Every finding on record at Green Valley Healthcare and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for three of ten residents (Resident #14, Resident#57 and Resident #74) reviewed for accident hazard. The facility failed to ensure a pair of scissors was not on Resident #14's bed on 06/15/2026. The facility failed to ensure a pair of scissors was not on Resident #57's bed on 06/15/2026. The facility failed to ensure a fingernail clipper was not on Resident #74's bedside table on 06/15/2026. These failures could prevent the residents from having an environment that was free from accidents and potential injury. Findings included: 1. Record review of Resident #14's Face Sheet, dated 06/17/2026, reflected a [AGE] year-old female, admitted on [DATE]. The resident was diagnosed with Type 2 Diabetes (a chronic condition where the body either resists insulin or do not produce enough of it, leading to high blood sugar), Psychotic disorder (severe mental illnesses characterized by a disconnection from reality, primarily involving hallucinations and delusions), and Anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations). Record review of Resident #14's Quarterly MDS Assessment, dated 06/04/2026, reflected a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #14's Comprehensive Care Plan, dated 03/14/2022, reflected the resident was at risk for side effects of anti-anxiety medication with interventions including to monitor for confusion, dizziness and drowsiness. During an observation and interview on 06/15/2026 at 8:30 AM. Resident #14 was in her bed, awake and watching television. Her room was clean and homelike. It was observed that on top of the resident's bed was a pair of scissors unattended and within reach. Resident #14 stated the scissors were her own and she used them when she wanted. During an interview on 06/15/2026 at 8:40 a.m., LVN A stated she was not aware Resident #14 had scissors and that it should not be inside Resident #14's room because it could cause harm or injury to Resident #14 or to others. 2. Record review of Resident #57's Face Sheet, dated 06/17/2026, reflected a [AGE] year-old male admitted [DATE]. The resident was diagnosed with Dementia (an umbrella term for a decline in mental ability-such as memory, thinking, and reasoning-severe enough to interfere with daily life), Psychotic disorder (severe mental illnesses characterized by a disconnection from reality, primarily involving hallucinations and delusions), Anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations.) and Parkinson's disease (a progressive neurological disorder that damages dopamine-producing brain cells. It primarily affects movement, leading to hallmark signs like resting tremors, muscle stiffness, slowed physical actions) Record review of Resident #57's Quarterly MDS Assessment, dated 03/17/2026, reflected a BIMS score of 15 indicating intact cognition. Record review of Resident #57's Comprehensive Care Plan, dated 03/14/2022, reflected the Resident #57 had an ADL self-care performance deficit r/t Parkinson's with intervention including assistance by one staff as necessary and, The resident has impaired thought processes r/t Dementia with the listed goal, The resident will develop skills to cope with cognitive decline and maintain safety. During an observation and interview on 06/15/2026 at 9:23AM, Resident #57 was in his bed and awake. His living area was clean and homelike. It was observed on top of Resident #57's bed was a pair of scissors unattended, and within reach. Resident #57 stated the scissors were his own and he used them to trim his beard. During an interview on 06/15/2026 at 8:40 a.m., LVN B stated she was not aware Resident #57 had scissors on his bed. LVN B stated the risk of having the scissors was injury as Resident #57 may cut himself or others. 3. Record review of Resident #74's Face Sheet, dated 06/17/2026, reflected an [AGE] year-old female admitted [DATE]. The resident was diagnosed with Type 2 Diabetes ( a chronic condition where your body doesn't use insulin properly or can't make enough of it, leading to high blood sugar), and Dementia (an umbrella term for a decline in mental ability-such as memory, thinking, and reasoning-severe enough to interfere with daily life). Record review of Resident #74's Quarterly MDS Assessment, dated 03/23/2026, reflected a BIMS score of 01 indicating severe cognitive impairment. Record review of Resident #74's Comprehensive Care Plan, dated 09/05/2024, reflected the Resident #74 had impaired cognitive function/dementia or impaired thought processes r/t Dementia with the goal: The resident will develop skills to cope with cognitive decline and maintain safety. Comprehensive Care Plan, dated 09/05/2024, also reflected, The resident is resistive to care r/t Dementia with interventions: Give clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed time. If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. During an observation and interview on 06/15/2026 at 9:30AM, Resident #74 was in her bed and awake. Observed on top of Resident #74's bedside table was a fingernail clipper unattended, and within reach. Resident #74 stated the fingernail clippers were her own and she used it to trim her fingernails as needed. During an interview on 06/15/2026 at 9:35 a.m., LVN B stated she was not aware Resident #74 had fingernail clippers in her room. LVN B stated the risk of having fingernail clippers was injury as Resident #74 may cut herself. During an interview on 06/16/2026 at 1:58 pm, the DON stated it could be family members that brought the scissors and fingernail clippers to the facility. She stated her expectation was that all staff removed sharp and dangerous items from resident rooms and stored them for supervised use. The DON stated staff were educated and trained in the proper use and safety of sharp objects like scissors and fingernail clippers. She stated the risk to residents could be cutting themselves or others. Record review of the facility's policy titled, Safety and supervision of Residents, revised December 2007, indicated policy statement, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Facility-Oriented Approach to Safety included:1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through acombination of employee training, employee monitoring, and reporting processes.4. Employees shall be trained and serviced in potential accident hazards and how toidentify and report accident hazards and try to prevent avoidable accidents.Resident-Oriented Approach to Safety included: 1. Our resident-oriented approach to safety addresses safety and accident hazards forindividual residents.2. Staff shall use various sources to identify risk factors for residents, including theinformation obtained from the medical history, physical exam, observation of theresident, and the MDS.3. The interdisciplinary care team shall analyze information obtained from assessmentsand observations to identify any specific accident hazards or risks for that resident.The care team shall target interventions to reduce the potential for accidents.4. Implementing interventions to reduce accident risks and hazards shall include thefollowing:a. communicating specific interventions to all relevant staff.b. assigning responsibility for carrying out interventions.c. providing training, as necessary.d. ensuring that interventions are implemented; ande. documenting interventions.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen (Kitchen #1) reviewed for kitchen sanitation. The facility failed to ensure food items were properly stored in the freezer. The facility failed to ensure dented cans were identified and removed. The facility failed to ensure food items were properly stored in the dry food pantry.Findings Include: During an observation of the facility's dry food pantry on 06/15/2026 at 09:12 a.m., revealed: The lid covering a large plastic container of yellow corn meal was not secured and exposed to air. One can of solid packed apples was dented. One can of sliced peaches was dented. During an observation of the facility's freezer on 06/15/2026 at 09:15 a.m., revealed: One box of chicken breasts was not secured and exposed to air. During an interview with the DM on 06/15/2026 at 09:20am, he stated when food deliveries arrived, staff were expected not to accept dented cans and if they noticed cans were dented after delivery, they were expected to move them to the dented can area of the dry food pantry. He further stated staff were expected to make sure all food was secured and not exposed to air. The DM reported that he had completed in-service training with dietary staff on these expectations. The DM stated the residents were at risk of being exposed to bacteria and could get sick if they consumed food that was not stored properly. A record review of the facility's policy titled, Food Receiving and Storage Policy, dated 03/05/2026, stated the following: Food Receiving All deliveries will be inspected for safe transport, damage, contamination and quality before acceptance. Any food suspected of spoilage, contamination, damage or improper temperature will not be accepted. Food Labeling and Dating Opened containers must be sealed or covered and dated. Additional Dry Storage Rules Opened food must be tightly sealed and dated. Dented cans must be removed or labeled Do Not Use

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #16) reviewed for resident rights. The facility failed to ensure visual privacy for Resident #16, whose breast was exposed while lying in bed and was visible from the hallway. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.Findings included: Record review of Resident #16's Face Sheet, dated 05/27/26, reflected she was a [AGE] year-old female, admitted [DATE], with diagnoses including Alzheimer's disease with early onset (a rare form of Alzheimer's disease striking people younger than 65; symptoms include memory loss, language difficulties, vision problems, and behavioral changes, which significantly impact daily life) and anxiety disorder (a group of mental health conditions characterized by intense, excessive, and persistent fear or worry about everyday situations). Record review of Resident #16's MDS Assessment, dated 06/02/26, reflected a BIMS Score of 14, indicating she was cognitively intact. Record review of Resident #16's Physician's Orders, dated 06/17/26, did not reflect any orders regarding requirements for personal care assistance. Record review of Resident #16's Care Plan, dated 05/27/26, reflected she had an ADL self-care performance deficit and required the assistance of at least one staff member for ADLs such as dressing, bathing/showering, and other personal hygiene activities. During an observation of Resident #16 from the 300 Hallway on 06/15/26 at 10:15 a.m., reflected Resident #16 was lying in her bed. She was not clothed and her right breast was exposed to anyone who walked by the room, as neither the privacy curtain nor her door was pulled shut. Observation indicated Resident #16's room was near the therapy where residents and staff regularly walked up and down the hallway past her room. When the surveyor walked into Resident #16's room, Resident #16 pulled her covers over her chest. During an observation of RN D on 06/15/26 at 10:24 a.m., she offered Resident #16 a hospital gown and Resident #16 declined. RN D pulled Resident #16's privacy curtain halfway shut to provide visual privacy for Resident #16 from other areas of the room and from the hallway. During an interview with RN D on 06/15/26 at 10:28 a.m., she stated Resident #16 preferred to be unclothed. She stated Resident #16 should still be provided with visual privacy, which was why she pulled her privacy curtain shut. RN D stated the risk of a resident not being provided with visual privacy and/or having their breasts exposed was a lack of dignity. During an interview with Resident #16 on 06/16/26 at 1:15 pm, she stated she realized her breasts were exposed when the surveyor walked into her room yesterday (06/15/26). She stated although she was not mentally affected by her breasts being exposed, she preferred to have visual privacy. In reference to her breasts being exposed, she said, I don't want an audience. During an interview with the Director of Nursing on 06/16/26 at 2:00pm, she stated Resident #16 should have been provided with visual privacy via her privacy curtain whenever she was unclothed. The Director of Nursing stated she was not sure of any risks when residents were not provided with visual privacy. Record review of the facility's, Nursing Facility Resident Rights policy, dated 03/06/26, reflected, .The following rights are guaranteed to residents of nursing facilities under federal law and law. and .To be treated with dignity, courtesy, and respect. The policy did not specifically address visual privacy.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health of safety of the resident or other residents for 1 (Resident #77) of 5 residents reviewed for accommodations. The facility failed to ensure Resident #77 was provided with the appropriate size brief. This failure could place residents at risk of maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: A record review of Resident #77's quarterly MDS assessment, dated 05/08/2026 revealed a [AGE] year-old female admitted [DATE]. Resident #77 had primary diagnoses of unspecified dementia without behavioral disturbance (a decline in cognitive function such as memory, thinking and reasoning) and noninfective gastroenteritis and colitis (inflammatory conditions of the digestive tract) and was incontinent of bowel and bladder. During an interview on 6/15/2026 at 10:45 a.m., Resident #77 stated for the past 3 days they have not had any briefs that fit, and she has had to wear undersized briefs. Resident #77 further stated this was a constant concern of the facility running out of her size. Resident #77 stated, The largest they have is 2X and yesterday my mind blew up, I couldn't stand being soaked in pee, they kept cutting me. I think some people get a stockpile in their room, and then they are short. I think some people use the big ones. I think that's why the big ones are in short supply. During an interview on 06/16/2026 at 11:10 a.m., the Staffing Coordinator stated she was filling in for the staff member that usually ordered supplies. She stated they ran out on Friday and over the weekend they did not have enough and that maybe there were too few ordered with the previous order. She stated they were able to find some in resident rooms over the weekend. The Staffing Coordinator stated the risk for residents was that they might feel discomfort wearing a smaller size brief. During an interview on 06/16/2026 at 2:12 p.m., the DON stated she was informed on the evening of 06/14/2026 that they were out of the 3X size brief and she went to two different stores to purchase them, but they did not have that size. She stated some residents had briefs in drawers in their rooms, and they found enough to make it through that night. She stated that the Administrator went to a sister facility on 06/15/2026 and got 3X size briefs from them. She stated their supply shipment usually arrived on Monday mornings, and it was late and did not arrive until Tuesday. The DON identified the risk for residents as a comfort thing and they got angry. During an interview on 06/17/2026 at 09:35 a.m., the Administrator stated he was informed they were running low on 3x size briefs on the night of 06/14/2026. He stated he was not told they ran out before the weekend, and he would address the staff to figure out why he was not informed. He stated that residents pulled briefs from the cart in the hallway and kept them in their rooms, which was how they found some the night of 06/14/2026, and he went to get some from a sister facility when their shipment did not arrive on 06/15/2026. The Administrator stated he did not know why they ran out, but it could be that their census was higher than usual, or maybe residents were pulling more from the carts. A policy regarding managing and ordering supplies was requested on 06/16/2026 at 2:03 p.m. via email to the Administrator, the facility did not provide one prior to exit.

Based on interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (Resident #111) reviewed for closed records. The facility failed to ensure Resident #111 discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care. Findings included: A record review of Resident #111's discharge MDS, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #111 had a primary diagnosis of acute kidney failure (kidney's inability to filter waste, balance fluids, and regulate electrolytes in the blood). A record review of Resident #111's transfer/discharge report, dated 06/04/2026, revealed the resident discharged home on [DATE]. A record review of Resident #111's Discharge summary, dated [DATE], revealed section 1 and 2 were not completed. During an interview on 06/16/2026 at 2:16 p.m., the DON stated the ADON had been initiating the discharge summaries, and everyone would get a notification to complete their section, and it was her expectation they complete their section when notified. The DON stated there was not a risk for residents because they never saw it and the SW set up the home health and DME services before they left the facility. During an interview on 06/17/2026 at 12:02 p.m., the SW stated she was responsible for completing sections 1 and 2 of the discharge summary and was still working on Resident #111's discharge summary. The SW stated the expectation was to complete the discharge summary as soon as possible, but she was not aware of a policy dictating a timeline in which it had to be completed. A request for a discharge summary policy was made on 06/17/2026 and the facility could not provide one prior to exit.

Based on observation, interview, and record review, the facility failed to ensure a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 6 residents (Resident #14 and Resident #29), reviewed for respiratory care. The facility failed to ensure that Resident #14 and Resident #29 were wearing and receiving continuous oxygen therapy per their physician's orders. This failure could place the residents at risk of health-associated infections.Findings included: 1.) Record review of Resident #14's Face Sheet, dated 06/17/26, reflected a [AGE] year-old female, admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases, primarily chronic bronchitis and emphysema, that cause breathing difficulties due to obstructed airflow) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #14's MDS Assessment, dated 06/04/26, reflected a BIMS Score of 10, indicating moderate cognitive impairment. Record review of Resident #14's Physician's Orders, dated 06/16/26 and initiated 11/18/22, reflected an active order for O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 states > 90%. Record review of Resident #14's Care Plan, dated 01/30/25, reflected, .The resident has altered respiratory status/difficulty breathing r/t ACTUE RESPIRATORY FAILURE. Interventions included administering medications as ordered and monitoring for effectiveness and side effects. During an observation on 06/15/26 at 9:06 a.m., Resident #14 was lying in her bed. The nasal canula for her oxygen therapy was observed lying on her chest; she was not receiving oxygen. Resident #14 did not appear to be in respiratory distress. During an interview with Resident #14 on 06/15/26 at 9:06 a.m., she denied shortness of breath. During an observation on 06/15/26 at 9:06 a.m., the ADON assessed Resident #14 using a pulse oximeter (a device that clips onto a fingertip, earlobe, toe, or other thin body parts to measure how much oxygen is in your blood and your heart rate), and her oxygen saturation (the percentage of hemoglobin in your blood that is carrying oxygen, reflecting how effectively your body delivers oxygen to tissues) was 95%. During an interview on 06/15/26 at 9:06 a.m., the ADON said Resident #14's nasal cannula was not properly placed and stated it was difficult to ensure residents kept their nasal cannulas in their nostrils at all times. She stated the risk of a resident not having their nasal cannula in place included shortness of breath and possible respiratory emergency. 2.) Record review of Resident #29's Face Sheet, dated 06/17/26, reflected an [AGE] year-old female, admitted [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases, primarily chronic bronchitis and emphysema, that cause breathing difficulties due to obstructed airflow) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of Resident #29's MDS Assessment, dated 03/26/26, reflected a BIMS Score of 03, indicating severe cognitive impairment. Record review of Resident #29's Physician's Orders, dated 06/16/26 and initiated 05/23/22, reflected an active order for O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 states > 90%. Record review of Resident #29's Care Plan, dated 07/15/24, reflected .The resident has altered respiratory status/difficulty breathing r/t COPD. Interventions included administering medications as ordered and monitoring for effectiveness and side effects. During an observation on 06/15/26 at 9:08 a.m., Resident #29's nasal canula for her oxygen therapy was hanging behind her left ear; she was not receiving oxygen. Resident #29 did not appear to be in respiratory distress. During an observation on 06/15/26 at 9:08 a.m., the ADON assessed Resident #29 using a pulse oximeter, and her oxygen saturation was 94%. During an interview on 06/16/26 at 1:56 pm, the DON stated it was the responsibility of nursing staff to ensure residents' oxygen tubing was always in place as ordered. She stated the risk of a resident not having their nasal cannula in place included shortness of breath. Record review of the facility's Oxygen Administration and Oxygen Safety policy, dated 03/2026, reflected, .Check the mask, tank, humidifying jar, etc. to be sure they are in good working order and are securely fastened.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature control for 3 residents (Resident #22, Resident #75 and Resident #105) medication on 1 of 3 medication carts (100 Hall nurse cart) reviewed for pharmacy services.1. The facility failed to ensure proper disposal of Resident #22's Tramadol 50mg tab when the blister pack was damaged. 2. The facility failed to ensure proper disposal of Resident #75's Acetaminophen-Codeine #3 tab when the blister pack was damaged. 3. The facility failed to ensure proper disposal of Resident #105's Lorazepam 0.5mg tab when the blister pack was damaged. 4. The facility failed to ensure CMA A ensured that Resident #11 swallowed her medication before leaving the resident's room. These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents.Findings included: 1. Record review of Resident #22's Comprehensive MDS Assessment, dated 05/05/2026, reflected the Resident #22 was an [AGE] year-old female, admitted [DATE]. She had a BIMS score of 08, indicating moderate cognitive impairment. The resident had diagnoses including Respiratory failure (a life-threatening condition where the lungs cannot adequately supply oxygen to the blood), anxiety disorder (a mental health condition characterized by excessive, persistent, and Depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical or emotional fatigue). Record review of Resident #22's Comprehensive Care Plan, dated 02/19/2026, reflected Resident #22 was on pain medication therapy Hydrocodone and Tramadol r/t right hip fracture. Interventions included administer medication as ordered by physician. Monitor/document side effects and effectiveness Q-Shift. Record review of Resident 22's active physician orders, dated 06/16/2026, reflected tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for Pain and with PT/OT. During an observation on 06/16/26 at 9:45 a.m., with LVN B, of the 100 Hall nurse cart, revealed Resident #22's Tramadol 50mg tab had a damaged blister bubble and the tablet still inside, at the time the medication cart was reviewed. 2. Record review of Resident #75's Comprehensive MDS Assessment, dated 03/03/2026, reflected the Resident #75 was a [AGE] year-old female, admitted [DATE]. She had a BIMS score of 03, indicating severe cognitive impairment. The resident had diagnoses including anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations) and depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical or emotional fatigue). Record review of Resident #75's active physician orders, dated 06/16/2026, reflected, Acetaminophen-Codeine Tablet 300-30mg Give 1 tablet by mouth every 6 hours as needed for Pain. During an observation on 06/16/26 at 9:45 a.m. with LVN B of the 100 Hall nurse cart, revealed Resident #75's Acetaminophen-Codeine Tablet 300-30 mg tab had a damaged blister bubble and the tablet still inside, at the time medication cart was reviewed. 3. Record review of Resident #105's Quarterly MDS Assessment, dated 03/21/2026, reflected that Resident #105 was an [AGE] year-old female, admitted [DATE]. She had a BIMS score of 08, indicating moderate cognitive impairment. The resident had diagnoses including Respiratory failure (a life-threatening condition where the lungs cannot adequately supply oxygen to the blood), Chronic obstructive pulmonary disease (a progressive lung disease that damages the airways and air sacs, making it difficult to breathe) and Depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical or emotional fatigue). Record review of Resident #105's Comprehensive Care Plan, dated 01/19/2026, reflected, The resident uses anti-anxiety medications Lorazepam r/t end of life care. Interventions included: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Record review of Resident #105's active physician orders, dated 06/16/2026, reflected, Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for Terminal restlessness and Moderate anxiety. During an observation on 06/16/26 at 9:45 a.m. with LVN B of the 100 Hall nurse cart, revealed Resident #105's Lorazepam Oral Tablet 0.5 MG had a damaged blister bubble and the tablet still inside, at the time the medication cart was reviewed.During an interview with LVN B on 06/16/2026 at 10:00 a.m., she stated she did not notice the blisters were damaged before it was brought to her attention. She stated the nurses were responsible for inspecting the blister packs at every shift change when they did the narcotic count. LVN B stated if a narcotic blister seal was broken, the medication should be discarded and witnessed by two nurses. She stated that the risk of a damaged blister would be the potential for drug diversion and contamination of medication. She stated the risk to the resident was medication not being effective if it was compromised. She stated that she had been in-serviced on medication storage. 4. Record review of Resident #11's Quarterly MDS Assessment, dated 05/12/2026, reflected Resident #11 was admitted on [DATE]. She was a [AGE] year-old female and had a BIMS score of 11 which indicated moderate cognitive impairment. The resident had diagnoses which included bipolar disorder (a mental health condition that causes extreme, uncontrollable shifts in a person's mood, energy, and activity levels), Muscle weakness and Chronic Obstructive Pulmonary Disease (a progressive, irreversible disease that blocks airflow, making it difficult to breathe). Record review of Resident #11's Comprehensive Care Plan, initiated 05/12/2026, reflected no areas indicating she could have medication at bedside or self-medicate. Record review of Resident #11's active physician orders, dated 06/16/2026, reflected no orders indicating she could have medication at beside or self-medicate. During an observation and interview on 06/15/20226 at 9:00 a.m., during initial tour, revealed 1 white oval pill and 2 white round pills in a medication cup on Resident #11's beside table. Resident #11 stated CMA A left it for her and that she would take it later. During an interview on 06/15/2026 at 9:02 a.m., LVN A revealed CMA A administered Resident #11's morning medication. She stated she always ensured the residents swallowed their medication before leaving the room but did not know why CMA A left medication in a cup for Resident #11. She stated Resident #11 did not have physician orders to self-medicate or have medication at bedside. She stated the risk to the resident was over medicating or missing to take medication. She stated she had been in-serviced on medication administration and medication storage and labelling. During an interview on 06/16/2026 at 1:00 pm, CMA A stated that Resident #11 asked her to leave the medications on her bedside table. CMA A stated she was supposed to watch the resident take her medication before leaving the room or bring it later to Resident #11 when she was ready to take her medication but failed to do that. CMA A stated the risk was Resident #11 missing the medication or another resident taking the medication. She stated she had been in-serviced on medication administration and medication storage and labelling. During an interview on 06/16/26 at 1:58pm, the DON stated if a blister pack seal was broken on any controlled medications, the pill should be discarded and witnessed by two nurses. The DON stated it was not 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. She stated nurses and medication aides were responsible for checking the medication blister packs for broken seals during medication count on the change of shifts. The DON stated the ADON audited the medication carts bi-weekly, then the pharmacy consultant audited the medication room, and the medication carts every month. She stated the nurses and the medication aides had been in-serviced on medication storage and administration.During an interview on 06/16/26 at 1:58 pm, the DON stated if the medication aides and nurses were doing the medications rights, they should be able to ensure they gave the right medication to the right patient. She stated the medication aides and nurses were expected to stand and watch residents swallow their medications before exiting the room. Record review of the facility's policy titled, Storage of Medication, dated 6/24/2025 reflected the following: Drugs and biologicals are stored in the packaging containers or other dispensing systems they are received. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 1 (Resident #1) of 3 residents reviewed for medication errors in that:The facility failed to administer Resident #1's Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG as ordered by the physician on 04/27/26, 04/28/26, 04/29/26.This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician.Findings included:Review of Resident #1's MDS assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS was a 15 indicating she was cognitively intact. Her diagnoses included: HTN.Record review of Resident #1's care plan with a competition date of 04/22/26 reflected: Focus: The resident has hypertension.Date Initiated: 04/06/2026.Goal: The resident will remain free from s/sx of hypertension through the review date.Interventions: Give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate.Review of Resident #1's consolidated physician orders for the month of April 2026 reflected:- Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP less than 110 or HR less than 60. Do not crushReview of Resident #1's MAR for April 2026 reflected Resident #1 received her Metoprolol Succinate ER Tablet outside of parameters on the following dates by the following staff:- 04/27/26 Resident #1's SBP was 101 and Medication Aide A administered the medication outside of parameters- 04/28/26 Resident #1's SBP was 108 and Medication Aide A administered the medication outside of parameters- 04/29/26 Resident #1's SBP was 108 and Medication Aide A administered the medication outside of parametersReview of Resident #1's nurses' notes for the dates of 04/01/26 through 05/04/26 revealed there was 1 note on 04/27/26 that reflected: 4/27/2026 09:00 [9:00 AM] Orders - Administration Note Note Text: Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP less than 110 or HR less than 60. Do not crush LOW/BP In an interview on 06/30/22 9:41AM, Medication Aide A stated she had administered the medication outside of parameters on 04/27/26, 04/28/26 and 04/29/26 for Resident #1. She stated she was to hold the blood pressure medication since it was below parameters and notify her nurse. She stated that if the blood pressure medication was administered below parameters, the resident blood pressure could lower more. In an interview on 05/04/26 at 12:15 PM, LVN B stated that the medication aides pass all routine medications and that he passed PRN medications. LVN B stated that if a medication aide received a blood pressure reading outside of parameters they were to recheck the blood pressure and if the blood pressure was still outside of parameters to notify him. He stated Medication Aide A had not notified him of any blood pressures being out of parameters for Resident #1. LVN B stated it was important to not give medication outside of parameters as it could cause a resident to bottom out resulting in adverse effects causing the resident to feel worse. In an interview on 05/04/26 at 12:50 PM, the DON stated she was not aware of blood pressure medications being administered outside of parameters. The DON stated that if a blood pressure was outside of parameters, she expected the nurse to notify the physician and hold the medication and indicate the hold on the MAR. The DON stated administrating the medication outside of parameters could cause the residents blood pressure and heart rate to drop significantlyReview of the facility policy titled Medication Administration revised 03/05/2026 reflected: 4. Medications are administered according to the prescriber orders.

Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #3) of 3 resident records reviewed.The facility failed to ensure Resident#1's Admission/Comprehensive MDS assessment was completed within 14 days following her admission to the facility.This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings included:Review of Resident #1's MDS assessment dated [DATE] revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS was a 15 indicating she was cognitively intact. Her diagnoses included: HTN, DVT, GERD .Record review of Resident #1's MDS Summary screen in the Electronic Health Record on 05/04/26 revealed the resident's MDS had an ARD date of 04/10/26 and was completed on 04/21/26 (11 days after the ARD date). In an interview on 05/04/26 at 12:50 PM, the DON stated that MDS Nurse was responsible for MDS's. She stated that she was not aware of MDS being incomplete and late. The DON stated that she is sent a list of MDS and signs them . She stated she was not an MDS nurse and never was an MDS nurse. In an interview on 05/04/26 at 1:04 PM, the MDS Nurse stated that she had been the MDS Nurse at the facility for about 12 years. The MDS Nurse stated that she knew that the SW had been behind on her sections of the MDS but had completed her part on 04/17/26, a Friday, so the MDS Nurse was not able to complete the MDS until 04/21/26. She stated that it was important for the MDS to be completed on time to ensure accurate billing.In an interview on 05/04/26 at 1:15 PM, the Administrator stated that the facility did not have a policy on MDS but use the RAI manual.Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1, dated October 2025, reflected 14th calendar day of the resident's admission (admission date + 13 calendar days). The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (treatment cart #1) of 4 reviewed for storage of medications.The facility failed to ensure treatment cart #1 was locked while unattended on 05/04/26This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included:An observation on 05/04/26 at 8:50 AM revealed treatment cart #1 was unlocked and unattended with no staff within eyesight of the medication cart. All drawers could be opened, and medication and supplies (needles, gauze, ointments, etc. ) could be easily accessed. In an interview on 05/04/26 at 8:54 AM, with LVN B stated treatment cart #1 belonged to the wound care nurse who was not at work. In an observation and interview on 05/04/26 at 8:55 AM, ADON C locked treatment cart #1. ADON C stated that her expectation was the treatment cart was locked when not in use. She stated it was the responsibility of the nurse who used the cart last to lock the cart. She said she did not know who had used the cart last. ADON C stated that it was important the cart was locked when unattended so people don't have access to what is inside. In an interview on 05/04/26 at 9:02 PM, ADON D revealed that the treatment cart should be locked when not in use, as there could be dangerous items in the cart that residents do not need access to. ADON D stated it was the responsibility of the nurse who last used the treatment cart to ensure it was locked. ADON D did not state if she knew who had used the cart last. In an interview on 05/04/26 at 12:50 PM, the DON stated that her expectation was the treatment cart was always locked unless it was in use. The DON stated that any staff member could lock the cart if they observed it unlocked. The DON stated it was important for the treatment cart to be locked when not in use as there were items for wound care that people don't need and if you searched hard enough scissors.Review of the facility policy titled Storage of Medications dated 06/24/2025 reflected: 3. The nursing staff is responsible for maintaining medication storage and prep areas in a clean, safe and sanitary manner.8. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. The facility failed to ensure Resident #1, who required a mechanical lift transfer, was free of an accident hazard on 08/12/25 when she was transferred by CNA B without a mechanical lift and sustained a significant injury. Resident #1 was transported to the local hospital and diagnosed with a right humerus fracture. An Immediate Jeopardy (IJ) was identified on 09/04/25 at 04:00 PM and an IJ Template was provided to the DON at 04:41PM. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the severity level of potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for accidents that could lead to a serious injury or harm.Record review of Resident #1's face sheet, dated 09/04/25, reflected the resident was a [AGE] year-old-female who admitted to the facility on [DATE] and discharged on 08/12/25. Resident #1's diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Side Dominant (stroke damages left hemisphere of the brain, leading to complete paralysis (hemiplegia) or significant weakness (hemiparesis) on the right side of the body), Lack of Coordination (difficulty with muscle control and movement), Syncope and Collapse (sudden loss of consciousness, often accompanied by loss of muscle tone and falling to the ground), Muscle Wasting and Atrophy (loss of muscle mass and strength), Muscle Weakness (decreased ability of muscles to contract and produce force), Chronic Pain Syndrome (persistent pain that lasts for at least three months and significantly impacts daily life), Soft Tissues Disorders (conditions that affect the muscles, ligaments, tendons, and other soft tissues of the body), End Stage Renal Disease (condition where kidneys have deteriorated to the point where they can no longer function properly) and Age-Related Physical Debility (general weakness, fatigue, and reduced physical capacity). Record review of Resident #1's MDS, dated [DATE], reflected she had a BIMS score of 08, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent on staff for all ADLs including self-care and mobility. Resident #1 used a wheelchair. Record review of Resident #1's care plan, dated 07/30/25 reflected Resident #1 had an ADLS self-care performance deficit. The resident required mechanical lift with two staff for transfers. The resident required total assistance by two staff to move her between surfaces. Record review of Resident #1's order summary report, dated 09/04/25, reflected the following:Hoyer Lift with two staff members for transfers every shift. Start date: 08/05/25 Record review of Resident #1's progress notes, dated 08/12/25 at 01:32PM by LVN A reflected the following: CNA [reported] she heard a popping sound to [Resident #1's] right arm during transfer. Resident [appeared] to be in severe pain. [Resident #1] refused prn hydrocodone and Tylenol. [Resident #1] stated she just wanted an x-ray done. [NP] notified. New order for [Resident #1] to go to hospital for evaluation. [Ambulance] took her to ER for evaluation. Record review of Resident #1's progress notes, dated 08/12/25 at 06:18PM by LVN C reflected the following: [Resident #1's] [RP] called to say that [Resident #1] was likely to spend the [night] at the hospital because she had a broken bone. She said they were waiting for an X-ray on the arm. Notified DON. Record review of Resident #1's hospital records, dated 08/13/25, reflected in part the following: admit date and Time: 08/12/2025 at 03:19 PM History of present illness: [Resident #1] is a 75 y.o. female that has a past medical history of Chronic pain disorder, Hemiparesis affecting right side as late effect of stroke, Neuromuscular disorder, Right-sided muscle weakness, Shortness of breath, Splenic artery aneurysm, Stroke, and Wheelchair dependent who presents with acute right arm pain after being repositioned in her chair today when her caretaker felt a pop near her shoulder. [Resident #1] is willing in pain, when asked where it hurts she points specifically to her arm. [Resident#1] has chronically dislocated right shoulder. Complaint: Per NH staff, concerned for right shoulder dislocation. Heard a pop while moving [Resident #1] from WC to bed.Impression at 04:30PM:1. Anterior dislocation [{upper bone moves forward out of its socket)] of the right shoulder. Right humeral neck fracture.2. Pleural effusion and infiltrates in the visualized right chest. Recommend a dedicated chest x-ray. Final Result: Limited axillary view with the persistent anterior glenohumeral dislocation.XR humerus right 2 views:1. Humeral neck fracture with mild displacement.2. Anterior glenohumeral dislocation of the shoulder.3. Vascular stent in the axillary region. XR shoulder right view:1. Anterior dislocation of the right shoulder. Right humeral neck fracture.2. Pleural effusion [(excess buildup of fluid)] and infiltrates in the visualized right chest. Recommend a dedicated chest x-ray. In an interview on 09/04/25 at 11:26AM, Resident #1's RP stated on 08/12/25 while Resident #1 was being transferred by facility staff and was injured. Resident #1's RP stated an aide was manually transferring Resident #1 from her wheelchair to the bed. RP stated while an aide was moving Resident #1 from the wheelchair, a family member who was visiting noticed that the resident needed to be changed, so the aide held Resident #1 up while the family member pulled down her pants, and that was when they heard a pop in the resident's arm. Resident #1's RP stated the aide was doing the transfer alone and without the mechanical lift, which was an improper transfer. RP stated Resident #1 complained of pain afterwards, so the EMTs were called, and the resident was transported to the local hospital. Resident #1's RP stated after further examination, it had been determined Resident #1 had a humerus fracture. In an interview on 09/04/25 at 12:04 PM, LVN A stated she worked with Resident #1, and she was only at the facility for about two weeks. LVN A stated she worked 1st shift on 08/12/25 when the incident occurred. She stated it was reported to her by CNA B that Resident #1 had been injured during a transfer. LVN A stated CNA B reported while moving the resident there was a pop in Resident #1's arm. LVN A stated CNA B should not have moved Resident #1 without assistance. LVN A also stated Resident #1's was a two-person transfer with a mechanical lift. LVN A stated Resident #1's family was in the room at the time and did not want CNA B to use the mechanical lift. LVN A stated after the incident was reported, she assessed Resident #1, and she complained of pain. LVN A stated she offered Resident #1 PRN medication for pain, but the resident refused. LVN A stated after some encouragement, Resident #1 took Tylenol. LVN A stated she asked Resident #1 if the facility could take an x-ray, but she also refused. LVN A stated Resident #1's RP insisted she be transported to the hospital, so LVN A stated she called an ambulance and notified the MD. LVN A stated according to the facility's policy, CNA B should have followed the MD orders regarding the transfer instead of listening to the family. She stated not following MD orders for transfers could place residents at risk of falling and sustaining injuries. In an interview on 09/04/25 at 12:22PM, CNA B stated she worked with Resident #1 on 08/12/25. She stated she was called into Resident #1's room to transfer her from the wheelchair to the bed. CNA B stated when she moved Resident #1, the family told her that Resident #1 needed to be changed. CNA B stated she asked Resident #1's family to assist by taking her pants off. CNA B stated she bear-hugged Resident #1 around her back, and while holding the resident up, her arms slid underneath Resident #1's arms and that was when she heard the resident's shoulder pop. CNA B stated Resident #1 groaned and expressed extreme pain. CNA B stated she placed Resident #1 back in her wheelchair and called LVN A to come assist. CNA B stated Resident #1 was assessed by LVN A then transported to the hospital. CNA B stated she knew that Resident #1 required a 2-person transfer using a mechanical lift; however, she worked with her previously and was always able to transfer her manually with no problems. CNA B stated Resident #1's family would also tell her not to use the mechanical lift, or they would transfer the resident manually themselves. In an interview on 09/04/25 at 12:58PM, the DON stated she worked on 08/12/25. The DON stated she was at the facility at the time of the incident with Resident #1. The DON stated it was reported that while CNA B was moving Resident #1 there was a pop in her arm. The DON stated the CNA did not follow protocol when she moved Resident #1. She stated CNA B should have gotten another staff to assist in moving the resident and used a mechanical lift for the transfer. The DON stated Resident #1 required total assistance with ADLs. She stated based on MD orders; Resident #1 was a two staff transfer with a mechanical lift. The DON stated she completed one on one training regarding transfers with all staff immediately after the incident occurred. The DON stated the facility's policy on mechanical lifts was to follow the MD orders. She stated Resident #1 had a MD order for two staff persons to transfer with the mechanical lift. The DON stated residents are assessed by a physical therapist and gives a recommendation for transfers to the MD, who writes the order. The DON stated not following the MD orders for transfers could place residents at risk for serious injuries. In an interview on 09/05/25 at 01:51 PM, the DOR stated she managed all PT staff and also provided therapy to the residents. The DOR stated she trained facility staff on properly using the mechanical lift and transfers. The DOR stated she was not familiar with Resident #1. She stated the facility provided in-services to staff about proper transfers with the mechanical lift. She stated she has educated residents on mechanical lifts and why it was the safest way to transfer. The DOR stated when a resident did not want to use the mechanical lift, either her or staff would educate the residents and family about safety. She stated the use of a mechanical lifts helped to reduce possible injury to the resident or staff during transfers. She stated the facility's policy on mechanical lifts was to always follow the MD orders on transfers, even if the resident does not want it used. In an interview on 09/05/25 at 03:45 PM, Administrator stated the expectations for staff was to follow MD orders for transfers. He stated there should be two staff to transfer a resident with a mechanical lift. He also stated if resident or family refused, staff are to educate on safety a mechanical lift to transfer. He also stated risks of not following MD orders to use a mechanical lift could result in the resident or staff getting injured. Record review of the facility's policy, revised on 07/18/18, titled Safe Patient Handling and Moving Protocol, reflected in part the following: The Q.A. Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. Two Person Transfer:Mechanical or Electric LiftTo be utilized when transferring residents who are non-weight bearing and unable/unsafe to be transferred by alternate methods. At no time will a staff member attempt to use a mechanical or electric lift without being in-serviced on equipment specific procedures. Mechanical and electric lift transfers must always be done with 2 staff members present. All staff shall adhere to each lift's specific manufacturer guidelines for safe handling and operation. Each facility shall determine the number and types of devices needed. Devices should be located so that they are easily accessible to employees. The facility should develop and assign routine maintenance schedules to ensure equipment is in good working order. This was determined to be an Immediate Jeopardy IJ on 09/04/25 at 04:00 PM. The DON was notified. The DON was provided with the IJ template on 09/04/25 at 04:41 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/25 at 12:32 PM: [Nursing Facility]Plan of RemovalSeptember 4, 2025F689 Free of Accident Hazards/Supervision The facility allegedly failed to ensure Resident #1 was free of an accident hazard when she was transferred by one CNA without a mechanical lift, and it resulted in a significant injury. Facility Medical Director was notified of the Immediate Jeopardy by DON on 9/4/25. Immediately on September 4, 2025 CCS in serviced DON on transfer policy to include utilization of a mechanical lift. Corporate Clinical Specialist (CCS) has demonstrated hands-on expertise in resident care practices, clinical compliance and evidence-based protocols, including the [corporate] transfer policy to include utilization of a mechanical lift. Training included following MD orders and what to do in the event the resident/family/RP has concerns or refusals regarding the transfer status. Compliance was verified through competency check off and quiz. On September 4, 2025 DON/MDS Coordinator completed an audit of all transfer statuses and updated care plans accordingly. On September 4, 2025 DON initiated in servicing with nursing staff on transfer policy to include utilization of a mechanical lift. Training included following MD orders and what to do in the event the resident/family/RP has concerns or refusals regarding the transfer status. Training will be completed on 9/5/2025. Competency checks on transfers were initiated with nursing staff by DON/Designee on September 4, 2025. Compliance was verified through competency check off and quiz. In servicing and competency checks will be completed on 9/5/2025. Staff will not be allowed to work until in servicing has been completed. Compliance will be monitored by DON. The above training material will be incorporated into the new hire orientation by DON effective September 4, 2025 and ongoing. Checkoff includes transfers to include utilization of a mechanical lift. In order to monitor current residents for potential risk, DON/ADON will complete daily audits of transfer procedures for all residents requiring mechanical lifts for the next 30 days, starting on September 5, 2025. Thereafter, the DON/ADON will complete weekly audits for 3 months. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action, starting September 5, 2025. The QA Committee will monitor quarterly up to a year to monitor Facility QA Committee for compliance. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the POR included the following: Interviews on 09/05/25, 12:48-02:47 PM, conducted with the Administrator, DON, nurses, CNAs, and Med Aides: LVN A (1st shift), CNA B (1st shift), LVN C (2nd shift), LVN D (1st shift), LVN E (prn), LVN F (1st shift), LVN G (1st shift), Med Aide H (1st shift), CNA I (1st shift), CNA J (1st shift), CNA K (1st shift), CNA L (1st shift), RN M(1st shift), CNA N (2nd shift), RN O (2nd shift), CNA P (2nd shift), CNA Q (2nd shift), CNA R (2nd shift), CNA S (2nd shift), RN T (new trainee), RN U (weekends), Med Aide V (weekends), CNA W (weekends), CNA X (1st shift), CNA Y (3rd shift), LPN Z (1st shift/weekends), CNA AA (nights) indicated they all participated in in-service trainings regarding the facility's transfer policy and how to use a mechanical lift starting on 09/04/25. All staff were able to state if resident was unable to bear weight staff must follow MD's orders/care plan and use mechanical lift transfer using two staff. Staff was able to state that residents that can bear weight and require manual assistance they must use a gait belt. Staff were also able to state that what to do in the event the resident, RP or family had refusal regarding the use of the mechanical lifts. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of all interventions put in place. Observation on 09/05/25 of Resident #2 revealed staff followed the facility's policy while transferring the resident using a mechanical lift. Interviews on 09/05/25 from 12:35-3:30 PM with RPs and Residents #3, #4, #5, #6, #7, #8, and #9 revealed there were no concerns for safety or quality of care regarding transfers at the facility. Record Reviews of Residents #2, #3, #4, #5, #6, #7, #8, and #9 care plans revealed they were all updated and included appropriate transfer procedures and interventions. Record review of a 1:1 in-service titled Utilization of Mechanical Lift, dated 09/04/25, reflected DON was educated on transfer policy to include the utilization of a mechanical lift. DON was also educated on following MD order and what to do if resident, family or RP had concerns or refusal regarding the transfer. Record review of an in-service titled Utilization of Mechanical Lift, dated 09/04/25, reflected all nursing staff were educated on the facility's mechanical lift policy, following MD orders and what to do in the event the resident, family or RP has concerns or refusals regarding the transfer status. Record review of an in-service titled Transfer Residents Properly, dated 09/04/25, reflected all nursing staff were educated on properly transferring residents according to MD orders. Staff were also educated on using two staff with mechanical lift transfers and educating resident, family, or RP on safety and following the care plan. Record review of a document provided by the Administrator titled Audit Attestation, dated 09/04/25, reflected all residents who required transfer assistance were audited to ensure proper transfer procedures were care planned and being implemented. Record review of a document provided by the Administrator titled QIPP QAPI Worksheet, dated 09/05/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency. In a follow-up interview on 09/05/25 at 02:47 PM, DON stated she ensured nursing staff were trained on transfers. She stated staff are to follow MD orders to ensure the safety of resident. She also stated if there was refusal from the resident, family or RP staff are to educate, document and inform a supervisor.An Immediate Jeopardy (IJ) was identified on 09/04/25 at 04:00 PM and an IJ Template was provided to the DON at 04:41PM. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the severity level of potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 13 of 16 resident rooms on the 100 hall (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13), and the air condition unit on the 100 hall, reviewed for environment. 1. The facility failed to ensure resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the air condition unit on the 100 hall was thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 04/15/25 at 11:02 AM of resident room [ROOM NUMBER] reflected the air vent in the room had thick black dirt between the vents. The bathroom sink faucet had light brownish stains along the base of the faucet. The bathroom floor had light brown stains along the edges of the floor and the bathroom door frame. The handrail in near the toilet had a dark reddish stain on it. An observation on 04/15/25 at 11:07 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had black dirt along and between the vents. The bathroom floor had light brown stains along the edges of the floor and the bathroom door frame. The mini fridge in the resident room had orange stain inside the bottom of the fridge. The bathroom sink faucet had light brownish stains along the base of the faucet. The doorway had thick dirt in the corner of the floor behind the door. An observation on 04/15/25 at 11:13 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There was also a thick white substance between the top vents. An observation on 04/15/25 at 11:17 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. A bed frame in the resident room had brown stains in a lower portion of the frame. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. An observation on 04/15/25 at 11:22 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black dirt along and between the vents. There was a thick white substance between the top vents. The air filters had thick dust on them. The bathroom sink faucet had brownish stains along the base of the faucet. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. An observation on 04/15/25 at 11:27 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black dirt along and between the vents. There was a thick white substance between the top vents. The bathroom sink faucet had brownish stains along the base of the faucet. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. An observation on 04/15/25 at 11:31 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. The bathroom toilet had brownish stains along the base of the it. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. An observation on 04/15/25 at 11:33 AM of an air condition unit at the end of the 100-hall near an exit door, reflected the air condition unit had thick black dirt along and between the vents. There was a thick white substance between the top vents. The air filters had thick dust on them. An observation on 04/15/25 at 11:38 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. One of the corners of the floor had thick black dirt. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. An observation on 04/15/25 at 11:41 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. A picture frame hanging on the wall had thick black and brown stains all over it. The bathroom toilet had brownish stains along the base of the it. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. The bathroom sink faucet had brownish stains along the base of the faucet. An observation on 04/15/25 at 11:48 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. The mini fridge in the resident room had brown stains inside the bottom of the fridge. An observation on 04/15/25 at 11:53 AM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. The bathroom sink faucet had brownish stains along the base of the faucet. The room floor had thick black dirt along the edges of the floor, especially in the corners and near the room door. An observation on 04/15/25 at 12:00 PM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. A vent on the wall had brown stains all over it. An observation on 04/15/25 at 12:05 PM of resident room [ROOM NUMBER] reflected the air condition unit in the room had thick black and brown dirt along and between the vents. There were thick white substances between the top vents. The bathroom floor had brown stains along the edges of the floor, in the corners, and the bathroom door frame. The bathroom sink faucet had brownish stains along the base of the faucet. In an interview on 04/17/25 at 10:32 AM, Housekeeping I stated she had been at the facility for 3 years. She stated they were supposed to clean all areas of the resident rooms, including bathrooms. She stated they cleaned the mini fridges in the resident rooms if they were asked to clean them. She was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13. She stated she would do a better job cleaning the rooms. She stated the risk of not thoroughly cleaning resident rooms is not good for the resident and their breathing. In an interview on 04/17/25 at 10:41 AM, the Housekeeping Supervisor stated he had been the supervisor for 5 years. He stated staff was responsible for cleaning the entire resident room, including the air condition units and the mini fridges in the rooms. He stated he checked the rooms once they finished cleaning the hall. He stated maintenance was responsible for cleaning the air filters and inside vents of the air condition units. He stated the risk of not cleaning the areas mentioned could impact the residents' breathing. He was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13, and he stated they were working on correcting the issues. In an interview on 04/17/25 at 10:50 AM, the Maintenance Director stated he had been at the facility for [AGE] years. He stated he was responsible for cleaning the inside of the air condition units and the air filters in the resident rooms. He stated they were cleaned monthly. He was shown pictures of the concerns observed in the air condition units in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and the air condition unit on the 100-hall, and he stated he was responsible for cleaning them. He stated the risk of not cleaning them could result in residents having respiratory problems. In an interview on 04/17/25 at 10:50 AM, the Administrator was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and the air condition unit on the 100-hall, and he stated housekeeping and maintenance were working on correcting the issues. He stated the risk of not cleaning the areas previously mentioned could impact the resident having a clean, homelike environment. He stated they completed leadership rounds daily, but may not had focused properly on the cleanliness of the rooms, and they will be more mindful of this. Record review of the facility's policy on Resident Room Cleaning (Undated) reflected Daily cleaning of resident rooms help to provide a sanitary environment, prevent odors, and prolong the useful life of furniture, equipment, paint, and floor finish.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for three (Resident #4, Resident #61, and Resident #186) of residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure Resident #186's medical information was not left on top of a documentation cart on 04/15/2025. 2. The facility failed to ensure MA H did not leave Resident #61s' medical information on top of the medication cart unattended on 04/15/2025. 3. The facility failed to ensure Resident #4's medical information was not left on top of a cart on 04/15/2025. 4. The facility failed to ensure MA I did not leave Resident #4's medical information on top of the medication cart unattended on 04/17/2025. These failures could place the residents at risk of their medical information being exposed to unauthorized individuals. Findings included: 1. Record review of Resident #186's Face Sheet, dated 04/15/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with disorientation. Record review of Resident #186's Comprehensive MDS Assessment, dated 04/08/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. Record review of Resident #186's Comprehensive Care Plan, dated 4/12/2025, reflected the resident had a fall on 04/12/2025 and sustained a skin tear to right forearm and right lateral calf was to continue with the interventions. Record review of Resident #186's Physician Order, dated 04/13/2025, reflected Cleanse right arm with NS, pat dry, and apply dry dressing every other day and prn every day shift AND every 1 hours as needed. Record review of Resident #186's Physician Order, dated 04/13/2025, reflected Cleanse skin tear to right lateral calf with NS, pat dry and apply dry dressing every other day and prn every day shift every other day AND every 1 hours as needed. Record review of Resident #186's Progress Notes, dated 04/12/2025, reflected Resident went to restroom by herself without waiting for staff to assist and fell trying to pull her pants up. Sustained skin tear x 3 to right forearm/elbow and skin tear to right lateral calf. Denies pain. Areas cleaned and dressings applied. Observation on 04/15/2025 at 10:40 AM revealed a piece of paper was left on top of a documentation cart parked on the hallway in front of the nurses' station. On the piece of paper was Resident #186's name and room number. On the same piece of paper were the skin tears the resident sustained during a fall. Observation and interview on 04/15/2025 at 10:45 AM, LVN C stated the piece of paper on top of the documentation table contained the name, room number, and some information about her skin tear. He said it should not be left on the documentation table for everyone to see. He said he was not aware who left the piece of paper. LVN C took the paper with him to the nurses' station. 2. Record review of Resident #61's Face Sheet, dated 04/15/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed asthma (lung disorder caused by narrowing of the airways). Record review of Resident #61's Comprehensive MDS Assessment, dated 04/10/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had asthma. Record review of Resident #61's Comprehensive Care Plan, dated 01/15/2025, reflected the resident had asthma related to allergies and one of the interventions was to administer medications as ordered. Record review of Resident #61's Physician Order, dated 04/13/2025, reflected Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for Congestion. Observation on 04/15/2025 at 11:49 AM revealed a piece of small piece of plastic bag packaging was observed on top of a medication cart. On the plastic bag was Resident #61's name, the name of the medication, the prescription number of the medication, the dose, the frequency, the physician's order, the diagnosis why the medication was being administered, and the name of the pharmacy. It was observed that nobody was attending the cart, and the cart was facing the hallway. Observation and interview on 04/15/2025 on 11:53 AM, MA H stated she left the cart because she administered Resident #61's medication. She said she should not leave any medication packaging on top of the medication cart unattended because they have information about the resident. She said she would be mindful that no information about the resident would be left on top of the cart. 3. Record review of Resident #4's Face Sheet, dated 04/15/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed hypertension (high blood pressure). Record review of Resident #4's Comprehensive MDS Assessment, dated 04/09/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had hypertension. Record review of Resident #4's Comprehensive Care Plan, dated 04/10/2025, reflected the resident had hypertension related and one of the interventions was to monitor for hypotension. Record review of Resident #4's Physician Order, dated 12/13/2024, reflected Amlodipine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP < 110. Record review of Resident #4's Progress Note, dated 4/15/2025, reflected Amlodipine Besylate Tablet 10 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP < 110 held due to b\p 98\68-60. Observation on 04/15/2025 at 12:18 PM revealed a piece of paper was on top of a cart parked on the nurses' station. On the piece of paper was written Resident #4's name and his blood pressure. The cart was facing the hallway. Observation and interview on 04/15/2025 at 12:21 PM, the Administrator stated the paper should not be left on the cart because it contained medical information about the resident and it should be confidential. He said he would find out who left it on the cart so he could educate whoever left it. The Administrator took the piece of paper and placed it inside the nurses' station. In an interview on 04/16/2025 at 3:19 PM, the DON stated personal and medical information about a resident should not be exposed for everybody to see because it was confidential. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all employees were expected to provide full privacy and confidentiality of information for all residents. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. In an interview on 04/17/2025 at 7:22 AM, the Administrator stated the staff must make sure the residents' information was not exposed and protected because it was a violation of the resident's privacy and confidentiality of the care/treatment they were receiving. He said the expectation was for all the staff to make sure the personal and medical information of a resident were not visible to unauthorized individuals. He said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality. 4. Record review of Resident #4's Comprehensive MDS Assessment, dated 04/09/2025, reflected the resident the resident had heart failure. Record review of Resident #4's Comprehensive Care Plan, dated 04/10/2025, reflected the resident had heart failure and one of the interventions was to administer medications as ordered. Record review of Resident #4's Physician Order, dated 03/04/2025, reflected Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 60 MG Give 60 mg by mouth one time a day related to ANGINA PECTORIS (chest pain), UNSPECIFIED. Do not crush. Observation on 04/17/2025 at 8:35 AM revealed a top potion of a blister pack was on top of the medication cart. On the top portion of the blister pack was Resident #4's name, the name of the medication, the prescription number of the medication, the dose, the frequency, the physician's order, the diagnosis why the medication was being administered, and the name of the pharmacy. It was observed that nobody was attending the cart and the cart was facing the hallway. Observation and interview on 04/17/2025 at 8:41 AM, MA I stated she went to a resident to administer medications. She said she would tear the top portion of the blister pack if the medication was done. She said she should have flipped it so the resident's information would not be exposed because it was HIPAA (violation). MA I took the top portion of the blister pack and flipped it. In an interview on 04/17/2025 at 8:49 AM, the ADON stated the staff should make sure that no information about any resident be left on top of the cart before leaving the cart unattended. She said the resident's information were confidential and should not be seen by unauthorized individuals. She said that was a HIPAA violation. She said the expectation was for the staff not to leave any personal or medical information about a resident. She said she would coordinate with the DON to do an in-service about privacy and confidentiality. Record review of the facility's policy, Charting and Documentation Nursing Services Policy and Procedures Manual for Long-Term Care, no revision date, revealed Policy Statement: All services provided to the resident shall be documented in the resident's medical record . Policy Interpretation and Implementation . information documented in the resident's clinical record is confidential.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five (Resident #3, #4, #80, #187, and #188) of twenty residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #3's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 04/15/2025. 2. The facility failed to ensure Resident #4's humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) had water in it on 04/15/2025. 3. The facility failed to ensure an Oxygen in Use sign was outside Resident #80's room on 04/15/2025. 4. The facility failed to ensure Resident #188's nasal cannula was properly stored when not in use on 04/15/2025. 5. The facility failed to ensure Resident #187's nasal cannula was properly stored when not in use on 04/16/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #3's Face Sheet, dated 04/15/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #3's Quarterly MDS Assessment, dated 04/13/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident had oxygen therapy. Record review of Resident #3's Quarterly Care Plan, dated 01/21/2025, reflected the resident had COPD and one of the interventions was O2 at 2 liters per minute via nasal cannula continuously. Record review of Resident #3's Physician Orders, dated 02/26/2024, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sats >90% every shift for O2 sat >90%. Observation on 04/15/2025 at 10:01 AM revealed Resident #3 was in her bed with eyes closed. It was observed that the resident was on oxygen therapy at 2 liters per minute via nasal cannula. An oxygen tank was observed near the door with a nasal cannula attached to it. The nasal cannula was coiled to the oxygen tank with the prongs touching the side of the oxygen tank. The nasal cannula was not bagged. During an observation and interview on 04/15/2025 at 10:06 AM, LVN E stated the oxygen tank at the side of the door was for Resident #3. She said the nasal cannula should not be coiled around the oxygen tank. She said it should be bagged to prevent respiratory infection. LVN E disconnected the nasal cannula and said she would get a new nasal cannula and a bag for it. She said she did not notice the nasal cannula not being bagged when she did her morning round. 2. Record review of Resident #4's Face Sheet, dated 04/15/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #4's Comprehensive MDS Assessment, dated 04/09/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had COPD. Record review of Resident #4's Comprehensive Care Plan, dated 04/10/2025, reflected the resident had oxygen therapy and one of the interventions was to change from mask to nasal cannula during meals. Record review of Resident #4's Physician Order, dated 02/25/2025, reflected O2 at 3 liters per minute via nasal cannula as needed for shortness of breath. May titrate to 1- 4 LPM to keep O2 sats > 90% every shift for O2 sat >90%. Observation on 04/15/2025 at 9:42 AM revealed Resident #4 was in his bed with eyes closed. It was observed that the resident was on oxygen therapy at 3 liter per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator with a humidifier bottle in it. The pre-filled humidifier bottle had no water in it. During an observation and interview on 04/15/2025 at 9:48 AM, RN B stated she did not notice that Resident #4's humidifier bottle was out of water or was running low. She said she should have checked it when she did her morning round. She said the purpose of the humidifier bottle was to moisten the nose and the throat and to prevent irritation. RN B disconnected the empty humidifier bottle and said she would get a new one. 3. Record review of Resident #80's Face Sheet, dated 04/15/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder. Record review of Resident #80's Physician Order, dated 04/13/2025, reflected O2 at 2 liters per minute via nasal cannula continuously/prn. May titrate to 3-4 LPM to keep O2 sats >90% every shift for shortness of breath or O2 sat <91%. Record review of Resident #80's Progress Notes, dated 04/13/2025, reflected the resident was readmitted to the facility from the hospital with a diagnosis of pneumonia (inflammation and fluid in the lungs caused by a bacterial, viral, or fungal infection). Observation on 04/15/2025 at 9:47 AM revealed the resident was in her bed with eyes closed. It was observed that the resident was on oxygen therapy at 3 liters per minute via nasal cannula. It was also observed that there was no Oxygen In Use sign outside the resident's room. During an observation and interview on 04/15/2025 at 2:18 PM, LVN D said if a resident was using oxygen, there should be an oxygen sign outside the door of the resident to inform everybody that oxygen was being used. He said the sign served as a reminder for potential hazards connected to oxygen use such as fire and explosions. 4. Record review of Resident #187's Face Sheet, dated 04/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body). Record review of Resident #187's Comprehensive MDS Assessment, dated 04/15/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident was on oxygen. Record review of Resident #187's Comprehensive Care Plan, dated 04/10/2025, reflected the resident had oxygen therapy and one of the interventions was to provide extension tubing during ambulation. Record review of Resident #187's Physician Order, dated 04/09/2025, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3 - 4 LPM to keep O2 sats >90% every shift for O2 sat >90%. Observation and interview on 04/16/2025 at 8:36 AM revealed Resident #187 was in his bed awake. It was observed that the resident was on oxygen therapy. It was also observed that there was an oxygen tank at the back of the resident's wheelchair. A nasal cannula was attached to the oxygen tank. The nasal cannula was not bagged and was touching the back of the wheelchair. The resident said he had been using the oxygen for weeks. He said he also had oxygen on his wheelchair that he used when he went to therapy. During an observation and interview on 04/16/2025 at 10:15 AM, RN A said she did not notice that the nasal cannula at the back of Resident #187's wheelchair was not bagged. She said she went inside the resident's room to administer the breathing treatment but did not notice the nasal cannula. She said the nasal cannula should be bagged to prevent infection. She disconnected the nasal cannula and said she would get a new one and a plastic bag to store it. 5. Record review of Resident #188's Face Sheet, dated 04/15/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic respiratory failure. Record review of Resident #188's Comprehensive MDS Assessment, dated 04/13/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had respiratory failure. Record review of Resident #188's Comprehensive Care Plan, dated 04/07/2025, reflected the resident had oxygen therapy and one of the interventions was to change from mask to nasal cannula during meals. Record review of Resident #188's Physician Order, dated 04/06/2025, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3 - 4 LPM to keep O2 sats >90% every shift for O2 sat >90%. Observation on 04/15/2025 at 11:46 AM revealed Resident #188 was in her bed with eyes closed. The resident was on oxygen therapy at 2 liters per minute via nasal cannula. It was also observed that the resident had an oxygen tank at the back of her wheelchair with nasal cannula attached to it. The nasal cannula was not bagged. Observation and interview on 04/15/2025 at 11:49 AM revealed LVN E disconnected the nasal cannula at the back of the wheelchair and said she would also get a new nasal cannula and a plastic bag for it. In an interview on 04/16/2025 at 3:19 PM, the DON stated the nasal cannulas were supposed to be in a bag when the residents were not using them to prevent cross contamination and worsening of respiratory issues the resident might already have. She said the humidifier should always have water in it to prevent dryness and irritation of the nasal passageway. She also said that if a resident was using oxygen, there should be a sign outside indicating that oxygen was being used. She said the sign was to alert the staff to avoid smoking and any potential sources of ignition. She said the expectation was for the staff to be mindful in making sure nasal cannulas were bagged when not in use, there was water in the humidifier bottle, and there was a sign outside the room when oxygen was being used. She said she would conduct an in-service about respiratory care. In an interview on 04/17/2025 at 7:22 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection. He said he was not a clinician and would let the DON take the lead in educating the staff about the issue of bagging the nasal cannula and the water in the humidifier. He said there should be sign outside the resident's room if oxygen was being used so the staff and the visitors would be aware. In an interview on 04/17/2025 at 8:49 AM, the ADON stated the nasal cannulas should be stored properly inside a plastic bag if the residents were not using them. She said the staff were responsible for ensuring the nasal cannulas and the breathing masks were clean every time the residents would use them. She said the expectation was for all nasal cannulas to be stored properly. She said another expectation was for the staff to check if the pre-filled humidifier bottle was running low or was empty. She said if it was running low, the staff should be ready to change it. She said the sign for oxygen use was to remind the staff to be careful not to cause any ignition that could cause fire. She said she would coordinate with the DON to do an in-service about respiratory care. Record review of the facility policy Oxygen Safety Health Oxygen Administration revised May 2024 reflected Oxygen Safety - General Rules . 5. No smoking signs shall be visible where oxygen is stored or being administered. Record review of the facility policy Oxygen Administration Health Oxygen Administration revised May 2024 reflected The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in procedure . 2. Place Oxygen in Use sign on the outside of the room entrance door . 12. Be sure there is water in the humidifying jar . 14. Periodically re-check water level in humidifier jar. Policy for respiratory care specific for bagging the nasal cannula was requested on 04/16/2025 via email but was not provided prior to exit.

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine and ice scoop holder in the facility kitchen was thoroughly cleaned. 2. The facility failed to ensure kitchen cooking equipment was cleaned. 3. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 4. The facility failed to ensure cooking equipment in the dining area was clean and sanitized. 5. The facility failed to label and date food stored in the refrigerator once it was opened and used. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 04/15/25 from 9:08 AM to 9:22 AM in the facility's only kitchen revealed: The ice machine, located in the kitchen had brown stains on the inside of the door and along the opening of the machine. The ice scoop holder, hanging on a wall near the ice machine, had brownish stains inside the bottom of the holder. One large bread toaster had built up dark brown dirt along the inside walls of the machine and along the tracks. One microwave, located in the dining area, had white stains plastered all over the outside of it and the inside had dried food stains on the plate and the inside walls. One toaster oven, located in the dining area, had white stains plastered all over the outside of it and the inside had dried food stains on the pans and the inside walls. There were two baking pans on the counter that was heavily stained with food stains. One containers of pears, located in the refrigerator, was not dated with the month, day and year the item was stored after opening. One glassed container of milk, located in the refrigerator, was not dated with the month, day, and year the item was stored. One large tea dispenser, located in the kitchen area, had tea in it and it did not have a lid placed on the top of the dispenser to avoid air-borne contaminants. o Five large cans of Tropical fruit salad, located in the dry storage area, was not dated with the month, day, and year the items were received from the vendor. Five large cans of Great northern beans, located in the dry storage area, was not dated with the month, day, and year the items were received from the vendor. In an interview on 04/16/25 at 2:10 PM, the Dietary Manager was advised of the findings in the kitchen. He was shown pictures of the concerns observed in the kitchen and the dining area. He stated he dated the food whenever it was stored after use. He stated he usually reviewed the kitchen for cleanliness at the start of their day and he often cleaned the items. He stated he spoke with the dishwasher who prepared the tea and advised him that he needed to ensure the tea dispenser was covered once the tea has been made. He stated they had a vendor service the ice machine monthly, but they could wipe it down. He stated he had a cleaning schedule for the kitchen staff and the kitchen equipment was cleaned weekly. He stated the toaster oven, and the microwave was used by the Activity Director, and she was responsible for cleaning the cooking equipment. He stated he would have someone clean the items. He stated the risk of not addressing the issues discussed could result in residents getting sick and dying. In an interview on 04/17/25 at 10:50 AM with the Administrator, he was shown pictures of the concerns observed in the kitchen area. He stated he had spoken with the Dietary Manager and was advised of the concerns observed in the kitchen area. He stated the risk of not addressing the concerns could result in residents getting sick. Record review of the facility's policy on Sanitization(dated January 2024), revealed The food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Record review of the facility's policy on Food Receiving and Storage (dated October 2022), revealed Foods shall be received and stored in a manner that complies with safe food handling practices.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #9, Resident #41, Resident #81, and Resident #187) of ten residents reviewed for Infection Control. 1. The facility failed to ensure CNA F changed her gloves and performed hand hygiene before, after, and while providing incontinent care to Resident #41 on 04/15/2025. 2. The facility failed to ensure LVN C wore a gown while administering Resident # 9's medications via g-tube 04/16/2025. 3. The facility failed to ensure LVN C wore a gown while administering Resident #81's medication via g-tube 04/16/2025. 4. The facility failed to ensure WCN J wore a gown while performing Resident #187's wound care and changed her gloves after touching the outside edge of the resident's foot on 04/16/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #41's Face Sheet, dated 04/15/2025, reflected the resident was an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with urinary tract infection on 01/31/2025. Review of Resident #41's Comprehensive MDS Assessment, dated 02/17/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated Resident #41 was always incontinent for bladder and bowel. Review of Resident #41's Comprehensive Care Plan, dated 04/13/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was clean perineal (area between the legs) with each incontinent care. Observation on 04/15/2025 at 11:39 AM revealed CNA F was about to provide incontinent care to Resident #41. She entered the room while holding a brief and padding. Once inside the room, she put on a pair of gloves. She did not wash or sanitize her hands before putting on the gloves. She placed the clean brief and the padding on the resident's overbed table. She also placed some wipes, a box of gloves, and a plastic bag on the overbed table. She lowered the head of the bed, raised the bed, and pulled the resident's blanket towards the resident's feet. She unfastened the resident's brief and pushed it between the resident's thighs. She removed her gloves, threw them on the plastic bag placed on the overbed table, and put on a new pair of gloves. She did not sanitize her hands before putting on the gloves. She pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. She did it three times. After cleaning the perineal area, she instructed and assisted the resident to roll towards the right side, and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it on the plastic bag. After throwing the soiled brief, she changed her gloves but did not sanitize her hands before putting on a new pair of gloves. She took the padding and the brief from the overbed table, placed it under the resident, and fixed it. She then instructed and assisted the resident to roll to the other side. After rolling the resident to the other side, she touched the other half of the soiled padding and placed it in a plastic bag. She then fixed the new brief and padding. She did not change her gloves after touching the soiled brief. After fixing the brief and the padding, CNA F assisted the resident to roll back and fastened the brief on both sides. CNA F took off her gloves and threw them in the trash bag. She went out of the resident's room and threw the soiled items. She did not wash her hands after performing incontinent care. In an interview on 04/15/2025 at 11:58 AM, CNA F stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she forgot to wash her hands before and after doing Resident #41's incontinent care. She said during the process, she changed her gloves but did not sanitize her hands before putting on a new pair of gloves. She said after touching the soiled padding on the plastic bag, she should have changed her gloves. She said she would be mindful the next time she does incontinent care to do hand hygiene and change her gloves after touching something soiled during incontinent care. 2. Record review of Resident #9's Face Sheet dated 04/16/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #9's Comprehensive MDS Assessment, dated 03/28/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 02. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach). Record review of Resident #9's Quarterly Care Plan, dated 04/07/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to use gloves and gown during use of the feeding tube. Record review of Resident #9's Physician Order, dated 04/10/2025, reflected every shift Osmolyte 1.2 rate of 60ml/hr X 22 hours to allow for ADLs. Observation on 04/16/2025 at 8:15 AM revealed LVN C was about to give Resident #9 morning medication. He said the resident only had one medication to take. LVN C sanitized his hands, put the medication in a small plastic cup, crushed it, and returned the crushed medication to the small plastic cup. After crushing the medication, he poured some water in a plastic cup. He said he would incorporate some water to the medication to dissolve it. He went inside the resident's room with the medication and the cup of water, and placed them on the resident's overbed table. He proceeded with medication administration via g-tube. He did not wear a gown before giving the medication. It was observed that there was a sign outside that the resident was on enhanced barrier precaution. 3. Record review of Resident #81's Face Sheet dated 04/16/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (presence of surgical opening in the stomach to support nutrition). Record review of Resident #81's Comprehensive MDS Assessment, dated 02/13/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach). Record review of Resident #81's Quarterly Care Plan, dated 02/14/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to use gloves and gown during use of the feeding tube. Record review of Resident #81's Physician Order, dated 04/10/2025, reflected every shift Tube Feeding Continuous: Formula: Jevity 1.2 at 55 cc/hr x 22 hours to allow for ADL care. Observation on 04/16/2025 at 7:43 AM revealed LVN C was about to give Resident #81's morning medication. He said he would check first the resident's blood pressure because one of the medication is an anti-hypertensive. He went inside the room and took the resident's blood pressure. He said he will just prepare two medications because the resident's blood pressure was 99/50 and he needed to hold the anti-hypertensive medication. LVN C sanitized his hands, put the medications in small plastic cups, crushed them, and returned the crushed medication to their respective small cups. After crushing the medications, he poured some water in a plastic cup. He said he would incorporate some water to the medication to dissolve it. He went inside the resident's room with the medications and the cup of water, and placed them on the resident's overbed table. He proceeded to administer the resident's medication via g-tube. He did not wear a gown when he was giving the medications. It was observed that there was a sign outside that the resident was on enhanced barrier precaution. In an interview on 04/16/2025 at 8:39 AM, LVN C stated he forgot to wear a gown before administering Resident #9 and Resident #81's medication. He said there was a sign outside the door that said if the feeding tube will be used, the staff must wear a gown to prevent cross contamination and infection. He said he will be mindful the next time he would administer medication via g-tube. 4. Record review of Resident #187's Face Sheet, dated 04/16/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with type 2 diabetes mellitus (high blood sugar). Record review of Resident #187's Comprehensive MDS Assessment, dated 04/15/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had a diabetic foot ulcer (slow healing wound that commonly occur in individuals with diabetes). Record review of Resident #187's Comprehensive Care Plan, dated 04/10/2025, reflected the resident had a diabetic foot ulcer to the right foot and one of the goals was that the resident will not have any complications. Record review of Resident #187's Physician Order, dated 04/10/2025, reflected Cleanse Right Foot DFU with WC, apply Iodosorb ointment into wound bed, gently pack with 1/4 Iodoform packing strips into wound using a Q-Tip. Cover with Non adherent dressing and wrap with Kerlix secured with Ace wrap PRN every 24 hours as needed for DFU. Observation on 04/16/2025 at 8:36 AM revealed WCN J was about to change the dressing on Resident #187's wound to the right foot. She sanitized her hands and prepared the iodosorb ointment, iodoform packing strips, kerlix, dry gauze, surgical scissors, Q-Tips, and non-adherent dressing. After preparing the things needed for wound care, she went inside the room, and brought with her the things needed for wound care, and placed them on the overbed table that she sanitized. After placing them on the table, she washed her hands and put on a pair of gloves. She then started to clean the wound to the right foot. She did not wear a gown while cleaning the wound. During the process of cleaning, WCN J inspected the outside edge of the resident's foot by touching it. She then proceeded to cover the wound with the new dressing. She did not change her gloves after she touched the side of the right foot. In an interview on 04/16/2025 at 9:01 AM, WCN J said she should have worn a gown because the resident was on enhanced barrier precaution. She said the purpose of which was to prevent cross contamination and development of infection. She said she should have changed her gloves after touching the side of the foot and before touching the dressing. In an interview on 04/16/2025 at 3:19 PM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care. She said gloves should be changed after touching anything soiled to make sure that microorganism will not transfer to the clean brief and clean dressing. She also said that if a resident was on enhanced barrier precaution, the staff should wear a gown when attending to them. She said residents with feeding tubes and open wounds required enhanced barrier precaution to decrease their exposure to pathogens that could cause infection. She said the expectation was for the staff to do hand hygiene before and after any care, change gloves from dirty to clean, and wear gowns when caring for residents on enhanced barrier precautions. She said she already started an in-service about infection control and hand hygiene. She said she would personally monitor the staff's adherence to the policy and procedure of infection control. In an interview on 04/17/2025 at 7:22 AM, the Administrator stated that staff must be mindful in preventing spread of germs and development of infection. He said he was not a clinician and would let the DON take the lead in educating the staff about the issue. In an interview on 04/17/2025 at 8:49 AM, the ADON stated staff must wash their hands before and after incontinent care. She said staff should be mindful that when they touched something dirty, they should change their gloves before touching something clean. She said this is true for both incontinent care and wound care. She also said that before putting on a new pair of gloves, staff must wash their hands or sanitize their hands. She said she would coordinate with the DON to do an in-service pertaining to hand hygiene, infection control, and wound care. Record review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . g. Before handling clean or soiled dressing . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves. Record review of facility policy, Enhanced Barrier Precaution reviewed 03/19/2025 revealed EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Record review of facility policy, Incontinent Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #18 and Resident #43) of eighteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #18 and Resident #43's rooms were in a position that was accessible to the resident on 04/15/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #18 Record review of Resident #18's Face Sheet, dated 04/16/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #18 was diagnosed with muscle weakness and gait abnormalities. Record review of Resident #18's Quarterly MDS Assessment, dated 03/03/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident was dependent for transfer, toileting hygiene, shower, dressing, and personal hygiene. Record review of Resident #18's Comprehensive Care Plan, dated 03/04/2025, reflected the resident had a risk for fall related to gait problems and one of the interventions was to be sure the resident's call light is withing reach. Observation and interview on 04/15/2025 at 9:40 AM revealed Resident #18 was sitting in her wheelchair inside her room. It was observed that the resident's call light was on the floor at the foot of the bed. It was also observed that the resident's bed was already made. When asked where her call light was, the resident said her call light was nowhere to be found. Observation and interview on 04/15/2025 at 9:49 AM, CNA G stated call lights should always be within reach of the residents because that was how they called the staff if they needed something. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She went inside Resident's #18's room and saw the call light on the floor. She pulled the call light from the floor and put it on top of the resident's bed. She said she should have made sure the call light was on top of the resident's bed when she transferred the resident to her wheelchair and made her bed. Resident #43 Record review of Resident #43's Face Sheet, dated 04/15/2025, reflected a [AGE] year-old female admitted on [DATE]. Resident #43 was diagnosed with muscle weakness and lack of coordination. Record review of Resident #43's Quarterly MDS Assessment, dated 02/10/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated the resident was dependent for toileting hygiene, dressing, bed mobility, and transfer. Record review of Resident #43's Comprehensive Care Plan, dated 02/27/2025, reflected the resident had a risk for fall related to gait problems and one of the interventions was to be sure the resident's call light was within reach. Observation and interview with Resident #43 on 04/15/2025 at 9:53 AM revealed Resident #43 was in her bed, awake. It was observed that the resident's call light was on the floor and coiled around an IV stand. When asked where her call light was, the resident just smiled, but did not reply. Observation and interview on 04/15/2025 at 10:01 AM, LVN E stated call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. She said the residents might fall trying to get the call light or trying to do some activities that needed assistance. She went inside Resident #43's room and saw the call light on the floor. She said she did not notice the call light was on the floor when she administered the resident's medication. She said she should have made sure the call light was with the resident before leaving the room, because the resident wanted to always hold her call light. In an interview on 04/16/2025 at 3:19 PM, the DON stated call lights were inside the residents' rooms so they can call the staff for assistance, a glass of water, pain medication, or because they needed to be changed. The DON said if the call lights were not within reach, their needs would not be met. The DON said all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the residents' room when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said she would educate the staff about the importance of call lights for the residents. In an interview on 04/17/2025 at 7:22 AM, the Administrator stated call lights should be within the reach of the residents at all times. He said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. He said the residents also used the call lights if they needed to be changed or they needed a pain medication. The Administrator said the residents might fall trying to get up and get what they needed. He said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. He said he would collaborate with the DON and the ADON about the issue regarding call lights. In an interview on 04/17/2025 at 8:49 AM, the ADON stated the call lights should always be with the residents. She said when the resident was already in her wheelchair, the call light should be on top of her bed so she could still call the staff if she needed to. She said the staff should make sure that the call lights were with the residents before they left the room. She said she would coordinate with the DON to do an in-service about call light placement. Record review of facility's policy Resident Call System Resident Call Light Policy revised 03/28/2023 revealed Policy: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . Policy Interpretation and Implementation . 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 6 residents (Residents #25 and #68) reviewed for accident prevention. 1. The facility failed to ensure Resident #25 had physician orders for the bolster pads that were applied to her mattress for fall prevention. 2. The facility failed to ensure Resident #68 had physician orders for her scoop mattress These failures could prevent the residents from having an environment that was free and clear of accidents and hazards. Findings include: 1. Record review of Resident #25's Face Sheet, dated 04/16/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia (cognitive decline), and muscle weakness. Record review of Resident #25's Quarterly Minimum Data Set (MDS) assessment, dated 12/24/24, reflected she had a BIMS score of 14 (intact cognitive response). For ADL care, it reflected for transfers, toileting, and bathing, the resident was totally dependent for assistance. Record review of Resident #25's Quarterly Care Plan, dated 02/17/25, reflected the resident was a high risk for falls and the need for safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, and personal items within reach. Record review of Resident #25's physician orders, dated 04/16/25, reflected no physician orders for the bolster pads. An Observation on 04/15/25 at 11:58 AM, revealed Resident #25 had bolster pads on her bed. 2. Record review of Resident #68's Face Sheet, dated 04/15/25, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia (cognitive decline), and history if falling. Record review of Resident #68's Quarterly Minimum Data Set (MDS) assessment, dated 03/14/25, reflected she had a BIMS score of 9 (moderate impairment). For ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #68's Quarterly Care Plan, dated 03/20/25, reflected the resident was a high risk for falls and the need for safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, and personal items within reach. Record review of Resident #68's physician orders, dated 04/16/25, reflected no physician orders for a scoop mattress. An observation on 04/15/25 at 11:58 AM, revealed Resident #68 had a scoop mattress on her bed. In an interview and observation at 04/16/25 at 09:45 AM, LVN M stated she was the floor nurse for Resident #25 and Resident #68. She observed the bolster pad that was attached to Resident #25's mattress, and she observed the scoop mattress Resident #68 was laying on. She stated both residents required orders for their equipment because it could restrict the resident's movement and could be a form of restraint. She stated she had checked and neither resident had orders for the equipment. She stated both residents were a fall risk. She stated the risk of not having physician orders was that the residents could injure themselves if they attempted to get out of their beds. She stated she had spoken with her DON, and they were investigating how the residents obtained the equipment. In an interview on 04/16/25 at 12:00 PM, the DON stated she was informed by LVN M of Resident #25 and Resident #68 having equipment without physician orders. She stated she was meeting with her staff to try and find out how Resident #25 received the bolster pads for her mattress and how Resident #68 was provided a scoop mattress. She stated they both should have physician orders to have the equipment to ensure there was no risk for the residents. She stated physician orders were required for the scoop mattress and the bolster pads, and she had obtained physician orders for both residents. The facility's policy Restraint Free Facility Initiative (01/23) reflected Achieving a restraint free facility status is certainly attainable and important but must be done methodically and strategically to ensure the safety and clinical best practice for our residents.

Based observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #41) of three residents observed for Incontinent Care. The facility failed to ensure that CNA F did not wipe Resident #41's perineal (area between the legs) area from back to front while providing incontinent care on 04/15/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections. Findings included: Review of Resident #41's Face Sheet, dated 04/15/2025, reflected the resident was an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with urinary tract infection on 01/31/2025. Review of Resident #41's Comprehensive MDS Assessment, dated 02/17/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated Resident #41 was always incontinent for bladder and bowel. Review of Resident #41's Comprehensive Care Plan, dated 04/13/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was clean peri-area with each incontinent care. Observation on 04/15/2025 at 11:39 AM revealed CNA F entered Resident #41's room to provide incontinent care. CNA F cleaned the resident's perineal area. After cleaning the resident's perineal area, CNA F instructed and assisted the resident to roll on her right side and began cleaning the bottom of the resident. She cleaned the bottom of the resident from back to front. She did it four times. In an interview on 04/15/2025 at 11:58 AM, CNA F stated the wiping during incontinent care should always be done from front to back to prevent urinary tract infection. She said she was not aware that when she cleaned the bottom of the resident, that she did it from back to front. She said she should be mindful of how she does incontinent care because the resident would be at risk for urinary tract infection. In an interview on 04/16/2025 at 3:19 PM, the DON stated cleaning the perineal area should be from front to back to prevent cross contamination and probable infection. She said the procedure should also be done when cleaning the bottom of the resident. She said it should also be done from front to back because if done the other way around, the germs from the resident's bottom will be introduced to the perineal area. She said the expectation was for the staff to practice the right procedure of incontinent care and to focus on the prevention of infection. She said she would do an in-service about incontinent care. In an interview on 04/17/2025 at 7:22 AM, the Administrator stated improper cleaning of the private parts could cause infection and the expectation was for the staff to follow the right procedure for incontinent care. He said he was not a clinician and would let the DON take the lead in educating the staff about the issue. In an interview on 04/17/2025 at 8:49 AM, the ADON stated the proper way of cleaning the resident's perineal area would be always front to back to avoid transfer of germs from the bottom to the front part of the resident. She said the purpose of which was to prevent infection. She said the expectation was for the staff to do incontinent care the right way which was cleaning the front part and the bottom from front to back. She said she would coordinate with the DON to do an in-service pertaining to incontinent care focusing on proper cleaning. Record review of facility policy, Perineal Care revised 02/2023 revealed Purpose: The purpose of this procedure is to prevent infection . Steps in the Procedure . For female resident . e. wash the rectal area thoroughly, wiping from the base of the labia (female reproductive organ) towards and extending over the buttocks.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two (Resident #9 and Resident #81) of two residents reviewed for Feeding Tube (a way of providing nutrition directly to the stomach). 1. The facility failed to ensure LVN C checked Resident #9's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering medication on 04/16/2025. 2. The facility failed to ensure LVN C checked Resident #81's g-tube placement and residual before administering medication on 04/16/2025. These failures could place residents with G-tubes at risk for infection, dehydration, and drug-to-drug interaction. Findings included: 1. Record review of Resident #9's Face Sheet dated 04/16/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #9's Comprehensive MDS Assessment, dated 03/28/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 02. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #9's Quarterly Care Plan, dated 04/07/2025, reflected the resident required tube feeding and one of the interventions was to verify g-tube placement and check for residual. Record review of Resident #9's Physician Order, dated 04/10/2025, reflected every shift Osmolyte 1.2 rate of 60 ml/hr X 22 hours to allow for ADLs. Record review of Resident #9's Physician Order, dated 04/10/2025, reflected every shift Verify G-tube placement & check for residual. Observation on 04/16/2025 at 8:15 AM revealed LVN C was about to give Resident #9 morning medication. He said the resident only had one medication to take. LVN C sanitized his hands, put the medication in a small plastic cup, crushed it, and returned the crushed medication to the small plastic cup. After crushing the medication, he poured some water in a plastic cup. He said he would incorporate some water to the medication to dissolve it. He went inside the resident's room with the medication and the cup of water, and placed them on the resident's overbed table. He put some water on the medication to dissolve it. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site, and disconnected the g-tube from the formula. After disconnecting the g-tube, he pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured the dissolved medication. He did not check for the placement of the g-tube and the residual before flushing and administering the medication. After pouring the medications, he flushed the g-tube, detached the syringe, connected the g-tube to the formula, and cleaned the table and the syringe. 2. Record review of Resident #81's Face Sheet dated 04/16/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (presence of surgical opening in the stomach to support nutrition). Record review of Resident #81's Comprehensive MDS Assessment, dated 02/13/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #81's Quarterly Care Plan, dated 02/14/2025, reflected the resident required tube feeding and one of the interventions was to monitor for distension (bloating or swelling of the stomach area). Record review of Resident #81's Physician Order, dated 04/10/2025, reflected every shift Tube Feeding Continuous: Formula: Jevity 1.2 at 55 cc/hr x 22 hours to allow for ADL care. Record review of Resident #81's Physician Order, dated 04/10/2025, reflected every shift Verify G-tube placement & check for residual. Record review of Resident #81's Physician Order, dated 04/10/2025, reflected Keppra 7.5 ml via g-tube two times a day. Record review of Resident #81's Physician Order, dated 04/10/2025, reflected Lactobacillus capsule via g-tube two times a day. Record review of Resident #81's Physician Order, dated 04/10/2025, reflected Metoprolol 12.5 mg via g-tube once daily for hypertension. Hold if SBP < 100. Observation on 04/16/2025 at 7:43 AM revealed LVN C was about to give Resident #81's morning medication. He said he would check first the resident's blood pressure because one of the medication is an anti-hypertensive. He went inside the room and took the resident's blood pressure. He said he will just prepare two medications because the resident's blood pressure was 99/50 and he needed to hold the anti-hypertensive medication. LVN C sanitized his hands, put the medications in small plastic cups, crushed them, and returned the crushed medication to their respective small cups. After crushing the medications, he poured some water in a plastic cup. He said he would incorporate some water to the medication to dissolve it. He went inside the resident's room with the medications and the cup of water, and placed them on the resident's overbed table. He put some water on the medications to dissolve it. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site, and disconnected the g-tube from the formula. After disconnecting the g-tube, he pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured a medication, flushed the g-tube, then poured the next medication. He did not check for the placement of the g-tube and the residual before flushing and administering the medication. After pouring the last medication, he flushed the g-tube, detached the syringe, connected the g-tube to the formula, and cleaned the table and the syringe. In an interview on 04/16/2025 at 8:39 AM, LVN C stated he forgot to check for the g-tube placement and to check the residual of both residents. He said the right procedure was to check the placement and the residual. He said g-tube placement was checked to ensure the tube was correctly positioned. He said the residual was also checked before administering medications to check if the stomach was not too full and could accommodate the medications and fluid to be introduced. He said he knew he needed to check for the placement and residual but failed to do so because he was nervous. In an interview on 04/16/2025 at 3:19 PM, the DON stated the placement of the g-tube and the residual should be checked. She said administering the morning medications would be the best time to check for placement to ensure the medications and the fluid would enter the stomach and not the lungs. She said the gastric residual should be checked before bolus feeding and medication administration to prevent aspiration and also to assess if the resident's stomach was emptying properly. She said the expectation was for the staff to follow the right procedure for medication administration via g-tube. She said she would do an in-service about enteral feeding. In an interview on 04/17/2025 at 7:22 AM, the Administrator stated the expectation was for the staff to follow the right procedure for administering medications via g-tube. He said he was not a clinician and would let the DON take the lead in educating the staff about the issue. In an interview on 04/17/2025 at 8:49 AM, the ADON stated both the residual and g-tube placement should be checked before giving the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place. She said even though the residents were on continuous feeding, the placement should still be checked. She said the gastric residual was also checked to prevent aspiration and also to assess if the rate of the formula should be modified. She said the expectation was for the staff to check for g-tube placement and to check for gastric residual every time they administer medications. She said she would coordinate with the DON to do an in-service about enteral feeding. Record review of the facility's policy Enteral (food or medication administration directly through the digestive system) Nutrition revised [DATE] revealed Adequate nutritional support through enteral nutrition . Policy Interpretation and Implementation: 1. The interdisciplinary team . conducts nutritional assessment . clinical necessity of enteral feeding . resident's response to them . 12. Need for supplemental orders, including . Confirmation of tube placement . Checks for gastric residual volume.

