Every finding on record at Heritage Park of Katy Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider and before transferring or discharging to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 (Resident #2) residents reviewed for proper discharge. -The facility did not send a copy of Resident #2's 30-day discharge notice of the intended discharge date to the Ombudsman at the same time the facility notified Resident #2 on 06/17/2026. The Ombudsman was first notified of Resident #2's discharge on [DATE] by e-mail exchange. This failure could place residents at risk of improper discharge and not having access to a knowledgeable advocate and a support system to guide them through the process of finding new placement or appealing. Findings included: Record review of Resident #2's face sheet, dated 07/24/2026, indicated a [AGE] year-old female originally admitted [DATE] and readmitted [DATE] with medical diagnoses including pressure ulcer of left heel (localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear), hydrocephalus (abnormal buildup of cerebrospinal (brain and spine area) fluid in the brain which could put pressure in the brain and cause damage), muscle wasting and atrophy (loss of muscle mass and strength) and weakness and paralysis due to history of stroke. Resident #2 was her own RP Record review of Resident #2's Quarterly MDS Assessment, dated 06/05/2026, indicated no discharge status at the time of the MDS. Resident #1 had a BIMS score of 11, indicating moderate cognitive impairment. Resident #2 was totally dependent on staff for putting on and taking off footwear, lower body dressing, showering and toileting and required maximal assistance with eating, oral and personal hygiene and upper body dressing. She was totally dependent with tub/shower transfer and going from chair to bed and bed to chair. Resident #2was always incontinent of bowel and bladder. Record review of Resident #2's 30-day notice, dated 06/17/2026, indicated it had Resident #2's signature on the front page of the fax sheet which was signed on 06/17/2026 and was to be mailed to Resident #2's family member's address. Resident #2's 30-day notice, which indicated services would end on 07/17/2026, was signed and dated 07/02/2026. There was no documentation that the notice was sent to the Ombudsman. Record review of the email containing the 30-day notice dated 07/07/2026 at 4:50p.m., indicated the Administrator copied the facility Ombudsman into the e-mail. The Administrator sent the fax addressed to Resident #2's family member. The notice indicated that Resident #2 was discharged for non-payment. Record review of Resident #2's progress notes, it read as follows: -07/14/2026 at 1:12p.m., Resident #2's family member called emergency services for a wound infection. When emergency services arrived, Resident #2 stated she did not want to go to the hospital. Emergency services took her vitals and stated Resident #2 was stable and left the facility. Resident #2's family member came in later and said she wanted to discharge Resident #2 and called emergency services again. At that time, Resident #2 agreed to be transported to the hospital when emergency services came. Interview with the Administrator on 07/24/2026 at 4:09p.m., he said he usually notified the Ombudsman by calling or e-mailing regarding individual residents or sending off notices for multiple residents at a single time. The Administrator said he could not locate any documents showing the Ombudsman was notified of Resident #2's discharge on [DATE] but that the facility bent over backward for Resident #2 and tried to help her with finding a new facility and they did not have her removed 30 days after the original notification. The Administrator said he followed the protocol and notified the Ombudsman before discharge. The Administrator said because Resident #2 was her own RP and could make her own decisions, the facility was not obligated to send the family member anything regarding her discharge. The Administrator said that Resident #2 was due to discharge to a personal care home the facility helped Resident #2 sign because Resident #2 or her family member failed to pay towards her stay after her insurance stopped paying for her facility stay. During an interview on 07/24/2026 at 4:19p.m., the Ombudsman stated Resident #2's family member requested the 30-day notice and when the Administrator e-mailed the notice to the family member he added the Ombudsman into the e-mail as well. The Ombudsman said that was the first time he received a notice about Resident #2's discharge which was on 07/07/2026. The Ombudsman said there were concerns from the family member that she was threatened with Resident #2's discharge for not providing some information. The Ombudsman said notification of discharge should be sent to the resident and Ombudsman at the same time so that the Ombudsman could advocate for the resident if need be. The Ombudsman said he saw Resident #2 at the hospital where the family member had requested Resident #2 be discharged to. During an interview on 07/24/2026 4:09p.m., Resident #2's family member said she had spoken to the Ombudsman on 07/07/2026 and talked to him about what she considered an improper facility-initiated discharge because the facility was sending Resident #2 to a personal care home that Resident #2 felt like could not manage all of Resident #2's medical conditions and the family member felt like she was not notified or given a chance to find more suitable place to discharge Resident #2. Resident #2's family member said the Ombudsman advised her to request a discharge notice and she received that notice by e-mail on 07/07/2026 which the family member said was sent to the Ombudsman as well. Resident #2's family member said she had Resident #2 discharged to a hospital on [DATE] because she was worried about Resident #2's wounds and wanted them to be examined. Resident #2's family member said Resident #2 was back to living with the family member and Resident #2 was very confused and would not be able to make decisions or know exactly what happened but that she was safe. Record review of the facility's policy titled, Discharge Planning Process, with an implement date of 03/01/2024, read in part, It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. 8. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community. This policy did not mention notifying the Ombudsman.

Based on observation, interview and record review, the facility failed to ensure controlled drug counts were in order and reconciled for two of two medication carts observed during change-of-shift. -Two medication carts controlled medication counts were conducted without staff cross-checking the medications cards and controlled medication count sheets. -The staff did not state the name of the medication when calling out the resident name and quantity. -The facility policy did not require both staff to confirm the quantity being verbalized was the quantity written on the controlled medication count sheet. The failure placed residents at risk for controlled medications to not be available when needed, and for controlled drug diversion. Findings include:Observation on 02/19/2026 at 2:02 p.m., revealed MA A and MA B conducting the change-of-shift count of the controlled medications for the Hall 400 Medication Aide cart. MA A was standing in front of the controlled medication lockbox, which was open. The lockbox was located on the right/front side of the cart. MA B was standing in front of the left side of the cart. MA B had the controlled medication count sheet book for the cart opened in front of her. MA A was starting her shift, relieving MA B. Continued observation revealed MA B looked at the medication count sheets in the book and called out a resident's name, then a quantity. She did not state what the medication was. MA A looked at the medication card and agreed to the number. The process was repeated for each of the controlled medications on the cart. Continuous observation revealed that at no time did MA B look at the medication cards and at no time did MA A look at the medication count sheets. Both staff signed the page in the book that designated MA A was responsible for all of the controlled medications on the cart, and that the counts were correct.Observation on 02/19/2026 at 2:05 p.m., revealed MA C and MA D conducted the change-of-shift count of the controlled medications for the Hall 400 Medication Aide cart. MA C was standing in front of the controlled medication lockbox, which was open. The lockbox was located on the right/front side of the cart. MA D was standing in front of the left side of the cart. MA D had the controlled medication count sheet book for the cart opened in front of her. MA C was starting her shift, relieving MA D. Continued observation revealed MA D looked at the controlled medication count sheets in the book and called out a resident's name, then a quantity. She did not state what the medication was. MA C looked at the medication card and agreed to the number. The process was repeated for each of the controlled medications on the cart. Continuous observation revealed that at no time did MA D look at the medication card and at no time did MA C look at the medication count sheets. Both staff signed the page in the book that designated MA C was responsible for all of the controlled medications on the cart, and that the counts were correct.In an interview on 02/19/2026 at 2:10 p.m., MA C said she did not look at the medication count sheets. In an interview on 02/19/2026 at 2:16 p.m., MA A initially said she looked at the cards and the medication count sheets. Three Surveyors had witnessed she had not looked at the medication count sheets as MA B called out the names and quantities. MA A then confirmed she did not look at the medication count sheets. In an interview on 02/19/2026 at 2:23 p.m., the DON said the change-of-shift count was to be conducted between the incoming MA and the MA that is at the end of her shift. The MA starting her shift was to be at the medication cards. The MA ending her shift was to be at the controlled medication count sheet book. She said the MA ending her shift was to say the quantity that was on the sheet, and the MA starting her shift confirmed. She said the two MAs did not need to say the name of the medication because the cards were in the same order as the medication count sheets in the book. The DON was given a scenario: If the outgoing MA was looking at the medication count sheet, and it said '21' but there were only 20 tablets on the medication card, if the outgoing MA said 20 instead of 21, would the incoming MA know the count was off if she did not look at the medication count sheet? The DON said the MA at the cards did not need to look at the controlled medication count sheets. In an interview on 02/19/2026 at 5:35 p.m., the Administrator was asked about the count system and was informed there was a concern with the technique used to count the controlled medications at change of shift. The concern was explained that if the MA or nurse ending her shift had diverted controlled medications and then told the MA or nurse starting her shift a quantity that matched the medication card instead of the number on the controlled medication count sheet, the discrepancy would be missed. The Administrator replied, I would not go with a hypothetical. I would follow our policy. He added that if the counts were off it may or may not affect the resident.Review of the facility policy Controlled Substance Reconciliation (revised July 2015) read, in part, .5. All narcotics need to be counted by two nurses or medication aides who are responsible for the cart. While one staff looks at the narcotic count sheet and calls out the name of the medication and the number of pills or the amount of MLs [milliliters] left the other staff member will confirm the medication name and number by looking at the actual blister pack or medication container. 6. Any discrepancies in narcotic count will be reported to administration before taking responsibility for the keys.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: -Five dented cans were stored with other cans used for resident meals in the dry storage room. -Food items were not sealed and not dated in the dry storage room. These failures could place residents who received meals from the kitchen at risk for food borne illness. Findings included: Observation on 11/5/24 at 9:00 am of the dry storage room revealed the following: -One 111 oz can of tomato paste with a large dent in the middle of the can -One 106 oz can of spaghetti sauce with a large dent at the top of the seam -One 112 oz can of banana pudding with a small dent at the bottom of the seam -One 112 oz can of vanilla pudding with a small dent at the bottom of the seam -One 108 oz can of sweet potatoes in syrup with a large dent in the middle of the can -One 25 lb bag of light brown sugar not sealed and not dated -One 5 lb bag of grits not sealed and not dated Interview with the Dietary Manager on 11/6/24 at 1:30 pm, she said she had worked at the facility since 7/1/24. The Dietary Manger said the dented cans were supposed to be kept in her office. She said all kitchen staff were responsible for dating and sealing food items and were supposed to check for dented cans. The Dietary Manager did not know why these items were missed. She said when food items that were not sealed could cause cross-contamination. She said the dented cans could have particles that could get loose and contaminate the food. The Dietary Manager said the risk to the resident was they could get sick from the cross contamination. Interview with [NAME] A on 11/6/24 at 1:38 pm, she said she had worked at the facility for 5 years. [NAME] A said the morning cooks were supposed to check if food items were sealed and dated. [NAME] A said the night shift were supposed to check for dented cans and put them in the Dietary Manager's office. She said if food items were not sealed the food could get contaminated and make the residents sick. [NAME] A did not know the risk of keeping dented cans in the dry storage room. Interview with [NAME] B on 11/6/24 at 1:45 pm, he said he had worked at the facility for 6 months and he worked the night shift. He said everyone in the kitchen helped with dating and sealing food items and checked for dented cans. He said if food items were not sealed it could cause cross-contamination and residents could get sick. [NAME] B did not know the risk of keeping dented cans in the dry storage room. Record review of the Dry Food Storage Policy, not dated, read in part . store opened and bulk items in tightly covered containers, all containers must be labeled and dated. When packages of cans are opened staff are to inspect for dents, or abnormalities, if any are found the cans are to be removed immediately and stored in the designated area .

Based on interview and record review, the facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) Level 1 Residents with a positive trigger for mental illness were provided with a PASRR Level II assessment for 1 (Resident #79) of 5 residents reviewed for mental illness. The facility did not correctly identify Resident #79 as having mental illness in her PASRR Level 1 Screening. This failure could place five residents with psychiatric diagnoses to trigger a positive PASRR Level I evaluation at risk for not receiving a PASRR Level II screening and receiving needed care and services to meet their needs. Findings included: Record review of Resident #79's face sheet dated 11/5/24, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), unspecified psychosis, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and unspecified mood disorder. Record review of the physician orders dated 10/4/24 revealed Resident #79 was prescribed Remeron 15 mg once daily for depression. Record review of quarterly MDS dated [DATE] indicated Resident #79 had a BIMS of 3, active diagnoses of depression and psychotic disorder and was taking an antidepressant. Record review of Resident #79's care plan dated 11/5/24 indicated Resident #79 had potential psychosocial well-being problems related to loss of independence, loss of home, depression, and little interest in doing favorite activities. Interventions included: assist, encourage, and support the resident to set realistic goals and encourage participation from resident who depends on others to make own decisions. Further review of care plan indicated Resident #79 was presented with sadness and feelings of grief related to losing her sister. Interventions included: assisting resident, family, and caregivers to identify strengths and positive coping skills; monitor, document, and report to MD PRN acute episode or feelings of sadness, signs and symptoms of depression, anxiety, and sad mood as per facility behavior monitoring protocols. Record review of the PASRR level 1 screening dated 11/1/22 indicated Resident #79 was negative for mental illness, intellectual disability, and developmental disability. Interview with the MDS Coordinator on 11/7/24 at 12:38 pm, he said he had worked at the facility for 2 and half years. The MDS Coordinator said he was responsible for conducting the PASRR screenings. He said Resident #79's PASRR was missed because the hospital she came from had marked no under the mental illness section. The MDS Coordinator said he did not think there was a risk to the resident because he never had a patient accept the mental illness services. He said residents would have to leave facility, and it would cost them to get a psych evaluation because that department does not offer transportation. The MDS Coordinator said the facility offered psych services there. Record review of the Resident Assessment-Coordination with PASRR Program policy dated 3/1/24 read in part . all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening .

Based on interviews and records reviews, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #26) of 31 residents reviewed for base-line care plans. The facility failed to ensure (Resident #26) had a baseline care plan developed within 48-hours after admission with goals based on admission orders and interventions, PASRR recommendations, Physician's orders, therapy services, dietary orders, and social services. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services. Findings included: Record review of Resident #26's Face Sheet (undated) revealed, an [AGE] year-old female who admitted to the facility on [DATE] and with diagnoses which included: unspecified dementia, unspecified severity, with other behavioral, Alzheimer's disease (a brain disorder that gradually worsens over time, causing memory loss, confusion, and behavior changes), unspecified, chronic kidney disease, stage 2 (mild), and generalized anxiety disorder. Record review of Resident #26's MDS assessment dated [DATE] revealed a BIMS score of 2 indicating she was significantly cognitively impaired. She exhibited wandering behavior 4-6 days per week, required substantial/maximal assistance with shower/bathe self, Lower body dressing, and putting on/taking off footwear. She required Partial/moderate assistance with bed to chair, toilet, tub/shower transfers. Record review of Resident #26's chart did not find a document titled Base Line Care Plan. The document the facility substituted for the Baseline Care Plan dated 10/23/2024 was incomplete. Record review of Resident #26's Initial Nursing Evaluation dated 09/29/2024 read in part .2. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. - Admission Performance- 03. Partial/moderate assistance. 3. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. - Admission Performance- 04. Supervision or touching assistance. 4. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. - Admission Performance- 06. Independent. 5. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). - Admission Performance- 04. Supervision or touching assistance. 6. Toilet transfer: The ability to get on and off a toilet or commode. - Admission Performance- 03. Partial/moderate assistance . The Initial Nursing Evaluation did not contain PASRR recommendations, Dietary orders, Physician's orders, or notate whether the resident had therapy services. Interview on 11/06/2024 at 3:24PM with the MDS Coordinator said the facility did not do a Baseline Care Plan, they wrote a Comprehensive Care Plan. He said the Comprehensive Care Plan was done within 72 hours of the resident's admission. Interview on 11/07/2024 at 12:19 PM with the MDS Coordinator said the Baseline Care was done within 48 hours and the Comprehensive Care plan within 21 days. He said there were no exceptions for the time to get them completed. He said yesterday he made a mistake saying 72 hours for the Base Line Care plan. When reviewing Resident #26's Comprehensive Care Plan he said 10/09/2024 was the date listed on the Focus part of the Care Plan. He said 10/09/2024 was not within 48 hours of the resident's admission. He said the Comprehensive Care Plan could not be used as the resident's Base Line Care Plan. He said he had worked at the facility a total of 2.5 years. He was the MDS Coordinator, and he worked Monday through Friday 8 AM- 5 PM. He was familiar with Resident #26. He said he routinely worked on the MDS assessments and assisted the DON with unit managers. He said Base Line Care Plans were supposed to be completed within 48 hours. He said the purpose of the Base Line Care Plan was to communicate the resident's needs to the staff working with that resident. He reviewed the Comprehensive Care Plan and saw Resident #26's ADLS and saw they were dated 10/09/2024. He observed her admitted [DATE]. He said those dates were not within 48 hours of each other. He said the Base Line Care plan may be located somewhere else in the system. After looking in the system he said it did not look like she had her Base Line Care Plan. He continued looking through the resident's online chart and said he found the Base Line Care plan in the Initial Nursing Evaluation- V3 dated 09/29/2024. He said they use the Initial Nursing Evaluation so there were not so many assessments. He said the Initial Nursing Evaluation incorporated all the necessary assessments. Interview on 11/07/2024 at 1:16PM with the MDS Coordinator said the required information on the Initial Nursing Evaluation had information for the care for the resident, how to do the ADLS, their code status, and incontinent status. He said the physician orders were not in the Initial Nursing Evaluation. He showed that the Dietary order was on the Eval. He said if a resident were on therapy, it would be on a Skilled Nursing Note. He said Resident #26 was not in therapy the first couple of days while at the facility. He said therapy services was not on the Initial Nursing Evaluation. He said the social worker did their own evaluation on the resident and was not a part of the Initial Nursing Evaluation. He said if the resident were PASRR positive, they would not know within 48 hours. He said the resident's goals and interventions were not listed on the Initial Nursing Evaluation. When asked what happened today with their version of the Base Line Care Plan missing information, he said he said he would have to talk with the person that helped set up the assessments to determine why the Physician's orders and therapy were not listed on the Initial Nursing Evaluation. He said a month and a half ago he had training on Base line care plans. He said he and the nursing team were responsible for ensuring all information was on the Base Line Care Plan. He said he could not answer the question of risk to residents if information was missing from the Base Line Care Plan or if staff did not follow procedure/policy regarding information on the Base Line Care Plan. When asked if there was missing information from the Base Line Care plan how would staff care for the resident, he responded with staff would not care for them in those areas. He did not answer what could happen to a resident if staff did not follow policy/protocol regarding completing the Base Line Care Plan. He said the nursing team, ADON, DON, Administrator were involved regarding meeting with the family and discussing the plan for the resident. Interview on 11/07/2024 at 1:30 PM with the ADON, she said the Base line care plan was done upon admission. She said it had to be done within 48 hours. She said the MDS nurse, DON or the admitting nurse wrote it. She said the Base Line Care Plan had the resident's code status, initial care plan which included the resident's ADLs, diagnosis, immunizations, TB skin, Braden scale (a tool used to predict the risk of pressure ulcers in patients). She said she was not sure if physician's orders were a part of the Base Line Care plan. She said therapy and dietary services should be on the Base Line Care plan. She said everything you needed to care for the resident was on the Base Line Care plan. She said every resident should have a Base line care plan. She said she had worked at the facility for 2 years and she was the ADON. She said she worked Monday through Friday 8 AM- 5 PM. She said her routine work duties were as staffing coordinator, worked on infection control and as unit manager of the 100 Hall. She said the policy or procedure for the Base Line Care plan was they needed to be complete and done within 48 hours. She said she did not know about Resident #26's Base Line Care plan. She said she did not recall when she last had in-service on Base Line Care plan. She said the ADONs, and the DON were responsible for ensuring policy/procedure was followed that the Base Line Care Plan was complete and had all necessary information. She said the risk to residents when policy/procedure for the Base Line Care Plan was not done or complete was staff potentially miss information pertinent to their care. She said it needed to be complete, so staff knew exactly know how to care for the residents. She said the worst thing that could happen to residents when proper protocols were not practiced was if there were things missing from the Base Line Care Plan then things for the resident could be missed like medications, or diagnosis that were pertinent to their care. Interview on 11/07/2024 at 1:40 PM with the DON she said the Base Line Care Plan was done upon admission and there was a time limit of 48 hours. She said the Base Line Care Plan was generated with the nursing evaluation and when the nurse did their assessment, the information was on that assessment. She said the required information on the Base Line Care Plan was what there on the Initial Nursing Evaluation V3 like the resident's ADLs, vital signs, basic information for the resident and asked if the resident had any issues with medications. She said she was the DON and had worked at the facility since the end of May 2024. She said as the DON she oversaw the education of staff, oversaw the nursing department, oversaw patient care, pharmacy, infection control, nutrition, and incidents and accidents. She said she was familiar with the resident. She said the resident should have a Base Line Care Plan. She said the Initial Nursing Evaluation was the Base Line Care Plan and had all the information it required. She said the Physician's orders were separate from the Initial Nursing Evaluation and was entered by the nurse. She said orders were entered on the patients Medication Administration Record. She said the resident's therapy services were in section B and section M of the Initial Nursing Evaluation V3. She said PASRR recommendations was not on the Initial Nursing Evaluation V3. She said the policy/procedure for Base Line Care Plan was that needed to be done within 48 hours and the assessments on the Initial Nursing Evaluation needed to be done. When asked what happened regarding missing required information, the DON said the Initial Nursing Evaluation was the form the facility used and there was nothing missing from that form. She said she was not sure when she was last trained on Base Line Care Plan. She said she could not answer a hypothetical regarding the risk to residents when staff did not follow policy/protocol and the Base Line Care Plan was incomplete or not done. She said for her, the Base Line Care Plan had all things completed and there was nothing missing. Interview on 11/07/2024 at 1:59 PM with the Administrator he said the Base Line Care Plan was done within 48 hours. He said nursing, any of the nurse managers could do the Base Line Care plan. He said information on the Base Line Care Plan had the resident's demographics, functional abilities, skin, general health, code status, and analyses which were under Initial Nursing Evaluation Sections A- O. He said he had worked at the facility since early [DATE] as Administrator, and he oversaw the operations of the facility. He said he did things like rounds, checked on patients, checked the facility's environment, checked with staff for their plans, established goals for staff, followed up on staff goals, spot checked areas of the facility, and was responsible for the financial part of the facility and ensured the bills were paid. He said he normally worked 6:30 AM- 4:30 PM to 5 PM, Monday- Friday. He said he made it a point to come in on the weekends too. He said he was familiar with the res and said she had the Initial Nursing Eval dated 09/29/2024. He said he was not sure where the PASRR recommendations was. He said he was not familiar with the Initial Nursing Evaluation and did not know where the dietary and therapy services were on there. He said the policy/procedure for Base Line Care Plan was for it to complete and done in 48 hours of the resident's admission. He said he did not complete the evaluation and did not know why there was missing information like PASRR recommendations and therapy services, dietary orders. He said he saw her dietary orders and it was on the Initial Nursing Evaluation. He said there was no risk to the resident when the Base Line Care Plan was incomplete because the information was duplicated elsewhere in the resident's chart. He said it the additional information was not necessarily obtained after the 48 hours of the resident's admission. He said he was ultimately responsible for ensuring policy/procedure was followed. Interview on 11/07/2024 at 2:28 PM- the Administrator, DON and MDS Nurse regarding risk to the residents when the Base Line Care Plan was incomplete and staff did not follow policy/protocol, the Administrator said all other information not included in the Base line Care plan could be found elsewhere. The DON said she was not saying the resident's health or safety could not be affected, she said the Initial Nursing Evaluation was complete and that was their Base Line Care Plan. The MDS Nurse said he was not necessarily saying that resident health and safety was not affected but felt like the initial evaluation had the same information as the Base Line Care Plan. Record review of the facility's Base Line Care Plan policy dated 03/01/2024 read in part . 1. The baseline care plan will: B. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: vii. Therapy services, if applicable. viii. PASRR recommendation, if applicable. 2. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 5. The MDS nurse shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. 11. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living .

Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (100 Hall Nurse Medication Cart) of four medication carts reviewed for storage of medications. The Nurse Medication Cart for 100 Hall had a torn protective seal on the back of Resident #211's Tramadol HCL 50mg (a narcotic used to treat moderately severe pain) medication blister pill card (a type of medication packaging, with multiple small, sealed compartments that hold individual doses of medication) found in the locked narcotic drawer during review of medication carts. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, infection, and drug diversion. Findings included: Record review of Resident #211's face sheet undated reflected a [AGE] year-old female first admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included heart failure (the heart is not pumping adequate blood throughout the body), Cellulitis (bacterial infection of the skin), fractured leg, and pain. Record review of Resident #211's care plan dated 07/08/2023 reflected: Focus: Resident #211 had acute and chronic pain related to previous injuries and fractures. Goal: Resident #211 will not have an interruption in normal activities related to pain. Interventions: Administer analgesia (pain) medications as ordered. Record review of Resident #211's quarterly MDS dated [DATE], reflected her BIMS score was 09 which indicated moderated cognitive impairment. Resident #211 required supervision and touch assistance from staff for transfers and showers. She received scheduled pain medication in the last 5 days. Resident #211 was identified as having medically complete conditions. Record review of Resident #211's active physician orders as of 11/01/2024 reflected an order for Tramadol HCL 50mg, two tablet by mouth every 12 hours as needed for chronic pain, start date 05/20/2024. Record review of Resident #211's MAR for 11/01/2024-11/30/2024 reflected Tramadol HCL 50mg Give two tablets every 12 hours as needed for chronic pain. Review with the MAR revealed no administration of Tramadol HCL 50mg. Observation and interview on 11/07/2024 at 1:53 PM during a random cart check revealed the narcotic storage of Resident #211's Tramadol HCL 50mg tablet #40 out of 60 tablets in the blister pill card, had a torn protective seal. The nurse assigned to the nurse cart for 100 Hall was LVN Q. LVN Q stated once a blister pack back was torn it was to be given to the DON. The DON would follow up with the pharmacy. The pharmacy would pick up the medication. LVN Q stated the risk of the torn back was possible contamination of the pill. The pill could have been taken out. LVN Q stated she did not know how this could have happened. LVN Q stated the backs were to be checked when the medications were counted. LVN Q stated this did not always happen. In an interview on 11/07/2024 at 2:05 PM the DON stated the staff were informed to check the carts to ensure the carts were clean. The DON stated the staff was to check for damage to the bubble packs. The DON continued and stated the staff was to check for expired medications. The DON stated the ADONs check the medication carts twice a week. The DON stated the risk was the pill could fall out and lead to a drug diversion. The DON stated to help prevent this from occurring in the futured no one could have long nails or [NAME] items near the medications due to the risk of puncture. In a phone interview on 11/07/2024 at 2:10 PM with the facility pharmacist, she stated the bubble packs were not to have torn backs. The backs were to be secured. The pharmacist stated the medication was to be wasted. The pharmacist stated there was risk of contamination and drug diversion. The pharmacist stated it was important the medication was kept secured. In an interview on 11/07/2024 at 3:11 PM with the administrator, he stated the backs should not be torn because the pull could be tampered with. The administrator stated the medications were to be checked during the shift changes. The administrator stated to prevent this again we will educate staff on what to do if the backs were torn. Record review of the facility policy titled Storage of Medications, revision dated 07/2015, read in part: Purpose: The purpose of this procedure is to make sure that medications are stored in a safe, secure, and orderly manner .

