigation. Interview with CNA M, who worked the first shift on Resident #1's unit, on 10/16/13 at 8:10 AM revealed she frequently cared for him. She stated on 10/13/13 she notified LVN C there was drainage on Resident #1's dressing. CNA M revealed Resident #1 usually would not take off his tee shirt except in the shower. CNA M stated there had not been a dressing on the site until Resident #1 fell on [DATE]. Interview with LVN E, who worked the second shift on Resident #1's unit, on 10/16/13 at 5:10 PM revealed she had not seen a wound, dressing or drainage on Resident #1's chest. She stated there was not a dressing on the resident after his fall on 10/07/13. Resident #1's Nurse's Note, dated 10/13/13 at 10:52 AM, reflected "incision site is open with purulent drainage." The physician and family were notified and the resident was sent to the ER. Interview with LVN C on 10/19/13 at 11:00 AM revealed on 10/13/13 when he saw the wound, he called the supervisor and treatment nurse to check the wound as well as notifying the physician and family. LVN C did not recall Resident #1 having a dressing previously, nor did LVN C identify anytime he had an occasion to check Resident #1's chest. A telephone interview with Resident #1's physician on 10/16/13 at 3:10 PM revealed he was not aware of the wound until 10/13/13. Resident #1's emergency room Physician's entry, dated 10/13/13 at 2:40 PM, reflected he came to the ER with a wound infection, and there was a left chest wound dehiscence (opening at a surgical site) of a pacemaker device. The opening measured two inches by one inch with purulent (containing pus) drainage. Resident #1 was admitted to the hospital and treated with intravenous antibiotics. Resident #1's Hospital physician progress notes [REDACTED]." Resident #1's physician's orders [REDACTED]. The Order also reflected to monitor for a change in condition. Observation of Resident #1 on 10/15/13 at 10:00 AM revealed he was alert and oriented to time, place and person. He had difficulty answering questions due to his severe hearing loss. An observation on 10/15/13 at 3:15 PM of Resident #1's wound care revealed an opened area approximately two inches by one inch in his left chest with his pacemaker clearly visible. The chest wall behind the pacemaker was also visible. The wound was clean and free of drainage. The facility's current policy, Change in Condition Reporting, dated May 2007, reflected any sudden or serious change would be communicated to the resident's physician with a request for a physician visit promptly and/or an acute care evaluation. The licensed nurse in charge would notify the physician. The facility's policy, Change in Condition Reporting, dated May 2007, did not reflect when the resident's physician would be notified of a change in condition. The facility's current policy regarding skin assessments, dated May 2007 reflected all residents would be assessed on admission, when a comprehensive assessment was required, and quarterly thereafter to identify the risk of skin breakdown. The facility's current policy regarding wound care, dated May 2007, reflected weekly assessments of skin would be completed on all residents with wounds requiring treatment and documented. An Immediate Jeopardy was identified on 10/16/13. The Administrator and DON were notified on 10/16/13 at 1:56 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 10/18/13 at 1:45 PM and reflected the following: 1. LVN B was terminated and his license was referred to the Texas State Board of Nursing. 2. Other staff members were interviewed by DON, ADON LVN Y, ADON LVN Z, ADON RN and ADON RN AA to determine if others had knowledge of Resident #1's wound. 3. The hospice provider for Resident #1 was changed following collaboration with the family. 4. Skin Assessments were conducted on all residents by the nursing administrative staff, which included the DON, ADON LVN Y, ADON LVN Z, ADON RN and ADON RN AA. These assessments were completed on 10/15/13. No new sites of altered skin integrity were found. 5. Specific schedules were established for weekly skin assessments on all facility units. 6. Nursing administrative staff in-serviced all clinical staff including six RNs, 50 LVNs, five Restorative Aides, 20 MAs, and 108 CNAs. In-service began on 10/18/13 and was scheduled to be completed by 10/23/13. Staff were not scheduled to work until the in-service was completed. Training included hand-outs and a post competency test. In-service for RNs, LVNs and MAs included: a. Wound care process and documentation of that process b. Physician and family communication for new and clarifying orders c. Changes in condition with proper notification d. Head to toe assessments e. Detailed care plan f. Notification process for skin integrity changes g. Weekly nurse manager skin assessments h. Ethics for unit staff where Resident #1 resided. Inservice for CNAs included: a. Change in condition report to the charge nurse of any skin condition In-service for Hospice providers included: a. Assessment documentation b. Reporting all changes to facility staff 7. Management and monitoring of the wound care program along with other major changes would be accomplished by nursing administration by the following: a. Reviewing all 24 hour reports, new physician's orders [REDACTED]. b. Wound care nurses providing care to all pressure wounds, non-pressure areas and surgical wounds. The charge nurse being responsible for notification of the wound care nurse. The wound care nurse attending the daily clinical meeting for issues and concerns. Wound care nurse coverage being seven days a week. c. Charge nurse skin assessments being followed up by skin assessments completed by the clinical manager to evaluate findings. Hospice patients would also have weekly skin assessments by the hospice nurse and communicated to facility staff. Interviews conducted beginning on 10/18/13 at 3:30 PM through 10/21/13 at 6:00 AM, with LVN MM, LVN H, LVN E, ADON LVN E, LVN U, LVN A, RN W, LVN D, RN AA, LVN C, RN V, LVN OO, LVN F, LVN PP, LVN I, RN W, LVN QQ, LVN RR, LVN HHH, LVN III, LVN SS, LVN TT, LVN VV, LVN WW, RN UU, CNA R, CNA Q, CNA YY, CNA FF, CNA ZZ, CNA N, CNA O, CNA M, CNA P, CNA AAA, CNA BBB, MA CCC, CNA DDD, CNA EEE, CNA FFF, CNA GGG, CNA L, CNA JJJ, CNA KKK, MA S, CNA LLL, CNA KK, CNA MM, CNA MMM, revealed they attended the in-service, except for one CNA who was scheduled to go the day of interview. All of those who attended were able to identify the content of the in-service and understood the significance of the content. On 10/21/13 the IJ was removed. On 10/21/13 at 2:45 PM , the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's roster provided on 10/14/13 reflected 27 residents resided on the unit where Resident #1 resided and where LVN B worked.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #1) of 27 residents reviewed for skin/wound care and/or pacemakers. 1. LVN B failed to notify Resident #1's physician when he saw the resident's surgical wound had opened and the pacemaker was clearly visible. 2. Staff failed to develop and implement a Care Plan, including interventions, for Resident #1's new pacemaker and care of the pacemaker surgical wound site. 3. LVN WW failed to clarify and write physician's orders [REDACTED]. 4. LVN B placed a dressing on Resident #1's opened surgical wound without a physician's orders [REDACTED]. 5. Staff failed to accurately assess Resident #1's skin related to his surgical wound pacemaker site. Resident #1 was admitted to the hospital and received an intravenous antibiotic. An Immediate Jeopardy (IJ) was identified on 10/16/13. While the IJ was removed on 10/21/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could also affect the 27 residents, who were cared for by LVN B, by placing them at risk for delayed medical care and treatment, increased infection, wound deterioration and/or death. Findings included: Resident #1's Admission Record, dated 08/22/13, reflected he was originally admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 08/29/13, reflected the resident was a [AGE] year-old male with [DIAGNOSES REDACTED]. The functional status indicated resident required set up assistance only for all activities of daily living. Resident was continent of bowel and bladder. The section on the MDS assessment regarding cognition was blank. Resident #1's Care Plan, dated 07/31/13, reflected only problems of falls and fall potential. On 10/16/13 at 3:30 PM, an interview with the DON revealed the MDS Coordinator responsible for care plans was on medical leave. Resident #1's Nursing Progress Note, dated 08/16/13 reflected the resident's pacemaker was being removed and a new one was to be implanted. Resident #1 was sent to the hospital via non- emergency transport for the procedure. Resident #1's Nursing Progress Note, dated 08/16/13 at 11:27 AM reflected he was not able to shower for one week, lift his left arm above his shoulder, or lift more than 10 pounds with his left arm. The Note also reflected not to remove the steri-strips on the wound for one week, and the physician would continue to monitor. An interview with LVN WW on 10/16/13 at 5:20 PM revealed she received Resident #1 back from getting the new pacemaker. She did not remember what documentation was sent back with the resident. LVN WW stated she did not transcribe the above information onto a Physician's Telephone Order because she did not think they were actually physician's orders [REDACTED]. Resident #1's Care Plan, dated 07/31/13, did not reflect an update and/or review regarding his new pacemaker, surgical wound site, or surgical wound site care. All of Resident #1's physician's orders [REDACTED]. Resident #1's Nursing Progress Notes from 08/18/13 through 10/13/13 did not reflect assessment of his surgical site. Resident #1's Skin Assessment, dated 08/19/13, did not reflect his new surgical site wound. Resident #1's Physician's Note from the Cardiologist, dated 09/26/13, reflected the resident saw the Cardiologist that day. Interview with Resident #1's family member on 10/16/13 at 11:30 AM revealed he/she took the resident to the doctor on 09/26/13 for a check-up following the visit of 08/16/13. The family member stated the doctor pulled the dressing back and told the him/her the pacemaker site looked good and to keep it covered. Resident #1's Hospice Visit Note Report, dated 09/30/13, reflected the facility was providing wound care. The Note reflected he had an abrasion to his forehead and a skin tear to his right arm following a fall, but there was no mention of a dressing to his chest. There were no other hospice notes regarding skin assessment, wounds or wound care. Interview on 10/15/13 at 2:35 PM with the Hospice DON, Hospice RN and Hospice CNA revealed the Hospice RN did not check the resident's wounds, but there was a dressing. The Hospice CNA stated there was a dressing, which he covered with a towel when showered Resident #1. They stated Resident #1 enrolled in hospice on 09/06/13. Interview on 10/14/13 at 3:40 PM with LVN MM, who worked the second shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1. She stated there was no evidence of swelling or infection at the site. Interview on 10/14/13 at 3:50 PM with LVN E, who worked the second shift on Resident #1's unit, revealed she had not seen a wound, dressing or drainage on Resident #1's chest. Interview with CNA NNN, who worked the second shift