Based on observation, interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of eight residents reviewed for notify of changes. -The facility failed to notify Resident #1's physician and responsible party when the resident showed signs of an altered mental status for at least 22 hours and was later diagnosed with severe sepsis at the local hospital. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate medical attention and required notifications being made when there is a change in their condition., which could lead to worsening of conditions and serious injury or harm. Findings included: Record review of Resident #1's face sheet, dated, 08/30/24, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Paraplegia (paralysis of the legs and lower body), Osteomyelitis (a bone infection that can occur when bacteria or fungi spread to the bone), and Polyneuropathy (malfunction of many peripheral nerves throughout the body). Record review of Resident #1's Admission MDS assessment, dated 07/11/24, revealed the resident had a BIMS score of 13 which suggested he was cognitively intact. Resident #1 was always incontinent of bowel and bladder. The Admission MDS assessment reflected Resident #1 was able to make himself understood. Further review reflected Resident #1 admitted with stage 4 pressure ulcers and required IV medication and isolation for infectious disease. Review of Resident #1's care plan initiated on 07/12/24 reflected the resident was at risk for hospitalization r/t sepsis. Interventions included administer medications as ordered, observe for changes in level of consciousness, mental status, or orientation and report significant changes to provider as indicated . Record review of Resident #1's progress notes reflected there was not a progress note by LVN B on 08/25/24 documenting that the aides reportedly witnessed a change of condition of the resident. Record review of Resident #1's progress notes, dated 08/26/24 at 03:36 AM by RN C, reflected the following: [Resident #1] yelling and screaming, stating he is not in bed and he [sic] going to fall. I need a forklift right now. I am tired of that man being [sic] my room, he is right there behind my bed. [Resident #1] is diaphoretic (sweating heavily), noted ring [sic] tinged urine in Foley. He is afebrile (without fever) at this time 98.9, resp 18, heart rate 102, blood glucose 126mg/dl. SPO2 97% on room air. Spent at bedside to console and reorient [Resident #1]. Care and monitoring ongoing. Record review of Resident #1's progress notes, dated 08/26/24 at 05:01 AM by RN C, reflected the following: [Resident #1] cont to shout out for help. Help me get this forklift. Also rambling speech unable to make sense of. Gave sponge bath and noted noted [sic] sacral wound foul smelling, ordered and sent UA specimen to lab. Cont to console and reassure [Resident #1] Record review of Resident #1's progress notes, dated 08/26/24 at 02:18 PM by LVN R, reflected the following: [Resident #1] had a UA collected this morning, results pending, new orders for STAT CBC, BMP, awaiting collection. Record review of Resident #1's progress notes, dated 08/27/24 at 04:39 AM by RN C, reflected the following: [Resident #1] has vomited approx. 150 cc brown emesis. [Resident #1] cont to have hallucinations at night seeing a man in room that is not present. [Resident #1] is easily consoled. Care and monitoring ongoing. Record review of Resident #1's progress notes, dated 08/27/24 at 10:00 AM by RN D, reflected the following: [Resident #1] hallucinating. HR 105, BP WNL, [Resident #1] c/o of nausea and dry heaving. Wound has foul smell. STAT CBC, CMP and UA sent to NP, Received order for NS @ 75 ml/hr and IM rocephin. [Resident #1] is preparing for discharge today. Discussed worsening condition with [DON] and [social services] and [NP]. [DON] and [social services] discussed with [Resident #1] and [RP]. [RP] has requested him to be sent to [local hospital] for further evaluation. [Transport service] gave ETA 1030 Record review of Resident #1's hospital records, dated 08/27/24, reflected the following: Chief complaint: [Resident #1] presents with AMS, hallucinations, baseline GCS (neurological scale) 15 but presenting with hallucinations over the past 48-72 hours. Being seen at [nursing facility] for wound care. . Laboratory Results: CBC with differential -WBC- 27.O6; reference range (4.00-11.00) Comprehensive Metabolic Panel -Glucose-101; reference range (70-100) -Potassium-2.7; reference range (3.5-5.0) . Final Diagnoses: severe sepsis, leukocytosis (high white blood cell count), hypokalemia (low potassium). Record review of Resident #1's orders on 08/30/24, reflected the following: -Cleanse wound with 1/4 strength Dakins (topical antiseptic). Apply skin prep to peri-wound. Windowpane around open wound with vac. Drape. Place foam in open wound and cover with vac. Drape. Cut small suction hole in drape and apple suction tubing. Attach tubing to clean canister tubing and turn machine on. Assure good suction. If unable to obtain seal, apply wet to dry dressing and change daily until vac can be reestablished. Wet to dry dressing daily and prn. Directions: one time a day every Tuesday, Thursday, and Saturday for wound care. Start Date: 07/13/24. End Date: 08/28/24 In an interview on 08/29/24 at 08:30AM, RN X, who worked at the local hospital, stated Resident #1 was admitted to the hospital on 08/27/24 for altered mental status and was diagnosed with severe sepsis likely due to a wound infection and UTI. RN X stated there were concerns that Resident #1's wounds were not being properly treated at the nursing facility and he was malnourished. RN X did not provide any further information. In an observation and interview on 08/29/24 at 08:45 AM, Resident #1 was lying in bed with a catheter and IV abx in place. Resident #1 was responsive but was unable to speak much due to physical and mental state. Resident #1 stated he felt better. He denied being neglected at the nursing facility; however, he stated there were good and bad staff there. Resident #1 stated he was provided all meals and treatments to his knowledge. Resident #1 stated he often refused the meals because he did not like the texture. Interview with Resident #1's RP, who was sitting bedside at the hospital, revealed she did not initially have concerns for abuse/neglect of Resident #1 during his stay at the nursing facility however, when she visited the resident at the nursing facility on 08/25/24 he was hallucinating and not acting like himself . RP stated Resident #1 stated he needed a forklift for work and stated there was a man standing in his room, and that is when she knew something was wrong. RP stated this was reported to staff whom she could not recall. RP stated Resident #1 was receiving wound care as ordered to her knowledge however, there had been an occasion where the wound vacuum had to be replaced due to not working properly. RP stated Resident #1 was very thin when he admitted to the nursing facility because he would be afraid to eat due to having a history of constipation, which started while at home. RP stated Resident #1 would be going back home with her once discharged from the hospital as he had been issued a notice that his insurance would no longer cover his stay at the nursing facility. In an interview on 08/29/24 at 12:57 PM, the DON stated Resident #1 admitted to the facility with infected wounds and had to be placed on IV abx and isolation immediately. The DON stated Resident #1 had only been admitted to the nursing facility for almost 2 months before receiving a notice of Medicare non-coverage and was due to discharge home with significant other. The DON stated Resident #1 was discharged to the local hospital on 08/27/24 instead due to AMS and smells coming from his wounds, and she did not feel it would be a safe discharge for him to go home. The DON stated it was first reported to her by RN C on 08/26/24 that Resident #1 had an AMS. The DON stated the MD was also notified by RN C and STAT orders for lab work was initiated. The DON stated Resident #1 was not ordered to be sent out to the hospital on 08/26/24. In an interview on 08/29/24 at 12:57 PM, LVN A, who was a wound care nurse, stated she worked at the nursing facility since 01/01/24. LVN A stated Resident #1 was very tiny and had 1-3 wounds in his sacrum (base of spine) area that would heal and reopen depending on how the resident was positioned. She stated Resident #1 received wound care three times weekly . LVN A stated Resident #1 had a wound vacuum to assist with healing. She stated there was one time the wound vacuum stopped working during treatment and she was able to order a new one that was delivered the same day. LVN A stated there was an order in place to do wet-to-dry care in case the wound vacuum ever stopped working, so there was never a break in care. LVN A stated Resident #1's wounds covered a large surface area and had pockets that did not allow for complete visualization. LVN A stated Resident #1 admitted with spores and bacteria that caused him to need IV abx and to be placed on isolation. LVN A denied ever smelling Resident #1's wound; however, she stated there were times when the sponge from the wound vacuum would smell. LVN A stated she went to do wound care on Resident #1 on 08/27/24 and he did not look good to her, so she went to report it to the nurse and the resident was sent out to the hospital. LVN A stated she did not get to complete wound care and only disconnected the wound vacuum for EMS to be able to transport Resident #1 to the hospital without taking the facility's equipment. In an interview on 08/29/24 at 02:04 PM, RN D stated she worked for 2.5 years at the facility. RN D stated she worked with Resident #1 on 08/26/24, 2pm-10pm. RN D stated the off-going nurse, RN C, reported Resident #1 was hallucinating and had a smelly wound, and the MD had already been notified and labs had been ordered. RN D stated Resident #1 did not complain about anything, slept most of her shift, and did not eat well which was not unusual. RN D stated she did not notice that Resident #1 had an AMS during that shift. RN D stated she returned to work on the morning of 08/27/24. RN D stated Resident #1's labs had come back by that time, and she reviewed them and sent them to the NP for MD. RN D stated the NP gave orders to start fluids and abx; however, just before she could get anything started, the facility made the decision to send Resident #1 out to the hospital. RN D stated when she went to check on Resident #1, he seemed off and was even yelling out for the nurse which was unusual because the resident never raised his voice. RN D stated when she helped reposition Resident #1, she could also smell his wound. In an interview on 08/29/24 at 02:25 PM, CNA E states she worked a double shift on 08/24/24 (Saturday) and worked with Resident #1. CNA E stated she assisted Resident #1 with breakfast, and he was talking to himself and stated he could see a little boy in his room that was about to fall. CNA E stated Resident #1 refused to raise his head to eat. CNA E stated by lunch time, Resident #1's hallucinations were worse, and she reported it to LVN B. CNA E stated she did not work with Resident #1 towards the end of her shift and did not know how he was for the remainder of the day or if LVN B followed up on her concerns. In an interview on 08/29/24 at 03:16 PM, LVN B stated she worked at the facility for 3 years. She stated she worked double shifts (6a-10p) on 08/24/24 and 08/25/24. LVN B stated Resident #1 was fine on 08/24/24 and she denied that CNA E or any other staff reported to her that Resident #1 was hallucinating or had a change in condition. LVN B stated she returned to the facility on [DATE] and Resident #1 was able to carry a normal conversation with her that morning and seemed fine. LVN B stated Resident #1 did not exhibit any hallucinations. LVN B stated by 7:30/8 PM she did rounds and closed Resident #1's blinds and he still seemed fine to her. LVN B stated CNA F and another aide reported to her around that time that Resident #1 had been hallucinating and seeing things. LVN B states she went back to Resident #1's room to provide care and to assess him, and Resident #1 did not say anything. LVN B denied initiating a conversation to see if the resident was hallucinating. LVN B stated she did not know how to assess for hallucinating because she could not directly ask Resident #1 if he was hallucinating. LVN B stated she did not report the aides concerns to the MD or DON and could not recall if she mentioned it to the oncoming nurse. LVN B stated any change in condition should be reported to the MD and reported at shift change. In an interview on 08/30/24 at 09:30 AM, RN C stated she worked at the facility for almost a month. She stated she worked overnight (10p-6a) on rotating shifts. RN C stated she worked overnight with Resident #1 on 08/25/24 leading into 08/26/24. RN C stated she did not recall LVN B reporting any significant information regarding Resident #1. RN C stated Resident #1's baseline was never normal anyway due to the resident admitting to the facility with multi-resistant organisms. RN C stated Resident #1 had to be on heavy abx via IV. RN C stated Resident #1 was always sensitive about lights and noises in his room. RN C stated early morning on 08/26/24 at around 3:30 AM, there was a significant change in Resident #1's condition. RN C stated during her rounds, Resident #1 got sick to his stomach, sweaty, and was stating that there was a man in the window. RN C stated she tried to reorient Resident #1 and comforted him. RN C stated she checked Resident #1's vitals and they were normal and there was no fever, which she thought was strange with the sweating. RN C stated she notified the MD right away thinking Resident #1 might have a UTI or was growing other bacteria as he had been off IV abx for about a week. RN C stated there was also a smell on Resident #1, but she was not sure if it was coming from his wounds or the wound vacuum. RN C stated the MD ordered labs and a consult with wound nurse. In a further interview on 08/30/24 at 10:04 AM, the DON stated it was the expectation for the nurses to report any change in condition, even if it was only reported by an aide and they did not observe it themselves, at least to the oncoming nurse for continued monitoring. The DON stated the risk of not reporting changes of condition could be not providing a resident appropriate care in a timely manner. In an interview on 08/30/24 at 10:26 AM, CNA F stated she worked with Resident #1 on 08/25/24 (6a-10p). CNA F stated Resident #1's RP was visiting with him on this day. CNA F stated she assisted Resident#1 with breakfast, and he was hallucinating, and this continued throughout her shift. CNA F stated she reported it to LVN B. In an interview on 09/03/24 at 12:15 PM, the MD stated Resident #1 had recently completed a round of abx; however, it did not mean the infection was completely gone. The MD stated Resident #1 was also under the care of the infectious disease team who were monitoring his wounds and infection. The MD stated she was notified around 5:00 AM on 08/26/24 that Resident #1 was having a change of condition that included hallucinating. The MD stated she gave an order for STAT labs. The MD stated hallucinating could have been indicative of worsening of wound or an infection. The MD stated the expectation was for the nurse to notify her as soon as the hallucinations were observed on 08/25/24 to prevent a delay in care; however, she stated her orders would have been the same. The MD stated she would not have sent Resident #1 immediately out to the hospital before collecting labs because it may have been an issue that could have been treated at the nursing facility. The MD stated it was not uncommon for residents to hallucinate with having something like a UTI and the hospitals sometimes prefer for the nursing facilities to manage such things in-house. The MD stated the risk of not immediately reporting the change of condition could be missing an infection that was too bad for the nursing facility to manage. Review of the facility's policy titled Change of Condition and Physician/Family Notification, revised 08/11/2020, revealed in part the following: Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: -An accident resulting in injury that has the potential for needed physician intervention. -A significant change in the resident's physical, mental, or psychosocial status. -A need to significantly alter treatment. -Transfer of the resident from the facility. Procedure: When the above situations exist, the licensed nurse will contact the resident's family and their physician. . An Immediate Jeopardy (IJ) was identified on 09/03/24 at 04:45 PM. The NFA was notified of an Immediate Jeopardy (IJ) on 09/03/24 at 5:45 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/04/24 at 1:00 PM and included: [Nursing Facility] September 3, 2024 POR - Change of Condition F580 On August 25, 2024, [Resident #1] nurse was notified about a change in resident mental status. The nurse did not document her assessment or report her findings to the physician. Immediately on September 3, 2024, CCS in-serviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Ln-service covered when to notify the Physician/NP for a change of condition, discussed what categories fall under change of condition, the process for notification of Physician/NP, escalation of the communication process if the Physician/NP cannot be reached, and examples of significant changes. Competency was verified via quiz. On September 3, 2024, Administrator and DON initiated in-services with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. services covered when to notify the Physician/NP for a change of condition, discussed what categories fall under change of condition, the process for notification of Physician/NP, escalation of the communication process if the Physician/NP cannot be reached, and examples of significant changes. Competency was verified via quiz. Nursing staff will not be allowed to work until In-servicing has been completed on September 4, 2024. On September 3, 2024, an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on September 3, 2024. In order to monitor current residents for potential risk, DON and CCS will monitor residents for change of condition beginning September 3, 2024, for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. On 09/04/24 the investigator began monitoring (1:12 PM-3:30 PM) if the facility implemented their plan of removal sufficiently to remove the IJ by: Observations, interviews, and records reviews of Residents #2, #3, #4, #5, #6, #7, and #8 revealed no furthers concerns for changes in physical, mental, or psychosocial status that required the physician or family to be notified of. Observations and record reviews revealed any wounds and other care needs were being monitored and treated according to physician orders. Interview with residents and/or RPs revealed no concerns for abuse/neglect or deficit in quality of care. Record review of an in-service conducted by the CCS dated 09/03/24 with the NFA and DON. Objectives of the in-service included the Change of Condition, Comprehensive Assessments and Notifications to the physician and RP. The CCS reviewed related policies and the NFA and DON completed pre-/post-tests with a passing score. Record review of a 24-hour report audit conducted by the CCS dated 09/03/24 at 10:59 PM revealed the CCS attest that she audited the last 30 days of 24-hour reports for resident changes in condition and to ensure the Physician/NP had been notified in a timely manner. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN D, LVN J, CNA I and CNA K], on the 2P - 10P shift [LVN H, CNA G, LVN L, CNA N, LVN Q and RN C (recently transitioned from 10P - 6A shift)], and 10P - 6A shift [LVN O, LVN M and CNA P] indicated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, documentation, and following up on lab results. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition and lab results. Each nurse demonstrated how to perform an abdominal assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of constipation, what must be reported to the charge nurse, and where to document a resident's bowel movement in the chart. Record review of in-services conducted by the DON dated 09/03/24 titled Change in Condition [with all nursing staff], POC Documentation [with CNAs], Bowel Assessment [with Nurses], Lab Services [with Nurses and Nursing Administration] and Physician Notification [with Nurses and Nursing Administration] were on-going to achieve 100% nursing dept participation. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to identify and provide needed care or services that resulted in an actual or potential decline in one or more resident's physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for quality of care. The facility failed to identify, monitor, assess, evaluate, and document Resident #1's changes in the bowel regimen. The facility failed to provide Resident #1 as needed (PRN) medication for constipation. The facility failed to evaluate Resident #1's bowel sounds as indicated and report significant abnormalities to the provider per the care plan intervention initiated, 07/12/2024. The facility failed to notify the provider of Resident #1's last known bowel movement on 08/08/24. The facility failed to notify the provider about Resident #1's STAT lab results received on 08/26/24 at 3:21 PM . On 08/27/24, Resident #1 was admitted to the hospital for altered mental status (AMS). Resident #1 was admitted , diagnosed , and treated for severe sepsis, chronic constipation, and fecal impaction. The facility failed to recognize Resident #1 was having a significant change of condition when he was yelling, hallucinating, and having and elevated heart rate. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices placed residents at high risk of, or the likelihood of, serious injury or harm by not receiving treatment, developing complications, and the development of sepsis. Findings included: Record review of Resident #1's Admission MDS assessment dated , 07/11/24, revealed a 78-years-old male, who admitted to the facility on [DATE] with medically complex conditions including, Paraplegia (paralysis of the legs and lower body), Osteomyelitis (a bone infection that can occur when bacteria or fungi spread to the bone), and Polyneuropathy (malfunction of many peripheral nerves throughout the body). The admission MDS assessment revealed a BIMS score of 13 which suggested Resident #1 was cognitively intact. Resident #1 was always incontinent of bowel and bladder. The Admission MDS assessment reflected Resident #1 did not have constipation. Resident #1's Order Summary Report, dated 08/31/24, reflected: Order date 07/04/24: Duloxetine HCl (An antidepressant medication used to treat neuropathy [nerve pain]. Constipation is a common side effect) Oral Capsule Delayed Release Particles 60 mg. Give 1 capsule by mouth one time a day for chronic muscle or bone pain. Order date 07/04/24: MiraLax (medication used to treat occasional constipation) Oral Powder 17 gm/scoop. Give 1 scoop by mouth every 24 hours as needed for laxative. Order date 07/23/24: Tramadol HCl (medication used to treat moderate to severe pain cause the digestive system to slow down its normal function that can make it hard for stool to pass, leading to constipation) Oral Tablet 50 mg. Give 1 tablet by mouth every 8 hours for pain. Review of Resident #1's comprehensive care plan initiated on 07/12/24 indicated: [Resident #1] at risk for side effects of anti-depressant medication. (Initiated 07/12/24). Interventions included monitor for side effects of anti-depressants: . constipation. (Initiated 07/12/24). The goal reflected [Resident #1] will not have any side effects of anti-depressants through the review period. (Initiated: 07/12/24; Revision: 07/24/24; Target: 10/22/24). [Resident #1] at risk related to alteration in bowel elimination constipation. (Initiated 07/12/24). Interventions included evaluate bowel sounds as indicated and report significant abnormalities to provider. (Initiated 07/12/24). The goal reflected [Resident #1] will have decreased episodes of constipation through next review period. (Initiated: 07/12/24; Revision: 07/24/24; Target: 10/22/24). [Resident #1] is on pain medication therapy Tramadol . (Initiated 07/12/24). Interventions included monitor/document/report PRN adverse reactions to analgesic therapy: altered mental status . constipation . nausea, vomiting . (Initiated 07/12/24). The goal reflected [Resident #1] will be free of any discomfort or adverse side effects from pain medication through next review period. (Initiated: 07/12/24; Revision: 07/24/24; Target: 10/22/24). Review of Resident #1's August 2024 MAR reflected Duloxetine 60 mg Delayed Release Particles capsule was administered daily as ordered on 08/01/24 - 08/27/2024. Tramadol 50 mg, 1 tablet, was administered daily, three times a day, every 8 hours as ordered on 08/01/24 - 08/27/2024 at 6:00 AM. The August 2024 MAR did not reflect MiraLax was ever administered PRN as ordered for constipation. Review of a 30-day look back at Resident #1's August 2024 ADL documentation/flow sheets for Bowel Movement reflected: On 08/05/24: 11:27 PM Incontinent, Formed/Normal, Small, Barrier cream applied. 08/06/24: 1:41 PM No Bowel Movement 8:30 PM No Bowel Movement 08/07/24: 12:41 AM Incontinent, Formed/Normal, Small, Barrier cream applied. 9:59 PM No Bowel Movement 11:09 PM Continent, Loose/Diarrhea, Small, Barrier cream applied. 08/08/24: 1:59 PM No Bowel Movement Review of Resident #1's August 2024 progress notes did not reflect PRN medication administered for constipation and its effectiveness, interventions provided for constipation relief, or that the provider and RP were notified. Review of Resident #1's August 2024 assessments did not reflect RN C completed an abdominal assessment of the resident after he vomited brown emesis to assess for signs of constipation. Review of Resident #1's STAT lab results, dated 08/26/24, revealed in part the following: Collected date: 08/26/24 at 12:30 PM Resulted date: 08/26/24 at 03:48 PM Test results: WBC-10.6 (range reference 3.6-10.2) RBC- 3.94 (range reference 4.06-5.63) Hemoglobin- 11.7 (range reference 12.5-16.3) Hematocrit- 35.7 (range reference 36.7-47.2) . A review of Resident #1's hospital medical records dated 08/29/24 reflected [Resident #1] arrived at the ED on 08/27/24 at 11:56 AM. The reason for visit reflected Altered Mental Status (AMS) . hallucinations over the past 48-72 hours. The visit diagnoses included Severe Sepsis and Chronic constipation. The ED provider notes indicated Resident #1 appeared in acute distress, was ill-appearing, symptoms were moderately severe, and Resident #1 reported vomiting. Review of Resident #1's CT scan of Abdomen and Pelvis with Contrast final result, dated 08/27/24 at 2:24 PM, revealed an extremely large rectal stool ball with very large obstructing colonic stool burden. Findings are concerning for impaction. During an interview on 08/29/24 at 12:57 PM, the DON stated Resident #1 admitted to the facility with infected wounds and had to be placed on IV abx and isolation immediately. The DON stated Resident #1 had only been admitted to the nursing facility for almost 2 months before receiving a notice of Medicare non-coverage and was due to discharge home with significant other. The DON stated Resident #1 was discharged to the local hospital on 08/27/24 instead due to AMS and smells coming from his wounds, and she did not feel it would be a safe discharge for him to go home. The DON stated it was first reported to her by RN C on 08/26/24 that Resident #1 had an AMS. The DON stated the MD was also notified by RN C and STAT orders for lab work was initiated. The DON stated Resident #1 was not ordered to be sent out to the hospital on 08/26/24. During an interview on 08/29/24 at 02:25 PM, CNA E states she worked a double shift on 08/24/24 (Saturday) and worked with Resident #1. CNA E stated she assisted Resident #1 with breakfast, and he was talking to himself and stated he could see a little boy in his room that was about to fall. CNA E stated Resident #1 refused to raise his head to eat. CNA E stated by lunch time, Resident #1's hallucinations were worse, and she reported it to LVN B. CNA E stated she did not work with Resident #1 towards the end of her shift and did not know how he was for the remainder of the day or if LVN B followed up on her concerns. During an interview on 08/29/24 at 03:16 PM, LVN B stated she worked at the facility for 3 years. She stated she worked double shifts (6a-10p) on 08/24/24 and 08/25/24. LVN B stated Resident #1 was fine on 08/24/24 and she denied that CNA E or any other staff reported to her that Resident #1 was hallucinating or had a change in condition. LVN B stated she returned to the facility on [DATE] and Resident #1 was able to carry a normal conversation with her that morning and seemed fine. LVN B stated Resident #1 did not exhibit any hallucinations. LVN B stated by 7:30/8 PM she did rounds, and closed Resident #1's blinds and he still seemed fine to her. LVN B stated CNA F and another aide reported to her around that time that Resident #1 had been hallucinating and seeing things. LVN B states she went back to Resident #1's room to provide care and to assess him, and Resident #1 did not say anything. LVN B denied initiating a conversation to see if the resident was hallucinating. LVN B stated she did not know how to assess for hallucinating because she could not directly ask Resident #1 if he was hallucinating. LVN B stated she did not report the aides concerns to the MD or DON and could not recall if she mentioned it to the oncoming nurse. LVN B stated any change in condition should be reported to the MD and reported at shift change. During a further interview on 08/30/24 at 10:04 AM, the DON stated it was the expectation for the nurses to report any change in condition, even if it was only reported by an aide and they did not observe it themselves, at least to the oncoming nurse for continued monitoring. The DON stated the risk of not reporting changes of condition could be not providing a resident appropriate care in a timely manner. During an interview on 08/30/24 at 10:26 AM, CNA F stated she worked with Resident #1 on 08/25/24 (6a-10p). CNA F stated Resident #1's RP was visiting with him on this day. CNA F stated she assisted Resident#1 with breakfast, and he was hallucinating, and this continued throughout her shift. CNA F stated she reported it to LVN B. During an interview on 08/31/24 at 2:25 PM, CNA E stated that she provided direct care to Resident #1. CNA E said that she worked with Resident #1 last Saturday (08/24/24) and he was confused and talking to himself. CNA E said that Resident #1 refused breakfast because he wanted to wait for his [RP] to come feed him. CNA E said that Resident #1 took a couple bites of the food and finished his drink. CNA E said that it was her responsibility to document whenever a resident had a bowel movement. CNA E said that she could not remember if Resident #1 had a bowel movement that day or explain why it was not reflected in her documentation. During an interview on 09/02/24 at 2:32 PM, RN C indicated that she worked 08/25/24 and 08/26/24, 10P - 6A shift and was the primary nurse for Resident #1. RN C said during the 08/25/24 10P - 6A shift, Resident #1 yelled and screamed. RN C said that [Resident #1] had blood-tinged urine in his indwelling catheter, did not have a temperature, heart rate was over 100 beats per minute, but was consoled and reoriented. RN C said Resident #1 continued to shout towards the end of her shift. RN C said that she gave Resident #1 a sponge bath and thought she smelled a foul smell from the wound vac (to Resident #1 sacrum). RN C then said that she noticed a stool blob at [Resident #1] anus when she wiped, like [Resident #1] did not have a complete bowel movement and some stool was still trapped. RN C said that when she called the doctor to get an order for an UA (08/26/24 at 5:00 AM), she did not mention the incomplete bowel movement because she did not think it was an issue. RN C said that Resident #1 vomited a brown emesis (can be caused by internal bleeding in the stomach, severe constipation, or inflammation of the stomach lining) overnight on the 08/26/24, 10P - 6A shift. RN C said that she did not report Resident #1 threw up because it looked like a cupcake and she [RN R] did not believe it was a gastric bleed. RN C said that she did not know the last time Resident #1 had a bowel movement but remembered the CNA (unknown name and unable to describe) told her [RN R] that Resident #1 had a bowel movement during a shift but could not remember because the days blended. RN C said that the doctor also ordered STAT labs with the UA order. RN C said that the facility would get the STAT lab results on the same day or early the next day based on the time of day the lab was collected. RN C said that the lab results were available on 08/26/24 during the 2P - 10P shift. RN C said that the lab results could inform the doctor if the resident had an infection, diagnose diseases, or identify other issues, like a gastric bleed. RN C said she did not review the lab results or check if the doctor was notified when Resident #1 threw up brown emesis or if his confusion was related to an infection. During an interview on 09/02/24 at 2:47 PM, the ADON stated she was familiar with Resident #1. The ADON stated she was not informed of Resident #1 did not have a bowel movement or unrelieved constipation. The ADON said the CNAs should notify the charge nurse when or if a resident did not have a bowel movement during the shift. The ADON said she expected nurses to perform an abdominal assessment (listen to bowel sounds, feel the abdomen for tenderness or if firm), assess for signs of constipation, implement care plan interventions, notify clinical department heads (ADON/DON) of resident change in condition, notify the provider, and the RP. The ADON said that the risk if constipation was not treated could be hemorrhoids or a serious complication such as fecal impaction if hard stool backed up into the colon. During an interview on 09/02/24 at 3:22 PM, the DON said that she had in-serviced staff last month that anything that was different and out of the ordinary for a resident was a change in condition. The DON said that she expected nurses to monitor the resident's bowel movements for change in frequency and consistency. The DON said that the nurse should perform an initial assessment if a resident did not have a bowel movement for 2 - 3 days, decreased appetite, nausea, vomiting, and/or pain. The DON said an initial assessment for constipation would include an abdominal assessment that included visual inspection for the shape, abdominal distention, feel for firmness, localized tenderness, and listen with a stethoscope for slowed or absent bowel sounds that could suggest constipation. The DON said that the nurse should check the administration record for PRN medications/treatments, implement nurse interventions per the care plan, notify the provider with their assessment findings, the resident response to interventions, and notify the family. The DON said that Task(s) and nurse progress notes would be review every morning for documentation of bowel movements frequencies and interventions as needed. During an interview on 09/03/24 at 12:15 PM, the MD said that she gave orders to collect STAT blood labs on Monday morning (08/26/24) when she was notified that Resident #1 was hallucinating. The MD did not recall being told that Resident #1's wound had a foul smell, that he vomited, or that he was constipated related to not having or an incomplete bowel movement. The MD said that constipation could lead to several complications that included acute confusion, nausea, poor appetite, rapid heart rate, and fecal impaction. The MD said that she expected to be notified as soon as possible about any change in condition. The MD said she was not notified when the STAT lab results were received. The MD said that the NP was called first and coordinated Resident #1's care with the facility staff. Record review of the facility's Bowel (Lower Gastrointestinal [GI] Tract) Disorders - Clinical Protocol, revised September 2017, reflected assessment and recognition, cause identification, treatment, management, monitoring and follow-up of bowel dysfunction. The nurse shall assess and document/report alteration in bowel movements; quantitative and qualitative description of bowel movements; presence of fecal impaction; abdominal assessment; onset, duration, frequency, and severity of signs and symptoms. Record review of the facility's Change of Condition and Physician/Family Notification policy, reviewed 05/17/24, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility A review of the Lab and Diagnostic Test Results - Clinical Protocol reviewed December 2022, indicated: - The physician will identify and order diagnostic and lab testing; staff will process test requisition and arrange for test; the laboratory, diagnostic provider will report results to facility - A nurse will review all results and report the finds to the physician/designee - A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) - A physician will respond within an appropriate time frame, based on the request from the nursing staff and the clinical significance of the information. This response maybe by calling the facility or writing new orders. The NFA was notified of an Immediate Jeopardy (IJ) on 09/03/24 at 5:45 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/04/24 at 1:00 PM and included: On August 26, 2024 orders were received for STAT labs. The results were received by the facility in the early evening of August 26, 2024. The facility nurse inadvertently overlooked the lab results and did not notify the MD until August 27, 2024. Immediately on September 3, 2024, CCS inserviced DON on the prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. On September 3, 2024, DON/designee initiated inservices with the licensed nurses on prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 4, 2024. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 4, 2024. On September 3, 2024, DON/designee initiated inservices with the CNAs/MA s on proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 4, 2024. On September 3, 2024, an audit of the 24-hour report and laboratory findings was conducted by DON/Designee to ensure Physician/NP has been notified timely. On September 3, 2024, an audit of BM documentation was completed by DON/designee. Medical Director was notified on September 3, 2024. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition and physician/np notification beginning September 3, 2024, for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition and to ensure timely notification of Physician/NP. DON compliance will be monitored weekly by CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of physician notification. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. On 09/04/24 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an in-service conducted by the CCS dated 09/03/24 with the NFA and DON. Objectives of the in-service included the Change of Condition, Comprehensive Assessments and Notifications to the physician and RP. The CCS reviewed related policies and the NFA and DON completed pre-/post-tests with a passing score. Record review of a 24-hour report audit conducted by the CCS dated 09/03/24 at 10:59 PM revealed the CCS attest that she audited the last 30 days of 24 hour reports for resident changes in condition and to ensure the Physician/NP had been notified in a timely manner. During an interview and record review on 07/01/24 at 2:49 PM, the DON indicated that she conducted surveillance rounds to visualize each resident's (six residents) urinary catheter site for s/s of infection and patency. The DON indicated that she performed a chart audit on each of the six residents with a urinary catheter to assure appropriate monitoring and treatment orders were in place. Record review of order summaries for the six residents revealed treatment orders were entered and TAR reflected orders were performed. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN D, LVN J, CNA I and CNA K], on the 2P - 10P shift [LVN H, CNA G, LVN L, CNA N, LVN Q and RN C (recently transitioned from 10P - 6A shift)], and 10P - 6A shift [LVN O, LVN M and CNA P] indicated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, documentation, and following up on lab results. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition and lab results. Each nurse demonstrated how to perform an abdominal assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of constipation, what must be reported to the charge nurse, and where to document a resident's bowel movement in the chart. Record review of in-services conducted by the DON dated 09/03/24 titled Change in Condition [with all nursing staff], POC Documentation [with CNAs], Bowel Assessment [with Nurses], Lab Services [with Nurses and Nursing Administration] and Physician Notification [with Nurses and Nursing Administration] were on-going to achieve 100% nursing dept participation. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #1) of four residents reviewed for laboratory services. The facility failed to notify the provider about Resident #1's STAT lab results received on 08/26/24 at 3:21 PM. On 08/27/24, Resident #1 was admitted to the hospital for altered mental status (AMS). Resident #1 was admitted , diagnosed , and treated for severe sepsis, chronic constipation, and fecal impaction. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices placed residents at high risk of, or the likelihood of, serious injury or harm by not receiving treatment, developing complications, and the development of sepsis. Findings included: Record review of Resident #1's Admission MDS assessment dated , 07/11/24, revealed a 78-years-old male, who admitted to the facility on [DATE] with medically complex conditions including, Paraplegia (paralysis of the legs and lower body), Osteomyelitis (a bone infection that can occur when bacteria or fungi spread to the bone), and Polyneuropathy (malfunction of many peripheral nerves throughout the body). The admission MDS assessment revealed a BIMS score of 13 which suggested Resident #1 was cognitively intact. Resident #1 was always incontinent of bowel and bladder. The Admission MDS assessment reflected Resident #1 did not have constipation. Record review of Resident #1's Order Summary Report, dated 08/31/24, reflected: Order date 07/04/24: Duloxetine HCl (An antidepressant medication used to treat neuropathy [nerve pain]. Constipation is a common side effect) Oral Capsule Delayed Release Particles 60 mg. Give 1 capsule by mouth one time a day for chronic muscle or bone pain. Order date 07/04/24: MiraLax (medication used to treat occasional constipation) Oral Powder 17 gm/scoop. Give 1 scoop by mouth every 24 hours as needed for laxative. Order date 07/23/24: Tramadol HCl (medication used to treat moderate to severe pain cause the digestive system to slow down its normal function that can make it hard for stool to pass, leading to constipation) Oral Tablet 50 mg. Give 1 tablet by mouth every 8 hours for pain. Record review of Resident #1's comprehensive care plan initiated on 07/12/24 indicated: [Resident #1] at risk for side effects of anti-depressant medication. (Initiated 07/12/24). Interventions included monitor for side effects of anti-depressants: . constipation. (Initiated 07/12/24). The goal reflected [Resident #1] will not have any side effects of anti-depressants through the review period. (Initiated: 07/12/24; Revision: 07/24/24; Target: 10/22/24). [Resident #1] at risk related to alteration in bowel elimination constipation. (Initiated 07/12/24). Interventions included evaluate bowel sounds as indicated and report significant abnormalities to provider. (Initiated 07/12/24). The goal reflected [Resident #1] will have decreased episodes of constipation through next review period. (Initiated: 07/12/24; Revision: 07/24/24; Target: 10/22/24). [Resident #1] is on pain medication therapy Tramadol . (Initiated 07/12/24). Interventions included monitor/document/report PRN adverse reactions to analgesic therapy: altered mental status . constipation . nausea, vomiting . (Initiated 07/12/24). The goal reflected [Resident #1] will be free of any discomfort or adverse side effects from pain medication through next review period. (Initiated: 07/12/24; Revision: 07/24/24; Target: 10/22/24). [Resident #1] at risk for hospitalization r/t sepsis. (Initiated 07/12/24). Interventions included administer medications as ordered, observe for changes in level of consciousness, mental status, or orientation and report significant changes to provider as indicated . Record review of Resident #1's August 2024 MAR reflected Duloxetine 60 mg Delayed Release Particles capsule was administered daily as ordered on 08/01/24 - 08/27/2024. Tramadol 50 mg, 1 tablet, was administered daily, three times a day, every 8 hours as ordered on 08/01/24 - 08/27/2024 at 6:00 AM. The August 2024 MAR did not reflect MiraLax was ever administered PRN as ordered for constipation. Record review of a 30-day look back at Resident #1's August 2024 ADL documentation/flow sheets for Bowel Movement reflected: On 08/05/24: 11:27 PM Incontinent, Formed/Normal, Small, Barrier cream applied. 08/06/24: 1:41 PM No Bowel Movement 8:30 PM No Bowel Movement 08/07/24: 12:41 AM Incontinent, Formed/Normal, Small, Barrier cream applied. 9:59 PM No Bowel Movement 11:09 PM Continent, Loose/Diarrhea, Small, Barrier cream applied. 08/08/24: 1:59 PM No Bowel Movement Record review of Resident #1's August 2024 progress notes did not reflect PRN medication administered for constipation and its effectiveness, interventions provided for constipation relief, or that the provider and RP were notified. Record review of Resident #1's STAT lab results, dated 08/26/24, revealed in part the following: Collected date: 08/26/24 at 12:30 PM Resulted date: 08/26/24 at 03:48 PM Test results: WBC-10.6 (range reference 3.6-10.2) RBC- 3.94 (range reference 4.06-5.63) Hemoglobin- 11.7 (range reference 12.5-16.3) Hematocrit- 35.7 (range reference 36.7-47.2) . Record review of Resident #1's progress notes, dated 08/26/24 at 03:36 AM by RN C, reflected the following: [Resident #1] yelling and screaming, stating he is not in bed and he [sic] going to fall. I need a forklift right now. I am tired of that man being [sic] my room, he is right there behind my bed. [Resident #1] is diaphoretic (sweating heavily), noted ring [sic] tinged urine in Foley. He is afebrile (without fever) at this time 98.9, resp 18, heart rate 102, blood glucose 126mg/dl. SPO2 97% on room air. Spent at bedside to console and reorient [Resident #1]. Care and monitoring ongoing. Record review of Resident #1's progress notes, dated 08/26/24 at 05:01 AM by RN C, reflected the following: [Resident #1] cont to shout out for help. Help me get this forklift. Also rambling speech unable to make sense of. Gave sponge bath and noted noted [sic] sacral wound foul smelling, ordered and sent UA specimen to lab. Cont to console and reassure [Resident #1] Record review of Resident #1's progress notes, dated 08/27/24 at 10:00 AM by RN D, reflected the following: [Resident #1] hallucinating. HR 105, BP WNL, [Resident #1] c/o of nausea and dry heaving. Wound has foul smell. STAT CBC, CMP and UA sent to NP, Received order for NS @ 75 ml/hr and IM rocephin. [Resident #1] is preparing for discharge today. Discussed worsening condition with [DON] and [social services] and [NP]. [DON] and [social services] discussed with [Resident #1] and [RP]. [RP] has requested him to be sent to [local hospital] for further evaluation. [Transport service] gave ETA 1030 Record review of Resident #1's hospital medical records dated 08/29/24 reflected [Resident #1] arrived at the ED on 08/27/24 at 11:56 AM. The reason for visit reflected Altered Mental Status (AMS) . hallucinations over the past 48-72 hours. The visit diagnoses included Severe Sepsis and Chronic constipation. The ED provider notes indicated Resident #1 appeared in acute distress, was ill-appearing, symptoms were moderately severe, and Resident #1 reported vomiting. Record review of Resident #1's CT scan of Abdomen and Pelvis with Contrast final result, dated 08/27/24 at 2:24 PM, revealed an extremely large rectal stool ball with very large obstructing colonic stool burden. Findings are concerning for impaction. In an interview on 08/29/24 at 12:57 PM, the DON stated Resident #1 admitted to the facility with infected wounds and had to be placed on IV abx and isolation immediately. The DON stated Resident #1 had only been admitted to the nursing facility for almost 2 months before receiving a notice of Medicare non-coverage and was due to discharge home with significant other. The DON stated Resident #1 was discharged to the local hospital on 08/27/24 instead due to AMS and smells coming from his wounds, and she did not feel it would be a safe discharge for him to go home. The DON stated it was first reported to her by RN C on 08/26/24 that Resident #1 had an AMS. The DON stated the MD was also notified by RN C and STAT orders for lab work was initiated. The DON stated Resident #1 was not ordered to be sent out to the hospital on 08/26/24. During an interview on 08/31/24 at 2:25 PM, CNA E stated that she provided direct care to Resident #1. CNA E said that she worked with Resident #1 last Saturday (08/24/24) and he was confused and talking to himself. CNA E said that Resident #1 refused breakfast because he wanted to wait for his [RP] to come feed him. CNA E said that Resident #1 took a couple bites of the food and finished his drink. CNA E said that it was her responsibility to document whenever a resident had a bowel movement. CNA E said that she could not remember if Resident #1 had a bowel movement that day or explain why it was not reflected in her documentation. During an interview on 09/02/24 at 2:32 PM, RN C indicated that she worked 08/25/24 and 08/26/24, 10P - 6A shift and was the primary nurse for Resident #1. RN C said during the 08/25/24 10P - 6A shift, Resident #1 yelled and screamed. RN C said that [Resident #1] had blood-tinged urine in his indwelling catheter, did not have a temperature, heart rate was over 100 beats per minute, but was consoled and reoriented. RN C said Resident #1 continued to shout towards the end of her shift. RN C said that she gave Resident #1 a sponge bath and thought she smelled a foul smell from the wound vac (to Resident #1 sacrum). RN C then said that she noticed a stool blob at [Resident #1] anus when she wiped, like [Resident #1] did not have a complete bowel movement and some stool was still trapped. RN C said that when she called the doctor to get an order for an UA (08/26/24 at 5:00 AM), she did not mention the incomplete bowel movement because she did not think it was an issue. RN C said that Resident #1 vomited a brown emesis (can be caused by internal bleeding in the stomach, severe constipation, or inflammation of the stomach lining) overnight on the 08/26/24, 10P - 6A shift. RN C said that she did not report Resident #1 threw up because it looked like a cupcake and she [RN R] did not believe it was a gastric bleed. RN C said that she did not know the last time Resident #1 had a bowel movement but remembered the CNA (unknown name and unable to describe) told her [RN R] that Resident #1 had a bowel movement during a shift but could not remember because the days blended. RN C said that the doctor also ordered STAT labs with the UA order. RN C said that the facility would get the STAT lab results on the same day or early the next day based on the time of day the lab was collected. RN C said that the lab results were available on 08/26/24 during the 2P - 10P shift. RN C said that the lab results could inform the doctor if the resident had an infection, diagnose diseases, or identify other issues, like a gastric bleed. RN C said she did not review the lab results or check if the doctor was notified when Resident #1 threw up brown emesis or if his confusion was related to an infection. During an interview on 09/02/24 at 2:47 PM, the ADON stated she was familiar with Resident #1. The ADON stated she was not informed of Resident #1 did not have a bowel movement or unrelieved constipation. The ADON said the CNAs should notify the charge nurse when or if a resident did not have a bowel movement during the shift. The ADON said she expected nurses to perform an abdominal assessment (listen to bowel sounds, feel the abdomen for tenderness or if firm), assess for signs of constipation, implement care plan interventions, notify clinical department heads (ADON/DON) of resident change in condition, notify the provider, and the RP. The ADON said that the risk if constipation was not treated could be hemorrhoids or a serious complication such as fecal impaction if hard stool backed up into the colon. During an interview on 09/02/24 at 3:22 PM, the DON said that she had in-serviced staff last month that anything that was different and out of the ordinary for a resident was a change in condition. The DON said that she expected nurses to monitor the resident's bowel movements for change in frequency and consistency. The DON said that the nurse should perform an initial assessment if a resident did not have a bowel movement for 2 - 3 days, decreased appetite, nausea, vomiting, and/or pain. The DON said an initial assessment for constipation would include an abdominal assessment that included visual inspection for the shape, abdominal distention, feel for firmness, localized tenderness, and listen with a stethoscope for slowed or absent bowel sounds that could suggest constipation. The DON said that the nurse should check the administration record for PRN medications/treatments, implement nurse interventions per the care plan, notify the provider with their assessment findings, the resident response to interventions, and notify the family. The DON said that Task(s) and nurse progress notes would be review every morning for documentation of bowel movements frequencies and interventions as needed. During an interview on 09/03/24 at 12:15 PM, the MD said that she gave orders to collect STAT blood labs on Monday morning (08/26/24) when she was notified that Resident #1 was hallucinating. The MD did not recall being told that Resident #1's wound had a foul smell, that he vomited, or that he was constipated related to not having or an incomplete bowel movement. The MD said that constipation could lead to several complications that included acute confusion, nausea, poor appetite, rapid heart rate, and fecal impaction. The MD said that she expected to be notified as soon as possible about any change in condition. The MD said she was not notified when the STAT lab results were received. The MD said that the NP was called first and coordinated Resident #1's care with the facility staff. Record review of the facility's Bowel (Lower Gastrointestinal [GI] Tract) Disorders - Clinical Protocol, revised September 2017, reflected assessment and recognition, cause identification, treatment, management, monitoring and follow-up of bowel dysfunction. The nurse shall assess and document/report alteration in bowel movements; quantitative and qualitative description of bowel movements; presence of fecal impaction; abdominal assessment; onset, duration, frequency, and severity of signs and symptoms. Record review of the facility's Change of Condition and Physician/Family Notification policy, reviewed 05/17/24, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility A review of the Lab and Diagnostic Test Results - Clinical Protocol reviewed December 2022, indicated: - The physician will identify and order diagnostic and lab testing; staff will process test requisition and arrange for test; the laboratory, diagnostic provider will report results to facility - A nurse will review all results and report the finds to the physician/designee - A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) - A physician will respond within an appropriate time frame, based on the request from the nursing staff and the clinical significance of the information. This response maybe by calling the facility or writing new orders. The NFA was notified of an Immediate Jeopardy (IJ) on 09/03/24 at 5:45 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 09/04/24 at 1:00 PM and included: On August 26, 2024 orders were received for STAT labs. The results were received by the facility in the early evening of August 26, 2024. The facility nurse inadvertently overlooked the lab results and did not notify the MD until August 27, 2024. Immediately on September 3, 2024, CCS inserviced DON on the prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. On September 3, 2024, DON/designee initiated inservices with the licensed nurses on prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 4, 2024. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 4, 2024. On September 3, 2024, DON/designee initiated inservices with the CNAs/MA s on proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on September 4, 2024. On September 3, 2024, an audit of the 24-hour report and laboratory findings was conducted by DON/Designee to ensure Physician/NP has been notified timely. On September 3, 2024, an audit of BM documentation was completed by DON/designee. Medical Director was notified on September 3, 2024. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition and physician/np notification beginning September 3, 2024, for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition and to ensure timely notification of Physician/NP. DON compliance will be monitored weekly by CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of physician notification. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. On 09/04/24 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an in-service conducted by the CCS dated 09/03/24 with the NFA and DON. Objectives of the in-service included the Change of Condition, Comprehensive Assessments and Notifications to the physician and RP. The CCS reviewed related policies and the NFA and DON completed pre-/post-tests with a passing score. Record review of a 24-hour report audit conducted by the CCS dated 09/03/24 at 10:59 PM revealed the CCS attest that she audited the last 30 days of 24 hour reports for resident changes in condition and to ensure the Physician/NP had been notified in a timely manner. During an interview and record review on 07/01/24 at 2:49 PM, the DON indicated that she conducted surveillance rounds to visualize each resident's (six residents) urinary catheter site for s/s of infection and patency. The DON indicated that she performed a chart audit on each of the six residents with a urinary catheter to assure appropriate monitoring and treatment orders were in place. Record review of order summaries for the six residents revealed treatment orders were entered and nTAR reflected orders were performed. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN D, LVN J, CNA I and CNA K], on the 2P - 10P shift [LVN H, CNA G, LVN L, CNA N, LVN Q and RN C (recently transitioned from 10P - 6A shift)], and 10P - 6A shift [LVN O, LVN M and CNA P] indicated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, documentation, and following up on lab results. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition and lab results. Each nurse demonstrated how to perform an abdominal assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of constipation, what must be reported to the charge nurse, and where to document a resident's bowel movement in the chart. Record review of in-services conducted by the DON dated 09/03/24 titled Change in Condition [with all nursing staff], POC Documentation [with CNAs], Bowel Assessment [with Nurses], Lab Services [with Nurses and Nursing Administration] and Physician Notification [with Nurses and Nursing Administration] were on-going to achieve 100% nursing dept participation. On 09/03/24, an Immediate Jeopardy was identified. The IJ template was provided to the facility on [DATE] at 5:45 PM. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult with the resident's physician; and notify, the resident representative(s) when there was a deterioration in resident's health condition for one (Resident #3) of three residents reviewed for skin conditions. The WCN failed to notify Resident #3's physician and responsible party of the deterioration of a pressure ulcer on the right heel. On 9/28/2023 the wound measured 2cm x 1.5cm and remained unchanged until 10/19/2023 when the wound measured 6x6 cm. The WCN failed to notify Resident #3's physician and responsible party of the presence of a new pressure injury along the inner edge of the right foot, extending from near the heel to the bunion region of the big toe. Resident #3 was discharged to the emergency roiagnom on [DATE] because of elevated temperature and weakness, then admitted to the hospital with the diagnosis of sepsis from pneumonia and right foot wound. An immediate Jeopardy (IJ) situation was identified on 10/30/2023. While the IJ was removed on 10/31/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident # 3's face sheet dated 10/26/2023 revealed a [AGE] year-old female admitted to the facility 12/3/2018 with a readmission on 1/12/2021. Her diagnoses included: cerebral palsy (lack of muscle control r/t brain dysfunction), muscle weakness and muscle wasting, aphasia (inability to speak). Record review of Resident # 3's quarterly MDS dated [DATE] revealed Resident #3 had severe cognitive impairment by a BIMS score of 00. Resident # 3 was dependent on staff for all ADL care and bathing, and required the assistance of 2 staff members for bed mobility and transfers. Section M skin conditions revealed yes for unhealed pressure ulcer/injuries and 2 stage 3 pressure ulcers. Record review of Resident #3's Wound-Weekly Observation tool dated 9/20/2023 revealed a stage 3 pressure injury on the right inner ankle. The wound was identified on 8/2/2023 and measured as 3.0cm x 0.5cm with 80 % of the wound bed appearing red (new tissue) and 20% of the tissue described as slough (non-viable yellowish/tan) tissue. Record review of Resident #3's Wound-Weekly Observation tool dated 9/28/2023 revealed a new stage 3 pressure injury to the right heel. The wound was identified on 9/28/2023, measurements were documented as 2.0cm x 1.5cm with 80% of the wound bed appeared pink, 10% red and 10% slough. Record review of Resident #3's progress note dated 10/10/2023 at 9:19 PM, LVN S wrote, antibiotic to be started 10/11/2023 after collection of right foot wound culture. Record review of Resident #3's Wound-Weekly Observation tool dated 10/12/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 7cm x 4cm. No change in appearance of the wound bed. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 12cm x 3cm. No change documented regarding the appearance of the wound bed. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury to the right heel had increased in size and measured 6cm x 6cm. The appearance of the wound bed was unchanged and described as 80% pink tissue, 10% red and 10% slough. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's culture results revealed, the specimen was collected on 10/18/2023 at 3:10 PM and resulted 10/22/2023 at 11:34 AM. The culture was scheduled for collection 10/11/2023 prior to the start of the antibiotic Keflex. Record review of Resident #3's Progress note dated 10/22/2023 at 6:26 PM, LVN wrote Received wound culture results .antibiotic changed to Linezolid 400mg BID x10 days. Record review of Resident #3's Progress note dated 10/23/2023 09:48 AM, LVN O wrote, Linezolid 400mg was not available in the Emergency kit and was on order from the pharmacy. At 10:02 AM, LVN O called the NP for Resident #3 to obtain a new order for Linezolid 600mg because the prescribed dose of 400mg was not available. Record review of Residents # 3's Order Summary Report dated 10/26/2023 reflected: as of 10/22/2023 Cleanse stage 3 (involves the layers of skin and fat, not muscle) pressure wound to right heel with NS, pat dry, apply Medihoney (medicated wound dressing) and optifoam (waterproof foam) dressing every other day. Every day shift every other day. As of 10/23/2023 Cleanse rt inner ankle stage 3 pressure injury with N/S pat dry apply therahoney (medicated wound dressing) cover with foam dressing change 3x weekly and PRN as needed for soiled or if dislodged. Review of Resident #3's, Departmental Notes/progress notes revealed the absence of progress notes and physician orders indicative of communication to the physician and RP regarding an increase in size of the wound on the right heel, the right inner ankle or the new wound on the inner edge of the right foot. No documentation was found informing the physician of the delay in obtaining the wound culture. In an interview on 10/26/2023 at 10:03 AM, WCN stated that she took photos of wounds when they deteriorated to document the changes. Reviewed three photo taken by WCN of Resident #3's right foot. Photo number 1, taken 09/28/2023 revealed redness from the inner aspect of the ankle extending upwards towards the great toe, stopped mid foot. Photo #2 taken 10/10/2023 revealed a large open wound near the ankle with a strip of black tissue extending from the right ankle, up the side of the foot to just below the bunion area of the right great toe. Photo #3, taken 10/18/2023, revealed that the black strip of tissue along the inner aspect of the right foot had come off revealing open tissue with areas of redness and slough. The open area extends from the wound on the inner right ankle to the base of the bunion region of the great toe. In an interview on 10/26/2023 at 11:24 AM, RP stated she was not informed of the wound the hospital found on the inner edge of the right foot. RP stated that she was not aware that the wound on the rt heel had gotten bigger. In an interview on 10/26/2023 at 1:45 PM WCN stated that when completing the Wound-Weekly Observation Tool Section D - Communication was used to identify who would be contacted for changes with the wound. Once contacted a progress note would be written with the information. WCN does not recall calling the physician or the RP on 10/19/2023 when she identified an increase in size in the wound on the Rt heel. WCN stated she did not call the physician or RP on 10/12/2023 reporting the appearance of a new wound on the inner edge of the right foot. WCN provided no explanation of why the physician or RP were not informed of the changes. WCN stated she was responsible for making the notifications to the physician, family and obtaining treatment orders from the physician. In an interview on 10/26/2023 at 3:16 PM, DON stated that the physician and the RP were to be notified when a wound changes or when a new wound was identified. When completing the wound observation tool, the communication section reflects who was notified. The progress note would contain a brief summary of what was told and if new orders were received. This notification was expected weekly as the wound observation tool was completed every 7 days. In an interview on 10/30/2023 at 10:15 AM, PCP stated she last saw Resident #3 on 10/12/2023 and observed the open wound on Resident #3's right heel and redness along inner right side of the foot. Resident was started on Keflex (antibiotic) on 10/10/2023, PCP expected that a wound culture was sent before starting the Keflex. After evaluation of the right foot, PCP discontinued the Keflex and ordered Levaquin oral tabs 500 mgs BID for wound infection. PCP said, this order may change once the culture results come back. PCP stated she was not made aware that on 10/19/2023 the wound on Resident #3's right heel had increased in size. PCP stated she was not notified of the development of a black strip of tissue that extended from the rt inner ankle to the base of the bunion region of the right foot. PCP was not notified of the delay in obtaining a wound culture of the wound on the right heel. Record review of facility policy, reviewed 1/2023, and titled, Change of Condition and Physician/Family Notification: Examples of Significant changes - development of wounds, rashes or bruises. Record review of facility policy, reviewed 1/2023, and titled, Skin Integrity Prevention and Treatment Program. Section Weekly Wound Assessment - d. physician updated; e. RP/or family if they are RP or Resident has directed family to be updated. On 10/26/2023 at 3:40 PM requested policy or reference material regarding the completion of the Wound Weekly Observation tool. DON reported on 10/23/2023 facility has no policy. This was determined to be an Immediate Jeopardy (IJ) on 10/30/2023 at 1:07 PM. The Administrator was notified. The Administrator was provided with a copy of the IJ Template on 10/30/2023 at 1:12 PM The following Plan of Removal was submitted by the facility was accepted on 10/31/2023 at 09:25 AM. Immediately on 10/26/2023 treatment nurse was suspended. Immediately on 10/26/2023 medical director was notified. Immediately on 10/26/2023 reassessment of current wounds was completed by CCS/DON/Designee, and an audit was completed to ensure correct physician orders were in place with notification of physicians. Inservice for nursing administration will be completed by CCS on 10/26/2023 on the following Skin policy and protocol to include reporting protocol of all skin changes, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out physician orders. Competency was validated for DON by CCS on 10/26/2023. On 10/26/2023 the DON/Designee completed in-servicing of nurses on the skin policy and protocol to include: reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family and carrying out of physician orders. On 10/26/2023 an inservice for certified nursing assistants will be completed by DON/Designee on immediate notification to their licensed nurse of any skin concerns that they observe. Inservice will be completed on 10/26/2023. No CNAs will be allowed to their scheduled shift until they complete the inservice. Employees will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. The above information will be included in new hire orientation effective October 26, 2023. In order to monitor current residents for potential risk, DON/Designee will conduct skin sweeps weekly x4weeks. After 4 weeks, the DON/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. CCS will monitor DON Compliance weekly. The facility QA Committed will meet weekly starting October 26, 2023 for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA committee. In-servicing will be completed on October 30, 2023. Monitoring for the implementation of the POR, initiated on 10/30/2023: Interview on 10/30/2023 at 3:25 PM, CNA B (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:47 PM, CNA C (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, CNA D (2:00 PM - 10:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:58 PM, CNA E (floater) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, LVN F (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:10 PM, LVN G (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:19 PM, ADON A had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:24 PM, RN H (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:31 PM, RN I (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:40 PM, CNA J (10:00 PM - 06:00 AM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:30 AM, CNA K (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:39 AM, CNA L (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:44 AM, CNA M (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 9:49 AM, LVN N (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:07 AM, LVN O (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:19 AM, RN P (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:41 AM, ADON Q had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. The administrator was notified that the IJ was removed on 10/31/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. The facility failed to ensure Resident #3 did not experience a worsening of an existing pressure ulcer and did not develop a new pressure ulcer. The pressure ulcer on the rt heel increased in size and a new pressure injury (inner edge of the right foot) was identified on 10/12/2023. The facility failed to ensure there was documentation in the clinical record in the form of the wound weekly observation tool documenting the occurrence of the new wound on the inner edge of the right foot. The facility failed to ensure Resident #3 was provided with individual treatment orders for the pressure injury that was identified on 10/12/2023. Resident #3 was discharged to the emergency room [DATE] r/t to elevated temperature and weakness. An immediate Jeopardy (IJ) situation was identified on 10/30/2023. While the IJ was removed on 10/31/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These deficient practices could place residents at risk for pressure sores being unidentified and untreated. Findings included: Record review of Resident #3's hospital records revealed that on 10/23/2023 at 7:38 PM Resident #3 arrived in the emergency room and then admitted to the hospital diagnosed with sepsis r/t pneumonia and right foot wound. Review of the Nurses admission assessment to the unit dated 10/24/2023 at 00:40 AM revealed - PU right heel and right foot. Red granulation (new) tissue, stage 3 (involving all layers of skin to the fat) w purulent drainage, medial rt foot stage 3 beefy red with moderate purulent drainage. As of 10/31/2023, Resident #3 remains in the hospital. Record review of Resident # 3's face sheet dated 10/26/2023 revealed a 43/F admitted to the facility 12/3/2018 with a readmission on 1/12/2021. Her diagnoses included: cerebral palsy (lack of muscle control r/t brain dysfunction), muscle weakness and muscle wasting, aphasia (inability to speak). Record review of Resident # 3's quarterly MDS dated [DATE] revealed Resident #3 had severe cognitive impairment by a BIMS score of 00. Resident # 3 was dependent on staff for all ADL care and bathing and required the assistance of 2 staff members for bed mobility and transfers. Record review of Resident #3's Wound-Weekly Observation tool dated 9/20/2023 revealed a stage 3 pressure injury on the right inner ankle. The wound was identified on 8/2/2023 and measured as 3.0cm x 0.5cm with 80 % of the wound bed appearing red (new tissue) and 20% of the tissue described as slough (non-viable yellowish/tan) tissue. Record review of Resident #3's Wound-Weekly Observation tool dated 9/27/2023 revealed the stage 3 pressure injury on the right ankle had no change in size. The wound bed was described as 95% red and 5% slough. Record review of Resident #3's Wound-Weekly Observation tool dated 9/28/2023 revealed a new stage 3 pressure injury to the right heel. The wound was identified on 9/28/2023, measurements were documented as 2.0cm x 1.5cm with 80% of the wound bed appeared pink, 10% red and 10% slough. Record review of Resident #3's dietary consultation dated 9/30/2023 revealed, recommendations to continue prostat and decubivite (supplements used for wound healing). Record review of Resident #3's Wound-Weekly Observation tool dated 10/5/2023 revealed the stage 3 pressure injury on the right ankle had no changes in size or appearance since the last evaluation completed on 9/27/2023. Record review of Resident #3's Wound-Weekly Observation tool dated 10/5/2023 revealed the stage 3 pressure injury to the right heel had no changes in size or appearance since the initial evaluation completed on 9/28/2023. Record review of Resident #3's Wound-Weekly Observation tool dated 10/12/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 7cm x 4cm. No evidence found in the record indicative of a therapeutic treatment causing the change in size. The wound bed was described as 95% appeared red and 5% slough which was unchanged from the previous evaluation. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/12/2023 revealed the stage 3 pressure injury to the right heel had no changes in size or appearance since the last evaluation. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury on the right inner ankle had increased in size and measured 12cm x 3cm. No evidence found in the record indicative of a therapeutic treatment causing the change in size. The wound bed was described as 95% with red tissue and 5% slough unchanged from the previous evaluation. Overall impression of the wound by the WCN was documented as worsening. Record review of Resident #3's Wound-Weekly Observation tool dated 10/19/2023 revealed the stage 3 pressure injury to the right heel had increased in size and measured 6cm x 6cm. The appearance of the wound bed was unchanged and described as 80% pink tissue, 10% red tissue and 10% slough. Overall impression of the wound by the WCN was documented as worsening. Record review of the October 2023 Wound-Weekly Observation tools revealed the absence of a tool addressing the new pressure injury identified on the inner edge of the rt foot. Record review of Residents # 3's Order Summary Report dated 10/26/2023 reflected as of 10/22/2023 Cleanse stage 3 (involves the layers of skin and fat, not muscle) pressure wound to right heel with NS, pat dry, apply Medihoney (medicated wound dressing) and optifoam (waterproof foam) dressing every other day. Every day shift every other day. As of 10/23/2023 Cleanse rt inner ankle stage 3 pressure injury with N/S pat dry apply therahoney (medicated wound dressing) cover with foam dressing change 3xweekly and PRN as needed for soiled or if dislodged. Record review of Resident #3's Care plan printed 10/26/2023 revealed as of 9/29/2023 Resident #3 had a stage 3 pressure ulcer to the right medial foot and right heel. Interventions included repositioning every 2 hours, a protective boot on the right foot, administration of medications as ordered; administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Record review of Resident #3's physician orders revealed the absence of physician orders regarding instructions for treatment of a new strip of black tissue identified on 10/12/2023 and measured at 7cm x 4cm on the inner edge of the right foot extending to the bunion region of the right foot. Review of Resident #3's, Departmental Notes/progress notes dated 10/10/2023 - 10/19/2023 revealed the absence of progress notes regarding the identification of a new pressure injury located on the inner edge of the right foot or the deterioration of the existing wound on the rt heel. In an interview on 10/26/2023 at 10:03 AM, WCN stated that she took photos of wounds when they deteriorated to document the changes. Reviewed three photos taken by WCN of Resident #3's right foot. Photo number 1, taken 09/28/2023 revealed redness from the inner aspect of the ankle extending upwards towards the great toe, stopped mid foot. Photo #2 taken 10/10/2023 revealed a large open wound near the ankle with a strip of black tissue extending from the right ankle, up the side of the foot to just below the bunion area of the right great toe. Photo #3, taken 10/18/2023, revealed that the black strip of tissue along the inner aspect of the right foot had come off revealing open tissue with areas of redness and slough. The open area extends from the wound on the inner right ankle to the base of the bunion region of the great toe. In an interview on 10/26/2023 at 1:45 PM WCN stated that she considered the new wound on the inner edge of the right foot to be an extension of the wound identified on the rt inner ankle. On 10/12/2023 she measured the wound on the rt ankle as 7cm x 4 cm. WCN nurse applied the treatment written for the wound on the rt inner ankle to the black strip of tissue found on the inner edge of the rt foot extending upwards towards the bunion region of the rt foot. WCN did not notify the physician or obtain orders for treatment of the new wound. In an interview on 10/26/2023 at 3:16 PM, DON stated that the Wound-Weekly Observation tool was completed for each wound identified on a resident. DON expects that each wound had a treatment order specific for the wound. DON expects that when a wound changes in appearance notification to the physician and family was completed timely. In an interview on 10/30/2023 at 10:15 AM, PCP stated she last saw Resident #3 on 10/12/2023 and observed the open wound on Resident #3's right heel and redness along inner right side of the foot. PCP stated she was not made aware that on 10/19/2023 the wound on Resident #3's right heel now measured 6cm x 6cm. PCP stated she was not notified of the development of a black strip of tissue that extended from the rt inner ankle to the base of the bunion region of the right foot which was measured at 12cm x 3cm. PCP stated that had she known about the deterioration of the heel wound and the development of a new wound she may have discharged the resident to the hospital for evaluation of the wounds. Record review of facility policy, reviewed 1/2023, and titled, Change of Condition and Physician/Family Notification: Examples of Significant changes - development of wounds, rashes or bruises. Record review of facility policy, reviewed 1/2023, and titled, Skin Integrity Prevention and Treatment Program. Section Weekly Wound Assessment - d. physician updated; e. RP/or family if they are RP or Resident has directed family to be updated. This was determined to be an Immediate Jeopardy (IJ) on 10/30/2023 at 1:07 PM. The Administrator was notified. The Administrator was provided with a copy of the IJ Template on 10/30/2023 at 1:12 PM The following Plan of Removal was submitted by the facility was accepted on 10/31/2023 at 09:25 AM. Immediately on 10/26/2023 treatment nurse was suspended. Immediately on 10/26/2023 medical director was notified. Immediately a complete head to toe skin sweep was initiated on 10/26/2023 and completed by CCS, DON, ADONs to include updated assessments which includes pressure and non pressure assessments; appropriate documentation, treatment orders if indicated, notification of MD/family, care plan update. Immediately on 10/26/2023 reassessment of current wounds was completed by CCS/DON/Designee, to include current measurements and staging as well as any required treatment changes. Immediately an audit was completed of Braden Scales, current treatment/wound orders and care plans to ensure accuracy. Audit was completed by CCS/DON/Designee on 10/26/2023. Inservice for nursing administration will be completed by CCS on 10/26/2023 on the following Skin policy and protocol to include reporting protocol of all skin changes, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family, and carrying out physician orders. Competency was validated for DON by CCS on 10/26/2023. On 10/26/2023 the DON/Designee completed in-servicing of nurses on the skin policy and protocol to include: reporting of all skin changes to nursing administration, process of assessment and documentation of all skin concerns, how to conduct a skin assessment, notification of MD/family and carrying out of physician orders. On 10/26/2023 an inservice for certified nursing assistants will be completed by DON/Designee on immediate notification to their licensed nurse of any skin concerns that they observe. Inservice will be completed on 10/26/2023. No CNAs will be allowed to their scheduled shift until they complete the inservice. Employees will receive education prior to being allowed to work. Staff will receive a quiz to ensure competency of all education provided. The above information will be included in new hire orientation effective October 26, 2023. In order to monitor current residents for potential risk, DON/Designee will conduct a skin sweep weekly x4weeks. After 4 weeks, the DON/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter. CCS will monitor DON compliance weekly. The facility QA Committed will meet weekly starting October 26, 2023 for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA committee. In-servicing will be completed on October 30, 2023. Monitoring for the implementation of the POR, initiated on 10/30/2023: Interview on 10/30/2023 at 3:25 PM, CNA B (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:47 PM, CNA C (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, CNA D (2:00 PM - 10:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:58 PM, CNA E (floater) had been in-serviced regarding reporting skin issues. Interview on 10/30/2023 at 3:52 PM, LVN F (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:10 PM, LVN G (2:00 PM - 10:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 4:19 PM, ADON A had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:24 PM, RN H (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:31 PM, RN I (10:00 PM - 6:00 AM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/30/2023 at 10:40 PM, CNA J (10:00 PM - 06:00 AM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:30 AM, CNA K (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:39 AM, CNA L (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 09:44 AM, CNA M (6:00 AM - 2:00 PM) had been in-serviced regarding reporting skin issues. Interview on 10/31/2023 at 9:49 AM, LVN N (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:07 AM, LVN O (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:19 AM, RN P (6:00 AM - 2:00 PM) had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. Interview on 10/31/2023 at 10:41 AM, ADON Q had been in-serviced regarding, expectations of CNA reporting of skin issues, skin assessments, notifications, obtaining treatment orders and documentation. The Administrator was notified that the IJ was removed on 10/31/2023. The facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implemtation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for two (Residents #1 and #2) of four residents reviewed for tube feedings. LVN A failed to correctly unclog Resident #1's g-tube when it appeared clogged. LVN A used a de-clogging tool (a flexible threaded device that is serrated approximately 2 inches at the end) incorrectly on Resident #1's j/g-tube that could have resulted in perforation (hole) of the j/g-tube and/or abdominal/ intestinal wall. LVN A used the tool without training or a physician's order. Following the use of the tool, LVN A failed to complete an assessment on Resident #1 or notify the physician or nursing administration. LVN A failed to correctly unclog Resident #2's j/g-tube combination when it appeared clogged. LVN A identified during an interview she used a de-clogging tool incorrectly on Resident #2's g-tube that could have resulted in perforation of the g-tube and/ or intestinal/abdominal wall. LVN A used the tool without training or a physician order. Following the use of the tool, LVN A failed to complete an assessment on Resident #2 or notify the physician or nursing administration. These failures placed residents at risk for perforation of the j/g-tube and/or intestinal wall, replacement of the j/g-tube, hospitalization , or even death. An Immediate Jeopardy was identified on 01/11/23. While the Immediate Jeopardy was removed on 01/13/22, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. Findings included: Review of Resident #1's MDS reentry assessment, dated 12/30/22, revealed the resident was a [AGE] year-old-female admitted to the facility on [DATE] with a readmission 12/30/22 from the hospital for urinary tract infection. The MDS assessment reflected Resident #1's cognition was severely impaired with a BIMS score of 99, and her diagnoses included dementia, protein calorie malnutrition, cerebral infraction (stroke), and hypertension (high blood pressure). The resident required the extensive assistance of two staff for activities of daily living and was totally dependent for eating (g-tube). Review of Resident #1's comprehensive care plan dated, 11/09/22 revealed the resident was at risk of complications related to tube feeding, aspiration (entrance of foreign substance into airway), and adequate nutrition and hydration. The care plan reflected no goals or approaches related to appropriate protocol for de-clogging the g-tube or the use of a g-tube de-clogger. Review of Resident #1's order summary report dated 12/30/22 reflected: enteral feed order (g-tube): every shift was to flush with 10cc H20 (water) between medications, administer 200cc Q (every) 4 hours to equal 1200cc/day. Flush with 60 cc free water before and 30cc between meds. Further review reflected no physician orders for the use of the de-clogger. Review of Resident #1's hospital transfer orders dated 12/30/22 reflected no order for the use of a g-tube de-clogger. An observation and interview on 01/11/23 at 6:15 p.m. revealed LVN A administered medication to Resident #1 through her g- tube. LVN A assessed for g-tube placement and poured medications mixed with water into the 60 ML syringe. The water did not flow into the g-tube. LVN A obtained a de-clogger from the bottom drawer of the medication cart, the de-clogger size (16-18 French, length 39.5 cm.) LVN A then inserted a de-clogger, into the g-tube without measuring the length of the g-tube, verifying the correct size, and not turning the tool in a clockwise direction during insertion and counterclockwise during removal. LVN A poured in the medications mixed with water into the g-tube and the fluid still not flow. LVN A repeated the de-clogging procedure (using de-clogging tool) again, poured the medications mixed with fluid into the g-tube and the fluid did not flow. LVN A then proceeded to massage the g-tube and then wiggled the g-tube. The water/medications still did not flow into the g-tube. LVN A continued to massage the g-tube, following the massaging of the g-tube, LVN A administered the medication and 10 ml of water without reassessing for placement of the tube after the tube had been de-clogged. LVN stated during this observation, she knew you were supposed to measure the de-clogger against the tube, she said that she did not know what size feeding tube Resident #1 had. An interview with LVN A on 01/11/23 at 6:20 p.m. revealed she was unaware of the different sizes of g-tube de-cloggers and she did not know the size or length of Resident #1's g-tube. LVN A stated she was unaware if Resident #1 had a physician's order to use the de-clogger. LVN A stated that she was comfortable using the de-clogger or she would not have used it, even though she had no formal training. She just used it this week on the resident across the hallway pointing at Resident #2's room. LVN A stated that she had not informed the physician, DON, or the family of the clogged tube or the use of the de-clogger. An interview with LVN A on 01/11/23 at 7:00 p.m. revealed she did not call the physician on 01/09/23 or 01/11/23 because the g-tube flushed after she used the de-clogger and the resident did not exhibit any pain. When LVN A was asked if she was aware of the potential danger of using the de-clogger without training and a physician's order, LVN A said, No. During this interview LVN A stated that she did not assess either Resident #1 or Resident #2 since the tubes' were unclogged and working again. LVN A stated what type of assessment would you do, if the g/j tube is unclogged and working. Review of Resident #1's nursing progress notes dated 01/11/23 revealed no documentation reflecting the use of the de-clogger or an assessment of Resident #1's condition after the use of the de-clogger. Further review reflected no documentation reflecting notification of the clogged g-tube to the DON or physician. Review of Resident #2's MDS quarterly assessment, dated 11/18/22, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a readmission on 12/31/22 from the hospital for j-tube clogging. The MDS assessment reflected Resident #2's cognition was severely impaired with a BIMS of 2, and her diagnoses included Alzheimer's, dementia, cerebral vascular accident (stroke), diabetes, malnutrition, and dysphagia (unable to swallow). The resident required the extensive assistance of two staff for activities of daily living and was totally dependent for eating (j-tube). Review of Resident #2's comprehensive care plan, dated 11/24/22, revealed the resident was at risk of complications related to tube feeding, aspiration, and adequate nutritional and hydration status, due to resident receiving nutrition by g-tube. The care plan reflected no goals or approaches related to appropriate protocol for de-clogging the j-tube or the use of a j/g-tube de-clogger. Review of Resident #2's order summary report dated 01/12/23 reflected: 12/31/22: start date: 10 ml of water between medications, every shift immediately flush g/j tube with 40-60 ml water any time tube feeding is disconnected or paused. J tube lumen (inside space of a tubular structure) is so tiny it will clog within minutes, 01/05/23 every shift Tube feeding: Free Water; Administer 100 cc every 2 hours for 22 hours a day to equal 100 cc/day, via pump. 01/12/23 as needed to unclog g-tube flush the tube with 30ml of warm water and attempt to dislodge the clog by milking/massaging the tube. Clamp tube for 15 minutes. Try flushing again. If the clog does not dislodge, call MD and send patient to the hospital. Further review reflected no physician's orders for the use of a j/g-tube de-clogger. Review of Resident #2's hospital transfer orders dated 12/31/22 reflected no order for the use of a j/g-tube de-clogger. Review of Resident #2's nursing progress notes dated for the week of 01/09/23-01/11/23 revealed no documentation reflecting the use of the de-clogger or an assessment of Resident #2's condition after the use of the de-clogger. Further review reflected no documentation reflecting notification of the clogged j/g-tube to DON or physician. An interview with LVN B on 01/11/23 at 11:00 a.m. revealed he had a resident who had a j/g-tube combination on his hallway (400). LVN B said he had no problems with the g-tubes clogging on his shift, but there was j/g-tube that clogged frequently. LVN B stated that if a tube became clogged, he would use warm water and he would massage the tube and if it did not unclog he would call the physician and send the resident to the hospital. LVN B stated the facility hadde-cloggers (long whip looking thing) on the medication cart and he has used one in the past but could not recall on which resident or when. LVN B stated he was not comfortable using the de-clogger, he had no formal training and when he had used the de-clogger in the past he had cut the end off of the de-clogger, because you can only go so far before you damage something. An interview with LVN C on 01/11/23 at 11:15 a.m. revealed she had a g-tube resident on her hall and she had worked on hall 400 that had j/g tubes. LVN C said that she had no problems with the g-tube clogging, but she had a resident on hall 400 that would frequently clog. LVN C stated that Resident #2 had a medication (Sodium Bicarb) that could be used to attempt to de-clog the j/g-tube. LVN C stated that if the medication did not work, then she would call the physician and send the resident to the hospital. LVN C acknowledge there were de-cloggers in the facility on the medication cart, but she could not recall the last time she had used one. LVN C stated she had no formal training on the use of the de-clogger. An interview with RN D on 01/11/23 at 11:20 a.m. revealed he had a resident with a g-tube on the hallways he had worked. RN D stated there was one j/g-tube in the facility and he had worked with that resident also. RN D stated Resident #2's tube clogged a lot, she had a medication (Sodium Bicarb) that could be used, but it never worked. He would send her out to the hospital. RN D stated there were de-cloggers on the medication cart and he had used the de-clogger in the past however, he could not recall when and on which resident. RN D stated there had been no formal training on the use of the de-clogger, there had been some in-services on g-tubes. An interview with RN E on 01/11/23 at 11:30 a.m. revealed she only worked on the rehabilitation hallway and there was no j/g-tubes on the hallway. RN E stated if she had a clogged tube, she would use warm water and flush the tube. RN E stated there are de-cloggers in the facility, but she had never used one. She stated she had not had any formal training on how to use the de-clogger, when asked about physician orders, she stated that she thought there were standing orders for that, but she was not sure. An interview with LVN G on 01/11/23 at 2:50 p.m. revealed that if she had a clogged g-tube, she would not use a de-clogger on a resident in this setting, she had no training about that. An interview with LVN A on 01/11/23 at 3:45 p.m. revealed she had no formal training on tube de-clogger. LVN A said she had worked at the facility for approximately one month and she knew that the de-cloggers were on the medication cart. She had never asked anyone if it was okay to use one, she thought since they were on the cart it was okay to use them LVN A said that it was much easier just to use the de-clogger to unclog the tube, than water, milking the tube (is what the nurse thought they called it), and then flushing again and again. LVN A said in the last month she had used the de-clogger on all three residents who received enteral feedings on the 400 hallway. An interview with the Medical Director on 01/11/23 at 5:15 p.m. revealed the facility should be using warm water or normal saline and massaging the tube, then flushing the tube to attempt to de-clog it. When the Medical Director understood that the facility nursing staff was using the de-clogger, she stated the whip that tool is used in the ICU and the ER at the hospital, not in this setting. The Medical Director stated that none of the facilities she was associated with used a de-clogger and she did not want the nurses at this facility to use them. She said the staff was not trained appropriately on the use of the de-clogger and it can be dangerous. Using the de-clogger could possibly perforate (pierce causing a hole) the intestine or the abdomen causing an infection or even death. The Medical Director stated she had not given orders for that and she was not going to. She stated she was unaware the facility was using them, no one had discussed this with her. An interview on 01/11/23 at 4:20 p.m. with ADON F revealed he was aware that there were de-cloggers on the medication carts. ADON F stated that he worked the floor whenever there was a need and he had used the de-clogger but could not recall on which resident or when he had used it. ADON F stated he had not given any in-services on the de-clogger and he had no formal training on how to use it. A review of the de-clogger packaging on 01/11/23 at 6:30 p.m. with LVN A revealed the following instructions: [Brand Name] De-clogger Rxd (prescribed) only Single use only 1. Determine the size of the gastric-tube 2. Select appropriate size de-clogger that corresponds to the size of the tube 3. Pause pump 4. Insert the de-clogger to the blockage and then slowly rotate in a clockwise direction and then reverse rotate in counter clockwise direction while removing it. Do not attempt to force the de-clogger through the entire blockage 5. Flush tube with 30cc of warm water 7. Once clear reconnect the delivery tube and restart the enteral feed Discard the de-clogger and document results. Review of Resident #2's clinical nurses' notes completed by LVN A, reflected on 01/09/23 at 9:53 p.m. Resident #2's j/g-tube was clogged. The tube was de-clogged and then flushed There was no further documentation of an assessment, physician notification regarding the use of the de-clogger, or follow-up of Resident #2's condition in the clinical record. In an interview on 01/11/23 at 7:00 p.m. with LVN A verified that she did use the de-clogger with Resident #2 on 01/09/23. LVN A stated she could not recall when she had used the de-clogger on the other resident on the hallway. An interview with the DON on 01/11/23 at 7:15 p.m. revealed there were eleven enteral feed residents in the facility ten g-tubes and one j/g combination tube, the de-clogger was in the facility on the medication carts to be used for clogged j-tubes and clogged g-tubes. She stated she was unaware of a nurse using a g-tube de-clogger on Resident #1 or Resident #2 and there had been no problems with the residents who have g-tubes in the facility having clogged tubes. The DON stated she had not trained the nurses on the usage of the de-clogger and she did not know who had ordered them, they were just in the facility ready to use. The DON stated she was unaware there were no physician orders for the de-cloggers to be used. When the DON was asked about how she felt about the nursing staff using the de-cloggers with no formal training, she stated they are experienced individuals, she had no problems. An observation on 01/11/23 at 8:00 p.m. revealed the DON removing a de-clogger from a medication cart on Hall 400. An interview with the DON on 01/11/23 at 8:00 p.m. revealed she was in-servicing the nursing staff on pulling the de-cloggers from the facility and they were not to be used. The facility did not have a policy and procedure to use the de-clogger and the Medical Director said they were dangerous to use in this environment due to the potential for perforation. The DON stated she had done a full sweep of the building and removed all g-tube de-cloggers from the treatment carts, medications carts, central supply, and residents' rooms. During this interview the DON stated on the evening of 01/11/23 she had notified the nursing staff and Central Supply Staff, with a sign, that she was not to order anymore g-tube de-cloggers and the nursing staff was not to use them anymore. An interview on 01/12/23 at 9:29 a.m. with LVN B revealed the nurses conducted in person report, at the change of shift, to discuss each resident. LVN B was asked if he was aware LVN A had trouble with Resident #1's g-tube flush and used a de-clogger, and he stated he had not been informed. LVN B stated he had assessed Resident #1 at 9:00 a.m. and administered the ordered flush with no problems. An interview on 01/12/23 at 11:33 a.m. with Medical Records/Central Supply revealed she had re-ordered the de-cloggers in the past three months but could not recall when she first started ordering the de-clogger. She stated she could not recall who asked her to order the de-clogger, the nurses just came to her with items they need, and she order them. Review of the article Best practices for unclogging feeding tubes in adults from the Nursing2018 journal, published June 2018, revealed: The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends warm water as the best initial choice for trying to unclog a feeding tube. First, attach a 30- or 60-mL piston syringe to the feeding tube and pull back the plunger to help dislodge the clog. Next, fill the flush syringe with warm water, reattach it to the tube, and attempt a flush. If you continue to meet resistance, gently move the syringe plunger back and forth to help loosen the clog. You can then clamp the tube to allow the warm water to penetrate the clog for up to 20 minutes. Additional second-line interventions include using a commercially available enzyme de-clogging kit or mechanical de-clogging device. These also must be used in accordance with facility policy and procedure and only by experienced clinicians. If the tube can't be unclogged by these methods, ASPEN recommends replacing it. Access on 01/13/23 from https://www.nursingcenter.com/journalarticle?Article_ ID= 4677008&Journal_ID=54016&Issue_ID=4676797 Review of the de-cloggers manufacture's recommendations on use of the Enteral Feeding Tube De-cloggers revealed the following: Instructions on Prophylactic Usage: PRECAUTIONS: Prior to any use of the product, the length of the feeding tube should be known. Use a de-clogger that is shorter than the feeding tube. Caution: Federal law restricts this device to sale by or on the order of a physician. DO NOT ATTEMPT TO FORCE THE DECLOGGER THROUGH THE ENTIRE BLOCKAGE. There are five different sizes and two lengths of the De-clogger Proper Usage: You should understand what different occurrences cause clogs in enteral feeding tubes so you know why exactly you are unclogging a tube. Here are some examples: kinks in the lines of the tubes, not flushing after putting medication in, dense formulas, small-bore feeding tubes and slow flowing formula can sometimes cause residue that forms buildup. Gastric acids can mix with the formula when the gastric residuals are being checked. Review of the facility's current policy and procedure entitled Enteral Nutrition dated October 2022 reflected, 14 . staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: aspiration; tube misplacement; skin breakdown; perforation of the stomach or small intestine leading to peritonitis; esophageal selling, strictures, fistulas; and clogging of the tube. The facility's policy/procedure had no documentation in regard to using or not using a de-clogger. The Administrator and DON were notified of the Immediate Jeopardy on 001/11/23 at 5:02 p.m. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/13/23 at 11:46 a.m. and reflected the following: Immediately on January 11th, 2023, RN, CCS in-service , RN, DON , ADON and , ADON on not using de-cloggers as well as the procedure to take when staff are unable to flush a G/J tube including contacting the physician. Compliance was verified through competency checkoffs on January 11th, 2023. Checkoffs included Feeding Tube Competency and Proper Administration of Medication via Enteral Tube Competency. Facility Medical Director was notified of the Immediate Jeopardy by Administrator on 1/11/2023. In consultation with the Medical Director the facility was guided to perform a one-time assessment of the 11 residents who have G/J tubes to include a physical evaluation of pain, nausea, vomiting, abdominal bloating. The Medical Director also ordered an upright KUB as well as a STAT CBC for the 11 residents who have G/J tubes as indicated. As an additional measure of precaution, the facility will have nursing administration complete hourly monitoring of signs and symptoms until radiology and lab results are received. At that time, monitoring will discontinue. All 11 G/J tube residents have new orders in place per Procedure to Unclog a Clogged G Tube effective January 11, 2023. On January 11th, 2023 RN, DON, ADON F and ADON W initiated in servicing with nurses on not using de-cloggers as well as the procedure to take when staff are unable to flush a G/J tube including contacting the physician and nursing supervisors. G/J tube competencies will be completed with nursing staff. Competency checkoffs will be completed on January 12th, 2023. Checkoffs included Feeding Tube Competency and Proper Administration of Medication via Enteral Tube Competency. Staff will not be allowed to work until in servicing has been completed. Compliance will be monitored by RN, DON. The above training material will be incorporated into the new hire orientation by RN, DON effective January 11, 2023, and ongoing. Checkoffs include Feeding Tube Competency and Proper Administration of Medication via Enteral Tube Competency. In order to monitor current residents for potential risk, RN, DON, will complete observation of staff, including weekend staff, performing G/J tube feeding/flushes 3x/week for 30 days, 2x/week days 31-60 and quarterly thereafter. The QA Committee will monitor quarterly up to a year for compliance. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Administrator, will monitor RN, DON, Compliance with observations of staff, including weekend staff, performing G/J tube feeding/flushes 3x/week for 30 days, 2x/week days 31-60 and quarterly thereafter by reviewing observation documentation. Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Interviews were conducted on 01/12/23 starting at 10:00 a.m. and continued through 01/13/23 at 3:00 p.m. with 22 nurses from various shifts regarding in-services which included g-tube proficiency, assessment, care, physician notification, physician orders and how to properly unclog a j/g-tube. The staff members were able to: Describe the correct process for assessing a j/g-tube. Describe the process for care of a j/g-tube Describe the process of how to properly unclog a j/g-tube. Describe the process of when to call the physician. Describe the process of not treating a resident unless you have a physician order. Interviewed staff members and shifts were: LVN A-worked 2:00 p.m. to 10:00 p.m. LVN B- worked 6:00 a.m. to 2:00 p.m. LVN C- worked 6:00 a.m. to 2:00 p.m. RN D- worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. RN E- worked all shifts ADON F- worked all shifts LVN G- worked 6:00 am to 2:00 p.m. LVN H - worked 10:00 p.m. to 2:00 p.m. RN I - worked 10:00 a.m. to 2:00 p.m. LVN J - MDS Coordinator LVN K - worked 2:00 p.m. to 10:00 p.m. LVN L - worked 2:00 p.m. to 10:00 p.m. RN M- weekend supervisor LVN N- worked 2:00 p.m. to 10:00 p.m. LVN O- treatment nurse LVN P- worked 10:00 p.m. to 6:00 p.m. RN Q-worked 10:00 p.m. to 6:00 a.m. LVN R-worked 10:00 p.m. to 6:00 a.m. LVN S-worked 2:00 p.m. to 10:00 p.m. LVN T-worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. LVN U-worked 2:00 p.m. to 10:00 p.m. LVN V- worked 2:00 p.m. to 10:00 p.m. An interview with the DON on 01/13/23 at 1:30 p.m. revealed going forward the facility would be following the policy and best practice for assessment and care of residents with j/g-tubes. She stated the nursing staff would be monitored for following physician orders with continued in-service and observation by the DON and ADON. An interview with the Administrator on 01/13/23 at 2:00 p.m. revealed going forward the facility would be following the policy for care and assessments of j/g-tubes and the importance of physician orders. He stated he would ensure the facility completed and continued the proficiency training for j/g-tubes. The Administrator was notified on 01/13/23 at 1:00 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 01/13/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

Based on observation, interview and record review, the facility failed to immediately consult a resident's physicain when the resident experienced a significant change in physical and/or mental status for one (Resident #1 ) of 11 residents reviewed for timely consultation with a physician. The facility did not consult Resident #1's physician when the resident had decreased blood pressure, no attainable oxygen levels, was dehydrated, and became confused and lethargic. The staff did not transfer Resident #1 to the hospital until she began having hallucinations. Resident #1 died the next day in the hospital [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility still monitoring the effectiveness of the Plan Removal. These failures could affect all 97 residents by placing them at risk for delays in treatment and care which could result in serious injury, harm and/or death. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had adequate hearing, clear speech, usually understood and had adequate vision. She had moderately impaired cognition, no s/s of [MEDICAL CONDITION], no mental status change, and no [MEDICAL CONDITION]. She required extensive assistance for transfers, locomotion, and dressing. She required limited assistance with eating and used a wheelchair for mobility. Her [DIAGNOSES REDACTED]. Resident #1's care plan updated on [DATE] reflected: Problem/Need: Alteration in Elimination-I am incontinent of urine, [DATE], [DATE]. Approach: Ongoing assessment of color, clarity and character of my urine, assess me for signs and symptoms of urinary tract infection, assess me for abdominal distention, assess me for compaction/impaction, assist me with perineal cleaning as needed, observe me for acute behavioral changes that may indicate UTI and evaluate my fluid and hydration status. Review of Resident #1's [DATE] physician's orders [REDACTED].@ 2LPM if O2 sat < 92, O2 sats checked Q shift, [MEDICATION NAME]-HCTZ ,[DATE] mg QD, [MEDICATION NAME] 4mg QAM and Q PRN. Put all meds in pudding or applesauce. Review of Resident #1's Nurse's Notes dated [DATE] reflected the resident fell on the floor while reaching for the phone. She complained of headache and had an elevated blood pressure of ,[DATE]. The resident was transferred to a hospital. The resident returned that evening with a mild concussion, swelling and bruising. Review of the MD's progress note from a visit on [DATE] reflected he saw the resident for a chief complaint of the family was concerned with the resident's current condition, recent falls, dementia and concerns the resident was had [MEDICAL CONDITION]. MD indicated medical records were reviewed from the [DATE] ER hospital visit. The note reflected Resident #1 was alert and oriented to person, place and time, her vitals were- blood pressure ,[DATE], pulse 93, temperature 97.2, respiratory rate 19, she had a normal mood and affect and her behavior was normal. MD's assessment/plan was to order a UA for C/S, CBC and CMP and he advised nurses to call him with the results as soon as possible. Review of Resident #1's Physician's Telephone Order, dated on [DATE] reflected the MD ordered the following labs: CBC, CMP, TSH, B12, Pre-[MEDICATION NAME] and a UA CS. Resident #1's results completed [DATE] at 5:33 PM reflected Resident #1 had high level of BUN at 42 (reference range ,[DATE]) and a high level of CREA at 2.1 (reference range 0XXX,[DATE].3). Both of the high values indicated dehydration). Resident #1's Urine Analysis results dated [DATE] at 5:53 PM indicated Resident #1 had a UTI. The following values were out of reference range: urine clarity (cloudy), urine white blood count (TNTC-too numerous to count), urine LEUK (Large) and urine bacteria (large). The values indicate she had a urinary tract infection. Resident #1's Nurse's Notes dated [DATE] reflected the resident, fell in her room on right side with wheelchair partially on top of her. Unwitnessed. Could not tell staff what had happened. Appeared agitated. No change in level of consciousness. Ordered x-ray for shoulder and reflected no injuries. Review of Resident #1's [DATE] MAR indicated [REDACTED]. The MA G did not circle her initials to reflect the [MEDICATION NAME] was held, nor did she document on the back why the medication was held (per protocol). The 7PM blood pressure check by the MA was ,[DATE]. It reflected the [MEDICATION NAME] was held. Review of Resident #1 ' s blood pressures for [DATE]-[DATE] were an average between ,[DATE] systolic and ,[DATE] diastolic. Interview with MA G on [DATE] at 4:02 PM revealed she worked weekend doubles. She did vitals when the MAR indicated [REDACTED]. She said oxygen saturation levels were taken by the nurses only. MA G reviewed the MAR for Resident #1 for [DATE] and said it reflected her blood pressure at 7AM was ,[DATE]. MA G said, I would not have administered the [MEDICATION NAME] (antihypertensive medication - lowers blood pressure) even though I know it's not circled as being held, but I know I didn't give it. She said Resident #1 took all of her 7AM meds fine that morning after the low blood pressure reading so she did not tell the nurse. MA G indicated the BP reading was alarming that morning but she typically was not concerned unless she noticed a resident was fatigued or were not acting themselves. Then she would report it. As the day progressed, MA G said Resident #1 appeared to get more and more tired. She said went into Resident #1s room around 6:30 PM to get her evening blood pressure and administer medication. She said Resident #1 could not talk at that point and could not respond, her eyes were closed and she appeared to be sleeping. MA G said she tried to wake her up, but she would not respond and looked sleepy, out of it. MA took Resident #1's blood pressure which was ,[DATE]. She said she held the [MEDICATION NAME]. When asked if she notified a nurse about Resident #1's condition, she said she could not remember. When asked why she did not alert the nurses to Resident #1's low blood pressure reading, she responded it was because she saw them going into her room with oxygen so she figured they were already aware of her decline. Review of Resident #1's Respiratory MAR for [DATE] reflected she was not administered any PRN oxygen on [DATE] during any of the shifts prior to transferring to the hospital. Resident #1's UA Culture and Sensitivity received on [DATE] at 10:45AM reflected >100,00 cfu/ml of Escherichia coli, which indicated the resident had an UTI. Resident #1's Nurse's Notes Late entry from LVN A on [DATE] at 6:51 PM reflected on [DATE] 10:30 AM Resident resting in bed with eyes open. Vital signs taken ,[DATE], 88, 17, 97.6 SPO2 unable to obtain at this time. This morning resident SPO2 was 96%, Residents hands very cold at this time. No SOB or labored breathing at this time. Resident denies pain. No S/S of distress or discomfort. Skin normal in color. Daughter is wanting to check on culture results. Informed her no results as of yet. Daughter stated that resident was seen at the hospital on Monday and they said she had a UTI and was not treated. Explained as soon as we have results doctor will order proper antibiotics. She stated she wants her started on ABT therapy while we are waiting on culture results. Notified on call and awaiting call back at this time. Resident #1's Nurse's Notes on [DATE] at 1130 AM reflected Resident resting in bed with eyes open, Daughter at bedside. VS taken ,[DATE] manual, 98.6, 18, 76. Resident is alert and oriented at this time. Answering questions, resident denies pain at this time. No SOB or labored breathing noted. Fluids encouraged. Informed daughter would check for culture results again, informed daughter that I can send resident to hospital for further evaluation if she would like. Both daughters refused to send to ER. Resident #1's Nurse's Notes on [DATE] at 12:15 PM reflected culture results here. Notified on call. New orders received [MEDICATION NAME] 1 GM IM now then start [MEDICATION NAME] 100 mg BID x 7 days. Notified RP of new orders and administered [MEDICATION NAME] 1GM IM to left gluteal, tolerated well. Vitals signs taken ,[DATE], 78, 98.6, 18. Unable to obtain SPO2 at this time. Resident's hands are cold to touch at this time. No S/S of distress. Resident denies pain or discomfort at this time. Will continue to monitor. Resident #1's Nurse's Notes on [DATE] at 1330 (1:30 PM) reflected resident C/O N/V (complained of nausea and vomiting) [MEDICATION NAME] 4MG given. Resident #1's Nurse's Notes on [DATE] at 1415 (2:15 PM) reflected the resident's daughter approached this nurse and another nurse (RN B) at the desk. Concerned about her mother. Stated she was disoriented and unable to sip through a straw. Offered to send to ER for evaluation. Daughter refused once more. Stated what can they do that you can't. Explained to daughter the hospital can take care of anything and a lot quicker than we can. Daughter refused. Interview with LVN A on [DATE] at 9:20 AM revealed she worked double weekends at the facility and worked on Hall 200. She stated her shifts on the weekends were 6am-10 pm both days. She said on Sunday, [DATE] she left at 2PM. She said a week prior on Monday [DATE], Resident #1 had fallen at the facility and had to be sent to the hospital and she'd been having a lot of falls. A few days prior, LVN A said she had seen herself, Resident #1 just fall out of her wheelchair. She said when she talked to the resident ' s family (date unknown) after the resident returned back to the facility from the [DATE] hospital visit, they told her the hospital had told the family Resident #1 barely had a UTI and the hospital did not want to treat it. LVN A said if a resident had a UTI and it went untreated for [REDACTED]. LVN A said the facility had gotten a UA and lab work on Resident #1 on [DATE] and she was the one who received the UA culture results on the 6A-2P Sunday shift on [DATE]. LVN A said UA cultures usually took 72 hours to be read. She said the UA culture confirmed Resident #1 had a UTI, which we already knew from the urine sample. She said in general when a resident had a UA with CS ordered, the UA usually came back first within 24 hours and indicated if the resident had a UTI, such as urine cloudiness. She said at that point, a doctor could treat the UTI based on the UA, but typically the doctor waited for the culture because if an antibiotic was started prematurely on a resident and did not work, then the next time it was used, that resident would be at risk for being intolerant to it. LVN A said Resident #1s UA would have come in a few days ago. The LVN reviewed the e-chart and said it appeared Resident #1 had fallen on the evening of [DATE] with no injuries. She said neuro checks were initiated that evening. The morning of [DATE] (time not remembered), LVN A said she was able to get an O2 sat on Resident #1 and the reading was 96. When she went back to check her O2 sat again around 10 AM, Resident #1's hands were cold and she could not get a reading. She tried to warm Resident #1's hands under a blanket but the resident kept pulling her hands out. LVN A said she was not concerned she was not able to get an O2 reading because Resident #1 seemed fine, like every other weekend. LVN A did state Resident #1 had thrown up on her shift that day and it was food, which was normal. She was given an anti-nausea medication on the overnight shift before they left at 6AM. LVN A said Resident #1 threw up almost every weekend at least one to two times on her shift and that was not unusual for her. LVN A said Resident #1 had been having increased falls since coming to her hall from the rehab unit. When the UA culture was received on her shift, Sunday [DATE] around 12:15 PM, LVN A said she contacted the MD's on call service and spoke with the NP regarding the culture and sensitivity results. The NP then wrote an order for [REDACTED]. LVN A said previous to the facility getting the order for Rocephen, Resident #1 was alert and oriented and could answer questions, but the family that was visiting did not think she looked right. LVN A said the family declined four times that day to send Resident #1 to the hospital. She said the RP kept asking what the hospital could do that the facility could not. She said when she left the facility at 2 PM, she gave her report to the oncoming nurse, RN B. LVN A said changes in condition were any kind of altered mental status (AMS), change in vitals, temperature increase and anything out of the normal. She said since Resident #1 was long-term, she knew what was normal. Review of telephone order dated [DATE] at 12:30 PM reflected, Roceplin 1 GM IM now, Start [DATE] [MEDICATION NAME] 100 mg BID for 7 days. Interview with RN B on [DATE] at 9:05 PM revealed he was a new RN of the past four months and had no prior nursing experience before that. He worked PRN on the weekends and worked the ,[DATE] PM shift on [DATE] with Resident #1. During his shift change report with LVN A on the 6A-2P shift around 2:00 PM, one of Resident #1's family members came up to them and said the resident could not pull fluids through her straw and was weak. LVN A told the family member she had just given Resident #1 an antibiotic and she was probably weak from a UTI and she would probably feel better the next day. She reassured the family member. LVN A did ask the family member if she wanted her to send Resident #1 to the hospital because the hospital could do things much faster, but he thought LVN A had reassured the family about the antibiotic, she did not feel then it was necessary. The family member left and said she would come back. After that, RN B said he did his rounds. He was in the process of hanging an IV for another resident and administering pain meds when Resident #1's roommate came down the hall in her wheelchair and told him Resident #1 looked bad. He went in to assess the resident, no vital signs were taken. He observed she had tea and a straw next to her. He tried to get her to drink the tea but she was too weak to drink from the straw. He got her water and tried to put the cup directly to her mouth. He reported she was able to drink about ½ a cup. RN B said Resident #1 looked lethargic and out of it, but in his mind, he was thinking about her being dehydrated. She was alert only with her eyes open. He did a quick look at her skin and it was cool and he saw a large knot on her head and her face was bruised. He stated she looked rough. He said no one told him that she had fallen that week. He then asked LVN D to check on Resident #1 because he had to change another resident's IV. She tried to get vitals on Resident #1 and was unsuccessful, then went to talk to RN C who went back into Resident #1's room. RN B stated RN C was unable to get O2 sats because the resident ' s fingers were cold. RN B said that did happen with people, but with Resident #1, hers never warmed up. He said that was when RN C decided to give the resident PRN oxygen via nasal cannula. RN B said he still thought the only issue was the resident was dehydrated. He said during that shift, he worked two different halls so he could not be in Resident #1's room all the time, but they did get her to drink about two cups of fluid over his shift in his estimation. He stated at dinner, he tried to feed her tomato soup and vanilla pudding. He felt she ate about 50%. He said Resident #1 was able to tell him she felt nauseous so he gave her a crushed [MEDICATION NAME] and put it in her soup so she would have an easier time swallowing it. He then asked the CNA to help finish feeding her and left the room. The CNA later reported to RN B that Resident #1 did not eat anything else after RN B had left the room, including the soup that had the crushed anti-nausea medication in it. Around 7:45 PM, a family member came to the facility, saw the resident, then went to RN C to tell her that Resident #1's condition had worsened from earlier that afternoon. RN C called the paramedics. She had seemed out of it from the beginning of the shift, according to RN B. However, he did not feel there was an emergency because Resident #1 had a history of [REDACTED]. RN B said, I was thinking if she could drink for me and if I could get her to drink more, her mental status would be better. He said he did not feel Resident #1 had a change of condition on his shift. RN B revealed he never tried to get O2 sats or call the on-call NP. He said the only alternative he knew of when an O2 sat could not be obtained was to draw blood and have it tested . RN B said he was never told of any low blood pressure readings, UTI, falls or lack of O2 sat from the 6A-2P nurse during the change of shift report. RN B said it never dawned on him Resident #1 could have been becoming septic. He said he learned [MEDICAL CONDITION] in nursing school but did not really know what to look for, he figured some indicators could be low blood pressure, confusion, nausea, vomiting, and high fever followed by a drop in temperature. He said after Resident #1's death, he went online to read [MEDICAL CONDITION] and she seemed to have the criteria for it. Resident #1's Nurse's Notes for [DATE] (Documented at 11:26 PM) by RN C reflected Called into room at 1600 (4:00 PM) after being told that nurse was unable to obtain O2 sats. Patient in bed awake, alert. Able to correctly give her birthdate and tell she was in a nursing home (unable to recall name of facility), Unable to obtain O2 sats. Lungs clear bilaterally to auscultation. Unable to palpate radial pulse. Apical pulse = 100/minute. Received report today that patient had been diagnosed with [REDACTED]. Oxygen started at 2L/minute via nasal cannula. Blood pressure (manual) = ,[DATE], Respirations 26/minute. Auxiliary temp =96.7. Patient drank ½ glass for primary nurse. Daughter came in, she said that her mother was worse now than she had been earlier today (about lunchtime). Stated that her mother (patient) did not realize she was here and that patient stated she saw little puppies on the floor. She asked that her mother be sent to the hospital. On call service notified and approved the transfer, Daughter called at approximately 2200 (10:00 PM) and stated the ambulance when to (name) hospital (a different one than requested) because patient's blood pressure was low and that they didn't know if the patient could make the trip downtown. Review of Resident #1 ' s hospital records were provided by the medical power of attorney and reflected A clinical primary impression [MEDICAL CONDITION] and a secondary impression of dehydrations and a UTI. --On [DATE]: Resident #1 was admitted for altered mental status, her eyes were open but she had no verbal or motor response. Upon ER initial physical exam, her vital signs at 8:53 pm were as follows-pulse ox was 100, blood pressure was ,[DATE], pulse was 100, respirations were 30 and temperature was 95.9, Oxygen was delivered via a [MEDICAL CONDITION]. She had shortness of breath. Her mental status was disoriented to person, place and time. Resident #1 was intubated, a central line was placed and IV fluids were administered. Blood pressure remained unstable. --On [DATE]: Cultures were taken were noted to be markedly acidotic with a high lactic acid and acute [MEDICAL CONDITION].