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 2 of 4 residents (Resident #1, and Resident #3) reviewed for incontinent care. - 1. The facility failed to ensure Resident #1's foley tubing was not touching the floor while Resident #1 was propelling himself between the nursing station and medication room. - 2. The facility failed to ensure Resident # 3's foley bag and tubing were not touching the floor while Resident #2 was laid in bed. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: 1. Record review of Resident #1's face sheet dated 03/05/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: dementia (loss of thinking, remembering, and reasoning, which may interfere with a person's daily life and activities), benign prostatic hyperplasia (condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and hypertension (a condition which the blood vessels have persistently raised pressure). Record review of Resident #1's quarterly MDS assessment, dated 02/08/24 revealed: Resident #1 revealed BIMS of 03 indicated severely impaired cognation Resident #1's functional status revealed he required limited to extensive assistance with bed mobility, transfer, and toilet use. Further review revealed Resident#1 had an indwelling catheter. Record review of Resident 1's care plan initiated 10/12/23 read in . the resident had indwelling catheter related difficulty in passing urine. Intervention: Catheter care every shift and PRN (as needed) and check tubing for kinks during each shift. Record review of Resident #1's March 2024 order summary report read in part .foley 6 - FR - 10 cc bulb every month or as needed for neuromuscular dysfunction of bladder. Order date: 02/15/24 . During an observation on 03/05/24 at 11:00 a.m., Resident #1 was seated in his wheelchair by the nursing station close to the medication room. As Resident #1 propelled himself, the foley tubing dragged on the floor. During an observation and interview on 03/05/24 at 11:02 a.m., LVN B said Resident #1's foley tubing was touching the floor as Resident #1 moved his wheelchair. During an interview on 03/05/24 at 11:38 a.m., Resident #1 could not say if he saw his Foley tubing touching the floor or if he had transferred himself from the bed to the wheelchair. During an interview on 03/05/24 at 11:40 a.m., CNA A said she did not remember seeing Resident #1's foley tubing touching the floor, and the tubing should not be touching the floor to prevent infection. CNA A said she did not get Resident #1 up in the morning because the night shift got him up, but she had seen Resident #1 a couple of times this morning but did not notice the foley tubing dragged on the floor as he propelled his wheelchair. CNA A said she had in-service training on working with residents who had Foley, and the charge nurse monitors the aides to ensure they provide care the correct way for the residents. During an interview on 03/05/24 at 3:07 p.m., LVN B said Resident #1's foley tubing was touching the floor as he propelled himself. LVN B said the foley tubing should not touch the floor because of infection. LVN B said the foley could leak urine on the floor, and other residents could get contaminated with any organism in Resident #1's urine. LVN B said Resident #1 could get UTI (urinary tract infection) from any microorganisms from the tube, which was picked up when Resident#1 was dragged the tubing on the floor if the germ traveled to the resident's bladder. LVN B said she had skills - check off on working with a resident with foley. LVN B said the nurse was responsible for ensuring Resident#1's foley tubing was not touching the floor. During an interview on 03/05/24 at 4:03 p.m., the DON said Resident #1's foley tubing should not be touching the floor because of infection control, which meant the urine could spill on the floor because it was a biological substance. The DON said it had to be cleaned and disinfected. The DON said the ADON, and the nurse managers monitor nurses when they make random rounds to ensure the residents receive appropriate care. The DON said he was unaware that Resident #1's foley tubing was touching the floor. 2. Record review of Resident #3's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had diagnoses which included: cerebral infraction (disrupted blood flow to the brain), diabetes mellitus (elevated levels of blood glucose), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #3's quarterly MDS assessment, dated 01/05/24 revealed: Resident #3 had a BIMS of 03 indicated severely impaired cognation. Resident #3's functional status revealed he required limited to extensive assistance with bed mobility, transfer, and toilet use. Further review revealed Resident #3 had a foley. Record review of Resident 3's care plan initiated 04/04/23 revealed the resident had indwelling catheter related to pressure ulcer to sacral area. Intervention: change foley catheter PRN (as needed) patency for sacral wound please document 16 FR/BULB 10 cc and check tubing for kinks during each shift. Record review of Resident #3's March 2024 order summary report read change foley catheter for patency as needed for sacral wound. Observation on 03/05/24 at 12:47 a.m. revealed Resident#3's foley bag and tubing were lying on the floor towards the foot of the bed. During an interview on 03/05/24 at 12:51 p.m., LVN F said Resident #3's foley bag and tubing were touching the floor by the foot of the bed. LVN F said the Foley bag and tubing were not supposed to touch the floor because it could stop the urine from draining, and it could be an infection control issue because Resident #3 could get UTI if the germs traveled to Resident #3 urethra. LVN F said he came to work at 6:00 a.m. and did not notice Resident #3 Foley's bag touching the floor when he made rounds, and his last round was at 11:45 a.m. LVN F said he would be the person who monitors the aides to make sure they provide appropriate care for residents with Foley, and the nurse managers monitor the nurses when they make rounds. LVN F said he had no training or skills check on Foley care. During an interview on 03/05/24 at 1:21 p.m., CNA T said Resident #3's foley bag and tubing should not touch the floor because it was cross-contamination, and Resident #3 could get infected. CNA T said she did not notice Resident #3's Foley bag and tubing were touching the floor when she came in at 6:09 a.m. and when she made rounds. CNA T said the foley bag and tubing were touching the floor because Resident #3's bed was in a low position, but if she had raised the bed a little, it could have prevented the foley from touching the floor. She said she had skills check-off and in-service training on how to work with a resident who had a Foley. CNA T said the charge nurse monitors the aide when she makes rounds to ensure the aides are providing care for the residents. During an interview on 03/05/24 at 4:06 p.m., the DON said the foley bag and tubing should not be touching the floor because of infection control. Record review of the facility registered and licensed nurse competency which included urinary catheterization and it revealed LVN B signed off on it on 03/01/24. Record review of the facility registered and licensed nurse competency which included urinary catheterization and it revealed LVN F signed off on it on 03/01/24. Record review of the facility nurse aide competency revealed, which included drain/tube management and it revealed CNA T signed off on 03/01/24. Record review of the facility policy on catheterization dated Copyright 2023 The Compliance Store, LLC. All rights reserved read in part . urinary catheterization .standards of practice to minimize risk for bacterial contamination .

Based on observations, interviews and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs for 2of 5 residents (Resident #2, and Resident #3) reviewed for call lights. The facility failed to have call light was within reach for Resident #2 and Resident #3 while the residents was in bed. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life. Findings included: Record review of resident #2's Face sheet revealed a [AGE] year-old female was in admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), diabetes mellitus (high blood sugar), and Hypertension (high blood pressure). Record review of resident #2's quarterly MDS dated [DATE] revealed a BIMS of 09 indicating moderate impaired cognition. Further review revealed Resident #2 needed total care assist with ADL care with one to two staff assistance and resident was incontinent of bowel and bladder. Resident #2's functional status revealed she required supervision with bed mobility, transfer, and toilet use. Further review revealed Resident #2 no fall. Record review of Resident #2's care plan edited 06/12/23 revealed resident at risk for falls related to weakness, and impaired balance: Intervention: be sure Resident#2's call light is within reach and encourage to use it for assistance as needed. During an observation and interview on 03/05/24 at 12:42 p.m., Resident #2's call light was tied to the head of the bed, and the remaining call light string fell on the floor behind the head of the bed. Resident # 2 was lying in bed, and when Surveyor N asked her to reach for her call light, Resident #2 tried, but she could not. Resident #2 said that sometimes she would use her cell phone to call the nurse when she could not reach her call light. During an observation and interview on 03/5/24 at 12:57 p.m., LVN F said Resident #2's call light was tied to the head of the bed, and the rest of the string was on the floor behind the head of the bed. LVN F said Resident #2's call light must be within reach when a resident was in the room, whether sitting in a chair or in bed. During an observation and interview on 03/05/24 at 1:05 p.m., CNA K said Resident #2's call light was tied at the head of the bed and fell to the floor behind the head of the bed. CNA K said she was not the resident aide. CNA K said Resident #'s2 call light should be within reach when the resident was in the room or bed for Resident #2 to call for assistance, and Resident #2 could fall if she tried to reach for the call light and lost her balance. CNA K said she had a skills check-off, which included call light positioning. During an interview on 03/05/24 at 1:17 p.m., CNA T said she did not notice the call light for Resident #2 was on the floor behind the head of the bed. CNA T said Resident #2's call light should be within reach. If Resident #2 falls, she could call for assistance or ask if Resident #2 needed help for any other care. CNA T said she had in-service on-call light placement. CNA T said the nurses are responsible for monitoring the aides to ensure they are providing care for the residents. During an interview on 03/05/24 at 4:10 p.m., the DON said Resident #2 call light should be within reach of Resident #2 so she could use the call light to call for assistance. The DON said the resident may only get assistance promptly if the call light was within reach of Resident #2. The DON did not respond when Surveyor N asked what could happen to Resident #2 if care was not provided to the resident on time because the call light was not within reach and Resident #2 could not call for help. Record review of Resident #3's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had diagnoses which included: cerebral infraction (disrupted blood flow to the brain), diabetes mellitus (elevated levels of blood glucose), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #3's quarterly MDS assessment, dated 01/05/24 revealed: Resident #3 revealed BIMS of 03 indicated severely impaired cognation Resident #3's functional status revealed he required limited to extensive assistance with bed mobility, transfer, and toilet use. Further review revealed Resident #3 had one fall. Record review of Resident 3's care plan initiated 04/04/23 revealed the resident was at risk of fall related to impaired mobility, poor cognition. Intervention: be sure Resident#3's call light was within reach and encourage Resident #3 to use it for assistance as needed. During an observation and interview on 03/05/24 at 12:45 a.m., it was revealed that Resident #3's call light was tied to the head of the bed, out of reach for the resident. When Surveyor N asked Resident #3 if she could reach the call light, Resident #3 did not respond. During an interview on 03/05/24 at 1:07 p.m., CNA K said Resident #3's call light was hanging on the head of the bed. The call light was not within reach, and Resident #3 could not reach it. CNA K said the call light should always be within reach. During an interview on 03/05/24 at 1:19 p.m., CNA T said she was the CNA for Resident #3 and she had made rounds since she came to work today, and was not the aide who tied the call light on the head of the bed for Resident #3. During an observation and interview on 03/05/24 at 2:28 p.m., LVN F said Resident #3's call light was attached to the head of the bed, and Resident #3 could not use the call light. LVN F said Resident #3 call light should be within so she could call for assistance. LVN F said Resident #3 could fall if Resident #3 tried to reach for the call light. LVN F also said Resident #3 could not get assistance on time when Resident #3 could not reach the call light, and it could delay care, which could have a critical outcome for Resident #3. LVN F said he did not remember any training about call lights, but he had general training. LVN F said he would be the person to monitor the aides, and the nurse managers monitor him when they make random rounds. During an interview on 01/07/24 at 4:36 p.m., the administrator said the call light should be within reach for all residents, and sometimes the resident throws the call light on the floor. When the administrator was asked what could happen if a resident needed assistance and could not reach the call light, The administrator did not respond but said the staff would place the call light within reach of the resident when the staff saw it was not within reach. Record review of undated facility policy on call light accessibility and timely response read in part . policy explanation and compliance guidelines #5 . staff will ensure the call light is within reach of the resident, and secured as needed .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #4) reviewed for ADLs. 1. The facility failed to ensure Resident #4 was provided personal grooming (fingernail care) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings included: 1. Record review of Resident #4's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on 1. 01/01/24. Resident #4 had diagnoses which included: dementia (loss of thinking, remembering, and reasoning, which may interferes with a person's daily life and activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #4's MDS assessment, dated 03/01/24 revealed: Resident #4's MDS was not done because Resident #4 was a new admit and she was admitted on [DATE]. Record review of Resident 4's care plan initiated 03/05/24 revealed the resident had an ADL self - care performance related to limited mobility and weakness. Intervention: The resident requires minimal to moderate assistance by 1-2 staff with personal hygiene. Further review revealed Resident #4 refuses fingernails to be clipped. During an observation and interview on 03/05/24 at 1:47 p.m., Resident #4's fingernails were two inches long on both hands. Resident #4 said CNA K showered her today, but she did not cut her fingernails, and she wanted her fingernails cut. Resident #4 said she had not refused the aides from cutting her fingernails. During an observation and interview on 03/05/24 at 1:49 p.m., CNA K said she was Resident #4's aide today and gave Resident #4 a shower. CNA K said she saw Resident #4's long fingernails on both hands very long but did not ask Resident #4 if she wanted her fingernails cut. CNA K SAID Resident #4 had not refused to cut her fingernails or refused to shower. CNA K said Resident #4 could scratch herself, and dirt could collect under Resident #4's fingernails. CNA K said she had a skills check-off, which included nail care. CNA K said residents' nails are cut on shower days and as needed. CNA K did not respond when asked why she did not offer to cut Resident #4's fingernails. CNA K said the charge nurse monitored the aides when they made rounds. During an interview on 03/05/24 at 4:13 p.m., the DON said CNA K should offer to cut Resident #4 fingernails during the shower and as needed. The DON said Resident #4 could scratch herself, and dirt could accumulate under the nails. The DON said he just texted the wound care nurse to go and cut Resident #4's fingernails, and she refused. The DON said he would care plan Resident #4's refusal to cut her fingernail. The DON said the nurse monitors the aides when she makes rounds and makes sure the aides are providing care for the residents. Surveyor N asked the DON if there was any documentation of Resident #4 refusing fingernail care before today (03/05/24), and he did not respond. During an interview on 03/07/24 at 4:42 p.m., the Administrator said the DON said Resident #4 refused to cut her fingernails, which was care planned. Then the Administrator said wait, and I would go and get the shower sheets. During an interview on 01/07/24 at 4:45 p.m., the Administrator returned and said the DON said there would be no need to look at Resident #4's shower sheets because he had care planned; Resident #4 refused care. Record review of the facility policy on nail care dated Copyright 2023 The Compliance Store, LLC. All rights reserved read in part . The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 4 residents reviewed for care plans (Resident #50) - The facility failed to care plan Resident #50's risk and history of falls and to put interventions in place to prevent further falls. The care plan was not updated or revised after each fall. An Immediate Jeopardy (IJ) was identified on 09/24/23 at 2:00 PM. While the IJ was removed on 09/26/23 at 4:32 AM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not having individual needs met and decreased the quality of life to prevent further falls. Findings included: Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on 7/8/23 with a diagnoses of mild intellectual disabilities ( when there are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills, epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, , unspecified fall. Resident #50 quarterly MDS dated [DATE] was also coded that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility. Record review of Resident #50's care plan dated 11/24/22 revealed the care plan did not contain a focus area for falls. Record review of Resident #50's EMR revealed the resident experienced falls on the following dates 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023, and 9/3/2023. These falls were updated on 9/8/2023 by the MDS RN. Record review of Resident #50's progress notes revealed the resident experienced an unwitnessed fall on 7/25/23. The resident was sent to the hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. On 9/28/23 Resident #50 the surveyor observed with right upper eyebrow large bruise and strips to the forehead . Interview with the DON on 9/8/23 at 4:29PM regarding Resident # 50's falls revealed she was responsible for looking to see if the care plans were revised and to see if it the interventions used were working. She said she could not remember when the care plan was modified for Resident #50. She said the root course for Resident #50's fall was for seizures. She said the floor mat was moved away because it does not prevent falls, it helps to prevent injuries. DON said Resident #50 was not on a low bed because it was inappropriate for him . She said MDS RN did the care plan for all Resident #50 falls , and he was in the facility. DON said she forget to document why the floor mat and low bed was not used on the care plan. Interview with the MDS-RN on 09/08/2023 at 4:46 PM revealed he had just added each fall from 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023, and 9/3/2023. to the care plan on 09/08/2023 . Interview on 09/08/2023 at 07:40 p.m. with the Director of Rehab, revealed Resident #50 may have used a rolling walker during therapy. He said there was a progress note he completed on 7/27/2023 regarding bed mobility, supervision, the use of bed rails. Low bed, floor mat, transfer standby assist, and for the nurses implement those devices Interview on 09/08/23 at 08: 20 PM with the Administrator, revealed all the staffs were responsible for addressing and ensuring the wellbeing of the residents. He said when a fall occurs an incident report should be completed by the floor nurse and the DON is alerted. He said a fall that results in a change of condition will be addressed in the morning meetings by the IDT the following day. He said his interventions was to ensure appropriate care plan to addressed individual needs immediately. He said fall interventions should have been addressed and updated to Resident #50's care plan at each fall or change of condition and they were not. The Administrator said it was the DON, MDS RN, and Therapy's responsibility to ensure those updates of the care plan. He said he signs off on all the incident reports and he was not aware of each of Resident #50's falls. He said Resident #50's falls would be discussed in the following morning meeting. This was determined to be an Immediate Jeopardy (IJ) on 09/24/23 at 2:00 PM. The DON, was notified. The DON was provided the Immediate Jeopardy template on 09/24/23 via email at 2:00 PM. The following Plan of Removal was submitted and accepted on 09/26/23 at 4:32 AM. Plan of Removal Immediate action: FOR REMOVAL OF IMMEDIATE Jeopardy On September 5th, 2023, an annual survey was initiated. On September 24th, 2023, at approximately 1:00 pm, the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Issue: F-Tag 656: Facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet Resident # 50's needs due to frequent falls and with major injury on 07/26/2023. The facility failed to care plan Resident # 50's risk/history of falls and to put interventions in place to prevent further falls leading to a fall with major injury on 07/26/2023. Done for those affected: On 09/24/2023 a new fall risk assessment was performed on resident #50 by DON, MDS Nurse and Rehabilitation Director. Completed on 09/24/2023. On 09/24/2023 the care plan was updated to include current interventions to minimize injuries from further falls. Completed on 09/24/2023. On 09/24/2023 PCP and medical director were notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 09/24/2023. On 09/24/2023 RP was notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 09/24/2023. On 09/24/2023 Head to toe assessment completed Resident # 50 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 09/24/2023. On 09/24/2023 DON and nurse managers audited residents who are at fall risk and started updating care plans as appropriate for those residents ensuring current interventions as appropriate. Care plans for residents with fall risk updated and completed on 9/25/23. Identify residents who could be affected: On 09/24/2023 Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified to be affected by the same deficient practice. Completed on 09/24/2023. Action Taken: On 09/24/2023 the care plan for resident # 50 was updated to reflect current interventions and assistive devices. Completed on 09/24/2023. Effective immediately (after care plan updated) on 09/24/2023, the Administrator / DON and/or designee began re-education to all staff on the facility fall risk assessment, care planning, implementing interventions, and on the use of assistive devices for resident # 50. Staff present in the facility on 09/24/2023 were in-serviced on 09/24/2023. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed. On 09/24/2023 All nurse managers were educated on ensuring resident care plans are updated after falls to include appropriate interventions and assistive devices, where applicable, either in person or by phone. Staff does not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed for that individual. On 09/24/2023 all residents with falls in the last 30 days were reviewed for any injuries that could be considered a major injury and care plans were reviewed. Completed on 9/24/23. Those that are not scheduled to work on 09/24/2023 will have the re-education completed prior to the start of their next scheduled shift. Phone calls made to nurses not currently working. On 09/24/2023, the Administrator, DON and Director of Rehabilitation Services provided one to one reeducation to all LVNs, RNs and nurse managers on adequate supervision, assistive devices, fall precautions, person-centered care planning with measurable objectives and timeframe, and adequate interventions. Education was completed on 09/25/2023. On 09/24/2023 the Care plan policy was reviewed by Administrator, VP of Operations, DON, MDS-RN, and nursing management. In-service provided by VP of Operations to above-listed individuals regarding the importance of comprehensive care plans and the update of care plans after a significant change, to include measurable outcomes. Completed on 09/24/2023. On 09/24/2023 administrator and DON in-serviced nurse managers on reporting and recognizing major injuries. Completed on 09/24/2023. On 09/24/2023 DON, MDS nurse and rehabilitation director assessed resident # 50 for interventions to minimize the risk of falls and injuries. Completed on 9/24/23. Surveyor Monitored the plan of removal and interview as follows: Observations were started on 09/24/23 at different times revealed the staffs knew how to minimize falls and injuries, by the use of floor mat, bed in lower position, call light within reached, rooms not cluttered. 3:00 PM, 4:00PM, 09/25/23, 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/26/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/27/23 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 7:30 PM, 09/28/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 09/29/23, 12:40 PM, 1:30 PM, 3:45 PM, 5:00 PM and continued through 09/30/23, 10:30 AM, 11:30 AM, and 12:30 PM, 1:30PM. Observations were started on 09/24/23 and continued through 09/30/23. Observation of Residents #19, #50, #62, #84 revealed adaptive devices of floor mat, low bed, bedrooms were free of clutter and were available for residents at risk for falls. Interviews were conducted on 09/24/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, 09/29/23 , 09/30/23 with over 20 staffs across all 6:00 AM to 6:00PM and 6:00PM to 6:00 AM shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS RN, CNA A, CNA B, CNA C, C.NA D LVN A, LVN B, LVN C, LVN D, LVN E, MA A, CNA H, CNA E, CNA F, CNA G, PT, OTA and RN A. All staff interviewed verbalized adequate understanding of plan of remove training received including Universal Fall Precautions policy/procedures, star program (residents that were high risk for fall, stars were placed on the entrance door), Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Over 25 Staffs were in-serviced on 09/26/23, 09/27/23 and 09/28/23 regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls care plan. Reporting, incidents, Kardex system and Fall Prevention Procedures. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. During an interview on 09/26/2023 at 1:59p.m. with DON, RN said, she believed the facility currently had an IJ because of the resident' s history of falls. She said the resident#50 did not need a 1 on 1 supervision, but because he had so many falls, it was a concern. She said there was no high risk falls care plan and she did not have a system in place to identify high risk for falls residents ( the Star program) to have nursing staffs monitored residents closely and document each falls. During an interview on 09/26/2023 at 2:32p.m. the Administrator said he believed the facility is currently has an IJ because there was Resident #50 that fell and sustained a major injury. He said he made sure that everybody understands how important about supervising residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents for fall were monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings and the use of assistive device to prevent fall and minimized injury. During an interview on 09/26/2023 at 1:33p.m. the ADON, LVN said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the high fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents and document care plan. She said things change and staff must continue to receive training to adapt to those changes and star fall program. During an interview on 09/28/2023 at 1:42 p.m. with MDS RN, RN said the facility has an IJ because there was a resident with frequent falls, and they did not put assistive device to prevent him for falling and it resulted in a major injury. He said they went back and reviewed what was going on with the resident. He said for now on he is going to pay closer attention to the residents that are high risk for falls care plan He said the care plans will be closely directed to the resident. He said he will work closer with the nursing staffs and document to show that the residents are being monitored. He said the care plans was not being done correctly since he has been at the facility. He said the care plans needs to be individualized on falls. The Administrator was informed the Immediate Jeopardy was removed on 09/28/23 at 9:46 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm 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.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #50) reviewed for free of accidents, hazards, supervision, and devices., in that: 1. The facility failed to provide and utilize assistive devices for Resident #50 who had experienced multiple falls and unwitnessed fall on 7/25/23. Interventions including assistive devices were not put in place after a fall on 07/25/23 resulting in hospitalization and resident fell again on 07/26/23 resulting in a major head injury and another hospitalization 2. The facility failed to implement interventions after each fall incident for Resident #50 on 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023 and 9/3/2023. No revisions were made to the care plan after all of the falls listed until surveyor intervention on 09/08/23. 3. The facility failed to follow their Fall Prevention Policy to include providing additional interventions when Resident #50 had multiple falls An Immediate Jeopardy (IJ) was identified on 09/24/23 at 2:00 PM. While the IJ was removed on 09/26/23 at 4:32 AM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could affect residents who were fall risk and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings include: Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on 7/8/23 with a diagnoses of mild intellectual disabilities ( when there, are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills, epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, , unspecified fall. Resident #50 quarterly MDS dated [DATE] was also coded that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility. Record review of Resident #50's EMR revealed the resident experienced falls 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023, and 9/3/2023. These falls were listed on 9/8/2023 by MDS RN. Record review of Resident #50's progress notes revealed resident experienced an unwitnessed fall on 7/25/23. The resident was sent to hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. On 9/8/23 Resident #50 was observed with right upper eyebrow large bruise and strips to the forehead. Observation on 9/5/23 at 10:00 AM, 11:00 AM, 2:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat . He was talking to himself and occasionally yelling out help. Observation indicated he would answer to his name when called out loudly. Observation on 9/6/23 at 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM revealed Resident #50 was not on a low bed and had no floor mat . Observation on 9/7/23 at 10:00 AM, 12:00 PM, 3:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat . Observation on 9/8/23 at 11:00 AM, 1:00 PM, 2:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat. Observation on 9/5/23 at 10:00 AM, 11:00 AM, 2:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat. During an interview with CNA A on 09/08/2023 at 2:54 PM, regarding falls/seizures , she said she would ensure residents were safe by moving any objects that could cause harm to resident and would call the nurse if resident was on the floor to assess resident. CNA A said Resident #50 was not on a low bed with floor mat and was on regular bed. During an interview with CNA B on 09/08/2023 at 2:57 p.m., regarding falls/seizures, she said she ensured resident were safe by moving things that could hurt the away. She would call the nurse assess the resident. CNA B said Resident #50 was not on a low bed with floor mat. Interview with the DON on 9/8/23 at 4:29PM said, regarding Resident # 50's falls, she said she was responsible for looking to see if the care plan was revised and to see if the interventions used were working. She said she cannot remember when the care plan was modified for Resident #50. She said the root course for Resident #50's fall was seizures. She said the floor mat was moved away because it does not prevent falls, it helps to prevent injuries. DON said Resident #50 was not on a low bed because it was not appropriate for him. Interview with ADON, LVN, on 9/8/23 at 3:00 p.m., she said Resident #50 was moved from 400 hall to 100 hall due to frequent falls and he was being monitored closely every 1hour he was not on a low bed with floor mat. Interview on 09/08/2023 at 07:40 PM with the Director of Rehab, said Resident #50 may have used a rolling walker during therapy. He said there was a progress note he completed on 7/27/2023 regarding bed mobility, supervision, the use of bed rails. Low bed, floor mat, and transfer standby assist and the nurses implement those devices. Interview on 09/08/23 at 08: 20 PM with the Administrator, said all the staff are responsible for addressing and ensuring the wellbeing of the residents. He said when a fall occurs an incident report should be completed by the floor nurse and the DON is alerted. He said a fall that results in a change of condition will be addressed in the morning meetings by the IDT the following day. He said interventions if not appropriate, will be to update the care plan immediately when discovered. He said fall interventions should have been addressed and updated to Resident #50's care plan at each fall/change of condition and they were not. The Administrator said it was the DON, MDS, and Therapy's responsibility to ensure those updates on the care planW. He said he signs off on all the incident reports and he was not aware of each of Resident #50's falls. He said Resident #50's fall would be discussed in the following morning meeting. Record review of the facility's policy dated (October 2022 Review). F689-Free of Accident Hazards Supervision Devices 42 C.F.R. 483.25(d)(1)(2): Fall Prevention Program. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 5. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator ( star program) on the name plate to resident's room door. iii. Place Fall Prevention Indicator on resident's wheelchair. b. Implement interventions from low /moderate risk protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: I. Assistive devices ii. Increased frequency of round iii. Sitter if indicated. iv. Medication regimen review v. Low bed vi. Alternate call system vii. Scheduled ambulation or toileting assistance. viii. Family/caregiver or resident education ix. Therapy services referral This was determined to be an Immediate Jeopardy (IJ) on 09/24/23 at 2:00 PM. The DON, was notified. The DON was provided the Immediate Jeopardy template on 09/24/23 via email at 2:00 PM. The following Plan of Removal was submitted and accepted on 09/26/23 at 4:32 AM. Plan of Removal Immediate action: On 9/26/23 an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: What does the facility need to change immediately to keep residents safe and ensure it does not happen again? What corrective actions have been implemented for the identified residents? The following action items were implemented immediately on 9/26/23. An in-service was initiated with licensed nurses on 09/26/23, by the Director of Nurse FOR REMOVAL OF IMMEDIATE JEOPARDY On September 5th, 2023, an annual survey was initiated at. On September 24th, 2023, at approximately 1:00 pm, the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Issue: F-Tag 689: Facility failed to ensure resident #50 had adequate supervision and assistive devices to prevent an accident on 07/25/23. The facility failed to accurately assess Resident # 50 risk for falls and assistive devices. The facility failed to update fall precaution interventions after severe falls. Done for those affected: On 09/24/2023 a new fall risk assessment was performed on resident #50 by DON, MDS Nurse and Rehabilitation Director. Completed on 9/24/23 and was reviewed surveyor. On 09/24/2023 PCP and medical director were notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 9/24/23 On 09/24/2023 RP was notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 9/24/23 On 09/24/2023 Head to toe assessment completed Resident # 50 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 09/24/2023. On 09/24/2023, other residents identified with frequent falls were reviewed for appropriate assistive devices, interventions, and fall risk . Completed on 09/24/2023. These was review by the surveyors. On 09/24/2023 all other residents care plans were reviewed for appropriate assistive devices and fall risk. Completed on 9/24/23 On 09/24/2023 all nurses and nursing staff present in the facility were in-serviced on facility fall risk assessment, care planning, implementing interventions, and on the use of assistive devices. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed for that individual. On 09/24/2023 all staff at the facility were in-serviced on current interventions and assistive devices for resident #50 either in person or by phone. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed for that individual. Identify residents who could be affected: On 09/24/2023 Administrator and/or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified to be affected by the same deficient practice. Completed on 9/24/23. Action Taken: On 09/24/2023 resident # 50 was assessed for appropriate assistive devices and adequate type of supervision to minimize the risk for falls and injuries. Care plan immediately updated to reflect new assessment including appropriate use of assistive devices and interventions. On 09/24/2023 All nurse managers were educated on ensuring resident care plans are updated after falls to include appropriate interventions and assistive devices, where applicable, either in person or by phone. Effective immediately (after care plan updated) on 09/24/2023, the Administrator / DON and/or designee began re-education to all staff on the facility fall risk assessment, care planning, implementing interventions, and on the use of assistive devices for resident # 50. Staff present in the facility on 09/24/2023 were in-serviced on 09/24/2023. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed. Those that are not scheduled to work on 09/24/2023 will have the re-education completed prior to the start of their next scheduled shift. Phone calls conducted for those not currently working. On 09/24/2023, the Administrator, DON and Director of Rehabilitation Services provided one to one re-education to all LVNs, RNs and nurse managers on adequate supervision, assistive devices, fall precautions, person-centered care planning with measurable objectives and timeframe, and adequate interventions. Education was completed on 09/25/2023. Surveyor Monitored the plan of removal and interview as follows: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by 9/26/23. Any direct care staff member not in-serviced by 9/27/23 will not be allowed to work until the in-servicing is completed. For the next 30 days the DON and ADON will monitor the nursing staff per week o given to determine retention of knowledge the universal fall precaution protocol. The results of these audits will be reviewed in the Quality Assurance and Performance Improvement meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. The QAPI Committee will continue to monitor monthly to identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Observations were started on 09/24/23 at different times, 3:00 PM, 4:00PM, 09/25/23, 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/26/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/27/23 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 7:30 PM, 09/28/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 09/29/23, 12:40 PM, 1:30 PM, 3:45 PM, 5:00 PM and continued through 09/30/23, 10:30 AM, 11:30 AM, and 12:30 PM, 1:30PM. Observations were started on 09/24/23 and continued through 09/30/23. Observation of Resident ( #19, #50, #62, #84 ) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on 09/24/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, 09/29/23 , 09/30/23 with over 20 staffs across all 6:00 AM to 6:00PM and 6:00PM to 6:00 AM shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS RN, CNA A, CNA B, CNA C, C.NA D LVN A, LVN B, LVN C, LVNC, LVN D, MA A, CNA D, CNA E, CNA F, CNA G, PT, OTA and RN A. All staff interviewed verbalized adequate understanding of plan of remove training received including Universal Fall Precautions policy/procedures, star program , Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Over 25 staffs were in-serviced on 09/26/23, 09/27/23 and 09/28/23 regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. During an interview on 09/26/2023 at 1:59p.m. with DON,RN said, she believed the facility currently has an IJ because of the resident's history of falls. She said the resident did not need a 1 on1 supervision, but because he had so many falls, it was a concern. She said there were no high risk falls care plan and she now have a system in place to identify high risk for falls residents ( the Star program) to have nursing staffs monitored residents closely and document each falls. During interview with the Administrator on 9/26/23 at 2:30 PM He stated that he had been an administrator for 20 some years. He Understood that the facility has an IJ because the facility did not report the incident to the State thus the facility did not investigate the incident. In investigating the incident, the facility will be able to ensure that abuse did not occur, and fall will not occur with injuries, having plan/ process in place by identifying the root cause of the fall. During an interview on 09/26/2023 at 2:32p.m. the Administrator said, he believes the facility is currently has an IJ because there was a resident that fell and sustained a major injury. He said he has made sure that everybody understands how important it is to supervise residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents are always monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings and the use of assistive device to prevent fall and minimized injury. During an interview on 09/26/2023 at 1:33p.m. the ADON, LVN said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the high fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents. She said things change and staff must continue to receive training to adapt to those changes and star fall program. During an interview on 09/28/2023 at 1:42 p.m. with MDS RN, RN said the facility has an IJ because there was a resident with frequent falls, and they did not put assistive device to prevent him for falling and it resulted in a major injury. He said they went back and reviewed what was going on with the resident. He said for now on he is going to pay closer attention to the residents that are high risk for falls. He said the care plans will be closely directed to the resident. He said he will work closer with the nursing staffs and document to show that the residents are being monitored. He said the care plans was not being done correctly since he has been at the facility. He said the care plans needs to be individualized on falls. The Administrator was informed the Immediate Jeopardy was removed on 09/28/23 at 9:46 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm 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.