on Resident #1's unit, on 10/14/13 at 3:55 PM revealed she had not seen a dressing on Resident #1's chest. Interview on 10/18/13 at 5:30 AM with LVN I, who worked the third shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1's chest. Interview with CNA Q, who worked the third shift on Resident #1's unit, on 10/18/13 at 5:40 AM revealed she changed Resident #1's tee shirt one day last week (week of 10/06/13 through 10/12/13) and there was not a dressing or anything unusual about his chest. Interview with LVN B on 10/15/13 at 3:05 PM revealed he changed Resident #1's dressing on 10/11/13 because it was soiled. LVN B stated the wound was opened and he could see the pacemaker. He revealed he thought the treatment nurse was taking care of the wound. LVN B stated there was no drainage. Interview with LVN A, the treatment nurse for the entire facility, on 10/15/13 at 2:00 PM revealed she had no information regarding a wound or wound care for Resident #1. Another interview with LVN B, on 10/16/13 at 12:15 PM with the DON present, revealed Resident #1's surgical site was never red or swollen and 10/11/13 was the first time he saw a dressing on the wound. LVN B stated again he thought the treatment nurse was taking care of it because there were no orders on Resident #1's Treatment Administration Record. He revealed he did not contact Resident #1's physician when he saw the opened wound on the resident's chest with his pacemaker exposed. When asked if he told the treatment nurse about the resident's opened wound, LVN B replied, "No." Interview with the DON and Administrator on 10/15/13 at 3:30 PM revealed they did not have any knowledge that LVN B was aware the resident's wound had opened and his pacemaker was exposed and LVN B placed a dressing over the site. The DON stated she was contacted by the ER regarding the information they received from LVN C on 10/13/13. She also stated the weekend supervisor told her about the wound after the arrival of the surveyors. The DON and Administrator revealed they had started an investigation. The DON stated, on 10/16/13 at approximately 2:00 PM, LVN B was suspended pending investigation. Interview with CNA M, who worked the first shift on Resident #1's unit, on 10/16/13 at 8:10 AM revealed she frequently cared for him. She stated on 10/13/13 she notified LVN C there was drainage on Resident #1's dressing. CNA M revealed Resident #1 usually would not take off his tee shirt except in the shower. CNA M stated there had not been a dressing on the site until Resident #1 fell on [DATE]. Interview with LVN E, who worked the second shift on Resident #1's unit, on 10/16/13 at 5:10 PM revealed she had not seen a wound, dressing or drainage on Resident #1's chest. She stated there was not a dressing on the resident after his fall on 10/07/13. Resident #1's Nurse's Note, dated 10/13/13 at 10:52 AM, reflected "incision site is open with purulent drainage." The physician and family were notified and the resident was sent to the ER. Interview with LVN C on 10/19/13 at 11:00 AM revealed on 10/13/13 when he saw the wound, he called the supervisor and treatment nurse to check the wound as well as notifying the physician and family. LVN C did not recall Resident #1 having a dressing previously, nor did LVN C identify anytime he had an occasion to check Resident #1's chest. A telephone interview with Resident #1's physician on 10/16/13 at 3:10 PM revealed he was not aware of the wound until 10/13/13. Resident #1's emergency room Physician's entry, dated 10/13/13 at 2:40 PM, reflected he came to the ER with a wound infection, and there was a left chest wound dehiscence (opening at a surgical site) of a pacemaker device. The opening measured two inches by one inch with purulent (containing pus) drainage. Resident #1 was admitted to the hospital and treated with intravenous antibiotics. Resident #1's Hospital physician progress notes [REDACTED]." Resident #1's physician's orders [REDACTED]. The Order also reflected to monitor for a change in condition. Observation of Resident #1 on 10/15/13 at 10:00 AM revealed he was alert and oriented to time, place and person. He had difficulty answering questions due to his severe hearing loss. An observation on 10/15/13 at 3:15 PM of Resident #1's wound care revealed an opened area approximately two inches by one inch in his left chest with his pacemaker clearly visible. The chest wall behind the pacemaker was also visible. The wound was clean and free of drainage. The facility's current policy, Abuse Prevention, dated February 2010 reflected staff of the facility would take action to protect and prevent neglect from occurring within the facility. The policy also reflected neglect was defined as the failure to provide goods and services necessary to avoid physical harm. The facility's current policy, Change in Condition Reporting, dated May 2007, reflected any sudden or serious change would be communicated to the resident's physician with a request for a physician visit promptly and/or an acute care evaluation. The licensed nurse in charge would notify the physician. The facility's policy, Change in Condition Reporting, dated May 2007, did not reflect when the resident's physician would be notified of a change in condition. The facility's current policy regarding skin assessments, dated May 2007 reflected all residents would be assessed on admission, when a comprehensive assessment was required, and quarterly thereafter to identify the risk of skin breakdown. The facility's current policy regarding wound care, dated May 2007, reflected weekly assessments of skin would be completed on all residents with wounds requiring treatment and documented. An Immediate Jeopardy was identified on 10/16/13. The Administrator and DON were notified on 10/16/13 at 1:56 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 10/18/13 at 1:45 PM and reflected the following: 1. LVN B was terminated and his license was referred to the Texas State Board of Nursing. 2. Other staff members were interviewed by DON, ADON LVN Y, ADON LVN Z, ADON RN and ADON RN AA to determine if others had knowledge of Resident #1's wound. 3. The hospice provider for Resident #1 was changed following collaboration with the family. 4. Skin Assessments were conducted on all residents by the nursing administrative staff, which included the DON, ADON LVN Y, ADON LVN Z, ADON RN and ADON RN AA. These assessments were completed on 10/15/13. No new sites of altered skin integrity were found. 5. Specific schedules were established for weekly skin assessments on all facility units. 6. Nursing administrative staff in-serviced all clinical staff including six RNs, 50 LVNs, five Restorative Aides, 20 MAs, and 108 CNAs. In-service began on 10/18/13 and was scheduled to be completed by 10/23/13. Staff were not scheduled to work until the in-service was completed. Training included hand-outs and a post competency test. In-service for RNs, LVNs and MAs included: a. Wound care process and documentation of that process b. Physician and family communication for new and clarifying orders c. Changes in condition with proper notification d. Head to toe assessments e. Detailed care plan f. Notification process for skin integrity changes g. Weekly nurse manager skin assessments h. Ethics for unit staff where Resident #1 resided. Inservice for CNAs included: a. Change in condition report to the charge nurse of any skin condition In-service for Hospice providers included: a. Assessment documentation b. Reporting all changes to facility staff 7. Management and monitoring of the wound care program along with other major changes would be accomplished by nursing administration by the following: a. Reviewing all 24 hour reports, new physician's orders [REDACTED]. b. Wound care nurses providing care to all pressure wounds, non-pressure areas and surgical wounds. The charge nurse being responsible for notification of the wound care nurse. The wound care nurse attending the daily clinical meeting for issues and concerns. Wound care nurse coverage being seven days a week. c. Charge nurse skin assessments being followed up by skin assessments completed by the clinical manager to evaluate findings. Hospice patients would also have weekly skin assessments by the hospice nurse and communicated to facility staff. Interviews conducted beginning on 10/18/13 at 3:30 PM through 10/21/13 at 6:00 AM, with LVN MM, LVN H, LVN E, ADON LVN E, LVN U, LVN A, RN W, LVN D, RN AA, LVN C, RN V, LVN OO, LVN F, LVN PP, LVN I, RN W, LVN QQ, LVN RR, LVN HHH, LVN III, LVN SS, LVN TT, LVN VV, LVN WW, RN UU, CNA R, CNA Q, CNA YY, CNA FF, CNA ZZ, CNA N, CNA O, CNA M, CNA P, CNA AAA, CNA BBB, MA CCC, CNA DDD, CNA EEE, CNA FFF, CNA GGG, CNA L, CNA JJJ, CNA KKK, MA S, CNA LLL, CNA KK, CNA MM, CNA MMM, revealed they attended the in-service, except for one CNA who was scheduled to go the day of interview. All of those who attended were able to identify the content of the in-service and understood the significance of the content. On 10/21/13 the IJ was removed. On 10/21/13 at 2:45 PM , the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's roster provided on 10/14/13 reflected 27 residents resided on the unit where Resident #1 resided and where LVN B worked.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one (Resident #1) of 27 residents reviewed for skin/wound care and/or pacemakers. 1. LVN B failed to notify Resident #1's physician when he saw the resident's surgical wound had opened and the pacemaker was clearly visible. 2. Staff failed to develop and implement a Care Plan, including interventions, for Resident #1's new pacemaker and care of the pacemaker surgical wound site. 3. LVN WW failed to clarify and write physician's orders [REDACTED]. 4. LVN B placed a dressing on Resident #1's opened surgical wound without a physician's orders [REDACTED]. 