[MEDICAL CONDITION] worsened and Resident #1 given maximum dose of [MEDICATION NAME] plus [MEDICATION NAME]. At 8:16 am, Resident #1 went into Asystole ([MEDICAL CONDITION]) and CPR was initiated. She regained a pulse and blood pressure. Post [MEDICAL CONDITION], doctor noted she had sustained severe [MEDICAL CONDITIONS] and persistent septic shock. While discussing Resident #1 ' s medical course with family and guarded prognosis, the doctor discussed the option of withdrawal of aggressive medical care in light of her [MEDICAL CONDITION] and [MEDICAL CONDITION]. During that conversation, Resident #1 had a second [MEDICAL CONDITION] event. Per family wishes expressed after the initial [MEDICAL CONDITION], the doctor did not attempt a second resuscitation. There were no palpable pulses, no heart sounds. She was declared dead at 9:00 am on [DATE]. Interview with RN C (Weekend supervisor) on [DATE] at 1:35 PM revealed she had not had any issues with Resident #1 on her 2PM-10PM shifts Saturday or Sunday. When she started her shift at 2PM, RN C said she overheard LVN A tell RN B her report on Resident #1. Two family members were present and she overheard LVN A tell them the facility could send the resident to the hospital. RN C said the family members said no. RN C said she was notified by LVN D (not sure of the time) that she could not get a pulse ox on Resident #1. RN C said she tried and could not get one either. RN C said she completed an assessment on Resident #1 at that time and noticed signs and symptoms of dehydration, as indicated by Resident #1's pale mucous membranes in her mouth and eyes. RN C said Resident #1 did appear weak but she was able to take a manual BP and said her atypical pulse was fine (note: this conflicted with her nursing note on [DATE]), regular respirations were okay but she could not get the pulse ox. RN C said Resident #1 did not display any breathing issues and had good air exchange forwards and backwards. RN C said she gave oxygen via nasal cannula and went to RN B to ask what was going on with the resident. RN C said the RN B reported Resident #1 had a UTI and antibiotics had been started that day. RN C said she asked Resident #1 two times after that if she was having any pain, and the resident responded, either no .I don't think so, or no .not really. RN C said Resident #1 did not appear to have AMS. That evening, RN C said the family member called and asked if the resident had eaten. She told the family member RN B had fed her. The family member could not believe it because she said the resident could not drink out of a straw earlier because she was so weak at lunch. The family member then came by the facility to check on Resident #1. She came back out and told RN C Resident #1 was worse than at lunch and she was seeing puppies on the floor. RN C said, So she is hallucinating? and the family member responded yes. RN C said she then informed the family member Resident #1 needed to be sent to the hospital. RN C said she went to see the resident at that time and she was awake. RNC did not indicate she assessed Resident #1 at that time. RN C said she called the NP and explained the resident had dehydration and hallucinations. The NP approved the transfer and the resident was sent out. RN C said she went to look at Resident #1 prior to EMT arrival and she was awake and looking around. She said the family member wanted Resident #1 to be taken to a specific hospital but EMT took Resident #1 to a different hospital because Resident #1's blood pressure was so low they did not know if she would make it to the hospital that was further away. She did not know what the blood pressure was. RN C said s/s of change in condition included a change in mentation, change in vitals, growing weak, not eating and any complaints of discomfort. She said UTIs in the elderly were really distinguishable more by their mentation, as well as quick onset of fever and dysuria (painful or difficult urination) at times. RN C said s/s [MEDICAL CONDITION] was low blood pressure, lower than normal temperature, high pulse and change in mentation. RN C said if a nurse could not get a resident's O2 reading, her expectation would be that she was notified. Further interview with RN C on [DATE] at 4:12 PM revealed a concerning blood pressure reading would be anything under 90 systolic. She said she would expect a MA to notify a charge nurse of a resident's low blood pressure reading so the nurse could do a manual blood pressure. Interview with CNA E on [DATE] at 2:35 PM revealed he had been Resident #1's CNA on [DATE]. He said she was strong, talked well and had sense. He said he worked a double on [DATE] and in the morning she was fine. He said he knew she ate some of her breakfast because he was the one who picked up her tray from her room and she had eaten roughly 50% and had asked for a cup of coffee. Around 3PM, CNA E stated he observed nurses going into her room more. RN B told CNA E Resident #1 was dehydrated and needed fluids. CNA E went into the resident's room with RN B who placed water beside her bed and encouraged CNA E and the other CNAs to try and help get her to drink. CNA E said he tried, but she would not drink. He said her eyes were open but were not moving. He stated his coworker told him the resident had not eaten lunch. CNA E stated, She was so weak. CNA E said after that, he remembered the nurses ended up calling 911during his shift and the resident was sent out. Interview with weekend CNA F on [DATE] at 2:50 PM revealed she worked weekend doubles and said Resident #1 was okay on Saturday, [DATE] and her intake for lunch and dinner was good. On [DATE], Sunday, the family was present while lunch was served to Resident #1 so she did not see how much she ate. CNA F said, She got really quiet and stopped talking after 2PM. She usually talked. Nothing seemed unusual until that afternoon after 4PM, then she it seemed like something was wrong. CNA F said she reported something seemed wrong with Resident #1 to RN B, RN C and LVN A. She said RN B checked Resident #1's vitals and told CNA F to try and feed the resident at dinner. For dinner, CNA F said Resident #1 only would eat some pudding and drank some fruit punch that CNA F fed her. CNA F said Resident #1 would open her mouth for a bite, but her body was not moving. She said the resident looked confused because she would open her eyes and look around in a confused manner. After 7pm, CNA F was working with other residents so she was not sure what happened before Resident #1 was sent out to the hospital. Interview with the NP on [DATE] via telephone at 6:25PM revealed she was the on call NP for MD's medical group the weekend of [DATE] and [DATE]. She had never met Resident #1 as she was not the attending NP for the facility. When asked if she remembered being contacted about Resident #1 who needed to be sent out to the hospital on [DATE] in the evening, she said yes, the family had requested it. She said it was strange because the facility had called her about Resident #1's UA on Saturday [DATE]. They said she kind of had a decline but not to the extent on Sunday when they called her and said the resident had been declining over the past month and a half. NP said, It was frustrating. I sent her out due to family request. I got very little info on her UA. They just called me for a positive UA. If I'd have known she was having a change in condition, I would have started her on IV fluids. She said she ordered the shot of Rocephen to help kick start the antibiotic in her system and did not know what was going on that weekend with Resident #1. NP said, They did not call and inform me Sunday they could not get O2 sats on her or she had a low blood pressure. I was asking them why wasn't her condition presented to me earlier? I was given limited basic info. I was wondering why we were waiting so long if you (facility) are telling me she had been declining for a month, like going from walking to falling to completely immobile? She said the CBC and CMP labs that were done on Resident #1 and collected on [DATE] were never presented to her that weekend. She would have looked at the resident's WB count to see [MEDICAL CONDITION] was a factor, or the BUN and [MEDICATION NAME] for signs of dehydration. No lab results were given to her except the UA. The NP asked if the facility had administered PRN oxygen when the O2 sats were unable to be taken that morning of [DATE]. NP was shocked that PRN oxygen was not administered to the resident the morning of [DATE] when they could not obtain a oxygen sat. She said when a systolic blood pressure was under 90, them something was wrong with the resident. She said she should have been called and expected as the on call NP that Resident #1 ' s information would have been articulated to her promptly. NP was concerned maybe the blood pressure medication had been given that morning. The NP said she was only as good as the information provided to her. She said her expectation of nursing staff when there was no O2 sat readings but a resident appeared stable, was for them to look for: cold skin, blue lips and try to warm them up, take their blood pressure, try a different area with the pulse ox like the earlobe, use a warm washcloth or a blanket to help get them warmer. She said she would expect and SBAR to be completed and for the facility to call her with the SBAR information to get further orders. Interview with Resident #1's MD on [DATE] at 5:15 PM revealed he had a care plan meeting with Resident #1's family member on [DATE] because he/she was concerned about Resident #1's increased falls. During that meeting, he said he explained to the family member what they were seeing was expected and the pattern she displayed was more like multi-infarct dementia/[MEDICAL CONDITION], where there was a more sudden decline than with [MEDICAL CONDITION]. He said he wanted to do blood work and UA first and if he was concerned with the results, he would send the resident to the hospital. The MD said he told the family member he could manage her (Resident #1) but would not keep her if she needed a higher level of care. The MD said he felt in retrospect, The family would have done her (Resident #1) a big favor if they would have left her here because of the stress a resident goes through when transferred out. He said he could have given Resident #1 fluids and IV antibiotics as an option had she not gone to the hospital. MD said if a resident was still alert and he knew the cause of the resident's change in condition, he felt he could treat and bring the resident back around. He said he had been following Resident #1 since admission and knew her. He said everything was put in place after that care plan meeting. The MD [MEDICAL CONDITION] could set in quickly and it depended on the person's immune system. He said low blood pressure was an indication of dehydration and the pulse would typically increase to make sure the person's organs got blood. He felt a concerning blood pressure was when the systolic was less than ,[DATE]; he said the diastolic could vary. He said he always told the nurses to repeat a blood pressure if it was low and it was important to always relate the reading to the symptoms present, if any. MD said, It's called vital signs for a reason. When MD was told during interview that Resident #1's blood pressure reading on [DATE] evening was ,[DATE], he said he did not believe it and if that had been the case, Resident #1 would have been unresponsive and would have had a massive stroke; she would not be alert and her body would have shut down. MD said had the on-call NP been notified earlier on [DATE] of any change in Resident #1's condition, IV fluids or bolus fluids could have been started and certain medications could have been ordered and given intramuscularly to boost her blood pressure. He said the NP had not been notified of any issues with Resident #1. Another interview with the MD on [DATE] at 1:01 PM revealed he and the facility could not send a resident to the hospital if the family did not want them to. He said Resident #1's family was told several times by the facility they could send her to the hospital but they refused. The MD said even if a resident was critical, if the family said no, he would not send the resident out. MD said, I can see where there were some issues with quality of care under assessments.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 10 residents reviewed for neglect. The facility did not recognize, intervene, or consult with the physician when Resident #1 had decreased blood pressure, no attainable oxygen levels, was dehydrated, and became confused and lethargic. The staff did not transfer Resident #1 to the hospital until she began having hallucinations. Resident #1 died the next day in the hospital [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility still monitoring the effectiveness of the Plan Removal. These failures could affect all 97 residents by placing them at risk for delays in treatment and care which could result in serious injury, harm and/ or death. Findings included: Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had adequate hearing, clear speech, usually understood and had adequate vision. She had moderately impaired cognition, no s/s of [MEDICAL CONDITION], no mental status change, and no [MEDICAL CONDITION]. She required extensive assistance for transfers, locomotion, and dressing. She required limited assistance with eating and used a wheelchair for mobility. Her [DIAGNOSES REDACTED]. Resident #1's care plan updated on [DATE] reflected: Problem/Need: Alteration in Elimination-I am incontinent of urine, [DATE], [DATE]. Approach: Ongoing assessment of color, clarity and character of my urine, assess me for signs and symptoms of urinary tract infection, assess me for abdominal distention, assess me for compaction/impaction, assist me with perineal cleaning as needed, observe me for acute behavioral changes that may indicate UTI and evaluate my fluid and hydration status. Review of Resident #1's [DATE] physician's orders [REDACTED].@ 2LPM if O2 sat < 92, O2 sats checked Q shift, [MEDICATION NAME]-HCTZ ,[DATE] mg QD, [MEDICATION NAME] 4mg QAM and Q PRN. Put all meds in pudding or applesauce. Review of Resident #1's Nurse's Notes dated [DATE] reflected the resident fell on the floor while reaching for the phone. She complained of headache and had an elevated blood pressure of ,[DATE]. The resident was transferred to a hospital. The resident returned that evening with a mild concussion, swelling and bruising. Review of the MD's progress note from a visit on [DATE] reflected he saw the resident for a chief complaint of the family was concerned with the resident's current condition, recent falls, dementia and concerns the resident was had [MEDICAL CONDITION]. MD indicated medical records were reviewed from the [DATE] ER hospital visit. The note reflected Resident #1 was alert and oriented to person, place and time, her vitals were- blood pressure ,[DATE], pulse 93, temperature 97.2, respiratory rate 19, she had a normal mood and affect and her behavior was normal. MD's assessment/plan was to order a UA for C/S, CBC and CMP and he advised nurses to call him with the results as soon as possible. Review of Resident #1's Physician's Telephone Order, dated on [DATE] reflected the MD ordered the following labs: CBC, CMP, TSH, B12, Pre-[MEDICATION NAME] and a UA CS. Resident #1's results completed [DATE] at 5:33 PM reflected Resident #1 had high level of BUN at 42 (reference range ,[DATE]) and a high level of CREA at 2.1 (reference range 0XXX,[DATE].3). Both of the high values indicated dehydration). Resident #1's Urine Analysis results dated [DATE] at 5:53 PM indicated Resident #1 had a UTI. The following values were out of reference range: urine clarity (cloudy), urine white blood count (TNTC-too numerous to count), urine LEUK (Large) and urine bacteria (large). The values indicate she had a urinary tract infection. Resident #1's Nurse's Notes dated [DATE] reflected the resident, fell in her room on right side with wheelchair partially on top of her. Unwitnessed. Could not tell staff what had happened. Appeared agitated. No change in level of consciousness. Ordered x-ray for shoulder and reflected no injuries. Review of Resident #1's [DATE] MAR indicated [REDACTED]. The MA G did not circle her initials to reflect the [MEDICATION NAME] was held, nor did she document on the back why the medication was held (per protocol). The 7PM blood pressure check by the MA was ,[DATE]. It reflected the [MEDICATION NAME] was held. Review of Resident #1 ' s blood pressures for [DATE]-[DATE] were an average between ,[DATE] systolic and ,[DATE] diastolic. Interview with MA G on [DATE] at 4:02 PM revealed she worked weekend doubles. She did vitals when the MAR indicated [REDACTED]. She said oxygen saturation levels were taken by the nurses only. MA G reviewed the MAR for Resident #1 for [DATE] and said it reflected her blood pressure at 7AM was ,[DATE]. MA G said, I would not have administered the [MEDICATION NAME] (antihypertensive medication - lowers blood pressure) even though I know it's not circled as being held, but I know I didn't give it. She said Resident #1 took all of her 7AM meds fine that morning after the low blood pressure reading so she did not tell the nurse. MA G indicated the BP reading was alarming that morning but she typically was not concerned unless she noticed a resident was fatigued or were not acting themselves. Then she would report it. As the day progressed, MA G said Resident #1 appeared to get more and more tired. She said went into Resident #1s room around 6:30 PM to get her evening blood pressure and administer medication. She said Resident #1 could not talk at that point and could not respond, her eyes were closed and she appeared to be sleeping. MA G said she tried to wake her up, but she would not respond and looked sleepy, out of it. MA took Resident #1's blood pressure which was ,[DATE]. She said she held the [MEDICATION NAME]. When asked if she notified a nurse about Resident #1's condition, she said she could not remember. When asked why she did not alert the nurses to Resident #1's low blood pressure reading, she responded it was because she saw them going into her room with oxygen so she figured they were already aware of her decline. Review of Resident #1's Respiratory MAR for [DATE] reflected she was not administered any PRN oxygen on [DATE] during any of the shifts prior to transferring to the hospital. Resident #1's UA Culture and Sensitivity received on [DATE] at 10:45AM reflected >100,00 cfu/ml of Escherichia coli, which indicated the resident had an UTI. Resident #1's Nurse's Notes Late entry from LVN A on [DATE] at 6:51 PM reflected on [DATE] 10:30 AM Resident resting in bed with eyes open. Vital signs taken ,[DATE], 88, 17, 97.6 SPO2 unable to obtain at this time. This morning resident SPO2 was 96%, Residents hands very cold at this time. No SOB or labored breathing at this time. Resident denies pain. No S/S of distress or discomfort. Skin normal in color. Daughter is wanting to check on culture results. Informed her no results as of yet. Daughter stated that resident was seen at the hospital on Monday and they said she had a UTI and was not treated. Explained as soon as we have results doctor will order proper antibiotics. She stated she wants her started on ABT therapy while we are waiting on culture results. Notified on call and awaiting call back at this time. Resident #1's Nurse's Notes dated [DATE] at 11:30 AM reflected the resident was resting in bed with eyes open, Daughter at bedside. VS taken ,[DATE] manual, 98.6, 18, 76. Resident is alert and oriented at this time. Answering questions, resident denies pain at this time. No SOB or labored breathing noted. Fluids encouraged. Informed daughter would check for culture results again, informed daughter that I can send resident to hospital for further evaluation if she would like. Both daughters refused to send to ER. Resident #1's Nurse's Notes dated [DATE] at12:15 PM reflected the culture results here. Notified on call. New orders received [MEDICATION NAME] 1 GM IM now then start [MEDICATION NAME] 100 mg BID x 7 days. Notified RP of new orders and administered [MEDICATION NAME] 1GM IM to left gluteal, tolerated well. Vitals signs taken ,[DATE], 78, 98.6, 18. Unable to obtain SPO2 at this time. Resident's hands are cold to touch at this time. No S/S of distress. Resident denies pain or discomfort at this time. Will continue to monitor. Resident #1's Nurse's Notes dated [DATE] at1330 (1:30 PM) reflected the resident C/O N/V (complained of nausea and vomiting) [MEDICATION NAME] 4MG given. Resident #1's Nurse's Notes dated [DATE] at1415 (2:15 PM) reflected the resident's daughter approached this nurse and another nurse (RN B) at the desk. Concerned about her mother. Stated she was disoriented and unable to sip through a straw. Offered to send to ER for evaluation. Daughter refused once more. Stated what can they do that you can't. Explained to daughter the hospital can take care of anything and a lot quicker than we can. Daughter refused. Interview with LVN A on [DATE] at 9:20 AM revealed she worked double weekends at the facility and worked on Hall 200. She stated her shifts on the weekends were 6am-10 pm both days. She said on Sunday, [DATE] she left at 2PM. She said a week prior on Monday [DATE], Resident #1 had fallen at the facility and had to be sent to the hospital and she'd been having a lot of falls. A few days prior, LVN A said she had seen herself, Resident #1 just fall out of her wheelchair. She said when she talked to the resident ' s family (date unknown) after the resident returned back to the facility from the [DATE] hospital visit, they told her the hospital had told the family Resident #1 barely had a UTI and the hospital did not want to treat it. LVN A said if a resident had a UTI and it went untreated for [REDACTED]. LVN A said the facility had gotten a UA and lab work on Resident #1 on [DATE] and she was the one who received the UA culture results on the 6A-2P Sunday shift on [DATE]. LVN A said UA cultures usually took 72 hours to be read. She said the UA culture confirmed Resident #1 had a UTI, which we already knew from the urine sample. She said in general when a resident had a UA with CS ordered, the UA usually came back first within 24 hours and indicated if the resident had a UTI, such as urine cloudiness. She said at that point, a doctor could treat the UTI based on the UA, but typically the doctor waited for the culture because if an antibiotic was started prematurely on a resident and did not work, then the next time it was used, that resident would be at risk for being intolerant to it. LVN A said Resident #1s UA would have come in a few days ago. The LVN reviewed the e-chart and said it appeared Resident #1 had fallen on the evening of [DATE] with no injuries. She said neuro checks were initiated that evening. The morning of [DATE] (time not remembered), LVN A said she was able to get an O2 sat on Resident #1 and the reading was 96. When she went back to check her O2 sat again around 10 AM, Resident #1's hands were cold and she could not get a reading. She tried to warm Resident #1's hands under a blanket but the resident kept pulling her hands out. LVN A said she was not concerned she was not able to get an O2 reading because Resident #1 seemed fine, like every other weekend. LVN A did state Resident #1 had thrown up on her shift that day and it was food, which was normal. She was given an anti-nausea medication on the overnight shift before they left at 6AM. LVN A said Resident #1 threw up almost every weekend at least one to two times on her shift and that was not unusual for her. LVN A said Resident #1 had been having increased falls since coming to her hall from the rehab unit. When the UA culture was received on her shift, Sunday [DATE] around 12:15 PM, LVN A said she contacted the MD's on call service and spoke with the NP regarding the culture and sensitivity results. The NP then wrote an order for [REDACTED]. LVN A said previous to the facility getting the order for Rocephen, Resident #1 was alert and oriented and could answer questions, but the family that was visiting did not think she looked right. LVN A said the family declined four times that day to send Resident #1 to the hospital. She said the RP kept asking what the hospital could do that the facility could not. She said when she left the facility at 2 PM, she gave her report to the oncoming nurse, RN B. LVN A said changes in condition were any kind of altered mental status (AMS), change in vitals, temperature increase and anything out of the normal. She said since Resident #1 was long-term, she knew what was normal. Review of telephone order dated [DATE] at 12:30 PM reflected, Roceplin 1 GM IM now, Start [DATE] [MEDICATION NAME] 100 mg BID for 7 days. Interview with RN B on [DATE] at 9:05 PM revealed he was a new RN of the past four months and had no prior nursing experience before that. He worked PRN on the weekends and worked the ,[DATE] PM shift on [DATE] with Resident #1. During his shift change report with LVN A on the 6A-2P shift around 2:00 PM, one of Resident #1's family members came up to them and said the resident could not pull fluids through her straw and was weak. LVN A told the family member she had just given Resident #1 an antibiotic and she was probably weak from a UTI and she would probably feel better the next day. She reassured the family member. LVN A did ask the family member if she wanted her to send Resident #1 to the hospital because the hospital could do things much faster, but he thought LVN A had reassured the family about the antibiotic, she did not feel then it was necessary. The family member left and said she would come back. After that, RN B said he did his rounds. He was in the process of hanging an IV for another resident and administering pain meds when Resident #1's roommate came down the hall in her wheelchair and told him Resident #1 looked bad. He went in to assess the resident, no vital signs were taken. He observed she had tea and a straw next to her. He tried to get her to drink the tea but she was too weak to drink from the straw. He got her water and tried to put the cup directly to her mouth. He reported she was able to drink about ½ a cup. RN B said Resident #1 looked lethargic and out of it, but in his mind, he was thinking about her being dehydrated. She was alert only with her eyes open. He did a quick look at her skin and it was cool and he saw a large knot on her head and her face was bruised. He stated she looked rough. He said no one told him that she had fallen that week. He then asked LVN D to check on Resident #1 because he had to change another resident's IV. She tried to get vitals on Resident #1 and was unsuccessful, then went to talk to RN C who went back into Resident #1's room. RN B stated RN C was unable to get O2 sats because the resident ' s fingers were cold. RN B said that did happen with people, but with Resident #1, hers never warmed up. He said that was when RN C decided to give the resident PRN oxygen via nasal cannula. RN B said he still thought the only issue was the resident was dehydrated. He said during that shift, he worked two different halls so he could not be in Resident #1's room all the time, but they did get her to drink about two cups of fluid over his shift in his estimation. He stated at dinner, he tried to feed her tomato soup and vanilla pudding. He felt she ate about 50%. He said Resident #1 was able to tell him she felt nauseous so he gave her a crushed [MEDICATION NAME] and put it in her soup so she would have an easier time swallowing it. He then asked the CNA to help finish feeding her and left the room. The CNA later reported to RN B that Resident #1 did not eat anything else after RN B had left the room, including the soup that had the crushed anti-nausea medication in it. Around 7:45 PM, a family member came to the facility, saw the resident, then went to RN C to tell her that Resident #1's condition had worsened from earlier that afternoon. RN C called the paramedics. She had seemed out of it from the beginning of the shift, according to RN B. However, he did not feel there was an emergency because Resident #1 had a history of [REDACTED]. RN B said, I was thinking if she could drink for me and if I could get her to drink more, her mental status would be better. He said he did not feel Resident #1 had a change of condition on his shift. RN B revealed he never tried to get O2 sats or call the on-call NP. He said the only alternative he knew of when an O2 sat could not be obtained was to draw blood and have it tested . RN B said he was never told of any low blood pressure readings, UTI, falls or lack of O2 sat from the 6A-2P nurse during the change of shift report. RN B said it never dawned on him Resident #1 could have been becoming septic. He said he learned [MEDICAL CONDITION] in nursing school but did not really know what to look for, he figured some indicators could be low blood pressure, confusion, nausea, vomiting, and high fever followed by a drop in temperature. He said after Resident #1's death, he went online to read [MEDICAL CONDITION] and she seemed to have the criteria for it. Resident #1's Nurse's Notes for [DATE] (Documented at 11:26 PM) by RN C reflected Called into room at 1600 (4:00 PM) after being told that nurse was unable to obtain O2 sats. Patient in bed awake, alert. Able to correctly give her birthdate and tell she was in a nursing home (unable to recall name of facility), Unable to obtain O2 sats. Lungs clear bilaterally to auscultation. Unable to palpate radial pulse. Apical pulse = 100/minute. Received report today that patient had been diagnosed with [REDACTED]. Oxygen started at 2L/minute via nasal cannula. Blood pressure (manual) = ,[DATE], Respirations 26/minute. Auxiliary temp =96.7. Patient drank ½ glass for primary nurse. Daughter came in, she said that her mother was worse now than she had been earlier today (about lunchtime). Stated that her mother (patient) did not realize she was here and that patient stated she saw little puppies on the floor. She asked that her mother be sent to the hospital. On call service notified and approved the transfer, Daughter called at approximately 2200 (10:00 PM) and stated the ambulance when to (name) hospital (a different one than requested) because patient's blood pressure was low and that they didn't know if the patient could make the trip downtown. Review of Resident #1 ' s hospital records were provided by the medical power of attorney and reflected A clinical primary impression [MEDICAL CONDITION] and a secondary impression of dehydrations and a UTI. --On [DATE]: Resident #1 was admitted for altered mental status, her eyes were open but she had no verbal or motor response. Upon ER initial physical exam, her vital signs at 8:53 pm were as follows-pulse ox was 100, blood pressure was ,[DATE], pulse was 100, respirations were 30 and temperature was 95.9, Oxygen was delivered via a [MEDICAL CONDITION]. She had shortness of breath. Her mental status was disoriented to person, place and time. Resident #1 was intubated, a central line was placed and IV fluids were administered. Blood pressure remained unstable. --On [DATE]: Cultures were taken were noted to be markedly acidotic with a high lactic acid and acute [MEDICAL CONDITION].[MEDICAL CONDITION] worsened and Resident #1 given maximum dose of [MEDICATION NAME] plus [MEDICATION NAME]. At 8:16 am, Resident #1 went into Asystole ([MEDICAL CONDITION]) and CPR was initiated. She regained a pulse and blood pressure. Post [MEDICAL CONDITION], doctor noted she had sustained severe [MEDICAL CONDITIONS] and persistent septic shock. While discussing Resident #1 ' s medical course with family and guarded prognosis, the doctor discussed the option of withdrawal of aggressive medical care in light of her [MEDICAL CONDITION] and [MEDICAL CONDITION]. During that conversation, Resident #1 had a second [MEDICAL CONDITION] event. Per family wishes expressed after the initial [MEDICAL CONDITION], the doctor did not attempt a second resuscitation. There were no palpable pulses, no heart sounds. She was declared dead at 9:00 am on [DATE]. Interview with RN C (Weekend supervisor) on [DATE] at 1:35 PM revealed she had not had any issues with Resident #1 on her 2PM-10PM shifts Saturday or Sunday. When she started her shift at 2PM, RN C said she overheard LVN A tell RN B her report on Resident #1. Two family members were present and she overheard LVN A tell them the facility could send the resident to the hospital. RN C said the family members said no. RN C said she was notified by LVN D (not sure of the time) that she could not get a pulse ox on Resident #1. RN C said she tried and could not get one either. RN C said she completed an assessment on Resident #1 at that time and noticed signs and symptoms of dehydration, as indicated by Resident #1's pale mucous membranes in her mouth and eyes. RN C said Resident #1 did appear weak but she was able to take a manual BP and said her atypical pulse was fine (note: this conflicted with her nursing note on [DATE]), regular respirations were okay but she could not get the pulse ox. RN C said Resident #1 did not display any breathing issues and had good air exchange forwards and backwards. RN C said she gave oxygen via nasal cannula and went to RN B to ask what was going on with the resident. RN C said the RN B reported Resident #1 had a UTI and antibiotics had been started that day. RN C said she asked Resident #1 two times after that if she was having any pain, and the resident responded, either no .I don't think so, or no .not really. RN C said Resident #1 did not appear to have AMS. That evening, RN C said the family member called and asked if the resident had eaten. She told the family member RN B had fed her. The family member could not believe it because she said the resident could not drink out of a straw earlier because she was so weak at lunch. The family member then came by the facility to check on Resident #1. She came back out and told RN C Resident #1 was worse than at lunch and she was seeing puppies on the floor. RN C said, So she is hallucinating? and the family member responded yes. RN C said she then informed the family member Resident #1 needed to be sent to the hospital. RN C said she went to see the resident at that time and she was awake. RNC did not indicate she assessed Resident #1 at that time. RN C said she called the NP and explained the resident had dehydration and hallucinations. The NP approved the transfer and the resident was sent out. RN C said she went to look at Resident #1 prior to EMT arrival and she was awake and looking around. She said the family member wanted Resident #1 to be taken to a specific hospital but EMT took Resident #1 to a different hospital because Resident #1's blood pressure was so low they did not know if she would make it to the hospital that was further away. She did not know what the blood pressure was. RN C said s/s of change in condition included a change in mentation, change in vitals, growing weak, not eating and any complaints of discomfort. She said UTIs in the elderly were really distinguishable more by their mentation, as well as quick onset of fever and dysuria (painful or difficult urination) at times. RN C said s/s [MEDICAL CONDITION] was low blood pressure, lower than normal temperature, high pulse and change in mentation. RN C said if a nurse could not get a resident's O2 reading, her expectation would be that she was notified. Further interview with RN C on [DATE] at 4:12 PM revealed a concerning blood pressure reading would be anything under 90 systolic. She said she would expect a MA to notify a charge nurse of a resident's low blood pressure reading so the nurse could do a manual blood pressure. Interview with CNA E on [DATE] at 2:35 PM revealed he had been Resident #1's CNA on [DATE]. He said she was strong, talked well and had sense. He said he worked a double on [DATE] and in the morning she was fine. He said he knew she ate some of her breakfast because he was the one who picked up her tray from her room and she had eaten roughly 50% and had asked for a cup of coffee. Around 3PM, CNA E stated he observed nurses going into her room more. RN B told CNA E Resident #1 was dehydrated and needed fluids. CNA E went into the resident's room with RN B who placed water beside her bed and encouraged CNA E and the other CNAs to try and help get her to drink. CNA E said he tried, but she would not drink. He said her eyes were open but were not moving. He stated his coworker told him the resident had not eaten lunch. CNA E stated, She was so weak. CNA E said after that, he remembered the nurses ended up calling 911during his shift and the resident was sent out. Interview with weekend CNA F on [DATE] at 2:50 PM revealed she worked weekend doubles and said Resident #1 was okay on Saturday, [DATE] and her intake for lunch and dinner was good. On [DATE], Sunday, the family was present while lunch was served to Resident #1 so she did not see how much she ate. CNA F said, She got really quiet and stopped talking after 2PM. She usually talked. Nothing seemed unusual until that afternoon after 4PM, then she it seemed like something was wrong. CNA F said she reported something seemed wrong with Resident #1 to RN B, RN C and LVN A. She said RN B checked Resident #1's vitals and told CNA F to try and feed the resident at dinner. For dinner, CNA F said Resident #1 only would eat some pudding and drank some fruit punch that CNA F fed her. CNA F said Resident #1 would open her mouth for a bite, but her body was not moving. She said the resident looked confused because she would open her eyes and look around in a confused manner. After 7pm, CNA F was working with other residents so she was not sure what happened before Resident #1 was sent out to the hospital. Interview with the NP on [DATE] via telephone at 6:25PM revealed she was the on call NP for MD's medical group the weekend of [DATE] and [DATE]. She had never met Resident #1 as she was not the attending NP for the facility. When asked if she remembered being contacted about Resident #1 who needed to be sent out to the hospital on [DATE] in the evening, she said yes, the family had requested it. She said it was strange because the facility had called her about Resident #1's UA on Saturday [DATE]. They said she kind of had a decline but not to the extent on Sunday when they called her and said the resident had been declining over the past month and a half. NP said, It was frustrating. I sent her out due to family request. I got very little info on her UA. They just called me for a positive UA. If I'd have known she was having a change in condition, I would have started her on IV fluids. She said she ordered the shot of Rocephen to help kick start the antibiotic in her system and did not know what was going on that weekend with Resident #1. NP said, They did not call and inform me Sunday they could not get O2 sats on her or she had a low blood pressure. I was asking them why wasn't her condition presented to me earlier? I was given limited basic info. I was wondering why we were waiting so long if you (facility) are telling me she had been declining for a month, like going from walking to falling to completely immobile? She said the CBC and CMP labs that were done on Resident #1 and collected on [DATE] were never presented to her that weekend. She would have looked at the resident's WB count to see [MEDICAL CONDITION] was a factor, or the BUN and [MEDICATION NAME] for signs of dehydration. No lab results were given to her except the UA. The NP asked if the facility had administered PRN oxygen when the O2 sats were unable to be taken that morning of [DATE]. NP was shocked that PRN oxygen was not administered to the resident the morning of [DATE] when they could not obtain a oxygen sat. She said when a systolic blood pressure was under 90, them something was wrong with the resident. She said she should have been called and expected as the on call NP that Resident #1 ' s information would have been articulated to her promptly. NP was concerned maybe the blood pressure medication had been given that morning. The NP said she was only as good as the information provided to her. She said her expectation of nursing staff when there was no O2 sat readings but a resident appeared stable, was for them to look for: cold skin, blue lips and try to warm them up, take their blood pressure, try a different area with the pulse ox like the earlobe, use a warm washcloth or a blanket to help get them warmer. She said she would expect and SBAR to be completed and for the facility to call her with the SBAR information to get further orders. Interview with Resident #1's MD on [DATE] at 5:15 PM revealed he had a care plan meeting with Resident #1's family member on [DATE] because he/she was concerned about Resident #1's increased falls. During that meeting, he said he explained to the family member what they were seeing was expected and the pattern she displayed was more like multi-infarct dementia/[MEDICAL CONDITION], where there was a more sudden decline than with [MEDICAL CONDITION]. He said he wanted to do blood work and UA first and if he was concerned with the results, he would send the resident to the hospital. The MD said he told the family member he could manage her (Resident #1) but would not keep her if she needed a higher level of care. The MD said he felt in retrospect, The family would have done her (Resident #1) a big favor if they would have left her here because of the stress a resident goes through when transferred out. He said he could have given Resident #1 fluids and IV antibiotics as an option had she not gone to the hospital. MD said if a resident was still alert and he knew the cause of the resident's change in condition, he felt he could treat and bring the resident back around. He said he had been following Resident #1 since admission and knew her. He said everything was put in place after that care plan meeting. The MD [MEDICAL CONDITION] could set in quickly and it depended on the person's immune system. He said low blood pressure was an indication of dehydration and the pulse would typically increase to make sure the person's organs got blood. He felt a concerning blood pressure was when the systolic was less than ,[DATE]; he said the diastolic could vary. He said he always told the nurses to repeat a blood pressure if it was low and it was important to always relate the reading to the symptoms present, if any. MD said, It's called vital signs for a reason. When MD was told during interview that Resident #1's blood pressure reading on [DATE] evening was ,[DATE], he said he did not believe it and if that had been the case, Resident #1 would have been unresponsive and would have had a massive stroke; she would not be alert and her body would have shut down. MD said had the on-call NP been notified earlier on [DATE] of any change in Resident #1's condition, IV fluids or bolus fluids could have been started and certain medications could have been ordered and given intramuscularly to boost her blood pressure. He said the NP had not been notified of any issues with Resident #1. Another interview with the MD on [DATE] at 1:01 PM revealed he and the facility could not send a resident to the hospital if the family did not want them to. He said Resident #1's family was told several times by the facility they could send her to the hospital but they refused. The MD said even if a resident was critical, if the family said no, he would not send the resident out. MD said, I can see where there were some issues with quality of care under assessments. Review of the MD's progress note was provided by th

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of 11 residents reviewed for neglect. The facility did not recognize, intervene, or consult with the physician when Resident #1 had decreased blood pressure, no attainable oxygen levels, was dehydrated, and became confused and lethargic. The staff did not transfer Resident #1 to the hospital until she began having hallucinations. Resident #1 died the next day in the hospital [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility still monitoring the effectiveness of the Plan Removal. These failures could affect all 97 residents by placing them at risk for delays in treatment and care which could result in serious injury, harm and/ or death. Findings included: 1) Review of facility's Abuse Program revised [DATE] and provided by the ADM on [DATE] reflected, Intent: Each resident has the right to be free from neglect, Definitions .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's Acute Condition Changes-Clinical Protocol dated [DATE] and provided by the DON on [DATE] reflected, .3. The Physician and nursing staff will identify any complications and/or problems that occurred during a recent hospital stay .5. Before contacting a physician about someone with an acute change in condition, the nursing staff will make pertinent observations and collect appropriate information to report to the Physician ., a. Phone calls to attending or on-call physicians should be made by adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status, 6. The nursing staff will contact the Physician based on the urgency of the situation Review of the facility's Change in Resident's Condition or Status policy dated [DATE] reflected, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .d. A significant change in the resident's physical/emotional/mental condition .g. A need to transfer the resident to a hospital .2. A Significant Change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without prompt intervention by staff, b. Impacts more than one of the resident's health status . 2) Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had adequate hearing, clear speech, usually understood and had adequate vision. She had moderately impaired cognition, no s/s of [MEDICAL CONDITION], no mental status change, and no [MEDICAL CONDITION]. She required extensive assistance for transfers, locomotion, and dressing. She required limited assistance with eating and used a wheelchair for mobility. Her [DIAGNOSES REDACTED]. Resident #1's care plan updated on [DATE] reflected: Problem/Need: Alteration in Elimination-I am incontinent of urine, [DATE], [DATE]. Approach: Ongoing assessment of color, clarity and character of my urine, assess me for signs and symptoms of urinary tract infection, assess me for abdominal distention, assess me for compaction/impaction, assist me with perineal cleaning as needed, observe me for acute behavioral changes that may indicate UTI and evaluate my fluid and hydration status. Review of Resident #1's [DATE] physician's orders [REDACTED].