Based on observation , interview, and record review, the facility failed to ensure allegations of abuse and neglect are thoroughly investigated and report results of the investigation to the stage agency within 5 working days of the incident for 2 of 9 residents (Resident #50 and #84) reviewed for allegations of neglect as evidence by: 1. The facility failed to report an unwitnessed fall to the state agency when Resident #84 was found on the floor had a large hematoma to the top of her head and was transferred to the hospital . Resident #84 could not state how she fell . 2. The facility failed to report an unwitnessed fall to the state agency when Resident #50 was found on the floor. Resident #50 was sent to hospital on 7/25/23 and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. These failures could place residents at the facility not having their complaints and concerns reported and investigated for potential mental, physical, or emotional abuse . The findings included: Resident #84 Resident #84 was [AGE] years admitted to the facility on [DATE] with diagnoses of age-related physical debility, pressure ulcer of sacral region, stage 4 (largest and deepest of all bedsore stages) lack of coordination, cachexia (excessive loss of weight), and cerebral infarction (Stroke). Resident #84 quarterly MDS dated [DATE] was revealed that she required total assistance of at least 2 persons assist with transfers from bed, wheelchair. According to the annual MDS she had unsteady balance and was not able to stabilize with staff assistance and used a rolling wheelchair for mobility. Her BIMS score was 03 (severe cognitive impairment). Record review of Resident #84's care plan, created dated 04/05/23 indicated she had impaired cognitive function and impaired thought processes related to dementia limited physical mobility related to weakness, increased risk for infection, falls, impaired verbal communication, loss of ability to do ADLs. Communication problem related to intrinsic and extrinsic factors such as: slurred/mumbled speech says few words difficult to understand. Interventions included communication, ask yes/no questions in order to determine the resident's needs. Ambulation: The resident requires (supervision assistance) by staff to walk and anticipate and meet needs. Review of the facility Incident report revealed nursing staff (agency nurse) completed a report for Resident #84's fall. On 9/17/23 at 8.40 PM: Incident Note: This writer was notified by resident's roommate, that resident is laying on the floor . Writer went into resident's room to check on resident. Resident found lying face down on the floor by the bedside. Resident assisted to lay on her back by this writer and other staff members. Total head to toe assessment done. Large sized hematoma noted to the left side of the forehead above the left eye area. Description: Resident was unable to give description Interview with the DON on 9/24/23 at 2:35 PM revealed Resident #84 fell in her room on 9/17/23 at about 8:40 PM, and had a bump to her head, was sent to the hospital, X-ray was done in the hospital. DON was asked why incident was not investigated and report to the state agency was not notified. DON said we are not supposed to report incident if resident were able to state how she fell . During interviews on 9/24/23 between 8:25 a.m. and 6:41 PM facility staffs said Resident #84 was very confused to self and would not be able to identify how she fell . Interview on 9/29/23 at 4:00 PM with RN B, who worked the weekend r Resident revealed #84 fell . She was taking care of another hall when Resident #84' roommate called her. She went to Resident room and found Resident #84 on the floor. Roommate curtain was closed, and she did not know what happened. Resident #84 was not able to verbalize how she fell , RN A said Resident #84 was very confused and her roommate. Resident #50 Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on 7/8/23 with a diagnoses of mild intellectual disabilities ( when there, are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills , epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, unspecified fall. Review of Resident #50's quarterly MDS dated [DATE] was revealed that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility . Record review of Resident #50's health notes dated 7/26/23 revealed he was sent to hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. Interview with C.NA A on 9/8/23 at 2:54 PM, revealed she said she worked with Resident #50 since April 2023. He was a 1 person assist and was sometimes able to verbalize his needs but was very confused. Interview with C.NA B on 9/8/23 at 2:57 PM, revealed she worked with Resident #50 since April 2023. He was 1 person assist and was sometimes able to verbalize his needs but was very confused not able to explain himself when he fell . Interview with LVN, MDS on 9/8/23 at 3:53 PM, via telephone revealed she completed Medicare MDS only and RN MDS completed Medicaid MDS assessment, and Resident #50 was not her resident. She said Resident #50 was very confused and each fall should be care plan and fall updated. Interview with the DON on 9/24/23 at 2:35PM, she said Resident #84 fell in his room on 9/17/23 at about 9:40 AM. She stated he had a bump to his head, was sent to the hospital, and CT scan was done in the hospital. The DON was asked why the incident was not investigated and reported to the state agency. DON said, we are not supposed to report incident if resident were able to state how he fell . During interviews on 9/24/23 between 8:25 a.m. and 6:41 PM facility staffs said Resident #50's was very confused to self and would not be able to identify how he fell . Interviews the DON and Administrator on 9/26/23 at 2:30 PM regarding thoroughly investigating and reporting incidents and accidents to the state agency revealed that following a fall with injury, they only reported falls with injury if residents was not able to tell the nursing staff how they fell and were following the state guidelines of reporting incident / accident. She said the falls were not suspicious of abuse and that was why it was not investigated. Record review of the Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated July 10,2019, (Long -Term Care Regulatory Provider Letter) indicated:2.0 Policy details and provider responsibilities. 2.1. Incidents that a NF Must report to HHSC and the time frames for reporting . Abuse, Neglect Exploitation Death due to unusual circumstances A missing resident Misappropriation Drug Theft Suspicious injuries of unknown source Fire Emergency situations that pose a threat to resident health and Safety Record Review of the facility's policy titled Abuse Investigations, (revised April 2017) read in part . All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required state or local laws, within (5) working days of the reported incident.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 2 of 4 Residents (Residents #50 and #84) reviewed for abuse and neglect. 1. The facility failed to report an unwitnessed fall to the state agency when Resident #84 was found on the floor had a large hematoma to the top of her head and was transferred to the hospital . Resident #84 could not state how she fell . 2. The facility failed to report an unwitnessed fall to the state agency when Resident #50 was found on the floor. Resident #50 was sent to hospital on 7/25/23 and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. This failure could place residents at risk for abuse, neglect and serious bodily injury by not reporting incidents as required. The findings included: Resident #84 Resident #84 is [AGE] years admitted to the facility on [DATE] with diagnoses of age-related physical debility, pressure ulcer of sacral region, stage 4 (largest and deepest of all bedsore stages) lack of coordination, cachexia (excessive loss of weight), cerebral infarction (Stroke). Resident #84 quarterly MDS dated [DATE] was also coded that she required total assistance of at least 2 persons assist for transfers from bed, wheelchair. According to the annual MDS she had unsteady balance and was not able to stabilize with staff assistance and used a rolling wheelchair as her mobility. BIMS score 03 ( severe cognitive impairment). Record review of Resident #84's care plan, created dated 04/05/23 indicated she have impaired cognitive function and impaired thought processes related to dementia limited physical mobility related to weakness. increased risk for infection, falls, impaired verbal communication, loss of ability to do ADL' s. Communication problem related to intrinsic and extrinsic factors such as: slurred/mumbled speech says few words difficult to understand. Interventions included communication, ask yes/no questions in order to determine the resident's needs. Ambulation: The resident requires (supervision assistance) by staff to walk and anticipate and meet needs. Review of the facility Incident report revealed nursing staff (agency nurse) completed a report for Resident #84's fall. On 9/17/23 at 8.40 PM: Incident Note: This writer was notified by resident's roommate, that resident is laying on the floor. Writer went into resident's room to check on resident. Resident found lying face down on the floor by the bedside. Resident assisted to lay on her back by this writer and other staff members. Total head to toe assessment done. Large sized hematoma noted to the left side of the forehead above the left eye area. Description: Resident was unable to give description documented by the nurse. Interview with the DON on 9/24/23 at 2:35PM she said Resident #84 fell in her room on 9/17/23 at about 8:40 PM, and had a bump to her head ,was sent to the hospital, X-ray was done in the hospital. DON was asked why incident was not investigated and report to the state agency was not notified. DON said we are not supposed to report incident if resident were able to state how she fell . During interviews on 9/24/23 between 8:25 a.m. and 6:41p.m. facility staffs said Resident #19's was very confused to self and would not be able to identify how she fell . -RN A 6p to 6a -LVN A 6a to 6p -CNA C 6a to 6p -LVN C 6a to 6p -CNA D 6p to 6a Interview on 9/29/23 at 4:00 PM with RN B, she said work weekend that Resident #84 fell . She was taking care of another hall when Resident #84' roommate called her. She went to Resident room and found Resident #84 on the floor. Roommate curtain was pulled and she did not know what happened. Resident #84 was not able to verbal how she fell , RN A said resident #84 was very confused and her roommate. Resident #50 Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on 7/8/23 with a diagnoses of mild intellectual disabilities ( when there, are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills, epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, personal history of traumatic brain injury, unspecified fall. Resident #50 quarterly MDS dated [DATE] was also coded that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility. Record review of Resident #50's health notes dated 7/26/23 revealed he was sent to hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. Interview with C.NA A on 9/8/23 at 2:54 PM, she said she worked with Resident #50 since 4/2023, he was 1 person assist and was sometimes able to verbalized needs but was very confused. Interview with C.NA B on 9/8/23 at 2:57 PM, she said she worked with Resident #50 since 4/2023, he was 1 person assist and was sometimes able to verbalized needs was very confused not able to explained himself when he fell . Interview with LVN, MDS on 9/8/23 at 3:53 PM, via telephone she said she does Medicare MDS only and RN MDS does Medicaid and Resident #50 was not her resident. She said Resident #50 was very confused and each fall should be care planned and fall care plan updated. Interview with the DON on 9/24/23 at 2:35PM she said Resident #84 fell in his room on 9/17/23 at about 9:40 AM, and had a bump to his heads was sent to the hospital, CT scan was done in the hospital. DON was asked why incident was not investigated and report to the state agency was not notified. DON said, we are not supposed to report incident if resident were able to state how he fell . During interviews on 9/24/23 between 8:25 a.m. and 6:41p.m. facility staffs said Resident #50's was very confused to self and would not be able to identify how he fell . -RN A 6p to 6a -LVN A 6a to 6p -CNA C 6a to 6p -LVN C 6a to 6p -CNA D 6p to 6a. Interviews the DON and Administrator on 9/26/23 at 2:30 PM regarding thoroughly investigating and reporting incident/accident to the state agency revealed that following fall with injury, they only report falls with injury if residents was not able to tell the nursing staff how they fell and were following the state guidelines of reporting incident / accident. She said the falls were not suspicious of abuse and that was why it was not investigated. Record review of the Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated July 10,2019, (Long -Term Care Regulatory Provider Letter) indicated:2.0 Policy details and provider responsibilities. 2.1. Incidents that a NF Must report to HHSC and the time frames for reporting . Abuse, Neglect Exploitation Death due to unusual circumstances A missing resident Misappropriation Drug Theft Suspicious injuries of unknown source Fire Emergency situations that pose a threat to resident health and Safety

Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 8 residents (Residents #50) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #50 returned from the hospital and had a significant decline. This failures could placed residents at risk of having an assessment that does not reflect significant changes in their conditions and need for additional care/treatment. The findings included: Resident #50 Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on 07/08/2023 with a diagnoses of mild intellectual disabilities ( when there, are limits to a person's ability to learn at an expected level and function in daily life), , personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills, epilepsy ( abnormal electrical activity in the brain), not intractable, without status epilepticus, personal history of traumatic brain injury, unspecified fall. Record review of Resident #50's MDS schedule reflected a quarterly MDS dated [DATE];. BIMS score was 9 out of 15 indicating moderate cognitive impairment. There was not a significant change assessment documented on the schedule. Observation on 09/08/2323 at 8:40 a.m. revealed Resident #50 was in the wheelchair in the dining room, propelling himself on a wheelchair. Resident #50 was not on a low bed and no floor mat noted throughout the survey, he was talking to himself and occasionally yelling out help. Observation indicated he would answer to his name when called out loudly. . Record review of Resident #50's comprehensive care plan dated 11/24/22 revealed his fall risk was care planned, all goals and interventions were created on 11/21/2022 . The residents falls on 3/18/23 (unwitnessed), 03/25/2023 (unwitnessed), 060/9/2023 (unwitnessed), 06/30/2023 (unwitnessed), 07/25/2023 (unwitnessed), 07/26/2023 (unwitnessed), 08/8/2023 (unwitnessed), 08/15/2023 (witnessed), 08/20/2023, 09/2/2023 (Unwitnessed), 09/03/2023 (unwitnessed) and 09/07/2023 (unwitnessed). Further review revealed these falls were added to the care plan on 09/08/2023. Record review of Resident #50's admission MDS was also coded that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the admission MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility device since 07/17/2023. Record review of Resident #50 sustained a head injury on the left top of his head, which resulted in a large hematoma . on 07/26/2023 and on 09/02/2023 had right upper eyes bruise and strips to forehead. Review of Resident #50's care plan , revealed, Resident #50 is at high risk for falls related to intrinsic and extrinsic factors such as: Weakness, impaired balance, impaired mobility, cognitive decline, limited mobility, dementia, muscle weakness, hypertension, and history of falls. Care plan (C/P) updated 11/24/2022 Resident # 50 continues with high risk for falls, has poor safety awareness, impulsive, cognition poor, continues to self-transfer. High risk for falls with major injuries C/P updated 05/23/2023 Resident #50 with high risk for serious injuries related to fResident # 50 continues to ambulate, transfer without assistance. Record review of Resident #50's fall risk evaluation dated 08/15/2023 , was scored as a 11 out of 10 indicating the score of 11 indicated he was a very high risk for falls. Record review of Resident #50's fall risk evaluation dated 09/082023 was scored as a 12 out of 10 indicating the score indicated he was a very high risk for falls. Record review of Resident #50's fall risk evaluation dated 09/08/2023 was scored as a 11 out of 10 indicated he was a very high risk for falls. Interview with the DON on 09/0820/23 at 4:29PM said, regarding resident falls, the nurses supposed to assess the resident, notify the doctor, the family, and the DON, call 911 and send the resident for evaluation, look for the route course of the fall, would move resident to nurses' station, fall evaluation, review medication NP seizures, and medication will be added if needed. She said MDS RN did the care plan for all Resident #50 falls, and he was in the facility. She stated that this failure could cause her to miss care areas that would trigger on a significant change assessment. Interview with the MDS-RN on 09/08/2023 at 4:46 PM MDS-RN said Resident #50 came back into the building, and he just added each fall (07/25/2023 and 07/26/2023) to the MDS on 09/08/2023 . He said this error could result in the resident's decline not being captured or care planned correctly. This failure would then result in a comprehensive care plan not being completed, which could cause the resident to not receive the care that would trigger from a Significant Change assessment. The facility's policy and procedure for Resident Assessments and/or Significant Changes was not provided at the time of exit.

Based on interview and record review, the facility failed to ensure dialysis service was provided consistently with professional standards of practice for 1 of 3 residents (Residents #72) reviewed for dialysis services. The facility failed to keep ongoing communication with the dialysis facility for Resident #72. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] was readmitted on [DATE] . Her diagnoses included fluid overload, retention of urine, dependence on dialysis, muscle wasting and atrophy and abnormalities of gait and mobility. Record review of Resident #72's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #72's care plan undated revealed the resident has diagnosis of renal failure and received dialysis. Goal and innervations were outlined. Intervention did not address maintaining an on-going communication with the dialysis facility for Resident #72. Record review of Resident #72's progress notes dated 08/28/2023 revealed the resident had end stage renal disease, required dialysis Monday, Wednesday, and Friday. Interview on 09/05/2022 at 9:48am revealed Resident #72 was in his bed in his room. He was alert, oriented X3 and was able to make needs known. Resident stated he had been going to dialysis since 07/03/2023. Resident stated his dialysis days were Monday, Wednesday, and Friday. When asked if facility staff gave him a communication paper or form for his dialysis, resident said no. When asked if his dialysis facility provided a form of communication form/paper that contained summary of how his daily dialysis went, the resident said, he had never received anything like that from both facilities. Interview on 09/08/2022 about 03:32 p.m., the DON said was asked how the facility. DON said she did not think the facility has maintained ongoing communication with the dialysis facility for Resident #72. The DON stated staff should have been providing a form of communication to resident to take to his dialysis facility and should return with one. Interview on 09/08/2022 at 05:58 p.m., the DON said she looked further into the dialysis communication form requested. She was told facility staff gave the resident a communication form when leaving for dialysis, but the resident did not return with them. When asked if the facility reached out to the dialysis facility and inquired why the communication forms were not given to the resident at the end of his dialysis, DON said she wasn't sure facility had not done that. Record review of nursing home transfer agreement provided by the facility dated November 2014 revealed in providing dialysis treatments to designated residents, center shall adhere to the requirement of applicable state and federal law and regulations and shall maintain policies and procedure that provide for quality patient care, infection control, emergency care, proper waste handling, maintaining of equipment, water treatment, patient record keeping and patient safety. Record review of facility's dialysis resident policy revised 01/2022 did not address communication strategies between dialysis center and the facility.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 (Resident #32) reviewed for medication administration. The facility failed to ensure that LVN A did not administered Resident #4's Prednisolone Acetate Ophthalmic (eye drop medication used to treat inflammation of the eyes) to Resident #32. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Resident #32 Record Review of Resident #32 electronic face sheet dated 09/08/23 revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #32 had the diagnosis of inflammation of the eyes. Record Review of Resident #32 Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 10, which indicated Resident #32's cognition was moderately impaired. The MDS reflected Resident #32 required a scheduled eye medication regimen. Record review of Resident #32's physician orders revealed an order dated 09/03/2020 at 09:00a.m., Prednisolone Acetate ophthalmic 1% 1 drop in right eye one time a day for 7 days then stop 09/10/23. Record Review of Resident #32's MAR, dated September 2023, revealed she was scheduled to receive the following: Prednisolone Acetate ophthalmic 1% 1 drop in right eye one time a day for 7 days then stop 09/10/23 at 09:00 am. Further review of the MAR revealed there were check marks or initials by these medications, which indicated they had been administered. Observation and interview on 9/6/23 at 8:11 AM during medication administration, LVN B used Resident #4's Prednisone Acetate 1% 1 drop to Resident #32's eye right. LVN B was shown the name on the medication bottle and room number, LVN B said the eye bottle was placed in Resident #32's box, she did know it was another resident medication. In an interview on 09/06/23 at 9:58 AM, LVN B stated she will be more careful by checking the medications multiple times before administration. LVN B said not checking the medications could result in errors. An interview with the DON on 9/8/23 at 03:15 PM revealed it was important to administer right medications to the right resident,. The DON stated the medications could lose their potency or cause an unexpected reaction and she was going to do in-services. Review of the facility's Policy's titled Administrating Medications, revised April 2019 read in part: Policy statement: Medications are administered in a safe and timely manner, and as prescribed 4. Medications are administered in accordance with prescriber order, including any required time frame 10. The individual administering the medication checks the label THREE(3) times to verify the right resident, right medication, right dosage, right time .before giving the medication .

