Every finding on record at Harmony Care at Brookshire

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #2) and 1 of 2 staff (CNA B) reviewed for infection control. The facility failed to ensure CNA B washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #2 on 06/17/26. This failure could place residents at risk for cross contamination and the spread of infection. Finding included:Review of Resident #2's face sheet dated 6/17/26 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: cerebral infarction( ischemic stroke), cognitive communication deficit, essential primary hypertension, ( high blood pressure), hyperlipidemia ( high fat in the blood), major depression disorder ( causes ongoing sadness, hopelessness and loss of interest that lasts at least two weeks, it can affect sleep, energy and relationships) and anxiety( a feeling of fear, dread and uneasiness), type 2 diabetes mellitus with other diabetic kidney complication(excess glucose in the blood) and AKA ( above knee amputation). Review of Resident #2's quarterly MDS assessment dated [DATE] reflected Resident #2's BIMS score was 12 indicating moderate impaired cognition. Resident #2 was assessed to require dependent assistance for all ADLs. Resident #2 was further assessed to have functional limitations in range of motion due to left AKA to lower extremities. Further review revealed Resident #2 required substantiation assistance with ADL care with one staff assist.Record review of Resident #2's care plan dated 04/10/26 revealed Resident #2 had incontinent bowel and bladder. Interventions: perform routine rounding to include incontinence care and brief changes. Observation on 6/17/26 at12:49 PM during incontinent care with Resident #2 lying in bed. C NA B went in Resident #2's room with cleaned gloves and a clean brief, C NA B said she was going to change Resident #2 stated he was soiled. C NA B done clean gloves, without washing hands, she unfastened brief Wipe in-between the buttocks resident had moderate pasty stool and the BM got on the gloves, C NA B did not change gloves, she picked the wet wipes and wipe the BM on the soiled gloves 3 times and while wiping in-between the buttocks. C NA did not clean around the bottom then picked up a cleaned brief using the same gloves, pick up ointment and applied around the buttocks and fastened the brief, then covered the resident with the bed linen.During an interview on 6/17/26 at 1:02 PM, C NA B said she was very nervous. CNA B stated if she did not wash or sanitize her hands when going from a dirty to clean surface, it could cause cross contamination and a risk of transferring infection.In an interview on 6/18/26 at 8:05 PM, the DON stated it was the facility's policy for staff to wash or sanitize their hands when going from a dirty to clean surface. She stated staff were in-serviced on infection control and hand hygiene. Record review of the facility policy, revised December 2025, titled, Hand Hygiene revealed the following: Handwashing/Hand HygienePolicy StatementThis facility considers hand hygiene as the primary means to prevent the spread of healthcare-associatedinfections.Policy Interpretation and ImplementationAdministrative Practices to Promote Hand Hygiene1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing thetransmission of healthcare-associated infections.2. All personnel are expected to adhere to hand-hygiene policies and practices to help prevent the spreadof infections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand-rub, etc.) are readilyaccessible and convenient for staff to use to encourage compliance with hand hygiene policies. Alcohol basedhand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflowthroughout the facility.Indications for Hand Hygiene1. Hand hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic task (for example, placing an indwelling device or handling an invasivemedical device);c. after contact with blood, body fluids, or contaminated surfaces;d. after touching a resident;e. after touching the resident's environment;f. before moving from work on a soiled body site to a clean body site on the same resident; andg. immediately after glove removal.Reviewed/Revised [DATE]. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.3. Wash hands with soap and water:a. when hands are visibly soiled; andb. after contact with a resident with infectious diarrhea including, but not limited to infections causedby norovirus, salmonella, shigella and C. difficile.4. Single-use disposable gloves should be used:a. before aseptic procedures;b. when anticipating contact with blood or body fluids; andc. When in contact with a resident, or the equipment or environment of a resident, who is on ContactPrecautions.5. The use of gloves does not replace hand washing/hand hygiene.Promoting Healthy Hand Skin and Fingernails1. Personnel with direct-care resident responsibilities should maintain short, natural fingernails.a. Fingernails should not extend past the fingertips.b. Wearing artificial fingernails is strongly discouraged among staff members with direct resident-careresponsibilities and is prohibited among those caring for severely ill or immunocompromisedresidents.c. The infection preventionist may request the removal of artificial fingernails and/or nail polish at anytime if it is determined that they present an infection control risk.2. Measures for primary and secondary prevention of dermatitis include:a. avoiding hot water;b. patting instead of rubbing hands to dry;c. applying facility-approved hand moisturizers; andd. taking periodic breaks from gloves to allow hands to dry.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #2) reviewed for incontinent care. The facility failed to ensure CNA B properly cleaned Resident #2 during incontinent care on 06/17/2026.This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included:Record review of Resident #2's face sheet, dated 6/17/26, reflected a [AGE] year-old male, admitted [DATE], with the following diagnoses: cerebral infarction (ischemic stroke), cognitive communication deficit, essential primary hypertension (high blood pressure), hyperlipidemia (high fat in the blood), major depression disorder ( causes ongoing sadness, hopelessness and loss of interest that lasts at least two weeks, it can affect sleep, energy and relationships) and anxiety (a feeling of fear, dread and uneasiness), type 2 diabetes mellitus with other diabetic kidney complication (excess glucose in the blood) and AKA (above knee amputation). Record review of Resident #2's quarterly MDS assessment, dated 05/27/2026, reflected Resident #2's BIMS score was 12, indicating moderate impaired cognition. Resident #2 was assessed to require dependent assistance for all ADLs. Resident #2 was further assessed to have functional limitations in range of motion due to left AKA to lower extremities. Further review revealed Resident #2 required substantial assistance with ADL care with one staff assist.Record review of Resident #2's care plan, dated 04/10/26, revealed Resident #2 had incontinent bowel and bladder. Interventions: perform routine checking to include incontinence care and brief changes. Observation on 6/17/26 at 12:49 PM, CNA B went in Resident #2's room with clean gloves and a clean brief. CNA B said she was going to change Resident #2. She stated, he was soiled. CNA B donned(put on) clean gloves, without washing her hands, unfastened Resident #2's soiled brief and used the wet wipes cleaning the perineal area ( the perineum, which is the area of skin at based of the scrotum to the anus in male) retracted the foreskin to the penis and cleaned, then repositioned Resident #2 on the left side and wiped between the buttocks but did not clean around the buttocks and CNA B picked the clean brief from the bag and placed it under the resident.During an interview on 6/17/26 at 1:02 PM, CNA B said she had in-service with 2 CNAs before starting to work for the facility and she was very nervous and forgot to change her gloves. CNA B said not cleaning the buttocks could cause skin breakdown and odors.During an interview on 6/18/26 at 8:05 PM, the ADM said CNA B was supposed to perform incontinent care procedures and wash her hands according to the procedures.During an interview on 6/18/26 at 8:13 PM, the DON said CNA B was supposed to follow incontinent care procedures and wash her hands. The DON said there was a possibility that nothing would happen if CNA B did not clean around the bottom. Record review of the facility's policies and procedures, revised September 2025, titled, Perineal Care, indicated, Purpose:The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Preparation1.Review the resident's care plan to assess for any special needs of the resident.2.Assemble the equipment and supplies as needed.Equipment and SuppliesThe following equipment and supplies will be necessary when performing this procedure:Wash basin;Towels;For a male resident:1.Use wipesCleanse perineal area starting with urethra and working outward.2.Retract foreskin of the uncircumcised male.3.Wash and rinse urethral area using a circular motion.4.Continue to wash the perineal area including the penis, scrotum and inner thighs.5.Thoroughly rinse perineal area in same order, using fresh water and wipes.6.Gently dry perineum following same sequence.7.Reposition foreskin of uncircumcised male.8.Ask the resident to turn on his side with his upper leg slightly bent, if able.9.Rinse washcloth and apply soap or skin cleansing agent.10.Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.11.Dry area thoroughly.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #1 and Resident #2) out of 7 residents observed for resident rights. LVN B failed to sit at eye level when feeding Resident #1 their lunch in the dining room, LVN B stood while feeding Resident #1.CNA A failed to sit at eye level when feeding Resident #2 their lunch in the dining room. CNA A stood while feeding Resident #2. This failure could place residents at risk for choking and compromising their dignity and respect. Findings: Resident #1 Record review of Resident #1's face sheet dated 03/04/26 revealed an [AGE] year-old female admitted to the facility on [DATE] and again on 08/22/24. Resident #1's diagnoses included the following: dementia (a decline in memory, thinking, behavior, and daily functioning), dysphagia (difficulty swallowing) following cerebrovascular (decrease in blood flow to the brain) disease, epilepsy (seizures), Parkinson's disease (impaired movement issues) without dyskinesia (involuntary uncontrollable body movement), and depression.Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 5 indicating that Resident #1's cognition was severely impaired. Section GG-Functional Abilities revealed that Resident #1 was dependent on staff for eating.Record review of Resident #1's Physician Order Summary Report for the month of February 2026 included the following order:-Dated 03/07/23 Regular diet mechanical soft texture, thin consistency, double portions with all meals for weight maintenance and wound healing. Record review of Resident #1's Comprehensive Care Plan revised 12/15/25 revealed that resident was being care planned for nutritional problem risk for malnutrition r/t receiving mechanically altered diet with divided plate all meals, requires assist with eating. An intervention included monitor/document /report PRN any s/sx of dysphagia: pocketing food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Resident #2 Record review of Resident #2's face sheet dated 03/04/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's diagnoses consisted of the following: cerebral infarction (when blood flow to the brain is blocked or reduced), gastro-esophageal reflux disease without esophagitis (when someone experience heartburn without visible damage to the esophagus {a muscular tube that serves as the route for transporting food and liquids from the throat to the stomach}, epigastric pain (discomfort beneath the ribcage and above the navel), lack of coordination, and dysphagia (difficulty swallowing). Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 8 indicating that Resident #2's cognition was moderately impaired. Section GG-Functional Abilities revealed that Resident #2 required setup or clean-up assistance with eating. Record review of Resident #2's Comprehensive Care Plan revised 03/02/26 reflected resident being care planned for ADL self-care performance deficit r/t fatigue, impaired balance. An intervention reflected that Resident #2 was independent with eating. Record review of Resident #2's Physician Order Summary Report for the month of February 2026 included the following order:-Dated 04/04/25 Regular diet pureed texture (food that is blended to a smooth, pudding-like texture), regular/thin liquids consistency. Observation on 03/04/26 at 12:36PM of Resident #1 sitting in the dining room in wheelchair at the dining table. Further observation was made of LVN B standing on Resident #1's left side feeding resident their lunch (mechanical soft diet) that consisted of green beans, chopped ground beef, mashed potatoes, and a slice of cake for dessert. Observation on 03/04/26 at 12:40PM of Resident #2 sitting in wheelchair in the dining room at the dining room table with lunch (food was pureed) plate in front of him. CNA A came to the dining room to assist Resident #2 with setting up his food. CNA A began to feed Resident #2 standing on resident right side. At 12:45 PM CNA A left Resident #2's side leaving the dining room. While CNA A was gone, Resident #2 began to open his cup of ice cream and began to feed himself. At 12:47PM CNA A returned to the dining room and began to feed Resident #2 again standing on Resident #2's right side. At 12:48PM CNA C instructed CNA A to get a chair, sit down, and feed Resident #2. CNA A then got a chair and did what CNA C asked him to do. Interview on 03/04/26 at 12:50PM CNA C said she was taught in CNA school to never stand while feeding a resident but to sit at eye level when feeding a resident. CNA C this was done to not make the resident feel threaten and to respect the resident. Interview on 03/04/26 at 12:53PM with LVN B said he had been working at the facility for a little over 2 months on the morning shift. LVN B said he had been a nurse since 2018. LVN B said when feeding a resident one should not stand to feed the resident instead, one should get a chair and sit while feeding the resident. LVN B said it really did not matter if he stood or sat while feeding a resident and that it was a matter of preference. LVN B said he had received in-service on Resident Rights. LVN B said the more he thought about it if someone was standing while feeding him, he would not like it because he would feel disrespected. Interview on 03/04/26 at 1:08PM with CNA A said he had been instructed while feeding a resident, he should always sit instead of standing to make eye contact with the resident and to allow the resident to feel comfortable. CNA A said when he entered the dining room to assist with feeding Resident #2, he saw LVN B standing while feeding Resident #1 therefore he stood. CNA A said he did not want LVN B to look bad. Interview on 03/04/26 at 1:13PM with ADON said he had been working at the facility since 2025 as the ADON. The ADON said when staff were assisting residents with feeding, they were supposed to sit at eye level with the resident. The ADON said this was done to assess if resident was swallowing correctly without signs or symptoms of choking to ensure the resident was tolerating the ordered diet. The ADON said staff should not stand when feeding a resident because it was disrespectful to the resident. The ADON said he would not like it if someone was standing while feeding him. Interview on 03/04/26 at 1:22PM with the DON said she had been working at the facility for a year. The DON said staff should not be standing while feeding a resident but sitting. The DON said this was done to preserve the resident's dignity and also a matter of respect. Interview on 03/04/26 at 1:43PM with Resident #2 in his room. Resident #2 was alert to name and knew that he was residing in a Nursing facility. Resident #2 said he did not like when staff stood when feeding his meal. Resident #2 said it made him feel bad and that he did not want to elaborate on it any further. Attempted interview on 03/04/26 at 1:50PM with Resident #1. Resident #1 was not interview able. Record review of the facility policy on Assistance with Meals revised March of 2022 reflected in part: .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident.Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: not standing over residents while assisting them with meals. Record review of the facility policy on Resident Rights revised January of 2026 reflected in part: .Employees shall treat all residents with kindness, respect, and dignity recognizing each resident's individuality.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food to be used later with a temperature in the danger zone was discarded which pan of mechanical soft sausage in the steamtable 131.1 degrees Fahrenheit2. The facility failed to ensure that food past the used by date were discarded which included a pan of cooked rice in the refrigerator use by date 2/7/26, a pan of mashed potato use by date 2-3-26, a pan of Salisbury steak use by date 1-7-26, a package of shredded cheddar cheese use by date 1-12-26, a package of deli meat turkey use by date 1-29-26,a package of shredded swiss cheese use by date 12-15-25.3. The facility failed to ensure food was stored 6 inches off the floor. 1 case of frozen ground beef in the freezer. 2 fruit cocktail cases on the storeroom floor These failures could place residents who consumed food from the kitchen at risk of food borne illness and disease. Observation of the facility kitchen on 02-09-26 at 8:45 AM revealed the following. 1. A pan of mechanical soft sausage 131.1 degrees Fahrenheit in the refrigerator .2. A pan of cooked rice use by date 2-7-26 in the refrigerator.3 A pan of mashed potatoes use by date 2-3-26 in the refrigerator .4. A pan of Salisbury steak use by date 1-7-26. in the refrigerature5. A package of shredded cheddar cheese use by date 1-12 26 in the refrigerator6. A package of deli meat turkey use by date 1-29-26 in the refrigerator.7. A package of shredded Swiss cheese use by date 12-15-25 in the refrigerator.8. 1 case of frozen ground beef in the freezer on the floor.9. 2 cases of fruit cocktail cans on the storeroom floor in the kitchen area. In an interview with the Dietary Food Service Manager on 2-07-26 at 8:45 AM, she stated that the following foods were stored in the refrigerator to be used for later date should be discarded prior to the use by date. She stated the leftover food within the danger zone (40 degrees Fahrenheit to 140 degrees Fahrenheit) should have been discarded. She further stated that she will in-service dietary staff on proper handling, storing, dating leftover food for compliance. The dietary manager stated that all foods should be stored off the floor to prevent cross contamination like pest and vermin. Record review of the facility's policies and procedures for Food Safety dated 3-30-23 read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded on the used by date unless otherwise indicated. For food storage keep off floor.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 5 of 28 residents ( Resident #96, Resident #2, Resident # 65, Resident #83 and Resident #32) and 3 of 3 staffs (CNA H, LVN S,LVN G ) reviewed for infection control. -The facility failed to ensure CNA H performed hand hygiene during incontinent care on Resident #32. During incontinent care for Resident #32 CNA used wet wipes to clean in-between the buttocks, cleaning the buttocks from the top of the buttockstoward the vaginal area.- LVN S failed to change gloves and perform hand hygiene before opening the medication cart twice and did not wear PPE while performing Accu-Chek for Resident #83 on EBP.- LVN G failed to wear PPE and gloves while checking Resident #83's blood pressure on 2/11/26. -The facility failed to clean and line the trash can with a trash liner in Resident #96's room.-The facility failed to label and store Resident # 2 and Resident #65's personal care item at sink area of a semi-private shared room. These failures could place residents at risk for spread of infection and cross contamination and decrease in quality of life.During an observation/interview on 02/10/2026 at 10:01 a.m. toothbrush and toothpaste were observed at sink side of shared room of Resident #2 and Resident #65. Resident #2 stated that the toothbrush and toothpaste were his as he had just brushed his teeth that morning. During an observation on 02/10/2026 at 11:58 a.m. toothbrush and toothpaste were observed at sink side of shared room of Resident #2 and Resident #65. During an observation/interview on 02/12/2026 at 11:51 a.m. toothbrush and toothpaste were observed at sink side of shared room of Resident #2 and Resident #65. Resident #2 stated that no one had spoken to him about the placement of his toothbrush and toothpaste at the sink and asked had he needed to move them. Record review of Resident #32's face sheet, dated 2/11/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses of other venous thrombosis and embolism(blood clot that forms in a vein), hypokalemia(low potassium in the blood), tracheostomy status( surgically created hole in the front of the neck that leads directly into the windpipe ( trachea) to help a person breathe), essential (primary) hypertension(high blood pressure), hyperlipidemia, ( abnormal high fat in blood), hyperosmolality and hypernatremia( a condition in which the blood has a high concentration of salt), gastrostomy status( a surgical opening into the stomach), elevated white blood cell count, unspecified( immune system working hard to fight something off,most common infection, inflammation or stress ), acute and chronic respiratory failure with hypoxia( body tissues and organ are not getting enough oxygen in the blood), functional quadriplegia( total loss of use of all four limbs ( both arms and both legs and the torso ), anoxic brain damage ( a serious often permanent injury that occurs when the brain is completely deprived of oxygen ), anemia, protein-calorie malnutrition. and sepsis( a life -threatening medical emergency caused by the body's extreme. Dysfunctional response to an infection) . Record review of Resident #32's admission MDS, dated [DATE], reflected the BIMS score was blank out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent to bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #32 was incontinent to bladder with indwelling Foley Catheter and bowel with colostomy . Record review of Resident #32's care plan dated 12/24/25 reflected Resident #32 has an ADL self-care performance deficit, the goal was resident will improve current level of function through the review date: Resident #32 required total assist with one to two person for bathing/showering, dressing, bed mobility, personal hygiene, toilet use and follow principles of infection control and universal precaution to incontinent care. Review of Resident #32's Physician's orders from 12/22/2025 through 12/22/2025 reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 12/22/2025. Record review of Resident #32's MAR revealed she was on antibiotics Augmentin ES on 1/14/26 for urinary tract infection. Observation of F/C and incontinent care performed by C.NA H and assisted by RN W, revealed Resident #32 was lying on the bed on her right side, C.NA H donned clean gloves and using the wet wipes, cleaned in-between the buttocks from top to bottom of the perineal area, and around the buttocks, then placed a brief under Resident #32's buttocks. She then cleaned the perineal area, cleaned the groin, and cleaned exposed F/C tubing. Without changing gloves she fastened the clean brief then took off dirty gloves. Interview with RN W on 2/11/26 at 2:32 PM, regarding F/C and incontinent care, she said the did not change gloves throughout the procedure. Interview with C.NA on 2/11/26 at 2:36 PM she said she has been working 7 months, 6:00 AM -2:00 PM to 10 :00PM, she said she thought she did good.She was told about not changing gloves. C.NA H said she was very sorry. C.NA H said she had bi-weekly in-services about hand washing and not changing the gloves could cause cross contamination and infection. Interview with DON on 2/11/26 at 5:10 PM, she said she had handwashing in-service, a month ago and she was the one that trained CNA H. DON said she does monitor CNAs randomly for incontinent care/infection control. Resident #83 Record review of Resident #83's face sheet dated 2/11/26 revealed an [AGE] year-old female resident that was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #83 had diagnoses including: other cerebral infarction ( a type of ischemic stroke where blood flow to part of the brain id blocked usually by a clot due to occlusion or stenosis (narrowing) of small artery, essential (primary) hypertension(high blood pressure) heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), hypokalemia (lower than normal potassium level in the bloodstream), dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach) glaucoma( high fliud pressure inside the eye) and protein-calorie malnutrition Record review of Resident #83's quarterly MDS assessment, dated 11/30/25, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required total assistance from staff with ADL care. During observation rounds on 2/10/26 at 4:22 PM, Resident #83 had an Enhanced Barrier Precaution sign posted on the door. Observation on 2/10/26 at 4:36 PM, revealed LVN S Resident #83's opened medication cart , picked up the Accu check machine and lancet strip, then entered Resident #83's room to check her blood glucose. He donned clean gloves, but did not wear PPE. LVN S then proceeded to check Resident #83's blood glucose. He did not have enough blood on the lancet to read the blood glucose level. At 4:47 PM LVN S left Resident #83's room with the soiled gloves, picked up the medication cart key from his uniform pocket, opened the medication cart, then picked up a lancet, then doffed gloves. LVN S donned cleaned gloves without washing hands and without using PPE, went to Resident #83's room to check blood glucose. LVN S went to the medication cart with the same gloves, opened it and picked up Germicidal wipes and cleaned the Accu-Chek machine then doffed gloves and used hand sanitizer. In an interview with LVN S on 2/10/26 at 5:41 p.m., regarding not donning PPE and changing gloves while opening the medication cart, he said he forgot. He said he did have in-service about using PPE and hand washing every 2 weeks to prevent infection to him and the resident. Observation of LVN G on 2/11/26 at 8:10 a.m., during medication administration to Resident #83 revealed LVN G entered resident room and checked the blood pressure without PPE and gloves. In an interview with LVN G on 2/12/26 at 12:00 PM, regarding not wearing PPE and not wearing gloves while checking Resident #83's blood pressure, LVN G said she forgot, and she was very sorry. She knew not donning PPE and gloves while taking care of Resident on EBP could spread infection to other residents. She said she had in-services monthly on the use of PPE and handling residents on EBP. In an interview with DON on 2/12/26 at 2:00 PM, regarding EBP and hand washing the nurses were not performing, the DON stated nurses were supposed don PPE. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. Resident #96: Record review Resident #96's Facesheet reflected the resident admitted to the facility on [DATE] with diagnosis of muscle weakness, dysphagia (difficulty swallowing), other lack of coordination, cognitive communication deficit, need for assistance with personal care, traumatic subarachnoid hemorrhage (bleed in the brain due to trauma) with loss of consciousness of unspecified duration, fracture of facial bones (breaks in the facial bone due to trauma), traumatic pneumothorax (collapsed lung), nondisplaced intertrochanteric fracture of left femur (break in bone but remains in proper alignment), tracheostomy status, and gastrostomy status . Record review of Resident #96's Care Plan reflected the resident had a tracheostomy , was at risk for increased secretions/congestion, infection and respiratory distress, ensure tracheostomy in place date initiated/revision: 02/10/2026. Record review of Resident #96's MDS dated [DATE] reflected a BIMS of 99 reflecting the resident was unable to answer the questions. During an observation on 02/10/2026 at 09:03 a.m. Resident #96's trash can was observed sitting next to the resident's door with no trash lining within and a blue surgical glove and brown discoloration/debris at the bottom of the trash can. During an observation on 02/10/2026 at 11:53 a.m. Resident #96's trash can was observed sitting next to the resident's door with no trash lining within and a blue surgical glove and brown discoloration/debris at the bottom of the trash can. Resident #2: Record review of Resident #2's factsheet reflected he admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction (blood clots formed in the brain, disrupting blood flow causing a stroke) affecting right dominant side, iron deficiency anemia (low level of the iron vitamin in the body restricting blood flow), type 2 diabetes mellitus (chronic condition where the body does not produce enough insulin or does not use insulin effectively, leading to high blood sugar levels as glucose restricting energy) with unspecified complications, hyperlipidemia (high cholesterol and triglycerides—in the blood, often leading to dangerous plaque buildup in arteries), hypomagnesemia (low serum magnesium levels leading to neuromuscular, cardiac, and neurological dysfunction.), depression (a serious, common mood disorder causing persistent sadness, loss of interest, and physical symptoms that impair daily life), generalized anxiety disorder (persistent, excessive, and uncontrollable worry about everyday events ), atrial fibrillation (heart's upper chambers (atria) quiver instead of beating effectively), weakness, acquired absence of left leg below knee (post-amputation), other abnormalities of gait and mobility, and other lack of coordination . Record review of Resident #2's undated Care Plan reflected resident wanders, deemed a risk for wandering, with a cognitive communication deficit diagnosis. Date initiated/date revision: 12/26/2025. Record review of Resident #2's undated Care Plan reflected resident cognitive impairment: as impaired cognition and was at risk for further decline and injury (Resident has cognitive impairment in short-term memory) date Initiated: 12/24/2025 Revision on: 12/31/2025. Record review of Resident #2's MDS dated [DATE] reflected the resident had a BIMS score of 06 reflecting he had severely impaired cognition. Resident #65 Record review of Resident #65's facesheet reflected resident admitted on [DATE] with diagnoses of fracture of right acetabulum (break in right side of hip fracture), multiple fractures of ribs, muscle weakness, unsteadiness on feet, other lack of coordination, and cognitive communication deficit. Record review of Resident #65's MDS dated [DATE] reflected the resident had a BIMS score of 12 reflecting the resident had moderately impaired cognition. Record review of Resident #65's care plan reflected resident had cognitive impairment, impaired cognition and was at risk for further decline and injury due to cognitive impairment in short-term memory) date initiated/revision on 01/26/2026. During an interview on 02/11/2026 at 08:44 a.m. ADON A stated she was over the facility's infection prevention program. She stated after learning that the trash can in Resident #96's room without a trash liner while containing debris and a disposal surgical glove violated proper infection control protocols. She stated that someone would have to reach into the trash can to discard the glove and they were unaware as to what the glove was used for. She stated unlined and soiled trash cans in resident rooms place all who came in contact at risk of potential bacteria agents, especially Resident #96 who had a tracheostomy system and gastrostomy status with multiple injuries. She stated that it would have been her expectations that the trash would have been cleaned out when the bag was discharged and that the glove would not have been thrown into the trash can while not containing a liner. She stated it had been the responsibility of the housekeeping staff to pull the trash, re insert a new liner and clean out and/or replace the trash can. She stated it was also the responsibility of the nursing and CNA staff to inform housekeeping if trash cans went without liners, were found soiled and/or not placing trash items including surgical gloves within the trash can. She stated the can was to remain lined with a trash bag for infection control purposes. She stated it was the housekeeping director's (HD) responsibility to perform regular monitoring of housekeeping tasks. She stated Resident #2 and Resident #65's toothbrush and toothpaste at sink side of a semi-private shared room was against facility policy. She stated it posed an additional infection control risk as the residents could grab and use the wrong toothbrush sharing saliva, other residents could enter in to the room and use the items and nursing and CNAs staff could wash their hands at the sink after providing incontinent or other care that could potentially splash or drip on to the items at sink side. She stated that the resident's toothbrushes and toothpastes should have been stored away. During an interview on 02/11/2026 at 10:38 a.m. HD stated that he had been the HD for 1-year and was responsible for making rounds of the facility to ensure that the housekeeping and laundry responsibilities were performed. He stated he had not been made aware that the trash can in Resident #96's room was not lined with a trash bag and contained a surgical glove and discoloration debris. He stated that typically, a trash can should never be left unlined as the staff line the cans with 2-3 liners and each time they pull, the trash reline the trash with another bag . He stated if his staff found a trash can soiled, they were to immediately clean/sanitize, and/or replace or dispose of the soiled trash can, but it should not be relined with debris within. He stated he took responsibility for the condition of the trash can in Resident #96's room and stated that there were no excuses. He stated the soiled trash can would not place any risks to Resident #96's health as the resident was bedbound. During an interview on 02/12/2026 at 01:39 p.m. ADON A stated that she told the ADM and DON about Resident #2 and Resident #65's toothbrushes and toothpaste at sink side on 02/11/2026 and the staff on that hall were educated on storing personal items. She stated that there was a new set of staff working the hall on this date and more than likely contributed to the personal items being back at sink side. She stated that both residents' personal items were to have been labeled and stored away out of sight either in their bedside table or bathroom. She stated she will reshare that information with ADM and the DON. She stated she was not aware of any in-services performed on infection control because of the personal items at sink side. During an interview on 02/12/2026 at 2:45 p.m. DON stated that nursing and CNA staff received skills check off training upon hire that covers infection control. She stated that it had been her expectation that the trash cans would be lined at all times and that trash would not be put within an unlined trash can because it was appropriate not to . She stated it was also her expectation that if a trash can had become dirty it would be cleaned and sterilized immediately. She stated that unlined and soiled trash cans posed no risks to residents with tracheotomy status. She stated that CNAs were responsible for informing housekeeping if a trash can needed a trash bag and the HD was responsible for ensuring housekeeping staff emptied and relined trash cans. She stated it was the responsibility of everyone at the facility to ensure resident's toothbrushes were not at the sink and labeled and stowed away. She stated that toothbrushes left at the sink unlabeled in a shared room could put residents at risk of using the wrong toothbrush. She stated that CNAs received in-service training on infection control last week. During an interview on 02/12/2026 at 05:57 p.m. ADM stated he had no comment regarding infection control and deferred to the DON for expectation. He stated that resident's toothbrushes left at a shared room sink should be clearly identified so that the roommates do not share toothbrushes. He stated he was unaware of the risk of sharing toothbrushes. Record review of policy titled Interview Cleaning and Disinfecting Non-Critical Resident-Care Items reflected: Level I PurposeThe purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. Preparation1. Assemble the equipment and supplies as needed. 2. Record review of the facility's Hand Hygiene policy dated 6/2019 and updated 3/2024 revealed in part: .It is the policy of this facility that proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicated. Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Procedure: After: After removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand washing may not be necessary until completion of the procedure. If glove hands become contaminated as gloves are changed hands can be washed. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident inn bed . 3. Record review of the Infection Control Program (Revised 3/2024) revealed in part: .Policy: Evidence-based policies and procedures are the foundation of a facility's infection control and prevention program. Goals: A Decrease in the risk of infections and communicable diseases to residents, employees, volunteers, and visitors .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 14% based on 5 errors out of 34 opportunities, which involved 2 of 7 residents (Resident #35, and Resident #83) reviewed for medication errors.The facility failed to ensure MA P administered the correct dose of Vitamin B-12 (use to make and support healthy) to Resident #35 on 2/10/26.LVN G failed to administer Timolol Maleate (used to lower high fluid pressure inside the eye) Ophthalmic Solution 0.5 % eyedrops ophthalmic drops, on 2/11/25, initialed as given to Resident #83, when it was not given.LVN G failed to administer Brimonidine Tartrate (used to lower pressure of the eye) 0.2 % Solution eyedrops ophthalmic drops, on 2/11/25, initialed as given to Resident #83, when it was not given.LVN G failed to administer Dorzolamide HCl Solution(commonly used to lower high fluid pressure inside the eye) 2 % Solution eyedrops ophthalmic drops, on 2/11/25, initialed as given to Resident #83, when it was not given.LVN G failed to administer a substantial amount of potassium CL via GT ( medication used for essential mineral and electrolyte that keep the heart beating regularly, muscles contracting and nerves communicating) to Resident # 83 after dissolving potassium CL in water in the medication cup, on 2/11/26. These failures could place residents at risk for increased negative side effects, and a decline in health. h.Record review of Resident #35's face sheet dated 02/11/26 revealed an [AGE] year-old male was admitted on [DATE]. Resident #35 had diagnoses which included: anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress) hypertension( blood vessels is too high), and heart failure (heart does not pump enough blood for the body's needs),hyperlipidemia (abnormally high fat and lipids), Parkinson's disease is (progressive neuro degenerative disorder, not a condition with a functional use. It involves the death of brain cells that produce dopamine), chronic kidney disease (cannot properly filter waste and extra fluid from your blood, causing toxins to build up). Record review of Resident #83's Physician order dated 2/4/2026 reflected in part . 2/4/26 had give Vitamin B complex B_12 1 tablet by mouth AM. There were no physician order for Vitamin B-12 500 mcg.Record review of Resident #83's MAR dated February 2026 reflected in part . take Vitamin B complex B_12 one tablet by mouth AM.Observation of medication administration on 2/10/26 at 9:55AM by MA A revealed MA A gave Resident#35 Vitamin B-12 500mcg 1 tablet and Vitamin B complex B 12 1 tablet by mouth. During medication administration, MA stated [Resident #35] takes 2 Vitamin B. Resident #83 Record review of Resident #83's face sheet dated 2/11/26 revealed a [AGE] year-old female resident that was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #83 had diagnoses included: other cerebral infarction ( a type of ischemic stroke where blood flow to part of the brain id blocked usually by a clot due to occlusion or stenosis (narrowing) of small artery, essential (primary) hypertension(high blood pressure) heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), hypokalemia (lower than normal potassium level in the bloodstream), dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach) glaucoma( high fluid pressure inside the eye) and protein-calorie malnutrition. Record review of Resident #83's quarterly MDS assessment, dated 11/30/25, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required total assistance from staff with ADL's care.Record review of Resident #83's physician order for February 2026 revealed in part . Potassium Chloride Crys ER 20 MEQ Tablet extended release Give 1 tablet via PEG -Tube one time a day for low potassium order date 2/01/26 . may swirl and dissolve in 4-6oz of water.Record review of Resident #83's physician order for February 2026 revealed in part. instill Timolol Maleate Ophthalmic Solution 0.5 % 1 drops ophthalmic to both eyes twice dailyRecord review of Resident #83's physician order for February 2026 revealed in part. instill 0.2 % Solution eyedrops both eyes 1 drops, twice daily.Record review of Resident #83's physician order for February 2026 revealed in part. instill Dorzolamide HCl Solution 2% 1 drop to both eyes three times daily. During an observation on 2/11/26 at 8:10 a.m. revealed LVN G punched 3 medications into a medication cup, crushed them and diluted with 20mls of water and dissolved Potassium Chloride Crys ER 20 MEQ in 20 mls of water in a medication cup and administered all medication via GT. LVN G was about to discard the medication cups with a substantial amount of Potassium residual left. The state surveyor intervened after showing LVN G the Potassium left in the medication cup. LVN G said It takes a long time for Potassium to be administered via [Resident #83's GT. I will give it. She then poured 20mls of water and Potassium to administer in via GT. LVN G did not administer LVN G Aspirin 81 mg chewable give 1 tablet per peg tube and the following eye drops medications Timolol Maleate Ophthalmic Solution 0.5 % eyedrops ophthalmic drops, on 2/11/26, initialed as given, when it was not given to Resident #83 Brimonidine Tartrate 0.2 % Solution eyedrops ophthalmic drops, on 2/11/26, initialed as given when it was not to Resident #83 administered Dorzolamide HCl Solution 2% eyedrops ophthalmic drops, on 2/11/26, initialed as given, when it was not given to Resident #83 Interview with LVN G on 2/12/26 at 9:00 AM, regarding not administering Potassium Chloride Crys ER 20 MEQ and not diluting with 4oz-6oz of water (120mls -180mls of water), she said she would be careful. LVN G said she omitted Aspirin 81 mg during medication administration on 2/11/26 at 8:10 AM; she went back and administered it to Resident #83. LVN G was asked about the eye drops initialed when it was not given on the MAR. LVN G did not give any response. She knew that potassium ER not given in totality would cause low potassium in the leading to muscle weakness, cramps, spasms, severe fatigue, heart palpitations and constipation. In an interview with the DON on 2/12/26 at 2:38 PM, regarding her expectation for medication administration was for nurses to administer medication as ordered by the physician. The DON said the facility was working on changing medication pass times to 6:00 AM to 11:00 AM since 2/6/2026 but she had not gotten to many residents because the census was over 80 and she had not gotten to Resident #83. She said always monitored the staff periodically and the pharmacist did monitor the staff also and last time the pharmacist monitored staff was in December 2025.In an interview on 2/12/26 at 2:40 PM, the Administrator said he expected nursing staff to give medications timely, correctly, and according to the physician orders.Record review of the facility's Administering Medications policy, undated 3/2024 revealed in part Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions.Medications must be administered in accordance with the orders, including any required time frame.Record review of the facility medication administration updated 3/2024 MED - PASS, Inc reflected in part . Medications are administered in a safe and timely manner, and as prescribed .Record review of facility policy on administering medications through an enteral tube updated 3/2024 reflected in part . Purpose . the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .

Based on interviews and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 10 of 10 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 10 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. During a confidential group interview on 02/11/2026 at 02:10 p.m., with 10 confidential residents, all residents stated that there were no weekend activities and nothing to do around the facility on those days. Four of the 10 residents stated it was boring, and it was nonsense that the facility could not provide them with activities on the weekends. Four of the 10 residents stated the morale was down in the facility because there were no activities on the weekends. One of the 10 residents stated that not having activities on the weekends proved that the facility did not give a shit about them. Five of the 10 residents stated that the facility left out coloring sheets for them to do when the Activities Director was not at the facility but stated they could color on their own time and did not consider coloring an activity worth calling an activity. Interview on 02/12/2026 at 10:16 a.m. the Activities Director (AD) stated she had been in her role at the facility since 10/27/2025 and worked Monday – Friday between 8:00 a.m. and 5:00 p.m. She stated prior to that date, she had been the AD's assistant for 1.5 years. She stated that she had not been working at the facility on Saturdays or Sundays, but left activity packets out that contained coloring sheets, daily chronicle news for that day, and a [NAME] for the residents to do on the weekends. She stated that the facility had a job posting for a part-time weekend activity director that would offer 16 total hours per week. She stated that she had interviewed a few prospects, but they were not interested in taking the position unless it offered the opportunity to acquire more hours, which she stated the facility would not. She stated that every 3rd Sunday, a pastor from a local church provided the resident's a church service and other volunteer groups came into the facility such as a sorority and high school band which they showcased on their facility Facebook page. She stated however, there were no staff led activities on Saturdays and Sundays at the facility. She stated that she would provide the job posting for the weekend part-time AD position. During an interview with the Administrator (ADM), he stated that he was aware that the residents had no activities on Saturdays and Sundays. He stated that the facility was looking to fill a weekend part-time AD position and stated he would defer to the AD for the progress on filling that position. Record review of the facility's Activities Calander titled December 2025 reflected Activities Packets Available for Saturdays 12/06, 12/13, 12/20, and 12/27. On Sunday 12/01, 12/14, 12/21 and 12/28 the calendar listed Activities Packets Available. Record review of the facility's Activities Calander titled January 2026 reflected Activities Packets Available for Saturdays 01/03, 01/10, 01/17, 01/24 and 01/31. On Sunday 01/04 and 01/11 the calendar listed Activities Packets Available and on 01/18 and 01/25, no activities listed. Record review of the facility's Activities Calander titled February 2026 reflected, Activities Packets Available for the Saturdays on 02/07, 02/14, and 02/21 and on 02/28 a Black History Program with [NAME] at 10:30 a.m. On Sunday 02/01, 02/08, 02/15, and 02/22 the calendar reflected Activities Packets Available on those days. Record review of the facility job posting on a job board reflected that as of 01/14/2026 an Activities Director position had been posted. Record review of policy titled Nursing Home Resident Activities Policy reflected, 1. Purpose To establish a comprehensive, person-centered Activities Program that supports residents' physical, cognitive, emotional, social, and spiritual well-being in alignment with federal and state regulations, professional standards, and residents' goals, preferences, and cultural backgrounds. 2. Scope This policy applies to the Activities Director, activities staff, volunteers, contracted service providers, nursing, social services, rehabilitation, dietary, environmental services, and all other personnel who plan, implement, or support resident activities. 5. Policy Statement The facility provides an ongoing, person-centered program of activities that is directed by a qualified Activities Director and designed to meet the interests and enhance the physical, mental, and psychosocial well-being of each resident. Activities are accessible and equitably offered to residents across all functional levels, including those who are short-stay, on isolation/precautions, or living with dementia or behavioral health conditions. Activity goals and interventions are integrated into each resident's care plan and evaluated at least quarterly and with significant change in condition. Residents are offered meaningful choices, can refuse participation without retaliation, and may request reasonable accommodation to support participation. 6.3 Program Planning & Calendar - Publish a monthly activities calendar in accessible formats and locations; provide alternate formats for residents with low vision or language needs. - Offer a balanced mix of physical, cognitive, creative, social, intergenerational, outdoor, cultural, and spiritual options seven days per week, including evenings and weekends as indicated by resident preference. - Ensure adaptation for residents with dementia (validation, Montessori-based, music, sensory stimulation) and those on isolation/precautions (in-room or virtual engagement). - Schedule community outings with risk assessment, supervision ratios, transportation safety, and emergency plans.

Based on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 1 of 10 confidential residents reviewed for personal privacy. The facility failed to ensure facility staff knocked on residents' doors prior to entering their rooms.This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know and could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. During a confidential group meeting, residents stated that staff had not knocked on their doors and announced themselves before entering their room. One of 10 confidential group residents stated that she had been in the middle of dressing when staff walked into her room. She stated that the staff had no regard in providing her with privacy and freedom of feeling exposed.During an interview on 02/12/2026 at 09:27 a.m. the Administrator (ADM) stated that he had been made aware that knocking on residents' doors before entering their rooms had been an issue. He stated that the staff received in-service training on customer service once a month which included - no expectations knock on resident's doors before entering a resident's room. He stated staff were to knock, wait and give the residents the ability to welcome the staff in, and then enter, and announce the goal of the visit. He stated during the visit with the residents, staff were to communicate with the residents what care service they were provided the entire visit. He stated staff received in-service training on abuse, neglect and exploitation 3 times a month which also covers customer service responsibilities.During an interview on 02/12/2026 at 10:16 a.m. the Activities Director (AD) stated that she had been made aware by the residents during resident council meetings in the past (exact date unknown) concerns about staff not knocking and announcing themselves before entering a resident room. She stated she had informed the Director of Nursing (DON) (exact date unknown) and the DON had made herself present at one of the resident council meetings to address the residents' concerns. She stated thereafter, the nursing and certified nursing staff (CNAs) received an in-service training on customer service

During a confidential group meeting, residents stated that staff had not knocked on their doors and announced themselves before entering their room. One of 10 confidential group residents stated that she had been in the middle of dressing when staff walked into her room. She stated that the staff had no regard in providing her with privacy and freedom of feeling exposed. During an interview on 02/12/2026 at 09:27 a.m. the Administrator (ADM) stated that he had been made aware that knocking on residents' doors before entering their rooms had been an issue. He stated that the staff received in-service training on customer service once a month which included - no expectations knock on resident's doors before entering a resident's room. He stated staff were to knock, wait and give the residents the ability to welcome the staff in, and then enter, and announce the goal of the visit. He stated during the visit with the residents, staff were to communicate with the residents what care service they were provided the entire visit. He stated staff received in-service training on abuse, neglect and exploitation 3 times a month which also covers customer service responsibilities. During an interview on 02/12/2026 at 10:16 a.m. the Activities Director (AD) stated that she had been made aware by the residents during resident council meetings in the past (exact date unknown) concerns about staff not knocking and announcing themselves before entering a resident room. She stated she had informed the Director of Nursing (DON) (exact date unknown) and the DON had made herself present at one of the resident council meetings to address the residents' concerns. She stated thereafter, the nursing and certified nursing staff (CNAs) received an in-service training on customer service

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (secured unit). -The secured unit nurse medication cart A contained opened undated medication. These failures placed residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing.During an observation on [DATE] at 9:58 AM of the nurse medication cart A for the locked unit, the following opened medications were not dated when they were opened:Azelastine HCL Nasal spray 0.1% Fluticasone Propionate Nasal spray 50 mcg In an interview with LVN K, on [DATE] at 9:58AM, she said the medication should be dated when opened and it was good for 30 days and it would not be effective after 30 days. LVN K said she was not aware when it was open and she checks the medication cart for expired medication weekly.During an interview on [DATE] at 2:38 p.m., the DON said nasal spray medications opened should have an open date. The DON said the medicines would not be effective for the treatment after 30 days.Record review of the facility policy Revised February 2023: Storage of drugs and Biologicals: Medication Labeling reflected:Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.1. The medication label includes, at a minimum: expiration date, when applicable;resident's name; route of administration; andappropriate instructions and precautions.

Based on observation, interviews, and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 6 residents (Residents #83) reviewed for significant medication errors. LVN G failed to administer a substantial amount of potassium CL via GT ( medication used for essential mineral and electrolyte that keep the heart beating regularly, muscles contracting and nerves communicating) to Resident # 83 after dissolving potassium CL in water in the medication cup, on 2/11/26 This failure could place residents at risk of abnormal heart rhythms, and potential hospitalizationRecord review of Resident #83's face sheet dated 2/11/26 revealed a [AGE] year-old female resident that was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #83 had diagnoses included: other cerebral infarction ( a type of ischemic stroke where blood flow to part of the brain id blocked usually by a clot due to occlusion or stenosis (narrowing) of small artery, essential (primary) hypertension(high blood pressure) heart failure (when the heart cannot pump enough oxygen - rich blood to meet the body's needs), hypokalemia (lower than normal potassium level in the bloodstream), dementia (decline in thinking, remembering, and reasoning), and gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach) and protein-calorie malnutritionRecord review of Resident #83's physician order for February 2026 read in part . Potassium Chloride Crys ER 20 MEQ Tablet extended release Give 1 tablet via PEG-Tube one time a day for low potassium order date 2/01/26 . may swirl and dissolve in 4-6oz of water.During an observation on 2/11/26 at 8:10 a.m.,LVN G punched Potassium Chloride Crys ER 20 MEQ dissolved in 20 mls of water in medication cup and did not administer all medication via GT and discarded the medication cup with Potassium residual it, the state surveyor intervened after showing LVN G the Potassium left in the medication cup. LVN G said it takes a long time for Potassium to be administered via Resident 83's GT, I will give it she then poured 20mls of water and Potassium to administer in via GT. Interview with LVN G on 2/12/26 at 9:00 AM, regarding not administering all of the Potassium Chloride Crys ER 20 MEQ and not diluting with 4-60oz of water (120mls -180mls of water), she said she will be careful. LVN G said she knew that potassium ER not given in totality would cause low potassium in the leading to muscle weakness, cramps, spasms, severe fatigue, heart palpitations and constipation. During an interview on 2/12/26 at 2:38 p.m., the DON said potassium ER should be dissolved in water as ordered by the physician. The DON said Resident #83 could not be getting the dosage required to maintain his potassium level, and Resident #83 could have signs and symptoms of hypokalemia. The DON said monitored the nurses and made random rounds. The DON said the nurses had skills - check off for medication administration before the nurses passed out medication to residents. She was requesting for Potassium in liquid form the pharmacy.Record review of the facility undated policy on medication administration and management revealed in part . step 111: administering the medication pass .#6 the authorized licensed or certified/permitted medication aide .seeks assistance from the nursing supervisor/designee and consulting pharmacist when any aspect of medication administration is in question . #7 E . medications which cannot be crushed: #2 . or extended - release tablets .

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #96) of 4 residents reviewed for enteral nutrition. The facility failed to properly label Resident #96's enteral feeding formula to identify what date, time and by which staff administered and hung the feeding. This failure could place residents who had gastrostomy tube at risk receiving expired fluids. Findings included: Record review Resident #96's Facesheet reflected the resident admitted to the facility on [DATE] with diagnosis of weakness, dysphagia (difficulty swallowing), cognitive communication deficit, need for assistance with personal care, traumatic subarachnoid hemorrhage (bleed in the brain due to trauma) with loss of consciousness of unspecified duration, gastrostomy status. Record review Resident #96's Minimum Data Set (MDS) dated [DATE] Brief Interview for Mental Status (BIMS) 99 reflecting the resident was unable to answer the questions. Record review Resident #96's Care Plan reflected the resident had a tracheostomy date initiated/revision: [DATE]. Record review Resident #96's Order dated order [DATE] 01:05 p.m. summary: NPO nothing by mouth (NPO) diet. NPO texture, NPO consistency. Record review Resident #96's Order dated [DATE] at 02:57 p.m. summary order date: [DATE] 02:57 p.m. Turn off continuous enteral feeding. Record review Resident #96's Order dated: [DATE] at 15:04 Restart continuous enteral feeding. Formula: Isosource 1.5; Rate: 75 mL/hr for 20 hours. one time a day for to provide feeding Order Summary: Restart continuous enteral feeding. Formula: Isosource 1.5; Rate: 75 mL/hr for 20 hours. one time a day for to provide feeding. During an observation on [DATE] at 09:03 a.m. revealed Resident #96's iso-source formula had no date/time to indicate when the formula was administered or initialed by which nurse administration the formula. During an observation on [DATE] at 11:53 a.m. revealed Resident #96's iso-source formula had no date/time to indicate when the formula was administered or initialed by which nurse administration the formula. During an observation on [DATE] at 11:53 a.m. revealed Resident #96's iso-source formula had no date/time to indicate when the formula was administered or initialed by which nurse administration the formula. During an interview on [DATE] at 01:00 p.m. LVN A stated on [DATE] he had not hung Resident #96's formula but had hung it on [DATE]. He stated Resident #96's formula on [DATE] should have had a label dated/initialed to know when it was hung and by whom so if there were ever any questions the facility knew who to hold accountable and when and what time it had begun being administered. He stated in addition it was important to date the formula to know of the formula's expiration date. He stated the formula should also be labeled with the volume the resident was to receive an hour and the rate of full. During an interview on [DATE] at 01:39 p.m. ADON A stated Resident #96's formula should have been labeled with the resident's name, rate and amount of flow, and date and time it was hung and initialed by whichever staff hung the formula to know who hung the formula and when it was hung. She stated that licensed vocational nurse (LVN A) had labeled Resident #96's formula on [DATE], but the label had fallen off on the floor and was found and relabeled. During an interview on [DATE] at 2:45 p.m. the DON stated residents who require tube feeding formula should have their formula bags labeled to reflect the resident's name, room number, rate and amount of flow, date and time the formula was hung. She stated that labeling information should be taken directly off the resident's medication administration record (MAR). She stated the importance of labeling the formula was to know who hung it and when as they did not want to be giving residents expired formula. Residents receiving expired formula could lead to gastrointestinal issues, nausea, and vomiting. Nurses received a training skills check on tube feeding administration upon hire and annually, last given in [DATE]. She stated labeling the formula bag was an expectation and covered in the training. Record review of policy titled Enteral Feedings – Safety Precautions dated 2001 reflected: Level III. Purpose To ensure the safe administration of enteral nutrition. Preparation 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 2. The facility will remain current in and follow accepted best practices in enteral nutrition. Preventing errors in administration. 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. Record review of policy titled Enteral Nutrition dated 2001, revised [DATE] reflected: Policy Statement Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation The interdisciplinary team, including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: evaluation of the resident's current clinical and nutritional status; relevant functional and psychosocial factors; and a review of interventions to maintain oral intake prior to the use of a feeding tube and the resident's response to them. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice, the residents' advance directives, treatment goals and facility policies.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 3 residents (Residents #32) reviewed for incontinent care, in that: CNA H did not clean Resident #32's open labia during indwelling Foley Catheter incontinent care. During incontinent care for Resident#32 CNA used wet wipes to clean in-between the buttocks, cleaning the buttocks from the top of the buttockstoward the vaginal area. These failures could place residents at-risk for infection due to improper care practices. Record review of Resident #32's face sheet, dated 2/11/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses diagnosis of other venous thrombosis and embolism (blood clot that forms in a vein), hypokalemia(low potassium in the blood), tracheostomy status( surgically created hole in the front of the neck that leads directly into the windpipe ( trachea) to help a person breathe), essential (primary) hypertension(high blood pressure), hyperlipidemia, ( abnormal high fat in blood), hyperosmolality and hypernatremia( a condition in which the blood has a high concentration of salt), gastrostomy status( a surgical opening into the stomach), elevated white blood cell count, unspecified( immune system working hard to fight something off, most common infection, inflammation or stress ), acute and chronic respiratory failure with hypoxia( body tissues and organ are not getting enough oxygen in the blood), functional quadriplegia( total loss of use of all four limbs ( both arms and both legs and the torso ), anoxic brain damage ( a serious often permanent injury that occurs when the brain is completely deprived of oxygen ), anemia, protein-calorie malnutrition. and sepsis( a life -threatening medical emergency caused by the body's extreme. Dysfunctional response to an infection). Record review of Resident #32's admission MDS, dated [DATE], reflected the BIMS score was blank out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #32 was incontinent to bladder with indwelling Foley Catheter and bowel with colostomy ( a surgical procedure that creates an opening ( called a stoma) in the abdomen to allow stool and gas to leave the body). Record review of Resident #32's care plan dated 12/24/25 reflected Resident #32 has an ADL self-care performance deficit, the goal was resident will improve current level of function in through the review date: Resident #32 required total assist with one to two persons for bathing/showering, dressing, bed mobility, eating, personal hygiene/oral. Toilet use and follow principles of infection control and universal precautions to incontinent care.Review of Resident #32's Physician's orders from 12/22/2025 through 12/22/2025 reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 12/22/2025. Record review of Resident #32's MAR reflected she was on antibiotics Augmentin ES on 1/14/26 for urinary tract infection. Observation of F/C and incontinent care performed by CNA H 2/11/26 at 2:20 PM and was assisted by RN W revealed Resident #32 was lying in bed on her right side. CNAH donned (put on) cleaned gloves and using the wet wipes cleaned in-between the buttocks from top to bottom of the perineal area, and around the buttocks The CNA placed a brief under Resident #32's buttocks and she then proceeded to clean the perineal area, cleaned the groin, and she did not open the resident's labia. to clean. She cleaned the exposed F/C tubing , not from the insertion site and did not clean the F/C in a circular motion. Without changing gloves she fastened the clean brief then doffed (take off)her dirty gloves. Interview with RN W on 2/11/26 at 2:32 PM, regarding F/C and incontinent care, what she thought C.NA H did not do when performing incontinent/ F/care. RN W said C.NA H did not change gloves throughout the procedure. CNA H did not open the labia to clean and she did not clean the F/C at the insertion site. Interview with CNA on 2/11/26 at 2 2:36 PM she said she has been working 7months, she works 6:00 AM -2:00 PM to 10 :00PM. She said she thought she did good. She stated she was told about not changing her gloves, not opening the resident's labia and not cleaning in-between her buttocks from the inside out CNAH said she had in-services bi-weekly about hand washing and had one time on indwelling Foley Catheter. Interview with the DON on 2/11/26 at 5:10 PM, she said she had a handwashing in-service a month ago and she was the one that trained CNA H. The DON said she did monitor CNAs randomly for incontinent care/infection control. Record review of the Skilled check list, titled Catheter Care-Skill, not dated . 10. With non-dominant hand: Female: Gently retract labia to fully expose urethral meatus and catheter insertion site. Maintain position of hand throughout.14. Using a clean washcloth, clean catheter tubing using one cloth per stroke, in a circular motion. Clean from the most proximal (Closest to the body) to the most distal (Farthest for the body). Continue cleaning in this manner until tubing is clean.Record review of Resident #32's face sheet, dated 2/11/2026, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses diagnosis of other venous thrombosis and embolism (blood clot that forms in a vein), hypokalemia(low potassium in the blood), tracheostomy status( surgically created hole in the front of the neck that leads directly into the windpipe ( trachea) to help a person breathe), essential (primary) hypertension(high blood pressure), hyperlipidemia, ( abnormal high fat in blood), hyperosmolality and hypernatremia( a condition in which the blood has a high concentration of salt), gastrostomy status( a surgical opening into the stomach), elevated white blood cell count, unspecified( immune system working hard to fight something off, most common infection, inflammation or stress ), acute and chronic respiratory failure with hypoxia( body tissues and organ are not getting enough oxygen in the blood), functional quadriplegia( total loss of use of all four limbs ( both arms and both legs and the torso ), anoxic brain damage ( a serious often permanent injury that occurs when the brain is completely deprived of oxygen ), anemia, protein-calorie malnutrition. and sepsis( a life -threatening medical emergency caused by the body's extreme. Dysfunctional response to an infection). Record review of Resident #32's admission MDS, dated [DATE], reflected the BIMS score was blank out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #32 was incontinent to bladder with indwelling Foley Catheter and bowel with colostomy ( a surgical procedure that creates an opening ( called a stoma) in the abdomen to allow stool and gas to leave the body). Record review of Resident #32's care plan dated 12/24/25 reflected Resident #32 has an ADL self-care performance deficit, the goal was resident will improve current level of function in through the review date: Resident #32 required total assist with one to two persons for bathing/showering, dressing, bed mobility, eating, personal hygiene/oral. Toilet use and follow principles of infection control and universal precautions to incontinent care.Review of Resident #32's Physician's orders from 12/22/2025 through 12/22/2025 reflected orders for the following: Foley Catheter cleansing and perineal hygiene daily and as needed if soiled, using a catheter securing device with a start date of 12/22/2025. Record review of Resident #32's MAR reflected she was on antibiotics Augmentin ES on 1/14/26 for urinary tract infection. Observation of F/C and incontinent care performed by CNA H 2/11/26 at 2:20 PM and was assisted by RN W revealed Resident #32 was lying in bed on her right side. CNAH donned (put on) cleaned gloves and using the wet wipes cleaned in-between the buttocks from top to bottom of the perineal area, and around the buttocks The CNA placed a brief under Resident #32's buttocks and she then proceeded to clean the perineal area, cleaned the groin, and she did not open the resident's labia. to clean. She cleaned the exposed F/C tubing , not from the insertion site and did not clean the F/C in a circular motion. Without changing gloves she fastened the clean brief then doffed (take off)her dirty gloves. Interview with RN W on 2/11/26 at 2:32 PM, regarding F/C and incontinent care, what she thought C.NA H did not do when performing incontinent/ F/care. RN W said C.NA Hdid not change gloves throughout the procedure. CNA H did not open the labia to clean and she did not clean the F/C at the insertion site. Interview with CNA on 2/11/26 at 2 2:36 PM she said she has been working 7months, she works 6:00 AM -2:00 PM to 10 :00PM. She said she thought she did good. She stated she was told about not changing her gloves, not opening the resident's labia and not cleaning in-between her buttocks from the inside out CNAH said she had in-services bi-weekly about hand washing and had one time on indwelling Foley Catheter. Interview with the DON on 2/11/26 at 5:10 PM, she said she had a handwashing in-service a month ago and she was the one that trained CNA H. The DON said she did monitor CNAs randomly for incontinent care/infection control. Record review of the Skilled check list, titled Catheter Care-Skill, not dated . 10. With non-dominant hand: Female: Gently retract labia to fully expose urethral meatus and catheter insertion site. Maintain position of hand throughout.14. Using a clean washcloth, clean catheter tubing using one cloth per stroke, in a circular motion. Clean from the most proximal (Closest to the body) to the most distal (Farthest for the body). Continue cleaning in this manner until tubing is clean.

Based on interviews and record review, the facility failed to ensure effective administration to maintain the highest practicable well-being of each resident. The facility operated without an administrator from 08/20/25 to 09/13/25, in the 1 of 1 facility reviewed for administration.Record review of personnel records revealed the Former Administrator was terminated on 08/19/2025, there was no record of a licensed interim or permanent replacement appointed from the period of 08/20/2025 - 09/13/2025. During an interview on 09/13/2025 @ 10:30am with the nurse supervisor, she stated that the facility had not had a facility administrator, since 08/2025. She stated that DON, who was not a state-licensed nursing home administrator, was informally made responsible for the Administrator's tasks. During interview on 09/13/2025 @ 1:00pm with DON, stated that the prior facility administrator was terminated 08/19/2025. She stated she was not aware if Human Resources staff had documentation of a designated full-time acting Administrator since the prior Administrator was terminated. She stated that she was informed the facility had a thirty-day window period to hire an Administrator; and a new Administrator was expected to start at the facility on 09/ 29/ 2025. She stated that administrative duties were reassigned informally among the facility department heads. She stated the VP of Operations holds a state administrator license and had been in contact with the department heads. Attempted telephone interview on 09/13/2025 @ 1:45pm with Human Resources Staff was unsuccessful; voicemail requested a return follow up call. During telephone interview on 09/13/2025 @ 2:35pm with the facility's VP of Operations, he stated that the Former Administrator was terminated on 08/19/2025. He stated the facility had no full-time, state-licensed nursing home Administrator on staff since the Former Administrator was terminated. He stated that the facility had a thirty-day window to hire an Administrator; and a new licensed administrator was hired and expected to assume Administrator role and duties on 09/ 29/ 2025. He stated the facility department's heads were provided with his contact information. He stated that he holds a state administrator license and had last visited the facility on 08/19/2025. He stated nursing leadership (DON and department heads) had been in regular communication with him via a group text message created. He stated the DON and department heads were not licensed administrators. During interviews on 09/13/2025 at various times, staff (CNA S, CNA O, CNA T, Nurse A, Nurse J, Nurse I) stated that the facility had not had a facility administrator, since 08/2025 and they were not aware of a designated acting Administrator responsible for carrying out administrative duties. Staff interviews confirmed that several administrative duties had been reassigned informally to the facility's DON. The staff stated that the DON was the person they report to for administrative issues that presented since the Former Administrator left the facility.During interviews on 09/13/2025 at various times, residents (1, #2, #3, #4 and #5) stated that they did not know who the Administrator was since the Former Administrator left. Residents reported no immediate safety concerns. All residents interviewed stated they would report any concerns to the facility DON. The signed Administrator's job description was requested from the facility's VP of Operations on 09/13/2025 at various times (2:35pm, 3:30pm, 5:34pm) via telephone call and (5:06pm and 6:00pm) via email request. The facility failed to provide the requested document. The facility provided Policy, titled Administrator, revised March 2021, indicated in part:Policy Statement: A licensed Administrator is responsible for the day-to-day functions of the facility.Policy Interpretation and Implementation: (g). ensuring that an adequate number of personnel are employed to meet resident needs. (i). maintaining his/her license on a status as required by law and maintaining a copy of such license or registration on premises. (d). implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities.