5. Staff failed to accurately assess Resident #1's skin related to his surgical wound pacemaker site. Resident #1 was admitted to the hospital and received an intravenous antibiotic. An Immediate Jeopardy (IJ) was identified on 10/16/13. While the IJ was removed on 10/21/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could also affect the 27 residents, who were cared for by LVN B, by placing them at risk for delayed medical care and treatment, increased infection, wound deterioration and/or death. Findings included: Resident #1's Admission Record, dated 08/22/13, reflected he was originally admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 08/29/13, reflected the resident was a [AGE] year-old male with [DIAGNOSES REDACTED]. The functional status indicated resident required set up assistance only for all activities of daily living. Resident was continent of bowel and bladder. The section on the MDS assessment regarding cognition was blank. Resident #1's Care Plan, dated 07/31/13, reflected only problems of falls and fall potential. On 10/16/13 at 3:30 PM, an interview with the DON revealed the MDS Coordinator responsible for care plans was on medical leave. Resident #1's Nursing Progress Note, dated 08/16/13 reflected the resident's pacemaker was being removed and a new one was to be implanted. Resident #1 was sent to the hospital via non- emergency transport for the procedure. Resident #1's Nursing Progress Note, dated 08/16/13 at 11:27 AM reflected he was not able to shower for one week, lift his left arm above his shoulder, or lift more than 10 pounds with his left arm. The Note also reflected not to remove the steri-strips on the wound for one week, and the physician would continue to monitor. An interview with LVN WW on 10/16/13 at 5:20 PM revealed she received Resident #1 back from getting the new pacemaker. She did not remember what documentation was sent back with the resident. LVN WW stated she did not transcribe the above information onto a Physician's Telephone Order because she did not think they were actually physician's orders [REDACTED]. Resident #1's Care Plan, dated 07/31/13, did not reflect an update and/or review regarding his new pacemaker, surgical wound site, or surgical wound site care. All of Resident #1's physician's orders [REDACTED]. Resident #1's Nursing Progress Notes from 08/18/13 through 10/13/13 did not reflect assessment of his surgical site. Resident #1's Skin Assessment, dated 08/19/13, did not reflect his new surgical site wound. Resident #1's Physician's Note from the Cardiologist, dated 09/26/13, reflected the resident saw the Cardiologist that day. Interview with Resident #1's family member on 10/16/13 at 11:30 AM revealed he/she took the resident to the doctor on 09/26/13 for a check-up following the visit of 08/16/13. The family member stated the doctor pulled the dressing back and told the him/her the pacemaker site looked good and to keep it covered. Resident #1's Hospice Visit Note Report, dated 09/30/13, reflected the facility was providing wound care. The Note reflected he had an abrasion to his forehead and a skin tear to his right arm following a fall, but there was no mention of a dressing to his chest. There were no other hospice notes regarding skin assessment, wounds or wound care. Interview on 10/15/13 at 2:35 PM with the Hospice DON, Hospice RN and Hospice CNA revealed the Hospice RN did not check the resident's wounds, but there was a dressing. The Hospice CNA stated there was a dressing, which he covered with a towel when showered Resident #1. They stated Resident #1 enrolled in hospice on 09/06/13. Interview on 10/14/13 at 3:40 PM with LVN MM, who worked the second shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1. She stated there was no evidence of swelling or infection at the site. Interview on 10/14/13 at 3:50 PM with LVN E, who worked the second shift on Resident #1's unit, revealed she had not seen a wound, dressing or drainage on Resident #1's chest. Interview with CNA NNN, who worked the second shift on Resident #1's unit, on 10/14/13 at 3:55 PM revealed she had not seen a dressing on Resident #1's chest. Interview on 10/18/13 at 5:30 AM with LVN I, who worked the third shift on Resident #1's unit, revealed she had not seen a dressing on Resident #1's chest. Interview with CNA Q, who worked the third shift on Resident #1's unit, on 10/18/13 at 5:40 AM revealed she changed Resident #1's tee shirt one day last week (week of 10/06/13 through 10/12/13) and there was not a dressing or anything unusual about his chest. Interview with LVN B on 10/15/13 at 3:05 PM revealed he changed Resident #1's dressing on 10/11/13 because it was soiled. LVN B stated the wound was opened and he could see the pacemaker. He revealed he thought the treatment nurse was taking care of the wound. LVN B stated there was no drainage. Interview with LVN A, the treatment nurse for the entire facility, on 10/15/13 at 2:00 PM revealed she had no information regarding a wound or wound care for Resident #1. Another interview with LVN B, on 10/16/13 at 12:15 PM with the DON present, revealed Resident #1's surgical site was never red or swollen and 10/11/13 was the first time he saw a dressing on the wound. LVN B stated again he thought the treatment nurse was taking care of it because there were no orders on Resident #1's Treatment Administration Record. He revealed he did not contact Resident #1's physician when he saw the opened wound on the resident's chest with his pacemaker exposed. When asked if he told the treatment nurse about the resident's opened wound, LVN B replied, "No." Interview with the DON and Administrator on 10/15/13 at 3:30 PM revealed they did not have any knowledge that LVN B was aware the resident's wound had opened and his pacemaker was exposed and LVN B placed a dressing over the site. The DON stated she was contacted by the ER regarding the information they received from LVN C on 10/13/13. She also stated the weekend supervisor told her about the wound after the arrival of the surveyors. The DON and Administrator revealed they had started an investigation. The DON stated, on 10/16/13 at approximately 2:00 PM, LVN B was suspended pending investigation. Interview with CNA M, who worked the first shift on Resident #1's unit, on 10/16/13 at 8:10 AM revealed she frequently cared for him. She stated on 10/13/13 she notified LVN C there was drainage on Resident #1's dressing. CNA M revealed Resident #1 usually would not take off his tee shirt except in the shower. CNA M stated there had not been a dressing on the site until Resident #1 fell on [DATE]. Interview with LVN E, who worked the second shift on Resident #1's unit, on 10/16/13 at 5:10 PM revealed she had not seen a wound, dressing or drainage on Resident #1's chest. She stated there was not a dressing on the resident after his fall on 10/07/13. Resident #1's Nurse's Note, dated 10/13/13 at 10:52 AM, reflected "incision site is open with purulent drainage." The physician and family were notified and the resident was sent to the ER. Interview with LVN C on 10/19/13 at 11:00 AM revealed on 10/13/13 when he saw the wound, he called the supervisor and treatment nurse to check the wound as well as notifying the physician and family. LVN C did not recall Resident #1 having a dressing previously, nor did LVN C identify anytime he had an occasion to check Resident #1's chest. A telephone interview with Resident #1's physician on 10/16/13 at 3:10 PM revealed he was not aware of the wound until 10/13/13. Resident #1's emergency room Physician's entry, dated 10/13/13 at 2:40 PM, reflected he came to the ER with a wound infection, and there was a left chest wound dehiscence (opening at a surgical site) of a pacemaker device. The opening measured two inches by one inch with purulent (containing pus) drainage. Resident #1 was admitted to the hospital and treated with intravenous antibiotics. Resident #1's Hospital physician progress notes [REDACTED]." Resident #1's physician's orders [REDACTED]. The Order also reflected to monitor for a change in condition. Observation of Resident #1 on 10/15/13 at 10:00 AM revealed he was alert and oriented to time, place and person. He had difficulty answering questions due to his severe hearing loss. An observation on 10/15/13 at 3:15 PM of Resident #1's wound care revealed an opened area approximately two inches by one inch in his left chest with his pacemaker clearly visible. The chest wall behind the pacemaker was also visible. The wound was clean and free of drainage. The facility's current policy, Change in Condition Reporting, dated May 2007, reflected any sudden or serious change would be communicated to the resident's physician with a request for a physician visit promptly and/or an acute care evaluation. The licensed nurse in charge would notify the physician. The facility's policy, Change in Condition Reporting, dated May 2007, did not reflect when the resident's physician would be notified of a change in condition. The facility's current policy regarding skin assessments, dated May 2007 reflected all residents would be assessed on admission, when a comprehensive assessment was required, and quarterly thereafter to identify the risk of skin breakdown. The facility's current policy regarding wound care, dated May 2007, reflected weekly assessments of skin would be completed on all residents with wounds requiring treatment and documented. An Immediate Jeopardy was identified on 10/16/13. The Administrator and DON were notified on 10/16/13 at 1:56 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 10/18/13 at 1:45 PM and reflected the following: 1. LVN B was terminated and his license was referred to the Texas State Board of Nursing. 2. Other staff members were interviewed by DON, ADON LVN Y, ADON LVN Z, ADON RN and ADON RN AA to determine if others had knowledge of Resident #1's wound. 3. The hospice provider for Resident #1 was changed following collaboration with the family. 4. Skin Assessments were conducted on all residents by the nursing administrative staff, which included the DON, ADON LVN Y, ADON LVN Z, ADON RN and ADON RN AA. These assessments were completed on 10/15/13. No new sites of altered skin integrity were found. 5. Specific schedules were established for weekly skin assessments on all facility units. 6. Nursing administrative staff in-serviced all clinical staff including six RNs, 50 LVNs, five Restorative Aides, 20 MAs, and 108 CNAs. In-service began on 10/18/13 and was scheduled to be completed by 10/23/13. Staff were not scheduled to work until the in-service was completed. Training included hand-outs and a post competency test. In-service for RNs, LVNs and MAs included: a. Wound care process and documentation of that process b. Physician and family communication for new and clarifying orders c. Changes in condition with proper notification d. Head to toe assessments e. Detailed care plan f. Notification process for skin integrity changes g. Weekly nurse manager skin assessments h. Ethics for unit staff where Resident #1 resided. Inservice for CNAs included: a. Change in condition report to the charge nurse of any skin condition In-service for Hospice providers included: a. Assessment documentation b. Reporting all changes to facility staff 7. Management and monitoring of the wound care program along with other major changes would be accomplished by nursing administration by the following: a. Reviewing all 24 hour reports, new physician's orders [REDACTED]. b. Wound care nurses providing care to all pressure wounds, non-pressure areas and surgical wounds. The charge nurse being responsible for notification of the wound care nurse. The wound care nurse attending the daily clinical meeting for issues and concerns. Wound care nurse coverage being seven days a week. c. Charge nurse skin assessments being followed up by skin assessments completed by the clinical manager to evaluate findings. Hospice patients would also have weekly skin assessments by the hospice nurse and communicated to facility staff. Interviews conducted beginning on 10/18/13 at 3:30 PM through 10/21/13 at 6:00 AM, with LVN MM, LVN H, LVN E, ADON LVN E, LVN U, LVN A, RN W, LVN D, RN AA, LVN C, RN V, LVN OO, LVN F, LVN PP, LVN I, RN W, LVN QQ, LVN RR, LVN HHH, LVN III, LVN SS, LVN TT, LVN VV, LVN WW, RN UU, CNA R, CNA Q, CNA YY, CNA FF, CNA ZZ, CNA N, CNA O, CNA M, CNA P, CNA AAA, CNA BBB, MA CCC, CNA DDD, CNA EEE, CNA FFF, CNA GGG, CNA L, CNA JJJ, CNA KKK, MA S, CNA LLL, CNA KK, CNA MM, CNA MMM, revealed they attended the in-service, except for one CNA who was scheduled to go the day of interview. All of those who attended were able to identify the content of the in-service and understood the significance of the content. On 10/21/13 the IJ was removed. On 10/21/13 at 2:45 PM , the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's roster provided on 10/14/13 reflected 27 residents resided on the unit where Resident #1 resided and where LVN B worked.