Based on observation, interview and record review the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable when applicable for 2 of 4 medication Carts reviewed for medication storage. The facility failed to ensure the medication (med) chart 100-hall did not have the expired medications Packets of Arginaid ( Arginne powder) ( used to help support the unique nutritional needs of individuals with wounds). The facility failed to ensure the Nurses medication carts 300-hall did not have the opened and undated medications: *Alphagan Brimonidine tartrate ophthalmic solution 0.1% ( used for an alpha adrenergic receptor agonist of indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension). *Prednisolone Acetate ophthalmic suspension 1 vial for ( drug used to treat inflammation of the eyes caused by certain condition), and *Fluticasone Propionate Nasal spray 50 mcg for 1 spray in each Nostril daily ( used to treat sneezing, itchy or runny nose or other symptoms caused by hay fever and chronic rhinosinusitis). These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: 300 Hall Nursing Cart Observation of 300 hall nurses' medication cart with LVN ADON on 9/7/23 at 2:22 PM revealed the following medications were opened and undated 1.Alphagan Brimonidine tartrate ophthalmic solution 0.1% 1 bottle. 2. Prednisolone Acetate ophthalmic suspension 1 bottle. 3. Fluticasone Propionate Nasal spray 50 mcg for 1 spray in each Nostril daily Interview with ADON on 9/7/23 at 2:22 PM she said those medications should be dated when opened. 100 Hall MA Cart Observation of 100 hall medication cart with MA A on 9/7/23 at 3:09 PM , Revealed there were 11 packets of Arginaid in the original container, had expired 20 August 2023. In an interview with MA A on 9/7/23 at 3:30 PM she stated she checked her medication cart for expired medication on a daily basis and said Arginaid box was just open last week. Interview with the ADON on 09/07/23 at 4:00 PM, the ADON said she, the MA's and the charge nurses were supposed to check the medication cart for expired medications every daily and any open eye drops bottle and suspended medications should have open date. The ADON said her expectation was to not have any expired medications in the med cart and expired medications would not produce desire result. In an interview with the DON on 9/8/23 at 11:03 AM revealed her expectation was for the nurses to return . She would have the ADON audit the medication cart more frequently instead of monthly. The DON stated giving residents expired medications could change chemical composition of the drugs over time which and could be rendered unsafe or ineffective. An interview with the DON on 9/8/23 at 03:15 PM revealed it was important not to administer expired medications because the expiration dates were there for a reason. The DON stated the medications could lose their potency or cause an unexpected reaction because their chemical makeup could be altered after the expiration dates. According to the FDA website accessed on (date) at (website) revealed , drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity when it is stored according to its labeled storage conditions. If a drug has degraded, it might not provide the patient with the intended benefit because it has a lower strength than intended. In addition, when a drug degrades it may yield toxic compounds that could cause consumers to experience unintended side effects.

Based on observation, interview, and record review the facility failed to ensure an adequately furnished space for dining and activities for 1 of 1 dining room and 1 of 1 activity room reviewed for dining and activity rooms. The facility did not provide an adequately furnished dining room or activity room for dining and resident activities. This failure could place the residents at risk for psychosocial harm and decreased quality of life. Findings included: Record review of the face sheet indicated Resident #55 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including dementia, behavior disturbance, psychotic disturbance, mood disturbance anxiety and muscle wasting and atrophy (thinning or loss of muscle tissue). Record review of the MDS dated [DATE] indicated Resident #55 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated he was moderately cognitively impaired. The MDS indicated Resident #12 needed supervision and 1-person physical assist for all activities of daily living. Observation and interview with Resident #55 on 9/7/2023 at 11:54a.m., revealed him coming out of the restroom inside of his room. He said the facility needs chairs in the dining room. He said those who are wheelchair accessible use their wheelchair as a chair. He said residents without wheelchairs need a chair. He said he must bring chairs from one place to another. He said this is unheard of. He said he has told staff and the Administrator multiple times about the lack of chairs in the dining room. Observation on 9/7/2023 at 11:57a.m., revealed two chairs to a table in the dining room area. There are three tables without chairs. Majority of the residents in the dining room area, are at the table sitting in their wheelchairs. There weren't many chairs available. Observation and interview on 9/7/2023 at 12:03p.m., revealed Resident #55 sitting at a dining room table with two female residents. Both women at the table were using their walker as a chair. Resident #8 said he grabbed his chair from the activity room. Observation on 9/7/2023 at 12:04p.m., revealed a male resident carrying a chair to a table in the dining room area. During Resident Council on 09/06/2023 at 10:59a.m., Resident #55 said there was not enough chairs for seating in the dining room area when the meals are being served. He said he has to carry a chair in from the activity's room or other areas of the facility. He said he has to get in the dining hall early, to ensure he gets a place at the table. He said they were supposed to be ordering more chairs, but it has been a while and he has yet to see new chairs. He said the facility had brought some tables, but no chairs. Resident #55 was observed a chair from the activity's room out to the dining area. He did not want help carrying the chair, he said it helps keep him strong. During an interview on 9/6/2023 at 5:38p.m. at the end day conference with Administrator, said they ordered new tables and chairs. He said the chairs were custom made chairs. He said the tables have already arrived and been put together. He said the chairs are taking longer because they are custom made and it is difficult to ship. He said he does not know how much longer it will be before the chairs arrive. He said residents have enough places to sit. He said sometimes staff bring chairs from other areas. He said residents should not have to bring their own chairs, staff will bring in the chair from other areas if they need to, and help residents carry the chairs. Record Review of the facility's policy on dining was not provided by the facility. 44669

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medication carts ( 100 Hall Nursing Cart, 300 Hall Nursing Cart, and 400 Hall Nursing Cart) reviewed for drug labeling and storage. - The facility failed to ensure the 100 Hall Nursing Cart, 300 Hall Nursing Cart and the 400 Hall Nursing Cart did not contain multidose containers with no open dates. - LVN C failed to ensure the 300 Hall Nursing cart was secured/locked when not in use and unattended. These failures could place residents at risk of adverse medication reactions and drug diversions. Findings Included: 100 Hall Nursing Cart In an observation and interview on [DATE] at 9:55 AM, inventory of the 100 Hall Nursing Cart with LVN B revealed: - 1 10 mL open and in-use vial of [MEDICATION(S)] R insulin at room temperature with no open date - 1 10 mL sealed vial of [MEDICATION(S)] insulin at room temperature with no open date. LVN B said that when insulin vials or pens were removed from the refrigerator or punctured, nursing staff must label the container with the date it was opened. She said the open date was used to track the expiration date and since the insulin vials did not have an open date their expiration dates could not be establish so they could no longer be used because after the beyond use date insulin loses its efficacy and can become contaminated. LVN B said nursing staff were expected to check their medication carts as used for expired and inappropriately labeled medications such as insulin and once identified they must be discarded in the drug disposal bin located in the medication storage room. She said the use of expired insulin could place residents at risk of ineffective therapy and infection. 300 Hall Nursing Cart Observation on [DATE] at 12:06 PM revealed, Nurse Medication Cart in 300 Hall was observed unlocked in the hall in front of room [ROOM NUMBER].No staff was present at the 300 Hall Nurse Medication cart. There were no residents, staff, or visitors in the hall at this time. Observation and interview on [DATE] at 12:07PM revealed, LVN C walked out of room [ROOM NUMBER] and returned to the Nurse Medication Cart on 300 hall. She stated she left it quickly because she heard a resident calling out for assistance. LVN C stated the cart was to be locked any time you leave it because it was a safety risk. LVN C stated anyone could get into the medication cart and take something out. LVN stated she has been in serviced on the importance of securing the medication cart. Inventory of the Nurse Medication Cart on 300 Hall on [DATE] at 12:07PM revealed: - First drawer contained insulins, glucose monitoring supplies, syringes. - Second drawer contained tums, antiacid, vitamins, [MEDICATION(S)] 5% topical patch, individual resident medications. - Third drawer contained creams and ointments - Fourth drawer contained medication supplies In an interview on [DATE] at 8:34 AM, the DON stated all medication carts were to be locked when left unattended. There was no exception to the rule because there was a risk to anyone getting into the medication cart and taking something out, they should not have. The DON stated she looks at the carts when she walks around, and she had not seen any medication carts unlocked. The DON stated in the three months since she has been here, she has not done any in-services. The DON stated to prevent this from occurring again she will have a one-on-one in-service with the nurse involved on the importance of securing the medication carts and then she will in-service the rest of the facility staff to lock the medication carts when leaving them. In an interview on [DATE] at 01:32 PM with the Administrator, he stated it was absolutely very important for the medication carts to be locked when left unattended. He said it was a safety risk because any resident could get into the cart and take something. In an observation and interview on [DATE] at 9:40 AM, inventory of the 300 Hall Nursing Cart with LVN J revealed: - 1 open and in-use [MEDICATION(S)] insulin pen room at temperature with no open date - 1 open and in use [MEDICATION(S)] insulin pen at room temperature with no open date. - 2 open and in-use [MEDICATION(S)] pens, an injectable medication used to treat diabetes, at room temperature with no open date. LVN J said that nursing staff were expected to check their carts as used for inappropriately labeled medications. She said once a multi-dose insulin container was opened or taken from the refrigerator it should be labeled with the date in order to track the expiration date. LVN J said since the insulin containers did not have an open date, she could not determine their expiration date so they must be discarded in the drug disposal bin located in the medication storage room. She said once expired insulin loses its efficacy and can become contaminated and use of expired insulin would place residents at risk for insufficient therapy and infection. 400 Hall Nursing Cart In an observation and interview on [DATE] at 9:45 AM, inventory of the 400 Hall Nursing Cart with LVN A revealed: - 1 open and in use [MEDICATION(S)] insulin pen at room temperature with no open date. - 1 open and in use [MEDICATION(S)] pen at room temperature with no open date. - 1 open and in-use [MEDICATION(S)] insulin pen at room temperature with no open date. LVN A said that nursing staff were expected to check their carts daily for expired and inappropriately labeled medications and the pharmacist audits the carts weekly. She said multi-dose insulin containers should be labeled with an open date once opened or taken out of the refrigerator in order to track their expiration date. She said once insulin expires it should not be used because the efficacy changes. LVN A said since the insulin pens didn't have an open date their expiration could not be determine so they must be discarded in the drug disposal bin located in the medication storage room. She said use of expired insulin places residents at risk of insufficient therapy. In an interview on [DATE] at 11:45 AM, the DON said all multidose insulin containers should be labeled with an open date when punctured or taken out of the fridge. She said the open date was used to track the expiration date because each manufacturer has a different beyond use date and after the manufacturer specified date the insulin loses efficacy/potency and there was a risk of contamination. She said if the expiration date cannot be determined the insulin must be discarded in the drug disposal bin located in the med room because use of expired insulin places residents at risk of adverse reactions. Record review of the facility policy titled Labeling of Medications and Biologicals with no revision date revealed, 8- labels for multi-use vials must include: a- the date the vial was initially opened or accessed (needle-punctured), b- all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that open vial, c- unopened or unassessed (needle-punctured) vials should be discarded according to the manufacturer's expiration date. Record review of the facility policy titled Medication Storage with no revision date revealed, 1, a- All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c- during medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage are/cart. 8- Unused medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . These medications are destroyed in accordance with out Destruction of Unused Drugs Policy. Record review of the facility policy titled Destruction of Unused Drugs with no revision date revealed, 2- unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed .

Based on observation, interview, and record review, the facility failed to ensure that the resident with pressure ulcers receives appropriate treatment/services received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers, for 1 Resident (Resident #20) of 18 residents reviewed for pressure ulcers. The facility failed to complete daily wound care on Resident #20's pressure ulcers as ordered by the physician. The facility failed to complete weekly skin evaluations every Tuesday as ordered by the physician. The facility failed to document wound care for Resident #20 on Treatment Administration Record per care plan. The facility failed to document the date on Resident #20's wound dressing per care plan. This failure could place residents at risk of complications including worsening of existing wounds and infection and at risk of unidentified deterioration in existing pressure ulcers/injuries. Findings included: Record review of Resident #20's face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE], with an original admitted [DATE]. Resident #20 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #20's MDS revealed the MDS was still in progress. Record review of Resident #20's care plan dated 05/13/22 revealed Resident #20 had multiple pressure ulcers related to immobility. Staff are supposed to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Record review of the Resident #20's progress note dated 7/8/2022 02:05 revealed Admission Summary Note Text: Resident was brought by 2 EMT ambulance staff on stretcher from [hospital name] hospital and readmitted to facility to the services or Dr. [physician name] he was treated in hospital for [CONDITION(S)] and discharged to facility to start oral [MEDICATION(S)] 100mg 2 times a day x30days for [CONDITION(S)]. he has a history of other medical conditions including multiple wounds to sacrum and bilateral lower extremities, [CONDITION(S)], [CONDITION(S)] with [CONDITION(S)], [CONDITION(S)] status, urinary retention, Foley Catheter in place, draining clear yellow urine and other medical conditions. head to toe assessment completed with V/S. medication verification with NP completed. order entry completed. DON notified. treatments initiated. re-oriented to staff, room, bed controls and routine. he denied pains and discomfort at this time and no s/s of distress. will continue to monitor. Written by: LVN G Record review of the Resident #20's progress note dated 7/8/2022 15:32 revealed Skin/Wound Note Text: Resident assessed and noted with multiple wounds. Left heel DTI, left lateral ankle stage 4 approximately 2.0 x 2.8 x 0.5, left lateral lower leg unstageable wound approximately 5.0 x 1.5, left scapula unstageable wound approximately 5.5 x 2.4, right thigh open blister approximately 4.0 x5.4 x 0.1, right proximal and distal lower leg unstageable wounds, right heel stage 2 approximately 4.0 x 1.8 x 0.1, right ischial stage 4 approximately 6.4 x 4.4 x 2.4, sacra stage 4 approximately 9.5 x 7.5 x 2.3. Dr. [physician name] wound care MD was notified and orders given. All wounds were cleanse and dressing applied. Resident reposition for comfort and no c/o at this time. Will continue to monitor. Written by: LVN B. Record review of Resident #20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Every day shift for wound care. Start date 7/9/22. Cleanse left lateral lower leg and right proximal, distal lower leg with NS/WC, pat dry, apply santyl and calcium alginate and cover with dry dressing daily. Every day shift for wound care. Start date 7/09/22. Cleanse right heel and thigh with NS/WC, pat dry, apply collagen and cover with dry dressing daily. Every day shift for Wound care. Start date 7/09/22. Cleanse sacral, right ischial and left lateral ankle with NS/WS, pat dry, apply silver alginate and cover with dry dressing daily. Every day shift for Wound care. Start date 7/09/22. Record review of Resident #20's MAR/TAR dated 07/2022 revealed no wound care documented on 07/16/22, 07/17/22, and 07/20/22 for: 1. Cleanse heel with NS/WC, pat dry, apply skin prep and leave OTA daily. Every day shift for wound care. 2. Cleanse left lateral lower leg and right proximal, distal lower leg with NS/WC, pat dry, apply santyl and calcium alginate and cover with dry dressing daily. 3. Cleanse right heel and thigh with NS/WC, pat dry, apply collagen and cover with dry dressing daily. Every day shift for Wound care. 4. Cleanse sacral, right ischial and left lateral ankle with NS/WS, pat dry, apply silver alginate and cover with dry dressing daily. Every day shift for Wound care. Record review of Resident #20's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 7/12/22, start date 7/19/22. Record review of Resident #20's Skin and Wound Evaluation documents revealed his last skin/wound evaluation was completed on 07/11/22. Observation and interview on 07/21/22 at 10:31 AM revealed Resident #20 was lying in bed with pillow under his left side. Resident was in a low bed. Resident #20 stated he did not get wound care yesterday (07/20/22). He said he was given a shower and the staff did not make sure he got his wound care. Observation of wound care of Resident #20's by LVN B revealed: 1-Observation on 07/21/22 at 11:16 AM revealed left ankle wound dressing removed. Dressing was dated 7/19/22. Wound cleaned with wound cleanser, dried silver alginate applied and redressed. 2-Observation on 07/21/22 11:21 AM revealed left calf dressing removed. Dressing was dated 7/19/22. Small healing wound almost completely closed. Collagen applied redressed. 3-Observation on 07/21/22 11:25 AM revealed left heel area open to the air, skin prep applied. 4-Observation on 07/21/22 11:29 AM revealed Right heel dressing removed dated 7/19/22. Small healing wound collagen applied and Redressed. 5-Observation on 7/21/22 11:33 AM revealed Left shoulder blade wound dressing removed. Dressing was dated 7/19/22. Wound cleaned with santyl and Ca++ alginate applied redressed. 6-Observation on 7/21/22 11:44 AM revealed large open sacral wound with foul smelling Serosanguinous drainage. The dressing was saturated and undated. Wound cleaned with wound cleanser, santyl and Ca++ applied lightly packed with dry gauze. Dry dressing applied. 7-Observation on 07/21/22 11:54 AM revealed open right Ischial wound dressing saturated and undated. Wound cleaned with wound cleanser, santly and Ca++ applied lightly packed with gauze and Redressed. 8-Observation on 7/21/22 12:03PM revealed open blister to right thigh dressing removed dated 7/19/22. Area cleaned with skin cleanser, collagen applied and redressed. 9-Observation on 7/21/22 12:10 PM revealed right calf wound dressing was undated. Wound cleaned with wound cleanser, Santyl and Ca++ applied dry dressing. In an interview on 07/21/22 at 10:34 AM, LVN A stated she did not do Resident #20's wound care the previous day (07/20/22). Resident #20 was getting a shower and she was about to leave the facility, she got off at 6pm. The 6pm nurse (LVN E) was supposed to complete the wound care. She told the 6pm nurse to do wound care. Surveyor attempted to contact LVN E on 07/21/22 at 11:58 AM, left voicemail message. No call returned. In an interview on 07/21/22 at 12:35 PM, LVN A stated all wound care for Resident #20 was supposed to be completed daily. The dressing was supposed to be dated for all wounds. She thought LVN B who used to be the wound care nurse was supposed to do the wound care. LVN B worked the floor yesterday. She said she was not aware LVN B was not doing wound care. The DON was responsible for setting the schedule and making sure assignments were communicated. On the MAR/TAR they have sections for the nurse and the med aide to complete. Wound care had its own tab that the wound care nurse would complete. The wound care nurse would go under that tab and document the completion of wound care. It was important to perform wound care daily so the resident's wound will not get infected, it was important to date the dressing so the nursing staff will know the wound care had been completed. Resident #20 was on antibiotics for infection. In an interview on 07/21/22 at 1:44 PM, LVN B stated she was not the wound care nurse, the nurses on the floor were supposed to complete their own wound care. She said she was not sure why Resident #20 did not have his wound care yesterday. The nurses on the floor were supposed to complete their own skin assessments and wound evaluations. It was important to complete the skin assessments and document the date on the dressing, so the nursing staff know that the dressing had been changed. The wound care should be completed daily, and staff are supposed to follow the physician orders. The tab on the TAR notified the nurses they are supposed to complete wound care. In an interview on 07/21/22 at 2:34 PM, LVN D stated she completed the wound care on the weekend. She said she forgot to document on 07/16/22 and 07/17/22. She said that the rule was if it was not documented it was not done. Some time she had another nurse complete the documentation. Wound care orders are supposed to be completed daily or as ordered. The dressing should be dated after wound care. It was important to complete wound care as ordered to prevent infection and promote wound healing. It was important to document the date on the dressing, so staff know that the wound care was completed. In an interview on 07/21/22 at 11:27 AM, the DON stated there was a lack of communication between her and the previous wound care nurse, LVN B. The previous wound care nurse completed the wound evaluations on Mondays, but she thought they were done on Thursday or Friday after wound doctor completed his assessment. As of last Friday, the facility switched over to the ADON because the wound care nurse did not want to do the wounds anymore. The ADON will oversee wound care and the floor nurses will do wound care. The ADON was out due to a personal matter. The ADON was supposed to be monitoring the wound evaluations per the Performance Improvement Action Plan. Record review of the facility Performance Improvement Action Plan dated 05/01/2022 revealed .Topic/Opportunity/Problem: Identified skin assessment has not completed on time. Current Measurement/Target: Will make sure all skin assessments will be completed weekly. Wound nurse will complete all assessments on weekly bases. Action/Interventions: The treatment nurse will evaluate and treat the wounds . Treatment nurse will do weekly assessments on every resident in building. Treatment nurse will document weekly on each resident .Target dates 09/30/21. Responsible: Treatment Nurse, LVN's, ADON's. In an interview on 07/21/22 at 1:33 PM, the DON stated she did not have a policy on pressure ulcer treatment. In an interview on 07/21/22 at 2:20 PM, the DON stated this week the floor nurses start doing their own wound care. The facility was in the process of training nurses on how to do the wound care before the survey started. The nurses are supposed to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was the one checking everyone's wound care yesterday. The DON completed his wound care yesterday. She did not document on the TAR, that was her fault. She may not have got to all his wounds, she only looked at his butt. She did not perform treatment on his legs, heal or ankles. It was her mistake. She needed to look at his orders. She did not know he had those other wounds. It was important to make sure the wound care was completed daily because the wound could deteriorate. The wound care could be monitored for effectiveness for any needed changes. The nurses on the floor are aware they are supposed to be completing their own wound care. It was important for them to complete the weekly wound assessment to make sure the wounds are not deteriorating. The weekend supervisor LVN D completed the wound care on the weekend nurse. The wound treatment nurse was completing the wound care, so she was not sure if they had any previous training with the floor nurses on wound care. Record review of the facility training revealed the facility last trained nurses on Weekly Skin Assessment on 4/6/22. Record review of the facility's policy for Clean Dressing Change, not dated, revealed Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Policy Explanation and Compliance Guidelines .3. Each wound will be treated individually 13. Measure wound using disposable measuring guide 16. Secure dressing. Mark with initials and date. Record review of the facility's policy for Pressure Injury Surveillance, not dated, revealed Policy: A system of surveillance is utilized for preventing, identifying, reporting, and investigating any new or worsening pressure injuries in the facility. Policy Explanation and Compliance Guidelines: 1. The treatment nurse or ADON serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. 2. RN's and LPN's participate in surveillance through assessment of residents and reporting changes in condition to the resident's physician's and management staff, per protocol for notification of changes and in-house reporting of new or worsened pressure injuries. 3. The facility assessment will be used to prioritize surveillance efforts. In turn, surveillance data will provide information for subsequent monitoring