Based on observation, interviews, and record review, the facility failed to ensure that all staff were trained in the procedures for reporting abuse, neglect, exploitation, or misappropriation of resident property for 6 of 6 facility employees reviewed for training. The facility failed to provide training on the identity of the Abuse Coordinator and the procedures for reporting abuse. This deficient practice has the potential to affect all residents by placing them at risk for unrecognized or unreported abuse due to staff being unaware of who to report to and how to initiate the facility's abuse reporting process. Observation 09/13/2025 @ 2:40pm, during the onsite visit, revealed the facility had not update the signage and posting of the facility's Abuse Coordinator. The posting reflected the Former Abuse Coordinator, who was terminated on 08/19/2025, contact information.During interview on 09/13/2025 @ 1:00pm with DON, stated that the Former Abuse Coordinator was terminated 08/19/2025. She stated the in - service was usually provided by the administrator. She stated the facility failed to provide training on the identity of the Abuse Coordinator and the procedures for reporting abuse. She stated that signage and posting had not been updated but would be updated following the interview. She stated failure to updated and train staff of the Abuse Coordinator could have potentially affected the residents by placing them at risk for unreported abuse. During telephone interview on 09/13/2025 @ 2:35pm with the facility's VP of Operations, he stated that the prior facility Administrator/ Abuse Coordinator was terminated on 08/19/2025. He stated the facility had no full-time Abuse Coordinator since 08/19/2025. He stated the facility was responsible and had not provided training on the identity of the Abuse Coordinator and the procedures for reporting abuse. He stated he would be the identified facility Abuse Coordinator; staff would be informed and trained regarding the process and who to contact. He stated the signage and posting with updated Abuse Coordinator's contact would be updated following the interview.During staff interviews on 09/13/2025, 6 out of 6 direct care staff members (CNA S, CNA O, CNA T, Nurse A, Nurse J, Nurse I) were unable to identify the facility's designated Abuse Coordinator. Staff stated they had not received recent or updated in-service training on abuse reporting protocols or on the identity of the person responsible for handling abuse allegations.The training records or sign-in sheets showing that Abuse Coordinator training had been conducted within the last 30 days, were requested from the facility's VP of Operations on 09/13/2025 at various times (2:35pm, 3:30pm, 5:34pm). The facility failed to provide the requested documentation.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 5 hallways, (Hall 100 and Hall 400) and the conference room. The facility had live gnats in areas of the facility including Halls 100 and 400, and in the conference room. This failure could place residents at risk for resident health, safety and quality of life. Findings included: In an observation on 07/18/25 at 08:15am approximately 10 gnats were flying around the conference room. In an observation on 07/18/25 at 10:11am, approximately 12 gnats were observed near the dining area in Hall 100. In an observation on 07/18/25 at 12:58pm, approximately 5 gnats were observed flying throughout Hall 400. On 07/18/2025 at 1:11pm, the Pest control log for the last 90 days was requested from the Administrator. The pest control log was not provided. In an interview on 07/18/25 at 2:11pm, the ADON stated they recently had a problem with gnats but reported things had gotten better; it used to be worse. She also reported she educated staff on picking up food trays as soon as residents were done eating to help control the issue. She stated pest control did go to the facility, but she was not sure how often. In an interview on 07/18/25 at 2:31pm, the Maintenance Director stated pest control came out once a month unless they were called out more specifically. He stated he was not aware that there was an issue with gnats because no one had informed him that there were any issues. In an interview on 07/18/25 at 2:46pm, the Administrator confirmed the last pest control visit occurred on Tuesday (July 15, 2025). She stated she was not aware of any current complaints regarding pests or gnats in the building and did not mention any additional follow-up since that date. Record review of the facility's verification of service, receipt of consumer information sheet for pest control reflected the date of service and locations treated was unclear on the form. Record review of the facility's pest control policy (Revised May 2008), reflected Policy Statement: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents

Based on observations, interviews, and record reviews 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 1 out of 2 residents (Resident #3) reviewed for environment. - The facility failed to ensure Resident #3's room was clean and a homelike environment. There was sheetrock debris and dust on the resident's floor and on her windowsill. - The facility failed to relocate Resident #3 to another room while sheetrock repair work was actively being performed in her room. This deficient practice could place residents at risk of environmental hazards such as airborne dust, construction debris, noise and physical risk which could lead to a decreased quality of life. Findings included: Record review of Resident #3's Electronic Health Record revealed a [AGE] year-old female with diagnoses including Dementia, Protein Calorie Malnutrition and Paralytic Syndrome (loss of muscle function, causing weakness or inability to move). Record review of the Resident #3's Quarterly MDS revealed a BIMS score of 03, which indicates severely impaired. Section GG of the MDS revealed the resident did not use any mobility devices and she required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with chair/bed-to-chair transfer. On 07/18/25 at 10:45am, surveyor observed Maintenance staff conducting Sheetrock repairs in Resident #3's room. The work included sanding drywall. There were larges pieces of debris observed on the windowsill of the room as well as on the floor beneath the window. The resident was present in the room and sitting in bed, within close proximity (about 4 feet) to the work area. In an interview on 07/18/25 at 10:50am, Resident #3 stated, It's loud and they usually have a fan. Due to the resident's cognition level, she was unable to answer additional questions that was asked by the surveyor. In an observation on 07/18/25 at 1:01pm, Maintenance staff were observed continuing to do repairs in Resident #3's room while the resident was in her room; pieces of debris and dust was located on the floor near the resident's window and on the windowsill. In an interview on 07/18/25 at 2:11pm, the ADON stated she was unaware of the exact work that was being completed in Resident #3's room but stated that work was active on only one side of the room and reported that the roommate that was closer to the repairs was moved to another room. When asked why both residents were not relocated to another room, she reported that they relocated the roommate that was on the side with the repairs and stated the administrator recommended when residents should be removed. The ADON stated they tried to keep residents out of their rooms when repairs were being completed but stated it was sometimes difficult because the residents were on the memory care unit. In an interview on 07/18/25 at 2:31pm, the Maintenance Director stated he was completing repairs in Resident #3's room. He stated the sheetrock was replaced, windowsill was taken out and he went in to start sanding the wall. He stated he began completing work in the room on Wednesday (07/16/25) and anticipated the work being completed by Tuesday (07/22/25) the following week. He stated he still needed to patch the sheetrock, texture the wall and paint. He stated he had not seen the resident that resided closest to the window since repairs had begun. He stated he was unsure of who had been moved out of the room. He stated the resident could have been relocated but he was unsure. He stated they tried to keep the residents out of the room but because they were in memory care, the residents sometimes wandered back into the room. In an interview on 07/18/25 at 2:46pm, the Administrator stated the wall in Resident #3's room was being repaired. She stated Resident #3 was not relocated to another room because they did not have anywhere to move her due to limited space. She stated they kept residents out of their rooms during the day while repairs were being completed. Record review of the facility's policy on Homelike Environment (Revised February 2021) read in part: . The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment

Based on interviews and record reviews, the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 5 residents (Resident #1) reviewed for abuse.The facility failed to ensure an allegation of rough care and treatment was investigated and documentation was maintained regarding CNA A holding the back of Resident #1 neck and with force pushing her head into the mattress trying to get her up from wheelchair and into bed. This failure could place residents as risk for abuse and neglect.Record review of Resident #1's face sheet dated 07/07/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with a primary diagnosis of Dementia (a group of symptoms affecting memory, thinking and social abilities). Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMs score of 03 which indicated the resident was severely cognitively impairment. The assessment indicated Resident #1 required maximum assistance with transfers.Record review of the facility's incident documentation revealed the incident was reported and submitted to HHS on 04/15/2205. Further review of TULIP revealed the Facility Investigation Report was Received Date on 4/22/2025. Record review of physical progress note revealed, provider was made aware of the incident abuse. Record review of SW progress note dated 04/15/2025 revealed, responsible party and Medical Director were of allegation.Record review of skin assessment dated [DATE] revealed, no injury on assessment. Record review of Resident #1 's and the facility's records revealed additional related documentation of this event.Observation on 07/05/2025 at 1:20pm, of the facility, revealed there was a sign was posted in the front lobby listing Abuse Coordinator's contact information.Observation on 07/05/2025 at 1:46pm, of Resident #1, revealed she could not follow along and provide detail responses in an attempted interview. No visible safety concerns or injury were present at the time of the observation. Attempted a telephone interview on 07/05/2025 at 2:05pm, with CNA A. There was no answer; left a voicemail.During interview on 07/05/2025 at 2:13pm, with Nurse K, she stated she witnessed CNA A holding the back of Resident #1 neck and repeatedly pushed Resident #1 head into the mattress while assisting Resident #1 into bed. She stated she immediately intervened and asked CNA A to leave Resident #1. She stated she assessed Resident #1 and completed a head-to-toe assessment of Resident #1 skin. She stated at the time of her assessment, there were not visual findings of injury. She stated after she settled Resident #1, she instructed CNA A to discontinue care of residents. Thereafter, she stated she reported what she had witnessed to the DON and Former Administrator. She stated at the time of the incident Resident #1 did not have a roommate. She stated she and CAN A were the only two present in the room with Resident #1 at the time of the incident. She stated she was unaware if others may have heard or seen the incident. She stated she provided the DON with a written statement to include the details for the incident. Nurse K denied witnessing other incident of abuse by CNA A and staff working at the facility. She stated CNA A was suspended by the DON after the DON and Former Administrator was made aware of the incident. She stated she had not seen the CNA A since the incident and believed CNA A was no longer employee at the facility. She stated she did not recall if other resident was assessed for possible abuse following the incident. She stated she did not recall if staff were interviewed by the DON and Former Administrator regarding the incident. Nurse K stated she as well all staff was in - serviced on abuse/neglect and resident's rights following the incident.Attempted a telephone interview on 07/09/2025 at 1:05pm, with CNA A. There was no answer; left a voicemail.During an interview on 07/09/2025 at 4:30pm with the DON, she explained her role as part of a comprehensive abuse investigation was not only in managing the direct response to the incident, but also in evaluating staff witnesses and ensuring the safety and monitoring of other residents who may have been affected or exposed. She stated she was responsible for identifying all staff members who were on duty during the incident. She stated she would investigate if staff witnessed the incident or were possibly aware of prior abuse concerns. When asked if she recalled the incident involving CNA A and Resident #1, she stated she recalled the incident. When asked if staff interviews and resident safety care round were completed during the investigation, she stated both tasks were completed as part of her investigation related to the incident. She stated she interviewed CNA A and Nurse K during the investigation. She stated Nurse K, the charge nurse of Resident # 1, on 04/14/2025 night shift, reported allegations of CNA A being seen by Nurse K holding the back of Resident #1 neck and with force pushing her head into the mattress trying to get her up from wheelchair and into bed. She stated CNA A denied allegations. She stated CNA A was suspended and terminated as a precaution measure to prevent future abuse. She stated the allegation were unfound because it was Nurse K word against CNA A word. She stated no other employees were interviewed during the investigation. When asked about resident interviews, she stated Resident #1 was not interviewed because the Resident #1 was not interviewable due to cognitive impairment. She was not aware if Resident #1 had a roommate. She stated the SW completed safety care rounds and met with other residents on the unit individually. When asked about record and documentation of the referenced encounters, she stated she had to follow up with the SW related to the documentation. During an interview on 07/09/2025 at 5:08pm, the SW stated he's worked in his role as the SW at the facility for two plus years. The SW explained his role as part of a comprehensive abuse investigation was to assess the safety and psychosocial well-being of the resident identified in the investigation and other residents. He stated when an abuse allegation was made, involving a staff member, it was critical to determine whether the abuse was isolated or systemic. He stated other residents may have been affected or at similar risk. He stated when notified of an abuse incident it was his responsibility to identify at-risk residents. He stated he would start by reviewing other residents under the care of the alleged abuser (same hall/unit). Thereafter, he would conduct safety care rounds by meeting with each identified resident privately to assess. He explained in the individual meetings, he would assess for the resident safety, signs of fear or distress, or unreported incidents. When asked if he recalled the incident involving CNA A and Resident #1, he stated he recalled the incident. He initially stated he completed safety care rounds related the incident. When asked where the information was documented, he stated that safety care round documentation was submitted to the Former Administrator. When asked if his encounter with the resident was documented in the clinical record, he stated all encounters was documented in social worker's progress notes which was part of the resident's clinical record. Later during the interview, he stated he did not remember the incident with Resident #1. The SW stated he would research the incident and notify the surveyor about his findings. During an interview on 07/09/2025 at 5:33pm, with the Administrator, she stated she started working in her current position in June 2025. She stated she was not aware of Resident #1's incident. She said any allegations of abuse should be immediately reported to the HHSC and then investigated.During an interview with the DON on 07/10/2025 at 10:19am, the DON stated she completed staff interviews on 07/09/2025, the evening after meeting with state surveyor. She stated staff denied witnessing the incident involving CNA A and Resident #1 on 04/2025. The DON stated the staff statements did not involve the specific date. She stated she followed up with SW related to safety round documentation and he revealed he did not have documentation as he did not interview residents following the incident involving CNA A and Resident #1. She stated she was responsible to working with the SW and Administrator in ensuring the clinical safety and wellbeing of all residents, especially those who may received care from the accused employee. She stated it was her responsibly along aside the Administrator to identify, interview, document, and report findings of a comprehensive abuse investigation. She stated failing to do so, placed resident at risk for potential harm.During an interview on 07/10/2025 at 11:09 am, the Administrator stated she is the facility's abuse coordinator. She stated as the abuse coordinator she must report to HHSC immediately, and then start the investigation. The Administrator stated that if a staff member were identified in the incident, she would suspend the staff member while continuing the investigation. The Administrator stated she would also notify Resident #1's physician and the responsible party. The Administrator stated the staff would conduct resident quality of life and safety rounds and staff in-service on abuse/neglect and residents' rights. The Administrator stated investigation actions, findings, and documentation should be maintained and submitted to HHSC within 5 days. The Administrator stated she was unaware of the incident or allegation of abuse regarding CNA A and Resident #1 because she was not working in facility during the period of the incident. The Administrator stated she met with the SW after learning of the incident on 07/09/2025 and was informed by the SW that the resident safety care rounds were not completed as part of the comprehensive abuse investigation. She stated it was the SW role to complete resident safety care rounds as part of an abuse investigation. She stated she did not understand or know why other residents were not assessed. She stated failure to complete a thorough abuse investigation by interviewing staff who may have witnessed the incident, and resident who may have been affected, placed residents at risk for possibly abuse.During an interview on 07/10/2025 at 11:28am, with the SW, he stated that he did not complete safety care rounds in relation to the incident. The SW failed to explain why the task was not completed. When asked how residents could be affected by the failure to complete a comprehensive abuse investigation, including safety care rounds, he stated the failure could have a psychosocial impact on the resident as well as place the resident at risk for harm.Attempted a telephone interview with the former Administrator on 07/10/2025 at 12:58pm. There was no answer; left a voicemail.During an interview on 07/09/2025 at between 10:00 am and 12:00pm, with staff (CNA C, CAN T, CAN S, CAN K, LVN M, LVN I, LVN J, and RN A), revealed they had been trained in abuse and neglect, and repositioning techniques. The staff stated the last in - services occurred within the past 90 days but was unaware of the specific date of in - service. Staff denied witnessing abuse and/or neglect at the facility. All staff identified the Administrator as the abuse coordinator. Staff stated they felt that there was enough staff support with resident's needs. They stated that sometimes they was short, but staff worked together to meet the needs of the resident. Record review of CNA A file revealed she was terminated from the facility on 04/15/2025 for abuse allegations. The facility's Employee Misconduct Registry and Nurse Aide Registry background check dated 04/01/2025 revealed no findings for CNA A prior to hire.Record review of PIR revealed staff was in -serviced on abuse and neglect and repositioning resident on 04/15/2025 following the incident. Record review of the facility's Abuse, Neglect and Exploitation Policy published 09/2022 revealed, Abuse of any kind against residents is strictly prohibited. The policy did not incident specific details on how to investigate and report abuse.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 1 of 7 residents (Resident # 1) reviewed for pharmacy services. The facility failed to ensure that Resident # 1 received her prescribed medication, Midodrine, according to physician's orders on 2/9/2025. Resident #1 was administered 10 tablets of Midodrine (medicationused to treat low blood pressure) instead of the ordered one tablet. Resident # 1's blood pressure was 189/96 before being transported to the hospital for an overdose of Midodrine An Immediate Jeopardy (IJ) was identified on 2/13/2025. While the IJ was removed on 2/14/2025, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place all residents at risk of drug diversion, health decline, and/or death. Findings include: Record review of Resident # 1's face sheet date 2/11/2025, revealed she was admitted to the facility on [DATE]. Resident # 1's diagnoses included: dementia ( condition characterized by progressive or persistent loss of intellectual functioning, diabetes ( chronic condition that affects the way the body processes blood sugar), hypotension ( a condition where the blood pressure is lower than normal), psychosis (a mental health condition characterized by a loss of contact with reality), lack of coordination (a condition that affects the ability to control and execute movements smoothly and accurately) and hypertensive heart disease with heart failure (a condition where high blood pressure (hypertension) over time damages the heart muscle, leading to an inability of the heart to pump blood effectively) Record review of Resident # 1's Quarterly MDS dated [DATE] revealed she was capable of making herself understood; she had a BIMS score of 6 (severely impaired cognition), she did not exhibit behaviors related to rejection of care; she did exhibit wandering behaviors (1 to 3 days); she required supervisions for bed mobility, transfer, eating, and toilet use; she required set-up with bed mobility, transfer and toilet use; she did not require setup or physical help from staff with eating; she was not incontinent of bowel and bladder. Record review of Resident # 1's care plan, revised on 10/3/2024 revealed the following care: * Resident # 1 has impaired cognition and is at risk for further decline and injury AEB. Goal: Resident # 1 needs will be met, and dignity maintained over the next 90 days. Interventions: All time for task and responses; explain all procedures using terms/gestures the resident can understand; and involve in care to maintain or increase level of independence. * Resident # 1 was at risk for Stroke. Goal: Resident # 1 will remain free of Stroke like symptoms. Interventions: if symptomatic, perform Cincinnati Prehospital Stroke evaluation. * Resident # 1 has an adverse reaction to medication. Goal: Resident will be monitored for symptoms related to the adverse reaction due to polypharmacy. Interventions: add medication to tolerance list until allergy can be confirmed; administer allergy medication per facility protocol or standing order; evaluate breathing; and evaluate circulation. Record review of Resident #1's physician's orders for February 2025 revealed the following active medication orders: * Aldactone Oral Tablet 25 MG (Spironolactone). Give 1 tablet by mouth one time a day related to Edema. Active: 11/2/2024 * Furosemide Oral Tablet 40 MG. Give 1 tablet by mouth one time a day for Edema. Active: 10/1/2024 * Melatonin Oral Tablet 3 MG. Give 1 tablet by mouth at bedtime related to Insomnia. Active 10/1/2024 * Midodrine HCL Oral Tablet 10 MG. Give 10 mg by mouth three times a day for hypotension hold if systolic blood pressure is over 120. Active date: 2/10/2025 * Polyethylene Glycol 3350 Powder. Give 1 scoop by mouth one time a day related to Constipation. Active 10/2/2024 * Trazadone HCL Tablet 50 MG. Give 1 tablet by mouth at bedtime related to Generalized, Anxiety Disorder. Active 10/2/2024 Record review of Resident #1's physician's orders for February 2025 revealed the following discontinued medication orders: * Midodrine HCL Oral Tablet 10 MG. Give 10 tablet by mouth three times a day for hypotension hold if systolic blood pressure is over 120. Start date 1/2/2025 and Discontinued date 2/9/2025. * Black box warning for Midodrine - Appropriate use Because midodrine can cause marked elevation of supine blood pressure, it should be used in patients whose lives are considerably impaired despite standard clinical care. The indication for use of midodrine in the treatment of symptomatic orthostatic hypotension is based primarily on a change in a surrogate marker of effectiveness, an increase in systolic blood pressure measured 1 minute after standing, a surrogate marker considered likely to correspond to a clinical benefit. * Dose Warning: This order is outside of the recommended dose or frequency Midodrine HCl Oral Tablet 10 MG. Give 10 tablet by mouth three times a day for hypotension hold if SBP greater than 120. The dosing regimen of 10 tablets 3 times per day exceeds the usual dosing regimen of 0.25 tablet daily to 1.75 tablets 3 times per day. The single dose of 10 tablets exceeds the maximum single dose of 1.75 tablets. The usual dosing regimen is 0.25 tablet daily to 1.75 tablets 3 times per day. Record review of order details revealed, dated 1/2/2025, revealed Midodrine HCL Oral Tablet. Give 10 tablet by mouth three times a day for hypotension; hold if systolic blood pressure is above 120. Record review of nurses note, dated 2/9/2025, revealed MA A administered 100 mg of Midodrine instead of 10 mg to Resident # 1 and prior to MA A administering this medication Resident # 1 blood pressure was 110/53 at 9:25 pm. Resident # 1 blood pressure was 189/96 at 10:10 pm. Record review of medication administration record revealed on 2/9/2025 at 9:00 pm there was no documentation for the administering of Midodrine. Record review of medical records from a local hospital revealed Resident # 1 was admitted on [DATE] with a diagnosis of drug overdose, accidental or unintentional with blood pressure 191/99. The admitting physician documented unsure why Resident # 1 was on Midodrine given documented history of hypertension, reportedly patient received 100 mg of Midodrine instead of usual 10 mg. In an interview on 2/11/2025 at 10:30 am, Medical Director stated he were not the attending physician for Resident # 1. He stated that he was aware Resident # 1 was administered medication in error by a MA. He stated that Resident # 1 was administered Midodrine in error. He stated that a resident was given to much Midodrine and the adverse consequences could result in altered mental status, respiratory distress, neurological changes, nausea, and vomiting. He stated that he expected the Nurses and MA's to administer medication as ordered, review medication, and give medication correctly. In a telephone interview on 2/11/2025 at 10:45 am, EMS staff stated that Resident # 1 was administered an overdose of Midodrine. She stated that when EMS arrived at the nursing facility Resident # 1's blood pressure was 189/96. She stated she was told that Resident # 1 was given 100 mg of Midodrine instead of the 10 mg. She stated that she spoke with MA A who stated she gave Resident # 1 10 tablets of Midodrine. She stated that MA A told her this medication was given to Resident # 1 at 9:25 pm. She stated that the nursing facility did not contact EMS until 10:10 pm. She stated that Resident # 1 was transported to a local hospital. She stated that when Resident # 1 arrived at the local hospital Resident # 1's blood pressure was 191/99. In an interview on 2/11/2025 at 3:02 p.m., Nurse E stated that on 2/9/2025 MA A showed her the orders for Resident # 1 and the written order revealed to administer 10 tablets. Nurse E stated that MA A told her that she had given Resident # 1 10 Midodrine tablets. She stated that she immediately informed Nurse B as she was the supervisor. She stated if a resident was administered too much Midodrine the adverse consequences can be stroke, myocardial infarction and the blood pressure will go up. In an interview on 2/11/2025 at 3:09 pm Nurse B she stated that on 2/9/2025 at approximately 9:00 p.m. MA A informed her that she gave Resident # 1 medication incorrectly. She stated that MA A administered 10 Midodrine tablets to Resident # 1. She stated that she reviewed Resident # 1's orders in the PCC and the written orders reflected: 10 Midodrine (10 mg) tablets 3 times a day; hold if systolic blood pressure is over 120. She stated that she checked Resident # 1's blood pressure and it was 125/could not remember the diastolic number. She stated that 911 was contacted immediately. She stated that when EMS arrived Resident # 1's blood pressure was 189/she stated she could not remember the diastolic number. She stated that the order on the blister pack was Midodrine 10 mg- give 1 tablet three times a day hold if systolic blood pressure is higher than 120. She stated if a resident was administered too much Midodrine the adverse consequences can be increased blood pressure and this could result in a stroke. In an interview on 2/11/2025 at 3:40 p.m. Nurse A stated that MA A asked her to look at the medication. She stated that MA A told her that she gave Resident # 1 10 Midodrine tablets. She stated at the time of this incident Resident # 1's blood pressure was 125/could not remember diastolic number. She stated that EMS arrived 20 minutes later and Resident # 1's blood pressure was 189/96 and Resident # 1 was transported to the local hospital. She stated if a resident is administered to much Midodrine the adverse consequences are hypertension, feeling dizzy, headache and heart failure. In an interview on 2/11/2025 at 3:59 p.m., ADON A she stated that she was the nurse who took the orders and entered the orders in the system. She stated that the NP ordered Midodrine 10 mg three times a day to be given if they systolic is below 120. She stated that she did not realize that she entered 10 tablets instead of 10 mg. She stated if a resident is administered to much Midodrine the adverse consequences are high blood pressure could result in a stroke. In an interview on 2/11/2025 at 4:19 pm, Pharmacy Consultant, stated that she did not recall reviewing Resident # 1's medication regiment. She stated that she reviews the medication regiment and she makes sure they have the correct diagnosis and dosages. She stated that she reviews PCC and the blister packs. She stated that she reviews the medication remotely and she must have seen 10 mg instead of 10 tablets. She stated if a resident is administered to much Midodrine the adverse consequences are hypertension, headaches, and dizziness. In an interview on 2/11/2025 at 4:35 p.m. MA A she stated that Resident # 1 orders read administer 10 tablets of Midodrine. She stated that she administered 10 tablets of Midodrine to Resident #1. She stated that she took Resident # 1's blood pressure and it was 110/50 something. She stated that she looked at the MAR and per the MAR she was to hold the Midodrine as Resident # 1's blood pressure was not over 120. She stated that she was told to follow the directives as listed on the MAR and she popped 10 tablets from the blister pack and she administered 10 tablets to Resident # 1. She stated that she thought orders on the MAR was wrong, but she had administered the medication to Resident # 1. She stated if a resident is administered to much Midodrine the adverse consequences are high blood pressure, stroke or heart attack. In an interview /observation on 2/11/2025 at 5:15 p.m. Resident # 1 stated that she was well. Resident # 1 was fixing the linen on her bed. Resident # 1 did not have any knowledge regarding her medication. She stated that she did not have any concerns. In an interview on 2/12/2025 at 11:05 a.m., NP revealed her to deny making a verbal order for 10 tablets of Midodrine three times a day. She stated that she ordered 10 mg of Midodrine three times a day hold if the systolic blood pressure is over 120. She stated that giving Resident # 1 10 Midodrine tablets could have caused Resident # 1 to have high blood pressure and a stroke. She stated that she was told that Resident #1 was given 10 Midodrine tablets. She stated that she ordered for Resident # 1 to be sent to the hospital immediately. In an interview on 2/12/2025 at 12:48 p.m., MA B stated that she was trained to follow the MAR. She stated that if the MAR and blister are not matching, she would tell the nurse. She stated that Midodrine was given to residents who have hypotension. She stated that before Midodrine was administered the MA or nurse must follow the parameters. She stated before administering Midodrine the resident's blood pressure must be checked, and the blood pressure must be within the parameter on the resident's order. She stated that she has administered Midodrine to Resident # 1 and she stated she did not notice the order on the MAR said 10 tablets. She stated that was an error. She stated that as a MA she knows that it is not normal to give a resident 10 tablets out the same blister pack. She stated that normally residents will receive one or two pills out the same blister pack. In an interview on 2/12/2025 at 1:04 p.m., Nurse C stated Midodrine was used to elevate the blood pressure. She stated that residents normally get 1 tablet and 5-10 mg. She stated that if a resident is administered to much Midodrine the resident's blood pressure is rise quickly and this can lead to a stroke. She stated that vital signs will change immediately. She stated if this order was put into the MAR incorrectly the nurse will receive an error message. She stated the management team was responsible for monitoring the orders and making certain the MAR and the blister pack matches. In an interview on 2/12/2025 at 1:18 pm, Nurse D stated she has worked with Resident # 1. She stated that Resident # 1 took Midodrine for hypotension. She stated that Resident # 1 took 10 mg of Midodrine one tablet, three times a day. She stated that the parameters were hold if the systolic blood pressure is more than 120. She stated that the protocol for administering medication is ensure it was the right person, right medication, and right dosage. She stated that if a resident is given to much Midodrine the resident's blood pressure will be high and this can lead to a stroke and/or heart attack. In an interview on 2/12/2025 at 1:42 p.m., Nurse J once she received a verbal order from the NP or physician she must verify the order by repeating the order to the doctor. She stated that when she put the order in PCC she must verify and make certain the order was correct. She stated that Midodrine is used for residents that have low blood pressure and it has parameters. She stated that the normal dosage for is 5 to 10 mg it depends on the order. She stated that the blood pressure must be checked prior to administering the Midodrine. She stated that the adverse consequences are headaches, nose bleeds, dizziness, and a stroke. In an interview on 2/12/2025 at 1:57 p.m., the DON, revealed that she was made aware of the Midodrine situation on 2/10/2025. She stated that the nurse called and texted her on 2/9/2025, however, she did not hear her phone ring as it was late. She stated that the normal range for Midodrine is 5mg-20 mg to be given if the systolic is with 110-120 parameters. She stated that she was told that Resident # 1 was administered 10 tablets of Midodrine. She stated that this could have cause Resident # 1's blood pressure to elevate and possibly a stroke. The DON stated that she should get a report of the irregularities identified on the MRR. She stated that the if the medication is different between the MAR and the blister pack staff should clarify before giving the medication to the resident. She stated that the MA's should inform the nurse if there any medication discrepancies. The nurse should clarify any medication discrepancies with the resident's physician and/or nurse practitioner. In an interview on 2/12/2025 at 2:18 p.m., the Administrator, stated that he was notified on 2/9/2025 that Resident # 1 was sent out to the hospital. He stated that on 2/10/2025 he was made aware that it was a medication error and Resident # 1 was given more medication than the card stated. He stated Resident #1 was sent out to the hospital immediately. He stated that the medication was not self-reported because at the time there was no indication of an allegation of abuse and no indication of neglect and there were no adverse situation that occurred. The Administrator stated that the following was taken: every resident was audited on Midodrine for accuracy, education transcript for nurses, the rights of administration for the nurses and MA's, MA A and ADON A received one on one education and disciplinary action, an ADHOC QAPI meeting, and abuse and neglect in service. The Administrator stated that he expected that if there was a medication error, staff assess patient, document, notify the physician or NP, notify the resident's family, and notify the DON. In a follow up interview with ADON A on 2/12/2025 at 3:24 p.m. she stated that on 2/10/2025 she was in serviced on the 10 rights of Drug Administration which include right time, right frequency, right dosage and right medication. She stated she was also in serviced on transcribing to include repeating the orders back to the NP and/or physician and double-checking orders when putting the orders in PCC. She stated she also had skills check training which consisted of passing medication to include checking the MAR and blister pack and making certain she gave the right medication to the right patient. In a follow up interview with MA A on 2/12/2024 at 3:33 p.m. MA A stated that on 2/10/2025 she was in serviced on the 10 Rights of Drug Administration to include right time, right resident, right drug, right dosage and resident history. MA A stated that she was in serviced on Midodrine and she stated Midodrine is a medication that raised blood pressure and has parameters. In an interview on 2/12/2025 at 3:42 p.m., MA C stated that she has administered Midodrine to Resident # 1. She stated Midodrine was given to residents who have hypotension. She stated if a resident is administered to much Midodrine the adverse consequences for the resident is shock and high blood pressure. She stated that Resident # 1 has orders for Midodrine 10 mg (1 tablet) three times a day and the parameters are to hold the medication if Resident # 1's systolic blood pressure is higher than 120. She stated that when giving a resident medication she reviews the MAR and blister pack. MA C stated she did not notice Resident # 1's orders on the MAR read 10 tablets. MA C stated that on 2/10/2025 she was in serviced on the 10 Rights of Drug Administration to include right drug, right patient, right dosage, evaluation, and right to refuse. She stated that on 2/10/2025 she was in serviced on the medication Midodrine. An Immediate Jeopardy (IJ) was identified on 2/13/2025 at 12:35 pm, due to the above failures. The Administrator and DON were notified. The Administrator and DON was provided the IJ template at 12:37 pm. The following Plan of Removal was submitted by the facility and was accepted on 2/13/2025 at 6:37 pm: Plan of Removal F755 Resident was administered 100mg of Midodrine instead of the verbally ordered amount of 10mg. Resident assessed by LVN and sent to ER for evaluation. (returned 2/11/2025) Family called MD/NP notified. Audit all Midodrine orders by DON 2/10/2025 Resident #1 medication clarified/fixed 2/10/2025 (ultimately discontinued upon hospital return) Notify Medical Director 2/10/2025 11:03am brief QAPI discussion to establish plan (this) New orders will be reviewed by DON/designee daily to ensure accurately transcribed and that the computerized order matches the medication card. Results of these audits will be discussed in morning meeting and any discrepancies will be rectified immediately. LVN disciplinary action and 1:1 education 2/10/2025 related to transcription and medication administration to ensure the computerized order matches the medication card. MA disciplinary action and 1:1 education 2/10/2025 related to medication administration to ensure the computerized order matches the medication card. MA removed from MA role as of 2/10/2025 until further education and training occurs and she successfully completes 3 competency checks by DON. Facility MAs and nurses re-educated on medication administration started 2/10/2025 by the DON. Education was completed on 2/11/2025 and staff not allowed to work without training completion. The education consisted of right person, right time, right dosage, right route, right drug. Also included matching computerized order to medication card. Nurses and MAs were provided education and post-test for Midodrine administration specifically by the DON on 2/10/2025 and no one can return to work unless education has been completed. Nurses re-educated on transcription of orders/meds started 2/10/2025 by the DON. Education was completed on 2/11/2025 and staff not allowed to work without training completion. This education consisted of rights as well as repeating back to prescriber for accuracy. Notified Pharmacy Consultant by DON 2/11/2025 and will review all active residents' entire medication regimen monthly and provide verbal and written reports for verification. Next visit scheduled for week of 2/17/2025. Abuse, Neglect & Exploitation re-education started 2/11/2025 by the DON for all active staff members to include types, coordinator, and notification. This was completed on 2/11/2025 and staff may not return to work until the education is completed. Full Ad hoc QAPI 2/11/2025 with Medical Director present DON audit all new orders from 2/1-2/11/2025 on 2/11/2025 with no inaccuracies found. DON/designee to complete 100% audit of all medications for all current residents completed 2/13/2025 with no discrepancies identified. Policies Reviewed with no changes required: Abuse, Neglect and Exploitation, Medication Administration, Medication Orders, Medication Regimen Review. Monitoring for implementation of the POR was conducted on 2/14/2025: In a telephone interview on 2/14/2025 at 10:30 am MA D stated that she was in serviced on 2/10/2025. She stated that she was in serviced on 10 Rights of Drug Administration to include right drug, right patient, and right dosage. She stated that was in serviced on passing medication to include making certain the MAR and the blister packs match. She stated if the MAR and the blister pack does not match, she must report it to the nurse. She stated that she was in serviced on Midodrine to include what the medication is for and the parameters. In an interview on 2/14/2025 at 2:42 pm Nurse F stated she received an in -service on 2/10/2025 regarding 10 Rights of Drug Administration, Midodrine, Medication Administration and Medication Transcribe. She stated that 10 rights of drug administration include right medication, right patient, right time, right dosage, and right documentation. She stated that when taking orders from NP or physician she must repeat the order back to the NP/physician. She stated that if there any discrepancies with the residents orders she must contact the NP or physician. In an interview on 2/14/2025 at 3:15 pm with Nurse G he stated he was in serviced on 2/10/2025. He stated he was in serviced on Medication transcription, 10 rights of drug administration, medication administration and Midodrine. He stated that Midodrine is a medication used mainly with residents who have hypotension, and this medication is used to raise blood pressure. He stated that the normal dosage 1 tablet and 5-10 mg. He stated that this medication is administered based on the parameters. He stated the rights of drug administration include right medication, right patient, right medication, right dosage, right [NAME], right time, right documentation, history, assessment and evaluation. In an interview on 2/14/2025 at 3:27 pm with ADON B she stated she in serviced the Nurses and MA's on 2/10/2025. She stated that the in-services were 10 Rights of Drug Administration and Midodrine. She stated that staff were in serviced to follow upon each medication. If there is a discrepancy between the blister pack and the MAR staff should notify the nurse manager immediately prior to administering the medication. She stated that she in serviced the Nurses and CMAs on the medication Midodrine. Staff was in-serviced that Midodrine is used to treat low pressure and each Midodrine should have parameters. She stated she was in serviced on medication transcription and administration. In a telephone interview on 2/14/2025 at 3:45 p.m., Nurse A she stated she was in serviced on 2/12/2025. She stated that she was in serviced on the medication Midodrine, 10 Rights of Drug Administrations, and Medication Administration. She stated that the in services covered transcribing to include repeating the orders back to the NP or physician. She stated that if there is a medication the on-call physician should be contacted immediately. She stated that she was in services on the 10 rights of medication to include right patient, right medication, right dose, right route, right documentation, and right time. In an interview on 2/14/2025 at 3:50 pm, Nurse H stated in serviced on 2/10/2025. She stated that she was in serviced on 10 Rights of Drug Administration, Midodrine, Medication Administration and Transcribe. Nurse H stated that the resident has the right to dignity, the right to refuse, the right to grievances. She stated that Midodrine is used to treat hypotension and when a resident is taking Midodrine there are parameters specific to that resident as ordered by the NP or physician. Nurse H stated that the adverse consequences of the medication Midodrine are high blood pressure, dizziness which could lead to elevated blood pressure and stroke. She stated that the 10 rights of medication-right patient, right medication, right dose, right route, right time and right documentation. She stated that when taking orders from the NP or physician the order must be read back to the NP or physician for accuracy. In an interview on 2/14/2025 at 4:10 pm, Nurse I stated she was in serviced on 2/10/2025. She stated that she was in serviced on Midodrine. She stated that Midodrine is used for low blood pressure. She stated that if a resident is given to much resident the adverse consequences could be heart failure. She stated that she in serviced on medication transcribing to include check order and make certain it the orders has the correct date, time, route and repeat the orders back to the physician. She stated she was in serviced on the 10 Right of Drug Administration to include right medication, right patient, right route, right time, and right to refuse. She stated that if a medication is given error the supervisor and NP need to be contacted immediately. In an interview on 2/14/2025 at 4:30 p.m., Nurse B stated she was in serviced on 2/10/2025. She stated that she was in serviced on Midodrine. She stated the order on the MAR must match the blister pack. She stated that Midodrine has parameters, and this must be notated on the MAR and the blister pack. She stated that when verbally receiving orders from the NP or physician she must repeat the order back for accuracy. She stated that was in serviced on Midodrine. She stated that Midodrine is given to residents who have low blood pressure. She stated that this medication must be administered according to the NP or physician's order. She stated that was in serviced on the 10 Rights of Drug Administration. Nurse B stated both in services were completed on 2/14/2025. In an interview on 2/14/2025 at 4:45 p.m., Resident # 1 stated she was well and she did not have any concerns. She stated did not know anything about her medication. She stated that staff administers the medication, and she could not remember anything else pertaining to her medication. Record review of the facility's Pharmscript policy dated (8/2020) revealed read in part .The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify communicate, address and resolve concerns and issues related to the provision of pharmaceutical services. This includes, but not limited to:5 d) Assisting in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors and the provisions of and monitoring of the use of medication-related devices, 6a) reviewing the medication regiment of each resident at least monthly or [NAME] frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review, and documenting the review findings in the resident's medical record or in a steadily retrievable format if utilizing electronic documentation, 6g) reviewing medication administration records (MARs), treatment administration records (TARs) and physician orders to ensure proper documentation of medications orders and administration of medications to residents. Record review of the facility's Medication Regimen Review Verification (MRR) dated January 2025 revealed on 1/9/2025 the pharmacist consultant reviewed Resident # 1 MRR and documented Medication Regimen Review has been performed and any inappropriate findings were communicated to the Physician and Director of Nursing through the utilization of the Pharmaceutical Consultant Report. The current prescription therapy is considered appropriate at this time and any indicators concerning the Interpretive Guidelines will be addressed when clinical conditions warrant such attention. Record review of the facility's Nursing Policies and Procedures dated (revised 6/2019) revealed read in part The facility's nursing and pharmacy services will assess, monitor and evaluate the effectiveness of the therapeutic medication regimen including all drugs ( prescription and non-prescription) in order to enhance the resident's quality of life; 3) the authorized licensed or certified/permitted medication aide or by state regulatory or guidelines staff members follow the MAR prepared for the patient/resident/by identifying: a)right resident, b)right drug, c)right dose, d)right time, e) right route, f)right charting, g)right results and h) right reason, 4) The authorized licensed or certified /permitted medication aide or by state regulatory guidelines staff member identifies, that the following information, but not limited to, id documented on the MAR: a)correct physician's order, b)medication and label are correct, and c) label and physician's order are correct; 5) The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member reads the label on the medication three (3) times: a)before removing the medication from the drawer, b) before pouring the medication and c)after pouring the medication;6) The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member seeks assistance from the nursing supervisor/designee and consulting pharmacist when any aspect of medication administration is in question. Record review confirmed the medication carts were audited as noted on the POR. Record review confirmed all Midodrine orders were audited as noted on the POR. Record review an [TRUNCATED]

Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 (Resident #29) residents reviewed for pain management. C.NA A failed to stop performing incontinent care while Resident #29 was in pain. C.NA A failed to notify the LVN B of Resident #29's pain in a timely manner after incontinent care in AM. This failure could place resident at risk for increased pain causing undo suffering. Findings included: Record review of Resident #29's face sheet, dated 12/05/2024, reflected the resident was [AGE] years old, female, and admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, , pain, and unspecified osteoarthritis, unspecified site ( a degenerative joint disease, in which the tissues in the joint break down over time),. Record review of Resident #29's admission MDS, dated [DATE], reflected the resident's BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was dependent to chair/bed-to-chair transfer and substantial/maximal assistance (helper does more than half the effort) to personal hygiene. Further record review of the MDS indicated Resident # 29 was frequent incontinent to bladder and bowel. Record review of Resident #29's care plan dated 10/23/24 reflected Resident #29 has an ADL self-care performance deficit, the goal was resident will improve current level of function in through the review date: Resident #29 requires total assist X1 for bathing/showering, dressing, bed mobility, eating, personal hygiene/oral. Toilet use, transfer and follow principles of infection control and universal precaution to incontinent care. Record review of physician's order dated 9/19/24 revealed Acetaminophen tablet 325 mg =Give 2tablets by mouth Q4 hours as needed for pain-Give 2 of 325mg tablets=650 mg Record review Resident #29's MAR documented Pain assessment dated [DATE] reflected Resident #29 used numerical scale. Administer medications as ordered if any pain verbalized/observed. No document of pain was administered. Record review of facility Pain assessment for months of November and December 2024 reflected Resident #29 did not have any documentation of have any pain. Record review of Nurses note dated 12/3/2024 at 5:00PM reflected Note Text: Received Doppler results indicating positive for deep venous thrombosis in the right popliteal and mid femoral, and left middle femoral veins. NP made aware. No new orders received at the moment. NP will be in the building to see the resident. RP made aware. Will continue with plan of care. Record review of physician's orders dated 12/5/24 revealed Tramadol HCl Tablet 50 MG, Give 0.5 tablet by mouth two times a day for moderate to severe pain Give 0.5 of 50 mg tablet = 25 mg Observation on 12/03/2024 at 8:33 AM CNA-A providing incontinent care to Resident #29. Resident #29 had left foot contracted to the knee, , left knee pressing resting on the right thigh. C.NA A undid the soiled brief, while repositioning Resident #29 to her right side to clean her, resident was grimacing, moaning and saying No, No in pain, CNA A did not stop performing incontinent care, she continued to clean while Resident #29 was in pain. C.NA A repositioned to her left side, Resident #29 was grimacing, moaning and said No, No in pain. While C.NA A was fastening Resident #29's clean brief resident was grimacing and moaning in pain. Interview on 12/03/2024 at 1:45 PM C.NA A said she just started working with facility in October 2024, she stated Resident #29 was in a lot of pain. Interview with LVN B on 12/03/24 at 4:45 PM LVN B said she was not aware of Resident #29 being in pain during incontinence care and she was going to assessed resident and notified the NP. LVN B did call NP and obtain doppler order. In an interview with the DON on 12/05/24 at 12:52 PM she stated CNA A should have stopped incontinent when resident was in pain. The DON stated nurses were instructed to monitor for pain every shift. She stated the negative effects for not monitoring residents' pain would be the pain would be unmanaged. Interview with PT on 12/5/24 at 1:37 PM she said Resident #29 started having pain to her left knee over the weekend and doppler was done and she had DVT and he was applying the knee brace to her left knee to prevent contracture. Record review of facility policy titled Clinical Care-Pain undated reflected that . Procedure: Recognition: Identify Pain and Pain Risk, Predisposing Conditions: 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes a review of known diagnoses or conditions that commonly cause or predispose resident/patients to pain, for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes. It also includes a review of any current treatments for pain, including all complementary ( non-pharmacologic) treatments. Such assessments should occur on admission to the facility, periodically thereafter and, whenever there is a significant change in condition and at any time pain is suspected.