Based on observation, interview and record review, it was determined the facility failed to immediately consult with the resident's physician and interested family member when the resident had a significant change in physical status for one (Resident #1) of 27 residents reviewed for skin/wound care and/or pacemakers. 1. LVN B failed to immediately consult with Resident #1's physician when he saw the resident's surgical wound had opened and the pacemaker was clearly visible. Resident #1 was admitted to the hospital and received an intravenous antibiotic. An Immediate Jeopardy (IJ) was identified on 10/16/13. While the IJ was removed on 10/21/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could also affect the 27 residents, who were cared for by LVN B, by placing them at risk for delayed medical care and treatment, increased infection, wound deterioration and/or death. Findings included: Resident #1's Admission Record, dated 08/22/13, reflected he was originally admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 08/29/13, reflected the resident was a [AGE] year-old male with [DIAGNOSES REDACTED]. The functional status indicated resident required set up assistance only for all activities of daily living. Resident was continent of bowel and bladder. The section on the MDS assessment regarding cognition was blank. Resident #1's Care Plan, dated 07/31/13, reflected only problems of falls and fall potential. Resident #1's Nursing Progress Note, dated 08/16/13 reflected the resident's pacemaker was being removed and a new one was to be implanted. Resident #1 was sent to the hospital via non- emergency transport for the procedure. Resident #1's Nursing Progress Note, dated 08/16/13 at 11:27 AM reflected he was not able to shower for one week, lift his left arm above his shoulder, or lift more than 10 pounds with his left arm. The Note also reflected not to remove the steri-strips on the wound for one week, and the physician would continue to monitor. Resident #1's Physician's Note from the Cardiologist, dated 09/26/13, reflected the resident saw the Cardiologist that day. Interview with Resident #1's family member on 10/16/13 at 11:30 AM revealed he/she took the resident to the doctor on 09/26/13 for a check-up following the visit of 08/16/13. The family member stated the doctor pulled the dressing back and told the him/her the pacemaker site looked good and to keep it covered. Interview with LVN B on 10/15/13 at 3:05 PM revealed he changed Resident #1's dressing on 10/11/13 because it was soiled. LVN B stated the wound was opened and he could see the pacemaker. He revealed he thought the treatment nurse was taking care of the wound. LVN B stated there was no drainage. Interview with LVN A, the treatment nurse for the entire facility, on 10/15/13 at 2:00 PM revealed she had no information regarding a wound or wound care for Resident #1. Another interview with LVN B, on 10/16/13 at 12:15 PM with the DON present, revealed Resident #1's surgical site was never red or swollen and 10/11/13 was the first time he saw a dressing on the wound. LVN B stated again he thought the treatment nurse was taking care of it because there were no orders on Resident #1's Treatment Administration Record. He revealed he did not contact Resident #1's physician when he saw the opened wound on the resident's chest with his pacemaker exposed. When asked if he told the treatment nurse about the resident's opened wound, LVN B replied, "No." Interview with the DON and Administrator on 10/15/13 at 3:30 PM revealed they did not have any knowledge that LVN B was aware Resident #1's wound had opened and his pacemaker was exposed, and LVN B covered the area with a dressing. The DON stated she was contacted by the ER regarding the information they received from LVN C on 10/13/13. She also stated the weekend supervisor told her about the wound after the arrival of the surveyors. The DON and Administrator revealed they had started an investigation. The DON stated, on 10/16/13 at approximately 2:00 PM, LVN B was suspended pending investigation. Interview with CNA M, who worked the first shift on Resident #1's unit, on 10/16/13 at 8:10 AM revealed she frequently cared for him. She stated on 10/13/13 she notified LVN C there was drainage on Resident #1's dressing. CNA M revealed Resident #1 usually would not take off his tee shirt except in the shower. CNA M stated there had not been a dressing on the site until Resident #1 fell on [DATE]. Resident #1's Nurse's Note, dated 10/13/13 at 10:52 AM, reflected "incision site is open with purulent drainage." The physician and family were notified and the resident was sent to the ER. Interview with LVN C on 10/19/13 at 11:00 AM revealed on 10/13/13 when he saw the wound, he called the supervisor and treatment nurse to check the wound as well as notifying the physician and family. LVN C did not recall Resident #1 having a dressing previously, nor did LVN C identify anytime he had an occasion to check Resident #1's chest. A telephone interview with Resident #1's physician on 10/16/13 at 3:10 PM revealed he was not aware of the wound until 10/13/13. Resident #1's emergency room Physician's entry, dated 10/13/13 at 2:40 PM, reflected he came to the ER with a wound infection, and there was a left chest wound dehiscence (opening at a surgical site) of a pacemaker device. The opening measured two inches by one inch with purulent (containing pus) drainage. Resident #1 was admitted to the hospital and treated with intravenous antibiotics. Resident #1's Hospital physician progress notes [REDACTED]." Resident #1's physician's orders [REDACTED]. The Order also reflected to monitor for a change in condition. Observation of Resident #1 on 10/15/13 at 10:00 AM revealed he was alert and oriented to time, place and person. He had difficulty answering questions due to his severe hearing loss. An observation on 10/15/13 at 3:15 PM of Resident #1's wound care revealed an opened area approximately two inches by one inch in his left chest with his pacemaker clearly visible. The chest wall behind the pacemaker was also visible. The wound was clean and free of drainage. The facility's current policy, Change in Condition Reporting, dated May 2007, reflected any sudden or serious change would be communicated to the resident's physician with a request for a physician visit promptly and/or an acute care evaluation. The licensed nurse in charge would notify the physician. The facility's policy, Change in Condition Reporting, dated May 2007, did not reflect when the resident's physician would be notified of a change in condition. An Immediate Jeopardy was identified on 10/16/13. The Administrator and DON were notified on 10/16/13 at 1:56 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 10/18/13 at 1:45 PM and reflected the following: 1. LVN B was terminated and his license was referred to the Texas State Board of Nursing. 2. Nursing administrative staff in-serviced all clinical staff including six RNs, 50 LVNs, five Restorative Aides, 20 MAs, and 108 CNAs. In-service began on 10/18/13 and was scheduled to be completed by 10/23/13. Staff were not scheduled to work until the in-service was completed. Training included hand-outs and a post competency test. In-service for RNs, LVNs and MAs included: Physician and family communication for new and clarifying orders Changes in condition with proper notification Ethics for unit staff where Resident #1 resided. Inservice for CNAs included: Change in condition report to the charge nurse of any skin condition 7. Management and monitoring of the wound care program along with other major changes would be accomplished by nursing administration by the following: Interviews conducted beginning on 10/18/13 at 3:30 PM through 10/21/13 at 6:00 AM, with LVN MM, LVN H, LVN E, ADON LVN E, LVN U, LVN A, RN W, LVN D, RN AA, LVN C, RN V, LVN OO, LVN F, LVN PP, LVN I, RN W, LVN QQ, LVN RR, LVN HHH, LVN III, LVN SS, LVN TT, LVN VV, LVN WW, RN UU, CNA R, CNA Q, CNA YY, CNA FF, CNA ZZ, CNA N, CNA O, CNA M, CNA P, CNA AAA, CNA BBB, MA CCC, CNA DDD, CNA EEE, CNA FFF, CNA GGG, CNA L, CNA JJJ, CNA KKK, MA S, CNA LLL, CNA KK, CNA MM, CNA MMM, revealed they attended the in-service, except for one CNA who was scheduled to go the day of interview. All of those who attended were able to identify the content of the in-service and understood the significance of the content. On 10/21/13 the IJ was removed. On 10/21/13 at 2:45 PM , the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's roster provided on 10/14/13 reflected 27 residents resided on the unit where Resident #1 resided and where LVN B worked.

Based on observation, interview and record review, it was determined the facility failed to provide services that met professional standards of quality for one (Resident #1) of 27 residents reviewed for skin/wound care and/or pacemakers. 1. LVN B failed to notify Resident #1's physician when he saw the resident's surgical wound had opened and the pacemaker was clearly visible. 2. LVN B placed a dressing on Resident #1's opened surgical wound without a physician's orders [REDACTED]. Resident #1 was admitted to the hospital and received an intravenous antibiotic. An Immediate Jeopardy (IJ) was identified on 10/16/13. While the IJ was removed on 10/21/13, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures could also affect the 27 residents, who were cared for by LVN B, by placing them at risk for delayed medical care and treatment, increased infection, wound deterioration and/or death. Findings included: "?217.11. Standards of Nursing Practice. The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others ... (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered...(vi) contacts with other health care team members concerning significant events regarding client's status...(M)Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications...(P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care...." Resident #1's Admission Record, dated 08/22/13, reflected he was originally admitted to the facility on [DATE]. Resident #1's MDS assessment, dated 08/29/13, reflected the resident was a [AGE] year-old male with [DIAGNOSES REDACTED]. The functional status indicated resident required set up assistance only for all activities of daily living. Resident was continent of bowel and bladder. The section on the MDS assessment regarding cognition was blank. Resident #1's Care Plan, dated 07/31/13, reflected only problems of falls and fall potential. Resident #1's Nursing Progress Note, dated 08/16/13 reflected the resident's pacemaker was being removed and a new one was to be implanted. Resident #1 was sent to the hospital via non- emergency transport for the procedure. Resident #1's Nursing Progress Note, dated 08/16/13 at 11:27 AM reflected he was not able to shower for one week, lift his left arm above his shoulder, or lift more than 10 pounds with his left arm. The Note also reflected not to remove the steri-strips on the wound for one week, and the physician would continue to monitor. Resident #1's Care Plan, dated 07/31/13, did not reflect an update and/or review regarding his new pacemaker, surgical wound site, or surgical wound site care. All of Resident #1's physician's orders [REDACTED]. Resident #1's Nursing Progress Notes from 08/18/13 through 10/13/13 did not reflect assessment of his surgical site. Resident #1's Skin Assessment, dated 08/19/13, did not reflect his new surgical site wound. Resident #1's Physician's Note from the Cardiologist, dated 09/26/13, reflected the resident saw the Cardiologist that day. Interview with Resident #1's family member on 10/16/13 at 11:30 AM revealed he/she took the resident to the doctor on 09/26/13 for a check-up following the visit of 08/16/13. The family member stated the doctor pulled the dressing back and told the him/her the pacemaker site looked good and to keep it covered. Interview with LVN B on 10/15/13 at 3:05 PM revealed he changed Resident #1's dressing on 10/11/13 because it was soiled. LVN B stated the wound was opened and he could see the pacemaker. He revealed he thought the treatment nurse was taking care of the wound. LVN B stated there was no drainage. Interview with LVN A, the treatment nurse for the entire facility, on 10/15/13 at 2:00 PM revealed she had no information regarding a wound or wound care for Resident #1. Another interview with LVN B, on 10/16/13 at 12:15 PM with the DON present, revealed Resident #1's surgical site was never red or swollen and 10/11/13 was the first time he saw a dressing on the wound. LVN B stated again he thought the treatment nurse was taking care of it because there were no orders on Resident #1's Treatment Administration Record. He revealed he did not contact Resident #1's physician when he saw the opened wound on the resident's chest with his pacemaker exposed. When asked if he told the treatment nurse about the resident's opened wound, LVN B replied, "No." Interview with the DON and Administrator on 10/15/13 at 3:30 PM revealed they did not have any knowledge that LVN B was aware the resident's wound had opened and his pacemaker was exposed and LVN B placed a dressing over the site. The DON stated she was contacted by the ER regarding the information they received from LVN C on 10/13/13. She also stated the weekend supervisor told her about the wound after the arrival of the surveyors. The DON and Administrator revealed they had started an investigation. The DON stated, on 10/16/13 at approximately 2:00 PM, LVN B was suspended pending investigation. Interview with CNA M, who worked the first shift on Resident #1's unit, on 10/16/13 at 8:10 AM revealed she frequently cared for him. She stated on 10/13/13 she notified LVN C there was drainage on Resident #1's dressing. CNA M revealed Resident #1 usually would not take off his tee shirt except in the shower. CNA M stated there had not been a dressing on the site until Resident #1 fell on [DATE]. Resident #1's Nurse's Note, dated 10/13/13 at 10:52 AM, reflected "incision site is open with purulent drainage." The physician and family were notified and the resident was sent to the ER. Interview with LVN C on 10/19/13 at 11:00 AM revealed on 10/13/13 when he saw the wound, he called the supervisor and treatment nurse to check the wound as well as notifying the physician and family. LVN C did not recall Resident #1 having a dressing previously, nor did LVN C identify anytime he had an occasion to check Resident #1's chest. A telephone interview with Resident #1's physician on 10/16/13 at 3:10 PM revealed he was not aware of the wound until 10/13/13. Resident #1's emergency room Physician's entry, dated 10/13/13 at 2:40 PM, reflected he came to the ER with a wound infection, and there was a left chest wound dehiscence (opening at a surgical site) of a pacemaker device. The opening measured two inches by one inch with purulent (containing pus) drainage. Resident #1 was admitted to the hospital and treated with intravenous antibiotics. Resident #1's Hospital physician progress notes [REDACTED]." Resident #1's physician's orders [REDACTED]. The Order also reflected to monitor for a change in condition. Observation of Resident #1 on 10/15/13 at 10:00 AM revealed he was alert and oriented to time, place and person. He had difficulty answering questions due to his severe hearing loss. An observation on 10/15/13 at 3:15 PM of Resident #1's wound care revealed an opened area approximately two inches by one inch in his left chest with his pacemaker clearly visible. The chest wall behind the pacemaker was also visible. The wound was clean and free of drainage. The facility's current policy, Change in Condition Reporting, dated May 2007, reflected any sudden or serious change would be communicated to the resident's physician with a request for a physician visit promptly and/or an acute care evaluation. The licensed nurse in charge would notify the physician. The facility's policy, Change in Condition Reporting, dated May 2007, did not reflect when the resident's physician would be notified of a change in condition. The facility's current policy regarding wound care, dated May 2007, reflected weekly assessments of skin would be completed on all residents with wounds requiring treatment and documented. An Immediate Jeopardy was identified on 10/16/13. The Administrator and DON were notified on 10/16/13 at 1:56 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 10/18/13 at 1:45 PM and reflected the following: 1. LVN B was terminated and his license was referred to the Texas State Board of Nursing. LVN B's Counseling/Disciplinary Notice, dated 10/24/13, reflected he was terminated on 10/22/13. On 10/21/13 the IJ was removed. On 10/21/13 at 2:45 PM , the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "pattern" because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's roster provided on 10/14/13 reflected 27 residents resided on the unit where Resident #1 resided and where LVN B worked.