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 2 of 17 residents (CR#1 and Resident #3) reviewed for neglect. The facility failed to have a system that ensured staff were properly trained and by appropriate staff on transfers for residents who required assistance or who were dependent on staff for transfers. The facility failed to have a system that ensured licensed nursing staff were not trained by CNA's on transferring of residents. The facility failed to have a system that identified staff training on residents' transfers. The facility failed to have a system that ensured CNAs were trained on transfers and that they followed proper transfer technique . As a result, CR#1 who had bilateral upper and lower extremities contractures and was dependent on staff for ADLs , sustained a [MEDICAL CONDITION] of unknown origin. Resident #3 who had contractures to bilateral lower extremities was improperly transferred by staff. An immediate jeopardy was identified on 8/16/19. While the IJ was lowered on 8/21/19, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident and one current resident and placed other residents who require staff assistance with transfers at risk of injury and decline in health . Findings include: CR#1 Record review of CR#1's face sheet revealed she was a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR#1's Quarterly MDS dated [DATE] revealed, the resident required extensive, two-person assistance for transfers. Further record review of the Quarterly MDS revealed, a surface-to-surface transfer (transfer between bed and chair or wheelchair) coded as a 2 indicating, Not steady, only able to stabilize with staff. The resident required total assistance with transfers and was unable to assist with transfers. MDS active diagnose indicated unspecified joint contractures with bilateral upper and lower extremity impairment. Record review of CR#1's Care plan with an initiation date of 03/23/2019 read in part, .Interventions: bathing/showering: The resident is totally dependent on (1-2) staff to provide bath/shower)(3x week) and as necessary. Bed mobility: The resident is extensive assistance on (1-2) staff for repositioning and turning in bed frequently and as necessary .Transfer: The resident is extensive to total assistance on (1-2) staff for transferring. The care plan did not address the gait belt transfer or type of transfer device needed to safely transfer the resident. Record review of nursing progress notes dated 08/01/19 read in part, CNA reported that during ADL care resident noted to be in pain, CNA's also reported that resident's right leg flaccid and rotated inward. [MEDICAL CONDITION] noted to right lateral hip and right knee. Right post Tibial pulse 3+ regular. No discoloration noted. NP notified, new order received to send resident to ER for evaluation. Family member called and came to facility. Family member spoke to charge nurse and DON and stated, due to previous surgery, ligaments become so tight doctors have had to release them in the past to prevent dislocation and that's what it looks like happened this time to me. Family requested resident be sent to local hospital via 911. EMS arrived, and resident transferred to local hospital via stretcher. Record review of the hospitals History and Physical dated 08/03/19 read in part, Patient is a [AGE] year old lady with past medical history of [REDACTED]. X-rays are obtained of the extremities that reveals a right femur fracture .Patient apparently winces in paint intermittently since this occurred but is nonverbal . Further record review of the hospitals History and Physical read in part, Pertinent Imaging: IMPRESSION: Right femur subtrochanteric fracture, Assessment/Plan: 1. Subtrochanteric and comminuted [MEDICAL CONDITION] femur. Patient has come here for orthopedics evaluation .5. Preoperative examination Type of surgery: Unclear at this time, Medical issues that may interfere with surgery: Given patient's [MEDICAL CONDITION] and multiple chronic contractures it may affect healing process as well as approved for surgical intervention . Interview on 08/04/19 at 8:24 AM with the RP, she stated the resident was transferred to another hospital because of a complex fracture that could not be managed at the hospital she was originally transferred to. She stated the physician called this injury a spiral fracture w/splinters and stated he did not think this was a result of a fall. The RP stated on Wednesday 07/31/19 around 5:00 pm, her family member went to visit the resident and the resident was fine when she left. When she came back the following day around 11:00 AM, she said according to her family member , the resident's right leg looked disfigured and her foot was pointing inward. She said no one at the facility could tell her what happened. She stated the resident was completely immobile, she can't roll herself from side to side and she can't use her arms. She further stated the resident was non-verbal, so she was unable to tell what happened. Interview on 08/04/19 at 10:50 AM with CNA A, she stated the resident was total assist and was non-verbal, stating the only time she says anything is if she has pain and she will only cry. When asked if she could explain what occurred when the resident's leg was noted to be injured, she stated the resident never cries unless she is in pain. She stated when she came back to work, the resident had a shower when CNA B, CNA C, and herself noticed the residents leg was floppy and turned inwards, further stating the leg is normally stiff. She said at that point she knew something wasn't right. She stated that LVN A who only worked PRN said the resident probably had a Charlie horse and nothing was done, so she asked another nurse, LVN B to assess the residents' leg. She stated LVN B noticed some swelling to the residents' right leg and after the assessment, the Family member was contacted, and the Family member came to the facility and said the knee or hip was either dislocated or broken, but this is because of her condition. When asked if the injury to the residents' leg could have been due to the care provided by the staff or during a transfer, she stated it is not something we did. Interview on 08/04/19 at 2:13 PM with CNA C, she stated only thing she knew about the resident was she had to be transferred out. She stated she had not worked with the resident in a couple of weeks and she only would braid her hair but did not provide direct care. Interview on 08/04/19 at 2:20 PM with CNA B, she stated she was getting ready to give the resident a shower on Thursday 08/01/19 when she noticed her leg wasn't contracted like it normally was, stating it was just hanging. She stated she asked CNA C, to come to the shower room to look and see if she saw a difference in the resident's leg. She stated CNA C also saw the difference. She stated she did not notice the resident's leg like this prior to Thursday, stating she had no interactions with her on Wednesday. She stated the resident will only cry a lot when she is on her cycle and that she was on her cycle at the time. She stated they asked LVN B to come assess the resident while she was in the shower room after LVN A assessed the resident and said it was a charlie horse ( painful muscle spasms of the leg) . When asked if she documented the changes to the residents' leg, she stated it is facility policy to document changes on the shower sheets which is kept in a book at the nurses' station. She said something like this change is automatically reported to the nurse by the CNA, further stating she did document the change on the shower sheet. Interview on 08/04/19 at 2:28 PM with LVN B, he stated he does not work on the hall the resident was on, but the nurse who was working that hall was brand new, stating it was her first day on the floor by herself and the other CNA's asked him to assess the resident because her leg did not look right. He said he assessed the resident in the shower chair and her leg was not turned in at the time, but it was flaccid. He stated when the CNA's put her in bed, the DON was asked to come assess the resident and at this time the residents' leg was completely turned inward and flaccid. He stated the NP was contacted and orders were given to send her to the ER. He stated he never worked with the resident, but he is aware that when she is on her cycle, she cries, but she normally does not have any issues except during her cycle. He stated he was not sure if the resident was transferred with a Hoyer lift, stating there was no sling in her chair at the time he assessed her. He further stated the it is policy for the CNA's and/or shower aid to report any changes in residents' skin or behaviors and if a CNA notices any changes, they will call for another CNA and one of the CNA's will get the nurse, so he/she can assess the resident. Interview on 08/04/19 at 2:41 PM with the DON, she stated it had been reported to the nurse by a CNA's A and B that the residents leg was not normal. After it was reported to the nurse, LVN B assessed the resident 1st in the shower chair and said her leg did not look normal. She said she then assessed the residents leg while she was in her bed and her right leg was flaccid and the left leg was rigid. She stated the RP was notified and asked if she wanted the facility to call 911, further stating the RP made it to the facility within 15 minutes after being contacted. The DON said she asked the RP what do you think, and the RP asked the facility to call 911 because the leg looked 100% abnormal. She further stated the RP had told her this is what happened when the resident was younger, stating she has had ligament problems and they became extremely tight and could dislocate the hip so she had to have surgeries to release the tendons. Interview at on 08/05/19 at 8:38 AM with the RP, she stated the Orthopedic surgeon is weighing the risk and benefits of doing surgery to repair the resident's fractured femur. She stated because of the way the resident's femur is shaped, stating like an s, she is not a candidate to have surgery because the pin would not go straight through the bone like it would on a person whose femur did not have a deformity. She stated she is waiting to speak to the surgeon to determine what the plan is. She said at this time, they are managing the resident's pain with scheduled [MEDICATION NAME] and Tylenol. When asked if she knew how the resident was being transferred during showers and onto her wheelchair, she stated the facility does not use a Hoyer lift, further stating the resident only weighs a little over 100lbs., but it is dead weight, so she would need to be transferred by at least two people. She said if they were using a Hoyer, she never sees the sling behind the resident. The RP stated she spoke to the DON on Thursday 08/01/19 at 3:48 PM and informed her the resident had a severe fracture to her femur and requested documents (POA, guardianship) to be faxed to her. She stated she was hung up on by the staff 4 times and then told the resident was not at the facility. She said since the resident has been in the hospital, she has not received a call from anyone at the facility. She further stated the resident will not be returning to the facility on ce she is discharged , stating they are in the process of finding another facility to place the resident. Observation on 08/05/19 at 8:40am of CR#1 at a local hospital revealed, swelling to the right upper thigh with the right leg internally rotated and resting on a pillow. The resident was completely immobile and non-verbal and only able to moan and cry. Her upper extremities were straight and stiff and resting on pillows with contractures to her hands. Her left lower extremity was contracted. Interview on 08/14/19 at 11:27 AM with CNA B, when asked how the resident was transferred to the shower room. She stated the resident was a two person transfer and a gait belt was used. She stated that she and CNA A transferred the resident from her bed, to her wheelchair, then to the shower chair using the gait belt. She said when they took the resident's gown off, she noticed the leg was not right. She stated the resident was on her cycle, so she was not whining more than usual further stating the resident whines a lot when she is on her cycle. She stated the residents' nurse, LVN A assessed the resident while she was in the shower room and said it could be a charlie horse. CNA B stated LVN A was new, so they asked LVN B to assess the resident in the shower room and he stated something was wrong with her leg. She stated the resident was then transferred back to her bed and the DON assessed her and said that there was something wrong with her leg. CNA B did not say how or who trained her on resident transfers. Further interview on 08/14/19 at 1:11 PM with CNA B, when asked what time the resident received her shower and when was her leg noted to be turned inward, she stated the shower was between 9:45-10:30 AM and she noticed the difference in the leg before the shower started, further stating LVN A assessed the resident in the shower room while she was sitting in the shower chair. She stated she continued with the shower and after the shower was completed, she and CNA C transferred the resident back to her wheelchair, then to the bed using a gait belt. She further stated after the resident was transferred back to bed the DON assessed the residents leg. She stated The RP was notified about the resident's leg before lunch which she stated was around 10:45 AM-12:00 noon. Interview on 08/14/19 at 1:22 PM with LVN A, she stated the resident was in the shower room when she was asked by CNA B to assess the resident's leg. She stated there was a bruise on her right hip area, it was a greenish color with a yellow tint and the leg was hard and stiff. She stated that she told the CNAs that she would assess the resident more when she is in her room. She stated while the resident was sitting in her wheelchair in her room she gave her 1 50 mg tablet of [MEDICATION NAME] and the DON then assessed the resident when she was transferred to her bed. When asked how the resident was transferred, she stated she thinks she is a Hoyer lift transfer and is at least a two person assist. She further stated she did not see the residents leg like this before, but she was new. She stated the resident did not appear to be in pain, but she had been crying, further stating she was told the resident cries when she is on her cycle. She said she did notice some blood dropping from the resident when she was in the shower room, so she knew she was on her cycle. LVN C could not provide an answer as to why the shower was not stopped for further assessment, only stating she did not think the resident was in pain, but she was on her cycle and that was why she was crying. Interview on 08/14/19 at 2:33 PM with the DON, when asked what type of transfer CR#1 required, she stated she is a two person assist, further stating she was not a Hoyer lift transfer. When asked who assesses the residents and determines the type of transfer required, she stated they are assessed by PT and then they go by what is safest transfer for the resident. Interview on 08/14/19 at 3:02 PM with the Director of Therapy, when asked who determines how a resident is transferred, he stated if a resident is not on PT services, then the facility will continue the transfer that was previously used at the hospital or the transferring facility, further stating they will review the medical records for the type of transfer previously used. He stated if the resident is picked up for PT services, then they will then be assessed for transfers. When asked who's responsible for training staff on transfers, he stated PT or OT will do the training with the staff. He said they try to do training once every 6 months sometimes, or if there is an incident, there will be a refresher training. When asked how the staff are trained on transfers, he stated PT demonstrates the transfer then the staff must do a return demonstration on Gait belt, Hoyer lift and sliding board transfers, stating sliding boards are used only if deemed appropriate and sliding boards will be a one-on-one training. Further interview with the Director of Therapy, when asked how CR#1 was transferred to her wheelchair using a gait belt if she was contracted, he stated the residents' new wheelchair laid flat and the arms of the chair would go super low where the resident could slide across. He stated in his opinion, the resident was a candidate for a Hoyer lift transfer, further stating PT always considers a Hoyer transfer safer and it is often encouraged. He stated in his documentation, it only showed the resident was a two-person transfer. He said the resident could have been lifted with the gait belt because she could not put her feet down and she was not an active participant. Further stating if a gait belt transfer becomes a lift, then it is not safe, therapeutic practice & would not be recommended. Interview on 08/14/19 at 4:08 PM with RN A, he stated he thought CR#1 required a Hoyer lift transfer, stating it takes two people to transfer her. He stated he only works PRN, so he wasn't certain. When asked if he received training on transfers, he stated yes, he had training when he started working at the facility. He further stated the Lead CNA's train the nurses and other CNA's. Interview on 08/14/19 at 4:15 PM with LVN C, when asked what type of transfer CR#1 was, she stated the resident was a two person transfer because of her contractures, further stating she was not sure if she was a Hoyer lift or Gait belt transfer. When asked what type of training she received on transfers, she stated the facility provides videos over everything for training and the Lead CNA's train the nurses and CNA's on transfers. She further stated the Lead CNA's receive training from PT and once they can demonstrate proper transfer techniques with PT, they then will train the nurses and other CNA's. Interview on 08/14/19 at 4:23 PM with LVN D, when asked if she knew how CR#1 was transferred she reported she was a two-person transfer. She further stated, I want to keep my conscious clear, but honestly with me, I did not always see a gait belt being used and I never seen a Hoyer lift being used. She stated the resident would be transferred using The bucket, which she described as bucket a person on each side of the resident or one person at the head and someone at the feet and the resident is lifted and transferred without use of the gait. Interview on 08/15/19 at 2:23 PM with PT A, when asked who and when is staff trained on resident transfers, she stated if a resident is on PT services they go to the staff that is caring for the resident that day and train the staff on the transfer. She further stated if there is new equipment, they also will train the staff on proper use. She stated PT will do an in-service with staff annually and they do not keep a check off list of staff trained on transfers. She further stated there should be a record, but they don't keep a check off list. Interview on 08/15/19 at 2:36 PM with CNA E, when asked what type of transfers total dependent residents are, she stated total dependent residents are transferred with a Hoyer lift, further stating gait belts aren't for the total dependent residents, but they have been used on residents before. When asked when her last transfer training was, she stated her last training was with PT, but she could not provide when she received the training. When asked when does PT train staff on transfers, she stated if a resident is new or when the staff doesn't know what to do with the resident for transfers. She stated PT will show them how to transfer using a Hoyer lift, gait belt, or sliding board. When asked who trains the night shift, she stated they will come in early for training, when asked if they don't come in early, who then trains the night shift, she stated the Lead CNA's will do the training. Interview on 08/15/19 at 2:41 PM with CNA F, when asked what type of transfers the total dependent residents are, she stated the sling & sit-n-stand (Hoyer lift) are always used and a 2-person transfer. When asked who does the transfer training for staff, she stated it depends on who is here, but most of the time, I do the training for the 300 Hall sometimes. She stated she trains CNA's as well since she has been at the facility the longest. She further stated PT will teach every CNA how to transfer, how to use new equipment and how to transfer new residents. She stated new employees are trained by the Lead CNA or PT. When asked what type of resident receives gait belt transfer, she stated residents who need limited assistance used gait belt transfers. CNA F said her last training was 1 month ago with PT on hoyer and gait belt transfers. Interview on 08/15/19 at 2:48 PM with LVN B, when asked who trains the staff on transfers, he stated the Lead CNA's train nurses and CNA's on transfers monthly. He stated he received transfer training with PT when he first started working at the facility. Record review of facility's training log from (MONTH) 2019 to present revealed two lead CNAs transfer check off . However, there were no evidence of other nursing staff transfer training . Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS dated [DATE] revealed, no documentation of a BIMS. The Staff Assessment for Mental Status revealed both short and long-term problems, and Moderately Impaired documented for Cognitive Skills for Daily Decision Making. Further record review of Resident #3's Quarterly MDS revealed he required extensive, two-person assistance for transfers. The functional Limitation in Range of Motion revealed the resident had impairments to his bilateral upper and lower extremities. Record review of Resident #3's Care plan with an initiation date of 09/19/2018 read in part, .Interventions-TRANSFER: The resident requires (extensive assistance) by (1-2) staff to move between surfaces . there was no documentation stating a gait belt should be used during transfers. Observation of a two-person gait belt transfer from wheelchair to bed on 08/15/19 at 1:14 PM with CNA C and CNA D revealed, Resident #3 sitting in his wheelchair, he had contractures to his bilateral upper and lower extremities. Due to his lower extremity contractures, Resident #3's feet were not able to touch the wheelchair foot rests. CNA D applied the gait belt to the residents' waist and adjusted it accordingly. CNA C tilted the top of the wheelchair forward, then CNA D counted to 3, lifted the resident by the gait belt and transferred him onto the bed. CNA C was positioned at the residents' legs during the transfer. Prior to transferring the resident, the wheels on the wheelchair where not locked by the CNA's causing it to move during the transfer. Interview on 08/15/19 at 1:23 PM with CNA D, when asked who trains the CNA's on transfers and what types of transfers are staffed trained on, he stated PT trains all staff on Gait belt and Hoyer lift transfers. He said the training is every 4-5 months and his last training was about 2 months ago. When asked if he was trained to lift a person by the gait belt when transferring, he stated yes. CNA D was informed by the surveyor that the wheels were not locked prior to transferring the resident and asked if the wheels should be locked before a resident is transferred onto or from the wheelchair, he stated Yes, they should be locked. Interview on 08/15/19 at 1:25 pm with CNA C, when asked when who trains the staff on transfers and what type of transfers staff are trained on, she stated she has only been working at the facility for 1 ½ months and she had training when she started. She further stated PT does the training and staff are trained on gait belt, Hoyer lift, sliding board, and regular transfers on residents who don't require total dependence. When asked if she was trained to lift residents if they are gait belt transfers, she stated residents who are totally dependent and transfer with gait belt must be lifted. When asked what residents would be transferred with Hoyer lifts, she stated a Hoyer lift transfer is a resident who it totally dependent, has drop feet and can't do anything for herself. When asked if the wheels on the wheelchair should be locked during a transfer, she stated, yes. Interview on 08/16/19 at 4:32 PM with the DON, when asked what the process was for training staff on resident transfers, the DON stated PT trains the Lead CNA's, then the CNA's will train the other CNA's. She stated Nurse managers complete training during orientation which is multi-dynamic, meaning there are multiple trainings and there are check offs they must complete. When asked how the facility ensures nurses are receiving transfer training throughout the year, she stated they have routine checkoffs' for everybody and the nurse are checked off by nurse managers. When asked how staff are monitored throughout the year on proper transfer techniques, she stated she monitors and will sit in on all check offs. She further stated PT will check off nurses. When asked how the check is off completed by PT, she stated everyone goes into the PT room or in groups and they must demonstrate the transfer. She further stated if anyone is observed doing something incorrectly, they will stop them, then have them do it correctly. She stated on several occasions, she will go down to a resident's room along with the other nurse managers and if there are any concerns or corrections needed, they will make the corrections. The DON could not provide specific training dates for transfers other than stating nurses receive training during orientation. Interview on 08/16/19 at 4:46 PM with the Administrator, when asked what the training process was for nursing staff on proper transfer techniques, he stated the nursing staff is trained by the nurse managers, further stating the PT department trains nurses and CNA's. He stated when someone comes in who is different or if staff have questions, the PT director goes over the transfer with staff. He further stated that the ACP company will do different equipment training and answer questions staff may have. He stated the ACP company training is geared more towards PT but will train staff who are available. When asked how the facility monitors and tracks training for both CNA's & nurses, he stated PT is out and about and will get with CNA's and watch them do a transfer, further stating PT is constantly asking questions and training. When asked if there was a check off sheet for transfers, he stated he would have to ask the DON. He further stated PT does a training with the residents and it involves prompting residents to ask questions or to tell PT or staff if the transfer is not done correctly. When asked how the facility ensures nurses and CNA's are monitored throughout the year on transfer training, he stated they recently started a computer-based training in (MONTH) that has videos on transfers, stating the staff just are going out and doing the training. He said this computer training was something he wanted to get out quickly and to cover different subjects. He stated ACP stops by monthly, but their training is geared more towards PT. The Administrator could not provide evidence of current staff transfer training or how staff was monitored throughout the year to ensure proper transfer technique was being used. Record review of staff transfer training revealed two Lead CNA's checked off on transfers. There was no evidence of current documentation showing the nursing staff were properly trained and trained by the appropriate staff on transfers. Record review of American Nurse Today Gait Belts 101: A tool for patient and nurse safety dated (MONTH) 2019 read in part, .After the gait belt is properly secured, ensure that the patient's feet are placed flat on the floor (no tiptoes or dangling feet) .A gait belt is used to steady a patient-it is not a lifting device. You can help the patient by raising or lowering the bed Resource Gait belts are one option for steadying patients and should never be substituted for lifting devices. Record review of the facility's Abuse and Neglect -Clinical Protocol dated (MONTH) (YEAR) read in part, .Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .6. The healthcare practitioner and staff will help identify potential or actual abuse or neglect within the facility, for example: .b. Significant injuries in physically dependent individuals .d. Problems related to staff knowledge, skill or performance that might affect how the residents/patients are being care for . The facility Administrator and the DON were notified on 8/16/19 at 5:33pm of immediate jeopardy identified due to the above failures. A Plan of Removal was submitted by the Administrator on 8/16/19 at 8:44pm. After several revisions, the final Plan of Removal was accepted on 8/18/19 at 4:49am. The plan of removal included the following: IJ Component - Abuse/Neglect: Plan of action All nursing staff will be in-serviced and checked-off regarding proper transfer techniques prior to caring for and initial contact of residents' post 7.00pm (MONTH) 16, 2019. This training will be conducted by the Director of Therapy, OTA, or other licensed therapy staff approved to provide said training by both the Director of Therapy and the Director of Nursing, RN, DON. No UAP (e.g., CNA, MA, etc .) will be authorized to train staff regarding transfers. Only trained therapy and nursing staff are allowed to transfer a resident. The approved trainer of transfers list will be located at the nurses station and with the Director of Therapy / Designee, Director of Nursing / Designee, and the Administrator / Designee. This list includes licensed therapy staff and the Director of Nursing, who was trained by the Director of Therapy on (MONTH) 17, 2019, at 3:30pm. For the current matrix, this in-servicing started at 1900 hours on (MONTH) 16, 2019. This training is expected to be completed by 10.30pm on (MONTH) 20, 2019. Any staff not trained must receive training prior to their shift or they will not be allowed to work. For auditing and verification purposes, a list of the trained nursing staff will be located at the nurses station and with the Director of Nursing / Designee and Administrator / Designee. This was completed at 7:00pm on (MONTH) 16, 2019. A list of all resident transfer level of care will be located at the nurses station, all nurse med carts, and with the Administrator / Designee. Resident transfer level of care must be approved by Director of Therapy / Designee and/or Director of Nursing. This was completed at 9:45pm on