Based on observation, record review, and interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering acuity of the facility residents for one of four nurses ( LVN #A) reviewed for competency, in that : LVN A failed to identify Resident #1's change in condition. LVN A failed to consult with an RN for proper assessment of Resident #1 when he experienced a significant change in condition. LVN A failed to communicate all of Resident #1's symptoms to the NP when he experienced a significant change in condition. LVN A failed to call 911 for prompt medical transportation/ intervention for Resident #1 instead requested EMS ambulance which took longer time to transfer the resident to the ER. Resident #1 was diagnosed with [REDACTED]. Resident #1 died at the hospital. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures could affected all residents who experienced a change in condition. Findings include: Resident #1 Record review of Resident #1's face-sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He was diagnosed with [REDACTED]. He was discharged from the facility on [DATE] when he was transferred to a local hospital where he passed away. Record review of Resident #1's Minimum Data Set (MDS), dated [DATE] revealed he had a BIMS score of 10 indicating moderate cognitive impairment, he required extensive one-staff assistance with bed mobility, dressing, toilet use, and personal hygiene, extensive two-staff assistance with transferring, set-up assistance and supervision with eating and locomotion via wheelchair, he was always incontinent of bladder and frequently incontinent of bowel, he received scheduled and was at least offered PRN pain medication within the previous five days of the assessment, felt pain frequently, and he did not have any wounds at the time of the assessment. Record review of Resident #1's care plan, updated [DATE] revealed he had impaired circulation due to [MEDICAL CONDITION] (Interventions included: Inspect foot/ankle/calf skin for changes: maceration, redness, purple tinge, blue, rust coloring, weeping, [MEDICAL CONDITION], puffiness, tenderness, areas with no sensation), he was on pain medication (Tylenol with [MEDICATION NAME] #3) due to poor circulation/disease process (Interventions included: Administer medications as ordered, For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications, Monitor for altered mental status, anxiety, lack of appetite, nausea, vomiting, pruritis, respiratory distress .Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness, monitor for and document any [MEDICAL CONDITION], notify doctor and he had scattered bruising to his left leg and discoloration to his toes (Interventions included: Monitor/document location, size and treatment of [REDACTED]. to doctor). Record review of Resident #1's weights and vitals summary from [DATE] through February 16, 2020 revealed the following vital signs: -,[DATE].2020: Pulse 71 bpm (Regular), Respiration 20 breaths/minute. - [DATE]: Pulse 75 bpm (Unable to Determine), Respiration 20 breaths/minute. - [DATE]: Pulse 120 bpm (Irregular - new onset), Respiration 26 breaths/minute, Temperature (1:06 a.m.) 100.7 degrees Fahrenheit (2:22 a.m.) 100.1 degrees Fahrenheit. Further review of the records revealed no other documentation of vital signs for Resident #1 on [DATE] or [DATE]. Observation and interview with Resident #1 on [DATE] at 10:50 a.m. revealed he was alert and oriented and was sitting in a wheelchair in his room. His right leg was amputated above the knee. He did not mention the blister on his left leg or complain of pain at that time. Record review of Resident #1's Progress Notes for [DATE] and February 2020 revealed the following entries: [DATE] - LVN A wrote: Resident was observed with a reddened area/blister on his left calf and that is none tender or painful, Nurse Practitioner (NP) was informed . [DATE] - Wound Care RN wrote: Weekly skin notes: Open blister to left calf noted with moderate amount or serous drainage. His [MEDICAL CONDITION] is decreasing and noted at 2+. Resident is in compliance with elevating left leg throughout the day ad he denies any pain/discomfort. Treatment performed and continues as indicated. [DATE] - Wound Care LVN wrote: Wound rounds noted to left leg calf wound macerated resident states that he had a shower. Wound assessed and noted moderate serous, wound bed 80% necrotic tissues, 20% granulation, surrounding skin reddened. Resident denies pain. NP notified, and new order placed in PCC. [DATE] (9:35 p.m.) - Wound Care RN wrote: During scheduled wound treatment resident's old dressing noted to left posterior calf with 75% saturated serous drainage. The wound bed displayed 100% granulation tissue with the surrounding skin exhibiting mild [DIAGNOSES REDACTED] and 3+ [MEDICAL CONDITION]. He denies any pain/discomfort with light palpation. No tingling, numbness, or changes from his baseline exhibited . [DATE] (6:49 p.m.) - RN C wrote: 24% or less for 2 or more meals in 24 hours. Resident has food at beside and eats throughout the day. [DATE] (1:00 a.m.) - LVN A wrote: Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] MG, Give 1 tablet by mouth every 8 hours as needed for pain. [DATE] (1:38 a.m.) - LVN A wrote: Resident alert and oriented x3, complaining of left leg pain at level ,[DATE], Tylenol #3 administered as scheduled with no relief. Started vomiting x3 and had a temperature 100.6. Tylenol and [MEDICATION NAME] were administered, with no relief, vital signs BP ,[DATE], Pulse 120, Resp 26. [DATE] (1:40 a.m.) - LVN A wrote: NP ordered Tylenol 650mg tab po Q6h for temperature over 100 and [MEDICATION NAME] 4mg x 1 dose for nausea/vomiting, and also to send to hospital if condition worsen. On further assessment noted that patient's lower leg is changing color. Patient sent to local hospital due to increase pain and darkening of lower extremity . Record review of a hand-written nurse's note by LVN A, dated [DATE] revealed At about 10 pm upon nurse's rounds, Resident was noted sitting in his wheelchair watching television. Nurse administered his scheduled medications with no complaints verbalized. At about 12:55 p.m. resident placed a call light and nurse checked on him and it is at that time he complained of left leg pain at a level of ,[DATE]. Resident stated I think I placed my leg on a bed remote control! On assessment noted dressing to left leg on the back intact with no drainage. No redness or skin impairment was noted on the entire left leg at that time. Tylenol #3 tab was administered as needed for pain and after 30 minutes a re-assessment was performed, and resident was still complaining of pain of his left leg. Resident was observed vomiting yellowish vomit with food particles mixed at that time. Noted with chills and had a temperature of 100.6 degrees Fahrenheit (temporal) Orders were obtained from NP of [MEDICATION NAME] 4mg tab po start for vomiting and nausea, Tylenol 650mg tab po Q6hrs for temperature more. Resident was re-assessed and noted his left leg had started changing color varying from light red to dark red warm and tender on touch. Resident was then sent to a local hospital emergency room for further management at 3:36 a.m. by ambulance. Record review of Resident #1's Wound Reports revealed the following measurements: [DATE] - [DATE] - Blister (start date [DATE]) left lower leg - length: 1.5cm, width: 2cm, depth: .1cm, (Treatment - Med/honey/calcium alginate). [DATE] - [DATE] - Blister (start date [DATE]) left lower leg - length: 1.5cm, width: 2cm, depth: .1 (Treatment - med/honey, calcium alginate). Record review of Resident #1's TAR for February 2020 revealed the following treatments: Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by skin prep, leave open to air, until resolved. Every day shift for blister. Order date: [DATE], Discontinued: [DATE]. Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by triple antibiotic ointment, cover with dry dressing, until resolved. Every day shift for blister. Order date: [DATE], Discontinued: [DATE] Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by [MEDICATION NAME]/calcium alginate, cover with dry dressing, until resolved. Every day shift for blister. Order date: [DATE], Discontinued: [DATE]. Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by [MEDICATION NAME]/calcium alginate, cover with transparent film wound dressing, until resolved. Every day shift for blister. Order date: [DATE]. Record review of Resident #1's MAR for February 2020 revealed he was prescribed: Date of order: [DATE] - Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] MG: Give 1 tablet by mouth every 8 hours as needed for pain (a dose was administered by LVN A on [DATE] at 1:00 a.m. and was documented to be ineffective). Date of Order: [DATE] - Tylenol Tablet 325 MG: Give 2 tablets by mouth every six hours as needed for fever more than 100 for three days (a dose was administered by LVN A on [DATE] at 2:22 a.m. for temperature of 100.1). Date of order: [DATE] - [MEDICATION NAME] Tablet 4 MG: Give 1 tablet by mouth one time only for vomiting for 1 Day (a dose was administered by LVN A on [DATE] at 2:20 a.m.). In an interview with Wound Care LVN on [DATE] at 3:25 p.m., she stated Resident #1 had a history of [REDACTED]. He had an open blister on his left calf and self-transferred using a sliding board. She stated his death was heart-breaking for her because she was just kidding around with him the Thursday before he died . She said the blister was intact but had opened maybe two days prior to him asking her to cover it because transferred himself. Wound Care LVN said at that time she saw dark tissue and considered it necrotic. She called the NP who ordered [MEDICATION NAME]. The blister improved after a couple of days to 100% granulation. On Wednesday the previous week, he said he was doing well and was not in any pain. She did wound care that Thursday and he was fine and joking in the hallway. She was told he went out on that weekend with a low-grade fever, vomiting, and [MEDICAL CONDITION](fast heart rate) with leg discoloration. When asked if Wound Care LVN thought those were symptoms of infection, she stated they were not signs of infection but would be an indication of [MEDICAL CONDITION] embolism. She said the last time she saw the wound it was not dark, there was no bruising, and Resident #1, who was alert and oriented, was happy with the progress. In an interview with the DON on [DATE] at 3:45 p.m., she stated she, the Administrator, and ADON had just started working at the facility on [DATE]. She said fever, vomiting, [MEDICAL CONDITION] and a change in wound color were signs and symptoms of infection. In a telephone interview with Wound Care RN on [DATE] at 10:40 a.m., she stated Resident #1's did not know his blister opened. He was ordered to prop his leg up for the [MEDICAL CONDITION], so she said maybe it popped when he put the leg up. On the last day she saw him, his [MEDICAL CONDITION] was at 3, it had deceased but went back up to 3. He was not showing signs of infection and his wound bed looked good with 100% granulation and no pain. When asked if fever, vomiting, [MEDICAL CONDITION] and a change in wound color would indicate infection, Wound Care RN stated it would not indicate infection but would indicate [MEDICAL CONDITION]. In a telephone interview with LVN A on [DATE] at 1:15 p.m., she stated Resident #1 liked to take his evening medications at 10:00 p.m. At 12:00 a.m., the resident put on his call light and complained of leg pain. He said he thought he had pressed it up against the bed remote control. She said she gave him a Tylenol #3 and checked with him again after 30 minutes. At that time, he said the pain had gone away a little bit. When she checked on him again at 1:00 a.m., he was still sitting in his chair. He vomited and said he thought it was something he ate. She went back after ,[DATE] minutes and Resident #1 said he was not well because of the nausea. The nurse got an order for [REDACTED]. She took his temperature and it was elevated. She looked at his leg at 2-something and it was changing colors. The nurse called transportation to take the resident to the hospital. Resident #1 asked not to go out because he wanted the NP to go to the facility to see him. She stated the transportation ambulance arrived in 30 minutes and took him to the hospital. The nurse stated the situation was not threatening enough to call 911. She had looked at the leg earlier and it was fine, it was clean, no oozing, and no redness. In an interview with the NP on [DATE] at 2:30 p.m., she stated she had gotten a call in the middle of the night that Resident #1's leg was red and hot to touch. She stated it was automatic to her with those symptoms in addition to a fever, the only solution was to send out to the hospital. She thought it might have been [MEDICAL CONDITION]. The NP said it was the middle of the night, she heard red and hot and said send out. She said it was in the nurse's judgement to call 911 because it depended on what she saw. When asked if the nurse relayed the resident's vital signs, including the [MEDICAL CONDITION] the NP stated she did not hear any of that. She heard red and hot and said send out. The NP said she did not recall if the nurse called her twice or if she ordered Tylenol and [MEDICATION NAME]. She said the order must have been prior to the red and hot notification, but she was not saying she did not order the medications. In an interview with the DON on [DATE] at 10:00 a.m., she stated she had reviewed Resident #1's Wound Care notes and thought she could have described the color of the wound instead of using the term necrotic. She thought LVN A's course of action on [DATE] was appropriate because signs of infection were noted by the nurses and they sent the resident out appropriately. Record review of Resident #1's hospital records revealed Pre-Arrival Summary revealed his estimated time of arrival was documented as [DATE] at 5:06 a.m. Emergency Department Triage revealed he was triaged in the hospital's emergency roiagnom on [DATE], at 5:25 a.m. for fever and shortness of breath. His vital signs at that time were: blood pressure (,[DATE]), Pulse (133 bpm - High), Respiratory Rate (30 breaths/minute - High), oxygen saturation (90% - low). Emergency Department Assessment revealed the following critical lab values: Critical Result Comment: lactic acid was 6.3 was at 5.34am (which is high and indicates severe infection (sepsis), or shock) and rose to 9.6 at 7:42 a.m. Consultation ([DATE] at signed at 10:38 a.m.) revealed it read in part, .Plan: to operating room for debridement, IV antibiotics .I discussed at length the patient's condition with his family member .I explained that he may not survive this infection however surgery is the only thing that would potentially control the infection. I told the family member he would likely be in the ICU intubated for a week. After our discussion, the family member agrees to proceed with surgery but does not want his leg amputated . Consult Notes ([DATE] signed at 3:45 p.m.) revealed the reason for the consultation was listed as Severe septic shock. The note read in part, .He presented to the emergency room center this morning with right lower extremity [MEDICAL CONDITION]. He was noted to by hypotensive receiving 3 L of IV fluids in the ER. Noted to have severe lactic acidosis. Clinical suspicion for [DIAGNOSES REDACTED] (flesh-eating bacteria infection that results in the death of parts of the body's soft tissue, with severe disease of sudden onset that spreads rapidly.) was high. General surgery was consulted and after discussion with the patient's family member was planning to take him to surgery for [REDACTED]. However, patient continued to deteriorate. He was placed on max pressors with [MEDICATION NAME], and [MEDICATION NAME]. Despite this patient continued to be hemodynamically unstable. Further discussions were held with the resident's family member. We discussed optional courses of care. We talked about going to the operating room however it was extremely unlikely That he would make it there at that time given his hemodynamic instability. We then discussed palliative options and with comfort care and [MEDICATION NAME] extubation. Decision was made to make the patient comfort care which is appropriate in his case . Consultation ([DATE] signed at 3:45 p.m.) revealed the note read in part, Assessment/Plan: 1. Severe septic shock secondary to [DIAGNOSES REDACTED] 2. [MEDICAL CONDITION] of the left lower extremity with likely [DIAGNOSES REDACTED] 3. [MEDICAL CONDITION] with RVR which is likely appropriate given his septic state 4. Metabolic acidosis 5. Coronary Disease 5. [MEDICAL CONDITION] Plan: 1. Discontinue mechanical ventilation 2. Discontinue pressor therapy 3. Comfort care measures have been initiated 4. All of patient's family's questions and concerns have been answered . Disposition: Patient was pronounced dead at 3:27 p.m. on February 16, 2020 .[MEDICAL CONDITION] with septic shock . Record review of the facility's policy, Quality Of Care, revealed it was not dated. The policy read in part, Our Facility is committed to ensure that the care being provided to our residents is delivered safely .We want to promote effective communication in coordination of their care and effectively prevent and treat their chronic disease processes .Quality in healthcare means providing personal centered care that meets the needs of the resident in an affordable safe manner .Quality of care is a collaborative effort that involves the resident, the Attending Physician/Nurse Practitioner, family and the community as a whole. Record review of facility policy, Risk And Skin Assessment Of A Resident revealed it was not dated. The policy read in part, Our facility will assess all residents for factors that place them at risk for developing pressure injury and for ongoing monitoring of skin integrity. The nurse will complete a risk assessment using the Braden Scale for Predicting Pressure Injury Risk. This is completed on admission, weekly for the first four weeks, quarterly, and with any significant change in condition/cognition or functional ability. The nurse will complete weekly skin assessments for ongoing monitoring of resident's skin .The nurse will obtain appropriate treatment orders from the Attending Physician/Nurse Practitioner and appropriately carry them out. Record review of facility policy, Change in a Resident's Condition revealed it was not dated. The policy read in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician and Representative when a change in resident's physical and/or mental medical condition has occurred. Prior to notifying the Physician or healthcare provider, the nurse will make observations and gather pertinent information for the physician, including (for example) information prompted by change of condition. In an interview with the DON on [DATE], at 12:45 p.m., she stated the facility did not have a policy specifically concerning assessments or nursing services. She stated they use the Change in a Resident's Condition policy when referring to development of infection or any change of condition. On [DATE], at 4:15 p.m., the Administrator was notified that an IJ, IT, and SQC had been identified based on the above findings. A copy of the IJ template was provided and a plan to remove the IJ was requested. The final plan of removal was accepted on [DATE] after several revisions were submitted. Plan to remove immediate jeopardy The resident is no longer in the facility and is now deceased . The LVN who took care of the resident was identified and was provided training on the following areas: changes in condition, appropriate intervention, recognizing need to call 911, documentation including the SBAR and completion of transfer form. The LVN was also trained to consult with RN if there is any question related to assessment and to notify the MD/NP of any resident change of condition immediately. The training was provided by the DON (Director of Nursing) on [DATE]. All residents have the potential to be affected by the alleged deficient practice. A facility-wide audit was initiated on [DATE] to ensure changes in condition are identified promptly and appropriate intervention were implemented. The audits are conducted by the DON and ADON. No concern has been identified at this time. The audit was completed on [DATE]. The following policies and procedures were reviewed and revised by on [DATE], by the DON, NHA (Nursing Home Administrator) and Medical Director: Recognizing Change in Condition with Notification to the Practitioner, including following orders for new interventions and determining when to call 911. On [DATE], the DON and ADON (Assistant Director of Nursing) initiated training to the licensed nurses regarding recognizing the change of condition, recognizing change in skin/wound color, signs of infection, monitoring vital signs during acute change in condition and notifying 911 of acute change in condition for transfer to hospital. LVNs will be provided with training to consult RN if they have questions on their assessments. All in-services will be done on [DATE]. Licensed staff will not be allowed to work until they receive the training. CNAs will also be provided with training related to identifying and reporting any changes in conditions to charge nurse, utilizing stop and watch tool. All resident change of condition is discussed and reviewed during morning Clinical meetings and during all shift change clinical reporting, including the weekends. Clinical management team makes daily rounds and will identify resident changes in condition through nursing observation, staff/resident interview and review of 24-hour reports. The nursing supervisors during the weekend will conduct the clinical meetings. Ad-Hoc QAPI meeting was held on [DATE] to review the alleged deficiency and the review of the P&Ps concerning changes of condition and transfers. The medical director was involved with the reviews and plan of removal. All licensed staff will be required to have training before assuming patient care responsibilities. The DON will be responsible to ensure plan is completed by [DATE]. Monitoring: The surveyor monitored the plan to remove the immediate jeopardy as follows: Record review of the facility's policy, Change In A Resident's Condition, revealed it was revised on [DATE]. The document was revised to include the following statement, The nurse will follow the orders and initiate interventions from the Attending Physician/Nurse Practitioner and notify 911 for resident transport to the hospital. In an interview with the DON on [DATE], at 1:55 p.m., she stated she had already started in-services of staff, including the night nurse. The DON said there was no RN on duty that night and LVN A did not consult anyone for assessment, but she would prefer LVN A to not waste time consulting an RN, but she did call the NP for direction. She said LVN A's timeline was off and she attributed the [MEDICAL CONDITION] Resident #1's pain. LVN A told her the resident's pain level did decrease but she did not document it. Another nurse did come over and assist but they did not stay with the resident. They discussed in the in-services how often vitals should be done in that type of situation and it varied but every ,[DATE] minutes was the answer. The DON said it was protocol in the facility prior to the current administration to call a transportation ambulance rather than calling 911. In an interview with RN Manager D on [DATE], at 1:48 p.m., she stated she was the weekend supervisor, but her shift was over by the time the incident occurred. Resident #1 did not have any issues during the day. She stated she had been recently educated on the signs and symptoms of infection, which included fever, temperature above or below a resident's baseline, redness, changes in wound color, heat, nausea, vomiting. They were also educated on recognizing any change in condition, which included anything out of the ordinary for that resident, such as appetite changes, sleep habits, pain, diarrhea, and other symptoms. RN Manager D stated Resident #1's symptoms would have indicated infection/sepsis. She said it is important to know a resident's baseline. Her course of action would have been to call 911. Transport would delay treatment and 911 would have come quicker. She stated she would have called the doctor, take vitals, gave pain medications, and repeat vitals every 15 minutes to look at the trends until EMS arrived. She stated all of their shifts have and RN. Based on what the state wants, the nursing board said RN's have to do the assessments but some LVN's do better than some R.N.'s. She stated even RN's needed help in an emergency. In an interview with LVN E on [DATE], at 4:15 p.m., she stated she was not at the facility that weekend. She was recently in-serviced on crisis emergencies. One nurse would enter information in the computer and another nurse should stay with the resident. She said the CNA's relay information to the nurses about the change in condition. They went over signs of infection, including fever, pain, and abnormal vitals. Even before the in-service, she would have recognized those symptoms of infection. She said in an acute incident, check vitals and call 911 straight away, don't wait. They would do vitals every ,[DATE] minutes and document according to times. They would also document resident appearance and changes in vitals. LVN E said LVN's cannot do assessments and have to consult and RN She stated there was an RN on each shift. In an interview with RN F on [DATE], at 4:32 p.m., she stated she was recently in-services on changes in vitals, calling another nurse to stay with the resident, doing vitals every 15 minutes, and knowing baseline. She said of a resident complained of nausea or pain, take vitals. Once they see a change in condition, check vitals every 15 minutes and call the doctor. If there is no answer, they call 911. Signs and symptoms of infection include fever, abnormal vitals like [MEDICAL CONDITION] and if there is a wound, redness, warmth, drainage, smell. bleeding, or any changes. If there [MEDICAL CONDITION], call 911. In an interview with RN G on [DATE], at 4:50 p.m., she stated she was recently in-serviced on signs and symptoms [MEDICAL CONDITION] [MEDICAL CONDITION] fever, changes in blood pressure, warmth, inflammation, nausea, vomiting, and chills. They were informed to call 911 for any emergency that cannot be treated in-house. Vitals should be done every ,[DATE] minutes, and someone should stay with a resident in an emergency at all times. She said RN's should do the assessments because LVN's cannot do them. There was always an RN on duty. They were also in-serviced on assessing wound color and temperature, calling 911, notification to physicians, completing SBAR's and transfer paperwork, timely documentation of vital signs. She stated she knew a lot about the signs and symptoms [MEDICAL CONDITION] but learned about [MEDICAL CONDITION] a symptom and how [MEDICAL CONDITION] could come about. In an interview with CNA H on [DATE], at 5:25 p.m., she stated the CNA's were also in-serviced recently on recognizing and reporting changes in residents' conditions, and the importance in knowing residents' normal behavior. They also talked about skin changes and documenting changes and reporting them to nurses. In an interview with CNA# I on [DATE], at 5:45 p.m., he stated he had recently been in-serviced on changes in resident conditions, stop and watch. The talked about recognizing changes in residents' normal behavior and baselines like pain, eating, nausea, bowel habits and other abnormal things. The CNA's report changes to the nurses and document in the computer. In an interview with RN J on [DATE], at 12:20 a.m., she stated there was always an RN on duty. They were recently in-serviced on giving thorough reports, calling 911 right away and not waiting for transport in emergencies, recognizing changes like abnormal vitals, shortness of breath, signs and symptoms of infection like increase in heart rate, respiratory rate, and fever. They were also educated on notification to NP and documenting vitals every 15 minutes until the ambulance arrived. In an interview with RN Manager K on [DATE], at 12:45 a.m., she stated there was not an RN on duty at all times. On the night Resident #1 went out, there was an LVN manager. She said she was taught in school that RN's were supposed to do assessments but generally, al nurses should assess. If there was anything unusual, the nurse should notify the charge nurse or DON. They were in-serviced on signs and symptoms of infection, including fever, malaise, pain, and warm skin. If there was a wound, they look for drainage, odor, and color changes. They should call the doctor for orders or call 911 not wasting time if they cannot treat in-house. If there was a change in condition, they do vitals and re-check in intervals, looking for trends. They talked about the importance of documenting everything they do. In an interview with LVN L on [DATE], at 11:55 p.m., he stated he was on duty the night Resident #1 went out. He was called over to help by LVN A. He had spoken to the resident earlier during the shift that day and he was fine. He could not recall what time LVN A went to get him for help but she said Resident #1's leg was hurting. LVN A gave him medicine. A short time later, LVN A noted swelling, altered mental status, and vomiting and that was when she called him for help. He knew Resident #1 had a blister on the back of his leg because he was getting treatments. The resident said he thought he laid his leg on something. There was swelling and different stages of discoloration from slightly under the knee and down the leg.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 13 residents (Resident #1) reviewed for quality of care. The facility failed to accurately assess Resident #1 and failed to continue monitoring Resident #1 after a change in his condition was identified. The facility failed to identify and communicate Resident #1's deteriorating change in condition ( fever, vomiting, elevated heart rate) to his physician/NP for properly intervention. The facility failed to call 911 for prompt transportation/ intervention for Resident #1 instead requested EMS ambulance which took longer time to transfer the resident to the ER. Resident #1 was diagnosed with [REDACTED]. Resident #1 died at the hospital. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures could affected all residents who experienced a change in condition. Findings include: Resident #1 Record review of Resident #1's face-sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. He was diagnosed with [REDACTED]. He was discharged from the facility on [DATE] when he was transferred to a local hospital where he passed away. Record review of Resident #1's Minimum Data Set (MDS), dated [DATE] revealed he had a BIMS score of 10 indicating moderate cognitive impairment, he required extensive one-staff assistance with bed mobility, dressing, toilet use, and personal hygiene, extensive two-staff assistance with transferring, set-up assistance and supervision with eating and locomotion via wheelchair, he was always incontinent of bladder and frequently incontinent of bowel, he received scheduled and was at least offered PRN pain medication within the previous five days of the assessment, felt pain frequently, and he did not have any wounds at the time of the assessment. Record review of Resident #1's care plan, updated [DATE] revealed he had impaired circulation due to [MEDICAL CONDITION] (Interventions included: Inspect foot/ankle/calf skin for changes: maceration, redness, purple tinge, blue, rust coloring, weeping, [MEDICAL CONDITION], puffiness, tenderness, areas with no sensation), he was on pain medication (Tylenol with [MEDICATION NAME] #3) due to poor circulation/disease process (Interventions included: Administer medications as ordered, For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications, Monitor for altered mental status, anxiety, lack of appetite, nausea, vomiting, pruritis, respiratory distress .Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness, monitor for and document any [MEDICAL CONDITION], notify doctor and he had scattered bruising to his left leg and discoloration to his toes (Interventions included: Monitor/document location, size and treatment of [REDACTED]. to doctor). Record review of Resident #1's weights and vitals summary from [DATE] through February 16, 2020 revealed the following vital signs: -,[DATE].2020: Pulse 71 bpm (Regular), Respiration 20 breaths/minute. - [DATE]: Pulse 75 bpm (Unable to Determine), Respiration 20 breaths/minute. - [DATE]: Pulse 120 bpm (Irregular - new onset), Respiration 26 breaths/minute, Temperature (1:06 a.m.) 100.7 degrees Fahrenheit (2:22 a.m.) 100.1 degrees Fahrenheit. Further review of the records revealed no other documentation of vital signs for Resident #1 on [DATE] or [DATE]. Observation and interview with Resident #1 on [DATE] at 10:50 a.m. revealed he was alert and oriented and was sitting in a wheelchair in his room. His right leg was amputated above the knee. He did not mention the blister on his left leg or complain of pain at that time. Record review of Resident #1's Progress Notes for [DATE] and February 2020 revealed the following entries: [DATE] - LVN A wrote: Resident was observed with a reddened area/blister on his left calf and that is none tender or painful, Nurse Practitioner (NP) was informed . [DATE] - Wound Care RN wrote: Weekly skin notes: Open blister to left calf noted with moderate amount or serous drainage. His [MEDICAL CONDITION] is decreasing and noted at 2+. Resident is in compliance with elevating left leg throughout the day ad he denies any pain/discomfort. Treatment performed and continues as indicated. [DATE] - Wound Care LVN wrote: Wound rounds noted to left leg calf wound macerated resident states that he had a shower. Wound assessed and noted moderate serous, wound bed 80% necrotic tissues, 20% granulation, surrounding skin reddened. Resident denies pain. NP notified, and new order placed in PCC. [DATE] (9:35 p.m.) - Wound Care RN wrote: During scheduled wound treatment resident's old dressing noted to left posterior calf with 75% saturated serous drainage. The wound bed displayed 100% granulation tissue with the surrounding skin exhibiting mild [DIAGNOSES REDACTED] and 3+ [MEDICAL CONDITION]. He denies any pain/discomfort with light palpation. No tingling, numbness, or changes from his baseline exhibited . [DATE] (6:49 p.m.) - RN C wrote: 24% or less for 2 or more meals in 24 hours. Resident has food at beside and eats throughout the day. [DATE] (1:00 a.m.) - LVN A wrote: Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] MG, Give 1 tablet by mouth every 8 hours as needed for pain. [DATE] (1:38 a.m.) - LVN A wrote: Resident alert and oriented x3, complaining of left leg pain at level ,[DATE], Tylenol #3 administered as scheduled with no relief. Started vomiting x3 and had a temperature 100.6. Tylenol and [MEDICATION NAME] were administered, with no relief, vital signs BP ,[DATE], Pulse 120, Resp 26. [DATE] (1:40 a.m.) - LVN A wrote: NP ordered Tylenol 650mg tab po Q6h for temperature over 100 and [MEDICATION NAME] 4mg x 1 dose for nausea/vomiting, and also to send to hospital if condition worsen. On further assessment noted that patient's lower leg is changing color. Patient sent to local hospital due to increase pain and darkening of lower extremity . Record review of a hand-written nurse's note by LVN A, dated [DATE] revealed At about 10 pm upon nurse's rounds, Resident was noted sitting in his wheelchair watching television. Nurse administered his scheduled medications with no complaints verbalized. At about 12:55 p.m. resident placed a call light and nurse checked on him and it is at that time he complained of left leg pain at a level of ,[DATE]. Resident stated I think I placed my leg on a bed remote control! On assessment noted dressing to left leg on the back intact with no drainage. No redness or skin impairment was noted on the entire left leg at that time. Tylenol #3 tab was administered as needed for pain and after 30 minutes a re-assessment was performed, and resident was still complaining of pain of his left leg. Resident was observed vomiting yellowish vomit with food particles mixed at that time. Noted with chills and had a temperature of 100.6 degrees Fahrenheit (temporal) Orders were obtained from NP of [MEDICATION NAME] 4mg tab po start for vomiting and nausea, Tylenol 650mg tab po Q6hrs for temperature more. Resident was re-assessed and noted his left leg had started changing color varying from light red to dark red warm and tender on touch. Resident was then sent to a local hospital emergency room for further management at 3:36 a.m. by ambulance. Record review of Resident #1's Wound Reports revealed the following measurements: [DATE] - [DATE] - Blister (start date [DATE]) left lower leg - length: 1.5cm, width: 2cm, depth: .1cm, (Treatment - Med/honey/calcium alginate). [DATE] - [DATE] - Blister (start date [DATE]) left lower leg - length: 1.5cm, width: 2cm, depth: .1 (Treatment - med/honey, calcium alginate). Record review of Resident #1's TAR for February 2020 revealed the following treatments: Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by skin prep, leave open to air, until resolved. Every day shift for blister. Order date: [DATE], Discontinued: [DATE]. Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by triple antibiotic ointment, cover with dry dressing, until resolved. Every day shift for blister. Order date: [DATE], Discontinued: [DATE] Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by [MEDICATION NAME]/calcium alginate, cover with dry dressing, until resolved. Every day shift for blister. Order date: [DATE], Discontinued: [DATE]. Left Lower Calf: Cleanse with normal saline/wound cleaner, pat dry followed by [MEDICATION NAME]/calcium alginate, cover with transparent film wound dressing, until resolved. Every day shift for blister. Order date: [DATE]. Record review of Resident #1's MAR for February 2020 revealed he was prescribed: Date of order: [DATE] - Tylenol with [MEDICATION NAME] #3 Tablet ,[DATE] MG: Give 1 tablet by mouth every 8 hours as needed for pain (a dose was administered by LVN A on [DATE] at 1:00 a.m. and was documented to be ineffective). Date of Order: [DATE] - Tylenol Tablet 325 MG: Give 2 tablets by mouth every six hours as needed for fever more than 100 for three days (a dose was administered by LVN A on [DATE] at 2:22 a.m. for temperature of 100.1). Date of order: [DATE] - [MEDICATION NAME] Tablet 4 MG: Give 1 tablet by mouth one time only for vomiting for 1 Day (a dose was administered by LVN A on [DATE] at 2:20 a.m.). In an interview with Wound Care LVN on [DATE] at 3:25 p.m., she stated Resident #1 had a history of [REDACTED]. He had an open blister on his left calf and self-transferred using a sliding board. She stated his death was heart-breaking for her because she was just kidding around with him the Thursday before he died . She said the blister was intact but had opened maybe two days prior to him asking her to cover it because transferred himself. Wound Care LVN said at that time she saw dark tissue and considered it necrotic. She called the NP who ordered [MEDICATION NAME]. The blister improved after a couple of days to 100% granulation. On Wednesday the previous week, he said he was doing well and was not in any pain. She did wound care that Thursday and he was fine and joking in the hallway. She was told he went out on that weekend with a low-grade fever, vomiting, and [MEDICAL CONDITION](fast heart rate) with leg discoloration. When asked if Wound Care LVN thought those were symptoms of infection, she stated they were not signs of infection but would be an indication of [MEDICAL CONDITION] embolism. She said the last time she saw the wound it was not dark, there was no bruising, and Resident #1, who was alert and oriented, was happy with the progress. In an interview with the DON on [DATE] at 3:45 p.m., she stated she, the Administrator, and ADON had just started working at the facility on [DATE]. She said fever, vomiting, [MEDICAL CONDITION] and a change in wound color were signs and symptoms of infection. In a telephone interview with Wound Care RN on [DATE] at 10:40 a.m., she stated Resident #1's did not know his blister opened. He was ordered to prop his leg up for the [MEDICAL CONDITION], so she said maybe it popped when he put the leg up. On the last day she saw him, his [MEDICAL CONDITION] was at 3, it had deceased but went back up to 3. He was not showing signs of infection and his wound bed looked good with 100% granulation and no pain. When asked if fever, vomiting, [MEDICAL CONDITION] and a change in wound color would indicate infection, Wound Care RN stated it would not indicate infection but would indicate [MEDICAL CONDITION]. In a telephone interview with LVN A on [DATE] at 1:15 p.m., she stated Resident #1 liked to take his evening medications at 10:00 p.m. At 12:00 a.m., the resident put on his call light and complained of leg pain. He said he thought he had pressed it up against the bed remote control. She said she gave him a Tylenol #3 and checked with him again after 30 minutes. At that time, he said the pain had gone away a little bit. When she checked on him again at 1:00 a.m., he was still sitting in his chair. He vomited and said he thought it was something he ate. She went back after ,[DATE] minutes and Resident #1 said he was not well because of the nausea. The nurse got an order for [REDACTED]. She took his temperature and it was elevated. She looked at his leg at 2-something and it was changing colors. The nurse called transportation to take the resident to the hospital. Resident #1 asked not to go out because he wanted the NP to go to the facility to see him. She stated the transportation ambulance arrived in 30 minutes and took him to the hospital. The nurse stated the situation was not threatening enough to call 911. She had looked at the leg earlier and it was fine, it was clean, no oozing, and no redness. In an interview with the NP on [DATE] at 2:30 p.m., she stated she had gotten a call in the middle of the night that Resident #1's leg was red and hot to touch. She stated it was automatic to her with those symptoms in addition to a fever, the only solution was to send out to the hospital. She thought it might have been [MEDICAL CONDITION]. The NP said it was the middle of the night, she heard red and hot and said send out. She said it was in the nurse's judgement to call 911 because it depended on what she saw. When asked if the nurse relayed the resident's vital signs, including the [MEDICAL CONDITION] the NP stated she did not hear any of that. She heard red and hot and said send out. The NP said she did not recall if the nurse called her twice or if she ordered Tylenol and [MEDICATION NAME]. She said the order must have been prior to the red and hot notification, but she was not saying she did not order the medications. In an interview with the DON on [DATE] at 10:00 a.m., she stated she had reviewed Resident #1's Wound Care notes and thought she could have described the color of the wound instead of using the term necrotic. She thought LVN A's course of action on [DATE] was appropriate because signs of infection were noted by the nurses and they sent the resident out appropriately. Record review of Resident #1's hospital records revealed Pre-Arrival Summary revealed his estimated time of arrival was documented as [DATE] at 5:06 a.m. Emergency Department Triage revealed he was triaged in the hospital's emergency roiagnom on [DATE], at 5:25 a.m. for fever and shortness of breath. His vital signs at that time were: blood pressure (,[DATE]), Pulse (133 bpm - High), Respiratory Rate (30 breaths/minute - High), oxygen saturation (90% - low). Emergency Department Assessment revealed the following critical lab values: Critical Result Comment: lactic acid was 6.3 was at 5.34am (which is high and indicates severe infection (sepsis), or shock) and rose to 9.6 at 7:42 a.m. Consultation ([DATE] at signed at 10:38 a.m.) revealed it read in part, .Plan: to operating room for debridement, IV antibiotics .I discussed at length the patient's condition with his family member .I explained that he may not survive this infection however surgery is the only thing that would potentially control the infection. I told the family member he would likely be in the ICU intubated for a week. After our discussion, the family member agrees to proceed with surgery but does not want his leg amputated . Consult Notes ([DATE] signed at 3:45 p.m.) revealed the reason for the consultation was listed as Severe septic shock. The note read in part, .He presented to the emergency room center this morning with right lower extremity [MEDICAL CONDITION]. He was noted to by hypotensive receiving 3 L of IV fluids in the ER. Noted to have severe lactic acidosis. Clinical suspicion for [DIAGNOSES REDACTED] (flesh-eating bacteria infection that results in the death of parts of the body's soft tissue, with severe disease of sudden onset that spreads rapidly.) was high. General surgery was consulted and after discussion with the patient's family member was planning to take him to surgery for [REDACTED]. However, patient continued to deteriorate. He was placed on max pressors with [MEDICATION NAME], and [MEDICATION NAME]. Despite this patient continued to be hemodynamically unstable. Further discussions were held with the resident's family member. We discussed optional courses of care. We talked about going to the operating room however it was extremely unlikely That he would make it there at that time given his hemodynamic instability. We then discussed palliative options and with comfort care and [MEDICATION NAME] extubation. Decision was made to make the patient comfort care which is appropriate in his case . Consultation ([DATE] signed at 3:45 p.m.) revealed the note read in part, Assessment/Plan: 1. Severe septic shock secondary to [DIAGNOSES REDACTED] 2. [MEDICAL CONDITION] of the left lower extremity with likely [DIAGNOSES REDACTED] 3. [MEDICAL CONDITION] with RVR which is likely appropriate given his septic state 4. Metabolic acidosis 5. Coronary Disease 5. [MEDICAL CONDITION] Plan: 1. Discontinue mechanical ventilation 2. Discontinue pressor therapy 3. Comfort care measures have been initiated 4. All of patient's family's questions and concerns have been answered . Disposition: Patient was pronounced dead at 3:27 p.m. on February 16, 2020 .[MEDICAL CONDITION] with septic shock . Record review of the facility's policy, Quality Of Care, revealed it was not dated. The policy read in part, Our Facility is committed to ensure that the care being provided to our residents is delivered safely .We want to promote effective communication in coordination of their care and effectively prevent and treat their chronic disease processes .Quality in healthcare means providing personal centered care that meets the needs of the resident in an affordable safe manner .Quality of care is a collaborative effort that involves the resident, the Attending Physician/Nurse Practitioner, family and the community as a whole. Record review of facility policy, Risk And Skin Assessment Of A Resident revealed it was not dated. The policy read in part, Our facility will assess all residents for factors that place them at risk for developing pressure injury and for ongoing monitoring of skin integrity. The nurse will complete a risk assessment using the Braden Scale for Predicting Pressure Injury Risk. This is completed on admission, weekly for the first four weeks, quarterly, and with any significant change in condition/cognition or functional ability. The nurse will complete weekly skin assessments for ongoing monitoring of resident's skin .The nurse will obtain appropriate treatment orders from the Attending Physician/Nurse Practitioner and appropriately carry them out. Record review of facility policy, Change in a Resident's Condition revealed it was not dated. The policy read in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician and Representative when a change in resident's physical and/or mental medical condition has occurred. Prior to notifying the Physician or healthcare provider, the nurse will make observations and gather pertinent information for the physician, including (for example) information prompted by change of condition. In an interview with the DON on [DATE], at 12:45 p.m., she stated the facility did not have a policy specifically concerning assessments or nursing services. She stated they use the Change in a Resident's Condition policy when referring to development of infection or any change of condition. On [DATE], at 4:15 p.m., the Administrator was notified that an IJ, IT, and SQC had been identified based on the above findings. A copy of the IJ template was provided and a plan to remove the IJ was requested. The final plan of removal was accepted on [DATE] after several revisions were submitted. Plan to remove immediate jeopardy The resident is no longer in the facility and is now deceased . The LVN who took care of the resident was identified and was provided training on the following areas: changes in condition, appropriate intervention, recognizing need to call 911, documentation including the SBAR and completion of transfer form. The LVN was also trained to consult with RN if there is any question related to assessment and to notify the MD/NP of any resident change of condition immediately. The training was provided by the DON (Director of Nursing) on [DATE]. All residents have the potential to be affected by the alleged deficient practice. A facility-wide audit was initiated on [DATE] to ensure changes in condition are identified promptly and appropriate intervention were implemented. The audits are conducted by the DON and ADON. No concern has been identified at this time. The audit was completed on [DATE]. The following policies and procedures were reviewed and revised by on [DATE], by the DON, NHA (Nursing Home Administrator) and Medical Director: Recognizing Change in Condition with Notification to the Practitioner, including following orders for new interventions and determining when to call 911. On [DATE], the DON and ADON (Assistant Director of Nursing) initiated training to the licensed nurses regarding recognizing the change of condition, recognizing change in skin/wound color, signs of infection, monitoring vital signs during acute change in condition and notifying 911 of acute change in condition for transfer to hospital. LVNs will be provided with training to consult RN if they have questions on their assessments. All in-services will be done on [DATE]. Licensed staff will not be allowed to work until they receive the training. CNAs will also be provided with training related to identifying and reporting any changes in conditions to charge nurse, utilizing stop and watch tool. All resident change of condition is discussed and reviewed during morning Clinical meetings and during all shift change clinical reporting, including the weekends. Clinical management team makes daily rounds and will identify resident changes in condition through nursing observation, staff/resident interview and review of 24-hour reports. The nursing supervisors during the weekend will conduct the clinical meetings. Ad-Hoc QAPI meeting was held on [DATE] to review the alleged deficiency and the review of the P&Ps concerning changes of condition and transfers. The medical director was involved with the reviews and plan of removal. All licensed staff will be required to have training before assuming patient care responsibilities. The DON will be responsible to ensure plan is completed by [DATE]. Monitoring: The surveyor monitored the plan to remove the immediate jeopardy as follows: Record review of the facility's policy, Change In A Resident's Condition, revealed it was revised on [DATE]. The document was revised to include the following statement, The nurse will follow the orders and initiate interventions from the Attending Physician/Nurse Practitioner and notify 911 for resident transport to the hospital. In an interview with the DON on [DATE], at 1:55 p.m., she stated she had already started in-services of staff, including the night nurse. The DON said there was no RN on duty that night and LVN A did not consult anyone for assessment, but she would prefer LVN A to not waste time consulting an RN, but she did call the NP for direction. She said LVN A's timeline was off and she attributed the [MEDICAL CONDITION] Resident #1's pain. LVN A told her the resident's pain level did decrease but she did not document it. Another nurse did come over and assist but they did not stay with the resident. They discussed in the in-services how often vitals should be done in that type of situation and it varied but every ,[DATE] minutes was the answer. The DON said it was protocol in the facility prior to the current administration to call a transportation ambulance rather than calling 911. In an interview with RN Manager D on [DATE], at 1:48 p.m., she stated she was the weekend supervisor, but her shift was over by the time the incident occurred. Resident #1 did not have any issues during the day. She stated she had been recently educated on the signs and symptoms of infection, which included fever, temperature above or below a resident's baseline, redness, changes in wound color, heat, nausea, vomiting. They were also educated on recognizing any change in condition, which included anything out of the ordinary for that resident, such as appetite changes, sleep habits, pain, diarrhea, and other symptoms. RN Manager D stated Resident #1's symptoms would have indicated infection/sepsis. She said it is important to know a resident's baseline. Her course of action would have been to call 911. Transport would delay treatment and 911 would have come quicker. She stated she would have called the doctor, take vitals, gave pain medications, and repeat vitals every 15 minutes to look at the trends until EMS arrived. She stated all of their shifts have and RN. Based on what the state wants, the nursing board said RN's have to do the assessments but some LVN's do better than some R.N.'s. She stated even RN's needed help in an emergency. In an interview with LVN E on [DATE], at 4:15 p.m., she stated she was not at the facility that weekend. She was recently in-serviced on crisis emergencies. One nurse would enter information in the computer and another nurse should stay with the resident. She said the CNA's relay information to the nurses about the change in condition. They went over signs of infection, including fever, pain, and abnormal vitals. Even before the in-service, she would have recognized those symptoms of infection. She said in an acute incident, check vitals and call 911 straight away, don't wait. They would do vitals every ,[DATE] minutes and document according to times. They would also document resident appearance and changes in vitals. LVN E said LVN's cannot do assessments and have to consult and RN She stated there was an RN on each shift. In an interview with RN F on [DATE], at 4:32 p.m., she stated she was recently in-services on changes in vitals, calling another nurse to stay with the resident, doing vitals every 15 minutes, and knowing baseline. She said of a resident complained of nausea or pain, take vitals. Once they see a change in condition, check vitals every 15 minutes and call the doctor. If there is no answer, they call 911. Signs and symptoms of infection include fever, abnormal vitals like [MEDICAL CONDITION] and if there is a wound, redness, warmth, drainage, smell. bleeding, or any changes. If there [MEDICAL CONDITION], call 911. In an interview with RN G on [DATE], at 4:50 p.m., she stated she was recently in-serviced on signs and symptoms [MEDICAL CONDITION] [MEDICAL CONDITION] fever, changes in blood pressure, warmth, inflammation, nausea, vomiting, and chills. They were informed to call 911 for any emergency that cannot be treated in-house. Vitals should be done every ,[DATE] minutes, and someone should stay with a resident in an emergency at all times. She said RN's should do the assessments because LVN's cannot do them. There was always an RN on duty. They were also in-serviced on assessing wound color and temperature, calling 911, notification to physicians, completing SBAR's and transfer paperwork, timely documentation of vital signs. She stated she knew a lot about the signs and symptoms [MEDICAL CONDITION] but learned about [MEDICAL CONDITION] a symptom and how [MEDICAL CONDITION] could come about. In an interview with CNA H on [DATE], at 5:25 p.m., she stated the CNA's were also in-serviced recently on recognizing and reporting changes in residents' conditions, and the importance in knowing residents' normal behavior. They also talked about skin changes and documenting changes and reporting them to nurses. In an interview with CNA# I on [DATE], at 5:45 p.m., he stated he had recently been in-serviced on changes in resident conditions, stop and watch. The talked about recognizing changes in residents' normal behavior and baselines like pain, eating, nausea, bowel habits and other abnormal things. The CNA's report changes to the nurses and document in the computer. In an interview with RN J on [DATE], at 12:20 a.m., she stated there was always an RN on duty. They were recently in-serviced on giving thorough reports, calling 911 right away and not waiting for transport in emergencies, recognizing changes like abnormal vitals, shortness of breath, signs and symptoms of infection like increase in heart rate, respiratory rate, and fever. They were also educated on notification to NP and documenting vitals every 15 minutes until the ambulance arrived. In an interview with RN Manager K on [DATE], at 12:45 a.m., she stated there was not an RN on duty at all times. On the night Resident #1 went out, there was an LVN manager. She said she was taught in school that RN's were supposed to do assessments but generally, al nurses should assess. If there was anything unusual, the nurse should notify the charge nurse or DON. They were in-serviced on signs and symptoms of infection, including fever, malaise, pain, and warm skin. If there was a wound, they look for drainage, odor, and color changes. They should call the doctor for orders or call 911 not wasting time if they cannot treat in-house. If there was a change in condition, they do vitals and re-check in intervals, looking for trends. They talked about the importance of documenting everything they do. In an interview with LVN L on [DATE], at 11:55 p.m., he stated he was on duty the night Resident #1 went out. He was called over to help by LVN A. He had spoken to the resident earlier during the shift that day and he was fine. He could not recall what time LVN A went to get him for help but she said Resident #1's leg was hurting. LVN A gave him medicine. A short time later, LVN A noted swelling, altered mental status, and vomiting and that was when she called him for help. He knew Resident #1 had a blister on the back of his leg because he was getting treatments. The resident said he thought he laid his leg on something. There was swelling and different stages of discoloration from slightly under the knee and down the leg. Resident #1 was out of it by this time. He helped the resident into bed and cleaned him up. They gave him medication for fever then the fever increased (TRUNCATED)