Based on observation, interview and record review, it was determined the facility failed ensure one CNA (CNA A) of 128 CNAs employed demonstrated competency to care for one (Resident #1) of six residents reviewed for falls. 1) Resident #1 had a physician's orders [REDACTED]. CNA A was aware Resident #1 was agitated and the bed alarm was not working after assisting the resident to the bathroom. Shortly (10 minutes) after being assisted back to bed with the non-working alarm, Resident #1 fell to the floor catching her finger in the door plate and severing her finger. CNA A did not inform the charge nurse of the bed alarm not alarming or that Resident #1 was exhibiting agitation. This failure resulted in Resident #1's loss of a finger and resulting surgery. The finger could not be re-attached. These failures could have affected the four residents with chair/bed alarms on the Schepps/Jacobs halls where CNA A was assigned, by placing them at risk for falls, lacerations, fractures and head injuries. 2) CNA A was told by Resident #1 that someone 'beat her up.' CNA A did not report the allegation of abuse to the Abuse Coordinator (which was the ADM). This failure could have caused continued abuse to any of the 28 cognitively impaired residents on the Schepps and Jacobs hall where CNA A was normally assigned. Findings included: 1) Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Provider Investigation Report revealed the incident date was 02/11/12 and the time was 10:50 a.m. The report reflected Resident #1 had an 'Injury of unknown origin.' Under Description of Injury was, "(Resident #1)'s ring finger, on her right hand, had an avulsion injury between the middel (sic) and tip of finger." Under Description of Assessment" was, "Resident was noted on the floor with right hand bleeding, noted tip of finger laying (sic)on floor beside door frame to bathroom. Pressure dressing was applied and the extremity was elevated." Investigation Findings was checked, "Confirmed." A hand typed "Investigation Summary' reflected, "...Based on the investigation it appears (Resident #1) lost her balance near her bathroom and as she fell , she grabbed the door jam and caught her finger in the door plate." Included with the Provider Investigation, was an inservice that was provided to staff after the incident. The inservice reflected, "All patients with an alarm must be checked on at the beginning of the shift to ensure alarm is turned on. Nurse and CNA are both responsible for checking the alarms to make sure they are turned on and are functioning properly. CNA's are responsible for positioning patient properly on the alarm to ensure that alarm will go off accordingly. If an alarm is not functioning properly, the nurse must be notified to replace the alarm." This was completed on 02/13/12, two days after the incident. Also included with the Provider Investigation was a Counseling/Disciplinary Notice dated 02/14/12 for CNA A. The report reflected, "On 02/12/12, a patient under your care had an unfortunate fall that resulted in a severe injury. Part of this patient's care plan was to ensure she was on a bed alarm while in bed. During the investigation of this incident you stated that you helped the resident to the bathroom [ROOM NUMBER] minutes prior to the incident occurring. You also stated after you left her in her bed with the alarm on (sic). On 02/12/12 and 02/13/12 you were further questioned into the events that occurred...You stated the alarm did not go off when you assisted her from the bed to the bathroom. When questioned if the alarm beeped when you put her back to bed to signal that it was properly in place you stated that it did not. You also stated you did not notify the nurse that the alarm appeared to not be functioning properly...This was an unfortunate accident, however it may have been avoidable had we ensured the alarm was properly working and positioned correctly...." A quarterly MDS assessment dated [DATE] for Resident #1 reflected she was moderately impaired in her decision making skills. She exhibited short and long-term memory problems. She had [MEDICAL CONDITION] and was verbally abusive to staff at times. She required extensive assistance from one person for bed mobility, transfers, locomotion and toileting. She had an additional [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] for Resident #1 reflected she was severely impaired in her decision making skills. She exhibited short and long-term memory problems. She required extensive assistance from one person for bed mobility, transfers, locomotion and toileting. She had an additional [DIAGNOSES REDACTED]. One fall caused a minor injury and the other fall caused a major injury. A quarterly MDS assessment dated [DATE] for Resident #1 reflected the Interview for Mental Status was completed. Resident #1 scored '00,' indicating severe impairment. She had [MEDICAL CONDITION] and hallucinations. She required extensive assistance from one person for bed mobility and toileting. She required extensive assistance from two staff for transfers and locomotion. She had a [DIAGNOSES REDACTED]. The most recent fall risk assessment dated [DATE] in the clinical record for Resident #1 revealed she scored a 14, indicating she was a High risk for falls. Review of a Care Plan for Fall Risk, initialed on 09/12/11 for Resident #1 revealed a Potential for injury or falls from unsteady gait and poor balance. Approaches included:...2) Monitor resident's location and activities frequently...4) Assure resident has proper shoes (non-skid) on when out of bed, 5) Record and report any trends that precipitate injuries from unsteady gait...9) 11/1/11 Pressure alarm while in bed...." This care plan was reviewed on 02/12/12. Observation on 02/23/12 at 10:10 a.m. revealed Resident #1 was in her bed. The half side rail was raided. There was a bandage dated 02/23/12 to the right ring finger. An attempted interview at this time with Resident #1 revealed she did not speak much English. LVN B entered the room at that time. An attempt to observe the right ring finger stump was unsuccessful, as Resident #1 began to exhibit signs of agitation. LVN B was able to translate for the surveyor. When asked what happened to her finger, Resident #1 at first stated she had a little fall. Resident #1 was not able to give details of the fall, or was not willing to. When asked if someone was in the room with her when she fell , Resident #1 stated no. After much explanation from LVN B to Resident #1, Resident #1 was beginning to become agitated. Resident #1 then stated she did not fall. LVN B added that Resident #1 became agitated easily. Interview on 02/23/12 at 10:15 a.m. with Resident #3 revealed she lived directly across the hall from Resident #1 and observed Resident #1 on the floor on the day of the incident. Resident #3 stated she did not hear the alarm sound prior to seeing Resident #1 on the floor. Interview on 02/23/12 at 1:15 p.m. with CNA A revealed she was assigned to Resident #1 on 02/11/12, at the time of the incident. She stated Resident #1 had a tendency to get up and would lose her balance and fall. She stated at approximately 10:40 a.m., she observed Resident #1 was agitated and her legs were hanging out of her bed. CNA A stated she entered the room and thought that maybe Resident #1 needed to go to the bathroom. CNA A stated she got Resident #1 out of the bed to take her to the bathroom. When asked if the bed alarm sounded when she got Resident #1 out of the bed, CNA A stated it did not. CNA A stated she took Resident #1 to the bathroom, and then placed her back into her bed. When asked what she did about the bed alarm not sounding, CNA A stated she observed the bed alarm was in the 'on' position, but it did not 'beep' or alarm when she removed Resident #1 from the bed, or placed her back into the bed. When asked if she informed her charge nurse of the bed alarm not alarming, or that Resident #1 was exhibiting signs of agitation, CNA A stated she did not. CNA A stated she was in another resident's room, about 10 minutes after leaving Resident #1 in her bed with the malfunctioning bed alarm, when she was informed by another resident that a lady was on the floor. CNA A stated when she looked towards Resident #1's door, she observed Resident #1 sitting on her buttocks, in the floor between the head of the bed and the bathroom door. CNA A stated there was blood on Resident #1's hand. When asked if the bed alarm was alarming, CNA A stated it was not. CNA A stated she immediately informed the nurse. When asked if she had been inserviced on the bed alarm prior to using it, CNA A stated she had not. When asked what the purpose of the chair/bed alarm was, CNA A stated it was to alert the staff when a resident was attempting to get up without help. When asked what she did different now, CNA A stated she checked the alarm to make sure it was alarming, and not that it was just in the on position. CNA A added that Resident #1 had numerous falls, and that one time, she came back to work after a few days off and Resident #1 had bruises all over her face. CNA A stated she asked Resident #1 was happened and Resident #1 told her that someone beat her up. When asked if she reported the abuse allegation to anyone, CNA A stated she did not. When asked why she did not report the allegation of abuse to the charge nurse, the DON or the Abuse Coordinator, CNA A stated she just did not because the resident was 'joking.' CNA A left the interview at that time. The surveyor immediately walked toward the ADM office to inform him of the abuse allegation. CNA A A approached the surveyor and stated, she 'may have' reported the abuse allegation to the charge nurse (LVN B) but she was not sure. At that time, the surveyor entered the ADM office with CNA A and informed him of the abuse allegation that had not been reported. Interview and observation on 02/24/12 at 9:50 a.m. with LVN B revealed CNA A did not report to her that Resident #1 alleged someone had beat her, within the past month. Resident #1 was in her bed, and did not have non-slip socks on. Telephone interview on 02/24/12 at 10:55 a.m. with LVN E revealed he was the nurse supervisor on 02/11/12 when Resident #1 had the fall. He stated he entered the room and the alarm was not sounding. He stated he observed Resident #1's right ring finger on the floor, along with a gold ring. He stated he placed the finger on ice, and had the resident transported to a local hospital via 911. He stated he was the person who interviewed the staff initially. He stated a nurse, a MA and CNA A all stated the bed alarm was not sounding at the time of the incident. Review of the Consolidated Orders (Chart) Report, dated 02/13/12 for Resident #1 revealed an order was written on 11/01/11 for, "Pressure Alarm-check placement q (every) shift." Review of ED Nursing Record from a local ER for Resident #1 dated 02/11/12 revealed, "11:44...Pt has severed right 3rd digit...." Review of Discharge Instructions for Resident #1 dated 02/11/12, revealed, "Discharge Instructions: Amputation, finger tip...Special Notes: The hand specialist was consulted in the ED and agrees that the pt is not a candidate for finger reattachment...." Review of Accident/Incident Report (A/I) for Resident #1 revealed: a) 09/11/11 5:45 p.m. Resident #1 was found on the floor and the primary injury was "Bil knees swollen/bruise noted." Follow-up/Interventions to Prevent Recurrence was Non slip slippers or shoes applied. b) 09/17/11 4:30 a.m. Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. c) 10/01/11 9:00 p.m. Resident #1 was found on the floor. The injury was a laceration. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. d) 10/17/11 6:05 a.m. Resident #1 was found on the floor the injury was a skin tear to (left) arm. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT and a Review of medications. e) 12/09/11 12:15 a.m. Resident #1 was found on the floor. The injury was a bump on the head and a laceration. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. A facial x-ray was completed after this fall and was negative. f) 12/24/11 12:00 (a.m./p.m. not identified). Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. g) 12/25/11 1:00 p.m. Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. h) 01/28/12 4:15 p.m. Resident #1 had a witnessed fall. The injury was a laceration to the chin. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. i) 02/10/11 12:15 p.m. Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Pressure alarm repositioned. j) 02/11/12 10:50 a.m. Resident #1 was found on the floor and the primary injury was "Amputation." Follow-up/Interventions to Prevent Recurrence was blank. Review of the instructions for the Pressure Pad for Direct Supply Attendant Resident Monitors, revealed, "Use:...Position pad under the resident's buttock area to indicate when he or she exits a chair or bed; pad can alternately be positioned under a resident's upper back to indicate when they sit up in bed...ALWAYS TEST THE SYSTEM BEFORE EVERY USE...Troubleshooting...If you determine either the pad or the monitor is not working properly...contact Direct Supply...." 2) Review of Employee Inservice Report for CNA A printed on 02/23/12 and provided by the DON revealed CNA A had attended inservices regarding Abuse & Neglect on 12/23/10 and 03/23/11. She attended inservice on 01/09/12 regarding Reporting Abuse. 3) The CMS 802 dated 02/23/12 provided by the DON reflected there were 34 residents checked for Falls/Fractures. The DON provided a list of residents who used a bed/chair alarm on 02/23/12. There were 34 residents who had alarms. There were four residents on the Schepps and Jacob hall where CNA A was assigned.