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 8 residents (CR#1 and CR#2) reviewed for quality of care, in that; The facility failed to assess, develop and implement a safe mode of transfer for CR#1 who was dependent on staff for all ADLs and who had bilateral upper and lower extremity contractures was cared for in a manner that prevented her from sustaining spiral right [MEDICAL CONDITION] of unknown origin. The facility failed to provide prompt assessment and intervention to CR#1 when a change in condition was identified. The facility failed to consult CR#2's physician and failed to provide prompt intervention to CR#2 who was identified to have facial [MEDICAL CONDITION]. CR#2 was found unresponsive 11 hours later . An immediate jeopardy was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 2 former residents and placed other residents in the facility at risk of not receiving needed care and treatment necessary to prevent decline in health or diminished quality of life. Findings include: CR#1 Record review of CR#1's face sheet revealed she was a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR#1's Quarterly MDS dated [DATE] revealed, the resident required extensive, two-person assistance for transfers. Further record review of the Quarterly MDS revealed, a surface-to-surface transfer (transfer between bed and chair or wheelchair) coded as a 2 indicating, Not steady, only able to stabilize with staff. The resident required total assistance with transfers and was unable to assist with transfers. The MDS active diagnose indicated unspecified joint contractures with bilateral upper and lower extremity impairment. Record review of CR#1's Care plan with an initiation date of [DATE] read in part, .Interventions: bathing/showering: The resident is totally dependent on (,[DATE]) staff to provide bath/shower (3x week) and as necessary. Bed mobility: The resident is extensive assistance on (,[DATE]) staff for repositioning and turning in bed frequently and as necessary .Transfer: The resident is extensive to total assistance on (,[DATE]) staff for transferring. The care plan did not address the gait belt transfer or type of transfer device needed to safely transfer the resident. Record review of CR#1's nursing progress notes dated [DATE] read in part, CNA reported that during ADL care resident noted to be in pain, CNA's also reported that resident's right leg flaccid and rotated inward. [MEDICAL CONDITION] noted to right lateral hip and right knee. Right post Tibial pulse 3+ regular. No discoloration noted. NP notified, new order received to send resident to ER for evaluation. Family member called and came to facility. Family member spoke to charge nurse and DON and stated, due to previous surgery, ligaments become so tight doctors have had to release them in the past to prevent dislocation and that's what it looks like happened this time to me. Family requested resident be sent to local hospital via 911. EMS arrived, and resident transferred to local hospital via stretcher. Record review of the CR#1's shower sheet dated [DATE] and signed by CNA B revealed, leg is limp with an arrow pointing to the right leg. Record review of CR#1's Skin Observation Tool revealed no evidence of the injury documented for the date of [DATE]. Record review of CR#1's EHR ( Electronic health record) revealed no evidence of assessment completed after the injury was identified by LVN A and the DON. Record review of CR#1's hospitals History and Physical dated [DATE] read in part, Patient is a [AGE] year old lady with past medical history of [REDACTED]. X-rays obtained of the extremities reveals a right femur fracture .Patient apparently winces in pain intermittently since this occurred but is nonverbal . Further record review of the hospitals History and Physical read in part, Pertinent Imaging: IMPRESSION: Right femur subtrochanteric fracture, Assessment/Plan: 1. Subtrochanteric and comminuted [MEDICAL CONDITION] femur. Interview on [DATE] at 8:24 AM with the RP, she stated the resident was transferred to another hospital because of a complex fracture that could not be managed at the hospital she was originally transferred to. She stated the physician called this injury a spiral fracture w/splinters and stated he did not think this was a result of a fall. The RP stated on Wednesday [DATE] around 5:00 pm, her family member went to visit the resident and the resident was fine when she left. When she came back the following day around 11:00 AM, she said according to her family member, the residents right leg looked disfigured and her foot was pointing inward. She said no one at the facility could tell her what happened. She stated the resident is completely immobile, she can't roll herself from side to side and she can't use her arms, she further stated the resident is non-verbal, so she was unable to state what happened. Interview on [DATE] at 10:50 AM with CNA A, she stated CR#1 was total assist and was non-verbal, stating the only time she says anything is if she has pain and she will only cry. When asked if she could explain what occurred when the resident's leg was noted to be injured, she stated the resident never cries unless she is in pain. She stated when she came back to work after two days of being off duty , the resident had a shower when CNA B, CNA C, and herself noticed the resident's leg was floppy and turned inwards, further stating the leg is normally stiff. She said at that point she knew something wasn't right. She stated that LVN A who only worked PRN said the resident probably had a Charlie horse (intense muscle spasms of the leg) and nothing was done, so she asked another nurse, LVN B to assess the residents' leg. She stated LVN B noticed some swelling to the residents' right leg and after the assessment, the sister was contacted, and the sister came to the facility and said the knee or hip was either dislocated or broken, but this is because of her condition. When asked if the injury to the residents' leg could have been due to the care provided by the staff or during a transfer, she stated it is not something we did. Interview on [DATE] at 2:13 PM with CNA C, she stated only thing she knew about the resident was she had to be transferred out. She stated she had not worked with the resident in a couple of weeks and she only would braid her hair but did not provide direct care. Interview on [DATE] at 2:20 PM with CNA B, she stated she was getting ready to give the resident a shower on Thursday [DATE] when she noticed her leg wasn't contracted like it normally was, stating it was just hanging. She stated she asked CNA C, to come to the shower room to look and see if she saw a difference in the resident's leg. She stated CNA C also saw the difference. She stated she did not notice the resident's leg like this prior to Thursday, stating she had no interactions with her on Wednesday. She stated the resident will only cry a lot when she is on her cycle and that she was on her cycle at the time. She stated they asked LVN B to come assess the resident while she was in the shower room after LVN A assessed the resident and said it was a Charlie horse and asked the aides to continue with the shower . When asked if she documented the changes to the residents' leg, she stated it is facility policy to document changes on the shower sheets which is kept in a book at the nurses' station. She said something like this change is automatically reported to the nurse by the CNA, further stating she did document the change on the shower sheet. Interview on [DATE] at 2:28 PM with LVN B, he stated he did not work on the hall the resident was on, but the nurse who was working that hall was brand new and it was her first day on the floor by herself, the other CNA's asked him to assess the resident because her leg did not look right. He said he assessed the resident in the shower chair and her leg was not turned in at the time, but it was flaccid. He stated when the CNA's put her in bed, the DON was asked to come assess the resident and at this time the residents' leg was completely turned inward and flaccid. He stated the NP was contacted and orders were given to send her to the ER. He stated he never worked with the resident, but he was aware that when she was on her menstrual cycle, she cries, but she normally does not have any issues except during her cycle. He stated he was not sure if the resident was transferred with a Hoyer lift, stating there was no sling in her chair at the time he assessed her. He further stated the it is policy for the CNA's and/or shower aids to report any changes in residents' skin or behaviors and if a CNA notices any changes, they will call for another CNA and one of the CNA's will get the nurse, so he/she can assess the resident. LVN B said CR#1's leg did not look right when he looked at it. Interview on [DATE] at 2:41 PM with the DON, she stated it had been reported to the nurse by CNA's A and B that the resident's leg was not normal. After it was reported to the nurse, LVN B assessed the resident 1st in the shower chair and said her leg did not look normal. She said she then assessed the resident's leg while she was in her bed and her right leg was flaccid and the left leg was rigid. She stated the RP was notified and asked if she wanted the facility to call 911, further stating the RP made it to the facility within 15 minutes after being contacted. The DON said she asked the RP what do you think, and the RP asked the facility to call 911 because the leg looked 100% abnormal. She further stated the RP had told her this is what happened when the resident was younger, stating she has had ligament problems and they became extremely tight and could dislocate the hip, so she had to have surgeries to release the tendons. Interview at on [DATE] at 8:38 AM with the RP, when asked if she knew how the resident was transferred during showers and onto her wheelchair, she stated the facility did not use a Hoyer lift because she never saw a Hoyer lift sling on or around CR#1. CR#1's RP stated the resident only weighs a little over 100lbs., but it is dead weight, so she would need to be transferred by at least two people. She said if they were using a Hoyer, she never sees the sling behind the resident. The RP stated she spoke to the DON on Thursday [DATE] at 3:48 PM and informed her the resident had a severe fracture to her femur. Observation on [DATE] at 8:38 PM of CR#1 at a local hospital revealed, swelling to the right upper thigh with the right leg internally rotated and resting on a pillow. The resident was completely immobile and non-verbal and only able to moan and cry. Her upper extremities were straight and stiff and resting on pillows with contractures to her hands. Her left lower extremity was contracted. Interview on [DATE] at 11:27 AM with CNA B, when asked how the resident was transferred to the shower room. She stated the resident was a two person transfer and a gait belt was used. She stated that she and CNA A transferred the resident from her bed, to her wheelchair, then to the shower chair using the gait belt. She said when they took the resident's gown off, she noticed the leg was not right. She stated the resident was on her cycle, so she was not whining more than usual further stating the resident whines a lot when she is on her cycle. She stated the residents' nurse, LVN A assessed the resident while she was in the shower room and said it could be a Charlie horse, she stated LVN A was new, so they asked LVN B to assess the resident in the shower room and he stated something was wrong with her leg. She stated the resident was then transferred back to her bed and the DON assessed her and said that there was something wrong with her leg. Further interview on [DATE] at 1:11 PM with CNA B, when asked what time the resident received her shower and when was her leg noted to be turned inward, she stated the shower was between 9:,[DATE]:30 AM and she noticed the difference in the leg before the shower started, further stating LVN A assessed the resident in the shower room while she was sitting in the shower chair. She stated she continued with the shower and after the shower was completed, she and CNA C transferred the resident back to her wheelchair, then to the bed using a gait belt. She further stated after the resident was transferred back to bed the DON assessed the resident's leg. She stated The RP was notified about the resident's leg before lunch which she stated was around 10:45 AM-12:00 noon. Interview on [DATE] at 1:22 PM with LVN A, she stated the resident was in the shower room when she was asked by CNA B to assess the resident's leg. She stated there was a bruise on her right hip area, it was a greenish color with a yellow tint and the leg was hard and stiff. She stated that she told the CNA that she would assess the resident more when she is in her room. She stated while the resident was sitting in her wheelchair in her room she gave her 1 50 mg tablet of [MEDICATION NAME] and the DON then assessed the resident when she was transferred to her bed. When asked how the resident was transferred, she stated she thinks she is a Hoyer lift transfer and is at least a two person assist. She further stated she did not see the resident's leg like this before, but she was new. She stated the resident did not appear to be in pain, but she had been crying, further stating she was told the resident cries when she is on her cycle. She said she did notice some blood dropping from the resident when she was in the shower room, so she knew she was on her cycle. LVN A could not provide an answer as to why she did not stop the shower to further assess the resident, only stating she did not think the resident was in pain, but she was on her cycle and that was why she was crying. Interview on [DATE] at 2:33 PM with the DON, when asked what type of transfer CR#1 required, she stated she is a two person assist, further stating she was not a Hoyer lift transfer. When asked who assesses the residents and determines the type of transfer required, she stated they are assessed by PT and then they go by what is safest transfer for the resident. Interview on [DATE] at 3:02 PM with the Director of Therapy, when asked who determines how a resident is transferred, he stated if a resident is not on PT services, then the facility will continue the transfer that was previously used at the hospital or the transferring facility, further stating they will review the medical records for the type of transfer previously used. He stated if the resident is picked up for PT services, then they will then be assessed for transfers. When asked who's responsible for training staff on transfers, he stated PT or OT will do the training with the staff. He said they try to do training once every 6 months sometimes, or if there is an incident, there will be a refresher training. When asked how the staff are trained on transfers, he stated PT demonstrates the transfer then the staff must do a return demonstration on Gait belt, Hoyer lift and sliding board transfers, stating sliding boards are used only if deemed appropriate and sliding boards will be a one-on-one training. Further interview with the Director of Therapy, when asked how CR #1 was transferred to her wheelchair using a gait belt if she was contracted, he stated the residents' new wheelchair laid flat and the arms of the chair would go super low where the resident could slide across. He stated in his opinion, the resident was a candidate for a Hoyer lift transfer, further stating PT always considers a Hoyer transfer safer and it is often encouraged. He stated in his documentation, it only showed the resident was a two-person transfer. He said the resident should not have been lifted with the gait belt because she could not put her feet down and she was not an active participant. Further stating if a gait belt transfer becomes a lift, then it is not safe practice & would not be recommended because. CR#2 Record review of CR#2's face sheet revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Record review of CR#2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. MDS revealed CR#2 required extensive assistance with one person assist for bed mobility, toilet use and personal hygiene. MDS indicated that CR#2 was always incontinent of bowel/bladder and received [MEDICAL TREATMENT] while residing at the facility. Record review of Physician order [REDACTED].#2 read in part . Full Code Status. [MEDICAL TREATMENT] Monday-Friday at 6:00 AM; one time a day, every Monday, Tuesday, Wednesday, Thursday and Friday. Record review of MAR for CR#2 dated [DATE]-[DATE] read in part . [MEDICAL TREATMENT] Monday-Friday at 6:00 AM; one time a day, every Monday, Tuesday, Wednesday, Thursday and Friday. Record review of Care Plans for CR#2 revealed the following care plans which read in part . [MEDICAL CONDITION] initiated on [DATE]; CR#2 will be free of [MEDICAL CONDITION]. Interventions: Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing, monitor/document/report prn any signs and symptoms of [MEDICAL CONDITION]- dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation. [MEDICAL TREATMENT] related to [MEDICAL CONDITION] initiated on [DATE]; CR#2 will have no signs or symptoms of complications from [MEDICAL TREATMENT]. Interventions: encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments and resident receives [MEDICAL TREATMENT] in house, monitor labs and report to physician as needed, monitor/document/report as needed any signs and symptoms of infection to access site. Activities of daily living self-care performance deficit related to activity intolerance, confusion, fatigue, impaired balance and limited mobility; resident will improve current level of function in (toileting task), resident will be able to safely perform toileting task using standard commode and grab bars. Interventions: Resident is totally dependent on staff (1 person) for bath/shower, extensive assistance of 1 staff for bed mobility, extensive assistance of 1 staff for dressing, personal hygiene, toilet use, and transfer, monitor/document report as needed any changes. Record review of 24-hour report dated [DATE] did not mention that CR#2 had [MEDICAL CONDITION] (swelling of the lower layer of skin and tissue just under the skin or mucous membranes). 24-hour report only noted that CR#2 was scheduled for [MEDICAL TREATMENT] the following day (Friday). Record review of CR#2's progress notes read in part . [DATE] at 6:54 PM written by LVN H: [MEDICAL CONDITION] noted in CR#2's face, vital signs stable, with no distress noted. Nurse Practitioner notify, awaiting response, will tell night nurse to follow up. Will continue to monitor. [DATE] at 5:27 AM written by RN J: CR#2 slept all night with no complaints. Vital signs at 11:30 PM; blood pressure ,[DATE], pulse 81, respirations 18. Incontinent care given at 5:30 AM, staff in to weigh resident prior to [MEDICAL TREATMENT] appointment but resident was non-responsive, low blood pressure ,[DATE]. Called 911 to transport CR#2 to hospital. Nurse Practitioner notified of change in condition and ordered transfer. DON notified, and responsible party notified. Interview with DON on [DATE] at 4:30 PM, she said CR#2 had not returned from the hospital after she was found un-responsive in her room on [DATE] and she would not be returning as she died while in the hospital. Interview with LVN H on [DATE] at 3:15 PM regarding CR#2, she said that she noticed CR#2 had [MEDICAL CONDITION] to her face on [DATE] at 5:00 PM when she was performing her rounds. LVN H said she called the Nurse Practitioner at approximately 5:10 PM and it went to voice mail and she (LVN H) left a voicemail for the Nurse Practitioner to call back ASAP. LVN H said the nurse for the night shift came on at 7:00 PM and she notified the oncoming nurse (RN J) about CR#2's facial [MEDICAL CONDITION] and asked her to follow up with the Nurse Practitioner (NP) as the NP had not returned the call by shift change. LVN H said she documented on the 24-hour report that CR#2 had [MEDICAL CONDITION]. LVN H was asked what the policy of notifying physicians of change in condition was, she said that nursing staff is to call the NP first and they are to continue to reach out to the NP 3 times at 15-minute intervals then they are to notify the residents physician if the NP does not respond. LVN H said if the resident's physician does not respond then the nursing staff is to notify the medical director for orders. LVN H was asked if CR#2 was noted to have [MEDICAL CONDITION] at 5:00 PM, why did she only contact the NP one time. LVN H said maybe I didn't call because I was giving report to the oncoming nurse. LVN H said she should have called the medical director since the NP did not return her call. Interview with DON on [DATE] at 3:18 PM regarding nursing documentation and calls to the physicians, NP's or other nursing items that needed to be documentation. DON said that if it's not documented, it didn't happen. DON said that the NP should have been notified regarding CR#2 and the nurse should have kept trying. Interview with RN J on [DATE] at 5;45 AM regarding CR#2, she said she was notified by LVN H at change of shift that CR#2 had [MEDICAL CONDITION] and that LVN H had left a message for the NP. RN J said she did not follow up regarding notifying the NP or physician because CR#2 seemed normal on her shift and was responsive throughout the shift. RN J said she did not note any abnormalities regarding CR#2 on her shift until CR#2 became unresponsive. RN J said she notified the NP around 5:00 AM when CR#2 was found unresponsive and NP ordered CR#2 to be transferred to the hospital. RN J asked if CR#2 had died . RN J was asked what the facility policy was for notifying physicians or the NP regarding a change in condition. RN J said nursing staff should call the NP every 15 minutes 3 times. If no response from the NP, then nursing staff should call the residents physician and if the resident's physician is not reached then nursing staff should call the medical director. RN J said that sometimes when they call the NP or physicians the voice mail is full and nursing staff is unable to leave a message. Interview with DON on [DATE] at 3:25 PM, she said CR#2 had a history of [REDACTED]. DON said that RN J noted on her charting on [DATE] during her shift that her assessment was normal, and she did not note any [MEDICAL CONDITION]. DON was asked if the nursing staff should have continued to try and reach the NP or physician when the [MEDICAL CONDITION] was noted, and the DON said LVN H should have continued to call the NP prior to change of shift. DON did not say if RN J should have followed up and continued to call NP or physicians after she was informed at shift change of CR#2's [MEDICAL CONDITION]. DON was asked what the policy for change in condition and notifying the physician. DON said the nurses are to contact the NP first and make a total of 3 tries. She said nursing staff should call the NP every 15 minutes and if they are unable to reach the NP then they are to call the residents physician and the medical director. DON said that CR#2 did not die the day she was transferred via 911 to the hospital but died about a week later. Record review of the facility's policy and procedures on Change in a Resident's Condition or Status dated 2001 and revised (MONTH) (YEAR) read in part . Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). It is important to remember that the facility's first priority is the care, comfort, and safety of its residents. These items should always come first. 1. The nurse will notify the resident's attending Physician or physician on call when there has been a(an) a. Accident or incident involving the resident; b. Discovery of injuries of an unknown origin; c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications two (2) or more consecutive times); g. Need to transfer the resident to a hospital/treatment center; h. Discharge without proper medical authority; and/or i. Specific instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Licensed nursing staff will complete a comprehensive assessment of the resident as soon as possible. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Record review of policy and procedure for Guidelines for Notifying Physician/Physician Extender of Clinical Problems provided by the facility dated 2005 with a revised date of (MONTH) 2014 read in part . These guidelines are to help ensure that 1)medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. The immediate (acute) and non-immediate (sub-acute) problems listed are not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. The practitioner is responsible for: 1. Responding in a timely manner to calls; especially regarding Immediate Notification problems. 2. Communicating sufficient detail to appropriate staff about the assessment and management of the problem and the resident/patient. Immediate Notification (Acute) Problems The following symptoms, signs and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include: 1. Witnessed cardiac or respiratory arrest for individuals who have full code status. 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs) unless the individual is receiving palliative care. 3. The following symptoms: a. Sudden in onset or a marked change b. Unrelieved by measures which have already been prescribed. Record review of facility policy and procedure on Resident Examination and Assessment provided by the facility dated 2001 and revised on (MONTH) 2014 read in part . the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Reporting: Notify the physician of any abnormalities such as, but not limited to: a. abnormal vital signs; b. labored breathing; breath sounds that are not clear; or cough, productive or nonproductive; c. change in cognitive, behavioral or neurological status from baseline; d. distended, hard abdomen or absence of bowel sounds; e. wounds or rashes on the resident's skin; and f. worsening pain, as reported by the resident. The facility Administrator and the DON were notified on [DATE] at 5:33pm of immediate jeopardy identified due to the above failures. A Plan of Removal was submitted by the Administrator on [DATE] at 8:44pm. After several revisions, the final Plan of Removal was accepted on [DATE] at 4:49am. The plan of removal included the following: IJ Component - Abuse/Neglect: Plan of action All nursing staff will be in-serviced and checked-off regarding proper transfer techniques prior to caring for and initial contact of residents' post 7.00pm (MONTH) 16, 2019. This training will be conducted by the Director of Therapy, OTA, or other licensed therapy staff approved to provide said training by both the Director of Therapy and the Director of Nursing, RN, DON. No UAP (e.g., CNA, MA, etc .) will be authorized to train staff regarding transfers. Only trained therapy and nursing staff are allowed to transfer a resident. The approved trainer of transfers list will be located at the nurses' station and with the Director of Therapy / Designee, Director of Nursing / Designee, and the Administrator / Designee. This list includes licensed therapy staff and the Director of Nursing, who was trained by the Director of Therapy on (MONTH) 17, 2019, at 3:30pm. For the current matrix, this in-servicing started at 1900 hours on (MONTH) 16, 2019. This training is expected to be completed by 10.30pm on (MONTH) 20, 2019. Any staff not trained must receive training prior to their shift or they will not be allowed to work. For auditing and verification purposes, a list of the trained nursing staff will be located at the nurses station and with the Director of Nursing / Designee and Administrator / Designee. This was completed at 7:00pm on (MONTH) 16, 2019. A list of all resident transfer level of care will be located at the nurses station, all nurse med carts, and with the Administrator / Designee. Resident transfer level of care must be approved by Director of Therapy / Designee and/or Direc

Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 10 residents (CR#1) reviewed for Administration, in that: The Administrator failed to: Supervise the DON to ensure that nursing staff were able to provide safe and correct transfers for residents who required assistance or were dependent on staff for transfers. The DON failed to: Supervise, train and monitor nursing staff to properly transfer residents who required assistance with transfers or were dependent on staff for transfers. These failures resulted in an immediate jeopardy on 8/16/19. While the IJ was lowered on 8/21/19 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed all resident dependent on staff for transfers at risk of injuries and decline in health . Findings include: Interview with the DON on 08/17/19 at 2:00 PM, when asked what type of procedure there was to make sure the transfer needs for residents were being met, she said that all nursing staff received on-boarding orientation training. The DON did not elaborate on what that meant. The DON was asked how she ensured the nurses and CNAs were competent in their skills for caring for residents who required assistance or were dependent on staff for transfer, she said the CNAs were checked off by the lead CNAs for transfers and nurses had training with orientation. The DON was asked what type of plan was in place for residents that required assistance or were dependent on staff for transfers and how does staff know what type of transfer a resident requires. She said that the nurses always performed some type of assessment when a resident was admitted to the facility. The DON was asked how she thought the IJ, SQC, IT came about, and she said she would like to review information before answering any other questions and that she would get back to the surveyor. The DON said that she sees a lot of things that may have contributed but would have to get back to the surveyor at a later time. Interview with the Administrator on 08/17/19 at 2:20 PM, when asked what type of procedure there was to make sure the transfer needs of the residents were being met, he said that PT trained the lead CNA's on resident transfers and then they train the nursing staff. The Administrator was asked how he monitored the DON to ensure the systems she monitored were being done sufficiently. The Administrator said that the DON has her systems and I go through them and tell her they need to be in binders. The Administrator said he audited the check-offs and interviewed staff and residents to see if there were any concerns. The Administrator was asked how he thought the IJ, SQC, IT came about, and he said that the report he received initially from staff was that there were no visible signs of injury to CR#1. He said there may have been a shaded area or bruising. The Administrator said the DON called the RP and when the RP arrived that the decision was made to send CR#1 to the hospital for evaluation. The Administrator said that the facility had no idea how it happened and that the facility was not aware of the injury as the hospital usually initiated the contact once a resident was admitted to the hospital. The Administrator said the medical director was on staff at the hospital, but he was unable to give the facility any information regarding the resident due to HIPA[NAME] The Administrator did not mention transfers during the interview. Interview with the DON on 08/19/19 at 7:10 AM, she said that transfers was a big part of the IJ and how staff were previously performing transfers prior to the I[NAME] The DON further said that the nurse who was notified of CR#1's injury did not handle it correctly and the nurse should have done a complete assessment then and there and should have stopped the shower. The DON said knowing what she knows now the nurse should have performed a complete assessment when she was notified. Interview on 08/14/19 at 2:33 PM with the DON, when asked how the facility assessed and determined what type of transfer a resident required, she said that physical therapy completed an assessment and made a decision for the residents for the type of transfer that was needed. Interview on 08/14/19 at 3:02 PM with the Director of Therapy, when asked who assessed and determined how a resident was transferred, he stated if a resident was on PT services on admission or if residents were later placed on PT services, then PT will assess the resident regarding transfers. The Director of Therapy said that if a resident was not on PT services, then the facility would continue the transfer that was previously used at the hospital or the transferring facility, further stating they would review the medical records for the type of transfer previously used. When asked who was responsible for training staff on transfers, he stated PT or OT would do the training with the staff. He said they try to do training once every 6 months sometimes, or if there was an incident, there would be a refresher training. When asked how the staff were trained on transfers, he stated PT demonstrates the transfer then the staff must do a return demonstration for Gait belt, Hoyer lift and sliding board transfers, stating sliding boards were used only if deemed appropriate and sliding boards would require a one-on-one training. The Director of Therapy was asked if he could provide skilled check off sheets for staff that was trained, and he said he did not have any skilled check off sheets and to follow up with the DON. Interview on 08/15/19 at 2:23 PM with PT A, when asked who and when was staff trained on resident transfers, she stated if a resident was on PT services and required assistance with transfers they go to the staff that was caring for the resident and train the particular staff on the transfer. She further stated if there was new equipment, they would train the staff on proper use. She stated PT would do an in-service with staff annually. She said they do not keep a check-off list of staff trained on transfers. She further stated there should be a record of training. Interview on 08/15/19 at 3:56 PM with the DON regarding resident transfers and training of staff, she said that the Lead CNA's were trained on transfers and checked off by PT. The DON said after the lead CNA's were trained then they could train and check-off the other CNA's on transfers. The DON was asked how the nurses were trained regarding transfers and she said that PT did a big training and the nurses go to that along with other staff. The DON did not say when the training was offered or how often. The DON said that when the nurses attend the big training that PT did not have a return demonstration for them. She said there was not a transfer check-off sheet for the nurses regarding transfers but there was a check-off sheet for the CNA's when they were trained on transfers by the lead CNA's. Interview on 08/16/19 at 4:32 PM, with the DON, she stated PT will check-off nurses. When asked how the check-off was completed by PT, she stated everyone goes into the PT room or in groups and they must demonstrate the transfer. The DON could not provide specific training dates for transfers other than stating nurses received training during orientation. The DON could not provide check off sheets for the nurses or CNAs that revealed they had been checked off on resident transfers that included return demonstration. Interview on 08/16/19 at 4:46 PM with the Administrator, when asked what the training process was for nursing staff on proper transfer techniques, he said the nursing staff was trained by the nurse managers, further stating the PT department trained nurses and CNA's. He stated when someone comes in who is different or if staff have questions, the PT director goes over the transfer with staff. He further stated that the ACP company will do different equipment training and answer questions staff may have. He stated the ACP company training was geared more towards PT but would train staff who were available. When asked how the facility monitored and tracked training for both CNAs and nurses, he stated PT was out and about and would get with CNAs and watch them do a transfer, further stating PT was constantly asking questions and training. When asked if there was a check-off sheet for transfers, he stated he would have to ask the DON. He further stated PT did a training with the residents and it involved prompting residents to ask questions or to tell PT or staff if the transfer was not done correctly. When asked how the facility ensured nurses and CNAs were monitored throughout the year on transfer training, he stated they recently started a computer-based training in (MONTH) 2019 that had videos on transfers, stating the staff were going out and doing the training. He said this computer training was something he wanted to get out quickly and to cover different subjects. He stated ACP stopped by monthly, but their training was geared more towards PT. The Administrator could not provide evidence of current staff transfer training check-offs or how staff were monitored throughout the year to ensure proper transfer technique was being used. Interview with LVN G on 08/15/19 at 6:30 AM, she said that PT will train staff on a particular resident if they need assistance transferring. LVN G said that CNA's will sometimes show the nurses the transfers and tell the nurses what type of transfer a resident required. LVN G said she could not remember when the last in-service on transfers was and said she could not remember any in-service check-off on the transfer of residents. Interview on 08/15/19 at 2:48 PM with LVN B, when asked who trains the staff on transfers, he stated the lead CNAs train nurses and CNAs on transfers monthly. Record review of staff transfer training provided by the facility revealed two lead CNAs were checked-off on transfers by PT. There was no evidence of current documentation showing the nursing staff or CNA's were properly trained and trained by the appropriate staff on transfers. Record review of nursing staff employee records did not reveal any hands-on training with return demonstration for transfers of residents. However, a transfer checkoff sheet was found for the two lead CNAs completed by the PT department . Please refer to F600 and F684 for additional details The facility Administrator and the DON were notified on 8/16/19 at 5:33pm of immediate jeopardy identified due to the above failures. A Plan of Removal was submitted by the Administrator on 8/16/19 at 8:44pm. After several revisions, the final Plan of Removal was accepted on 8/18/19 at 4:49am. The plan of removal included the following: IJ Component - Abuse/Neglect: Plan of action All nursing staff will be in-serviced and checked-off regarding proper transfer techniques prior to caring for and initial contact of residents' post 7.00pm (MONTH) 16, 2019. This training will be conducted by the Director of Therapy, OTA, or other licensed therapy staff approved to provide said training by both the Director of Therapy and the Director of Nursing, RN, DON. No UAP (e.g., CNA, MA, etc.) will be authorized to train staff regarding transfers. Only trained therapy and nursing staff are allowed to transfer a resident. The approved trainer of transfers list will be located at the nurses' station and with the Director of Therapy / Designee, Director of Nursing / Designee, and the Administrator / Designee. This list includes licensed therapy staff and the Director of Nursing, who was trained by the Director of Therapy on (MONTH) 17, 2019, at 3:30pm. For the current matrix, this in-servicing started at 1900 hours on (MONTH) 16, 2019. This training is expected to be completed by 10.30pm on (MONTH) 20, 2019. Any staff not trained must receive training prior to their shift or they will not be allowed to work. For auditing and verification purposes, a list of the trained nursing staff will be located at the nurses' station and with the Director of Nursing / Designee and Administrator / Designee. This was completed at 7:00pm on (MONTH) 16, 2019. A list of all resident transfer level of care will be located at the nurses' station, all nurse med carts, and with the Administrator / Designee. Resident transfer level of care must be approved by Director of Therapy / Designee and/or Director of Nursing. This was completed at 9:45pm on (MONTH) 16, 2019. The Director of Therapy and licensed therapy staff have been instructed by the Administrator and Director of Nursing to audit all resident's functional abilities and ADLs at 3:00pm on (MONTH) 17, 2019. This audit will commence at 6:00pm on (MONTH) 19, 2019, and the expected completion of this audit is at 5:0pm on (MONTH) 20, 2019. The Administrator and Director of Nursing instructed the MDS Coordinator, RN, to update patient care records and care plans. This activity will commence at 9:00am on (MONTH) 19, 2019, and the expected completion of this activity is at 5:30pm on (MONTH) 21, 2019. Any changes to patient ADLs will automatically be available in the CNAs Point of Care (P[NAME]) located within the EMR system, PointClickCare. Monitoring The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Interviews with different staff including nursing staff from multiple shifts on 08/17/19 through 08/21/19 revealed they had been in-serviced on A/N/E policies and procedures, proper transfer techniques and current matrix in-service. Observations on 08/17/19 revealed PT conducting in-service training to all nursing staff on proper transfer techniques. Observations on 08/20/19 and 08/21/19 revealed CNA's transferring staff using proper transfer techniques. Record review of in-services conducted included, proper transfer techniques and check off list prior to caring for and initial contact of residents, current matrix in-servicing, notifying the appropriate staff (DON, abuse coordinator/Administrator) if A/N is suspected. As of 08/21/19 most of the staff had been in-serviced. Record review of the approved trainer of transfer list revealed the list located at the nurses' station documenting the list of approved staff trained to transfer residents along with the licensed therapy staff and the DON who were also trained by the Director of Therapy. Record review of the resident transfer level of care revealed a list of all residents' level of care located at the nurses' station and medication carts in addition to a list with the DON and Administrator. Record review of residents ADL's and functional abilities audit revealed each resident audited for ADL and functional ability and sorted by hall. This audit was completed by the Director of Therapy on 08/20/19. Record review of resident care plans revealed, updated care plans reflecting each residents ADL and current functional ability. This update was completed on 08/21/19. During the monitoring phase, interviews were conducted by the surveyor on different shifts with the nursing staff, nurse management, and CNA's. All interviewed staff verbalized up to date knowledge on proper transfer techniques and identifying and reporting abuse and neglect per facility policies and procedures. Observations were conducted during the monitoring phase of the three residents that were identified with concerns related to proper transfers of dependent residents and no concerns were noted. The Administrator was notified that the IJ was lowered on 08/21/19 at 6:20pm. However, the facility remained out of compliance at a scope of pattern and severity of actual harm that is not immediate jeopardy due to the facility needing more time to monitor the plan of removal for effectiveness.