@ 2LPM if O2 sat < 92, O2 sats checked Q shift, [MEDICATION NAME]-HCTZ ,[DATE] mg QD, [MEDICATION NAME] 4mg QAM and Q PRN. Put all meds in pudding or applesauce. Review of Resident #1's Nurse's Notes dated [DATE] reflected the resident fell on the floor while reaching for the phone. She complained of headache and had an elevated blood pressure of ,[DATE]. The resident was transferred to a hospital. The resident returned that evening with a mild concussion, swelling and bruising. Review of the MD's progress note from a visit on [DATE] reflected he saw the resident for a chief complaint of the family was concerned with the resident's current condition, recent falls, dementia and concerns the resident was had [MEDICAL CONDITION]. MD indicated medical records were reviewed from the [DATE] ER hospital visit. The note reflected Resident #1 was alert and oriented to person, place and time, her vitals were- blood pressure ,[DATE], pulse 93, temperature 97.2, respiratory rate 19, she had a normal mood and affect and her behavior was normal. MD's assessment/plan was to order a UA for C/S, CBC and CMP and he advised nurses to call him with the results as soon as possible. Review of Resident #1's Physician's Telephone Order, dated on [DATE] reflected the MD ordered the following labs: CBC, CMP, TSH, B12, Pre-[MEDICATION NAME] and a UA CS. Resident #1's results completed [DATE] at 5:33 PM reflected Resident #1 had high level of BUN at 42 (reference range ,[DATE]) and a high level of CREA at 2.1 (reference range 0XXX,[DATE].3). Both of the high values indicated dehydration). Resident #1's Urine Analysis results dated [DATE] at 5:53 PM indicated Resident #1 had a UTI. The following values were out of reference range: urine clarity (cloudy), urine white blood count (TNTC-too numerous to count), urine LEUK (Large) and urine bacteria (large). The values indicate she had a urinary tract infection. Resident #1's Nurse's Notes dated [DATE] reflected the resident, fell in her room on right side with wheelchair partially on top of her. Unwitnessed. Could not tell staff what had happened. Appeared agitated. No change in level of consciousness. Ordered x-ray for shoulder and reflected no injuries. Review of Resident #1's [DATE] MAR indicated [REDACTED]. The MA G did not circle her initials to reflect the [MEDICATION NAME] was held, nor did she document on the back why the medication was held (per protocol). The 7PM blood pressure check by the MA was ,[DATE]. It reflected the [MEDICATION NAME] was held. Review of Resident #1 ' s blood pressures for [DATE]-[DATE] were an average between ,[DATE] systolic and ,[DATE] diastolic. Interview with MA G on [DATE] at 4:02 PM revealed she worked weekend doubles. She did vitals when the MAR indicated [REDACTED]. She said oxygen saturation levels were taken by the nurses only. MA G reviewed the MAR for Resident #1 for [DATE] and said it reflected her blood pressure at 7AM was ,[DATE]. MA G said, I would not have administered the [MEDICATION NAME] (antihypertensive medication - lowers blood pressure) even though I know it's not circled as being held, but I know I didn't give it. She said Resident #1 took all of her 7AM meds fine that morning after the low blood pressure reading so she did not tell the nurse. MA G indicated the BP reading was alarming that morning but she typically was not concerned unless she noticed a resident was fatigued or were not acting themselves. Then she would report it. As the day progressed, MA G said Resident #1 appeared to get more and more tired. She said went into Resident #1s room around 6:30 PM to get her evening blood pressure and administer medication. She said Resident #1 could not talk at that point and could not respond, her eyes were closed and she appeared to be sleeping. MA G said she tried to wake her up, but she would not respond and looked sleepy, out of it. MA took Resident #1's blood pressure which was ,[DATE]. She said she held the [MEDICATION NAME]. When asked if she notified a nurse about Resident #1's condition, she said she could not remember. When asked why she did not alert the nurses to Resident #1's low blood pressure reading, she responded it was because she saw them going into her room with oxygen so she figured they were already aware of her decline. Review of Resident #1's Respiratory MAR for [DATE] reflected she was not administered any PRN oxygen on [DATE] during any of the shifts prior to transferring to the hospital. Resident #1's UA Culture and Sensitivity received on [DATE] at 10:45AM reflected >100,00 cfu/ml of Escherichia coli, which indicated the resident had an UTI. Resident #1's Nurse's Notes Late entry from LVN A on [DATE] at 6:51 PM reflected on [DATE] 10:30 AM Resident resting in bed with eyes open. Vital signs taken ,[DATE], 88, 17, 97.6 SPO2 unable to obtain at this time. This morning resident SPO2 was 96%, Residents hands very cold at this time. No SOB or labored breathing at this time. Resident denies pain. No S/S of distress or discomfort. Skin normal in color. Daughter is wanting to check on culture results. Informed her no results as of yet. Daughter stated that resident was seen at the hospital on Monday and they said she had a UTI and was not treated. Explained as soon as we have results doctor will order proper antibiotics. She stated she wants her started on ABT therapy while we are waiting on culture results. Notified on call and awaiting call back at this time. Resident #1's Nurse's Notes on [DATE] at 11:30 AM reflected the resident resting in bed with eyes open, Daughter at bedside. VS taken ,[DATE] manual, 98.6, 18, 76. Resident is alert and oriented at this time. Answering questions, resident denies pain at this time. No SOB or labored breathing noted. Fluids encouraged. Informed daughter would check for culture results again, informed daughter that I can send resident to hospital for further evaluation if she would like. Both daughters refused to send to ER. Resident #1's Nurse's Notes on [DATE] at 12:15 PM reflected the culture results here. Notified on call. New orders received [MEDICATION NAME] 1 GM IM now then start [MEDICATION NAME] 100 mg BID x 7 days. Notified RP of new orders and administered [MEDICATION NAME] 1GM IM to left gluteal, tolerated well. Vitals signs taken ,[DATE], 78, 98.6, 18. Unable to obtain SPO2 at this time. Resident's hands are cold to touch at this time. No S/S of distress. Resident denies pain or discomfort at this time. Will continue to monitor. Resident #1's Nurse's Notes on [DATE] at 1330 (1:30 PM) reflected the resident's C/O N/V (complained of nausea and vomiting) [MEDICATION NAME] 4MG given. Resident #1's Nurse's Notes on [DATE] at 1415 (2:15 PM) reflected the fesident's daughter approached this nurse and another nurse (RN B) at the desk. Concerned about her mother. Stated she was disoriented and unable to sip through a straw. Offered to send to ER for evaluation. Daughter refused once more. Stated what can they do that you can't. Explained to daughter the hospital can take care of anything and a lot quicker than we can. Daughter refused. Interview with LVN A on [DATE] at 9:20 AM revealed she worked double weekends at the facility and worked on Hall 200. She stated her shifts on the weekends were 6am-10 pm both days. She said on Sunday, [DATE] she left at 2PM. She said a week prior on Monday [DATE], Resident #1 had fallen at the facility and had to be sent to the hospital and she'd been having a lot of falls. A few days prior, LVN A said she had seen herself, Resident #1 just fall out of her wheelchair. She said when she talked to the resident ' s family (date unknown) after the resident returned back to the facility from the [DATE] hospital visit, they told her the hospital had told the family Resident #1 barely had a UTI and the hospital did not want to treat it. LVN A said if a resident had a UTI and it went untreated for [REDACTED]. LVN A said the facility had gotten a UA and lab work on Resident #1 on [DATE] and she was the one who received the UA culture results on the 6A-2P Sunday shift on [DATE]. LVN A said UA cultures usually took 72 hours to be read. She said the UA culture confirmed Resident #1 had a UTI, which we already knew from the urine sample. She said in general when a resident had a UA with CS ordered, the UA usually came back first within 24 hours and indicated if the resident had a UTI, such as urine cloudiness. She said at that point, a doctor could treat the UTI based on the UA, but typically the doctor waited for the culture because if an antibiotic was started prematurely on a resident and did not work, then the next time it was used, that resident would be at risk for being intolerant to it. LVN A said Resident #1s UA would have come in a few days ago. The LVN reviewed the e-chart and said it appeared Resident #1 had fallen on the evening of [DATE] with no injuries. She said neuro checks were initiated that evening. The morning of [DATE] (time not remembered), LVN A said she was able to get an O2 sat on Resident #1 and the reading was 96. When she went back to check her O2 sat again around 10 AM, Resident #1's hands were cold and she could not get a reading. She tried to warm Resident #1's hands under a blanket but the resident kept pulling her hands out. LVN A said she was not concerned she was not able to get an O2 reading because Resident #1 seemed fine, like every other weekend. LVN A did state Resident #1 had thrown up on her shift that day and it was food, which was normal. She was given an anti-nausea medication on the overnight shift before they left at 6AM. LVN A said Resident #1 threw up almost every weekend at least one to two times on her shift and that was not unusual for her. LVN A said Resident #1 had been having increased falls since coming to her hall from the rehab unit. When the UA culture was received on her shift, Sunday [DATE] around 12:15 PM, LVN A said she contacted the MD's on call service and spoke with the NP regarding the culture and sensitivity results. The NP then wrote an order for [REDACTED]. LVN A said previous to the facility getting the order for Rocephen, Resident #1 was alert and oriented and could answer questions, but the family that was visiting did not think she looked right. LVN A said the family declined four times that day to send Resident #1 to the hospital. She said the RP kept asking what the hospital could do that the facility could not. She said when she left the facility at 2 PM, she gave her report to the oncoming nurse, RN B. LVN A said changes in condition were any kind of altered mental status (AMS), change in vitals, temperature increase and anything out of the normal. She said since Resident #1 was long-term, she knew what was normal. Review of telephone order dated [DATE] at 12:30 PM reflected, Roceplin 1 GM IM now, Start [DATE] [MEDICATION NAME] 100 mg BID for 7 days. Interview with RN B on [DATE] at 9:05 PM revealed he was a new RN of the past four months and had no prior nursing experience before that. He worked PRN on the weekends and worked the ,[DATE] PM shift on [DATE] with Resident #1. During his shift change report with LVN A on the 6A-2P shift around 2:00 PM, one of Resident #1's family members came up to them and said the resident could not pull fluids through her straw and was weak. LVN A told the family member she had just given Resident #1 an antibiotic and she was probably weak from a UTI and she would probably feel better the next day. She reassured the family member. LVN A did ask the family member if she wanted her to send Resident #1 to the hospital because the hospital could do things much faster, but he thought LVN A had reassured the family about the antibiotic, she did not feel then it was necessary. The family member left and said she would come back. After that, RN B said he did his rounds. He was in the process of hanging an IV for another resident and administering pain meds when Resident #1's roommate came down the hall in her wheelchair and told him Resident #1 looked bad. He went in to assess the resident, no vital signs were taken. He observed she had tea and a straw next to her. He tried to get her to drink the tea but she was too weak to drink from the straw. He got her water and tried to put the cup directly to her mouth. He reported she was able to drink about ½ a cup. RN B said Resident #1 looked lethargic and out of it, but in his mind, he was thinking about her being dehydrated. She was alert only with her eyes open. He did a quick look at her skin and it was cool and he saw a large knot on her head and her face was bruised. He stated she looked rough. He said no one told him that she had fallen that week. He then asked LVN D to check on Resident #1 because he had to change another resident's IV. She tried to get vitals on Resident #1 and was unsuccessful, then went to talk to RN C who went back into Resident #1's room. RN B stated RN C was unable to get O2 sats because the resident ' s fingers were cold. RN B said that did happen with people, but with Resident #1, hers never warmed up. He said that was when RN C decided to give the resident PRN oxygen via nasal cannula. RN B said he still thought the only issue was the resident was dehydrated. He said during that shift, he worked two different halls so he could not be in Resident #1's room all the time, but they did get her to drink about two cups of fluid over his shift in his estimation. He stated at dinner, he tried to feed her tomato soup and vanilla pudding. He felt she ate about 50%. He said Resident #1 was able to tell him she felt nauseous so he gave her a crushed [MEDICATION NAME] and put it in her soup so she would have an easier time swallowing it. He then asked the CNA to help finish feeding her and left the room. The CNA later reported to RN B that Resident #1 did not eat anything else after RN B had left the room, including the soup that had the crushed anti-nausea medication in it. Around 7:45 PM, a family member came to the facility, saw the resident, then went to RN C to tell her that Resident #1's condition had worsened from earlier that afternoon. RN C called the paramedics. She had seemed out of it from the beginning of the shift, according to RN B. However, he did not feel there was an emergency because Resident #1 had a history of [REDACTED]. RN B said, I was thinking if she could drink for me and if I could get her to drink more, her mental status would be better. He said he did not feel Resident #1 had a change of condition on his shift. RN B revealed he never tried to get O2 sats or call the on-call NP. He said the only alternative he knew of when an O2 sat could not be obtained was to draw blood and have it tested . RN B said he was never told of any low blood pressure readings, UTI, falls or lack of O2 sat from the 6A-2P nurse during the change of shift report. RN B said it never dawned on him Resident #1 could have been becoming septic. He said he learned [MEDICAL CONDITION] in nursing school but did not really know what to look for, he figured some indicators could be low blood pressure, confusion, nausea, vomiting, and high fever followed by a drop in temperature. He said after Resident #1's death, he went online to read [MEDICAL CONDITION] and she seemed to have the criteria for it. Resident #1's Nurse's Notes for [DATE] (Documented at 11:26 PM) by RN C reflected Called into room at 1600 (4:00 PM) after being told that nurse was unable to obtain O2 sats. Patient in bed awake, alert. Able to correctly give her birthdate and tell she was in a nursing home (unable to recall name of facility), Unable to obtain O2 sats. Lungs clear bilaterally to auscultation. Unable to palpate radial pulse. Apical pulse = 100/minute. Received report today that patient had been diagnosed with [REDACTED]. Oxygen started at 2L/minute via nasal cannula. Blood pressure (manual) = ,[DATE], Respirations 26/minute. Auxiliary temp =96.7. Patient drank ½ glass for primary nurse. Daughter came in, she said that her mother was worse now than she had been earlier today (about lunchtime). Stated that her mother (patient) did not realize she was here and that patient stated she saw little puppies on the floor. She asked that her mother be sent to the hospital. On call service notified and approved the transfer, Daughter called at approximately 2200 (10:00 PM) and stated the ambulance when to (name) hospital (a different one than requested) because patient's blood pressure was low and that they didn't know if the patient could make the trip downtown. Review of Resident #1 ' s hospital records were provided by the medical power of attorney and reflected A clinical primary impression [MEDICAL CONDITION] and a secondary impression of dehydrations and a UTI. --On [DATE]: Resident #1 was admitted for altered mental status, her eyes were open but she had no verbal or motor response. Upon ER initial physical exam, her vital signs at 8:53 pm were as follows-pulse ox was 100, blood pressure was ,[DATE], pulse was 100, respirations were 30 and temperature was 95.9, Oxygen was delivered via a [MEDICAL CONDITION]. She had shortness of breath. Her mental status was disoriented to person, place and time. Resident #1 was intubated, a central line was placed and IV fluids were administered. Blood pressure remained unstable. --On [DATE]: Cultures were taken were noted to be markedly acidotic with a high lactic acid and acute [MEDICAL CONDITION].[MEDICAL CONDITION] worsened and Resident #1 given maximum dose of [MEDICATION NAME] plus [MEDICATION NAME]. At 8:16 am, Resident #1 went into Asystole ([MEDICAL CONDITION]) and CPR was initiated. She regained a pulse and blood pressure. Post [MEDICAL CONDITION], doctor noted she had sustained severe [MEDICAL CONDITIONS] and persistent septic shock. While discussing Resident #1 ' s medical course with family and guarded prognosis, the doctor discussed the option of withdrawal of aggressive medical care in light of her [MEDICAL CONDITION] and [MEDICAL CONDITION]. During that conversation, Resident #1 had a second [MEDICAL CONDITION] event. Per family wishes expressed after the initial [MEDICAL CONDITION], the doctor did not attempt a second resuscitation. There were no palpable pulses, no heart sounds. She was declared dead at 9:00 am on [DATE]. Interview with RN C (Weekend supervisor) on [DATE] at 1:35 PM revealed she had not had any issues with Resident #1 on her 2PM-10PM shifts Saturday or Sunday. When she started her shift at 2PM, RN C said she overheard LVN A tell RN B her report on Resident #1. Two family members were present and she overheard LVN A tell them the facility could send the resident to the hospital. RN C said the family members said no. RN C said she was notified by LVN D (not sure of the time) that she could not get a pulse ox on Resident #1. RN C said she tried and could not get one either. RN C said she completed an assessment on Resident #1 at that time and noticed signs and symptoms of dehydration, as indicated by Resident #1's pale mucous membranes in her mouth and eyes. RN C said Resident #1 did appear weak but she was able to take a manual BP and said her atypical pulse was fine (note: this conflicted with her nursing note on [DATE]), regular respirations were okay but she could not get the pulse ox. RN C said Resident #1 did not display any breathing issues and had good air exchange forwards and backwards. RN C said she gave oxygen via nasal cannula and went to RN B to ask what was going on with the resident. RN C said the RN B reported Resident #1 had a UTI and antibiotics had been started that day. RN C said she asked Resident #1 two times after that if she was having any pain, and the resident responded, either no .I don't think so, or no .not really. RN C said Resident #1 did not appear to have AMS. That evening, RN C said the family member called and asked if the resident had eaten. She told the family member RN B had fed her. The family member could not believe it because she said the resident could not drink out of a straw earlier because she was so weak at lunch. The family member then came by the facility to check on Resident #1. She came back out and told RN C Resident #1 was worse than at lunch and she was seeing puppies on the floor. RN C said, So she is hallucinating? and the family member responded yes. RN C said she then informed the family member Resident #1 needed to be sent to the hospital. RN C said she went to see the resident at that time and she was awake. RNC did not indicate she assessed Resident #1 at that time. RN C said she called the NP and explained the resident had dehydration and hallucinations. The NP approved the transfer and the resident was sent out. RN C said she went to look at Resident #1 prior to EMT arrival and she was awake and looking around. She said the family member wanted Resident #1 to be taken to a specific hospital but EMT took Resident #1 to a different hospital because Resident #1's blood pressure was so low they did not know if she would make it to the hospital that was further away. She did not know what the blood pressure was. RN C said s/s of change in condition included a change in mentation, change in vitals, growing weak, not eating and any complaints of discomfort. She said UTIs in the elderly were really distinguishable more by their mentation, as well as quick onset of fever and dysuria (painful or difficult urination) at times. RN C said s/s [MEDICAL CONDITION] was low blood pressure, lower than normal temperature, high pulse and change in mentation. RN C said if a nurse could not get a resident's O2 reading, her expectation would be that she was notified. Further interview with RN C on [DATE] at 4:12 PM revealed a concerning blood pressure reading would be anything under 90 systolic. She said she would expect a MA to notify a charge nurse of a resident's low blood pressure reading so the nurse could do a manual blood pressure. Interview with CNA E on [DATE] at 2:35 PM revealed he had been Resident #1's CNA on [DATE]. He said she was strong, talked well and had sense. He said he worked a double on [DATE] and in the morning she was fine. He said he knew she ate some of her breakfast because he was the one who picked up her tray from her room and she had eaten roughly 50% and had asked for a cup of coffee. Around 3PM, CNA E stated he observed nurses going into her room more. RN B told CNA E Resident #1 was dehydrated and needed fluids. CNA E went into the resident's room with RN B who placed water beside her bed and encouraged CNA E and the other CNAs to try and help get her to drink. CNA E said he tried, but she would not drink. He said her eyes were open but were not moving. He stated his coworker told him the resident had not eaten lunch. CNA E stated, She was so weak. CNA E said after that, he remembered the nurses ended up calling 911during his shift and the resident was sent out. Interview with weekend CNA F on [DATE] at 2:50 PM revealed she worked weekend doubles and said Resident #1 was okay on Saturday, [DATE] and her intake for lunch and dinner was good. On [DATE], Sunday, the family was present while lunch was served to Resident #1 so she did not see how much she ate. CNA F said, She got really quiet and stopped talking after 2PM. She usually talked. Nothing seemed unusual until that afternoon after 4PM, then she it seemed like something was wrong. CNA F said she reported something seemed wrong with Resident #1 to RN B, RN C and LVN A. She said RN B checked Resident #1's vitals and told CNA F to try and feed the resident at dinner. For dinner, CNA F said Resident #1 only would eat some pudding and drank some fruit punch that CNA F fed her. CNA F said Resident #1 would open her mouth for a bite, but her body was not moving. She said the resident looked confused because she would open her eyes and look around in a confused manner. After 7pm, CNA F was working with other residents so she was not sure what happened before Resident #1 was sent out to the hospital. Interview with the NP on [DATE] via telephone at 6:25PM revealed she was the on call NP for MD's medical group the weekend of [DATE] and [DATE]. She had never met Resident #1 as she was not the attending NP for the facility. When asked if she remembered being contacted about Resident #1 who needed to be sent out to the hospital on [DATE] in the evening, she said yes, the family had requested it. She said it was strange because the facility had called her about Resident #1's UA on Saturday [DATE]. They said she kind of had a decline but not to the extent on Sunday when they called her and said the resident had been declining over the past month and a half. NP said, It was frustrating. I sent her out due to family request. I got very little info on her UA. They just called me for a positive UA. If I'd have known she was having a change in condition, I would have started her on IV fluids. She said she ordered the shot of Rocephen to help kick start the antibiotic in her system and did not know what was going on that weekend with Resident #1. NP said, They did not call and inform me Sunday they could not get O2 sats on her or she had a low blood pressure. I was asking them why wasn't her condition presented to me earlier? I was given limited basic info. I was wondering why we were waiting so long if you (facility) are telling me she had been declining for a month, like going from walking to falling to completely immobile? She said the CBC and CMP labs that were done on Resident #1 and collected on [DATE] were never presented to her that weekend. She would have looked at the resident's WB count to see [MEDICAL CONDITION] was a factor, or the BUN and [MEDICATION NAME] for signs of dehydration. No lab results were given to her except the UA. The NP asked if the facility had administered PRN oxygen when the O2 sats were unable to be taken that morning of [DATE]. NP was shocked that PRN oxygen was not administered to the resident the morning of [DATE] when they could not obtain a oxygen sat. She said when a systolic blood pressure was under 90, them something was wrong with the resident. She said she should have been called and expected as the on call NP that Resident #1 ' s information would have been articulated to her promptly. NP was concerned maybe the blood pressure medication had been given that morning. The NP said she was only as good as the information provided to her. She said her expectation of nursing staff when there was no O2 sat readings but a resident appeared stable, was for them to look for: cold skin, blue lips and try to warm them up, take their blood pressure, try a different area with the pulse ox like the earlobe, use a warm washcloth or a blanket to help get them warmer. She said she would expect and SBAR to be completed and for the facility to call her with the SBAR information to get further orders. Interview with Resident #1's MD on [DATE] at 5:15 PM revealed he had a care plan meeting with Resident #1's family member on [DATE] because he/she was concerned about Resident #1's increased falls. During that meeting, he said he explained to the family member what they were seeing was expected and the pattern she displayed was more like multi-infarct dementia/[MEDICAL CONDITION], where there was a more sudden decline than with [MEDICAL CONDITION]. He said he wanted to do blood work and UA first and if he was concerned with the results, he would send the resident to the hospital. The MD said he told the family member he could manage her (Resident #1) but would not keep her if she needed a higher level of care. The MD said he felt in retrospect, The family would have done her (Resident #1) a big favor if they would have left her here because of the stress a resident goes through when transferred out. He said he could have given Resident #1 fluids and IV antibiotics as an option had she not gone to the hospital. MD said if a resident was still alert and he knew the cause of the resident's change in condition, he felt he could treat and bring the resident back around. He said he had

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 #1 ) of 11 residents reviewed for quality of care. The facility did not recognize, intervene, or consult with the physician when Resident #1 had decreased blood pressure, no attainable oxygen levels, was dehydrated, and became confused and lethargic. The staff did not transfer Resident #1 to the hospital until she began having hallucinations. Resident #1 died the next day in the hospital [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a pattern of actual harm due to the facility still monitoring the effectiveness of the Plan Removal. These failures could affect all 97 residents by placing them at risk for delays in treatment and care which could result in serious injury, harm and/ or death. Findings included: 1) Resident #1's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had adequate hearing, clear speech, usually understood and had adequate vision. She had moderately impaired cognition, no s/s of [MEDICAL CONDITION], no mental status change, and no [MEDICAL CONDITION]. She required extensive assistance for transfers, locomotion, and dressing. She required limited assistance with eating and used a wheelchair for mobility. Her [DIAGNOSES REDACTED]. Resident #1's care plan updated on [DATE] reflected: Problem/Need: Alteration in Elimination-I am incontinent of urine, [DATE], [DATE]. Approach: Ongoing assessment of color, clarity and character of my urine, assess me for signs and symptoms of urinary tract infection, assess me for abdominal distention, assess me for compaction/impaction, assist me with perineal cleaning as needed, observe me for acute behavioral changes that may indicate UTI and evaluate my fluid and hydration status. Review of Resident #1's [DATE] physician's orders [REDACTED].@ 2LPM if O2 sat < 92, O2 sats checked Q shift, [MEDICATION NAME]-HCTZ ,[DATE] mg QD, [MEDICATION NAME] 4mg QAM and Q PRN. Put all meds in pudding or applesauce. Review of Resident #1's Nurse's Notes dated [DATE] reflected the resident fell on the floor while reaching for the phone. She complained of headache and had an elevated blood pressure of ,[DATE]. The resident was transferred to a hospital. The resident returned that evening with a mild concussion, swelling and bruising. Review of Resident #1's Physician's Telephone Order, dated on [DATE] reflected the MD ordered the following labs: CBC, CMP, TSH, B12, Pre-[MEDICATION NAME] and a UA CS. Resident #1's results completed [DATE] at 5:33 PM reflected Resident #1 had high level of BUN at 42 (reference range ,[DATE]) and a high level of CREA at 2.1 (reference range 0XXX,[DATE].3). Both of the high values indicated dehydration). Resident #1's Urine Analysis results dated [DATE] at 5:53 PM indicated Resident #1 had a UTI. The following values were out of reference range: urine clarity (cloudy), urine white blood count (TNTC-too numerous to count), urine LEUK (Large) and urine bacteria (large). The values indicate she had a urinary tract infection. Resident #1's Nurse's Notes dated [DATE] reflected the resident, fell in her room on right side with wheelchair partially on top of her. Unwitnessed. Could not tell staff what had happened. Appeared agitated. No change in level of consciousness. Ordered x-ray for shoulder and reflected no injuries. Review of Resident #1's [DATE] MAR indicated [REDACTED]. The MA G did not circle her initials to reflect the [MEDICATION NAME] was held, nor did she document on the back why the medication was held (per protocol). The 7PM blood pressure check by the MA was ,[DATE]. It reflected the [MEDICATION NAME] was held. Review of Resident #1 ' s blood pressures for [DATE]-[DATE] were an average between ,[DATE] systolic and ,[DATE] diastolic. Interview with MA G on [DATE] at 4:02 PM revealed she worked weekend doubles. She did vitals when the MAR indicated [REDACTED]. She said oxygen saturation levels were taken by the nurses only. MA G reviewed the MAR for Resident #1 for [DATE] and said it reflected her blood pressure at 7AM was ,[DATE]. MA G said, I would not have administered the [MEDICATION NAME] (antihypertensive medication - lowers blood pressure) even though I know it's not circled as being held, but I know I didn't give it. She said Resident #1 took all of her 7AM meds fine that morning after the low blood pressure reading so she did not tell the nurse. MA G indicated the BP reading was alarming that morning but she typically was not concerned unless she noticed a resident was fatigued or were not acting themselves. Then she would report it. As the day progressed, MA G said Resident #1 appeared to get more and more tired. She said went into Resident #1s room around 6:30 PM to get her evening blood pressure and administer medication. She said Resident #1 could not talk at that point and could not respond, her eyes were closed and she appeared to be sleeping. MA G said she tried to wake her up, but she would not respond and looked sleepy, out of it. MA took Resident #1's blood pressure which was ,[DATE]. She said she held the [MEDICATION NAME]. When asked if she notified a nurse about Resident #1's condition, she said she could not remember. When asked why she did not alert the nurses to Resident #1's low blood pressure reading, she responded it was because she saw them going into her room with oxygen so she figured they were already aware of her decline. Review of Resident #1's Respiratory MAR for [DATE] reflected she was not administered any PRN oxygen on [DATE] during any of the shifts prior to transferring to the hospital. Resident #1's UA Culture and Sensitivity received on [DATE] at 10:45AM reflected >100,00 cfu/ml of Escherichia coli, which indicated the resident had an UTI. Resident #1's Nurse's Notes Late entry from LVN A on [DATE] at 6:51 PM reflected on [DATE] 10:30 AM Resident resting in bed with eyes open. Vital signs taken ,[DATE], 88, 17, 97.6 SPO2 unable to obtain at this time. This morning resident SPO2 was 96%, Residents hands very cold at this time. No SOB or labored breathing at this time. Resident denies pain. No S/S of distress or discomfort. Skin normal in color. Daughter is wanting to check on culture results. Informed her no results as of yet. Daughter stated that resident was seen at the hospital on Monday and they said she had a UTI and was not treated. Explained as soon as we have results doctor will order proper antibiotics. She stated she wants her started on ABT therapy while we are waiting on culture results. Notified on call and awaiting call back at this time. 1130 Resident resting in bed with eyes open, Daughter at bedside. VS taken ,[DATE] manual, 98.6, 18, 76. Resident is alert and oriented at this time. Answering questions, resident denies pain at this time. No SOB or labored breathing noted. Fluids encouraged. Informed daughter would check for culture results again, informed daughter that I can send resident to hospital for further evaluation if she would like. Both daughters refused to send to ER. 1215 Culture results here. Notified on call. New orders received [MEDICATION NAME] 1 GM IM now then start [MEDICATION NAME] 100 mg BID x 7 days. Notified RP of new orders and administered [MEDICATION NAME] 1GM IM to left gluteal, tolerated well. Vitals signs taken ,[DATE], 78, 98.6, 18. Unable to obtain SPO2 at this time. Resident's hands are cold to touch at this time. No S/S of distress. Resident denies pain or discomfort at this time. Will continue to monitor. 1330 (1:30 PM) Resident C/O N/V (complained of nausea and vomiting) [MEDICATION NAME] 4MG given. 1415 (2:15 PM) Residents daughter approached this nurse and another nurse (RN B) at the desk. Concerned about her mother. Stated she was disoriented and unable to sip through a straw. Offered to send to ER for evaluation. Daughter refused once more. Stated what can they do that you can't. Explained to daughter the hospital can take care of anything and a lot quicker than we can. Daughter refused. Interview with LVN A on [DATE] at 9:20 AM revealed she worked double weekends at the facility and worked on Hall 200. She stated her shifts on the weekends were 6am-10 pm both days. She said on Sunday, [DATE] she left at 2PM. She said a week prior on Monday [DATE], Resident #1 had fallen at the facility and had to be sent to the hospital and she'd been having a lot of falls. A few days prior, LVN A said she had seen herself, Resident #1 just fall out of her wheelchair. She said when she talked to the resident ' s family (date unknown) after the resident returned back to the facility from the [DATE] hospital visit, they told her the hospital had told the family Resident #1 barely had a UTI and the hospital did not want to treat it. LVN A said if a resident had a UTI and it went untreated for [REDACTED]. LVN A said the facility had gotten a UA and lab work on Resident #1 on [DATE] and she was the one who received the UA culture results on the 6A-2P Sunday shift on [DATE]. LVN A said UA cultures usually took 72 hours to be read. She said the UA culture confirmed Resident #1 had a UTI, which we already knew from the urine sample. She said in general when a resident had a UA with CS ordered, the UA usually came back first within 24 hours and indicated if the resident had a UTI, such as urine cloudiness. She said at that point, a doctor could treat the UTI based on the UA, but typically the doctor waited for the culture because if an antibiotic was started prematurely on a resident and did not work, then the next time it was used, that resident would be at risk for being intolerant to it. LVN A said Resident #1s UA would have come in a few days ago. The LVN reviewed the e-chart and said it appeared Resident #1 had fallen on the evening of [DATE] with no injuries. She said neuro checks were initiated that evening. The morning of [DATE] (time not remembered), LVN A said she was able to get an O2 sat on Resident #1 and the reading was 96. When she went back to check her O2 sat again around 10 AM, Resident #1's hands were cold and she could not get a reading. She tried to warm Resident #1's hands under a blanket but the resident kept pulling her hands out. LVN A said she was not concerned she was not able to get an O2 reading because Resident #1 seemed fine, like every other weekend. LVN A did state Resident #1 had thrown up on her shift that day and it was food, which was normal. She was given an anti-nausea medication on the overnight shift before they left at 6AM. LVN A said Resident #1 threw up almost every weekend at least one to two times on her shift and that was not unusual for her. LVN A said Resident #1 had been having increased falls since coming to her hall from the rehab unit. When the UA culture was received on her shift, Sunday [DATE] around 12:15 PM, LVN A said she contacted the MD's on call service and spoke with the NP regarding the culture and sensitivity results. The NP then wrote an order for [REDACTED]. LVN A said previous to the facility getting the order for Rocephen, Resident #1 was alert and oriented and could answer questions, but the family that was visiting did not think she looked right. LVN A said the family declined four times that day to send Resident #1 to the hospital. She said the RP kept asking what the hospital could do that the facility could not. She said when she left the facility at 2 PM, she gave her report to the oncoming nurse, RN B. LVN A said changes in condition were any kind of altered mental status (AMS), change in vitals, temperature increase and anything out of the normal. She said since Resident #1 was long-term, she knew what was normal. Review of telephone order dated [DATE] at 12:30 PM reflected, Roceplin 1 GM IM now, Start [DATE] [MEDICATION NAME] 100 mg BID for 7 days. Interview with RN B on [DATE] at 9:05 PM revealed he was a new RN of the past four months and had no prior nursing experience before that. He worked PRN on the weekends and worked the ,[DATE] PM shift on [DATE] with Resident #1. During his shift change report with LVN A on the 6A-2P shift around 2:00 PM, one of Resident #1's family members came up to them and said the resident could not pull fluids through her straw and was weak. LVN A told the family member she had just given Resident #1 an antibiotic and she was probably weak from a UTI and she would probably feel better the next day. She reassured the family member. LVN A did ask the family member if she wanted her to send Resident #1 to the hospital because the hospital could do things much faster, but he thought LVN A had reassured the family about the antibiotic, she did not feel then it was necessary. The family member left and said she would come back. After that, RN B said he did his rounds. He was in the process of hanging an IV for another resident and administering pain meds when Resident #1's roommate came down the hall in her wheelchair and told him Resident #1 looked bad. He went in to assess the resident, no vital signs were taken. He observed she had tea and a straw next to her. He tried to get her to drink the tea but she was too weak to drink from the straw. He got her water and tried to put the cup directly to her mouth. He reported she was able to drink about ½ a cup. RN B said Resident #1 looked lethargic and out of it, but in his mind, he was thinking about her being dehydrated. She was alert only with her eyes open. He did a quick look at her skin and it was cool and he saw a large knot on her head and her face was bruised. He stated she looked rough. He said no one told him that she had fallen that week. He then asked LVN D to check on Resident #1 because he had to change another resident's IV. She tried to get vitals on Resident #1 and was unsuccessful, then went to talk to RN C who went back into Resident #1's room. RN B stated RN C was unable to get O2 sats because the resident ' s fingers were cold. RN B said that did happen with people, but with Resident #1, hers never warmed up. He said that was when RN C decided to give the resident PRN oxygen via nasal cannula. RN B said he still thought the only issue was the resident was dehydrated. He said during that shift, he worked two different halls so he could not be in Resident #1's room all the time, but they did get her to drink about two cups of fluid over his shift in his estimation. He stated at dinner, he tried to feed her tomato soup and vanilla pudding. He felt she ate about 50%. He said Resident #1 was able to tell him she felt nauseous so he gave her a crushed [MEDICATION NAME] and put it in her soup so she would have an easier time swallowing it. He then asked the CNA to help finish feeding her and left the room. The CNA later reported to RN B that Resident #1 did not eat anything else after RN B had left the room, including the soup that had the crushed anti-nausea medication in it. Around 7:45 PM, a family member came to the facility, saw the resident, then went to RN C to tell her that Resident #1's condition had worsened from earlier that afternoon. RN C called the paramedics. She had seemed out of it from the beginning of the shift, according to RN B. However, he did not feel there was an emergency because Resident #1 had a history of [REDACTED]. RN B said, I was thinking if she could drink for me and if I could get her to drink more, her mental status would be better. He said he did not feel Resident #1 had a change of condition on his shift. RN B revealed he never tried to get O2 sats or call the on-call NP. He said the only alternative he knew of when an O2 sat could not be obtained was to draw blood and have it tested . RN B said he was never told of any low blood pressure readings, UTI, falls or lack of O2 sat from the 6A-2P nurse during the change of shift report. RN B said it never dawned on him Resident #1 could have been becoming septic. He said he learned [MEDICAL CONDITION] in nursing school but did not really know what to look for, he figured some indicators could be low blood pressure, confusion, nausea, vomiting, and high fever followed by a drop in temperature. He said after Resident #1's death, he went online to read [MEDICAL CONDITION] and she seemed to have the criteria for it. Resident #1's Nurse's Notes for [DATE] (Documented at 11:26 PM) by RN C reflected Called into room at 1600 (4:00 PM) after being told that nurse was unable to obtain O2 sats. Patient in bed awake, alert. Able to correctly give her birthdate and tell she was in a nursing home (unable to recall name of facility), Unable to obtain O2 sats. Lungs clear bilaterally to auscultation. Unable to palpate radial pulse. Apical pulse = 100/minute. Received report today that patient had been diagnosed with [REDACTED]. Oxygen started at 2L/minute via nasal cannula. Blood pressure (manual) = ,[DATE], Respirations 26/minute. Auxiliary temp =96.7. Patient drank ½ glass for primary nurse. Daughter came in, she said that her mother was worse now than she had been earlier today (about lunchtime). Stated that her mother (patient) did not realize she was here and that patient stated she saw little puppies on the floor. She asked that her mother be sent to the hospital. On call service notified and approved the transfer, Daughter called at approximately 2200 (10:00 PM) and stated the ambulance when to (name) hospital (a different one than requested) because patient's blood pressure was low and that they didn't know if the patient could make the trip downtown. Interview with RN C (Weekend supervisor) on [DATE] at 1:35 PM revealed she had not had any issues with Resident #1 on her 2PM-10PM shifts Saturday or Sunday. When she started her shift at 2PM, RN C said she overheard LVN A tell RN B her report on Resident #1. Two family members were present and she overheard LVN A tell them the facility could send the resident to the hospital. RN C said the family members said no. RN C said she was notified by LVN D (not sure of the time) that she could not get a pulse ox on Resident #1. RN C said she tried and could not get one either. RN C said she completed an assessment on Resident #1 at that time and noticed signs and symptoms of dehydration, as indicated by Resident #1's pale mucous membranes in her mouth and eyes. RN C said Resident #1 did appear weak but she was able to take a manual BP and said her atypical pulse was fine (note: this conflicted with her nursing note on [DATE]), regular respirations were okay but she could not get the pulse ox. RN C said Resident #1 did not display any breathing issues and had good air exchange forwards and backwards. RN C said she gave oxygen via nasal cannula and went to RN B to ask what was going on with the resident. RN C said the RN B reported Resident #1 had a UTI and antibiotics had been started that day. RN C said she asked Resident #1 two times after that if she was having any pain, and the resident responded, either no .I don't think so, or no .not really. RN C said Resident #1 did not appear to have AMS. That evening, RN C said the family member called and asked if the resident had eaten. She told the family member RN B had fed her. The family member could not believe it because she said the resident could not drink out of a straw earlier because she was so weak at lunch. The family member then came by the facility to check on Resident #1. She came back out and told RN C Resident #1 was worse than at lunch and she was seeing puppies on the floor. RN C said, So she is hallucinating? and the family member responded yes. RN C said she then informed the family member Resident #1 needed to be sent to the hospital. RN C said she went to see the resident at that time and she was awake. RNC did not indicate she assessed Resident #1 at that time. RN C said she called the NP and explained the resident had dehydration and hallucinations. The NP approved the transfer and the resident was sent out. RN C said she went to look at Resident #1 prior to EMT arrival and she was awake and looking around. She said the family member wanted Resident #1 to be taken to a specific hospital but EMT took Resident #1 to a different hospital because Resident #1's blood pressure was so low they did not know if she would make it to the hospital that was further away. She did not know what the blood pressure was. RN C said s/s of change in condition included a change in mentation, change in vitals, growing weak, not eating and any complaints of discomfort. She said UTIs in the elderly were really distinguishable more by their mentation, as well as quick onset of fever and dysuria (painful or difficult urination) at times. RN C said s/s [MEDICAL CONDITION] was low blood pressure, lower than normal temperature, high pulse and change in mentation. RN C said if a nurse could not get a resident's O2 reading, her expectation would be that she was notified. Further interview with RN C on [DATE] at 4:12 PM revealed a concerning blood pressure reading would be anything under 90 systolic. She said she would expect a MA to notify a charge nurse of a resident's low blood pressure reading so the nurse could do a manual blood pressure. Interview with CNA E on [DATE] at 2:35 PM revealed he had been Resident #1's CNA on [DATE]. He said she was strong, talked well and had sense. He said he worked a double on [DATE] and in the morning she was fine. He said he knew she ate some of her breakfast because he was the one who picked up her tray from her room and she had eaten roughly 50% and had asked for a cup of coffee. Around 3PM, CNA E stated he observed nurses going into her room more. RN B told CNA E Resident #1 was dehydrated and needed fluids. CNA E went into the resident's room with RN B who placed water beside her bed and encouraged CNA E and the other CNAs to try and help get her to drink. CNA E said he tried, but she would not drink. He said her eyes were open but were not moving. He stated his coworker told him the resident had not eaten lunch. CNA E stated, She was so weak. CNA E said after that, he remembered the nurses ended up calling 911during his shift and the resident was sent out. Interview with weekend CNA F on [DATE] at 2:50 PM revealed she worked weekend doubles and said Resident #1 was okay on Saturday, [DATE] and her intake for lunch and dinner was good. On [DATE], Sunday, the family was present while lunch was served to Resident #1 so she did not see how much she ate. CNA F said, She got really quiet and stopped talking after 2PM. She usually talked. Nothing seemed unusual until that afternoon after 4PM, then she it seemed like something was wrong. CNA F said she reported something seemed wrong with Resident #1 to RN B, RN C and LVN A. She said RN B checked Resident #1's vitals and told CNA F to try and feed the resident at dinner. For dinner, CNA F said Resident #1 only would eat some pudding and drank some fruit punch that CNA F fed her. CNA F said Resident #1 would open her mouth for a bite, but her body was not moving. She said the resident looked confused because she would open her eyes and look around in a confused manner. After 7pm, CNA F was working with other residents so she was not sure what happened before Resident #1 was sent out to the hospital. Interview with the NP on [DATE] via telephone at 6:25PM revealed she was the on call NP for MD's medical group the weekend of [DATE] and [DATE]. She had never met Resident #1 as she was not the attending NP for the facility. When asked if she remembered being contacted about Resident #1 who needed to be sent out to the hospital on [DATE] in the evening, she said yes, the family had requested it. She said it was strange because the facility had called her about Resident #1's UA on Saturday [DATE]. They said she kind of had a decline but not to the extent on Sunday when they called her and said the resident had been declining over the past month and a half. NP said, It was frustrating. I sent her out due to family request. I got very little info on her UA. They just called me for a positive UA. If I'd have known she was having a change in condition, I would have started her on IV fluids. She said she ordered the shot of Rocephen to help kick start the antibiotic in her system and did not know what was going on that weekend with Resident #1. NP said, They did not call and inform me Sunday they could not get O2 sats on her or she had a low blood pressure. I was asking them why wasn't her condition presented to me earlier? I was given limited basic info. I was wondering why we were waiting so long if you (facility) are telling me she had been declining for a month, like going from walking to falling to completely immobile? She said the CBC and CMP labs that were done on Resident #1 and collected on [DATE] were never presented to her that weekend. She would have looked at the resident's WB count to see [MEDICAL CONDITION] was a factor, or the BUN and [MEDICATION NAME] for signs of dehydration. No lab results were given to her except the UA. The NP asked if the facility had administered PRN oxygen when the O2 sats were unable to be taken that morning of [DATE]. NP was shocked that PRN oxygen was not administered to the resident the morning of [DATE] when they could not obtain a oxygen sat. She said when a systolic blood pressure was under 90, them something was wrong with the resident. She said she should have been called and expected as the on call NP that Resident #1 ' s information would have been articulated to her promptly. NP was concerned maybe the blood pressure medication had been given that morning. The NP said she was only as good as the information provided to her. She said her expectation of nursing staff when there was no O2 sat readings but a resident appeared stable, was for them to look for: cold skin, blue lips and try to warm them up, take their blood pressure, try a different area with the pulse ox like the earlobe, use a warm washcloth or a blanket to help get them warmer. She said she would expect and SBAR to be completed and for the facility to call her with the SBAR information to get further orders. Interview with Resident #1's MD on [DATE] at 5:15 PM revealed he had a care plan meeting with Resident #1's family member on [DATE] because he/she was concerned about Resident #1's increased falls. During that meeting, he said he explained to the family member what they were seeing was expected and the pattern she displayed was more like multi-infarct dementia/[MEDICAL CONDITION], where there was a more sudden decline than with [MEDICAL CONDITION]. He said he wanted to do blood work and UA first and if he was concerned with the results, he would send the resident to the hospital. The MD said he told the family member he could manage her (Resident #1) but would not keep her if she needed a higher level of care. The MD said he felt in retrospect, The family would have done her (Resident #1) a big favor if they would have left her here because of the stress a resident goes through when transferred out. He said he could have given Resident #1 fluids and IV antibiotics as an option had she not gone to the hospital. MD said if a resident was still alert and he knew the cause of the resident's change in condition, he felt he could treat and bring the resident back around. He said he had been following Resident #1 since admission and knew her. He said everything was put in place after that care plan meeting. The MD [MEDICAL CONDITION] could set in quickly and it depended on the person's immune system. He said low blood pressure was an indication of dehydration and the pulse would typically increase to make sure the person's organs got blood. He felt a concerning blood pressure was when the systolic was less than ,[DATE]; he said the diastolic could vary. He said he always told the nurses to repeat a blood pressure if it was low and it was important to always relate the reading to the symptoms present, if any. MD said, It's called vital signs for a reason. When MD was told during interview that Resident #1's blood pressure reading on [DATE] evening was ,[DATE], he said he did not believe it and if that had been the case, Resident #1 would have been unresponsive and would have had a massive stroke; she would not be alert and her body would have shut down. MD said had the on-call NP been notified earlier on [DATE] of any change in Resident #1's condition, IV fluids or bolus fluids could have been started and certain medications could have been ordered and given intramuscularly to boost her blood pressure. He said the NP had not been notified of any issues with Resident #1. Another interview with the MD on [DATE] at 1:01 PM revealed he and the facility could not send a resident to the hospital if the family did not want them to. He said Resident #1's family was told several times by the facility they could send her to the hospital but they refused. The MD said even if a resident was critical, if the family said no, he would not send the resident out. MD said, I can see where there were some issues with quality of care under assessments. Review of the MD's progress note was provided by the ADM on [DATE] after several requests over the past three days. The MD notes provided were from a visit on [DATE] where he saw the resident for a chief complaint of the family was concerned with the resident's current condition, recent falls, dementia and concerns the resident was had [MEDICAL CONDITION]. MD indicated medical records were reviewed from the [DATE] ER hospital visit. The note reflected Resident #1 was alert and oriented to person, place and time, her vitals were- blood pressure ,[DATE], pulse 93, temperature 97.2, respiratory rate 19, she had a normal mood and affect and her behavior was normal. MD's assessment/plan was to order a UA for C/S, CBC and CMP and he advised nurses to call him with the results as soon as possible. Interview with the DON on [DATE] at 10:17 AM revealed he had been employed as the DON for the facility for about a month. He said Resident #1 did not have a change in condition on [DATE] that he had been made aware of. He said a change in condition could mean a change in mental or physical abilities, change in ADLs, or change in appetite. He said indicators of a UTI were AMS, pain and burning during urination. The DON said none of those issues were reported to him by his nursing staff. He said some doctors would start a resident on antibiotics before a culture was completed, but it was up to the doctor ' s discretion. He said the nurse (he could not remember the name) had called him after Resident #1 had been sent to the hospital on the evening of [DATE] to alert him the resident had experienced a change in mental status and was hallucinating and they wanted her sent out. DON said Resident #1 died due [MEDICAL CONDITION]. He [MEDICAL CONDITION] could occur very quickly in the body, within hours, even if a person was on antibiotics. Interview with the DON on [DATE] at 3:20 PM revealed the only reason a UA with CS was ordered by the MD the week prior to Resident #1's death was because the family had come to the facility and told the doctor they wanted one. The DON said at that time, Resident #1 did not exhibit any signs or symptoms of a UTI. He said the family had told the facility Resident #1 allegedly had a positive UA at the hospital when she had been sent out for the fall on [DATE], but he never received any notification from the hospital about it. The DON said, (Resident #1) did have a UA done on [DATE] but it wasn't dirty enough to be treated. Interview with Resident #1's family member on [DATE] at 6:07 PM

Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for safe and functional medical equipment. During a transfer from bed to a shower chair by CNA A, Resident #1 fell when the shower chair wheel locks did not function properly and Resident #1 slid to the floor and fractured her femur. This was determined to be past noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure resulted in Resident #1 falling and fracturing her right femur, experiencing pain, being hospitalized , and having physical therapy. This failure could have affected 13 residents who were dependent for bathing in the facility. Findings included: Review of the MDS assessment dated [DATE], Resident #1 was a [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Provider Investigation Report dated 07/10/16 revealed on 07/09/16 at 10:30 AM, the Administrator was notified that Resident #1 was being sent to the hospital for a critical x-ray result. The Administrator ' s review of the report revealed the resident was transferred on 07/07/16 at 9:30 AM from her bed to a shower chair, rolled, and was sat on the floor. Her right femur was fractured. The provider did an environmental round for all shower chairs to check functionality. The facility determined the incident was a single occurrence that was accidental. The provider conducted in-servicing with knowledge check-offs. Witness statements included with the Provider Investigation Report reflected: On 07/07/016 from CNA A- I (CNA A) went into Resident #1 ' s room to get her up for her shower, the shower chair was already in the room, so I made sure that the shower chair was lock,(sic) but when I got her up to get in the shower chair, it went back on me and Resident #1 said she didn ' t fall, I slide (sic) her down on the floor, on her buttum (sic) so the locks on the chair did not work. And I went to get the nurse before we pick (sic) her up off the floor. On 07/12/16 from CNA E- I (CNA E) went to Resident #1 ' s room. And I saw resident sitting on floor. I asked her if she was ok and she told me that she didn ' t fall. That CNA A sat her on the floor because the shower chair moved, even though it was locked it still moved back. So I went to go get LVN B the nurse. On 07/09/16 from LVN B- On 07/07/16 at 9:20 AM, CNA A came to nurse station and stated Resident #1 was on floor and we just sat her on bottom (sic). On entry to room, CNA A and CNA E were in room. Resident #1 sitting on floor beside shower chair and bed. Head to toe assessment completed. Resident stated ' I didn ' t fall, they just sat me down on my butt. ' Shower chair locked and still rolling back. One CNA held shower chair stable and this writer and CNA A picked resident up off the floor. MD and R/P notified. ADON C notified. On 07/08/16 ADON D stated that Resident c/o pain at 12:00 PM. Re-assessed resident and Resident #1 stated it hurts a little but on left leg. Physician F notified. N.O. X-ray left hip, left femur. Family notified. Routine Norco 10/325 1 tab given. Effective 1:00 PM. Review of the Incident Investigation regarding Resident #1, dated 07/07/16 and signed by ADON D, reflected, During transfer from bed to shower chair x2 staff shower chair rolled back and resident sat on floor assessment done at that time resident c/o (complained of) no pain at 1210 PM resident c/o pain to another pt family member informed charge nurse on hall and to notify md for x-ray orders fracture noted resident sent to hospital. Post incident actions included: head to toe assessment, vital signs, picked up off of floor, new shower chairs with wheel locks. Review of Nurses Notes for Resident #1 by LVN B on 07/07/16 at 9:42 AM reflected, Resident was being transferred x2 staff from bed to shower chair. Shower chair rolled backwards during transfer and CNAs sat resident onto floor. No apparent injurys (sic) noted. Head to toe assessment completed and vitals stable. Resident picked up off floor x2 staff. Physician F notified and R/P notified. X-ray report dated 07/08/16 at 11:21 PM reflected, Generalized bony demineralization. Acute undisplaced fracture proximal shaft left femur. Review of Physician Telephone Orders for Resident #1 reflected: 07/09/16 Transfer Resident out to a local hospital. 07/12/16 - readmitted under the care of Physician F to facility. Diagnosis: [REDACTED]. Interview with Resident #1 on 07/27/16 at 9:35 AM revealed she was in her room and the shower chair slipped and she hit the floor. She broke her left leg and they had to put plates and rods in. The brakes on the shower chair were defective. It was the first and only time it had happened. Interview with CNA A on 07/26/16 at 12:55 PM revealed Resident #1 fell when transferred to the shower chair. When Resident #1 fell , it was the first time CNA A had used that particular shower chair. CNA A stated, We had seven shower chairs and five of those had the same problem of the wheels not staying locked. According to CNA A there are no more problems with the shower chairs currently. CNA A said, We didn ' t report the broken chairs. We had to write a report and corporate had a meeting on the following Saturday. CNA A said they usually reported things to maintenance such as wheelchairs for repairs, but the broken shower chairs were never reported. CNA A said CNA E moved out of the area and LVN B had resigned. A telephone interview with LVN B on 07/27/16 at 10:15 AM revealed she was told by CNA A that Resident #1 was transferring from the bed to a shower chair and slipped back. Resident #1 was laughing on the floor saying, I didn ' t fall- I just sat down. She had no pain that day, but reported pain to someone else the next day. An X-ray was done. Interview with ADON D on 07/26/16 at 1:52 PM revealed Resident #1 told another resident ' s family member that she was in pain on 07/08/16 and the facility obtained an X-ray. On 07/09/16 all the shower chair wheels were checked. Some were not good. She thought there were three old chairs taken out of the building and the others were reworked so the locks on the wheels worked. She believed there were maybe five shower chairs reworked. They were all working at the time of the interview. Interview with ADON C on 07/26/16 at 2:00 PM revealed on 07/07/16 he was on his way to the morning meeting and LVN B told him Resident #1 had slid to the floor during a transfer. She was transferred by CNA A. ADON C conducted in-services about transfers. He stressed checking the wheelchairs, brakes, and to be safe. Interview with DON on 07/26/16 at 2:14 PM revealed Resident #1 was a two person assist since her fall, and before her fall she was a one person assist. Her need fluctuated between her assessments. The aide that assisted Resident #1 said she clicked the brakes on the shower chair. All the shower chair legs were replaced for safety. There were seven shower chairs and the brakes were replaced on all of them. She was not sure how many did not work before. They all worked currently. Review of the Maintenance Book Policy undated but received as current on 07/28/16 from the Administrator, reflected, .It shall be the responsibility of all staff to write any Maintenance issues in the book to the maintenance director. The maintenance book is maintained at nurses ' station. Work requests should be placed in the appropriate file basket at the nurses ' station. Maintenance book will be monitored daily. Emergency requests will be given priority in making necessary repairs. Review of Maintenance Log dated 04/02/16 through 07/25/16 revealed nothing reported about shower chair brakes not locking or working. Review of a packing list dated 07/11/16 revealed five packages (4 per package) of replacement castors were delivered to the facility to correct the broken shower chairs. The facility took the following action to correct the non-compliance: Review of the in-services provided reflected all shifts were in-serviced with regards to the following: 07/07/16- Transferring/Safety/Falls-1. Before transferring staff make sure wheelchair/shower chair brakes are locked. 2. Follow the right transferring techniques -gaitbelt, hoyer lifts, sliding board, or two person assist. 3. Reports all falls to your charge nurse immediately. 4. Make sure equipment is functioning properly. Fall precautions. 07/09/16 Broken Equipment-Locks not working on shower chair-remove from use immediately and notify maintenance. Same if wheelchair locks not working or cracked broken equipment. 07/12/16 Incident reports and documentation-Correctly report all incidents immediately. Falls especially, do not move resident until assessment by nurse. Head to toe and range of motion test needs to be done and if pain, do not move. If injuries notify MD and send to ER if necessary per MD orders. Must fill out incident report and complete accurately all forms especially witness statements gathered at the time and attach to the incident report. Print it out after it is completed and place in DON door. Make sure you complete and notify MD and family of all incidents. Interview with CNA G on 07/28/16 at 10:00 AM revealed the process after finding broken broken equipment or equipment that does not work properly was to, Put a not on it that says 'Do not use' and put it somewhere it is not used. Let the supervisor and maintenance man know and write an incident report. Interview with CNA H on 07/28/16 at 10:03 AM revealed she would remove any broken equipment and tag it out. Then she would write it in the maintenance book. Interview with MA I on 07/28/16 at 10:05 AM revealed she would look for maintenance and write down any broken equipment in the maintenance book. She would also tell the charge nurse about it and take the equipment out of use. Observation on 07/27/16 at 10:10 AM revealed a shower chair in the 100 hall shower room had no difficulty locking when the brakes wre engaged. Observation on 07/27/16 at 10:15 AM revealed four shower chairs in the 300/400 hall shower room. The brakes locked effectively on all four chairs. Observation on 07/29/16 at 1:00 PM revealed an unnamed CNA wheeled a shower chair down 200 Hall and demonstrated that the brakes locked effectively. Resident Interviews conducted during the survey 07/26/16-07/29/16 with Residents #1, #3, #9, #15, and #17 all indicated no problems with shower chair brakes and all equipment was currently functional. Interview with Resident #10 ' s family member on 07/29/16 at 10:26 AM revealed Resident #10 ' s medical equipment was functional. Confidential group Interview with eight residents on 07/27/16 at 1:30 PM revealed no concerns or issues with medical equipment at the facility. The Resident Census and Conditions of Residents Form 672, completed and provided by ADON D on 7/26/16, reflected 13 residents that required assistance with bathing.