Based on observation, interview and record review, it was determined the facility failed ensure they implemented their interventions put in place to prevent accidents for two (Resident #1 and #2) of six residents reviewed for falls. 1) Resident #1 had a physician's orders [REDACTED]. CNA A was aware the bed alarm was not working, after assisting the resident to the bathroom. Shortly (10 minutes) after being assisted back to bed with the non-working alarm, Resident #1 fell to the floor catching her finger in the door plate and severing her finger. This failure resulted in Resident #1's loss of a finger and resulting surgery. The finger could not be re-attached. 2) Resident #2 had a physician's orders [REDACTED]. Resident #2 was in bed, unsupervised with her bed alarm lying on the bedside table. This failure could have caused Resident #2 to get out of bed, unsupervised and sustain a fall with injury including lacerations, fractures and head injuries. These failures could have affected the 34 residents with chair/bed alarms by placing them at risk for falls, lacerations, fractures and head injuries. Findings included: 1) Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Provider Investigation Report revealed the incident date was 02/11/12 and the time was 10:50 a.m. The report reflected Resident #1 had an 'Injury of unknown origin.' Under Description of Injury was, "(Resident #1)'s ring finger, on her right hand, had an avulsion injury between the middel (sic) and tip of finger." Under Description of Assessment" was, "Resident was noted on the floor with right hand bleeding, noted tip of finger laying (sic) on floor beside door frame to bathroom. Pressure dressing was applied and the extremity was elevated." Investigation Findings was checked, "Confirmed." A hand typed "Investigation Summary" reflected, "...Based on the investigation it appears (Resident #1) lost her balance near her bathroom and as she fell , she grabbed the door jam and caught her finger in the door plate." Included with the Provider Investigation, was an inservice that was provided to staff after the incident. The inservice reflected, "All patients with an alarm must be checked on at the beginning of the shift to ensure alarm is turned on. Nurse and CNA are both responsible for checking the alarms to make sure they are turned on and are functioning properly. CNA's are responsible for positioning patient properly on the alarm to ensure that alarm will go off accordingly. If an alarm is not functioning properly, the nurse must be notified to replace the alarm." This was completed on 02/13/12, two days after the incident. Also included with the Provider Investigation was a Counseling/Disciplinary Notice dated 02/14/12 for CNA A. The report reflected, "On 02/12/12, a patient under your care had an unfortunate fall that resulted in a severe injury. Part of this patient's care plan was to ensure she was on a bed alarm while in bed. During the investigation of this incident you stated that you helped the resident to the bathroom 10 minutes prior to the incident occurring. You also stated after you left her in her bed with the alarm on (sic). On 02/12/12 and 02/13/12 you were further questioned into the events that occurred...You stated the alarm did not go off when you assisted her from the bed to the bathroom. When questioned if the alarm beeped when you put her back to bed to signal that it was properly in place you stated that it did not. You also stated you did not notify the nurse that the alarm appeared to not be functioning properly...This was an unfortunate accident, however it may have been avoidable had we ensured the alarm was properly working and positioned correctly...." A handwritten statement from LVN G dated 02/11/12 reflected, "At approximately 10:50 a.m. I...was summoned from the Nurse's Station by (CNA A) to room S-10...I immediately noticed blood on the entry door, the wall of the bathroom entry, and the floor near the resident. Blood was noted to (right) hand, upon further assessment, resident's (right) ring fingertip (with) tissue was laying (sic) on the floor near bathroom entry...." A quarterly MDS assessment dated [DATE] for Resident #1 reflected she was moderately impaired in her decision making skills. She exhibited short and long-term memory problems. She had delusions and was verbally abusive to staff at times. She required extensive assistance from one person for bed mobility, transfers, locomotion and toileting. She had an additional [DIAGNOSES REDACTED]. A significant change MDS assessment dated [DATE] for Resident #1 reflected she was severely impaired in her decision making skills. She exhibited short and long-term memory problems. She required extensive assistance from one person for bed mobility, transfers, locomotion and toileting. She had an additional [DIAGNOSES REDACTED]. One fall caused a minor injury and the other fall caused a major injury. A quarterly MDS assessment dated [DATE] for Resident #1 reflected the Interview for Mental Status was completed. Resident #1 scored '00,' indicating severe impairment. She had delusions and hallucinations. She required extensive assistance from one person for bed mobility and toileting. She required extensive assistance from two staff for transfers and locomotion. She had a [DIAGNOSES REDACTED]. The most recent fall risk assessment dated [DATE] in the clinical record for Resident #1 revealed she scored a 14, indicating she was a High risk for falls. Review of a Care Plan for Fall Risk, initialed on 09/12/11 for Resident #1 revealed a Potential for injury or falls from unsteady gait and poor balance. Approaches included:...2) Monitor resident's location and activities frequently...4) Assure resident has proper shoes (non-skid) on when out of bed, 5) Record and report any trends that precipitate injuries from unsteady gait...9) 11/1/11 Pressure alarm while in bed...." This care plan was reviewed on 02/12/12. Observation on 02/23/12 at 10:10 a.m. revealed Resident #1 was in her bed. The half side rail was raised. There was a bandage dated 02/23/12 to the right ring finger. An attempted interview at this time with Resident #1 revealed she did not speak much English. LVN B entered the room at that time. An attempt to observe the right ring finger stump was unsuccessful, as Resident #1 began to exhibit signs of agitation. LVN B was able to translate for the surveyor. When asked what happened to her finger, Resident #1 at first stated she had a little fall. Resident #1 was not able to give details of the fall, or was not willing to. When asked if someone was in the room with her when she fell , Resident #1 stated no. After much explanation from LVN B to Resident #1, Resident #1 was beginning to become agitated. Resident #1 then stated she did not fall. LVN B added that Resident #1 became agitated easily. Interview on 02/23/12 at 10:15 a.m. with Resident #3 revealed she lived directly across the hall from Resident #1 and observed Resident #1 on the floor on the day of the incident. Resident #3 stated she did not hear the alarm sound prior to seeing Resident #1 on the floor. Interview on 02/23/12 at 1:15 p.m. with CNA A revealed she was assigned to Resident #1 on 02/11/12, at the time of the incident. She stated Resident #1 had a tendency to get up and would lose her balance and fall. She stated at approximately 10:40 a.m., she observed Resident #1 was agitated and her legs were hanging out of her bed. CNA A stated she entered the room and thought that maybe Resident #1 needed to go to the bathroom. CNA A stated she got Resident #1 out of the bed to take her to the bathroom. When asked if the bed alarm sounded when she got Resident #1 out of the bed, CNA A stated it did not. CNA A stated she took Resident #1 to the bathroom, and then placed her back into her bed. When asked what she did about the bed alarm not sounding, CNA A stated she observed the bed alarm was in the 'on' position, but it did not 'beep' or alarm when she removed Resident #1 from the bed, or placed her back into the bed. When asked if she informed her charge nurse of the bed alarm not alarming, or that Resident #1 was exhibiting signs of agitation, CNA A stated she did not. CNA A stated she was in another resident's room, about 10 minutes after leaving Resident #1 in her bed with the malfunctioning bed alarm, when she was informed by another resident that a lady was on the floor. CNA A stated when she looked towards Resident #1's door, she observed Resident #1 sitting on her buttocks, in the floor between the head of the bed and the bathroom door. CNA A stated there was blood on Resident #1's hand. When asked if the bed alarm was alarming, CNA A stated it was not. CNA A stated she immediately informed the nurse. When asked if she had been inserviced on the bed alarm prior to using it, CNA A stated she had not. When asked what the purpose of the chair/bed alarm was, CNA A stated it was to alert the staff when a resident was attempting to get up without help. When asked what she did different now, CNA A stated she checked the alarm to make sure it was alarming, and not that it was just in the on position. CNA A added that Resident #1 had numerous falls, and that one time, she came back to work after a few days off and Resident #1 had bruises all over her face. CNA A stated she asked Resident #1 was happened and Resident #1 told her that someone beat her up. When asked if she reported the abuse allegation to anyone, CNA A stated she did not. When asked why she did not report the allegation of abuse to the charge nurse, the DON or the Abuse Coordinator, CNA A stated she just did not because the resident was 'joking.' CNA A left the interview at that time. The surveyor immediately walked toward the ADM office to inform him of the abuse allegation. CNA A A approached the surveyor and stated, she 'may have' reported the abuse allegation to the charge nurse (LVN B) but she was not sure. At that time, the surveyor entered the ADM office with CNA A and informed him of the abuse allegation that had not been reported. Interview on 02/23/12 at 3:45 p.m. with the DON revealed Resident #1 had been moved closer to the nurses' station. When asked when that occurred, the DON stated she did not know and was asked to locate the date. The DON stated the facility only used the clip alarm (alarm that clips to the residents clothing and alarms when the residents stands up) and the pressure alarm (a strip that is placed under the fitted sheet or the seat of the chair, and when the resident rises from a sitting position, the alarm sounds). When asked if CNA A was inserviced on the pressure alarm prior to it being used on Resident #1, the DON was not sure. The DON was asked to check inservices for the information. Interview on 02/23/12 at 4:00 p.m. with the DON revealed there was not an inservice for the pressure alarm prior to Resident #1's incident on 02/11/12. Review of an attendance form for Club CNA dated 02/17/12 (six days after the incident with Resident #1) revealed the Class Description was, "Review the use of bed alarms & proper placement & technique..." Twenty-seven CNA's, of 110 CNAs on the list attended the 'Club CNA.' Interview and observation on 02/24/12 at 9:50 a.m. with LVN B revealed Resident #1 was in her bed, and did not have non-slip socks on. Telephone interview on 02/24/12 at 10:55 a.m. with LVN E revealed he was the nurse supervisor on 02/11/12 when Resident #1 had the fall. He stated he entered the room and the alarm was not sounding. He stated he observed Resident #1's right ring finger on the floor, along with a gold ring. He stated he placed the finger on ice, and had the resident transported to a local hospital via 911. He stated he was the person who interviewed the staff initially. He stated another nurse, a MA and CNA A all stated the bed alarm was not sounding at the time of the incident. Review of the Consolidated Orders (Chart) Report, dated 02/13/12 for Resident #1 revealed an order was written on 11/01/11 for, "Pressure Alarm-check placement q (every) shift." Review of ED Nursing Record from a local ER for Resident #1 dated 02/11/12 revealed, "11:44...Pt has severed right 3rd digit...." Review of Discharge Instructions for Resident #1 dated 02/11/12, revealed, "Discharge Instructions: Amputation, finger tip...Special Notes: The hand specialist was consulted in the ED and agrees that the pt is not a candidate for finger reattachment...." Review of Accident/Incident Report (A/I) for Resident #1 revealed: a) 09/11/11 5:45 p.m. Resident #1 was found on the floor and the primary injury was "Bil knees swollen/bruise noted." Follow-up/Interventions to Prevent Recurrence was Non slip slippers or shoes applied. b) 09/17/11 4:30 a.m. Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. c) 10/01/11 9:00 p.m. Resident #1 was found on the floor. The injury was a laceration. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. d) 10/17/11 6:05 a.m. Resident #1 was found on the floor. The injury was a skin tear to the left arm. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT and a Review of medications. e) 12/09/11 12:15 a.m. Resident #1 was found on the floor. The injury was a bump on the head and a laceration. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. A facial x-ray was completed after this fall and was negative. f) 12/24/11 12:00 (a.m./p.m. not identified.) Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. g) 12/25/11 1:00 p.m. Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. h) 01/28/12 4:15 p.m. Resident #1 had a witnessed fall. The injury was a laceration to the chin. Follow-up/Interventions to Prevent Recurrence was Referral to PT/OT. i) 02/10/11 12:15 p.m. Resident #1 was found on the floor. There was no injury. Follow-up/Interventions to Prevent Recurrence was Pressure alarm repositioned. j) 02/11/12 10:50 a.m. Resident #1 was found on the floor and the primary injury was "Amputation." Follow-up/Interventions to Prevent Recurrence was blank. Review of PT notes for Resident #1 reflected she refused a PT evaluation on 01/09/12 (two times), 01/10/12 and 01/11/12. On 02/14/12, PT attempted an evaluation but was not able to due to the resident being at day surgery. On 02/15/12 an OT evaluation was attempted and Resident #1 refused. Review of the instructions for the Pressure Pad for Direct Supply Attendant Resident Monitors, revealed, "Use:...Position pad under the resident's buttock area to indicate when he or she exits a chair or bed; pad can alternately be positioned under a resident's upper back to indicate when they sit up in bed...ALWAYS TEST THE SYSTEM BEFORE EVERY USE...Troubleshooting...If you determine either the pad or the monitor is not working properly...contact Direct Supply...." 2) Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] for Resident #2 revealed she was moderately impaired in her decision making skills. She had short and long-term memory problems. She required extensive assistance from two staff for bed mobility and transfers. She had two falls without injury. Review of a care plan initiated on 02/13/12 for History of Falls for Resident #2 revealed the resident had a history of [REDACTED]...11) Bed alarm to be used when in bed d/t residents cognitive status...." Review of the Consolidate Physicians' Orders dated 02/01/12 through 02/29/12 for Resident #2 revealed, "Bed/chair alarm on at all times...." Review of a physician order [REDACTED]." Review of the TAR dated February 2012 for Resident #2 revealed, "Bed/chair alarm on at all times." 02/23/12 was initialed on 02/23/12. Observation on 02/23/12 at 12:21 p.m. revealed Resident #2 was in her bed, with her meal on the bedside table, unsupervised. There was a chair/bed alarm on the bedside table that was not connected to Resident #2. Interview on 02/23/12 at 12:25 p.m. with CNA C revealed the alarm that was lying on the bedside table was supposed to be connected to Resident #2, she thought. CNA C connected the bed alarm to Resident #2 at that time. Interview on 02/23/12 at 12:32 p.m. with LVN D revealed the alarm that was now connected to Resident #2, was the alarm that was used in the chair, and the bed, for Resident #2. LVN D was informed at that time of the alarm not being connected to Resident #2 at 12:21 p.m. LVN D stated hospice had just left Resident #2's room, and they probably did not apply the alarm when they left the room. Interview on 02/23/12 at 1:00 p.m. with the ADM revealed after the incident with Resident #1, the facility checked all the chair/bed alarms in the facility to ensure they were functioning. He was informed at that time of the observation at 12:21 p.m. with Resident #2 not having her physician ordered bed alarm in use. 3) The CMS 802 dated 02/23/12 provided by the DON reflected there were 34 residents checked for Falls/Fractures. The DON provided a list of residents who used a bed/chair alarm on 02/23/12. There were 34 residents who had alarms.

Based on interview and record review, the Administrator and DON failed to effectively and efficiently use its resources to attain the highest practicable physical well-being of each resident for one (Resident #29) of one dependent resident, who was not provided adequate supervision to prevent a fall. The DON and Administrator failed to initiate interventions to protect Resident #29 from receiving care from CNA F, who had repeated episodes of exhibiting strange behavior. CNA F had slurred speech, glazed eyes, and confusion. These failures resulted in Resident #29 sustaining a hip and femur fracture from a fall when she was left unsupervised by CNA F. Findings included: Resident #29 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #29 was non-ambulatory, required extensive assistance of one-person for transfers, and required extensive assistance for eating, dressing and bathing. She was incontinent of bowel and bladder. LVN M, the charge nurse for Resident #29 stated, during an interview on 02/03/12 at 2:30 PM, Resident #29 was very dependent but was able to transfer to a wheelchair with one person pivot assistance and a gait belt. An interview with Resident #20's Physician, Physician G, was conducted on 02/03/12 at 4:00 PM. Physician G stated Resident #29 had End Stage Dementia. Physician G stated the family members understood there was no way to reverse the Dementia. Hospice care was suggested. Physician G stated Resident #29 was extremely demented. A Counseling/Disciplinary Notice dated 06/01/11 reflected the last day CNA F worked was 05/18/11 and CNA F was being discharged (terminated) from the facility. The Notice reflected on 04/09/11 CNA F was observed by her supervisor exhibiting strange behaviors which included slurred speech and difficulty caring for residents. The Notice also reflected CNA F was taking medications due to a recent surgery and she was sent home for the remainder of her shift. The Counseling/Disciplinary Notice dated 06/01/11 reflected on 04/11/11 CNA F was observed by her supervisor exhibiting strange behaviors which included glazed eyes, sleepiness, confusion, crying, and failure to adequately supervise the transfer of a resident. The Notice reflected the Executive Director and another nurse corroborated the unusual behaviors. The Notice reflected CNA F admitted she was taking strong prescription medications due to her recent surgery and she was reminded of the facility's drug-free policy and they would not tolerate someone working under the influence. The Notice reflected CNA F was told she could not return to work until a physician released her from the medications and felt it was safe for her to return to work. The Notice reflected on 04/14/11 CNA F presented a note from her physician which reflected she no longer needed the prescriptions and CNA F was allowed to return to work. Further review of the Counseling/Disciplinary Notice dated 06/01/11 revealed on 05/18/11 a nurse was informed CNA F appeared sleepy, had glazed eyes and was acting strangely. The Staff Development nurse completed an Observed Behavior Checklist and based on her observations she sent CNA F to be tested for drugs. The Notice reflected the drug test came back non-negative. The Notice reflected CNA F was suspended on 05/18/11 and the facility continued to investigate. The Notice further revealed on 05/18/11 CNA F was seen walking through the halls and stating in a slurred manner "'I'm so sexy."' The Notice reflected that same morning one of CNA F's residents fell while being transferred by CNA F. The Notice reflected CNA F reported to her nurse that she slid the resident to the floor, but follow-up investigation revealed the resident had a [MEDICAL CONDITION] as a result of a fall. CNA F's employee file reflected a leave of absence request for medical leave to start on 01/31/11. There was also a return to work form from a physician which reflected CNA F was released to return to work on 03/14/11. Included in the file was a letter from a physician dated 04/13/11 which reflected CNA F was medically cleared to return to work and another letter from a different physician reflecting CNA F no longer required pain medication. A review of the Accident/Incident Report dated 05/18/11, which was not signed by the Administrator and DON until 07/01/11, for Resident #29 reflected an accident occurred on 05/18/11. The report reflected the accident was investigated by LVN M. The accident report reflected, "The CNA stated Resident was being transferred from bed to the wheelchair when resident legs got weak and CNA slid resident to the floor. Resident was unable to explain what happened CNA was unavailable to report what had happened (sic)." The report also reflected the CNAs were in-serviced on proper transferring techniques by the therapy department. The accident investigation included a written statement by CNA F dated 06/03/11. The statement reflected, " ... I remember getting her (Resident #29) up on 05/18/11 on a Wednesday I was getting her up I left out the room everything was lower bed pad on the floor went to get towel, pad, diaper to get her up she was on the floor I told my charge nurse (sic)." A review of Resident #29's Nurse's Notes dated 05/18/11 at 9:00 AM reflected, "Resident was up in wheelchair. 1.5 cm (centimeter) skin abrasion on L (left) leg below knee... Notified (Physician B). Res (resident) c/o (complains of) pain on low back (Physician B) gave NO (new order) for x-ray of lower back. Notified (family member) about new order for x-ray and skin abrasion on (L) leg...." The Nurse's Notes for Resident #29 also reflected the family member called on 05/18/11 at 8:30 PM and requested a urine analysis for the resident due to a history of Urinary Tract Infections. The notes reflected the night nurse collected the specimen with a catheter at 2:00 AM on 05/19/11. Review of the x-ray report for 05/18/11 reflected no fractures of the back. On 05/19/11 at 7:30 AM the Nurse's Notes for Resident #29 reflected, "CNA" went to get Resident #29 up for breakfast and the resident was complaining of pain of the left leg and hip. The notes reflected the left leg was swollen and shorter than the right leg. LVN M notified the Nurse Practitioner and an x-ray of the hip was ordered. At 11:00 AM on 05/19/11 the x-ray company called LVN M and reported Resident #29's left hip was fractured. Resident #29 was transferred to the ER at 11:45 AM on 05/19/11. A review of Resident #29's emergency room Admission Record dated 05/19/11 revealed Resident #29 had an x-ray at the hospital which confirmed a [MEDICAL CONDITION] and a femur fracture. The ED (Emergency Department) Physician Record dated 05/19/11 at 1:19 PM reflected the differential [DIAGNOSES REDACTED]." The ED Nursing Record notes dated 05/19/11 at 12:52 PM reflected the resident had an abrasion to the left elbow and left knee. The record reflected Resident #29 was discharged to the nursing home at 6:33 PM. The family had declined hip surgery. An interview was conducted with LVN H, a weekend supervisor, on 02/02/12 at 6:00 PM. He stated, "From what I can recall, she (CNA F) came in on Saturday or Sunday. One of the aides said she didn't look right. I went and interviewed her. She said she took [MEDICATION NAME] (prescription narcotic for pain). She didn't look right to me. It was early in the morning, like one or two hours into her shift. I have worked with her before and she was not like herself. I sent her home and told her she could not come to work like this." An e-mail given to the surveyors by RN J on 02/03/12 was reviewed. The e-mail was dated 04/11/12 at 1:20 PM from the Executive Director to RN J and the Administrator. It detailed the conversation he had with LVN H about CNA F. The e-mail reflected LVN H's observations of CNA F