Based on interview, and record review, the facility failed to immediately consult with the physician when the resident experienced a change in condition for 1 of 8 residents (CR #2) reviewed for notification of changes, in that; CR #2's physician was not consulted when she experienced a change in condition . CR#2 was found unresponsive 11 hours later. CR#2 was transferred to the hospital where she passed away. This failure affected one former resident and placed her at risk of delay of appropriate medical treatment and a worsening of a resident's condition. Findings include: CR#2 Record review of CR#2's face sheet revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Record review of CR#2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. MDS revealed CR#2 required extensive assistance with one person assist for bed mobility, toilet use and personal hygiene. MDS indicated that CR#2 was always incontinent of bowel/bladder and received [MEDICAL TREATMENT] while residing at the facility. Record review of Physician order [REDACTED].#2 read in part . Full Code Status. [MEDICAL TREATMENT] Monday-Friday at 6:00 AM; one time a day, every Monday, Tuesday, Wednesday, Thursday and Friday. Record review of MAR for CR#2 dated [DATE]-[DATE] read in part . [MEDICAL TREATMENT] Monday-Friday at 6:00 AM; one time a day, every Monday, Tuesday, Wednesday, Thursday and Friday. Record review of Care Plans for CR#2 revealed the following care plans which read in part . [MEDICAL CONDITION] initiated on [DATE]; CR#2 will be free of [MEDICAL CONDITION]. Interventions: Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles while breathing, monitor/document/report prn any signs and symptoms of [MEDICAL CONDITION]- dependent [MEDICAL CONDITION] of legs and feet, periorbital [MEDICAL CONDITION], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation. [MEDICAL TREATMENT] related to [MEDICAL CONDITION] initiated on [DATE]; CR#2 will have no signs or symptoms of complications from [MEDICAL TREATMENT]. Interventions: encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments and resident receives [MEDICAL TREATMENT] in house, monitor labs and report to physician as needed, monitor/document/report as needed any signs and symptoms of infection to access site. Activities of daily living self-care performance deficit related to activity intolerance, confusion, fatigue, impaired balance and limited mobility; resident will improve current level of function in (toileting task), resident will be able to safely perform toileting task using standard commode and grab bars. Interventions: Resident is totally dependent on staff (1 person) for bath/shower, extensive assistance of 1 staff for bed mobility, extensive assistance of 1 staff for dressing, personal hygiene, toilet use, and transfer, monitor/document report as needed any changes. Record review of 24 hour report dated [DATE] did not mention that CR#2 had [MEDICAL CONDITION] (swelling of the lower layer of skin and tissue just under the skin or mucous membranes). 24 hour report only noted that CR#2 was scheduled for [MEDICAL TREATMENT] the following day (Friday). Record review of CR#2's progress notes read in part . [DATE] at 6:54 PM written by LVN H: [MEDICAL CONDITION] noted in CR#2's face, vital signs stable, with no distress noted. Nurse Practitioner notify, awaiting response, will tell night nurse to follow up. Will continue to monitor. [DATE] at 5:27 AM written by RN J: CR#2 slept all night with no complaints. Vital signs at 11:30 PM; blood pressure ,[DATE], pulse 81, respirations 18. Incontinent care given at 5:30 AM, staff in to weigh resident prior to [MEDICAL TREATMENT] appointment but resident was non-responsive, low blood pressure ,[DATE]. Called 911 to transport CR#2 to hospital. Nurse Practitioner notified of change in condition and ordered transfer. DON notified, and responsible party notified. Interview with DON on [DATE] at 4:30 PM, she said CR#2 had not returned from the hospital after she was found un-responsive in her room on [DATE] and she would not be returning as she died while in the hospital. Interview with LVN H on [DATE] at 3:15 PM regarding CR#2, she said that she noticed CR#2 had [MEDICAL CONDITION] to her face on [DATE] at 5:00 PM when she was performing her rounds. LVN H said she called the Nurse Practitioner at approximately 5:10 PM and it went to voice mail and she (LVN H) left a voicemail for the Nurse Practitioner to call back ASAP. LVN H said the nurse for the night shift came on at 7:00 PM and she notified the oncoming nurse (RN J) about CR#2's facial [MEDICAL CONDITION] and asked her to follow up with the Nurse Practitioner (NP) as the NP had not returned the call by shift change. LVN H said she documented on the 24-hour report that CR#2 had [MEDICAL CONDITION]. LVN H was asked what the policy of notifying physicians of change in condition was, she said that nursing staff is to call the NP first and they are to continue to reach out to the NP 3 times at 15-minute intervals then they are to notify the residents physician if the NP does not respond. LVN H said if the resident's physician does not respond then the nursing staff is to notify the medical director for orders. LVN H was asked if CR#2 was noted to have [MEDICAL CONDITION] at 5:00 PM, why did she only contact the NP one time. LVN H said maybe I didn't call because I was giving report to the oncoming nurse. LVN H said she should have called the medical director since the NP did not return her call. Interview with DON on [DATE] at 3:18 PM regarding nursing documentation and calls to the physicians, NP's or other nursing items that needed to be documentation. DON said that if it's not documented, it didn't happen. DON said that the NP should have been notified regarding CR#2 and the nurse should have kept trying. Interview with RN J on [DATE] at 5;45 AM regarding CR#2, she said she was notified by LVN H at change of shift that CR#2 had [MEDICAL CONDITION] and that LVN H had left a message for the NP. RN J said she did not follow up regarding notifying the NP or physician because CR#2 seemed normal on her shift and was responsive throughout the shift. RN J said she did not note any abnormalities regarding CR#2 on her shift until CR#2 became unresponsive. RN J said she notified the NP around 5:00 AM when CR#2 was found unresponsive and NP ordered CR#2 to be transferred to the hospital. RN J asked if CR#2 had died . RN J was asked what the facility policy was for notifying physicians or the NP regarding a change in condition. RN J said nursing staff should call the NP every 15 minutes 3 times. If no response from the NP, then nursing staff should call the residents physician and if the resident's physician is not reached then nursing staff should call the medical director. RN J said that sometimes when they call the NP or physicians the voice mail is full and nursing staff is unable to leave a message. Interview with DON on [DATE] at 3:25 PM, she said CR#2 had a history of [REDACTED]. DON said that RN J noted on her charting on [DATE] during her shift that her assessment was normal, and she did not note any [MEDICAL CONDITION]. DON was asked if the nursing staff should have continued to try and reach the NP or physician when the [MEDICAL CONDITION] was noted, and the DON said LVN H should have continued to call the NP prior to change of shift. DON did not say if RN J should have followed up and continued to call NP or physicians after she was informed at shift change of CR#2's [MEDICAL CONDITION]. DON was asked what the policy for change in condition and notifying the physician. DON said the nurses are to contact the NP first and make a total of 3 tries. She said nursing staff should call the NP every 15 minutes and if they are unable to reach the NP then they are to call the residents physician and the medical director. DON said that CR#2 did not die the day she was transferred via 911 to the hospital but died about a week later. Record review of the facility's policy and procedures on Change in a Resident's Condition or Status dated 2001 and revised (MONTH) (YEAR) read in part . Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). It is important to remember that the facility's first priority is the care, comfort, and safety of its residents. These items should always come first. 1. The nurse will notify the resident's attending Physician or physician on call when there has been a(an) a. Accident or incident involving the resident; b. Discovery of injuries of an unknown origin; c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications two (2) or more consecutive times); g. Need to transfer the resident to a hospital/treatment center; h. Discharge without proper medical authority; and/or i. Specific instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Licensed nursing staff will complete a comprehensive assessment of the resident as soon as possible. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Record review of policy and procedure for Guidelines for Notifying Physician/Physician Extender of Clinical Problems provided by the facility dated 2005 with a revised date of (MONTH) 2014 read in part . These guidelines are to help ensure that 1)medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. The immediate (acute) and non-immediate (sub-acute) problems listed are not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician at any time if they feel a clinical situation requires immediate discussion and management. The practitioner is responsible for: 1. Responding in a timely manner to calls; especially regarding Immediate Notification problems. 2. Communicating sufficient detail to appropriate staff about the assessment and management of the problem and the resident/patient. Immediate Notification (Acute) Problems The following symptoms, signs and laboratory values (which are not all-inclusive) should prompt immediate notification of the physician, after an appropriate nursing evaluation. Immediate implies that the physician should be notified as soon as possible, either by phone, pager, text messaging, or other means. These situations include: 1. Witnessed cardiac or respiratory arrest for individuals who have full code status. 2. Rapid decline or continued instability (for example, markedly fluctuating vital signs) unless the individual is receiving palliative care. 3. The following symptoms: a. Sudden in onset or a marked change b. Unrelieved by measures which have already been prescribed.

Based on observation, interview and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 19 Residents (Resident #79) reviewed for comprehensive care plans, in that: Resident #79's [MEDICAL CONDITION] care plan intervention of padded wall and padded bed rail were not implemented resulting in injuries to her upper extremities and a fractured finger . This failure affected 1 resident and placed her at risk of fractures and further decline in health. Findings included: Resident #79 Record review of Resident #79'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 #79's quarterly MDS dated [DATE] revealed she had long term and short-term memory problems and had moderately impaired cognitive skills per staff assessment. The MDS reflected the resident had no behaviors towards herself or others and had no history of falls. Record review of Resident #79's undated care plan revealed she had [MEDICAL CONDITION] and was at risk for fractures. The care plan revealed the resident would hit the wall with her hands at night and would bang her hand on wheelchair arm rest. Interventions included, Resident's wall near bed, bed rails, and wheelchair arms will be padded. Continue to educate resident not to hit wall/rails/wheelchair. Record review of Resident #79's progress notes dated 8/18/2018 at 10:09 AM revealed, Upon assessment today, observed that resident's right hand was swollen, warm to touch and reddish. Called NP, new order, X-ray of the right hand, [MEDICATION NAME] 100mg PO bid x 7 days. Resident unable to verbalize pain, grunting when right hand was touched. Patient medicated for pain. DON/family member notified. Note was written by LVN #12. Record review of Resident #79's progress notes dated 8/18/2018 at 3:14PM revealed, X-ray result shows no dislocation or fracture in the right hand, NP notified, no new orders given. Upon investigation, resident's roommate verbalized that resident usually hit the wall with her hands at night. Residents wall padded, bed rails padded, monitor resident for increase swelling in right hand, educate resident not to hit the wall. DON/Family member notified. Note was written by LVN #12. Record review of Resident #79's incident report dated 11/3/18 prepared by LVN #12 revealed a CNA brought it to the nurse's attention that Resident #79's left hand pinky finger was swollen, finger was examined and found to be swollen to the knuckle area and bruising to her pinky finger. Resident was observed to be grimacing during examination of her finger, no other injuries were noted. New order was given for STAT 2 view X-ray of left hand and Apap 650mg for pain. It was noted on the report that resident had involuntary hand movement and had been noted to bang her hand on bedside wall, wheelchair, table, or other objects near resident. There was a witness statement from Resident #79's roommate (Resident #51) stating she often saw Resident #79 hands moving all over the place hitting the wall. Record review of Resident #79's progress notes dated 11/3/2018 at 4:35PM revealed, after receiving a shower this morning, CNA brought resident to show writer resident's left hand. Initially, as writer was attempting to exam resident's finger, the involuntary hand movements that resident routinely makes, made it difficult to examine. While examining resident's left hand, writer observed a large ecchymosis ( bruise) area around resident's pinky with swelling to knuckle area. Facial grimacing noted when area was slightly touched by writer. This writer then asked CNA who had brought injury to writer's attention, if he observed injury occurring. Immediately, CNA stated that injury was observed when taking resident into shower room. Resident also noted to have other ecchymosis ( bruise) areas to left arm. Resident has a history of having uncontrollable involuntary bilateral arm movements. Padding has been placed on wheelchair for her protection as well at protective sleeves to decrease incidents of injury. Further review revealed: At 8:10am, NP was notified of writer's observations. New order given for STAT 2 view X-ray to left hand. Order called in. Also ordered Apap 650mg every 6 hours for 48 hours given for pain. At 10:45am , X-ray techs arrive. Writer assists X-ray tech keeping resident's left hand as still as possible. X-ray tech was able to get 2 good pictures after many attempts had been made due to continuous involuntary hand movements. At 12:24 pm, X-ray results received via fax. Findings: acute fifth proximal phalanx fracture, no joint dislocation, soft tissue swelling adjacent to fracture. Bones are osteopenic. Mild interphalangeal [MEDICAL CONDITION] changes. At 12:26pm, NP notified of X-ray results. At 12:28pm, DON notified. At 12:29pm, message left with emergency contact #1 and RP. At 12:30pm, message left with emergency contact #2. At 12:31pm , the DON informed resident would be sent to ER for evaluation and treatment per MD order. At 12:33 Another call placed, and message left for RP informing him that resident would be going to hospital. Resident was assisted with feeding during lunch and laid down to rest. At 2:00pm, transportation company notified. At 3:50pm, EMS arrived. Resident was only able to answer questions using simple 1- or 2-word responses. CNA sent with resident to aide in conveying patient information to medical staff at hospital. At 4:00pm, call placed to hospital ER with report on resident. Note was written by LVN #12. Record review of Resident #79's X-ray results dated 11/3/18 at 11:52AM revealed acute fifth proximal phalanx fracture and resident bones were osteopenic. Record review of Resident #79's progress notes dated 11/4/2018 at 01:35AM revealed, 6:45PM, resident returned from ER, via transport, on stretcher, awake and alert, no s/s (signs or symptoms) of acute distress. VS (vital signs) WNL (within normal limits): T=97.6 R=20 =76 BP=128 76 O2%98. DX (diagnosis) is Non-displaced fracture of proximal phalanx of left little finger. New order for [MEDICATION NAME] 50 mg every 8 hours PRN pain of 4/6, for 5 days, NP notified of prescription and the interaction alerts. No change yet. Resident resting with left hand splint intact, hand resting on pillow fingers warm and no swelling evident, no s/s of pain or acute distress. Capillary refill good and resident able to move finger tips. Record review of Resident #79's NP notes dated 11/6/18 revealed she was contacted on Sunday to report resident had swelling and bruising to her left hand. The NP wrote, Patient has history of lying in bed towards her wall and hitting it. Padding is on the wall next to her bed. Patient was sent to ER for fifth phalangeal fracture and returned with the same night with confirmed fracture and splinted hand and wrist. Observation on 5/14/19 at 10:11AM, Resident #79 was not in her room. There was a flat rubber fall mat observed on the floor on the right side of the bed. The resident's left side of bed was pushed up against the wall. There was no mat on wall or bed rails observed. Observation on 5/15/19 at 10:30AM, Resident #79 was in the dining room sitting at a table by herself in a wheel chair. Wheel chair had padding on the sides and resident had sleeves on both forearms. Resident did not respond to greetings or questions. Observation on 5/16/19 at 2:48PM revealed, Resident #79 was lying in bed facing the wall, bed was set low and fall mat was on right side of the bed on the floor. Resident did not respond to greetings or questions asked. Resident did not have padding on the wall she was facing and there was not padding on the bed rails. Observation on 5/17/18 at 9:45AM, Resident #79 was not in her room. Fall mat on floor was still in place but no padding on wall or bed rails. Interview on 5/17/19 at 10:40AM, MDS Coordinator said the padding on the bed rails, wall, and wheel chair were still an intervention for the resident because she hits the wall with her hands and the padding should be in place to prevent injury. Interview and observation on 5/17/19 at 11:00AM, LVN #12 said Resident #79 was supposed to have a black padded mat in her room to be propped up on the wall next to her bed. she said the nurses are supposed to ensure the mat was in place because the resident hits the wall and injures herself. LVN #12 accompanied surveyor down to Resident #79's room to show surveyor the mat that was put on the wall and the mat was not located in the room by the nurse. She said she wasn't sure where the mat had gone to and said she had been off the last two days, but she thought she last saw the mat when she worked on Monday or Tuesday (5/13/19 or 5/14/19). The nurse said she would find where someone moved the mat and bring it back to the resident's room. LVN #12 added the resident needed the mat/padding on her wall and said the staff had to constantly checked for it being in place while the resident was in bed because she would knock it down. Observation and interview on 5/17/19 at 11:50AM, Maintenance #1 and Maintenance #2 were in Resident #79's room taking the bedrails off her bed and installing foam padding onto the bedrails. Maintenance #1 and #2 were asked if they were able to locate padding for resident's wall and Maintenance #2 replied, we are taking care of it. Interview on 5/17/19 at 1:06PM, Resident #51 (Resident #79's roommate) was in the room watching TV. Resident #51 said Resident #79 hits the wall all the time and she would hear it throughout the night. She said she had never seen the foam padding on Resident #79's bed rails or the mat that was now on the wall before but said she was glad they had put it there. Record review of Resident #51's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating she was cognitively intact. Interview on 5/17/19 at 1:38PM, the DON said she did not know how long the mat had been missing or where it had gone but she would investigate it and find out. The DON added the resident mat for her wall would often fall over or slide down and the nursing staff had reported it to her. She said they tried different techniques of keeping the mat in position, but they were not successful. She said maintenance had the mat fixed on the wall now where it won't be able to move. She said maintenance was not notified of the issue in the past. Interview on 5/17/19 at 4:04PM, LVN #12 said there was padding on the resident's bed rails, but it disappeared one day, and she was unsure of when and why it disappeared. Interview on 5/17/19 at 5:30PM, the DON said she tried to investigate what happened to the resident's wall padding/mat and when it went missing but was unable to get in contact with the nurses who worked. The DON said staff may have taken the mat out for cleaning and forgot to return it, and she was unsure about what happened to the padding for the bed rails. She said they have now added a checklist for the resident to make sure all her padding was in place (wheelchair, bed rails, and wall). Record review of the facility's Care Plans, Comprehensive Person-Centered policy (Revised (MONTH) (YEAR)) revealed, The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident.