Based on observations, interviews, and record reviews the facility failed to maintain all essential mechanical, electrical and patient care equipmetn in a safe and operating condition for one (Resident #1) of eight residents reviewed for safe and functional medical equipment. During a transfer from bed to a shower chair by CNA A, Resident #1 fell when the shower chair wheel locks did not function properly and Resident #1 slid to the floor and fractured her femur. This was determined to be past noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure resulted in Resident #1 falling and fracturing her right femur, experiencing pain, being hospitalized , and having physical therapy. This failure could have affected 13 residents who were dependent for bathing in the facility. Findings included: Review of the MDS assessment dated [DATE], Resident #1 was a [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Provider Investigation Report dated 07/10/16 revealed on 07/09/16 at 10:30 AM, the Administrator was notified that Resident #1 was being sent to the hospital for a critical x-ray result. The Administrator ' s review of the report revealed the resident was transferred on 07/07/16 at 9:30 AM from her bed to a shower chair, rolled, and was sat on the floor. Her right femur was fractured. The provider did an environmental round for all shower chairs to check functionality. The facility determined the incident was a single occurrence that was accidental. The provider conducted in-servicing with knowledge check-offs. Witness statements included with the Provider Investigation Report reflected: On 07/07/016 from CNA A- I (CNA A) went into Resident #1 ' s room to get her up for her shower, the shower chair was already in the room, so I made sure that the shower chair was lock,(sic) but when I got her up to get in the shower chair, it went back on me and Resident #1 said she didn ' t fall, I slide (sic) her down on the floor, on her buttum (sic) so the locks on the chair did not work. And I went to get the nurse before we pick (sic) her up off the floor. On 07/12/16 from CNA E- I (CNA E) went to Resident #1 ' s room. And I saw resident sitting on floor. I asked her if she was ok and she told me that she didn ' t fall. That CNA A sat her on the floor because the shower chair moved, even though it was locked it still moved back. So I went to go get LVN B the nurse. On 07/09/16 from LVN B- On 07/07/16 at 9:20 AM, CNA A came to nurse station and stated Resident #1 was on floor and we just sat her on bottom (sic). On entry to room, CNA A and CNA E were in room. Resident #1 sitting on floor beside shower chair and bed. Head to toe assessment completed. Resident stated ' I didn't fall, they just sat me down on my butt. ' Shower chair locked and still rolling back. One CNA held shower chair stable and this writer and CNA A picked resident up off the floor. MD and R/P notified. ADON C notified. On 07/08/16 ADON D stated that Resident c/o pain at 12:00 PM. Re-assessed resident and Resident #1 stated it hurts a little but on left leg. Physician F notified. N.O. X-ray left hip, left femur. Family notified. Routine [MEDICATION NAME] 10/325 1 tab given. Effective 1:00 PM. Review of the Incident Investigation regarding Resident #1, dated 07/07/16 and signed by ADON D, reflected, During transfer from bed to shower chair x2 staff shower chair rolled back and resident sat on floor assessment done at that time resident c/o (complained of) no pain at 1210 PM resident c/o pain to another pt family member informed charge nurse on hall and to notify md for x-ray orders fracture noted resident sent to hospital. Post incident actions included: head to toe assessment, vital signs, picked up off of floor, new shower chairs with wheel locks. Review of Nurses Notes for Resident #1 by LVN B on 07/07/16 at 9:42 AM reflected, Resident was being transferred x2 staff from bed to shower chair. Shower chair rolled backwards during transfer and CNAs sat resident onto floor. No apparent injurys (sic) noted. Head to toe assessment completed and vitals stable. Resident picked up off floor x2 staff. Physician F notified and R/P notified. X-ray report dated 07/08/16 at 11:21 PM reflected, Generalized bony demineralization. Acute undisplaced fracture proximal shaft left femur. Review of Physician Telephone Orders for Resident #1 reflected: 07/09/16 Transfer Resident out to a local hospital. 07/12/16 - readmitted under the care of Physician F to facility. Diagnosis: [REDACTED]. Interview with Resident #1 on 07/27/16 at 9:35 AM revealed she was in her room and the shower chair slipped and she hit the floor. She broke her left leg and they had to put plates and rods in. The brakes on the shower chair were defective. It was the first and only time it had happened. Interview with CNA A on 07/26/16 at 12:55 PM revealed Resident #1 fell when transferred to the shower chair. When Resident #1 fell , it was the first time CNA A had used that particular shower chair. CNA A stated, We had seven shower chairs and five of those had the same problem of the wheels not staying locked. According to CNA A there are no more problems with the shower chairs currently. CNA A said, We didn ' t report the broken chairs. We had to write a report and corporate had a meeting on the following Saturday. CNA A said they usually reported things to maintenance such as wheelchairs for repairs, but the broken shower chairs were never reported. CNA A said CNA E moved out of the area and LVN B had resigned. A telephone interview with LVN B on 07/27/16 at 10:15 AM revealed she was told by CNA A that Resident #1 was transferring from the bed to a shower chair and slipped back. Resident #1 was laughing on the floor saying, I didn ' t fall- I just sat down. She had no pain that day, but reported pain to someone else the next day. An X-ray was done. Interview with ADON D on 07/26/16 at 1:52 PM revealed Resident #1 told another resident ' s family member that she was in pain on 07/08/16 and the facility obtained an X-ray. On 07/09/16 all the shower chair wheels were checked. Some were not good. She thought there were three old chairs taken out of the building and the others were reworked so the locks on the wheels worked. She believed there were maybe five shower chairs reworked. They were all working at the time of the interview. Interview with ADON C on 07/26/16 at 2:00 PM revealed on 07/07/16 he was on his way to the morning meeting and LVN B told him Resident #1 had slid to the floor during a transfer. She was transferred by CNA A. ADON C conducted in-services about transfers. He stressed checking the wheelchairs, brakes, and to be safe. Interview with DON on 07/26/16 at 2:14 PM revealed Resident #1 was a two person assist since her fall, and before her fall she was a one person assist. Her need fluctuated between her assessments. The aide that assisted Resident #1 said she clicked the brakes on the shower chair. All the shower chair legs were replaced for safety. There were seven shower chairs and the brakes were replaced on all of them. She was not sure how many did not work before. They all worked currently. Review of the Maintenance Book Policy undated but received as current on 07/28/16 from the Administrator, reflected, .It shall be the responsibility of all staff to write any Maintenance issues in the book to the maintenance director. The maintenance book is maintained at nurses ' station. Work requests should be placed in the appropriate file basket at the nurses ' station. Maintenance book will be monitored daily. Emergency requests will be given priority in making necessary repairs. Review of Maintenance Log dated 04/02/16 through 07/25/16 revealed nothing reported about shower chair brakes not locking or working. Review of a packing list dated 07/11/16 revealed five packages (4 per package) of replacement castors were delivered to the facility to correct the broken shower chairs. The facility took the following action to correct the non-compliance: Review of the in-services provided reflected all shifts were in-serviced with regards to the following: 07/07/16- Transferring/Safety/Falls-1. Before transferring staff make sure wheelchair/shower chair brakes are locked. 2. Follow the right transferring techniques -gaitbelt, hoyer lifts, sliding board, or two person assist. 3. Reports all falls to your charge nurse immediately. 4. Make sure equipment is functioning properly. Fall precautions. 07/09/16 Broken Equipment-Locks not working on shower chair-remove from use immediately and notify maintenance. Same if wheelchair locks not working or cracked broken equipment. 07/12/16 Incident reports and documentation-Correctly report all incidents immediately. Falls especially, do not move resident until assessment by nurse. Head to toe and range of motion test needs to be done and if pain, do not move. If injuries notify MD and send to ER if necessary per MD orders. Must fill out incident report and complete accurately all forms especially witness statements gathered at the time and attach to the incident report. Print it out after it is completed and place in DON door. Make sure you complete and notify MD and family of all incidents. Interview with CNA G on 07/28/16 at 10:00 AM revealed the process after finding broken broken equipment or equipment that does not work properly was to, Put a not on it that says 'Do not use' and put it somewhere it is not used. Let the supervisor and maintenance man know and write an incident report. Interview with CNA H on 07/28/16 at 10:03 AM revealed she would remove any broken equipment and tag it out. Then she would write it in the maintenance book. Interview with MA I on 07/28/16 at 10:05 AM revealed she would look for maintenance and write down any broken equipment in the maintenance book. She would also tell the charge nurse about it and take the equipment out of use. Observation on 07/27/16 at 10:10 AM revealed a shower chair in the 100 hall shower room had no difficulty locking when the brakes wre engaged. Observation on 07/27/16 at 10:15 AM revealed four shower chairs in the 300/400 hall shower room. The brakes locked effectively on all four chairs. Observation on 07/29/16 at 1:00 PM revealed an unnamed CNA wheeled a shower chair down 200 Hall and demonstrated that the brakes locked effectively. Resident Interviews conducted during the survey 07/26/16-07/29/16 with Residents #1, #3, #9, #15, and #17 all indicated no problems with shower chair brakes and all equipment was currently functional. Interview with Resident #10 ' s family member on 07/29/16 at 10:26 AM revealed Resident #10 ' s medical equipment was functional. Confidential group Interview with eight residents on 07/27/16 at 1:30 PM revealed no concerns or issues with medical equipment at the facility. The Resident Census and Conditions of Residents Form 672, completed and provided by ADON D on 7/26/16, reflected 13 residents that required assistance with bathing.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for one (Resident #19) of 19 residents reviewed for neglect. LVN A failed to initiate CPR on Resident #19 on [DATE], when she assessed him with no pulse or heartbeat, and he was cold to touch. Resident #19 expired at the facility on [DATE]. This was determined to be past non-compliance at a severity level of an Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the 44 residents who were full code status, by placing them at risk for death and their wishes not being honored. Findings included: Resident #19's Face Sheet, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #19's Admission Care Plan, dated [DATE], reflected the resident's code status was a DNR. He needed assistance of one person with dressing, personal hygiene, bathing, eating, toileting, and transfers. The Care Plan did not address interventions specific to the DNR. Resident #19's Provider Notes (physician progress notes [REDACTED]. Resident #19 was confused and tried to get up without assistance. He had a poor appetite and had chronic [DIAGNOSES REDACTED] of the lungs according to his family. The facility's Provider Investigation Report, reported to DADS on [DATE], reflected Resident #19's family signed a DNR, but the physician had not signed the order. The facility considered the resident a full code which meant he would be provided CPR. LVN A did not initiate CPR after she was informed by a CNA that the resident was unresponsive. Resident #19 expired on [DATE]. The Provider Response section of the Investigation Report reflected LVN A and RN B (the nurse who pronounced Resident #19) were suspended pending investigation. All nursing staff was in-serviced and emergency quality assurance was initiated. The Investigation Summary reflected CPR should have been initiated due to the lack of the physician signature on the OOHDNR. Provider Action Taken Post-Investigation reflected LVN A was terminated for failure to follow policy and procedure and RN B was given a final reprimand on failure to follow resident code status. The emergency quality assurance continued. Attached to the facility's Provider Investigation Report was LVN A's written statement dated [DATE]. The statement reflected, .(Resident #19) was up at nurses station in his wheelchair. He was very restless trying to slide out of wheelchair. (CNA C) took him to TV room to watch him closely. After about an hour (Resident #19) looked tired and we placed him in bed. This was around midnight. (CNA D) states she checked on him @ (at) 0100 (1:00 a.m.). At 0200 (2:00 a.m.) she changed his brief. There were no signs or symptoms of any change of condition. At 0330 (3:30 a.m.) the CNA came to get me to assess (Resident #19). At that time he had no pulse, no heartbeat, and was cold to touch. I made the necessary phone calls to (the DON), (ADM), (ADON F). I got ahold (sic) of (RN B) to come pronounce his death. I called his family and broke the news. They came up here to see (Resident #19) and thanked us for all we did for (Resident #19). I called (name of funeral home) to have them to come pick (Resident #19) up. I also called and left message for (Physician E) informing him of (Resident #19's) death. On [DATE] at 8:43 a.m. an attempt was made to contact LVN A. A message was left, but not returned. On [DATE] at 11:13 a.m. another attempt was made to contact LVN A and a message was left. The call was not returned. On [DATE] at 11:55 a.m. the ADM was asked to contact LVN A. On [DATE] at 12:20 p.m. the ADM stated she had not received a call back from LVN A. An interview with RN B on [DATE] at 8:36 a.m. via telephone revealed she was home when LVN A called her at 4:00 a.m. to tell her Resident #19 was found dead and cold. She stated LVN A told her Resident #19 was a full code status but was cold to touch. RN B stated she told LVN A that did not matter. She stated she told LVN A to start CPR and initiate Code Blue procedures. RN B revealed when she arrived at the facility LVN A had not initiated CPR and had already contacted the family of the resident's death. RN B stated the family was with the deceased when she arrived. An interview with the ADM on [DATE] at 2:41 p.m. revealed LVN A told the ADM that when she assessed Resident #19 he was cold to touch and that was why she did not initiate CPR. The ADM stated that even though it was against the family's wishes, he was still considered a full code due to the physician not signing the DNR. The ADM revealed Physician E was usually timely in signing electronically the DNRs from his iphone. In this case, he was with his family member in the emergency room and did not sign the form. She stated Resident #19's family signed the DNR form the afternoon of [DATE]. The ADM revealed they quality assured the incident to prevent it from reoccurring. The facility started Code Blue drills. The facility conducted a DNR audit of all residents' clinical records. The ADM revealed LVN A was terminated. Review of Disciplinary Action Record dated [DATE] revealed LVN A was immediately suspended pending the investigation into Resident # 19's death. A Discipliary Action Report dated [DATE] revealed LVN A was terminated for failing to initiate CPR and failing to call 911 for Resident # 19 who was found unresponsive and without vital signs who was a full code. On [DATE] at 3:00p.m. a review of the Out of Hospital Do Not Resusitate document signed by the family on [DATE] revealed the document was not signed by the physician. An interview with the DON on [DATE] at 3:40 p.m. revealed LVN A should have initiated CPR on Resident #19 when she found him unresponsive. She stated she was on vacation when this incident occurred. She revealed RN B who worked at a sister facility was covering for her. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 3.htm reflected, A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. (Retrieved on [DATE]). The facility's current policy, Do Not Resuscitate Order, revised [DATE] reflected, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. The facility's current policy, CPR Policy, revised [DATE] reflected, 1. in the event of cardiopulmonary arrest of a resident/patient without a DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. Review of the faciliy document, titled, Abuse Program revised May of 2010 reveals, .2. Policy for Prohibition of Abuse, Neglect and Misappropriation of Property.POLICY: .1. The facility will prohibit neglect, mental or physical abuse.of residents. According to facility policy neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. It was determined this failure placed the facility's residents in an IJ from [DATE] through [DATE]. The facility took the following action to correct the non-compliance. 1. In-Service Training Report, dated [DATE], [DATE], [DATE] and [DATE] reflected licensed nurses, medication aides, and CNAs attended training regarding resident code status, DNR vs. full code status and code blue drills. In an interview on [DATE] at 1:15 P.M., The DON stated the in-service covered: how to ascertain the resident's code status, the location of resident code status information, what to do if a resident was found unresponsive and/or not breathing. The DON stated the facility staff was informed of the new procedure which was to keep an updated list of resident's code status on the crash cart. The DON also stated it was also on the CNA care plans, located in the residents' closets. The DON stated the facility's CPR policy and procedure and the Texas Board of Nurses's policy on initiation of CPR was reviewed with staff. The DON stated the Code Blue Drills consisted of mock scenarios in which a resident would be found unresponsive and staff would verbalize correct response. Additional in-service was provided on [DATE], [DATE], and [DATE] regarding Code Blue Drills. The summary reflected all residents were considered a full code status until there was a signed physician order [REDACTED]. 2. LVN A was suspended pending the investigation terminated, RN B received disciplinary action. 3. During new employee orientation, the facility will in-service the new employee on the facility's policy on Do Not Resuscitate Order. 4. During an interview on [DATE] at 8:00 a.m. LVN G (MDS nurse) was asked what action she would take if she came upon a resident that was determined to be unresponsive. She said she would check their code status in the chart and if they were a code status she would call for help instruct someone to dial 911 and begin CPR. During an interview on [DATE] at 9:03 a.m. CMA H was asked what action she would take if she was called to a resident ' s room and determined the resident was unresponsive. She said she had a list on her MAR that would tell her if the resident was a DNR or a code. She was then asked what she would do if the resident had a DNR on the chart but it was not signed by the Doctor. She said, I would begin CPR. During an interview on [DATE] at 1:34 p.m. CNA I said she had recently been trained on how to determine DNR/code status of a resident. She stated if the resident isn't responsive, alert the nurse and start CPR. When asked how she would determine if they were a DNR, she said by their care-plan inside their closet door. When asked if she had attended a code blue drill, she responded, Yes, they had us report to the scene, get the crash cart and begin CPR. During an interview on [DATE] at 1:56 p.m. CNA J was asked if she had attended in-service training on DNR/Code status determination. She nodded her head in the affirmative. She was asked how she would know if she needed to start CPR on an unresponsive resident, she said the code status was posted inside the closet door for every resident. If I went into a room and a resident was unresponsive, need to call nurse, 911 and perform CPR if the resident is a full code. During an interview on [DATE] at 2:04 p.m. CNA K was asked how she would determine if she needed to start CPR on an unresponsive resident. She said she would look inside closet door, if the sheet was red the resident is a DNR but if it is green you start CPR. During an interview on [DATE] at 2:11 p.m. CNA L stated she worked the 2:00 p.m. till 10:00 p.m. shift. She was asked where she would look to determine the code status of a resident she found to be unresponsive. She said she would check the resident ' s closet door for code status. She was asked if there was anywhere else she could look. She stated, Yes the crash cart located on the 400 hall. During an interview on [DATE] at 2:55 p.m. RN M says the in-service trainings occurred prior to her employment but she did receive the training as part of her orientation. She said she was told if the sheet is red then the resident is a DNR, if it is green then you do CPR. When asked if there were other places to find the code status of the resident she said, Yes it is in the MAR and on the crash cart. During an interview on [DATE] at 3:09 p.m. LVN N reports she works the 2:00 p.m. till 10:00 p.m. shift and she had attended in-service training. She was asked if she walked into a resident ' s room and found the resident to be unresponsive, what she would do. She said she would determine code status and, if they were a full code, I would start CPR. When asked how she would determine the resident ' s code status she said, I would look in the chart and could also get the information from the crash cart. During an interview on [DATE] at 3:20 p.m. CNA O reports she works the 2:00 p.m. till 10:00 p.m. shift. She says she attended in-service training on how to determine DNR/CPR status of residents and Code Blue drill. When asked what she would do if she found a resident that was unresponsive, she said she would determine code status and if they were a full code, start CPR. During a telephone interview on [DATE] at 4:30p.m. LVN P reported she worked the 10:00 p.m. till 6:00 am shift. She was asked if she attended in-service training on code status determination and Code Blue drills, she responded, Yes. The code status is in the chart, MAR and the crash cart. DNR are red sheets and Full codes are green sheets. When asked what she would do if she found a resident unresponsive, she said she would determine code status and start CPR if the were a full code. During a telephone interview on [DATE] at 4:35 p.m. CNA C reported she worked weekends. When asked if she found a resident to be unresponsive, what action would she take? She said she would determine if they were a full code and if so, she would start CPR. During a telephone interview on [DATE] at 4:42 pm LVN Q said she worked weekend double shifts, 2:00 p.m till 10:00 pm and 10:00 p.m. till 6:00 a.m. When asked how she would determine DNR/Full Code status she said she would check the advance directive to be sure of the code status. She said the information is also located on the front of the chart, red sheet is DNR and green sheet is CPR. During an interview on [DATE] at 4:53 pm LVN R said he worked weekend double shifts, 2:00 p.m. till 10:00 p.m. and 10:00 p.m. till 6:00 a.m. and attended in-service training on DNR/Full code determination and Code Blue drills. He was asked if he went into the room of a resident and found the resident unresponsive and cold to the touch and a full code, what would he do? He stated, I would start CPR, I would never go by touch, the resident might be cold natured, the air conditioner might me blowing on them, if they are unresponsive, you don't know when they stopped breathing, you have to start CPR. 5. On [DATE] at approximately 2:00 p.m., chart audits were conducted to assess for the presence of complete and accurate physician DNR orders as well as complete and accurate Out of Hospital Do Not Resusitate orders. No discrepancies were found. Current physician ' s DNR orders as well as complete and valid Out of Hospital Do Not Resuscitate orders were found on resident charts. A current list of the facility ' s Residents ' code status dated [DATE] was observed on the crash cart, no discrepancies were noted. 6. Observations of residents' rooms on [DATE] at 4:00 P.M., revealed Certified Nurse Aide care plans accurately reflected the residents' code status. 7. On [DATE] at approximately 4:00 p.m., a list of CPR certified staff was provided. It revealed there were CPR certified staff on all three shifts including weekends. The facility's resident roster, dated [DATE], reflected 50 residents had DNRs. Therefore the facility's other 44 residents were a full code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #19) of 19 residents reviewed for neglect. LVN A failed to provide Resident #19 with CPR on [DATE], when she assessed him with no pulse or heartbeat, and he was cold to touch. Resident #19 expired at the facility on [DATE]. This was determined to be past non-compliance at a severity level of an immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the 44 residents who were full code status, by placing them at risk for death and their wishes not being honored. Findings included: The facility's current policy, Do Not Resuscitate Order, revised [DATE] reflected, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .1. Do not resuscitate orders must be signed by the resident ' s Attending Physician on the physician's order [REDACTED]. The facility's current policy, CPR Policy, revised [DATE] reflected, 1. in the event of cardiopulmonary arrest of a resident/patient without a DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. Review of the faciliy document, titled, Abuse Program revised May of 2010 reveals, .2. Policy for Prohibition of Abuse, Neglect and Misappropriation of Property.POLICY: .1. The facility will prohibit neglect, mental or physical abuse.of residents. According to facility policy neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #19's Face Sheet, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #19's Admission Care Plan, dated [DATE], reflected the resident's code status was a DNR. He needed assistance of one person with dressing, personal hygiene, bathing, eating, toileting, and transfers. The Care Plan did not address interventions specific to the DNR. Resident #19's Provider Notes (physician progress notes [REDACTED]. Resident #19 was confused and tried to get up without assistance. He had a poor appetite and had chronic [DIAGNOSES REDACTED] of the lungs according to his family. The facility's Provider Investigation Report, reported to DADS on [DATE], reflected Resident #19's family signed a DNR, but the physician had not signed the order. The facility considered the resident a full code which meant he would be provided CPR. LVN A did not initiate CPR after she was informed by a CNA that the resident was unresponsive. Resident #19 expired on [DATE]. The Provider Response section of the Investigation Report reflected LVN A and RN B (the nurse who pronounced Resident #19) were suspended pending investigation. All nursing staff was in-serviced and emergency quality assurance was initiated. The Investigation Summary reflected CPR should have been initiated due to the lack of the physician signature on the OOHDNR. Provider Action Taken Post-Investigation reflected LVN A was terminated for failure to follow policy and procedure and RN B was given a final reprimand on failure to follow resident code status. The emergency quality assurance continued. Attached to the facility's Provider Investigation Report was LVN A's written statement dated [DATE]. The statement reflected, .(Resident #19) was up at nurses station in his wheelchair. He was very restless trying to slide out of wheelchair. (CNA C) took him to TV room to watch him closely. After about an hour (Resident #19) looked tired and we placed him in bed. This was around midnight. (CNA D) states she checked on him @ (at) 0100 (1:00 a.m.). At 0200 (2:00 a.m.) she changed his brief. There were no signs or symptoms of any change of condition. At 0330 (3:30 a.m.) the CNA came to get me to assess (Resident #19). At that time he had no pulse, no heartbeat, and was cold to touch. I made the necessary phone calls to (the DON), (ADM), (ADON F). I got ahold (sic) of (RN B) to come pronounce his death. I called his family and broke the news. They came up here to see (Resident #19) and thanked us for all we did for (Resident #19). I called (name of funeral home) to have them to come pick (Resident #19) up. I also called and left message for (Physician E) informing him of (Resident #19's) death. On [DATE] at 8:43 a.m. an attempt was made to contact LVN A. A message was left, but not returned. On [DATE] at 11:13 a.m. another attempt was made to contact LVN A and a message was left. The call was not returned. On [DATE] at 11:55 a.m. the ADM was asked to contact LVN A. On [DATE] at 12:20 p.m. the ADM stated she had not received a call back from LVN A. An interview with RN B on [DATE] at 8:36 a.m. via telephone revealed she was home when LVN A called her at 4:00 a.m. to tell her Resident #19 was found dead and cold. She stated LVN A told her Resident #19 was a full code status but was cold to touch. RN B stated she told LVN A that did not matter. She stated she told LVN A to start CPR and initiate Code Blue procedures. RN B revealed when she arrived at the facility LVN A had not initiated CPR and had already contacted the family of the resident's death. RN B stated the family was already with the resident when she arrived. An interview with the ADM on [DATE] at 2:41 p.m. revealed LVN A told the ADM that when she assessed Resident #19 he was cold to touch and that was why she did not initiate CPR. The ADM stated that even though it was against the family's wishes, he was still considered a full code due to the physician not signing the DNR. The ADM revealed Physician E was usually timely in signing electronically the DNRs from his iphone. In this case, he was with his family member in the emergency room and did not sign the form. She stated Resident #19's family signed the DNR form the afternoon of [DATE]. The ADM revealed they quality assured the incident to prevent it from reoccurring. The facility started Code Blue drills. The facility conducted a DNR audit of all residents' clinical records. The ADM revealed LVN A was terminated. Review of Disciplinary Action Record dated [DATE] revealed LVN A was immediately suspended pending the investigation into Resident # 19's death. A Discipliary Action Report dated [DATE] revealed LVN A was terminated for failing to initiate CPR and failing to call 911 for Resident # 19 who was found unresponsive and without vital signs who was a full code. On [DATE] at 3:00p.m. a review of the Out of Hospital Do Not Resusitate document signed by the family on [DATE] revealed the document was not signed by the physician. An interview with the DON on [DATE] at 3:40 p.m. revealed LVN A should have initiated CPR on Resident #19 when she found him unresponsive. She stated she was on vacation when this incident occurred. She revealed RN B who worked at a sister facility was covering for her. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 3.htm reflected, A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. (Retrieved on [DATE]). The facility's current policy, Do Not Resuscitate Order, revised [DATE] reflected, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. The facility's current policy, CPR Policy, revised [DATE] reflected, 1. in the event of cardiopulmonary arrest of a resident/patient without a DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. It was determined this failure placed the facility's residents in an IJ from [DATE] through [DATE]. The facility took the following action to correct the non-compliance. 1. In-Service Training Report, dated [DATE], [DATE], [DATE] and [DATE] reflected licensed nurses, medication aides, and CNAs attended training regarding resident code status, DNR vs. full code status and code blue drills. In an interview on [DATE] at 1:15 P.M., The DON stated the in-service covered: how to ascertain the resident's code status, the location of resident code status information, what to do if a resident was found unresponsive and/or not breathing. The DON stated the facility staff was informed of the new procedure which was to keep an updated list of resident's code status on the crash cart. The DON also stated it was also on the CNA care plans, located in the residents' closets. The DON stated the facility's CPR policy and procedure and the Texas Board of Nurses's policy on initiation of CPR was reviewed with staff. The DON stated the Code Blue Drills consisted of mock scenarios in which a resident would be found unresponsive and staff would verbalize correct response. Additional in-service was provided on [DATE], [DATE], and [DATE] regarding Code Blue Drills. The summary reflected all residents were considered a full code status until there was a signed physician order [REDACTED]. 2. LVN A was suspended pending the investigation terminated, RN B received disciplinary action. 3. During new employee orientation, the facility will in-service the new employee on the facility's policy on Do Not Resuscitate Order. 4. During an interview on [DATE] at 8:00 a.m. LVN G (MDS nurse) was asked what action she would take if she came upon a resident that was determined to be unresponsive. She said she would check their code status in the chart and if they were a code status she would call for help instruct someone to dial 911 and begin CPR. During an interview on [DATE] at 9:03 a.m. CMA H was asked what action she would take if she was called to a resident ' s room and determined the resident was unresponsive. She said she had a list on her MAR that would tell her if the resident was a DNR or a code. She was then asked what she would do if the resident had a DNR on the chart but it was not signed by the Doctor. She said, I would begin CPR. During an interview on [DATE] at 1:34 p.m. CNA I said she had recently been trained on how to determine DNR/code status of a resident. She stated if the resident isn't responsive, alert the nurse and start CPR. When asked how she would determine if they were a DNR, she said by their care-plan inside their closet door. When asked if she had attended a code blue drill, she responded, Yes, they had us report to the scene, get the crash cart and begin CPR. During an interview on [DATE] at 1:56 p.m. CNA J was asked if she had attended in-service training on DNR/Code status determination. She nodded her head in the affirmative. She was asked how she would know if she needed to start CPR on an unresponsive resident, she said the code status was posted inside the closet door for every resident. If I went into a room and a resident was unresponsive, need to call nurse, 911 and perform CPR if the resident is a full code. During an interview on [DATE] at 2:04 p.m. CNA K was asked how she would determine if she needed to start CPR on an unresponsive resident. She said she would look inside closet door, if the sheet was red the resident is a DNR but if it is green you start CPR. During an interview on [DATE] at 2:11 p.m. CNA L stated she worked the 2:00 p.m. till 10:00 p.m. shift. She was asked where she would look to determine the code status of a resident she found to be unresponsive. She said she would check the resident ' s closet door for code status. She was asked if there was anywhere else she could look. She stated, Yes the crash cart located on the 400 hall. During an interview on [DATE] at 2:55 p.m. RN M says the in-service trainings occurred prior to her employment but she did receive the training as part of her orientation. She said she was told if the sheet is red then the resident is a DNR, if it is green then you do CPR. When asked if there were other places to find the code status of the resident she said, Yes it is in the MAR and on the crash cart. During an interview on [DATE] at 3:09 p.m. LVN N reports she works the 2:00 p.m. till 10:00 p.m. shift and she had attended in-service training. She was asked if she walked into a resident ' s room and found the resident to be unresponsive, what she would do. She said she would determine code status and, if they were a full code, I would start CPR. When asked how she would determine the resident ' s code status she said, I would look in the chart and could also get the information from the crash cart. During an interview on [DATE] at 3:20 p.m. CNA O reports she works the 2:00 p.m. till 10:00 p.m. shift. She says she attended in-service training on how to determine DNR/CPR status of residents and Code Blue drill. When asked what she would do if she found a resident that was unresponsive, she said she would determine code status and if they were a full code, start CPR. During a telephone interview on [DATE] at 4:30p.m. LVN P reported she worked the 10:00 p.m. till 6:00 am shift. She was asked if she attended in-service training on code status determination and Code Blue drills, she responded, Yes. The code status is in the chart, MAR and the crash cart. DNR are red sheets and Full codes are green sheets. When asked what she would do if she found a resident unresponsive, she said she would determine code status and start CPR if the were a full code. During a telephone interview on [DATE] at 4:35 p.m. CNA C reported she worked weekends. When asked if she found a resident to be unresponsive, what action would she take? She said she would determine if they were a full code and if so, she would start CPR. During a telephone interview on [DATE] at 4:42 pm LVN Q said she worked weekend double shifts, 2:00 p.m till 10:00 pm and 10:00 p.m. till 6:00 a.m. When asked how she would determine DNR/Full Code status she said she would check the advance directive to be sure of the code status. She said the information is also located on the front of the chart, red sheet is DNR and green sheet is CPR. During an interview on [DATE] at 4:53 pm LVN R said he worked weekend double shifts, 2:00 p.m. till 10:00 p.m. and 10:00 p.m. till 6:00 a.m. and attended in-service training on DNR/Full code determination and Code Blue drills. He was asked if he went into the room of a resident and found the resident unresponsive and cold to the touch and a full code, what would he do? He stated, I would start CPR, I would never go by touch, the resident might be cold natured, the air conditioner might me blowing on them, if they are unresponsive, you don't know when they stopped breathing, you have to start CPR. 5. On [DATE] at approximately 2:00 p.m., chart audits were conducted to assess for the presence of complete and accurate physician DNR orders as well as complete and accurate Out of Hospital Do Not Resusitate orders. No discrepancies were found. Current physician ' s DNR orders as well as complete and valid Out of Hospital Do Not Resuscitate orders were found on resident charts. A current list of the facility ' s Residents ' code status dated [DATE] was observed on the crash cart, no discrepancies were noted. 6. Observations of residents' rooms on [DATE] at 4:00 P.M., revealed Certified Nurse Aide care plans accurately reflected the residents' code status. 7. On [DATE] at approximately 4:00 p.m., a list of CPR certified staff was provided. It revealed there were CPR certified staff on all three shifts including weekends. The facility's resident roster, dated [DATE], reflected 50 residents had DNRs. Therefore the facility's other 44 residents were a full code status.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for one (Resident #19) of 19 residents reviewed for neglect. LVN A failed to initiate CPR on [DATE] on Resident #19 when she assessed him without a pulse or heartbeat, and he was cold to touch. Resident #19 expired in the facility on [DATE]. This was determined to be past non-compliance at a severity level of an Immediate Jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the 44 residents who were full code status, by placing them at risk for death and their wishes not being honored. Findings included: Resident #19's Face Sheet, dated [DATE], reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #19's Admission Care Plan, dated [DATE], reflected the resident's code status was a DNR. He needed assistance of one person with dressing, personal hygiene, bathing, eating, toileting, and transfers. The Care Plan did not address interventions specific to the DNR. Resident #19's Provider Notes (physician progress notes [REDACTED]. Resident #19 was confused and tried to get up without assistance. He had a poor appetite and had chronic [DIAGNOSES REDACTED] of the lungs according to his family. The facility's Provider Investigation Report, reported to DADS on [DATE], reflected Resident #19's family signed a DNR, but the physician had not signed the order. The facility considered the resident a full code which meant he would be provided CPR. LVN A did not initiate CPR after she was informed by a CNA that the resident was unresponsive. Resident #19 expired on [DATE]. The Provider Response section of the Investigation Report reflected LVN A and RN B (the nurse who pronounced Resident #19) were suspended pending investigation. All nursing staff was in-serviced and emergency quality assurance was initiated. The Investigation Summary reflected CPR should have been initiated due to the lack of the physician signature on the OOHDNR. Provider Action Taken Post-Investigation reflected LVN A was terminated for failure to follow policy and procedure and RN B was given a final reprimand on failure to follow resident code status. The emergency quality assurance continued. Attached to the facility's Provider Investigation Report was LVN A's written statement dated [DATE]. The statement reflected, .(Resident #19) was up at nurses station in his wheelchair. He was very restless trying to slide out of wheelchair. (CNA C) took him to TV room to watch him closely. After about an hour (Resident #19) looked tired and we placed him in bed. This was around midnight. (CNA D) states she checked on him @ (at) 0100 (1:00 a.m.). At 0200 (2:00 a.m.) she changed his brief. There were no signs or symptoms of any change of condition. At 0330 (3:30 a.m.) the CNA came to get me to assess (Resident #19). At that time he had no pulse, no heartbeat, and was cold to touch. I made the necessary phone calls to (the DON), (ADM), (ADON F). I got ahold (sic) of (RN B) to come pronounce his death. I called his family and broke the news. They came up here to see (Resident #19) and thanked us for all we did for (Resident #19). I called (name of funeral home) to have them to come pick (Resident #19) up. I also called and left message for (Physician E) informing him of (Resident #19's) death. On [DATE] at 8:43 a.m. an attempt was made to contact LVN A. A message was left, but not returned. On [DATE] at 11:13 a.m. another attempt was made to contact LVN A and a message was left. The call was not returned. On [DATE] at 11:55 a.m. the ADM was asked to contact LVN A. On [DATE] at 12:20 p.m. the ADM stated she had not received a call back from LVN A. An interview with RN B on [DATE] at 8:36 a.m. via telephone revealed she was home when LVN A called her at 4:00 a.m. to tell her Resident #19 was found dead and cold. She stated LVN A told her Resident #19 was a full code status but was cold to touch. RN B stated she told LVN A that did not matter. She stated she told LVN A to start CPR and initiate Code Blue procedures. RN B revealed when she arrived at the facility LVN A had not initiated CPR and had already contacted the family of the resident's death. RN B stated the family was already with the deceased resident when she arrived. An interview with the ADM on [DATE] at 2:41 p.m. revealed LVN A told the ADM that when she assessed Resident #19 he was cold to touch and that was why she did not initiate CPR. The ADM stated that even though it was against the family's wishes, he was still considered a full code due to the physician not signing the DNR. The ADM revealed Physician E was usually timely in signing electronically the DNRs from his iphone. In this case, he was with his family member in the emergency room and did not sign the form. She stated Resident #19's family signed the DNR form the afternoon of [DATE]. The ADM revealed they quality assured the incident to prevent it from reoccurring. The facility started Code Blue drills. The facility conducted a DNR audit of all residents' clinical records. The ADM revealed LVN A was terminated. Review of Disciplinary Action Record dated [DATE] revealed LVN A was immediately suspended pending the investigation into Resident # 19's death. A Discipliary Action Report dated [DATE] revealed LVN A was terminated for failing to initiate CPR and failing to call 911 for Resident # 19 who was found unresponsive and without vital signs who was a full code. On [DATE] at 3:00p.m. a review of the Out of Hospital Do Not Resusitate document signed by the family on [DATE] revealed the document was not signed by the physician. An interview with the DON on [DATE] at 3:40 p.m. revealed LVN A should have initiated CPR on Resident #19 when she found him unresponsive. She stated she was on vacation when this incident occurred. She revealed RN B who worked at a sister facility was covering for her. http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 3.htm reflected, A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. (Retrieved on [DATE]). The facility's current policy, Do Not Resuscitate Order, revised [DATE] reflected, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .1. Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders [REDACTED]. The facility's current policy, CPR Policy, revised [DATE] reflected, 1. in the event of cardiopulmonary arrest of a resident/patient without a DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. It was determined this failure placed the facility's residents in an IJ from [DATE] through [DATE]. The facility took the following action to correct the non-compliance. 1. In-Service Training Report, dated [DATE], [DATE], [DATE] and [DATE] reflected licensed nurses, medication aides, and CNAs attended training regarding resident code status, DNR vs. full code status and code blue drills. In an interview on [DATE] at 1:15 P.M., The DON stated the in-service covered: how to ascertain the resident's code status, the location of resident code status information, what to do if a resident was found unresponsive and/or not breathing. The DON stated the facility staff was informed of the new procedure which was to keep an updated list of resident's code status on the crash cart. The DON also stated it was also on the CNA care plans, located in the residents' closets. The DON stated the facility's CPR policy and procedure and the Texas Board of Nurses's policy on initiation of CPR was reviewed with staff. The DON stated the Code Blue Drills consisted of mock scenarios in which a resident would be found unresponsive and staff would verbalize correct response. Additional in-service was provided on [DATE], [DATE], and [DATE] regarding Code Blue Drills. The summary reflected all residents were considered a full code status until there was a signed physician order [REDACTED]. 2. LVN A was suspended pending the investiation terminated, RN B received disciplinary action. 3. During new employee orientation, the facility will in-service the new employee on the facility's policy on Do Not Resuscitate Order. 4. During an interview on [DATE] at 8:00 a.m. LVN G (MDS nurse) was asked what action she would take if she came upon a resident that was determined to be unresponsive. She said she would check their code status in the chart and if they were a code status she would call for help instruct someone to dial 911 and begin CPR. During an interview on [DATE] at 9:03 a.m. CMA H was asked what action she would take if she was called to a resident ' s room and determined the resident was unresponsive. She said she had a list on her MAR that would tell her if the resident was a DNR or a code. She was then asked what she would do if the resident had a DNR on the chart but it was not signed by the Doctor. She said, I would begin CPR. During an interview on [DATE] at 1:34 p.m. CNA I said she had recently been trained on how to determine DNR/code status of a resident. She stated if the resident isn't responsive, alert the nurse and start CPR. When asked how she would determine if they were a DNR, she said by their care-plan inside their closet door. When asked if she had attended a code blue drill, she responded, Yes, they had us report to the scene, get the crash cart and begin CPR. During an interview on [DATE] at 1:56 p.m. CNA J was asked if she had attended in-service training on DNR/Code status determination. She nodded her head in the affirmative. She was asked how she would know if she needed to start CPR on an unresponsive resident, she said the code status was posted inside the closet door for every resident. If I went into a room and a resident was unresponsive, need to call nurse, 911 and perform CPR if the resident is a full code. During an interview on [DATE] at 2:04 p.m. CNA K was asked how she would determine if she needed to start CPR on an unresponsive resident. She said she would look inside closet door, if the sheet was red the resident is a DNR but if it is green you start CPR. During an interview on [DATE] at 2:11 p.m. CNA L stated she worked the 2:00 p.m. till 10:00 p.m. shift. She was asked where she would look to determine the code status of a resident she found to be unresponsive. She said she would check the resident ' s closet door for code status. She was asked if there was anywhere else she could look. She stated, Yes the crash cart located on the 400 hall. During an interview on [DATE] at 2:55 p.m. RN M says the in-service trainings occurred prior to her employment but she did receive the training as part of her orientation. She said she was told if the sheet is red then the resident is a DNR, if it is green then you do CPR. When asked if there were other places to find the code status of the resident she said, Yes it is in the MAR and on the crash cart. During an interview on [DATE] at 3:09 p.m. LVN N reports she works the 2:00 p.m. till 10:00 p.m. shift and she had attended in-service training. She was asked if she walked into a resident ' s room and found the resident to be unresponsive, what she would do. She said she would determine code status and, if they were a full code, I would start CPR. When asked how she would determine the resident ' s code status she said, I would look in the chart and could also get the information from the crash cart. During an interview on [DATE] at 3:20 p.m. CNA O reports she works the 2:00 p.m. till 10:00 p.m. shift. She says she attended in-service training on how to determine DNR/CPR status of residents and Code Blue drill. When asked what she would do if she found a resident that was unresponsive, she said she would determine code status and if they were a full code, start CPR. During a telephone interview on [DATE] at 4:30p.m. LVN P reported she worked the 10:00 p.m. till 6:00 am shift. She was asked if she attended in-service training on code status determination and Code Blue drills, she responded, Yes. The code status is in the chart, MAR and the crash cart. DNR are red sheets and Full codes are green sheets. When asked what she would do if she found a resident unresponsive, she said she would determine code status and start CPR if the were a full code. During a telephone interview on [DATE] at 4:35 p.m. CNA C reported she worked weekends. When asked if she found a resident to be unresponsive, what action would she take? She said she would determine if they were a full code and if so, she would start CPR. During a telephone interview on [DATE] at 4:42 pm LVN Q said she worked weekend double shifts, 2:00 p.m till 10:00 pm and 10:00 p.m. till 6:00 a.m. When asked how she would determine DNR/Full Code status she said she would check the advance directive to be sure of the code status. She said the information is also located on the front of the chart, red sheet is DNR and green sheet is CPR. During an interview on [DATE] at 4:53 pm LVN R said he worked weekend double shifts, 2:00 p.m. till 10:00 p.m. and 10:00 p.m. till 6:00 a.m. and attended in-service training on DNR/Full code determination and Code Blue drills. He was asked if he went into the room of a resident and found the resident unresponsive and cold to the touch and a full code, what would he do? He stated, I would start CPR, I would never go by touch, the resident might be cold natured, the air conditioner might me blowing on them, if they are unresponsive, you don't know when they stopped breathing, you have to start CPR. 5. On [DATE] at approximately 2:00 p.m., chart audits were conducted to assess for the presence of complete and accurate physician DNR orders as well as complete and accurate Out of Hospital Do Not Resusitate orders. No discrepancies were found. Current physician ' s DNR orders as well as complete and valid Out of Hospital Do Not Resuscitate orders were found on resident charts. A current list of the facility ' s Residents ' code status dated [DATE] was observed on the crash cart, no discrepancies were noted. 6. Observations of residents' rooms on [DATE] at 4:00 P.M., revealed Certified Nurse Aide care plans accurately reflected the residents' code status. 7. On [DATE] at approximately 4:00 p.m., a list of CPR certified staff was provided. It revealed there were CPR certified staff on all three shifts including weekends. The facility's resident roster, dated [DATE], reflected 50 residents had DNRs. Therefore the facility's other 44 residents were a full code status.