Based on observation , interview and record review, the facility failed to ensure that residents receive treatments and care in accordance with professional standards of practice, the comprehensive person- centered care plan that will meet each resident's needs for one of seven residents (CR#1) reviewed for quality of care. The facility did not conduct weekly skin assessments for CR #1 who had a [DIAGNOSES REDACTED]. The facility failed to identify and promptly address changes to CR #1's feet . CR#1 developed gangrene to the right leg which required amputation. These failures affected one former resident and placed him at risk of pain, and diminished quality of life. Findings include: Record review of CR #1's face sheet revealed he was an [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. He was diagnosed with [REDACTED]. He died at the facility on [DATE]. Record review of CR #1's MDS, dated [DATE] revealed he had a BIMS score of 10, indicating moderate cognitive impairment, he required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toilet use, and he was at risk for developing pressure ulcers/injuries. Record review of CR #1's care plan, last updated on [DATE] revealed CR #1 had impaired cognitive function/dementia or impaired thought processes, acute pain in the right knee and [DIAGNOSES REDACTED]. Interventions included: monitor extremities for signs and symptoms of injury, infection, or ulcers; monitor/document/report to MD as needed any signs and symptoms of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain; monitor/document/report to MD any signs and symptoms of skin problems related to [MEDICAL CONDITION]: redness, [MEDICAL CONDITION], blistering, itching, burning, bruises, cuts, other [MEDICAL CONDITION], and impaired circulation . Interventions also revealed; assess bilateral lower extremities for [MEDICAL CONDITION]. Record review of CR#1's weekly skin assessments conducted for CR #1 on the following dates revealed : -[DATE] - Are the resident's toenails in need of podiatry care ? (No) Is the resident's skin intact/unbroken? (Yes) Are there new skin issues not identified last week? (No). -[DATE] - Are the resident's toenails in need of podiatry care ? (Yes) Is the resident's skin intact/unbroken? (No) Are there new skin issues not identified last week? (Yes) . Further review of CR #1's skin assessment dated [DATE] revealed the following skin conditions: -Right buttock -Mild redness at the gluteal fold. -Left buttock - Mild redness at the gluteal fold. -Right heel - 1 cm x 2 cm Black lesion. Right toes - Right great toe 100% black, right third toe 50% plantar region black tissue. Between toes 1,2, and 3 [DIAGNOSES REDACTED] with moderate serosanguaneous drainage. Plantar generalized redness. -Other (specify) - +2 [MEDICAL CONDITION] to left foot. -Other (specify) - Right forearm multiple [MEDICAL CONDITION] (chronic). Notes was signed by the DON on [DATE]. Record review of CR#1's record revealed no documented evidence to show any skin assessments had been conducted for CR #1 between [DATE] and [DATE]. Record review of CR#1's progress notes for (MONTH) 2019 through (MONTH) 2019 revealed the following entries: -[DATE] - Shower tech (not named) reported that resident refused shower. RP was updated. -[DATE] - Charge Nurse A wrote: patient noted with necrotic tissue to great toe on right lower extremity. When patient asked if he knew origin of wound and approximate date and how foot was injured, patient family member spoke and stated, He has been complaining about pain to his foot for approximately two weeks. This nurse then inquired who was notified regarding complaint and the patient stated, the Nurse Practitioner. This nurse then asked if any staff members in the facility was told such as the nurse that gives him medication or the one that provides care/assistance that he could recall, if not a name maybe a color in uniform that he made aware of pain to his foot and the patient stated, Just the Nurse Practitioner. The family member stated, I doubt he told anyone there because the staff changes so often, but he did tell the Nurse Practitioner and she told him that he had gout in his toe and I know he did not make that up. Advised family member patient was being sent to the hospital for further evaluation and treatment and that he was currently refusing head to toe assessment by this nurse stating, I can tell you now I do not have anything on my body This entire note was crossed out and was not re-written. Reason for crossing note out was - incorrect documentation. Interview on [DATE] at 4:00pm , The DON said she Charge Nurse A wrote the above note. The DON said she asked Charge Nurse A to cross out/ cancel the note because it had person names in it and stated CR#1 had necrotic tissue on his toe. The DON said at that time they ( facility) did not know if the resident's toe was necrotic. The DON said other than this, the note was accurate, but Charge Nurse did not re- write the note after crossing it out. Record review of CR #1's hospital records revealed he was admitted to a local hospital on [DATE]. On [DATE] he had a right lower extremity arteriogram (an imaging test that uses X-rays and a special dye to see inside the arteries) and was transferred to ICU. On [DATE], his right leg was amputated above the knee and on [DATE] he was transferred out of ICU. Further review of the hospital records revealed the following: Right lower extremity arterial ultrasound. Impression: 1. Transition from normal triphasic to abnormal monophasic waveform at the level the proximal right superficial femoral artery, suggestive of hemodynamically significant stenosis in that location ( an obstruction/ blockage was identified in the right leg ) 2. 2.4 cm maximal diameter partially [MEDICAL CONDITION] popliteal artery aneurysm, grossly unchanged in size and appearance since [DATE], when allowing for differences in technique .4. No flow visualized within the distal right posterior tibial artery suspicious for occlusion . Assessment and Plan, this is an [AGE] year-old male with the following problems: 1. Gangrene of right 1st and 3rd toes - changes are mostly ischemic, no pus or [MEDICAL CONDITION] 2. Right heel unstageable wounds x2 with eschar 3. [MEDICAL CONDITION] previous bypass. Procedure: Right Amputation, Above knee . Record review of CR#1's progress note dated [DATE] revealed Resident brought to facility by stretcher at 7:15 p.m. alert and oriented x3. Afebrile. Resident is able to make needs known. Head to toe assessment done. Resident's right leg amputated above the knee. Stump is clean with sutures . Record review of facility document, In-Service Training Report, dated [DATE] revealed the facility's nurses and CNA's were trained on skin assessments. It read in part, CNA will/must notify nurse of any skin condition. Record review of facility document, In-Service Training Report, dated [DATE] revealed the facility's CNA's and nursing staff were trained on skin assessment/documentation/notification. It read in part, .Contents or summary of training sessions: .CNA will notify nurse of new skin conditions Record review of facility document, In-Service Training Report, dated [DATE] revealed the facility's nurses and CNA's were trained on skin assessments/notification. It read in part, Skin condition changes must be brought to the immediate attention of nurse. In a telephone interview with CR #1's family member on [DATE] at 12:50 p.m., revealed in (MONTH) 2019, another family member called her and said CR #1 had gangrene in his leg and foot. She said the facility's DON told them she had noted the black spots on the resident's foot but did nothing. The family member said 10 days later, CR #1 went to the hospital for an amputation. In an interview with the facility's DON on [DATE] at 1:30 p.m., she stated CR #1 had a vascular wound. He had black spots from his condition of [MEDICAL CONDITION]. She said the black spots would open and a Doppler test was done and found out his condition was much worse. She said he never had gangrene at the facility. She said if he had gangrene, it did not happen at the facility. When asked for the Doppler test order and result mentioned in the note, the DON said she would look for it but did not provide any prior to exit. In a later interview with the DON on [DATE], at 2:45 p.m., she stated no skin assessments were done in (MONTH) 2019 for the entire building. When she found out about the problem, she did a QAPI and did a skin assessment sweep of the entire building. The weekend treatment nurse was terminated and the other one was demoted back to the floor. CR #1 was sent out in (MONTH) 2019 because he had an itchy area he had complained to his family member about. They did a Doppler and the results were bad. They sent him out and his leg was amputated. She said it was from ischemia and became gangrene. The DON said it happened very quickly and it was handled quickly. She said the facility could not have caused gangrene. At that time, the facility was five weeks behind on skin assessments. The black spots were ischemia and the resident was sent to the hospital. The DON said she was hired in (MONTH) 2019 and at that time, things were not being done. The DON said she now supervised the charges nurse and treatment nurse to ensure skin assessment were done. Record review of CR#1's record revealed there was no evidence of ordered Doppler test or results from a Doppler in the progress notes and in all of the residents record. In an interview with LVN B on [DATE], at 3:15 p.m., she stated CR #1 was her patient before he died . He once complained of leg pain, but it was not swollen when she looked at it. He was a diabetic and already had dark spots on his leg. CR #1 would say he felt better after getting Tylenol. The day he went out to the hospital, the treatment nurse ( Charge Nurse A) was with him. CR #1 would always wear socks, but she saw his foot that day. It was strange he did not get up that day, so LVN B looked at his feet to see why. His foot was darker than usual. The resident was asleep and LVN B saw a little bit of blood on his toe. His foot just did not look okay. She went to get the treatment nurse. LVN B said she did not know if CR #1 was already being treated for [REDACTED]. She said the treatment nurse was responsible for doing skin assessments. She recalled all the nurses doing them and she did not recall being behind. In an interview with Charge Nurse C on [DATE] at 3:45 p.m., she stated she was one of the treatment nurses at the time CR #1 went out to the hospital. After that, she decided to go to the floor. As treatment nurse, she was responsible for the whole building and it was too much. She also did daily wound care. In (MONTH) 2019, she only did some weeks. She said she could not keep up. Each resident in the building got a head-to-toe skin assessment every week. They did have a system in place. Some were done on the weekends too. She never got to CR #1. She said she thought he was done on weekends. She did not recall ever doing any treatments or assessments on CR #1. In an interview with the DON on [DATE] at 4:30 p.m., she stated at the time CR #1 was sent out, there were two shower techs. She thought they were doing shower sheets, but she could not locate any shower sheets. No skin assessments were done for CR #1 between [DATE] and [DATE]. That was when she discovered the problem. His incident made her do the skin sweep of the building. Charge Nurse A was doing the weekend skin assessments and was terminated. CR#1 was getting showers during that time and the DON recalled Shower Tech D did mention something on CR #1's legs. He was being treated for [REDACTED]. She thought he was being treated by the treatment nurse at that time. Shower Tech D would have been the only one to give him showers at that time. She stated none of the current CNA's would have worked with him prior to his amputation. The DON provided several names of CNA's who may have worked with CR #1 prior to his amputation. The DON attempted to contact Shower Tech D by phone, but she did not answer. Record review of CR #1's TAR for (MONTH) 2019 through (MONTH) 2019 revealed CR #1 was not being treated for [REDACTED]. An attempt was made to contact Shower Tech D by phone on [DATE] at 5:53 p.m. A voicemail message was left but phone call was not returned. An attempt was made to contact CNA [NAME] by phone on [DATE] at 5:54 p.m. No message could be left. An attempt was made to contact CNA F by phone on [DATE] at 5:56 p.m. The number was disconnected. The DON was asked to provide physician notes for CR #1 prior to his amputation on [DATE], at 6:15 p.m. Facility policy on quality of care, change in condition , consult physician for a change as well as skin integrity were requested at this time but were not provided prior to exit. Record review of the physician notes for CR #1 revealed only [DATE] and dates of service after his amputation were available for review. Record review of facility policy Abuse and Neglect, dated [DATE], revealed it read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires, but fails to provide that service . Record review of facility policy Wound Care Policies and Procedures, revised ,[DATE] revealed it read in part, Subject: Licensed Nurse Skin Checks, Policy: All patients/residents will have a thorough weekly skin evaluation performed by a Licensed Nurse. It is also recommended that each facility also perform quarterly skin sweeps.Procedures: Weekly, the Licensed Nurse performs a head to toe check of the patient's/resident's skin, paying particular attention to: [NAME] The surfaces of the skin that come in contact with the bed and chair B. Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.) .Observing for: [NAME] Redness . B. Rashes C. Bruising D. Open areas 1. Any significant abnormal findings are reported to the patient's/resident's physician and patient/resident contact person .2. Documentation that the check was performed is denoted on the Medication Administration Record [REDACTED]. 3. Abnormal findings to be documented in the Nurse's Note or to be documented on the back of the TAR is space allows .

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 2 of 5 residents (CR #1 and #5) reviewed for neglect. The facility did not monitor Hoyer lift slings used for mechanical transfer of residents and did not have a way of ensuring worn out slings were not in use. The facility identified a hoyer lift sling was worn out but did not ensure other slings used for resident transfers were in good working condition. The facility failed to ensure the mechanical lift sling used to transfer CR#1 was in good condition . CR#1 sustained multiple facial fractures and multiple skin tears from a fall when the mechanically sling broke in two areas while he was suspended in the air during a transfer by two aides . The facility failed to assess, monitor for signs and symptoms of infection and provide care to Resident #5 's midline catheter located at her upper right chest wall. Resident #5's midline insertion site was found to have pus four months later and required transfer to hospital for surgical removal. These failures affected 2 residents and placed them at risk of subsequent neglect, harm, pain, mental anguish and or emotional distress. Findings included: TX 537/Intake # 9 TX 688/Intake # 7 TX 107/Intake # 3 TX 007/Intake # 1 TX 194/intake # 0 TX 308/Intake # 6 CR#1 Record review of CR#1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 8 indicating moderately impaired cognition , he required extensive assistance with transfers , required two people to assist with transfers and had no limitation in range of motion on both side of upper and lower extremities. Record review of CR#1's care plan dated 3/15/19 revealed CR#1 was at risk of fall and fractures and required utilization of mechanical lift with 2+ staff assistance for transfers. Record review of facility's laundry log dated 3/13/19 revealed Hoyer lift sling was worn out and was thrown away, a new Hoyer Lift sling was ordered to replace it. Record review of CR#1's nurse's notes dated on 3/28/19 at 13:25p.m revealed staff member called the attention of the nurse to CR#1's room, upon arrival resident was noted on the floor with left eye open laceration, multiple skin tear to left shoulder. CNA stated, while transferring resident from Hoyer lift to bed, the sling strap broke on one side , resident fell to the floor . BP 180/100, Pulse 74, Resp 20 unlabored, resident oriented x2, resident transported to local hospital. Record review of CR#1's incident report dated 04/01/19 written by CNA A revealed I went to transfer CR#1 with CNA B, CR#1 was in the Hoyer, examined the sling before use and there were no problem identified. CR#1 was in the air when one of the corners popped, I tried to move him over the bed , the another corner let go and CR#1 fell on the floor. It was very fast that CAN B tried to catch one of the corners but was not able to Record review of CR#1's incident report dated 04/01/19 written by CNA B revealed I was helping CNA A to transfer CR #1 from the shower chair to his bed using the Hoyer transfer . The Hoyer lift sling was examined before use and there was no problem found. We had the resident in by the bed when one of the strap broke then another one and the resident landed to the floor. I was behind the shower chair , CNA A was on the side with the button. The sling just snapped, I did not have time to do anything. Record review of CR#1's hospital discharge records dated 04/02/19 revealed CR#1 sustained a fall with associated underlying facial fractured and left cheek lacerations. CT of the face dated 4/2/19 revealed comminuted minimally depressed [MEDICAL CONDITION] orbital floor , comminuted and slightly depressed [MEDICAL CONDITION] wall of the left maxillary sinus along with blood within the maxillary sinus and minimally displaced left nasal bone fracture . He also had 7cm laceration of his left cheek which was washed out in the ER and repaired. CR#1 had abrasion and superficial lacerations over his arm Interview on 04/02/19 at 11:50a.m., the Administrator said the staff informed him of the incident that happened to CR#1. He said he didn't know how it happened, he said he gave in services to all nursing staffs, he said he ordered new slings to replace the old ones. Surveyor asked for the old sling to be observed, he said the old sling had been thrown away. Interview on 04/02/19 at 12:30p.m., CNA A and CNA B said they transferred CR#1 from bed to shower chair, they both said they checked the Hoyer sling/strap before the transfer and they did not notice any wear and tear on the sling strap. CNA A said she gave shower to the resident with the sling underneath the resident and then she wheeled resident to his room. CNA A said when she got to the room, she called for CNA B to help her with the transfer back to the bed. She said she did not check the sling strap before transferring the resident back to bed. CNA A said she was the one assisting with holding the resident while CNA B was controlling the mechanical lift, she said while the resident was on the air, one of the sling straps broke off the connection , she said as she was trying to ensure that CR#1 did not fall, the other sling strap on the same side broke off from the connection then the resident fell face down on the mechanical lift. CNA A said she rolled CR#1 over , CNA B quickly ran to call for help while she stayed with the resident. CNA A said the charge nurse assessed the resident, CR#1 sustained injury with blood on his face, the facility called 911 and the resident was transferred to the local hospital for treatment. CNA A said the facility gave in-service on the incident and all Hoyer mechanical lift were inspected. Observation and attempted interview on 04/03/19 at 10:00am at another skilled nursing facility revealed CR#1 was lying in bed, he did not respond to greetings and question asked about his fall, and was observed to have multiple injuries as following ; a. 13 stitches to wound under his left eye with measurement of 8.0cm x 1.0cm. b. Skin tear to right upper arm with measurement of 2.5cm x 1.0cm c. Skin tear with flap to right wrist with measurement of 3.0cm x 4.0cm d. Skin tear with flap to fore arm with measurement of 2.0cm x 6.5cm e. Skin tear to left upper arm with measurement of 14.0cm x 8.0cm f. Skin tear to left mid arm with 7 strips observed with fluid underneath with measurement of 7.0cm x 5.0cm g. Skin tear to left elbow with measurement of 3.0cm x 5.0cm h. Skin tear to left forearm with 4 strips with measurement of 4.0cm x 3.5cm i. Bruises to right chest wall j. Bruises to mid chest clavicle area k. Scar to left knee l. Bruises to left shin m. Laceration to scalp near left ear with measurement of 3.0cm x 1.0cm n. Bruises to left shoulder blade o. Scar to left shoulder with measurement of 1.0cm x 1.0cm p. Bloody blister on 3rd digit of left hand q. Left hand swollen with bruises on all fingers r. Swollen neck from mid area to left side with difficulty in swallowing. Interview on 04/04/19 at 10:00a.m., CNA A said she did not know who check the sling to ensure safety. She said she thought the Administrator checked them once a week but made sure she checked the slings before using it. She said she did not notice any wear and tear on the sling. she said the slings were washed by the laundry after each use. Interview on 04/04/19 at 10:55am, Laundry Aide A said staff returned about 6 slings daily to the laundry to be washed. She said she got two slings each shift which were washed in the machine and then air dried. She said the CNAs brought the dirty slings to the laundry to be washed and took the clean ones. She said the facility just bought some new slings, she noticed the old slings were not smooth, the colors were fading away, and she did not pay attention to the sling straps. She said she just knew that the colors were fading, and they looked old. Surveyor asked her why the old slings were thrown away, she said they should not have thrown them away, she said she thought they are still in the building. Interview on 04/04/19 at 11:20am, CNA C said she provided showers to residents on weekends and any day the shower tech was not available. She stated all I can say is that the shower slings were old and kind of loose. I cannot really described further the wear and tear of the sling, I noticed that whenever I helped the shower technician. I did not make any recommendation for new slings. I was informed that new slings were ordered. Interview on 04/04/19 at 11:38am, CNA D said she gave residents showers and noticed that said some of the slings were too old and not too good. She said the facility did not provide new Hoyer lift shower slings until after the incident. She said some aides told her that the slings were old but would not mention names. Interview on 04/04/19 at 11:50am, CNA [NAME] said she did not give showers but helped the shower technician during shower. She said the shower sling they had before were pretty old. She heard about CR#1's fall incident but was not in the building when the incident happened. She said the facility gave her in service after the incident on checking Hoyer lift slings prior to using them. In an interview on 04/04/19 at 1:50p.m., the DON said the facility assessed the resident and who was taking to a local hospital. The DON said she in serviced all the nursing staff on checking and monitoring of Hoyer lift's slings. The DON said all the old slings were thrown away, she re- educated CNAs to always check the sling before use and educated other staff to follow the manufacturer instruction before using it. The DON said she checked off CNAs of the training which she initiated after the CR#1's incident. Record review of facility in-service dated 03/28/19 revealed one on one in service provided to CNA A and CNA B on inspecting Hoyer lift slings and equipment for proper working condition with assistance from another staff member before use. Further review of facility in service log revealed in-services were provided to facility staff members on 03/29/19, 03/30/19 and 04/01/19 on the following areas; 1. Inspection of the sling to make sure they are in good condition 2. Making sure the resident's weight is appropriate for the sling 3. Ensure Hoyer battery is charge 4. 2 people for all Hoyer transfers 5. No combative resident should placed in the Hoyer. 6. Follow the manufacturer instruction when washing the sling 7. Only air dry the sling. 8. Any frayed sling should be pulled out of service Record review of facility provided information on Hoyer lift safe transfers guidelines not dated revealed it did not address monitoring the condition of the slings or straps. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and re - admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Admission Minimum Data Set (MDS) assessment, dated 12/07/18 revealed Resident #5 had clear speech, she had no difficulty understanding others and others had no difficulty understanding her. Resident #5 needed extensive assistance of one staff for all activities of daily living (ADLs) and had a BIMS score of 15 indicating intact cognition. The MDS did not indicate the resident had any midline catheter at her right chest wall. Record review of Resident#5's records from 11/30/18 to 02/26/19 did not reveal any documentation indicating Resident #5's admitted to the facility with midline catheter. Record review of Resident #5's admission and readmission skin assessment sheet for Resident #5 on 11/30/18 and 02/26/19 revealed skin intact, no documentation of midline catheter was present on the resident . Record review of Resident #5's care plan dated 02/26/19 did not reveal any care plan for Resident #5's midline catheter. Record review of nurse's progress note from 2/26/19 to 03/24/19 did not reveal any documentation of Resident #5's midline catheter line. Record review of nurse's progress note on 03/25/19 at 04:05p.m. written by ADON A revealed spoke to Resident #5 and educated her regarding need to have the tunneled catheter removed, resident was told local hospital was able to remove the catheter. Resident #5 refused to go to the local hospital. A new order was given to transfer resident to the ER . Resident #5's RP was notified Record review of nurse's progress note on 03/25/19 at 05:05p.m., written by ADON A revealed Resident #5 returned from hospital ER. Charge nurse was told that (Hospital staff) were unable to remove the tunneled catheter as this is an outpatient procedure Record review of nurse's progress note on 03/26/19 at 01:35p.m.,written by ADON B revealed Resident #5 was sent to ER to have the tunneled catheter removed, ER called the facility and reported they were unable to remove catheter due to scheduling, an appointment was set for 3/27/19 at 1:00pm. Record review of nurse's progress note on 03/27/19 at 01:32p.m. written by RN B revealed Resident #5 left facility for doctor's appointment for the removal of tunneled catheter . Interview on 04/02/19 at 11:50am, the Administrator said Resident #5 needed her line taken out, he said the resident refused to go to one of the local hospitals. The Administrator said the facility tried several local hospitals to get the line removed but none of the hospitals would take her. He said they finally got an appointment with VA medical center and the line was removed . The Administrator said the resident came back to the facility the same day and was doing fine. Interview on 04/02/19 at 11:55 a.m., the DON said Resident #5 was readmitted from hospital on [DATE] with a midline on her right chest wall. The DON said she did not know why the nurses in charge missed the midline during the resident's admission and readmission assessments. The DON said admission nurse was responsible for completion of head to toe assessment upon a resident's admission or readmission to the facility. The DON said the facility discovered that the resident has a midline on 03/26/19 when the VA program director came to visit Resident #5. She said they(facility) immediately got an order to remove at a local hospital to avoid complications. Interview on 04/02/19 at 01:00 p.m., the VA program manager said Resident #5's family member called and lodged a complaint about Resident #5's central line that was inserted last year, he said the family member was concerned that the line had been there for a longer period without use since re admission to the facility on [DATE]. He said he came to the facility on [DATE] to check on the resident when family member requested the line to be removed and found out the facility did not have doctor's order for the care of the line and had no documentation of the line in the nurses' progress notes. The VA program manager said he saw a dressing on the resident's right chest wall dated 3/13/19, he said it was transparent [MEDICATION NAME] dressing. There was no order for the dressing and he observed pus underneath the [MEDICATION NAME] dressing. The VA program manager said he gave a STAT order for one-week antibiotic, an order for [REDACTED]. He said he requested the facility to send him an action plan which will be reviewed by the VA medical team. Interview on 04/02/19 at 02:00 p.m., the ADON A said Resident #5 was re-admitted on [DATE] by RN A. She said the new admission protocol included head to toe assessment and checking the skin for any bruises, lines, tubes and pressure ulcers and reviewing admitting medications. She said the admitting nurse should document all findings in the EMR. When asked why nurses did not document Resident #5's midline catheter , she said she did not know why the nurses did not document because she could not speak for them. ADON A said she was responsible for ensuring Medicare residents were charted on correctly, admission and discharged residents are processed correctly. When asked why no staff identified the midline on the chest wall of Resident #5 upon admission and 4 months later , she said she just recently start looking at admission and discharge, there had been an in service for nurses on admission and skin assessment. ADON A said the wound care nurse was supposed to do skin assessments and the facility just got a full-time wound care nurse. ADON A said before the new wound care nurse was hired, the nurses were responsible for assigned residents' skin assessment. Interview on 04/02/19 at 02:39 p.m., RN B said she was not the one that admitted Resident #5 she said she completed head to toe assessment whenever a new resident was admitted . She said she did not know why the admitting charge nurse did not document the catheter line when the resident came in. When asked how a midline catheter line would be identified on a new resident, she said she will get information from the local hospital about the resident and assessment. Interview on 04/02/19 at 03:00 p.m., LVN B said the admission protocol included completion of head to toe assessment nurses. She said she will take the resident clothes off in order to verify any skin issue and would be looking for any abnormalities that needed to be documented and would ask the local hospital about the resident status before arrival. She said she will review discharged summary sent via fax to receptionist. Observation and Interview on 4/2/19 at 3:20 p.m. of Resident #5 who was in her room in wheelchair. Her right chest had a dressing dated 4/2/19. With the assistance of RN B, the dressing was removed, no pus was seen, and the surrounding area was red. Resident #5 could not respond to surveyor's question and appeared to be sleepy. Interview on 04/02/19 at 03:40 p.m., LVN C said if she had an admission coming in, she said she would receive report from the facility or local hospital, look at the report from the other facility for discharge instruction to be applied to the resident care , notify the doctor for further instruction, and also notify the family if there was any consent to be signed. She said she would then fax medication to pharmacy for any stat order. She said she would complete head to toe assessment, check the skin for abnormalities like bruises, redness and intravenous lines. She said if there was any intravenous line, she would check for the insertion date and notify the doctor for order to treat and document her findings in the progress note as well as give verbal report to an incoming shift. Phone interview on 04/02/19 at 03:50 p.m., Resident #5's family member said she lived out of state and Resident #5's central line was placed around thanksgiving time in (YEAR) at a local hospital for antibiotic treatment. She said it was placed on her upper right chest wall. Resident #5 was brought to the facility in (MONTH) (YEAR) with the central line. Family member said she came back in (MONTH) 2019 to visit Resident #5 and discovered the line had not been removed but was not in use. She said she asked one of the nurses why Resident #5 still had the line but no one gave her a concrete answer. She said she requested to speak to the doctor from a facility staff ( unknow name ) and never got any response back. Resident #5's family member further said, the line was sitting there for a long time, it got stacked and was surgically removed last week. Interview on 04/02/19 at 04:00 p.m., the DON said she assumed duty on (MONTH) 12th, (YEAR), did not know anything about Resident #5's central line. She said she first got to know about it when the VA program director came to the facility on [DATE]. She said she later knew that the line was had been inserted since (MONTH) (YEAR). She said the protocol for admission will be for the admitting nurse to have a complete body assessment, remove the resident's clothes to make sure all the skin is being assessed, get an order to remove any line that is not in use, document in the progress report any of the findings noted during assessment and verbally inform the incoming shift as well. Surveyor asked if the facility did a culture test of Resident #5's midline site she said no culture test was done Interview on 04/02/19 at 04:15 p.m., DON said Resident #5 did not return with any record after the line was removed at the hospital Interview on 04/04/19 at 12:10 p.m., LVN D said he was the MDS nurse and based his MDS assessment on information on the nurse's assessment and his own assessment. He said he completed head to toe assessment for information needed to the resident's MDSs. He said he did not do physical assessment on Resident #5but he remembered going through the nurses notes for her information. He said the only completed MDS section C and G section and the resident refused the skin assessment as at the time. Surveyor asked if he documented the resident refusal anywhere on the resident's record. LVN D said he did not document the refusal of the skin assessment. He stated, not that I recall. He said he did not include the central line on the resident's care plan following initial admission of Resident #5 because he did not know the resident has a midline central line. Interview on 04/04/19 at 01:30 p.m., RN A said the protocol for admission was for the admitting nurse to verify medications and make sure the resident was comfortable. RN A said he would complete a skin assessment to check for bruises, intravenous line, any wound or pressure, and would document all of his finding in the nurses' progress note. He said he was the one that re- admitted Resident #5 on 2/26/1 and he completed skin assessment on the resident. He further said he must have missed the part that she has a catheter line on her right upper chest wall. He said it was probably because the resident came in late into the shift and it was almost time for him to end his shift. Further interview at the same date and time with RN A, he said he knew the resident had the line before the readmission on 02/26/19 and he always flushed the line. Surveyor asked if there was an order to flush the line that he knew about but he said the facility has a standing order to flush lines. Surveyor asked for the documentation of the flush and RA A said he cannot say 100% if he documented the flush but he would look into it. RN A did not provide any documentation of Resident #5's midline catheter flushes requested prior to exit. Interview on 04/04/19 at 02:10 p.m., NP said she had been seeing Resident #5 since she admitted to the facility. NP said she conducted monthly focused visits and if there were any need for the resident to be seen, the facility would call for her service. She said she remembered the resident admitted with a tunneled line, but she forgot to document it in her progress note. NP said the line was the type that was surgically placed underneath the skin and if it was not in use it will not pose any danger to the resident. She said she did not give any order to care for the site because it was an oversight on her part. She said the facility nurses should have called her to request for order to treat. NP said she gave an order for [REDACTED].>Record review of the facility Policy titled Abuse and Neglect undated revealed the following Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires but fails to provide that services.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, comprehensive person-centered care plan, and the physician order to treat 1 of 5 residents ( Resident #5) reviewed for quality of care. Facility licensed nursing staff did not perform initial head to toe skin assessment on CR#1 on admission and on re-admission to identify a midline catheter on her left upper chest wall . The facility failed to obtain physician's orders at the time of admission on 11/30/18 and re-admission on 02/26/2019 for midline catheter treatment care for Resident #5. The facility failed to ensure Resident #5's admission and re-admission assessments MDS reflected that the resident had a midline catheter. The facility failed to ensure Resident #5 who was admitted with a midline catheter had care plan that addressed her midline catheter care. The facility failed to assess, monitor for signs and symptoms of infection and provide care to Resident #5 's midline catheter located at her upper right chest wall. Resident #5's midline insertion site was found to have pus four months later and required transfer to hospital for surgical removal. This failure affected 1 resident and placed her at risk of infection, occlusion, and inadequate catheter care. Findings included: TX 007/Intake # 1 Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and re - admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Admission Minimum Data Set (MDS) assessment, dated 12/07/18 revealed Resident #5 had clear speech, she had no difficulty understanding others and others had no difficulty understanding her. Resident #5 needed extensive assistance of one staff for all activities of daily living (ADLs) and had a BIMS score of 15 indicating intact cognition. The MDS did not indicate the resident had any midline catheter at her right chest wall. Record review of Resident#5's records from 11/30/18 to 02/26/19 did not reveal any documentation indicating Resident #5's admitted to the facility with midline catheter. Record review of Resident #5's admission and readmission skin assessment sheet for Resident #5 on 11/30/18 and 02/26/19 revealed skin intact, no documentation of midline catheter was present on the resident . Record review of Resident #5's care plan dated 02/26/19 did not reveal any care plan for Resident #5's midline catheter. Record review of nurse's progress note from 2/26/19 to 03/24/19 did not reveal any documentation of Resident #5's midline catheter line. Record review of Resident# 5's Physician orders dated revealed no physician order for [REDACTED].>Further review of CR#1's physician order revealed an order dated 3/25/19 to change right chest wall central line dressing one time a day for 7 days for [MEDICATION NAME]. This was the only order addressing CR#1's midline catheter . Record review of nurse's progress note on 03/25/19 at 04:05p.m. written by ADON A revealed spoke to Resident #5 and educated her regarding need to have the tunneled catheter removed, resident was told local hospital was able to remove the catheter. Resident #5 refused to go to the local hospital. A new order was given to transfer resident to the ER . Resident #5's RP was notified Record review of nurse's progress note on 03/25/19 at 05:05p.m., written by ADON A revealed Resident #5 returned from hospital ER. Charge nurse was told that (Hospital staff) were unable to remove the tunneled catheter as this is an outpatient procedure Record review of nurse's progress note on 03/26/19 at 01:35p.m.,written by ADON B revealed Resident #5 was sent to ER to have the tunneled catheter removed, ER called the facility and reported they were unable to remove catheter due to scheduling, an appointment was set for 3/27/19 at 1:00pm. Record review of nurse's progress note on 03/27/19 at 01:32p.m. written by RN B revealed Resident #5 left facility for doctor's appointment for the removal of tunneled catheter . Interview on 04/02/19 at 11:50am, the Administrator said Resident #5 needed her line taken out, he said the resident refused to go to one of the local hospitals. The Administrator said the facility tried several local hospitals to get the line removed but none of the hospitals would take her. He said they finally got an appointment with VA medical center and the line was removed . The Administrator said the resident came back to the facility the same day and was doing fine. Interview on 04/02/19 at 11:55 a.m., the DON said Resident #5 was readmitted from hospital on [DATE] with a midline on her right chest wall. The DON said she did not know why the nurses in charge missed the midline during the resident's admission and readmission assessments. The DON said admission nurse was responsible for completion of head to toe assessment upon a resident's admission or readmission to the facility. The DON said the facility discovered that the resident has a midline on 03/26/19 when the VA program director came to visit Resident #5. She said they (facility) immediately got an order to remove at a local hospital to avoid complications. Interview on 04/02/19 at 01:00 p.m., the VA program manager said Resident #5's family member called lodged a complaint about Resident #5's central line that was inserted last year, he said the family member was concerned that the line had been there for a longer period without use since re admission to the facility on [DATE]. He said he came to the facility on [DATE] to check on the resident when family member requested the line to be removed and found out the facility did not have doctor's order for the care of the line and had no documentation of the line in the nurses' progress notes. The VA program manager said he saw a dressing on the resident's right chest wall dated 3/13/19, he said it was transparent [MEDICATION NAME] dressing. There was no order for the dressing and he observed pus underneath the [MEDICATION NAME] dressing. The VA program manager said he gave a STAT order for one-week antibiotic, an order for [REDACTED]. He said he requested the facility to send him an action plan which will be reviewed by the VA medical team. Interview on 04/02/19 at 02:00 p.m., the ADON A said Resident #5 was re-admitted on [DATE] by RN A. She said the new admission protocol included head to toe assessment and checking the skin for any bruises, lines, tubes and pressure ulcers and reviewing admitting medications. She said the admitting nurse should document all findings in the EMR. When asked why nurses did not document Resident #5's midline catheter , she said she did not know why the nurses did not document because she could not speak for them. ADON A said she was responsible for ensuring Medicare residents were charted on correctly, admission and discharged residents are processed correctly. When asked why no staff identified the midline on the chest wall of Resident #5 upon admission and 4 months later , she said she just recently start looking at admission and discharge, there had been an in service for nurses on admission and skin assessment. ADON A said the wound care nurse was supposed to do skin assessments and the facility just got a full-time wound care nurse. ADON A said before the new wound care nurse was hired, the nurses were responsible for assigned residents' skin assessment. Interview on 04/02/19 at 02:39 p.m., RN B said she was not the one that admitted Resident #5 she said she completed head to toe assessment whenever a new resident was admitted . She said she did not know why the admitting charge nurse did not document the catheter line when the resident came in. When asked how a midline catheter line would be identified on a new resident, she said she will get information from the local hospital about the resident and assessment. Interview on 04/02/19 at 03:00 p.m., LVN B said the admission protocol included completion of head to toe assessment nurses. She said she will take the resident clothes off in order to verify any skin issue and would be looking for any abnormalities that needed to be documented and would ask the local hospital about the resident status before arrival. She said she will review discharged summary sent via fax to receptionist. Observation and Interview on 4/2/19 at 3:20 p.m. of Resident #5 who was in her room in wheelchair. Her right chest had a dressing dated 4/2/19. With the assistance of RN B, the dressing was removed, no pus was seen, and the surrounding area was red. Resident #5 could not respond to surveyor's question and appeared to be sleepy. Interview on 04/02/19 at 03:40 p.m., LVN C said if she had an admission coming in, she said she would receive report from the facility or local hospital, look at the report from the other facility for discharge instruction to be applied to the resident care , notify the doctor for further instruction, and also notify the family if there was any consent to be signed. She said she would then fax medication to pharmacy for any stat order. She said she would complete head to toe assessment, check the skin for abnormalities like bruises, redness and intravenous lines. She said if there was any intravenous line, she would check for the insertion date and notify the doctor for order to treat and document her findings in the progress note as well as give verbal report to an incoming shift. Phone interview on 04/02/19 at 03:50 p.m., Resident #5's family member said she lived out of state and Resident #5's central line was placed around thanksgiving time in (YEAR) at a local hospital for antibiotic treatment. She said it was placed on her upper right chest wall. Resident #5 was brought to the facility in (MONTH) (YEAR) with the central line. Family member said she came back in (MONTH) 2019 to visit Resident #5 and discovered the line had not been removed but was not in use. She said she asked one of the nurses why Resident #5 still had the line but no one gave her a concrete answer. She said she requested to speak to the doctor from a facility staff ( unknow name ) and never got any response back. Resident #5's family member further said, the line was sitting there for a long time, it got stacked and was surgically removed last week. Interview on 04/02/19 at 04:00 p.m., the DON said she assumed duty on (MONTH) 12th, (YEAR), did not know anything about Resident #5's central line. She said she first got to know about it when the VA program director came to the facility on [DATE]. She said she later knew that the line was had been inserted since (MONTH) (YEAR). She said the protocol for admission will be for the admitting nurse to have a complete body assessment, remove the resident's clothes to make sure all the skin is being assessed, get an order to remove any line that is not in use, document in the progress report any of the findings noted during assessment and verbally inform the incoming shift as well. Surveyor asked if the facility did a culture test of Resident #5's midline site she said no culture test was done Interview on 04/02/19 at 04:15 p.m., DON said Resident #5 did not return with any record after the line was removed at the hospital Interview on 04/04/19 at 12:10 p.m., LVN D said he was the MDS nurse and based his MDS assessment on information on the nurse's assessment and his own assessment. He said he completed head to toe assessment for information needed to the resident's MDSs. He said he did not do physical assessment on Resident #5but he remembered going through the nurses notes for her information. He said the only completed MDS section C and G section and the resident refused the skin assessment as at the time. Surveyor asked if he documented the resident refusal anywhere on the resident's record. LVN D said he did not document the refusal of the skin assessment. He stated, not that I recall. He said he did not include the central line on the resident's care plan following initial admission of Resident #5 because he did not know the resident has a midline central line. Interview on 04/04/19 at 01:30 p.m., RN A said the protocol for admission was for the admitting nurse to verify medications and make sure the resident was comfortable. RN A said he would complete a skin assessment to check for bruises, intravenous line, any wound or pressure, and would document all of his finding in the nurses' progress note. He said he was the one that re- admitted Resident #5 on 2/26/1 and he completed skin assessment on the resident. He further said he must have missed the part that she has a catheter line on her right upper chest wall. He said it was probably because the resident came in late into the shift and it was almost time for him to end his shift. Further interview at the same date and time with RN A, he said he knew the resident had the line before the readmission on 02/26/19 and he always flushed the line. Surveyor asked if there was an order to flush the line that he knew about but he said the facility has a standing order to flush lines. Surveyor asked for the documentation of the flush and RA A said he cannot say 100% if he documented the flush but he would look into it. RN A did not provide any documentation of Resident #5's midline catheter flushes requested prior to exit. Interview on 04/04/19 at 02:10 p.m., NP said she had been seeing Resident #5 since she admitted to the facility. NP said she conducted monthly focused visits and if there were any need for the resident to be seen, the facility would call for her service. She said she remembered the resident admitted with a tunneled line, but she forgot to document it in her progress note. NP said the line was the type that was surgically placed underneath the skin and if it was not in use it will not pose any danger to the resident. She said she did not give any order to care for the site because it was an oversight on her part. She said the facility nurses should have called her to request for order to treat. NP said she gave an order for [REDACTED].>The facility undated policy for Quality of Care on Skin Assessment read in part . Upon an admission or re -admission, a full body assessment should be performed, and any findings documented. MD and family are to be notified. Check areas for peripheral lines, central lines or any other artificial device (ex: catheter), indicate reason for the device if found. Ensure to get an order for [REDACTED].