having slurred speech and bursting into tears. The e-mail also reflected the Executive Director was concerned she was under the influence. The e-mail reflected LVN I observed CNA F almost allowing a resident to fall from a shower chair. The e-mail reflected, "...we can't have her working here in that condition. It is unsafe for her and for our residents." An interview with LVN M was conducted on 02/03/12 at 2:30 PM. LVN M stated she was CNA F's charge nurse. She stated she had worked with CNA F for some time and CNA F had a prolonged leave of absence from the facility for a medical problem. LVN M stated CNA F was a very good worker and did not need a lot of direction to accomplish her daily tasks. LVN M stated one day CNA F came to work and seemed sleepy, but LVN M could not remember the exact date or time. LVN M stated CNA F told her she had taken some medications that night to sleep. LVN M stated she called the staffing supervisor, RN J, to report CNA F seemed unusual. RN J came to take CNA F from the floor. LVN M also stated Resident #29 was a one person transfer with a gait belt. LVN M stated Resident #29 was able to a stand pivot with assistance to a wheelchair. An interview with RN J was conducted on 02/03/12 at 11:15 AM. RN J stated she thought CNA F was behaving strangely. She stated she completed the behavior observation sheet and determined CNA F might be under the influence of drugs or alcohol. RN J stated she took CNA F to the clinic for a urine drug screening. The final urine drug screening screening report for CNA F dated 05/26/11 was negative for Carboxy-THC, [MEDICATION NAME], Benzoylecgonine, Opiates, "PCP", Barbiturates, Benzodiazepines, [MEDICATION NAME], Methaqualone. An interview with LVN I was conducted on 02/03/12 at 11:40 AM. She stated she had worked with CNA F for over a year and CNA F was different after she (CNA F) returned from medical leave. She stated CNA F was drowsy and had slurred speech. LVN I further stated she thought CNA F's judgment was "off." LVN I stated she had observed CNA F at work drowsy with slurred speech during April. She further stated she reported this to RN J. CNA F was terminated from the facility on 06/01/11, according to a Counseling/Disciplinary Notice dated 06/01/11 and signed on 06/03/11. The CMS 670 dated 02/02/12 and provided by the facility reflected a census of 227

Based on interview and record review the facility failed to provide adequate supervision to prevent an accident for one (Resident #29) of one resident, who was both cognitively and physically impaired. The facility failed to initiate interventions to protect Resident #29 from receiving care from CNA F, who had repeated episodes of exhibiting strange behavior. CNA F had slurred speech, glazed eyes, and confusion. These failures resulted in Resident #29 sustaining a hip and femur fracture from a fall when she was left unsupervised by CNA F. Findings included: Resident #29 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #29 was non-ambulatory, required extensive assistance of one-person for transfers, and required extensive assistance for eating, dressing and bathing. She was incontinent of bowel and bladder. LVN M, the charge nurse for Resident #29 stated, during an interview on 02/03/12 at 2:30 PM, Resident #29 was very dependent but was able to transfer to a wheelchair with one person pivot assistance and a gait belt. An interview with Resident #20's Physician, Physician G, was conducted on 02/03/12 at 4:00 PM. Physician G stated Resident #29 had End Stage Dementia. Physician G stated the family members understood there was no way to reverse the Dementia. Hospice care was suggested. Physician G stated Resident #29 was extremely demented. A Counseling/Disciplinary Notice dated 06/01/11 reflected the last day CNA F worked was 05/18/11 and CNA F was being discharged (terminated) from the facility. The Notice reflected on 04/09/11 CNA F was observed by her supervisor exhibiting strange behaviors which included slurred speech and difficulty caring for residents. The Notice also reflected CNA F was taking medications due to a recent surgery and she was sent home for the remainder of her shift. The Counseling/Disciplinary Notice dated 06/01/11 reflected on 04/11/11 CNA F was observed by her supervisor exhibiting strange behaviors which included glazed eyes, sleepiness, confusion, crying, and failure to adequately supervise the transfer of a resident. The Notice reflected the Executive Director and another nurse corroborated the unusual behaviors. The Notice reflected CNA F admitted she was taking strong prescription medications due to her recent surgery and she was reminded of the facility's drug-free policy and they would not tolerate someone working under the influence. The Notice reflected CNA F was told she could not return to work until a physician released her from the medications and felt it was safe for her to return to work. The Notice reflected on 04/14/11 CNA F presented a note from her physician which reflected she no longer needed the prescriptions and CNA F was allowed to return to work. Further review of the Counseling/Disciplinary Notice dated 06/01/11 revealed on 05/18/11 a nurse was informed CNA F appeared sleepy, had glazed eyes and was acting strangely. The Staff Development nurse completed an Observed Behavior Checklist and based on her observations she sent CNA F to be tested for drugs. The Notice reflected the drug test came back non-negative. The Notice reflected CNA F was suspended on 05/18/11 and the facility continued to investigate. The Notice further revealed on 05/18/11 CNA F was seen walking through the halls and stating in a slurred manner "'I'm so sexy."' The Notice reflected that same morning one of CNA F's residents fell while being transferred by CNA F. The Notice reflected CNA F reported to her nurse that she slid the resident to the floor, but follow-up investigation revealed the resident had a fractured hip as a result of a fall. CNA F's employee file reflected a leave of absence request for medical leave to start on 01/31/11. There was also a return to work form from a physician which reflected CNA F was released to return to work on 03/14/11. Included in the file was a letter from a physician dated 04/13/11 which reflected CNA F was medically cleared to return to work and another letter from a different physician reflecting CNA F no longer required pain medication. A review of the Accident/Incident Report dated 05/18/11, which was not signed by the Administrator and DON until 07/01/11, for Resident #29 reflected an accident occurred on 05/18/11. The report reflected the accident was investigated by LVN M. The accident report reflected, "The CNA stated Resident was being transferred from bed to the wheelchair when resident legs got weak and CNA slid resident to the floor. Resident was unable to explain what happened CNA was unavailable to report what had happened (sic)." The report also reflected the CNAs were in-serviced on proper transferring techniques by the therapy department. The accident investigation included a written statement by CNA F dated 06/03/11. The statement reflected, " ... I remember getting her (Resident #29) up on 05/18/11 on a Wednesday I was getting her up I left out the room everything was lower bed pad on the floor went to get towel, pad, diaper to get her up she was on the floor I told my charge nurse (sic)." A review of Resident #29's Nurse's Notes dated 05/18/11 at 9:00 AM reflected, "Resident was up in wheelchair. 1.5 cm (centimeter) skin abrasion on L (left) leg below knee... Notified (Physician B). Res (resident) c/o (complains of) pain on low back (Physician B) gave NO (new order) for x-ray of lower back. Notified (family member) about new order for x-ray and skin abrasion on (L) leg...." The Nurse's Notes for Resident #29 also reflected the family member called on 05/18/11 at 8:30 PM and requested a urine analysis for the resident due to a history of Urinary Tract Infections. The notes reflected the night nurse collected the specimen with a catheter at 2:00 AM on 05/19/11. Review of the x-ray report for 05/18/11 reflected no fractures of the back. On 05/19/11 at 7:30 AM the Nurse's Notes for Resident #29 reflected, "CNA" went to get Resident #29 up for breakfast and the resident was complaining of pain of the left leg and hip. The notes reflected the left leg was swollen and shorter than the right leg. LVN M notified the Nurse Practitioner and an x-ray of the hip was ordered. At 11:00 AM on 05/19/11 the x-ray company called LVN M and reported Resident #29's left hip was fractured. Resident #29 was transferred to the ER at 11:45 AM on 05/19/11. A review of Resident #29's emergency room Admission Record dated 05/19/11 revealed Resident #29 had an x-ray at the hospital which confirmed a hip fracture and a femur fracture. The ED (Emergency Department) Physician Record dated 05/19/11 at 1:19 PM reflected the differential [DIAGNOSES REDACTED]." The ED Nursing Record notes dated 05/19/11 at 12:52 PM reflected the resident had an abrasion to the left elbow and left knee. The record reflected Resident #29 was discharged to the nursing home at 6:33 PM. The family had declined hip surgery. An interview was conducted with LVN H, a weekend supervisor, on 02/02/12 at 6:00 PM. He stated, "From what I can recall, she (CNA F) came in on Saturday or Sunday. One of the aides said she didn't look right. I went and interviewed her. She said she took Norco (prescription narcotic for pain). She didn't look right to me. It was early in the morning, like one or two hours into her shift. I have worked with her before and she was not like herself. I sent her home and told her she could not come to work like this." An e-mail given to the surveyors by RN J on 02/03/12 was reviewed. The e-mail was dated 04/11/12 at 1:20 PM from the Executive Director to RN J and the Administrator. It detailed the conversation he had with LVN H about CNA F. The e-mail reflected LVN H's observations of CNA F having slurred speech and bursting into tears. The e-mail also reflected the Executive Director was concerned she was under the influence. The e-mail reflected LVN I observed CNA F almost allowing a resident to fall from a shower chair. The e-mail reflected, "...we can't have her working here in that condition. It is unsafe for her and for our residents." An interview with LVN M was conducted on 02/03/12 at 2:30 PM. LVN M stated she was CNA F's charge nurse. She stated she had worked with CNA F for some time and CNA F had a prolonged leave of absence from the facility for a medical problem. LVN M stated CNA F was a very good worker and did not need a lot of direction to accomplish her daily tasks. LVN M stated one day CNA F came to work and seemed sleepy, but LVN M could not remember the exact date or time. LVN M stated CNA F told her she had taken some medications that night to sleep. LVN M stated she called the staffing supervisor, RN J, to report CNA F seemed unusual. RN J came to take CNA F from the floor. LVN M also stated Resident #29 was a one person transfer with a gait belt. LVN M stated Resident #29 was able to a stand pivot with assistance to a wheelchair. An interview with RN J was conducted on 02/03/12 at 11:15 AM. RN J stated she thought CNA F was behaving strangely. She stated she completed the behavior observation sheet and determined CNA F might be under the influence of drugs or alcohol. RN J stated she took CNA F to the clinic for a urine drug screening. The final urine drug screening screening report for CNA F dated 05/26/11 was negative for Carboxy-THC, Amphetamines, Benzoylecgonine, Opiates, "PCP", Barbiturates, Benzodiazepines, Propoxyphene, Methadone, Methaqualone. An interview with LVN I was conducted on 02/03/12 at 11:40 AM. She stated she had worked with CNA F for over a year and CNA F was different after she (CNA F) returned from medical leave. She stated CNA F was drowsy and had slurred speech. LVN I further stated she thought CNA F's judgment was "off." LVN I stated she had observed CNA F at work drowsy with slurred speech during April. She further stated she reported this to RN J. CNA F was terminated from the facility on 06/01/11, according to a Counseling/Disciplinary Notice dated 06/01/11 and signed on 06/03/11. The CMS 670 dated 02/02/12 and provided by the facility reflected a census of 227