Based on observation, interview and record review, it was determined the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care for for two (Residents #1 and #9) of seven residents reviewed for indwelling urinary (Foley) catheters. The facility failed to: 1. Assess the the characteristics of urine including the color, smell, liquidity and urine output for Residents #1 and #9 and monitor for signs and symptoms of a urinary tract infection. 2. Ensure Resident #1's and #9's Foley catheters were secured appropriately to prevent trauma to the urinary tract and meatus. Resident #9's Foley catheter had been secured directly on his leg with a strap across the top of it. 3. Assess the penis of both Residents #1 and #9 to ensure there were no skin breakdowns, the development of penile erosion and/or the worsening of penile erosion. These failures likely caused: Resident #1's development of penile erosion, which was not identified and treated appropriately by the facility; Resident #1's development of a urinary tract obstruction, which was not identified and treated appropriately by the facility, resulting in Resident #1's admission to an acute care hospital with Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #9's development of an open skin wound, tension on the catheter, and discomfort for the resident. Resident #9's development of penile erosion, which was not identified and treated prior to surveyor intervention. Resident #9's development of a discharge from his urinary meatus, around the resident's Foley catheter, and redness, swelling and discomfort along the resident's left groin (inguinal) area and on both the inner and outer aspects of the left side of his foreskin which were not identified and treated prior to surveyor intervention. These failures could affect all seven current residents with indwelling urinary catheters and placed them at risk for urethral trauma, unnecessary pain, infection [MEDICAL CONDITION]. Findings included: 1) A review of the 03/07/2012 Minimum Data Set (MDS) assessment in Resident #1's closed clinical record revealed the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS assessment reflected the resident was cognitively impaired and required cueing for recall. No behaviors were identified. The resident required the extensive assistance of two people for transfers, the extensive assistance of one person for dressing and wheelchair locomotion and had no limitations on his range of motion. The same MDS assessment reflected Resident #1 had an indwelling urinary catheter and was continent of bowel. The assessment identified Resident #1 was at risk for pressure ulcers. A review of Resident #1's care plans revealed a 03/09/2012 care plan to address the resident's use of an indwelling urinary catheter. Approaches to prevent infection from catheter-use included: A) Ongoing assessment of the color, clarity and character of Resident #1's urine. B) Assessment for symptoms of urinary tract infection [MEDICAL CONDITION]. C) Observation for acute behavioral changes, which may indicate a UTI. D) Changing Resident #1's catheter/bag every three weeks. E) Securing Resident #1's catheter tubing to his thigh to prevent pulling. F) Catheter care every shift. G) Encouraging Resident #1's fluid intake H) Evaluating Resident #1's fluid intake and hydration status. I) Monitoring Resident #1's catheter tubing for kinks or twists in the tubing. An interview conducted with a member of Resident #1's family at approximately 3:00 PM on 05/01/2012 revealed the family member was concerned about the catheter care Resident #1 had received while in the facility. The family member stated when Resident #1 was transferred to the emergency roiagnom on [DATE], the resident had a UTI. The family member stated there was erosion on the tip of Resident #1 penis because the resident did not get good catheter care while he was in the facility. The family member said in March 2012, Resident #1's urologist diagnosed Resident #1 with a UTI and informed a family member the erosion on the resident's penis was the result of poor catheter care. The family member stated the DON (Director of Nursing) was informed about Resident #1's UTI and the erosion on the resident's penis when Resident #1 returned to the facility. A review of records from the acute care hospital revealed: An emergency room (ER) nurse's note dated 04/29/2012 at 2:57 PM reflected the posterior side of Resident #1's penis was red and excoriated. Redness was noted on Resident #1's testicles and in his groin area. The admission history and physical dated 04/29/2012 and timed for 9:55 PM reflected Resident #1 had been on a "chronic indwelling Foley catheter for approximately 1 ? years secondary to [MEDICAL CONDITION]." The resident had very scant urine when he was admitted to the emergency room so the Foley catheter was replaced. A large amount of foul-smelling, brown-colored urine with pus drained out. Resident #1 appeared more alert and oriented after his catheter was replaced and his bladder was drained. Admission Laboratory work dated 04/29/2012: White Blood Cells (WBC) 13.7, Hemoglobin 11.9, Potassium 5.3, Creatinine 5.1, [MEDICATION NAME] 289, ALT 990. Urinalysis: Large leukocyte esterase, WBC clumping present, WBCs more than 182, [MEDICATION NAME] positive. A report dated 04/29/2012 of an Ultrasound of Resident #1's kidneys: Kidneys normal in size. Both ureters with Hydroureter (distension of the ureter (tube draining urine from the kidney to the bladder) with urine due to obstruction). Additional [DIAGNOSES REDACTED]. obstruction to catheter. A consultation dated 04/30/2012 reflected the resident had an indwelling Foley catheter with some ventral urethral erosion. A culture of the resident's urine reported growing 100,000 colonies of gram-negative rods. The consultation concluded with the [DIAGNOSES REDACTED]. A Nephrology Consult dated 04/30/2012 reflected: 1) Acute kidney Injury (reason for evaluation) 2) In ER immediate return of un-quantified amount of foul -smelling, fairly dark urine with a significant amount of sediment. Urine output fairly brisk since catheter replacement. 3) Recent abdominal pain and distention. 4) Increasing confusion at Nursing Home. A Urology consult dated 04/30/2012 reflected: 1) Acute kidney injury is likely a combination of hypoperfusion from his infection in addition to bladder outlet obstruction from obstruction of his Foley catheter. 2) Hydroureter appears to be due to bladder outlet obstruction from an obstruction of his Foley catheter. 3) Metabolic acidosis with mild [MEDICAL CONDITION] both likely from his acute kidney injury. 4) Lactic acid elevated as a marker [MEDICAL CONDITION]. AST and myoglobin elevated as well. 5) Foley catheter with a large amount of sediment in catheter needing to have catheter flushed. 6) Foley in place with redness involving penis and groin. Wound Care Nurse Notes dated 04/30/2012 reflected Resident #1 was admitted with Acute UTI, [MEDICAL CONDITION] and Acute [MEDICAL CONDITION]. On admission Resident #1 was noted to have a urethral erosion with an indwelling catheter. An interview with Certified Nurse Aide (CNA) F on 05/01/2012 at approximately 3:55 PM revealed the CNA was providing Resident #1's care on the morning the resident was transferred to the hospital. CNA F stated he did not know anything about Resident #1's urinary output that day because the resident's catheter drainage bag was obstructed from view by a privacy bag. CNA F stated if he had a resident with a Foley catheter, he checked the urine and emptied the drainage bag at the end of his shift. An interview with the 2:00 PM to 10:00 PM Charge Nurse, Licensed Vocational Nurse (LVN) B, on 05/01/2012 at approximately 5:30 PM revealed the LVN was not aware of how much Resident #1's usual urinary output had been because the facility did not keep urinary outputs without a direct physician's orders [REDACTED].#1's urine. An interview with the DON on 05/02/2012 at approximately 9:00 AM revealed residents' urinary drainage bags were emptied three times a day at the end of each shift. The DON stated if a resident's urinary drainage bag was too full before the end of the shift, facility staff emptied the drainage bag as needed. The DON revealed the facility did not keep an intake and output record for residents with indwelling catheters unless the resident's physician ordered it. The DON stated the LVN charge nurses were expected to check residents' indwelling urinary catheters to ensure the catheters were in place and draining properly. The DON stated the LVNs were expected to monitor the amount of urinary output from residents' indwelling catheters and to observe the color of the urine for cloudiness and darkened color. During the same interview, the DON revealed the treatment nurse (TN) performed weekly skin assessments for all residents in the facility. The DON stated the TN did her weekly skin checks on one of the four facility halls each day from Monday through Thursday. The DON revealed the TN performed residents' weekly skin checks while the residents were in their beds, rolling them from side to side to ensure all areas of skin were observed. The DON then stated the shower aides (SA) were the only facility staff who saw "the full body" of each resident. The DON stated the two shower aides switched off the halls whose residents they were assigned to shower each week, so they would observe the skin on each resident every other week. An interview conducted with the TN on 05/02/2012 at approximately 10:00 AM revealed she did a weekly skin check for all residents once a week. The TN denied observing erosion on Resident #1's penis during her weekly skin checks. An interview conducted with Shower Aide (SA) C on 05/02/2012 at approximately 10:10 AM revealed the SA did not give Resident #1 showers and so she was not aware of the resident's skin issues. The SA stated she checked the residents' indwelling catheters and "cleaned around them real good." The SA revealed she reported any problems with the residents' skin or catheters to the nurse. Interview with SA D on 05/02/2012 at approximately 10:30 AM revealed if the SA found any new red areas on a resident's skin during showers, it was reported to the TN. SA D stated she had observed Resident #1 with a sore on his penis and stated she reported it to the CNA (unidentified) so the CNA could chart the information in the kiosk. SA D stated the Wednesday before Resident #1 went to the hospital she noted the resident's urine had a "strong smell." A telephone interview conducted with LVN G on 05/02 2012 at approximately 2:40 PM revealed the LVN was charge nurse for Resident #1's hall on 04/28/2012 and 04/29/2012. LVN G revealed she did not check Resident #1's urinary output before the resident was transferred to the hospital the morning of 04/29/2012. LVN G stated Resident #1's urinary drainage bag was covered up while the resident was seated in his chair. LVN G stated on Saturday (04/28/2012) at approximately noon, Resident #1 had "about" 200 cubic centimeters (cc) of "hazy amber urine." LVN G revealed none of the CNAs had mentioned Resident #1's urine had a bad odor. A record review of Resident #1's April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A) An 11/02/2011 physician's orders [REDACTED]. Documentation on the same form reflected LVN B changed Resident #1's Foley catheter on 04/10/2012 and on 04/18/2012. B) An 09/08/2011 physician's orders [REDACTED]. Documentation on the same form reflected Resident #1's catheter care was performed on the 10:00 PM to 6:00 AM shift from 04/01/2012 through 04/29/2012. A record review of Resident #1's nurses notes revealed: A) On 09/18/2011, Resident #1's Foley catheter was changed. The skin on Resident #1's urethra was torn. Resident #1's physician and family would be notified. B) On 09/19/2011, Resident #1's physician ordered a urology consult regarding Resident #1's "damaged urethra." C) On 10/07/2012 and 03/20/2012, Resident #1's urologist treated the resident for a UTI. D) Resident #1's Foley catheter was changed "per order" on 12/16/2011, 01/02/2012, 01/25/2012, 03/05/2012 and 03/28/2012. Resident #1's nurses notes, dated 04/29/2012 at 12:00 PM, reflected the resident was transferred to the ER of an acute care hospital on the same date. A written statement, dated 04/27/2012 and received on 05/22/2012 via fax, revealed when CNA I emptied Resident #1's urinary catheter drainage bag on 04/27/2012, the urine in the bag was clear. A record review of the facility's documents entitled "Infection Control Log," dated from January through May 2012 revealed Resident #1 was treated for [REDACTED]. 2) Resident #9 was an [AGE] year-old male, whose 04/23/2012 MDS assessment reflected a 03/27/2012 admitted . The same MDS assessment reflected diagnoses, which included Heart Failure, Hypertension, [MEDICAL CONDITIONS] Disorder, Depression, Dysphagia and Gastrostomy. The assessment reflected the resident was cognitively impaired and had periods of inattention. No behavior indicators were checked. Resident #9 required supervision of one person for eating, extensive assistance of two people for transfers, dressing and hygiene and extensive assistance of one person for locomotion in the resident's wheelchair. Resident #9 was dependent on the assistance of one person for bathing. The MDS assessment reflected Resident #9 had an indwelling urinary catheter and was continent of bowel. A review of Resident #9's care plans revealed a care plan dated 04/03/2012, which addressed the resident's risk for increased UTIs related to the resident's indwelling #18 French Foley catheter. Approaches in the care plan included: A) Monitor urine for odor, color, sediment and amount of urine, etc. and report abnormals to physician. B) Keep tubing/bag below the bladder. Do not kink tubing. C) Catheter care per order. Resident #9's care plans did not address securing Resident #9's catheter to prevent pulling . On 05/16/2012 at approximately 11:15 AM Resident #9 was observed seated in his wheelchair at his bedside. The resident was neat and well groomed. Observation of CNA F as the CNA provided catheter care for Resident #9 at the same time revealed: A) Resident #9 had a Velcro strap around his left upper thigh to secure the resident's Foley catheter. but the catheter was not secured to the strap per the design of the strap. Instead the resident's catheter had been placed under the Velcro strap, next to the resident's skin. The catheter was observed to be stretched taut by the strap. Resident #9 pulled his Foley catheter up above the Velcro strap, reducing the tension on the catheter, before and after he was transferred from his wheelchair to his bed. After the transfer, the catheter was observed to be pulled tight again. B) When CNA F removed the Velcro strap from around Resident #9's thigh to provide the resident's catheter care, a small round open area was observed on Resident #9's thigh where the resident's Foley catheter had rested against his skin. C) The skin along the crease in Resident #9's left inguinal area was swollen and reddened. When CNA F wiped the area with moistened disposable cloths, Resident #9 complained it was "raw and inflamed." D) The outer and inner surfaces of the left side of Resident #9's foreskin and the resident's urethral meatus (opening) were reddened. Resident #9 complained of discomfort when his foreskin and urethral opening were cleaned. Resident #9 said the area was sore, especially when his catheter was too tight. A small amount of yellow drainage was observed at Resident #9's urethral opening and around the resident's Foley catheter E) CNA F replaced the Velcro strap around Resident #9's thigh when the CNA completed the resident's catheter care. CNA F fastened Resident #9's catheter between the two pieces of Velcro. CNA F stated the residents' Foley catheters were never supposed to be fastened under the Velcro strap next to the residents' skin. During an interview conducted at the time of the observation, CNA F revealed he checked the residents' catheters and the urine in the residents' drainage bags each time he got residents up or put them back to bed. CNA F stated he also checked the residents' catheters every two hours when he checked for incontinence. CNA F stated unless the residents' urinary drainage bags got too full, he generally emptied them at the end of his shift. During an interview conducted on 05/16/2012 at approximately 1:55 PM, LVN H, the 6:00 AM to 2:00 PM Charge Nurse for Resident #9's hall, was queried if CNA F had reported the redness and swelling in Resident #9's left inguinal area, the redness on the outside and inside left side of his foreskin and the redness and drainage from the resident's urethral meatus. LVN H stated she had not received a verbal report from CNA F. On 05/16/2012 at approximately 2:10 PM, LVN H stated, during the 6:00 AM to 2:00 PM shift, CNA F had put a notification on the LVN's cart, and she "just saw it." LVN H said she believed the redness and swelling in Resident #9's left inguinal area and the redness on the left side of the resident's foreskin was due to the diarrhea the resident had yesterday (05/15/2012) had "got in there (the folds of the skin)." LVN H was not able to explain what might have caused the redness on the inside of Resident #9's foreskin or the redness and drainage from the resident's urethral meatus. On 05/16/2012 at approximately 2:20 PM, LVN H stated she had checked Resident #9. LVN H stated she would monitor the redness in Resident #9's urethra and would get an order for [REDACTED]. LVN H further stated the TN would check the open areas on Resident #9's skin to determine if they needed treatment. During an interview conducted on 05/16/2012 at approximately 3:25 PM, CNA A stated she checked residents' catheters every two hours to ensure the catheters were in place and the urinary drainage bags were not full enough to need emptying. On 05/16/2012 at approximately 3:30 PM, the TN revealed she would monitor the open area of skin on Resident #9's thigh where the resident's Foley catheter had been against his skin under the Velcro strap. The TN stated the area was scabbed over at this time. The TN stated she had called Resident #9's physician about the open area on the resident's thigh. The TN revealed she had also informed the physician about the redness and the small amount of drainage the resident was having from his urethral meatus. The TN stated Resident #9's physician was coming to the facility that afternoon and would check the resident then. On 05/16/2012 at approximately 3:50 PM, the DON stated the CNAs were utilizing a form entitled "Early Warning Tool" to inform the LVNs about changes they noticed in residents while providing residents' care. The DON stated one copy of the form was to be given to the LVN and a second copy was to be given to him for follow-up. The DON revealed the "Early Warning Tool" was being used to help the LVNs remember the CNAs verbal reports about residents' condition changes. The DON stated the form also gave the CNAs a way to verify the reports had been given to the LVNs. During an interview on 05/17/2012 at approximately 10:10 AM with a CNA, who was identified as having been assigned to provide care for Resident #9, she stated she secured Resident #9's Foley catheter by placing the catheter on top of the resident's leg strap and securing the catheter with the attached Velcro strip. When the surveyor informed the CNA on 05/16/2012, Resident #9's catheter was placed between the resident's leg strap and his skin, the CNA replied, "That's because I wasn't here yesterday." On 05/17/2012 at approximately 10:20 AM, the surveyor, the TN and LVN H entered Resident #9's room to check the resident's perineal area. The surveyor observed as LVN H was preparing Resident #9 to transfer from his wheelchair to his bed. The LVN laid the Foley catheter drainage bag on the floor under the resident's wheelchair before securing the bag to the side of Resident #9's wheelchair. The resident's Foley catheter was observed to be properly secured to his leg on top of the Velcro leg strap at that time. LVN H told the surveyor when she made rounds that morning, she found Resident #9's Foley catheter was once again between the Velcro leg strap and the resident's skin. LVN H stated she would in-service the night shift regarding the proper way to secure residents' catheters. The TN, LVN H and the surveyor observed Resident #9's left inguinal area and foreskin had been treated with Barrier Cream. There was less redness and swelling in those areas. Resident #9's urethral meatus was reddened and had a small amount of yellow drainage. The TN stated when she spoke to Resident #9's physician's assistant (PA), the PA had ordered a culture and sensitivity of the drainage. LVN H said the specimen for the culture and sensitivity had not been collected yet. At that time, the TN obtained the specimen for the urethral meatus drainage culture and sensitivity. A review of the facility's "Infection Control Log," dated January 2012 through May 2012 revealed Resident #9 was treated for [REDACTED]. During an interview on 05/17/2012 at approximatey 5:20 PM , the DON revealed Resident #9 had a history of [REDACTED]. meatus drainage to come back positive for infection. The DON stated he would fax copies of the two test results to the surveyor. A review of Resident #9's April 2012 compiled and printed physician's orders [REDACTED]. 03/29/2012 - order for catheter care daily on the 10:00 PM to 6:00 AM shift and 03/29/2012 - order to change Foley catheter every month with a 16 French catheter with a 10 cc bulb. A review of Resident #9's physician's telephone orders revealed the following: 05/16/2012 - order to apply Barrier Cream to excoriated area BID (twice a day). 05/17/ - orders to culture the discharge from penis STAT and to obtain a urinalysis with culture and sensitivity STAT. A review of Resident #9's May 2012 Treat Administration Record (TAR) (Note: there were two TARs for May 2012) revealed: Undated note - flush/irrigate Foley catheter with 60 cc sterile water every shift. Documentation on the TAR reflected Resident #9's Foley catheter was flushed/irrigated on all three shifts from 05/01/2012 through 05/16/2012. 03/29/2012 - catheter care daily on the 10:00 PM to 6:00 AM shift. Catheter care was documented daily from 05/01/2012 through 05/16/2012. 04/10/2012 - change Resident #9's Foley catheter every month (18 French 10 cc). The TAR reflected Resident #9's Foley catheter was scheduled to be changed on 05/10/2012. There were no staff initials on 05/10/2012 on either of the May 2012 TARs to indicate Resident #9's Foley catheter was changed on that date or any other date between 05/01/2012 and 05/16/2012. 04/30/2012 - flush/irrigate Foley catheter with 60 cc sterile water PRN. Documentation on the TAR reflected Resident #9's Foley catheter was flushed on 04/07/2012 and 04/16 2012. Undated note - apply Barrier Cream to excoriated area BID X (times) 7 days the re-evaluate. A review of a faxed copy of a document entitled Office Visit Report, dated 05/18/2012 and received on 05/22/2012, revealed Resident #9 was examined by his physician for the complaint of an infection of the resident's penis with a penile discharge of two weeks duration. The report reflected, at the time of the visit, Resident #9 denied pain at the tip of his penis or pain below his waist. Resident #9's physician's GU ([MEDICAL CONDITION]) examination revealed, "Foley intact with meatal discharge." A urinalysis completed on that date reflected the following indicators for urinary tract infections: Protein (2+), Leukocyte Esterase (3+), and WBC TNTC (white blood cells too numerous to count) but no bacteria or [MEDICATION NAME]. Resident #9's physician noted, "Patient needs to have penile meatus around the Foley cleaned with Q-tip and hydrogen peroxide 3 times a day." The report further reflected Resident #9's physician had treated the resident for UTIs on 08/08/2011 and 12/29/2011. During an interview conducted with the DON on 05/22/2012, after reviewing Resident #9's faxed physician's report, the DON said Resident #9's physician had informed the facility it was not unusual for males with long-term indwelling catheters to develop penile erosions. The DON was not able to tell the surveyor why the TN and LVN H were not aware of the meatal discharge if the discharge had been present for two weeks prior to the surveyor's investigation. The surveyor was not provided copies of Resident #9's 05/17/2012 urinalysis and urethral meatus drainage culture. 3) A review of www.o-wm.com/...associated-urethral-erosion-four-elderly-men?page=0,1 <http://www.o-wm.com/...associated-urethral-erosion-four-elderly-men?page=0,1> on 05/29/2012 revealed: "If a urinary catheter is used, proper securement is a priority. Improper urinary catheter securement is associated with urethral erosion ... Devices designed to secure catheters include elastic leg straps and adhesive products to hold the catheter in place... Anchoring the catheter with a leg strap will allow some movement of the catheter and may avoid traction at the tip of the catheter. Conversely, improper positioning of a leg strap can allow the strap to migrate down the leg and place tension on the catheter...." Review of www.medhelp.org/posts/Dermatology/Small-erosion-on-glans-Penis/ <http://www.medhelp.org/posts/Dermatology/Small-erosion-on-glans-Penis/> on 05/15/2012 revealed erosion secondary to catheter placement can cause bleeding from the edges of the urethra and increases the risk of urinary tract infection. Patients may require urethral reconstruction, which is often a complex, multistep surgical procedure. Individuals with multiple medical comorbidities ultimately may require urinary diversion. Penile erosion may be physically and psychologically painful due to disfiguration. Caring for patients with urethral pressure ulcers is challenging. Unlike other pressure ulcers, urethral erosion is permanent and standard wound care may not be of benefit. Surgical correction is the only option to repair the defect. Review of the facility's document entitled "Catheter Care, Urinary," dated August 2002, revealed: "Purpose The purpose of this procedure is to prevent infection of the resident's urinary tract... General guidelines: #1 Observe the resident's level of urine for noticeable increases or decreases... #3 Check the urine for unusual appearance (i.e. color, blood, etc.)... #14 Observe the resident for signs of urinary tract infection and [MEDICAL CONDITION]. Report findings to supervisor immediately... Documentation The following information should be recorded in the resident's medical record: #1 The date and time that catheter care was given... #2 The name and title of the individual(s) giving the catheter care... #4 Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor... #5 Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, irritation, crusting, or pain...." A record review of the facility's document entitled "In-service Training Report" revealed the DON conducted an in-service regarding catheter care and monitoring urine output on 05/04/2012. Attached to the in-service was a document entitled "Early Warning Tool." A record review of the facility's document entitled "Departmental Orientation," "Annual" revealed between 07/25/2011 and 04/30/12, all licensed nursing staff had skills verification. Included in the skills verification was "[MEDICAL CONDITION]/Catheter Care," "Infection Control" and "Foley Catheter Insertion/Change." A record review of the facility's document entitled "CNA Competency Skills Checklist" revealed the CNAs were checked for competency of incontinent care from 02/15/2012 through 02/18/2012, on 03/20/2012 and on 04/26/2012. The last item on the CNA's incontinent care checklist reflected "Report any red or open areas to nurse." 4) The CMS form 672, Resident Census and Conditions of Residents, dated and signed by the DON on 05/16/2012, reflected there were seven residents with indwelling urinary catheters and five of the seven residents were admitted with their catheters.

Based on observation, interview and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers and a resident with pressure ulcers received the necessary treatment and services to promote healing, and prevent new pressure ulcers from developing for four (Residents #1, #4, #7 and #17) of ten residents reviewed for pressure ulcers. Resident #1 developed a facility-acquired a Stage II pressure ulcer on his right buttock and a pressure ulcer on the resident's left hip was not identified until it was a Stage III. The TN did not fully assess the resident when conducting weekly skin assessments. The Care Plan was not updated to include the current treatment for [REDACTED]. Resident #4 had two new facility- acquired Stage II pressure ulcers, on the back of both the resident's upper thighs, which had not been communicated to the treatment nurse. Resident #4 was not provided a pressure-relieving mattress until surveyor inquiry. Resident #7, who had pressure ulcers when she was admitted , did not have a pressure-relieving mattress or cushion on her wheelchair until surveyor inquiry. The resident had three new facility- acquired Stage II pressure ulcers, which had not been communicated to the treatment nurse resulting in a delay in treatment. Resident #17 developed two facility-acquired Stage II pressure ulcers on her buttocks on 05/02/2012. There was no anti-pressure device on the wheelchair. The TN inappropriately used [MEDICATION NAME] for a treatment for [REDACTED]. These failures contributed to the development of in-house pressure ulcers and a decline in current pressure ulcers for Residents #1, #4, #7 and #17, and placed five other residents identified as having developed in-house pressure ulcers at risk also for development of pressure ulcers, development of infection, undue pain and decline in healing of current pressure ulcers. Findings included: 1) A review of the Minimum Data Set ((MDS) dated [DATE] in Resident #1's closed clinical record revealed the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The assessment reflected the resident was cognitively impaired and required cueing for recall. No behaviors were identified. The resident required the extensive assistance of two people for transfers, the extensive assistance of one person for dressing and wheelchair locomotion and he had no limitations on his range of motion. The same MDS assessment reflected Resident #1 had an indwelling urinary catheter and was continent of bowel. The assessment identified Resident #1 as being at risk for pressure ulcers. An interview conducted with a member of Resident #1's family at approximately 3:00 PM on 05/01/2012 revealed the family member was concerned about the pressure ulcers Resident #1 had acquired while in the facility. Resident #1's family member stated he/she was also concerned because the family was not notified about the pressure ulcer on Resident #1' s left hip until after the resident was transferred to a hospital on [DATE]. The family member stated the physician at the hospital had informed them the pressure ulcer on the resident's left hip was not being treated appropriately, and the dressing had not been changed in four to five days. A review of records from the acute care hospital revealed: 1. A history and physical dated 04/29/2012 and timed for 9:55 PM reflected Resident #1 had redness over both heels and ingrown toenails. Sacral "decubitus" (pressure) ulcers (Stage I and Stage III) were present on admission. The resident had red irritation over his sacrum as well as Stage II to Stage III pressure ulcer on the left hip, which appeared dry with a yellow base. 2. An emergency room (ER) nurse note 04/29/2012 at 2:57 PM reflected: " The posterior side of the penis is red and excoriated. Redness is noted on testicles and groin area. " 3. Wound Care Nurse notes dated 04/30/2012 at 11:00 AM: "On admission, patient was noted to have a left trochanter (hip) pressure ulcer, skin breakdown to heels and urethral erosion with indwelling catheter. On exam, the hip is 100% covered with necrotic tissue and is foul-smelling, therefore it is unstageable. Patient has a blanched area to the right heel and right lateral midfoot consistent with Stage Is bordering on suspected deep tissue injury." An interview conducted with Certified Nurse Aide (CNA) A on 05/01/2012 at approximately 3:50 PM revealed the CNA had observed Resident #1 with a round pink area of skin on the resident's left hip during the weekend before the resident went to the hospital. CNA A stated she told the weekend 6:00 AM to 2:00 PM charge nurse about the pink area and was told to go ahead and get him up. CNA A said the charge nurse said she was busy and would check the resident later. An interview with the 2:00 PM to 10:00 PM charge nurse, Licensed Vocational Nurse (LVN) B on 05/01/2012 at approximately 5:30 PM revealed the LVN was not aware Resident #1 had any pressure ulcers. The LVN stated Resident #1 was alert, oriented and "very with it" and had not complained of any pain in his buttocks or left hip. An interview conducted with the Director of Nursing (DON) on 05/02/2012 at approximately 9:00 AM revealed the treatment nurse (TN) performed weekly skin assessments for all residents in the facility. The DON stated the TN did her weekly skin checks on one of the four facility halls each day from Monday through Thursday. The DON stated the TN performed residents' weekly skin checks while the residents were in their beds, rolling them from side to side to ensure all areas of skin were observed. The DON said the TN also checked residents' feet during her weekly skin checks. The DON then stated the shower aides (SA) were the only facility staff who saw "the full body" of each resident. The DON stated the two shower aides switched off on the halls whose residents they were assigned to shower each week, so they would observe the skin on each resident every other week. An interview conducted with the TN on 05/02/2012 at approximately 10:00 AM revealed she did a weekly skin check for all residents once a week. The TN stated she checked all the "hot spots," especially the heels. When queried about Resident #1, the TN revealed she did not usually do Resident #1's weekly skin check while the resident was in bed. The TN stated Resident #1 sat in either his wheelchair or in his recliner all day long because the resident did not like to go back to bed once he got up for the day. The TN said she performed Resident #1's skin checks while the resident sat in his chair. The TN stated on 04/23/2012, she had Resident #1 pull his pants down and shift from one hip to the other to check the resident's skin. The TN stated she normally checked the residents' heels, but not the rest of their feet when she performed her weekly skin checks. When queried specifically about Resident #1, the TN stated she removed Resident #1's shoes and pulled the resident's socks down over the resident's heels, but did not completely remove them. She stated she did not check any further than the residents' heels. The TN stated she did not observe any redness on Resident #1's heels on 04/23/2012, the date of the last assessment. An interview with the DON on 05/02/2012 at approximately 4:00 PM revealed he was not aware the TN was not checking the entire foot when she performed her weekly skin checks for the residents. The DON stated he would ensure the residents' entire foot was checked during future weekly skin checks. During the same interview on 05/02/2012 at approximately 10:00 AM, the TN stated when she was checking Resident #1's skin on 04/23/2012, she observed Resident #1 had a pink area (Stage I pressure ulcer) on his buttocks. The TN stated she treated the Stage I pressure ulcer on Resident #1's buttocks with a [MEDICATION NAME] dressing, which she initialed and dated 04/23/2012. The TN said she did not observe a pressure ulcer on Resident #1's left hip on 04/23/2012. The TN stated the DON notified her regarding the pressure ulcer on Resident #1's left hip on Friday (04/27/2012). The TN stated the pressure ulcer on Resident #1's left hip was open, moist and contained slough. She and the DON determined it was a Stage III pressure ulcer. The TN stated she treated Resident #1's left hip pressure ulcer with Hydrogel Gel and covered the pressure ulcer with a [MEDICATION NAME] Signal dressing, which she initialed and dated 04/27/2012. The TN said she "felt bad" she did not notify Resident #1's family about the Stage III pressure ulcer on the resident's left hip until 04/30/2012, after the resident left the facility. A review of the facility's Weekly Pressure Ulcer QI Log dated 04/27/2012 revealed: 1. On 04/21/2012, Resident #1 had a facility-acquired Stage II pressure ulcer on his right buttock, which measured 6 cm by 4 cm. There was no odor or drainage. The Stage II pressure ulcer on Resident #1's right buttock was treated with [MEDICATION NAME] Thin. Documentation reflected Resident #1's physician and family were notified on 04/23/2012. 2. On 04/27/2012, Resident #1 had a facility-acquired Stage III pressure ulcer on his left hip, which measured 3.8 cm by 3 cm by 0.1 cm. There was no odor and scant drainage. The log further reflected the Stage III pressure ulcer on Resident #1's left hip was treated with Safe-Gel and [MEDICATION NAME] Signal. Documentation reflected Resident #1's physician and family were notified on 04/27/2012. A review of the Resident #1's Nurse's Notes revealed on 04/30/2012 at 7:30 AM, the TN notified Resident #1's family member the facility "noted a pressure ulcer to hip and began orders to dress it on 04/27/2012." A review of the facility's undated procedure, provided as current, entitled "Physician/Family Notification" revealed: 1. Purpose: "To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: ...A significant change in the resident's physical, mental or psychosocial status. (See below for examples)" 2. Procedure: "When any of the above situations exists, the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached. A message may be left on an answering machine which does not leave specifics but leaves a request for the facility to be called." 3. "Examples of significant changes ...Development of a pressure sore." Resident #1's Wound/Skin Healing Record reflected the date of onset for the Stage II pressure ulcer on Resident #1's "sacrum/right buttock" was 04/21/2012. On 04/23/2012, the pressure ulcer measured 6 cm X 4 cm with a pink wound bed and pink surrounding tissue. No exudate or odor was reflected. A care plan for the Stage II pressure ulcer on Resident #1's right buttock was implemented on 04/23/2012. Interventions included a pressure-relieving mattress and [MEDICATION NAME] Thin. Resident #1's Wound/Skin Healing Record reflected the date of onset for the Stage III pressure ulcer on Resident #1's left hip was 04/27/2012. On 04/27/2012 the pressure ulcer measured 3.8 cm X 3.0 cm X 0.1 cm. The wound bed was pink/beefy red with slough (dead tissue). There was scant drainage and no odor. The wound edges/surrounding skin was swollen. A care plan for the Stage III pressure ulcer on Resident #1's left hip was implemented on 04/27/2012. Interventions included Safe-gel, [MEDICATION NAME] signal, a pressure-relieving mattress and a therapy evaluation to determine if the resident was using the appropriate wheelchair. Resident #1's TN documentation record reflected: Resident #1 had weekly head to toe skin checks performed on 04/02/2012, 04/09/2012, 04/16/2012 and 04/23/3012. No skin abnormalities were found until 04/23/2012. An order was obtained on 04/21/2012 to "Cleanse coccyx with NS (normal saline). Pat Dry. Apply [MEDICATION NAME] change q (every) 3 days and prn (as needed)." The order was initialed as being done on 04/21/2012, 04/24/2012 and 04/27/2012. An undated order reflected to "cleanse pressure ulcer to left hip with NS, pat dry, apply Safe Gel to wound bed, cover with [MEDICATION NAME] Signal q 72 hours and prn." The order was initialed on 04/27/2012. A review of the facility's current protocol, Dermal Wounds-Full Thickness Protocol-Stage III and IV, dated October 2010, revealed: "Stage III Pressure Ulcer: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. The wound presents clinically as a deep crater with or without undermining of adjacent tissues... D. Necrotic Wounds (not on the feet)-If the wound bed is covered with necrotic tissue, use an enzymatic debridement agent (Santyl). Apply a nickel thick layer of enzymatic [MEDICATION NAME] agent (Santyl) over the necrotic area and cover with gauze and secure with tape. Wounds with moderate to heavy drainage may require a more absorbent composite dressing (CombiDerm). Change dressing and reapply q day for Santyl to be most effective. A dressing with Santyl may be left in place for greater than 24 hours but clinician must realize the effectiveness of the Santyl is eliminated and autolytic debridement will begin... *Note: Santyl to be effective must be changed Q day...Choosing a practical dressing like [MEDICATION NAME] is important due to daily dressing change needs...Follow the "MEN" acronym - Must have moisture, cover Entire wound bed, apply Nickel thick...." A review of <http://dictionary.reference.com/browse/autolytic> on 05/14/2012 revealed autolysis is the breakdown of plant or animal tissue by the action of enzymes contained in the tissue affected; self-digestion. A review of www.webmd.com/drugs/drug-9489-Santyl+Top.aspx?drugid=9489&drugname= on 05/14/2012 revealed Santyl is used to help the healing [MEDICAL CONDITION] skin ulcers by helping to break up and remove dead skin and tissue. A review of http://www.biomaterials.org/week/bio17.cfm on 05/07/2012 <http://www.biomaterials.org/week/bio17.cfm%20on%2005/07/2012> revealed Hydrogel is commonly used for absorption, desloughing (removing a layer or mass of dead tissue separated from surrounding living tissue) and [MEDICATION NAME] (removing nonliving tissue from pressure ulcers...) ...of necrotics (dead cells) and fibrotic tissue ...in wound care. A review of <http://www.ehow.com/[MEDICATION NAME]-used.html> on 05/07/2012 reflected [MEDICATION NAME] is a skin dressing that promotes healing of wounds by providing a moist environment to the wound, causing [MEDICATION NAME] (the re-growth of skin over a wound) but no maceration (to make soft). The same article reflected a [MEDICATION NAME] dressing can stay in place for up to seven days. A review of <http://www.[MEDICATION NAME].com/en/cvtus-productsus/cvt-products/0/proddett/0/399/2321/[MEDICATION NAME]-signal-dressing.aspx?franchise=364&typesearch=16&proddett=2321&prodfamily=369> on 05/07/2012 revealed [MEDICATION NAME] Signal is an adhesive, tapered edge, modern [MEDICATION NAME] wound dressing with a change indicator used for the management of lightly to moderately exuding wounds. An interview with SA C on 05/02/2012 at approximately 10:10 AM revealed the SA did not give Resident #1's showers and so she was not aware of the resident's skin issues. SA C revealed the she checked the residents' skin for breakdown and open areas when she showered the residents. The SA stated she checked the residents' indwelling catheters and "cleaned around them real good." SA C said she checked between the residents' toes and checked their toenails while showering them. The SA stated she reported any problems with the residents' skin or nails to the nurse. Interview with SA D on 05/02/2012 at approximately 10:30 AM revealed if the SA found any new red areas on a resident's skin during showers, she reported them to the TN. SA C revealed she had observed Resident #1 with a sore on his penis and had reported it to the CNA (unidentified) so the CNA could chart the information in the kiosk. SA C said she did not observe any problems with Resident #1's skin when she showered him. During an interview on 05/02/2012 at approximately 5:45 PM, the DON revealed the 2:00 PM to 10:00 PM charge nurse for Resident #1's hall should have known about the resident's pressure ulcers because they were documented in the facility's 24-hour report book. The DON and Administrator stated the information about Resident #1's pressure ulcers, reported to the 6:00 AM to 2:00 PM charge nurse by the TN, should also have been included in the change-of-shift report to LVN B. 2) Resident #4's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #4's MDS assessment reflected the resident had severe cognitive impairment with a BIMS score of zero. The same MDS assessment reflected Resident #4's physical behavioral symptoms were directed toward others. The resident required extensive assistance from staff for bed mobility, transfers, wheelchair mobililty, eating, dressing and hygiene. The same MDS assessment reflected Resident #4 was dependent on others for bathing and was incontinent of both bowel and bladder. Resident #4 was identified as being at risk for pressure ulcers. The same MDS assessment reflected Resident #4 did not have any pressure ulcers but had previously had pressure ulcers. Resident #4's MDS assessment reflected the resident had a pressure-reducing device for her bed and skin treatments (ointments/medications). A review of Resident #4's 03/09/2012 Braden scale assessment for pressure ulcers revealed the resident was not a high risk for pressure ulcer development. Resident #4's current care plans reflected: A) An initial care plan dated 03/05/2012 for a Stage II pressure ulcer on the resident's left buttock included the following approaches: application of Santyl/[MEDICATION NAME] daily and an air mattress. On 05/08/2012, the care plan was updated with the following interventions: an air pressure pad was placed on Resident #4's bed and an air pad was placed in the resident's wheelchair. On 05/15/2012, a care plan update reflected the pressure ulcer was healed. B) A care plan dated 04/30/2012 was initiated for a Stage II pressure ulcer on the resident's left buttock. Approaches included a [MEDICATION NAME] spot. C) A care plan dated 04/30 2012 was initiated for a Stage II pressure ulcer on the resident's left buttock near her thigh. D) A care plan dated 04/30 2012 was initiated for shear on the resident's left buttock. Approaches included [MEDICATION NAME]. E) Approaches on each of the previous care plans included the following: assisting with turning and repositioning every two hours, use of padding between pressure areas and positioning devices for proper body alignment, pressure-relieving devices for bed and wheelchair, monitoring labs, dietary consult for proper nutrition to resolve the pressure area and keeping Resident #4's family informed about the resident's progress. A review of the facility's Weekly Pressure Ulcer QI Logs dated 04/27/2012 and 05/11/2012, revealed Resident #4 had an unstageable pressure ulcer on her left hip. On 04/27/2012, the pressure ulcer measured 2.1 cm X 1.0 cm. On 05/11/2012, the pressure ulcer measured 3.0 cm X 0.6 cm. On 05/02/2012 at approximately 11:45 AM, observation of Resident #4 during a dressing change by the TN revealed the resident had developed two new Stage II pressure ulcers on the posterior of both thighs. The pressure ulcers were located where the bottom edge of Resident #4's Hoyer lift sling pressed against the resident's thighs when she was out of bed. The Stage II pressure ulcer on the back of Resident #4's left upper thigh measured 1.5 cm by 0.3 cm. The Stage II pressure ulcer on the back of Resident #4's right upper thigh measured 1.6 cm by 0.5 cm. Both of these pressure ulcer had pink wound beds. Neither had drainage or odor. The TN covered these newly found pressure ulcers with [MEDICATION NAME] dressings. Observation during the procedure revealed Resident #4 did not have an anti-pressure mattress on her bed. During an interview at that time, the TN told the surveyor she had not been notified about the development of the two new pressure ulcers on the backs of Resident #4's thighs. When queried about an anti-pressure mattress, the TN stated Resident #4 was not on an air pressure mattress, because the resident scooted around so much in bed she would fall off the bed if she (the resident) had an air mattress. When asked about Resident #4's wheelchair, the TN stated she did not know what kind of pressure relief device the resident had in her wheelchair. At that time, CNA E, who was assisting the TN, stated she was supposed to notify the TN if she observed any resident with new areas of skin breakdown. CNA E stated she did not notice Resident #4 had new pressure ulcers on the backs of her thighs when she assisted Resident #4 to dress that morning, placed the Hoyer sling under the resident and transferred the resident via the Hoyer lift sling to get her up for breakfast. CNA E explained she did not notice the new pressure ulcers because the resident wanted her (CNA E) to hurry and get her (the resident) up for breakfast. On 05/16/2012 at approximately 10:30 AM, Resident #4 was observed in a wheelchair propelling herself around the facility's dining room and lobby with her right foot. The surveyor observed Resident #4 was sitting on a ROHO (pressure relieving) cushion in her wheelchair. Observation of Resident #4 on 05/16/2012 at approximately 10:50 AM revealed the resident had just gone to bed for incontinent care. CNA J, who was assisting wish incontinent care, revealed Resident #4 got out of bed at approximately 9:30 AM, was back in bed just long enough to have incontinent care at 11:00 AM and would be out of bed as soon as the resident's incontinent care and wound care was completed. An air pressure pad was now observed on Resident #4's bed. During an interview on 05/16/2012 at approximately 11:00 AM, the DON said the Stage II pressure ulcers on Resident #4's buttocks had healed once the resident had the air pressure pad for her bed and the ROHO cushion for her wheelchair. The DON said he had ordered an alternating pressure mattress with hard bumpers on the side so the sides would not deflate if Resident #4 rolled to the side. The DON stated he would keep the mattress in case Resident #4 started rolling off the bed but stated facility staff had no problem keeping the resident in bed at the present time. Observation of Resident #4 on 05/16/2012 at approximately 12:00 PM revealed the resident was sitting in her wheelchair eating lunch in the dining room. During an interview on 05/16/2012 at approximately 12:00 PM, CNA J revealed she did not need to ensure Resident #4 had pressure relief when the resident was up in her wheelchair, because Resident #4 "scoots her bottom around in her wheelchair and leans to either side." CNA J stated she occasionally changed Resident #4's position in bed by pulling her up and repositioning the resident with pillows, especially when the resident was lying on her left side and her arm got caught. During an interview conducted with the TN on 05/17/2012 at approximately 4:00 PM, she stated Resident #4 had been an every three-day dressing change. The TN stated the CNAs should have reported the new pressure ulcers to the charge nurses so they (nurses) could begin treatment right away. The TN added the charge nurses should have identified Resident #4's new pressure ulcers when they did their every-shift observation of the resident's dressings to ensure the dressing stayed in place. 3) Resident #7's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. No behaviors were identified. The MDS assessment reflected the resident required extensive assistance from two staff to complete her activities of daily living, and she was incontinent of both bowel and bladder. Resident #17 was identified as being at risk for pressure ulcers and had four Stage II pressure ulcers. The MDS assessment reflected two of Resident #7's Stage II pressure ulcers were facility-acquired. The MDS assessment reflected the resident had pressure reducing devices for her bed and chair. A record review of Resident #7's care plans revealed: A care plan dated 04/12/2012, which addressed Resident #7's 4 cm X 3 cm unstageable pressure ulcer on the left heel. Approaches included: applying skin prep, a pressure relieving mattress and Prevalone Boots (relieve pressure on heels) . A care plan dated 04/12/2012, which addressed Resident #7's 2.5 X 0.5 cm Stage II pressure ulcer on the sacrum. Approaches included: applying [MEDICATION NAME] Thin and a pressure relieving mattress. A care plan dated 05/02/2012 to address the 2 cm X 1.2 cm Stage II pressure ulcer on Resident #7's right buttock. Approaches included applying Barrier Cream. Approaches on each of the three pressure ulcer care plans included: assisting with turning and repositioning every two hours, use of padding between pressure areas and positioning devices for proper body alignment; pressure relieving devices for bed and wheelchair; monitoring labs; dietary consult for proper nutrition to resolve the pressure area and keeping Resident #7's family informed about the resident's progress. There were no care plans to address the 4.0 X 1.6 cm Stage II pressure ulcer on Resident #7's left upper thigh, or the 0.5 cm by 0.7 cm Stage II pressure ulcer on the resident's right upper thigh. On 05/02/2012 at approximately 11:45 AM, immediately prior to receiving care, Resident #7 stated she was experiencing a lot of discomfort on the backs of her upper thighs. The resident rubbed the areas she was referring to with her hands before the resident's disposable brief was removed. Resident #7 said she believed the sore places on the backs of her thighs had developed from the pressure of the elastic in her disposable briefs against her thighs. Resident #7 stated she had told the CNAs about the pain the resident was experiencing in the areas on her back upper thighs when they (CNAs) were providing the resident's incontinent care. Observation of Resident #7's wound care on 05/02/2012 at approximately 11:45 AM revealed the resident had developed three new facility-acquired Stage II pressure ulcers. Two of the new Stage II pressure ulcers were located on the back of both of her upper thighs. The pressure ulcers were located where the elastic in Resident #7's disposable briefs pressed against the resident's thighs. The Stage II pressure ulcer on the back of Resident #7's left upper high measured 4 cm by 1.6 cm. The Stage II pressure on the back of Resident #7's right upper thigh measured 0.5 cm by 0.7 cm. The third new Stage II pressure ulcer was located on Resident #7's right buttock, adjacent to the resident's sacrum. Resident #7's three new Stage II pressure ulcers had red wound beds, no drainage and no odor. The TN applied Barrier Cream on Resident #7's three new Stage II pressure ulcers. The TN stated she was using the Barrier Cream because Resident #7 was "incontinent and so mobile in bed." The surveyor observed there was no pressure-relieving mattress on Resident #7's bed. The surveyor also observed Resident #7 was not wearing her Prevalone boots. Interview with the TN at the time of the pressure ulcer care revealed the TN had not been notified about the development of the three new pressure ulcers on the back of the resident's thighs and the right buttock. When queried about a pressure-relieving mattress for Resident #7, the TN said she did not know why there was no pressure relieving mattress on Resident #7's bed. The TN stated she would ask the DON to get an air pressure relieving mattress for the resident. During the interview, the TN asked Resident #7 why she was not wearing her boots. Resident #7 replied she usually wore her boots while she was in bed. Resident #7 stated the [MEDICAL TREATMENT] center would not allow her to wear her boots while the resident was being dialyzed. Resident #7 revealed she had to lay on a hard recliner, with no padding, for four hours while she was in [MEDICAL TREATMENT]. Resident #7 stated laying in the recliner for that long was very painful, especially as she had trouble getting staff in the [MEDICAL TREATMENT] center to assist her with changing her position. Resident #7 revealed the mattress on her bed was so uncomfortable the resident had trouble sleeping at night. www.ehow.com/how_ 22_use-moisture-barrier-cream.html reviewed on 05/14/2012 <http://www.ehow.com/how_ 22_use-moisture-barrier-cream.html%20reviewed%20on%2005/14/2012> revealed according to Woundsource.com, a moisture barrier is a cream, paste or ointment that is formulated to protect the skin from excessive moisture due to incontinence, perspiration, or wound drainage. During an interview at approximately 5:45 PM on 05/02/2012, the DON revealed he would obtain an air pressure relief mattress for Resident #7. The DON and facility's Administrator stated they would work with the [MEDICAL TREATMENT] center to obtain something the center would accept as permissible for pressure relief and comfort for Resident #7. Observation of Resident #7 at approximately 11:00 AM on 05/16/2012 revealed the resident was seated at the foot of her bed in a wheelchair. The surveyor observed the pad in Resident #7's wheelchair was very thin and did not provide pressure relief for the resident. The surveyor also observed a low air loss pressure relieving mattress on Resident #7's bed. During an interview conducted with COTA K on 05/17/2012 at approximately 11:50 AM, the COTA stated the therapy department only evaluated the residents who received therapy services for pressure relief in their wheelchairs. COTA K stated each resident was assessed before his/her wheelchair cushion was prescribed to ensure the resident sat on the correct surface. COTA K revealed the resident's weight, physical condition and the stage of any pressure ulcer was evaluated prior to a wheelchair cushion being prescribed. COTA K stated the nursing department determined the correct sitting cushion for residents, who were not receiving therapy services. During an interview conducted on 05/17/2012 at approximately 1:45 PM, the DON confirmed he determined the appropriate wheelchair cushion for residents, who sat in wheelchairs and did not receive therapy services. The DON said he would order a ROHO cushion for Resident #7 to use while she sat in her wheelchair. The DON stated the ROHO cushion would also probably provide Resident #7 with pressure relief while the resident was at [MEDICAL TREATMENT]. The DON said the Stage II pressure ulcers on the backs of the resident's upper thighs and adjacent to her sacrum and the unstageable pressure ulcer on the resident's heel had healed rapidly once the resident was provided with a low air loss pressure relief mattress. The DON stated the thin pad in Resident #7's wheelchair was for comfort only; it was not designed to provide pressure relief. The DON revealed any long-term resident who used a wheelchair should have at least the thick foam pads in their wheelchairs for pressure relief. The DON stated he did not know why Resident #7's thin wheelchair pads had not been replaced with a thick foam pad for pressure relief. During an interview conducted on 05/17/2012 at approximately 4:00 PM, the TN revealed the CNAs had not known about Resident #7's three new (05/02/2012) pressure ulcers because the resident had Barrier Cream on her bottom. The TN stated she was the one who applied the Barrier Cream to Resident #7's bottom so the CNAs would not have seen the pressure ulcers. The TN could not explain why the CNAs had not observed the Stage II pressure ulcers during the resident's incontinent care. The TN stated the Stage II pressure ulcers discovered on 05/02/2012 were caused by the elastic on Resident #7