Based on observation, interview and record review, the facility failed to assure that all licensed nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 5 residents ( Resident #5) reviewed for Nursing Services. Facility licensed nursing staff did not perform initial head to toe skin assessment on CR#1 on admission and on re-admission to identify a midline catheter on her left upper chest wall . Facility licensed nursing staff failed to obtain physician's orders at the time of admission on 11/30/18 and re-admission on 02/26/2019 for midline catheter treatment care for Resident #5. The facility failed to ensure Resident #5 who was admitted with a midline catheter had care plan that addressed her midline catheter care. The facility failed to assess, monitor for signs and symptoms of infection and provide care to Resident #5 's midline catheter located at her upper right chest wall. Resident #5's midline insertion site was found to have pus four months later and required transfer to hospital for surgical removal. This failure affected 1 resident and placed her at risk of infection, occlusion, and inadequate catheter care. Findings included: TX 007/Intake # 1 Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and re - admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Admission Minimum Data Set (MDS) assessment, dated 12/07/18 revealed Resident #5 had clear speech, she had no difficulty understanding others and others had no difficulty understanding her. Resident #5 needed extensive assistance of one staff for all activities of daily living (ADLs) and had a BIMS score of 15 indicating intact cognition. The MDS did not indicate the resident had any midline catheter at her right chest wall. Record review of Resident#5's records from 11/30/18 to 02/26/19 did not reveal any documentation indicating Resident #5's admitted to the facility with midline catheter. Record review of Resident #5's admission and readmission skin assessment sheet for Resident #5 on 11/30/18 and 02/26/19 revealed skin intact, no documentation of midline catheter was present on the resident . Record review of Resident #5's care plan dated 02/26/19 did not reveal any care plan for Resident #5's midline catheter. Record review of nurse's progress note from 2/26/19 to 03/24/19 did not reveal any documentation of Resident #5's midline catheter line. Record review of Resident# 5's Physician orders dated revealed no physician order for [REDACTED].>Further review of CR#1's physician order revealed an order dated 3/25/19 to change right chest wall central line dressing one time a day for 7 days for [MEDICATION NAME]. This was the only order addressing CR#1's midline catheter . Record review of nurse's progress note on 03/25/19 at 04:05p.m. written by ADON A revealed spoke to Resident #5 and educated her regarding need to have the tunneled catheter removed, resident was told local hospital was able to remove the catheter. Resident #5 refused to go to the local hospital. A new order was given to transfer resident to the ER . Resident #5's RP was notified Record review of nurse's progress note on 03/25/19 at 05:05p.m., written by ADON A revealed Resident #5 returned from hospital ER. Charge nurse was told that (Hospital staff) were unable to remove the tunneled catheter as this is an outpatient procedure Record review of nurse's progress note on 03/26/19 at 01:35p.m.,written by ADON B revealed Resident #5 was sent to ER to have the tunneled catheter removed, ER called the facility and reported they were unable to remove catheter due to scheduling, an appointment was set for 3/27/19 at 1:00pm. Record review of nurse's progress note on 03/27/19 at 01:32p.m. written by RN B revealed Resident #5 left facility for doctor's appointment for the removal of tunneled catheter . Interview on 04/02/19 at 11:50am, the Administrator said Resident #5 needed her line taken out, he said the resident refused to go to one of the local hospitals. The Administrator said the facility tried several local hospitals to get the line removed but none of the hospitals would take her. He said they finally got an appointment with VA medical center and the line was removed . The Administrator said the resident came back to the facility the same day and was doing fine. Interview on 04/02/19 at 11:55 a.m., the DON said Resident #5 was readmitted from hospital on [DATE] with a midline on her right chest wall. The DON said she did not know why the nurses in charge missed the midline during the resident's admission and readmission assessments. The DON said admission nurse was responsible for completion of head to toe assessment upon a resident's admission or readmission to the facility. The DON said the facility discovered that the resident has a midline on 03/26/19 when the VA program director came to visit Resident #5. She said they (facility) immediately got an order to remove at a local hospital to avoid complications. Interview on 04/02/19 at 01:00 p.m., the VA program manager said Resident #5's family member called lodged a complaint about Resident #5's central line that was inserted last year, he said the family member was concerned that the line had been there for a longer period without use since re admission to the facility on [DATE]. He said he came to the facility on [DATE] to check on the resident when family member requested the line to be removed and found out the facility did not have doctor's order for the care of the line and had no documentation of the line in the nurses' progress notes. The VA program manager said he saw a dressing on the resident's right chest wall dated 3/13/19, he said it was transparent [MEDICATION NAME] dressing. There was no order for the dressing and he observed pus underneath the [MEDICATION NAME] dressing. The VA program manager said he gave a STAT order for one-week antibiotic, an order for [REDACTED]. He said he requested the facility to send him an action plan which will be reviewed by the VA medical team. Interview on 04/02/19 at 02:00 p.m., the ADON A said Resident #5 was re-admitted on [DATE] by RN A. She said the new admission protocol included head to toe assessment and checking the skin for any bruises, lines, tubes and pressure ulcers and reviewing admitting medications. She said the admitting nurse should document all findings in the EMR. When asked why nurses did not document Resident #5's midline catheter , she said she did not know why the nurses did not document because she could not speak for them. ADON A said she was responsible for ensuring Medicare residents were charted on correctly, admission and discharged residents are processed correctly. When asked why no staff identified the midline on the chest wall of Resident #5 upon admission and 4 months later , she said she just recently start looking at admission and discharge, there had been an in service for nurses on admission and skin assessment. ADON A said the wound care nurse was supposed to do skin assessments and the facility just got a full-time wound care nurse. ADON A said before the new wound care nurse was hired, the nurses were responsible for assigned residents' skin assessment. Interview on 04/02/19 at 02:39 p.m., RN B said she was not the one that admitted Resident #5 she said she completed head to toe assessment whenever a new resident was admitted . She said she did not know why the admitting charge nurse did not document the catheter line when the resident came in. When asked how a midline catheter line would be identified on a new resident, she said she will get information from the local hospital about the resident and assessment. Interview on 04/02/19 at 03:00 p.m., LVN B said the admission protocol included completion of head to toe assessment nurses. She said she will take the resident clothes off in order to verify any skin issue and would be looking for any abnormalities that needed to be documented and would ask the local hospital about the resident status before arrival. She said she will review discharged summary sent via fax to receptionist. Observation and Interview on 4/2/19 at 3:20 p.m. of Resident #5 who was in her room in wheelchair. Her right chest had a dressing dated 4/2/19. With the assistance of RN B, the dressing was removed, no pus was seen, and the surrounding area was red. Resident #5 could not respond to surveyor's question and appeared to be sleepy. Interview on 04/02/19 at 03:40 p.m., LVN C said if she had an admission coming in, she said she would receive report from the facility or local hospital, look at the report from the other facility for discharge instruction to be applied to the resident care , notify the doctor for further instruction, and also notify the family if there was any consent to be signed. She said she would then fax medication to pharmacy for any stat order. She said she would complete head to toe assessment, check the skin for abnormalities like bruises, redness and intravenous lines. She said if there was any intravenous line, she would check for the insertion date and notify the doctor for order to treat and document her findings in the progress note as well as give verbal report to an incoming shift. Phone interview on 04/02/19 at 03:50 p.m., Resident #5's family member said she lived out of state and Resident #5's central line was placed around thanksgiving time in (YEAR) at a local hospital for antibiotic treatment. She said it was placed on her upper right chest wall. Resident #5 was brought to the facility in (MONTH) (YEAR) with the central line. Family member said she came back in (MONTH) 2019 to visit Resident #5 and discovered the line had not been removed but was not in use. She said she asked one of the nurses why Resident #5 still had the line but no one gave her a concrete answer. She said she requested to speak to the doctor from a facility staff ( unknow name ) and never got any response back. Resident #5's family member further said, the line was sitting there for a long time, it got stacked and was surgically removed last week. Interview on 04/02/19 at 04:00 p.m., the DON said she assumed duty on (MONTH) 12th, (YEAR), did not know anything about Resident #5's central line. She said she first got to know about it when the VA program director came to the facility on [DATE]. She said she later knew that the line was had been inserted since (MONTH) (YEAR). She said the protocol for admission will be for the admitting nurse to have a complete body assessment, remove the resident's clothes to make sure all the skin is being assessed, get an order to remove any line that is not in use, document in the progress report any of the findings noted during assessment and verbally inform the incoming shift as well. Surveyor asked if the facility did a culture test of Resident #5's midline site she said no culture test was done Interview on 04/02/19 at 04:15 p.m., DON said Resident #5 did not return with any record after the line was removed at the hospital Interview on 04/04/19 at 12:10 p.m., LVN D said he was the MDS nurse and based his MDS assessment on information on the nurse's assessment and his own assessment. He said he completed head to toe assessment for information needed to the resident's MDSs. He said he did not do physical assessment on Resident #5but he remembered going through the nurses notes for her information. He said the only completed MDS section C and G section and the resident refused the skin assessment as at the time. Surveyor asked if he documented the resident refusal anywhere on the resident's record. LVN D said he did not document the refusal of the skin assessment. He stated, not that I recall. He said he did not include the central line on the resident's care plan following initial admission of Resident #5 because he did not know the resident has a midline central line. Interview on 04/04/19 at 01:30 p.m., RN A said the protocol for admission was for the admitting nurse to verify medications and make sure the resident was comfortable. RN A said he would complete a skin assessment to check for bruises, intravenous line, any wound or pressure, and would document all of his finding in the nurses' progress note. He said he was the one that re- admitted Resident #5 on 2/26/1 and he completed skin assessment on the resident. He further said he must have missed the part that she has a catheter line on her right upper chest wall. He said it was probably because the resident came in late into the shift and it was almost time for him to end his shift. Further interview at the same date and time with RN A, he said he knew the resident had the line before the readmission on 02/26/19 and he always flushed the line. Surveyor asked if there was an order to flush the line that he knew about but he said the facility has a standing order to flush lines. Surveyor asked for the documentation of the flush and RA A said he cannot say 100% if he documented the flush but he would look into it. RN A did not provide any documentation of Resident #5's midline catheter flushes requested prior to exit. Interview on 04/04/19 at 02:10 p.m., NP said she had been seeing Resident #5 since she admitted to the facility. NP said she conducted monthly focused visits and if there were any need for the resident to be seen, the facility would call for her service. She said she remembered the resident admitted with a tunneled line, but she forgot to document it in her progress note. NP said the line was the type that was surgically placed underneath the skin and if it was not in use it will not pose any danger to the resident. She said she did not give any order to care for the site because it was an oversight on her part. She said the facility nurses should have called her to request for order to treat. NP said she gave an order for [REDACTED].>Record review of the facility policy titled Competency of Nursing Staff dated 2001, revised on (MONTH) (YEAR) read in part . Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: a. Skin and wound care b. Identification of changes in condition .

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 6 resident (CR#1) reviewed for safe requirements. The facility did not monitor Hoyer lift slings used for mechanical transfer of residents and did not have a way of ensuring worn out slings were not in use. The facility identified a Hoyer lift sling was worn out but did not ensure other slings used for resident transfers were in good working condition. The facility failed to ensure the mechanical lift sling used to transfer CR#1 was in good condition . CR#1 sustained multiple facial fractures and multiple skin tears from a fall when the mechanically sling broke in two areas while he was suspended in the air during a transfer by two aides . This failure affected one closed record who sustained an avoidable fall with multiple fractures abrasion, laceration and bruises due to poorly maintained facility equipment. Findings included: TX 537/Intake # 9 TX 688/Intake # 7 TX 107/Intake # 3 TX 007/Intake # 1 TX 194/intake # 0 TX 308/Intake # 6 CR#1 Record review of CR#1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 8 indicating moderately impaired cognition , he required extensive assistance with transfers , required two people to assist with transfers and had no limitation in range of motion on both side of upper and lower extremities. Record review of CR#1's care plan dated 3/15/19 revealed CR#1 was at risk of fall and fractures and required utilization of mechanical lift with 2+ staff assistance for transfers. Record review of facility's laundry log dated 3/13/19 revealed Hoyer lift sling was worn out and was thrown away, a new Hoyer Lift sling was ordered to replace it. Record review of CR#1's nurse's notes dated on 3/28/19 at 13:25p.m revealed staff member called the attention of the nurse to CR#1's room, upon arrival resident was noted on the floor with left eye open laceration, multiple skin tear to left shoulder. CNA stated, while transferring resident from Hoyer lift to bed, the sling strap broke on one side , resident fell to the floor . BP 180/100, Pulse 74, Resp 20 unlabored, resident oriented x2, resident transported to local hospital. Record review of CR#1's incident report dated 04/01/19 written by CNA A revealed I went to transfer CR#1 with CNA B, CR#1 was in the Hoyer, examined the sling before use and there was no problem identified. CR#1 was in the air when one of the corners popped, I tried to move him over the bed , another corner let go and CR#1 fell on the floor. It was very fast that CNA B tried to catch one of the corners but was not able to Record review of CR#1's incident report dated 04/01/19 written by CNA B revealed I was helping CNA A to transfer CR #1 from the shower chair to his bed using the Hoyer transfer . The Hoyer lift sling was examined before use and there was no problem found. We had the resident in by the bed when one of the straps broke then another one and the resident landed to the floor. I was behind the shower chair ; CNA A was on the side with the button. The sling just snapped, I did not have time to do anything. Record review of CR#1's hospital discharge records dated 04/02/19 revealed CR#1 sustained a fall with associated underlying facial fractured and left cheek lacerations. CT of the face dated 4/2/19 revealed comminuted minimally depressed [MEDICAL CONDITION] orbital floor , comminuted and slightly depressed [MEDICAL CONDITION] wall of the left maxillary sinus along with blood within the maxillary sinus and minimally displaced left nasal bone fracture . He also had 7cm laceration of his left cheek which was washed out in the ER and repaired. CR#1 had abrasion and superficial lacerations over his arm Interview on 04/02/19 at 11:50a.m., the Administrator said the staff informed him of the incident that happened to CR#1. He said he didn't know how it happened, he said he gave in services to all nursing staffs, he said he ordered new slings to replace the old ones. Surveyor asked for the old sling to be observed, he said the old sling had been thrown away. Interview on 04/02/19 at 12:30p.m., CNA A and CNA B said they transferred CR#1 from bed to shower chair, they both said they checked the Hoyer sling/strap before the transfer and they did not notice any wear and tear on the sling strap. CNA A said she gave shower to the resident with the sling underneath the resident and then she wheeled resident to his room. CNA A said when she got to the room, she called for CNA B to help her with the transfer back to the bed. She said she did not check the sling strap before transferring the resident back to bed. CNA A said she was the one assisting with holding the resident while CNA B was controlling the mechanical lift, she said while the resident was on the air, one of the sling straps broke off the connection , she said as she was trying to ensure that CR#1 did not fall, the other sling strap on the same side broke off from the connection then the resident fell face down on the mechanical lift. CNA A said she rolled CR#1 over , CNA B quickly ran to call for help while she stayed with the resident. CNA A said the charge nurse assessed the resident, CR#1 sustained injury with blood on his face, the facility called 911 and the resident was transferred to the local hospital for treatment. CNA A said the facility gave in-service on the incident and all Hoyer mechanical lift were inspected. Observation and attempted interview on 04/03/19 at 10:00am at another skilled nursing facility revealed CR#1 was lying in bed, he did not respond to greetings and question asked about his fall, and was observed to have multiple injuries as following ; a. 13 stitches to wound under his left eye with measurement of 8.0cm x 1.0cm. b. Skin tear to right upper arm with measurement of 2.5cm x 1.0cm c. Skin tear with flap to right wrist with measurement of 3.0cm x 4.0cm d. Skin tear with flap to fore arm with measurement of 2.0cm x 6.5cm e. Skin tear to left upper arm with measurement of 14.0cm x 8.0cm f. Skin tear to left mid arm with 7 strips observed with fluid underneath with measurement of 7.0cm x 5.0cm g. Skin tear to left elbow with measurement of 3.0cm x 5.0cm h. Skin tear to left forearm with 4 strips with measurement of 4.0cm x 3.5cm i. Bruises to right chest wall j. Bruises to mid chest clavicle area k. Scar to left knee l. Bruises to left shin m. Laceration to scalp near left ear with measurement of 3.0cm x 1.0cm n. Bruises to left shoulder blade o. Scar to left shoulder with measurement of 1.0cm x 1.0cm p. Bloody blister on 3rd digit of left hand q. Left hand swollen with bruises on all fingers r. Swollen neck from mid area to left side with difficulty in swallowing. Interview on 04/04/19 at 10:00a.m., CNA A said she did not know who check the sling to ensure safety. She said she thought the Administrator checked them once a week but made sure she checked the slings before using it. She said she did not notice any wear and tear on the sling. she said the slings were washed by the laundry after each use. Interview on 04/04/19 at 10:55am, Laundry Aide A said staff returned about 6 slings daily to the laundry to be washed. She said she got two slings each shift which were washed in the machine and then air dried. She said the CNAs brought the dirty slings to the laundry to be washed and took the clean ones. She said the facility just bought some new slings, she noticed the old slings were not smooth, the colors were fading away, and she did not pay attention to the sling straps. She said she just knew that the colors were fading, and they looked old. Surveyor asked her why the old slings were thrown away, she said they should not have thrown them away, she said she thought they are still in the building. Interview on 04/04/19 at 11:20am, CNA C said she provided showers to residents on weekends and any day the shower tech was not available. She stated all I can say is that the shower slings were old and kind of loose. I cannot really described further the wear and tear of the sling, I noticed that whenever I helped the shower technician. I did not make any recommendation for new slings. I was informed that new slings were ordered. Interview on 04/04/19 at 11:38am, CNA D said she gave residents showers and noticed that said some of the slings were too old and not too good. She said the facility did not provide new Hoyer lift shower slings until after the incident. She said some aides told her that the slings were old but would not mention names. Interview on 04/04/19 at 11:50am, CNA [NAME] said she did not give showers but helped the shower technician during shower. She said the shower sling they had before were pretty old. She heard about CR#1's fall incident but was not in the building when the incident happened. She said the facility gave her in service after the incident on checking Hoyer lift slings prior to using them. In an interview on 04/04/19 at 1:50p.m., the DON said the facility assessed the resident and who was taking to a local hospital. The DON said she in serviced all the nursing staff on checking and monitoring of Hoyer lift's slings. The DON said all the old slings were thrown away, she re- educated CNAs to always check the sling before use and educated other staff to follow the manufacturer instruction before using it. The DON said she checked off CNAs of the training which she initiated after the CR#1's incident. Record review of facility in-service dated 03/28/19 revealed one on one in service provided to CNA A and CNA B on inspecting Hoyer lift slings and equipment for proper working condition with assistance from another staff member before use. Further review of facility in service log revealed in-services were provided to facility staff members on 03/29/19, 03/30/19 and 04/01/19 on the following areas; 1. Inspection of the sling to make sure they are in good condition 2. Making sure the resident's weight is appropriate for the sling 3. Ensure Hoyer battery is charge 4. 2 people for all Hoyer transfers 5. No combative resident should be placed in the Hoyer. 6. Follow the manufacturer instruction when washing the sling 7. Only air dry the sling. 8. Any frayed sling should be pulled out of service Record review of facility provided information on Hoyer lift safe transfers guidelines not dated revealed it did not address monitoring the condition of the slings or straps. Record review of information on Hoyer lift safe transfers guidelines did not reveal monitoring the condition of the slings or straps.

Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal, physical and mental abuse for three of 17 residents (Residents #31, #49 and #51) reviewed for abuse. The facility failed to supervise Resident #31 who was choked by Resident #49 when Resident #31 wandered into Resident #49's room. The facility failed to supervise Resident #31 who was hit in the face twice and had redness on his left cheek, by Resident #51 when he wandered into Resident #51's room in his wheelchair. Resident #31 said he wanted to get away from people who always tried to hurt him. These failures affected three residents and placed 41 other residents at risk of a poor quality of life from not receiving services and supervision needed to prevent injuries, mistreatment, and abuse. Findings include: Intake # 4 Record review of Resident #31's face sheet revealed an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #31's comprehensive MDS dated [DATE] revealed a BIMS score of 9, indicating he moderately impaired for daily decision making, had a wandering behavior that occurred one to three days during the assessment period and did not place the resident at a significant risk of getting to a potentially dangerous place. The MDS further revealed Resident #31's wandering did not significantly intrude on the privacy and activities of others. Record review of Resident #31's care plan dated 9/2/16 revealed Resident #31 was a potential elopement risk related to wandering, impaired safety awareness, and a history of attempts to leave the facility unattended. Goal was the resident's safety would be maintained through staff interventions. Approaches were to distract resident from wandering by offering pleasant diversions like structured activities, food, conversation, television, and books. Record review of Resident #31's care plan dated 9/2/16 revealed Resident #31 had impaired cognitive function and impaired thought processes related to dementia. Goal was the resident would be able to communicate basic needs on a daily basis, approaches were to cue, reorient and supervise as needed, engage the resident in simple , structured activities that avoid overly demanding tasks, keep the resident's routine consistent, as much as possible in order to decrease confusion, and the resident needs supervision/assistance with all decision making. Further review of Resident #31's care plan revised 9/2/16 revealed Resident #31 had verbally aggressive behaviors, cursing, threatening others, resistive to care related to mood disorder with psychotic symptoms, wanders into other residents' rooms. Goal was the resident's need would be met on a daily basis through staff interventions and staff would encourage cooperation, resident would decrease target behaviors through review date. Approaches included: administer medication [MEDICATION NAME] as ordered, monitor for side effects and effectiveness, assess for pain when resident shows target behavior and attempt interventions when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversations; if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #31 incident report dated 9/19/16 at 10:14 p.m., revealed staff heard a noise down the hallway. Nursing staff went into Resident #49's room and found he had thrown his tray on the floor. When nursing staff entered the room, they saw Resident #49 holding Resident #31 by his neck trying to choke him. Staff separated the two residents, assessed Resident #31 for injuries but none were noted. Resident #31 said a mad man was trying to choke him. Further review of this incident report revealed Resident #49 was asked why he choked Resident #31. Resident #49 said it was because Resident #31 was a son of a [MEDICAL CONDITION]. Further review revealed the incident occurred in room [ROOM NUMBER]. Record review of Resident #31's incident report dated 9/22/16 revealed a resident to resident altercation occurred between Resident #31 and Resident #51. Resident #31 stated somebody hit him in the face. Residents were separated immediately. Both residents were assessed for injury and none were noted. Redness was noted to the left side of Resident #31's face. The resident denied pain. Record review of Resident # 51's face sheet revealed an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #51's quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating he had severely impaired cognition. Record review of Resident #51's incident report dated 9/22/16 revealed there has been an episode of resident to resident altercation. (Resident #51) has been physical with another resident. (Resident #51) said that his things where being looked through by (Resident #31). When witnesses saw resident, (Resident #31) was just sitting in wheelchair asleep. Record review of Resident #51's care plan, initiated on 9/10/16 and revised on 10/5/16 revealed is verbally aggressive r/t angry outbursts at peers/staff, unpredictable behavior, mood swings. 9/22/16--Resident in altercation with another resident. Transferred to VA, returned next day 10/4/16--Hosp stay 9/26-10/4/16. Dx. Anxiety, Depression, Hallacinations, Dementia. The resident will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included: 10/4/16--[MEDICATION NAME] 0.5mg po TID Date Initiated: 10/05/2016. 10/4/2016--[MEDICATION NAME] 10mg po qd. Date initiated:10/05/16. 10/4/16--[MEDICATION NAME] 5mg tab BID. Date initiated: 10/05/2016. [MEDICATION NAME] 0.5mg po BID. Date Initiated: 10/05/2016. Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Monitor behaviors frequently throughout shift. Document observed behavior and attempted interventions. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . Record review of the provider's investigation report dated 9/22/16 revealed Resident #31 had the [DIAGNOSES REDACTED]. Resident #31 was asleep on his wheelchair in Resident #51's room. Resident #51 told Resident #31 to get out of his room. Housekeeper #4 assisted Resident #31 to move out from Resident # 51's room, but on the way out Resident #51 hit Resident #31 in the face twice. Resident #31 was immediately removed away from Resident #51. Resident #51 was sent to the hospital for psychiatric evaluation and was discharged the next day. Both residents were monitored hourly during the weekend. Resident #51 was removed from the facility on 9/26/16, he voluntarily accepted to be admitted to a behavioral clinic. Resident #31's daughter said she would not be pressing charges against Resident #51 because she knew Resident #31 liked to wander into other residents' rooms and provoke them. Police were notified. Further review of this report revealed an in-service on resident to resident altercations and unmanageable residents was provided to staff. Record review of a witness statement written by Housekeeper #4 revealed Resident #31 was sitting in his wheelchair in room [ROOM NUMBER] (Resident #51's room) asleep by Resident #51's bed. Resident #51 told Resident #31 to get out of his room. Housekeeper #4 told Resident #51 she would move Resident #31 out of the room. Resident#51 slapped Resident #31's face twice as she was pushing Resident #31 out of the room. Resident #51 followed Housekeeper #4 down the hall as she pushed Resident #31 saying I am going to hit you again. Record review of a witness statement written by CNA #42 dated 9/22/16 revealed she witnessed the altercation. Resident #31 was in his wheelchair asleep when Resident #51 entered the room and told Resident #31 to leave his room. Resident #31 was being assisted out of the room when Resident #51 hit Resident #31 twice on his face. Record review of the facility's investigation report dated 9/22/16 revealed the following in services were provided to staff members after the incident between Resident #31 and Resident #51: abuse and neglect (facility policy), reporting abuse to facility management, resident to resident altercations, and unmanageable residents. Record review of Resident #31's care plan for wandering, elopement risk and aggressive behaviors revealed the care plan was not updated following the incident on 9/22/16 with another resident. Record review of Resident #31's care plan revealed it was updated on 10/11/16 reflecting the resident to resident altercation of 9/22/16 as follows: resident asleep in another resident's room, other resident slapped (Resident #31) resulting in redness to his face. Goal was the resident's need would be met on a daily basis through staff interventions and staff would encourage cooperation, resident would decrease target behaviors through review date. Approaches included: staff removed resident to his own room, Resident denied any pain or discomfort, administer medication [MEDICATION NAME] as ordered, monitor for side effects and effectiveness, assess for pain when resident shows target behavior and attempts interventions, when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversations; if response is aggressive, staff to walk calmly away and approach later. Interview 10/11/16 at 11:20 a.m., Resident # 51 said Resident #31 was always in his room and going through his things. Resident #51 said he had told Resident #31 several times to stop going into his room but he continued to go in his room. Resident #51 said he got upset on that day and hit Resident #31 on his chest area. He felt bad afterwards about it. Resident #51 said he would not hit a resident again and further explained it was aggravating to always have Resident #31 sleeping in his room whenever he left his room. When asked if he had told anyone about this, Resident #51 said he had told staff several times and always called on them to come get Resident #31 out of his room. Observation on 10/11/16 at 1:00 p.m., Resident #31 was in the hallway in his wheelchair. He was propelling his wheelchair with his legs. Resident #31's bilateral feet and lower legs were swollen. Resident #31 was alert and somewhat oriented to person but confused and had no safety awareness. Interview on 10/11/16 at 3:15 p.m., Resident #31 was unable to remember the incident, but said someone struck him. He was unable to tell when or why. When asked if anyone choked him, he said he had to get away from all the crazy people here who were always trying to hurt him. He then started using profanity. Observation on 10/11/16 at 3:40 p.m., Resident #31 was by the facility's main entrance in his wheelchair sleeping. Observation and interview on 10/12/16 at 8:48 a.m., Resident #31's breakfast tray was observed in his room covered but uneaten and he was not in his room or nearby. Staff around the nurses' station stated they did not know where Resident #31 was. Resident #31 was later observed by the dining area drinking a cup of coffee, with no breakfast. When Resident #31 was asked about his breakfast in his room, he said no one told him his breakfast was in his room. Observation on 10/12/16 at 10:40 a.m., Resident #31 was sleeping in his wheelchair in the hallway. Observations throughout survey revealed Resident #31 was wandering about the unit and surveyors had to search around the facility to find him. When staff was asked where Resident #31 was, they did not know and would look for him with surveyors until he was found. Interview on 10/12/16 at 2:05 p.m., Housekeeper #4 said she went to clean Resident #51's room on 9/22/16 and saw Resident #31 in the room sleeping in his wheelchair next to Resident #51's bed. She further said while she was cleaning the room, Resident #51 returned to his room and saw Resident #31 sleeping beside his bed. Resident #51 got upset and started using foul language, cursing at Resident #31 and yelling out saying get him out of there. Housekeeper #4 said Resident #51 was very upset. She moved her cleaning cart out of the way and then started to move Resident # 31 out of the room. As she was wheeling the resident out, Resident #51 who was still yelling, followed her and hit Resident #31 twice on his face. Housekeeper #4 said she immediately took Resident #31 to the nurses' station away from Resident #51 and called for help. When Housekeeper #4 was asked why she did not move Resident #31 out of Resident #51's room when she entered the room and saw him sleeping, she said she did not think Resident#51 would react that way or would hit Resident #31. Housekeeper #4 said if she had moved the resident out of Resident #51's room at the time she found him, Resident #51 would not have seen him in the room or hit him. She agreed Resident #51 hitting Resident #31 was avoidable. Interview on 10/12/16 at 2:15p.m., CNA #42 said Resident #31 always wandered into Resident #51's room and Resident #51 always got really mad and upset about it. She further said Resident #31 was aggressive sometimes if you did not approach him the right way. Resident #31 was also verbally aggressive to staff. On the day of the incident, CNA #42 recalled she heard Resident #31 yelling and cursing out. As she headed toward his room she saw Housekeeper #4 trying to get Resident #31 out of Resident #51's room when Resident #51 hit Resident #31 on his face twice. Interview on 10/13/16 at 12:17 p.m., the DON said Resident #31 had dementia and wandered into other residents' rooms. He said he conducted the investigation regarding the altercation between Resident #31 and Resident #51. The DON said Resident #51 was sent to the psychiatric clinic for evaluation. The DON was asked about the facility's in-service and staff training which did not address increased supervision and frequent monitoring to ensure Resident #31's safety all times. The DON said staff were only provided an in-service about resident to resident altercation, abuse and neglect. The DON said at one time he had told Housekeepers not to touch the residents. Housekeepers should get the CNAs and the Nurses to assist the residents. The DON said he expected staff to immediately move the resident when found in another resident's room. When asked how the facility was protecting Resident #31 from future attacks, he said Resident #51 was sent out for evaluation and he had been calm since his return. Interview on 10/13/16 at 12:20p.m., when the DON was asked about the incident that occurred on 9/19/16 he said he learned that Resident #49 was found choking Resident #31 in Resident #49's room. The DON said this was the same room where Resident #51 hit Resident #31 on his face on 9/22/16. The DON said this incident was neither investigated nor reported because both residents had dementia. He further said his corporate office staff told him that incidents involving residents with dementia should not be reported. Observation on 10/13/16 at 4:10 p.m. revealed Resident #31's room was the first room past the nurses' station on the left side of the 400 hall. Further observation revealed Resident #49 and Resident #51 were roommates and their room was the last room on the left side of the 400 hall. Record review of the facility's policy and procedure regarding abuse and neglect revised April 2013 revealed The nurse will assess the individual and document related findings .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents with unmanaged problematic behavior, significant injuries in physically dependent individuals, problematic family issues, or problems related to staff knowledge, skill, or performance that might affect how the residents are being cared for .The staff, with the physician's input (as needed), will investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes .The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect .The physician and staff will address causes of problematic resident behavior where possible, such as mania, [MEDICAL CONDITION] and medication side effects .The Medical Director will advise facility management and staff about systems to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately .The staff and physician will monitor individuals who had been abused at least until their medical condition, mood, and function had stabilized and periodically thereafter. The CMS 672 dated 10/13/16 listed 44 residents with behavioral healthcare needs.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for three of 17 residents (Residents #31, #49 and #51) reviewed for abuse. The facility failed to supervise Resident #31 who was choked by Resident #49 when Resident #31 wandered into Resident #49's room. The facility failed to supervise Resident #31 who was hit in the face twice and had redness on his left cheek, by Resident #51 when he wandered into Resident #51's room in his wheelchair. Resident #31 said he wanted to get away from people who always tried to hurt him. These failures affected three residents and placed 41 other residents at risk of a poor quality of life from not receiving services and supervision needed to prevent injuries, mistreatment, and abuse. Findings include: Intake # 4 Record review of Resident #31's face sheet revealed an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #31's comprehensive MDS dated [DATE] revealed a BIMS score of 9, indicating he moderately impaired for daily decision making, had a wandering behavior that occurred one to three days during the assessment period and did not place the resident at a significant risk of getting to a potentially dangerous place. The MDS further revealed Resident #31's wandering did not significantly intrude on the privacy and activities of others. Record review of Resident #31's care plan dated 9/2/16 revealed Resident #31 was a potential elopement risk related to wandering, impaired safety awareness, and a history of attempts to leave the facility unattended. Goal was the resident's safety would be maintained through staff interventions. Approaches were to distract resident from wandering by offering pleasant diversions like structured activities, food, conversation, television, and books. Record review of Resident #31's care plan dated 9/2/16 revealed Resident #31 had impaired cognitive function and impaired thought processes related to dementia. Goal was the resident would be able to communicate basic needs on a daily basis, approaches were to cue, reorient and supervise as needed, engage the resident in simple , structured activities that avoid overly demanding tasks, keep the resident's routine consistent, as much as possible in order to decrease confusion, and the resident needs supervision/assistance with all decision making. Further review of Resident #31's care plan revised 9/2/16 revealed Resident #31 had verbally aggressive behaviors, cursing, threatening others, resistive to care related to mood disorder with psychotic symptoms, wanders into other residents' rooms. Goal was the resident's need would be met on a daily basis through staff interventions and staff would encourage cooperation, resident would decrease target behaviors through review date. Approaches included: administer medication Risperdal as ordered, monitor for side effects and effectiveness, assess for pain when resident shows target behavior and attempt interventions when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversations; if response is aggressive, staff to walk calmly away and approach later. Record review of Resident #31 incident report dated 9/19/16 at 10:14 p.m., revealed staff heard a noise down the hallway. Nursing staff went into Resident #49's room and found he had thrown his tray on the floor. When nursing staff entered the room, they saw Resident #49 holding Resident #31 by his neck trying to choke him. Staff separated the two residents, assessed Resident #31 for injuries but none were noted. Resident #31 said a mad man was trying to choke him. Further review of this incident report revealed Resident #49 was asked why he choked Resident #31. Resident #49 said it was because Resident #31 was a son of a bxxxx. Further review revealed the incident occurred in room #409. Record review of Resident #31's incident report dated 9/22/16 revealed a resident to resident altercation occurred between Resident #31 and Resident #51. Resident #31 stated somebody hit him in the face. Residents were separated immediately. Both residents were assessed for injury and none were noted. Redness was noted to the left side of Resident #31's face. The resident denied pain. Record review of Resident # 51's face sheet revealed an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #51's quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating he had severely impaired cognition. Record review of Resident #51's incident report dated 9/22/16 revealed there has been an episode of resident to resident altercation. (Resident #51) has been physical with another resident. (Resident #51) said that his things where being looked through by (Resident #31). When witnesses saw resident, (Resident #31) was just sitting in wheelchair asleep. Record review of Resident #51's care plan, initiated on 9/10/16 and revised on 10/5/16 revealed is verbally aggressive r/t angry outbursts at peers/staff, unpredictable behavior, mood swings. 9/22/16--Resident in altercation with another resident. Transferred to VA, returned next day 10/4/16--Hosp stay 9/26-10/4/16. Dx. Anxiety, Depression, Hallacinations, Dementia. The resident will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included: 10/4/16--Ativan 0.5mg po TID Date Initiated: 10/05/2016. 10/4/2016--Celexa 10mg po qd. Date initiated:10/05/16. 10/4/16--Namenda 5mg tab BID. Date initiated: 10/05/2016. Risperdal 0.5mg po BID. Date Initiated: 10/05/2016. Administer medications as ordered. Monitor/document for side effects and effectiveness. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Monitor behaviors frequently throughout shift. Document observed behavior and attempted interventions. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . Record review of the provider's investigation report dated 9/22/16 revealed Resident #31 had the [DIAGNOSES REDACTED]. Resident #31 was asleep on his wheelchair in Resident #51's room. Resident #51 told Resident #31 to get out of his room. Housekeeper #4 assisted Resident #31 to move out from Resident # 51's room, but on the way out Resident #51 hit Resident #31 in the face twice. Resident #31 was immediately removed away from Resident #51. Resident #51 was sent to the hospital for psychiatric evaluation and was discharged the next day. Both residents were monitored hourly during the weekend. Resident #51 was removed from the facility on 9/26/16, he voluntarily accepted to be admitted to a behavioral clinic. Resident #31's daughter said she would not be pressing charges against Resident #51 because she knew Resident #31 liked to wander into other residents' rooms and provoke them. Police were notified. Further review of this report revealed an in-service on resident to resident altercations and unmanageable residents was provided to staff. Record review of a witness statement written by Housekeeper #4 revealed Resident #31 was sitting in his wheelchair in room 409 (Resident #51's room) asleep by Resident #51's bed. Resident #51 told Resident #31 to get out of his room. Housekeeper #4 told Resident #51 she would move Resident #31 out of the room. Resident#51 slapped Resident #31's face twice as she was pushing Resident #31 out of the room. Resident #51 followed Housekeeper #4 down the hall as she pushed Resident #31 saying I am going to hit you again. Record review of a witness statement written by CNA #42 dated 9/22/16 revealed she witnessed the altercation. Resident #31 was in his wheelchair asleep when Resident #51 entered the room and told Resident #31 to leave his room. Resident #31 was being assisted out of the room when Resident #51 hit Resident #31 twice on his face. Record review of the facility's investigation report dated 9/22/16 revealed the following in services were provided to staff members after the incident between Resident #31 and Resident #51: abuse and neglect (facility policy), reporting abuse to facility management, resident to resident altercations, and unmanageable residents. Record review of Resident #31's care plan for wandering, elopement risk and aggressive behaviors revealed the care plan was not updated following the incident on 9/22/16 with another resident. Record review of Resident #31's care plan revealed it was updated on 10/11/16 reflecting the resident to resident altercation of 9/22/16 as follows: resident asleep in another resident's room, other resident slapped (Resident #31) resulting in redness to his face. Goal was the resident's need would be met on a daily basis through staff interventions and staff would encourage cooperation, resident would decrease target behaviors through review date. Approaches included: staff removed resident to his own room, Resident denied any pain or discomfort, administer medication Risperdal as ordered, monitor for side effects and effectiveness, assess for pain when resident shows target behavior and attempts interventions, when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversations; if response is aggressive, staff to walk calmly away and approach later. Interview 10/11/16 at 11:20 a.m., Resident # 51 said Resident #31 was always in his room and going through his things. Resident #51 said he had told Resident #31 several times to stop going into his room but he continued to go in his room. Resident #51 said he got upset on that day and hit Resident #31 on his chest area. He felt bad afterwards about it. Resident #51 said he would not hit a resident again and further explained it was aggravating to always have Resident #31 sleeping in his room whenever he left his room. When asked if he had told anyone about this, Resident #51 said he had told staff several times and always called on them to come get Resident #31 out of his room. Observation on 10/11/16 at 1:00 p.m., Resident #31 was in the hallway in his wheelchair. He was propelling his wheelchair with his legs. Resident #31's bilateral feet and lower legs were swollen. Resident #31 was alert and somewhat oriented to person but confused and had no safety awareness. Interview on 10/11/16 at 3:15 p.m., Resident #31 was unable to remember the incident, but said someone struck him. He was unable to tell when or why. When asked if anyone choked him, he said he had to get away from all the crazy people here who were always trying to hurt him. He then started using profanity. Observation on 10/11/16 at 3:40 p.m., Resident #31 was by the facility's main entrance in his wheelchair sleeping. Observation and interview on 10/12/16 at 8:48 a.m., Resident #31's breakfast tray was observed in his room covered but uneaten and he was not in his room or nearby. Staff around the nurses' station stated they did not know where Resident #31 was. Resident #31 was later observed by the dining area drinking a cup of coffee, with no breakfast. When Resident #31 was asked about his breakfast in his room, he said no one told him his breakfast was in his room. Observation on 10/12/16 at 10:40 a.m., Resident #31 was sleeping in his wheelchair in the hallway. Observations throughout survey revealed Resident #31 was wandering about the unit and surveyors had to search around the facility to find him. When staff was asked where Resident #31 was, they did not know and would look for him with surveyors until he was found. Interview on 10/12/16 at 2:05 p.m., Housekeeper #4 said she went to clean Resident #51's room on 9/22/16 and saw Resident #31 in the room sleeping in his wheelchair next to Resident #51's bed. She further said while she was cleaning the room, Resident #51 returned to his room and saw Resident #31 sleeping beside his bed. Resident #51 got upset and started using foul language, cursing at Resident #31 and yelling out saying get him out of there. Housekeeper #4 said Resident #51 was very upset. She moved her cleaning cart out of the way and then started to move Resident # 31 out of the room. As she was wheeling the resident out, Resident #51 who was still yelling, followed her and hit Resident #31 twice on his face. Housekeeper #4 said she immediately took Resident #31 to the nurses' station away from Resident #51 and called for help. When Housekeeper #4 was asked why she did not move Resident #31 out of Resident #51's room when she entered the room and saw him sleeping, she said she did not think Resident#51 would react that way or would hit Resident #31. Housekeeper #4 said if she had moved the resident out of Resident #51's room at the time she found him, Resident #51 would not have seen him in the room or hit him. She agreed Resident #51 hitting Resident #31 was avoidable. Interview on 10/12/16 at 2:15p.m., CNA #42 said Resident #31 always wandered into Resident #51's room and Resident #51 always got really mad and upset about it. She further said Resident #31 was aggressive sometimes if you did not approach him the right way. Resident #31 was also verbally aggressive to staff. On the day of the incident, CNA #42 recalled she heard Resident #31 yelling and cursing out. As she headed toward his room she saw Housekeeper #4 trying to get Resident #31 out of Resident #51's room when Resident #51 hit Resident #31 on his face twice. Interview on 10/13/16 at 12:17 p.m., the DON said Resident #31 had dementia and wandered into other residents' rooms. He said he conducted the investigation regarding the altercation between Resident #31 and Resident #51. The DON said Resident #51 was sent to the psychiatric clinic for evaluation. The DON was asked about the facility's in-service and staff training which did not address increased supervision and frequent monitoring to ensure Resident #31's safety all times. The DON said staff were only provided an in-service about resident to resident altercation, abuse and neglect. The DON said at one time he had told Housekeepers not to touch the residents. Housekeepers should get the CNAs and the Nurses to assist the residents. The DON said he expected staff to immediately move the resident when found in another resident's room. When asked how the facility was protecting Resident #31 from future attacks, he said Resident #51 was sent out for evaluation and he had been calm since his return. Interview on 10/13/16 at 12:20p.m., when the DON was asked about the incident that occurred on 9/19/16 he said he learned that Resident #49 was found choking Resident #31 in Resident #49's room. The DON said this was the same room where Resident #51 hit Resident #31 on his face on 9/22/16. The DON said this incident was neither investigated nor reported because both residents had dementia. He further said his corporate office staff told him that incidents involving residents with dementia should not be reported. Observation on 10/13/16 at 4:10 p.m. revealed Resident #31's room was the first room past the nurses' station on the left side of the 400 hall. Further observation revealed Resident #49 and Resident #51 were roommates and their room was the last room on the left side of the 400 hall. Record review of the facility's policy and procedure regarding abuse and neglect revised April 2013 revealed the nurse will assess the individual and document related findings. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish and mental illness. Abuse means the willful infliction of injury, unreasonable, confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish, the staff and physician will monitor individuals who had been abused at least until their medical condition, mood, and function had stabilized and periodically thereafter. The CMS 672 dated 10/13/16 listed 44 residents with behavioral healthcare needs.

Based on observation, interview and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores when they failed to implement pressure ulcer preventative measures for 1 resident reviewed who was identified to be at low risk of developing pressure sores (Resident #22). This deficient practice contributed to Resident #22 developing a Stage III pressure sore and placed an additional 6 residents identified as receiving skin preventative care at risk for not receiving treatment and services to promote healthy skin , and prevent new pressure sores from developing. Findings include: Review of Resident # 22 ' s admission information revealed a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 22 ' s quarterly MDS dated 4/13/12 revealed Resident # 22 ' s was at risk of pressure ulcers. Further review revealed no skin preventative treatments were provided. Record review of Resident # 22 ' s annual MDS dated 7/5/12 revealed Resident # 22 ' s was at risk of pressure ulcers. Further review revealed no skin preventative treatments were provided. Record review of Resident # 22 ' s form titled " Braden scale for predicting pressure sore " dated 7/16/12 revealed Resident # 22 was in the category of " at low risk of developing Pressure sore " . Cause of risk # 2 revealed Resident # 22 ' s skin was occasionally exposed to moisture. Further record review revealed last documented Braden scale were done 7/29/11 and 9/5/11. Record review of Resident # 22 ' s care plan dated 8/31/12 revealed Resident # 22 has pressure ulcer or has potential for impaired skin integrity as evidenced by Pressure ulcer of 2.0 by 1.0 Stage III to coccyx related to limited sensory perception, incontinence, decreased activities, impaired mobility and nutritional risk. Goal and approaches were outlined. There were no care plan prior to care plan dated 8/31/12 addressing Resident # 22 ' s risk of developing pressure ulcer and there was none identifying any preventative skin treatments for Resident # 22. Record review of Resident # 22 ' s weekly pressure ulcer record dated 8/31/12 revealed a Stage III pressure ulcer to Coccyx with dimensions as 2.0 by 1.0. Same record dated 9/5/12 revealed a Stage III pressure ulcer to Coccyx with dimensions as 3.0 by 1.0. No other weekly assessment record was found or was made available on request. Observation on 9/11/12 at 2:58P.M., Resident # 22 was seen in a wheel chair in his room wheeling about. His pants were wet with urine. Observation on 9/12/12 at 9:44 A.M., Resident # 22 was found in bed in his room saturated with urine. He was found lying on a wet sheet. Observation on 9/12/12 at 9:59A.M., during wound care revealed Resident # 22 had a Stage III pressure ulcer to his coccyx which was being treated with Santyl. Interview on 9/12/12 at 10:32A.M., LVN # 3 said Resident# 22 was found with a Stage III pressure ulcer on 8/31/12. She explained Resident # 22 ' s pressure ulcer was filled with yellowish slough. She said he had no pressure ulcer prior to this but was known to be at risk of developing pressure ulcer. She said weekly assessments should be completed by the nursing staff. She did not know why they were not done. She explained she would look in the thinned files to see if the assessments were thinned from the chart. Interview on 9/13/12 at 4:32 A.M., DON said she was aware of Resident# 22 ' s Stage III pressure ulcer. She said she would look for his skin assessment record, Braden scale assessment done and preventative measures done. No other records were provided upon exit. Facility ' s policy on pressure ulcer prevention was not provided upon request. Facility ' s CMS form 672 listed 10 Residents with pressure ulcers with 7 receiving preventative skin care.