Based on observation, interview and record review, the facility failed to ensure resident received treatment and care that are resident centered, in accordance with professional standards of practice for one of 19 residents (Resident #74) reviewed for quality of care, in that; Resident #74 had a fall with immediate complaints of pain to her shoulder and hip areas and was not provided prompt intervention until 13 hours after the fall. Resident #74 continued to complain of severe pain the following morning after her fall and was not provided effective pain management. The facility did not obtain all of Resident #74's ordered X-rays at once and as a STAT order . A pelvis X-ray was re-ordered 13 hours after they received incomplete results revealing fracture. Resident #74's hip and pelvis X-ray results were obtained 29 hours after the fall and complained of severe pain, results revealed a right femoral neck fracture. Resident #74 was transferred to a local hospital a clavicular was identified and she underwent a [MEDICAL CONDITION] surgery. These failures affected one resident and placed at risk of health decline and diminished quality of life. Findings include: Resident #74 Record review of Resident #74's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #74's Annual MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 04 indicating the resident's mental status was severely impaired. Further review of the MDS revealed she had no complaints of pain or history of falls. Record review of Resident #74's undated care plan revealed she was at risk for falls related to confusion and impairment balance and had an actual fall on 12/27/18. Her interventions included to anticipate and meet the resident's needs, make sure call light was within reach and encourage her to use it for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, for no apparent acute injury, determine and address causative factors of the fall. Observation and interview on 5/17/19 at 2:41pm, Resident #74 was laying in bed looking through a book. She said she had a great lunch and was now laying down because she was tired. The resident said she felt well but said her leg had been bothering her. She was asked what happened to her leg and the resident got confused as to what happened to her leg or what was wrong with it. Record review of Resident #74's incident report dated 12/27/18 at 6:45PM revealed the resident was found laying on her back in her bathroom yelling for help. She was assessed from head to toe and able to move every part of her body but complained of pain to her right hip and right shoulder. It was noted she had no injuries. Her vital signs were, 155/75, HR 82, T 97, 97.5, R 20. The resident reported her feet slipped when she got up from the toilet and she fell on her bottom. The resident was administered two tabs of Tylenol 235mg and the NP, RP, and DON were notified. The incident report was prepared by LVN #13. Record review of Resident #74's progress notes dated 12/27/18 at 6:26PM revealed Tylenol Tablet 325 MG to be given every 6 hours as needed for pain was given for complaints of pain to hip. LVN #13 wrote the note. Interview on 5/16/19 at 4:14PM, LVN #13 said he found Resident #74 after she fell on [DATE] and she reported she had slipped and fallen while transferring herself from toilet. He said the resident was on the floor when he found her, and she complained of pain to her shoulder and hip. He recalled he gave resident some Tylenol for the pain. He said he notified the physician who ordered X-rays. LVN #13 said it was shift change after he spoke with the NP so the oncoming nurse (LVN #9) carried out the order for the X-rays. He said the nurses worked 12 hour shifts and he had worked the 6AM - 6PM shift that day. Record review of Resident #74's progress notes dated 12/27/18 at 6:46PM revealed the NP was notified of the resident's fall and she ordered an X-ray for 2V pelvis, right shoulder, ribs, and femur. The nurse called mobile X at 7PM to place the order. Note was written by LVN #9. Record review of Resident #74's progress notes dated 12/28/18 at 5:47AM revealed the follow up pain scale for previous Administration of Tylenol was a 5 which was ineffective. Note was written by LVN #9. Record review of X-ray order confirmation dated 12/28/18 at 6:42AM revealed a STAT order for Resident #74 that included: shoulder, ribs, pelvis, and femur. Interview on 5/16/19 at 5:30PM, LVN #9 said herself and LVN #13 called the NP because she recalled speaking with the NP and getting X-ray orders for pelvis, hip, ribs and femur. She said she called in the X-rays as a routine order around 7PM on 12/27/18 because the X-ray company was supposed to be able to come out that same night. She said when it reached the end of her shift at 6AM, the X-ray company had not come to do the X-rays, so she called them back and changed the order to a STAT order. LVN #9 said the resident was in pain at the beginning of her shift but went to sleep and slept the rest of her shift. Record review of Resident #74's progress notes dated 12/28/18 at 8:07AM revealed Tylenol Tablet 325 mg , every 6 hours as needed for pain was given for complaints of pain. The resident was noted to be crying out in pain and stated her whole body hurt. The nurse also noted PRN Apap 650mg was given and was waiting to see if it was effective. LVN #12 wrote the note. Record review of Resident #74's X-ray results dated 12/28/18 at 9:28AM revealed no fracture or dislocation to the shoulder and no acute fracture to the rib/chest area. There were no results listed for the pelvis and femur areas as ordered. Record review of Resident #74's progress notes dated 12/28/18 at 6:15pm revealed a new order for [MEDICATION NAME] HCI Tablet 50mg to be given every 8 hours as needed for pain due to fall on the previous shift and increased complaints of pain. LVN #12 wrote the note. Record review of Resident #74's progress notes dated 12/28/18 at 6:42pm revealed PRN Tylenol given at 8:07am was ineffective and the resident follow up pain scale was a 9 out of 10. LVN #12 wrote the note. Record review of Resident #74's progress notes dated 12/28/18 at 6:54PM revealed the resident had fallen on the previous shift and during her rounds with the nurse from the previous shift the resident was noted to be yelling out for help. The resident was attempting to get up from her recliner to use the restroom but was screaming with complaints of pain as she lowered the recliner. The nurses offered to assist the resident, but she refused. Later in the morning the resident agreed to get assistance from the nurse to transfer to her wheel chair and she was noted to be grimacing in pain when she put weight on her right side. The resident was assisted to the bathroom and back into her wheel chair. The resident continued to cry out for help due to the pain. The resident was assisted to a bed instead of her recliner and was changed into a brief because of her decreased ability to use bathroom toilet. Staff were aware of resident's change in condition and did frequent checks on her. The NP came in to see the resident and gave new orders for [MEDICATION NAME] 50 MG every 8 hours and Biofreeze TID for pain. The results for X-ray to the shoulder and chest area were received with no fractures or dislocation. They were still waiting on the results from the pelvis and femur X-ray. Note was written by LVN #12. Interview on 5/17/19 at 4:04PM, LVN #12 said when she came in for her shift at 6AM on 12/28/18, herself and the night nurse did rounds when she heard Resident #74 yelling out for help. She said this was not out of the normal for her because she didn't use the call light she would always just yell out if she needed something. She said she went into the room and the resident was trying to get up from her recliner to use the restroom but was yelling in pain. The resident did not want assistance, but they were eventually able to help her because the resident kept attempting to get up with clear signs of pain. After they assisted her to the restroom, they moved the resident to another room with a bed in it because the resident only had a recliner in her room. She changed the resident into a brief and explained to her she was unable to get up like she used to because she had a fall and was hurting. LVN #12 said the resident kept forgetting she had fallen and would try and get up by herself, and when she did she would yell out in pain. The staff had to keep redirecting her to stay in bed and reminding her she had a fall and she was not able to walk. LVN #12 said the resident was in a lot of pain and the Tylenol she had given at the beginning of the shift was ineffective. She said she called the NP and notified her of the increased pain that morning and the NP said she was on her way to the facility and she would assess the resident when she got there. LVN #12 could not remember the exact time the NP came but said it may have been late morning to early afternoon. LVN #12 said she did not administer the PRN [MEDICATION NAME] on her shift because when she went in to check on the resident she did not complain of pain, she said she only had pain if she was trying to move or get out of bed. She said she administered the Biofreeze right after it was ordered. She said the resident just complained of the smell , so she didn't know if it was effective or not. LVN #12 said the X-ray company came in the morning of 12/28/18 to complete X-ray order and she saw them take scans of the resident's hip/lower body parts. She said when the results came in, they had only sent X-rays for the shoulder and chest area. Once the NP came in and she questioned where the rest of the results were, they contacted the X-ray company and they said they had the results and would send them over. She said the NP left but asked to be notified when the results were received . LVN #12 said she called the X-ray company several times throughout her shift and they just kept sending the same results for the shoulder and chest. She reported at the end of her shift, she tried contacting the X-ray company again and got put on hold for over 30 minutes, she had to leave for the day and asked the next shift nurse (LVN #4) to follow up on the X-rays for Resident #74. She left around 7:45PM on 12/28/18. Record review of Resident #74's X-ray confirmation form dated 12/28/18 at 10:39PM revealed a STAT order confirmed for the femur and pelvis. Record review of Resident #74's progress notes dated 12/28/18 at 10:42PM revealed X-ray of pelvis and femur right side was reordered at 10:00PM. The STAT order was initiated because the resident was unable to be repositioned or given incontinent care without having so much pain she would yell and strike out. Note was written by LVN #4. Record review of Resident #74's X-ray results dated 12/28/18 at 11:48PM revealed scans of the femur and pelvis showed [MEDICAL CONDITION] femoral neck without displacement. Record review of Resident #74's telephone order dated 12/29/18 at 12:30AM revealed send resident to the hospital for [DIAGNOSES REDACTED]. LVN #4 received the order. Record review of Resident #74's progress notes dated 12/29/18 at 1:40AM revealed resident was sent to the hospital due to X-ray results showed acute right [MEDICAL CONDITION] with right femoral neck fracture. The results were confirmed at 12:00am on 12/29/18. The NP was notified at 12:05am. Transportation and hospital were notified at 1:00AM. Note was written by LVN #4. Record review of Resident #74's telephone order dated 12/29/18 revealed Transport picked up at 2:10AM 12/29/18. LVN #4 received the order. Record review of Resident #74's hospital discharge records revealed she was admitted to the hospital on [DATE] and released on 1/2/19. The resident was diagnosed with [REDACTED]. The resident underwent [REDACTED]. Interview on 5/17/19 at 4:34P, LVN #4 could not recall anything about the incident with Resident #74. She said she remembered Resident #74 had a fall, but it was not on her shift. She said if she reordered an X-ray, it would have been because the original one wasn't done. LVN #4 was read her note about Resident #74 being in pain and unable to move without pain and she still could not recall the situation. She could not recall if she gave any medications on 12/28/18 or 12/29/18 but said if she had she would have signed it out. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED] 12/27/18 at 6:26PM for pain rated at a 3, medication was listed as ineffective. 12/28/18 at 8:07AM for pain rated at a 10, medication was listed as ineffective. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED]. Assess breathing, negative vocalizations, facial expressions, body language, and consolability. 1-3 = mild, 4-6= moderate, 7-10= severe pain (ordered on [DATE], 6:00PM) was rated at 0 every day except for 12/28/18 day shift which indicated a pain level of 9 (severe pain). Record review of Resident #74's NP progress note dated 12/28/18 revealed the resident was examined from a fall she had the previous day. She noted she was notified the previous day about the fall and that the resident had slipped and fell in her bathroom and complained of pain to her right side. The note read, Nursing requested a shoulder and hip X-ray based on where the patient complained of her pain. X-rays ordered STAT yesterday, patient started on Tylenol for pain. Further review of the note revealed the patient reported the Tylenol was not effective and she was having trouble getting out of bed and was now a two person assist. The NP's assessment and plan for groin pain/shoulder pain/generalized pain/fall at nursing home revealed she was awaiting right lower extremities X-rays and pelvic X-rays. The resident was to continue Tylenol and start [MEDICATION NAME] 50MG every 8 hours PRN. Avoid ambulation until X-rays reviewed and continue fall precautions. Interview on 5/17/19 at 2:30PM, the NP said she recalled ordering X-rays for Resident #74 after the nurse called her about the fall and complaints of pain to the shoulder and hip area. She said she ordered X-rays for the shoulder, chest, pelvis, and hip. The NP could not say for sure if she ordered the X-ray STAT on 12/27/18 but she referred to her notes and her notes say she had ordered the X-ray STAT. She said in a situation where there's was a fall and the resident was complaining of pain, she would typically make the X-ray orders STAT. She was not aware the order was not originally called in STAT on 12/27/18. The NP could not remember if someone had reported the resident's pain to her before she came in to see the resident on 12/28/18 and said she would usually write in her notes if she talked to staff. She said she examined the resident and she did have pain but does not recall someone reporting a pain level of 10. The NP said staff are expected to report pain levels that high to her. She ordered pain meds for the resident to help with the pain. She recalled there were issues with getting the X-ray results when she came in to see the resident and the staff were working on getting the results. NP said she told staff to notify her when they got the results. She could not remember if she was contacted about having to reorder the X-ray for pelvis and hip. The NP said once the results were not coming in she would have expected the X-rays to be reordered before 10:30PM. The NP said she may call and follow up on orders she's given but it was the facility's responsibility to keep her informed and fulfill the orders. Interview on 5/16/19 at 6:15PM, the Administrator said the facility had a lot of problem with the X-ray company used for Resident #74's fall and said they no longer use that company. He said they notified the NP right away after the fall and called in the order for the X-rays as soon as it was given. He knows the X-ray scanned the pelvis and the hip area because the nurse reported seeing them do it and it was confirmed after the order was called in that there was an order for [REDACTED]. He said the resident had pain, but the NP had ordered her some extra pain medications. He said he would print the MAR indicated [REDACTED] Interview on 5/17/19 at 5:30PM, the DON said nurses should have clarified whether an order was STAT whenever they got it from the NP. She said on 12/27/18, it was her understanding the X-ray orders for Resident #74 were routine. She said she was not at work on 12/27/18 -12/28/18. The DON said the staff should have assessed whether PRN pain medication should have been given based on what the resident stated her level of pain was, facial expression, body language and administer per parameters. The DON said the [MEDICATION NAME] may not have been given to Resident #74 because she was comfortable without it. She said she had spoken to the nurses about the situation and they revealed the resident only had pain or was uncomfortable when she moved the right hip area. The DON said they followed the orders the NP gave so they would not have sent the resident out to the hospital unless the NP ordered it. She said the NP did not like to send anyone out to the hospital if it's unnecessary, so she wanted to wait and see what the X-ray revealed. She said there was a delay in getting results and it was because the X-ray company would not send the results. She said they were in contact with the X-ray company back and forth all day and then they got a STAT order from the NP to have X-rays redone. Record review of the facility's policy titled When a Fall Occurs revealed, Notify NP, DON, RP within 1 hour. When notifying NP and DON indicate how fall occurred, if resident is on any blood thinner provide a full set of vital (including pain and location), and any injuries noted. Record review of the facility's Change in a Residents Condition or Status policy (Revised (MONTH) (YEAR)) revealed, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; g. need to transfer the resident to a hospital/treatment center.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of 19 residents (Resident #74) reviewed for pain management, in that : Resident #74 was not provided effective pain management after sustaining a fall in the facility resulting in [MEDICAL CONDITION] and hip. This failure affected one resident whose pain was not effectively controlled from a [MEDICAL CONDITION] and placed her at risk of further decline in mental or physical functioning. Findings include: Resident #74 Resident #74 Record review of Resident #74's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #74's Annual MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 04 indicating the resident's mental status was severely impaired. Further review of the MDS revealed she had no complaints of pain or history of falls. Record review of Resident #74's undated care plan revealed she was at risk for falls related to confusion and impairment balance and had an actual fall on 12/27/18. Her interventions included to anticipate and meet the resident's needs, make sure call light was within reach and encourage her to use it for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, for no apparent acute injury, determine and address causative factors of the fall. Observation and interview on 5/17/19 at 2:41pm, Resident #74 was laying in bed looking through a book. She said she had a great lunch and was now laying down because she was tired. The resident said she felt well but said her leg had been bothering her. She was asked what happened to her leg and the resident got confused as to what happened to her leg or what was wrong with it. Record review of Resident #74's incident report dated 12/27/18 at 6:45PM revealed the resident was found laying on her back in her bathroom yelling for help. She was assessed from head to toe and able to move every part of her body but complained of pain to her right hip and right shoulder. It was noted she had no injuries. Her vital signs were, 155/75, HR 82, T 97, 97.5, R 20. The resident reported her feet slipped when she got up from the toilet and she fell on her bottom. The resident was administered two tabs of Tylenol 235mg and the NP, RP, and DON were notified. The incident report was prepared by LVN #13. Record review of Resident #74's progress notes dated 12/27/18 at 6:26PM revealed Tylenol Tablet 325 MG to be given every 6 hours as needed for pain was given for complaints of pain to hip. LVN #13 wrote the note. Interview on 5/16/19 at 4:14PM, LVN #13 said he found Resident #74 after she fell on [DATE] and she reported she had slipped and fallen while transferring herself from toilet. He said the resident was on the floor when he found her, and she complained of pain to her shoulder and hip. He recalled he gave resident some Tylenol for the pain. He said he notified the physician who ordered X-rays. LVN #13 said it was shift change after he spoke with the NP so the oncoming nurse (LVN #9) carried out the order for the X-rays. He said the nurses worked 12 hour shifts and he had worked the 6AM - 6PM shift that day. Record review of Resident #74's progress notes dated 12/27/18 at 6:46PM revealed the NP was notified of the resident's fall and she ordered an X-ray for 2V pelvis, right shoulder, ribs, and femur. The nurse called mobile X at 7PM to place the order. Note was written by LVN #9. Record review of Resident #74's progress notes dated 12/28/18 at 5:47AM revealed the follow up pain scale for previous Administration of Tylenol was a 5 which was ineffective. Note was written by LVN #9. Record review of X-ray order confirmation dated 12/28/18 at 6:42AM revealed a STAT order for Resident #74 that included: shoulder, ribs, pelvis, and femur. Interview on 5/16/19 at 5:30PM, LVN #9 said herself and LVN #13 called the NP because she recalled speaking with the NP and getting X-ray orders for pelvis, hip, ribs and femur. She said she called in the X-rays as a routine order around 7PM on 12/27/18 because the X-ray company was supposed to be able to come out that same night. She said when it reached the end of her shift at 6AM, the X-ray company had not come to do the X-rays, so she called them back and changed the order to a STAT order. LVN #9 said the resident was in pain at the beginning of her shift but went to sleep and slept the rest of her shift. Record review of Resident #74's progress notes dated 12/28/18 at 8:07AM revealed Tylenol Tablet 325 mg , every 6 hours as needed for pain was given for complaints of pain. The resident was noted to be crying out in pain and stated her whole body hurt. The nurse also noted PRN Apap 650mg was given and was waiting to see if it was effective. LVN #12 wrote the note. Record review of Resident #74's X-ray results dated 12/28/18 at 9:28AM revealed no fracture or dislocation to the shoulder and no acute fracture to the rib/chest area. There were no results listed for the pelvis and femur areas as ordered. Record review of Resident #74's progress notes dated 12/28/18 at 6:15pm revealed a new order for [MEDICATION NAME] HCI Tablet 50mg to be given every 8 hours as needed for pain due to fall on the previous shift and increased complaints of pain. LVN #12 wrote the note. Record review of Resident #74's progress notes dated 12/28/18 at 6:42pm revealed PRN Tylenol given at 8:07am was ineffective and the resident follow up pain scale was a 9 out of 10. LVN #12 wrote the note. Record review of Resident #74's progress notes dated 12/28/18 at 6:54PM revealed the resident had fallen on the previous shift and during her rounds with the nurse from the previous shift the resident was noted to be yelling out for help. The resident was attempting to get up from her recliner to use the restroom but was screaming with complaints of pain as she lowered the recliner. The nurses offered to assist the resident, but she refused. Later in the morning the resident agreed to get assistance from the nurse to transfer to her wheel chair and she was noted to be grimacing in pain when she put weight on her right side. The resident was assisted to the bathroom and back into her wheel chair. The resident continued to cry out for help due to the pain. The resident was assisted to a bed instead of her recliner and was changed into a brief because of her decreased ability to use bathroom toilet. Staff were aware of resident's change in condition and did frequent checks on her. The NP came in to see the resident and gave new orders for [MEDICATION NAME] 50 MG every 8 hours and Biofreeze TID for pain. The results for X-ray to the shoulder and chest area were received with no fractures or dislocation. They were still waiting on the results from the pelvis and femur X-ray. Note was written by LVN #12. Interview on 5/17/19 at 4:04PM, LVN #12 said when she came in for her shift at 6AM on 12/28/18, herself and the night nurse did rounds when she heard Resident #74 yelling out for help. She said this was not out of the normal for her because she didn't use the call light she would always just yell out if she needed something. She said she went into the room and the resident was trying to get up from her recliner to use the restroom but was yelling in pain. The resident did not want assistance, but they were eventually able to help her because the resident kept attempting to get up with clear signs of pain. After they assisted her to the restroom, they moved the resident to another room with a bed in it because the resident only had a recliner in her room. She changed the resident into a brief and explained to her she was unable to get up like she used to because she had a fall and was hurting. LVN #12 said the resident kept forgetting she had fallen and would try and get up by herself, and when she did she would yell out in pain. The staff had to keep redirecting her to stay in bed and reminding her she had a fall and she was not able to walk. LVN #12 said the resident was in a lot of pain and the Tylenol she had given at the beginning of the shift was ineffective. She said she called the NP and notified her of the increased pain that morning and the NP said she was on her way to the facility and she would assess the resident when she got there. LVN #12 could not remember the exact time the NP came but said it may have been late morning to early afternoon. LVN #12 said she did not administer the PRN [MEDICATION NAME] on her shift because when she went in to check on the resident she did not complain of pain, she said she only had pain if she was trying to move or get out of bed. She said she administered the Biofreeze right after it was ordered. She said the resident just complained of the smell , so she didn't know if it was effective or not. LVN #12 said the X-ray company came in the morning of 12/28/18 to complete X-ray order and she saw them take scans of the resident's hip/lower body parts. She said when the results came in, they had only sent X-rays for the shoulder and chest area. Once the NP came in and she questioned where the rest of the results were, they contacted the X-ray company and they said they had the results and would send them over. She said the NP left but asked to be notified when the results were received . LVN #12 said she called the X-ray company several times throughout her shift and they just kept sending the same results for the shoulder and chest. She reported at the end of her shift, she tried contacting the X-ray company again and got put on hold for over 30 minutes, she had to leave for the day and asked the next shift nurse (LVN #4) to follow up on the X-rays for Resident #74. She left around 7:45PM on 12/28/18. Record review of Resident #74's X-ray confirmation form dated 12/28/18 at 10:39PM revealed a STAT order confirmed for the femur and pelvis. Record review of Resident #74's progress notes dated 12/28/18 at 10:42PM revealed X-ray of pelvis and femur right side was reordered at 10:00PM. The STAT order was initiated because the resident was unable to be repositioned or given incontinent care without having so much pain she would yell and strike out. Note was written by LVN #4. Record review of Resident #74's X-ray results dated 12/28/18 at 11:48PM revealed scans of the femur and pelvis showed [MEDICAL CONDITION] femoral neck without displacement. Record review of Resident #74's telephone order dated 12/29/18 at 12:30AM revealed send resident to the hospital for [DIAGNOSES REDACTED]. LVN #4 received the order. Record review of Resident #74's progress notes dated 12/29/18 at 1:40AM revealed resident was sent to the hospital due to X-ray results showed acute right [MEDICAL CONDITION] with right femoral neck fracture. The results were confirmed at 12:00am on 12/29/18. The NP was notified at 12:05am. Transportation and hospital were notified at 1:00AM. Note was written by LVN #4. Record review of Resident #74's telephone order dated 12/29/18 revealed Transport picked up at 2:10AM 12/29/18. LVN #4 received the order. Record review of Resident #74's hospital discharge records revealed she was admitted to the hospital on [DATE] and released on 1/2/19. The resident was diagnosed with [REDACTED]. The resident underwent [REDACTED]. Interview on 5/17/19 at 4:34P, LVN #4 could not recall anything about the incident with Resident #74. She said she remembered Resident #74 had a fall, but it was not on her shift. She said if she reordered an X-ray, it would have been because the original one wasn't done. LVN #4 was read her note about Resident #74 being in pain and unable to move without pain and she still could not recall the situation. She could not recall if she gave any medications on 12/28/18 or 12/29/18 but said if she had she would have signed it out. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED] 12/27/18 at 6:26PM for pain rated at a 3, medication was listed as ineffective. 12/28/18 at 8:07AM for pain rated at a 10, medication was listed as ineffective. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #74's (MONTH) (YEAR) MAR indicated [REDACTED]. Assess breathing, negative vocalizations, facial expressions, body language, and consolability. 1-3 = mild, 4-6= moderate, 7-10= severe pain (ordered on [DATE], 6:00PM) was rated at 0 every day except for 12/28/18 day shift which indicated a pain level of 9 (severe pain). Record review of Resident #74's NP progress note dated 12/28/18 revealed the resident was examined from a fall she had the previous day. She noted she was notified the previous day about the fall and that the resident had slipped and fell in her bathroom and complained of pain to her right side. The note read, Nursing requested a shoulder and hip X-ray based on where the patient complained of her pain. X-rays ordered STAT yesterday, patient started on Tylenol for pain. Further review of the note revealed the patient reported the Tylenol was not effective and she was having trouble getting out of bed and was now a two person assist. The NP's assessment and plan for groin pain/shoulder pain/generalized pain/fall at nursing home revealed she was awaiting right lower extremities X-rays and pelvic X-rays. The resident was to continue Tylenol and start [MEDICATION NAME] 50MG every 8 hours PRN. Avoid ambulation until X-rays reviewed and continue fall precautions. Interview on 5/17/19 at 2:30PM, the NP said she recalled ordering X-rays for Resident #74 after the nurse called her about the fall and complaints of pain to the shoulder and hip area. She said she ordered X-rays for the shoulder, chest, pelvis, and hip. The NP could not say for sure if she ordered the X-ray STAT on 12/27/18 but she referred to her notes and her notes say she had ordered the X-ray STAT. She said in a situation where there's was a fall and the resident was complaining of pain, she would typically make the X-ray orders STAT. She was not aware the order was not originally called in STAT on 12/27/18. The NP could not remember if someone had reported the resident's pain to her before she came in to see the resident on 12/28/18 and said she would usually write in her notes if she talked to staff. She said she examined the resident and she did have pain but does not recall someone reporting a pain level of 10. The NP said staff are expected to report pain levels that high to her. She ordered pain meds for the resident to help with the pain. She recalled there were issues with getting the X-ray results when she came in to see the resident and the staff were working on getting the results. NP said she told staff to notify her when they got the results. She could not remember if she was contacted about having to reorder the X-ray for pelvis and hip. The NP said once the results were not coming in she would have expected the X-rays to be reordered before 10:30PM. The NP said she may call and follow up on orders she's given but it was the facility's responsibility to keep her informed and fulfill the orders. Interview on 5/16/19 at 6:15PM, the Administrator said the facility had a lot of problem with the X-ray company used for Resident #74's fall and said they no longer use that company. He said they notified the NP right away after the fall and called in the order for the X-rays as soon as it was given. He knows the X-ray scanned the pelvis and the hip area because the nurse reported seeing them do it and it was confirmed after the order was called in that there was an order for [REDACTED]. He said the resident had pain, but the NP had ordered her some extra pain medications. He said he would print the MAR indicated [REDACTED] Interview on 5/17/19 at 5:30PM, the DON said nurses should have clarified whether an order was STAT whenever they got it from the NP. She said on 12/27/18, it was her understanding the X-ray orders for Resident #74 were routine. She said she was not at work on 12/27/18 -12/28/18. The DON said the staff should have assessed whether PRN pain medication should have been given based on what the resident stated her level of pain was, facial expression, body language and administer per parameters. The DON said the [MEDICATION NAME] may not have been given to Resident #74 because she was comfortable without it. She said she had spoken to the nurses about the situation and they revealed the resident only had pain or was uncomfortable when she moved the right hip area. The DON said they followed the orders the NP gave so they would not have sent the resident out to the hospital unless the NP ordered it. She said the NP did not like to send anyone out to the hospital if it's unnecessary, so she wanted to wait and see what the X-ray revealed. She said there was a delay in getting results and it was because the X-ray company would not send the results. She said they were in contact with the X-ray company back and forth all day and then they got a STAT order from the NP to have X-rays redone. Record review of the facility's Pain Assessment and Management policy (revised (MONTH) (YEAR)) revealed in part, .2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . Further review of the policy revealed in part, .Recognizing Pain 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. 2. Possible Behavioral Signs of Pain: a. Verbal expression such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changed in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitation in his or her level of activity due to presence of pain . 4. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling. 5. Review the Medication Administration Record [REDACTED]. The policy stated, Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident pain; 3. Prolonged unrelieved pain despite care plan interventions.

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for one of 19 residents (Resident #30) reviewed for neglect. The facility failed to promptly respond to and treat Resident #30's pain for five days. Resident #30 was found to have a fractured femur requiring hospitalization and surgery. This failure affected 1 resident and placed additional 4 residents on hospice at risk of neglect and decline in psychosocial, mental and health decline from not having their needs identified and addressed. Findings include: Intake # 7 Resident #30 Record review of Resident #30's Face sheet revealed an [AGE] year old female admitted to the facility 5/11/17. Her [DIAGNOSES REDACTED]. Record review of Resident #30's MDS dated [DATE] revealed a SAMS of 3 indicating severe cognitive impairment. Further review revealed Resident #30 required extensive assistance of two+ staff for bed mobility, transfers, dressing, and toilet use. Eating was coded as extensive assistance with one-person physical assistance. Impairment on lower extremity was coded. Record review of Resident #30's Care Plan dated 4/6/18 revealed Resident has an ADL self-care performance deficit related to dementia, limited mobility, limited range of motion (recent left femur fracture). Interventions include extensive assistance of one staff for bathing, eating, and personal hygiene. Resident #30 also required extensive assistance of one to two staff for bed mobility, dressing, toilet use, and transfers. Observation on 04/17/18 at 09:41 AM revealed Resident #30 was in memory care unit sitting in wheelchair in living area eating a sandwich. She appeared groomed and dressed appropriately with a boot on left foot. In an interview on 04/17/18 at 09:07 AM, the DON stated she was told Resident #30 was in pain on 4/1/18, and RN #7 was informed. An x-ray was later ordered which confirmed a fracture. Responsible party, hospice, and physician were all notified. Hospice ordered an x-ray 4/3/18. In an interview on 04/17/18 at 09:59 AM, CNA #10 stated she worked in memory care unit on 3/30/18 and noticed Resident #30 was pale, quiet, crying and wouldn't let go of the rail. CNA #10 went to get the nurse on duty and lead CNA. The nurse checked her vitals and informed her Resident #30 already had pain medicine. Nurse told CNA #10 to lay resident down around 2pm where the resident stayed the rest of the shift. Resident #30 screamed when her brief was changed and cried to the end of the shift. CNA #10 stated she completed the stop and watch form, which was done when residents have a change in condition. Resident #30's condition was the same each day CNA #10 worked with her and told the nurse on duty Resident #30 was in pain every day. A hospice nurse came on Monday 4/2/18 and gave Resident #30 a shower and prescribed a new medication. On Tuesday 4/3/18, the hospice nurse returned and gave Resident #30 a bed bath due to pain. CNA #10 informed hospice nurse that Resident #30 couldn't move at all. Hospice nurse showed CNA #10 Resident #30's hip which was swollen and looked like something popped out. In an interview on 04/17/18 at 10:11 AM, CNA #40 came in Friday 03/30/18 at 6am and night CNA informed her Resident #30 was in a lot of pain. When she tried to get Resident #30 up, and resident screamed. This behavior was unlike the resident, so CNA #40 informed the nurse on duty who informed her pain meds were given at 5am. Nurse told CNA #40 to wait until the medicine kicked in to get the resident up. After breakfast, CNA #40 and another CNA got Resident #30 up and she was still screamed in pain. Resident #30 held her leg, grimaced, and cried the rest of the day. On Saturday 03/31/18 and Sunday 04/01/18, Resident #30's mood was the same and the nurse on duty was informed both days. Interview on 04/20/18 at 08:51 AM, Resident #30's Family Member #1 stated family member went to visit on 3/31/18 and Resident #30 was complaining of pain to the leg. After talking to CNA, Family member was informed that Resident #30's pain complaints started on 3/30/18 to which Family member was upset she wasn't notified. Nurses on duty were unable to give her any information. Family Member #1 called hospice on Sunday and a nurse was sent out that day. An x-ray wasn't ordered until 4/3/18 where a fracture was confirmed. In an interview on 04/20/18 at 10:25 AM, RN #4 stated she worked PRN and was the nurse on duty on 4/3/18 from 2-10pm. RN #4 stated she reviewed medications with hospice nurse and made rounds. Resident #30 was in bed when they made rounds. She noticed her left leg looked shorter than the right and when she tried to pull the leg Resident #30 instantly screamed. RN #4 asked the CNA to come in who confirmed she was having pain. Upon observation of the hip area, it appeared swollen and dislocated. She then notified the NP and ADON. ADON looked at it and ordered an x-ray via NP which confirmed she had a femur fracture. RN #4 stated she administered [MEDICATION NAME] which alleviated the pain and sent the resident to the ER. RN #4 stated the facility's protocol when a resident expressed pain was to first assess for the location of the pain, administer PRN medications, and if it's not effective notify the NP. If the NP is unavailable, then notify the Medical Director. In an interview on 04/20/18 at 11:53 AM, LVN #5 worked on 3/30/18. She doesn't recall Resident #30 complaining of pain or administering pain medications. If a resident complained of pain, she would find out where the pain was coming from, check vitals, give PRN pain med, and call NP. If the medication was ineffective, she would inform NP that medication wasn't working and monitor the resident. In an interview on 04/20/18 at 12:51 PM, ADON stated if a resident complained of pain, the nurse should assess resident, reassess resident for pain, notify hospice first, and notify NP if pain persists. In an interview on 04/20/18 at 01:27 PM, RN #7 stated on Saturday 3/31/18 the CNA on duty and assigned to Resident #30 informed her Resident #30 was in pain. Upon assessment, Resident #30 was holding her leg. She administered PRN [MEDICATION NAME] and when she was reassessed Resident #30 was guarding her leg unwilling to let RN #7 touch it. RN #7 gave instructions for CNA on duty to monitor her. Around 8pm or 9pm, RN #7 was told Resident #30 cried while being changed. After contacting hospice, she then gave another dose of [MEDICATION NAME]. On Sunday 04/01/18, Resident #30 was still in pain and hospice was called again. Hospice nurse assessed her on Sunday and thought it was spasms, RN #7 asked if she should be sent to hospital, but Hospice Nurse said no. In an interview on 04/20/18 at 02:54 PM, Hospice Nurse stated the first communication from the facility was on Sunday 4/1/18. The on-call nurse was notified on Sunday that Resident #30 was experiencing pain and told the facility nurse to give [MEDICATION NAME] and call back if pain was persistent. On-call nurse visited Sunday to complete an assessment. The Resident wouldn't get out the bed on Tuesday 04/3/18 which was when the X-ray was ordered. If hospice nurse was informed medication wasn't working, then another visit would be made, and X-rays would have been ordered. Record review of Provider Investigative Report dated 4/10/18 revealed On 4/1/18 resident presented with pain of the left leg. Record review of Resident #30's Nurse's Notes revealed: Complain of left leg pain. [MEDICATION NAME] was administered but was of little help. Hospice notified. Stable vitals. Signed by RN #7. Dated 3/31/18 Resident complained of pain in left leg. [MEDICATION NAME] given, hospice notified. New order for [MEDICATION NAME] 10mg was given. Another note stated Resident verbalized leg pain. [MEDICATION NAME] given. Signed by RN #7. Dated 4/1/18 Patient tearful and holding left lower extremity. Non-verbal but moaning noted. PRN [MEDICATION NAME] given at this time for relief. Writer assisted CNA with peri-care and brief change to prevent further pain. Will monitor patient for relief. Signed by RN #7. Dated 4/2/18 at 5am. Record review of Progress Note dated 4/3/18 revealed Patient is seen and examined today to address concerns of left hip pain per hospice nurse. Upon observation left leg is shorter. She is in excruciating pain no relief [MEDICATION NAME] and Tylenol Number 3 stat x-ray is ordered. Patient's condition is not improving with current regimen so is being sent to the ER for acute care evaluation and treatment. Note was written by Nurse Practitioner Record review of Resident #30's physician order [REDACTED].>Record review of Resident #30's Progress Note dated 4/3/18 revealed a late entry note that stated Patient complained of pain, hospice nurse went in there with the charge nurse, left leg shorter than the right leg, attempted to straighten the left leg, resident started moaning, no discoloration noted, pointed to hip area, resident stated pain, pedal pulse 1+ present, slight swelling noted left hip, administered [MEDICATION NAME], notified NP, X-ray ordered, X-ray done to left femur, hip, tibia, and fibula. Note was written by RN#4 Record review of X-ray dated 4/3/18 revealed an acute [MEDICAL CONDITION] left femur and acute angulation of proximal femoral fracture. Record review of physician's orders [REDACTED]. [MEDICATION NAME] 20mg/ml: give .25ml sublingual every 4 hours PRN for pain or SOB ordered 5/11/17 [MEDICATION NAME] Suppository 650mg: insert 1 suppository rectally every 4 hours as needed for pain or increased temperature ordered 5/11/17 Notify Hospice of any change in condition and prior to any labs, x-rays, or hospitalization ordered 5/11/17 Assess every shift using pain scale assess breathing, negative vocalizations, facial expressions, body language, and ability to console, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain. All results of 4-7 require documentation. Record review of Resident #30's records revealed no pain assessment documented rom 03//30/18 to 4/3/18 Record review of Resident #30's Controlled Drug Receipt Form dated 5/11/17 revealed [MEDICATION NAME] 20mg. Doses were administered 3/30/18, 3/31/18, and 4/1/18 twice each day. Record review of Resident #30's MAR indicated [REDACTED]. Further review revealed no documentation for pain. Record review of Resident #30's MAR indicated [REDACTED]. Further review revealed no documentation for pain. Record review of Resident #30's progress noted dated 4/6/8 revealed readmitted from hospital with [DIAGNOSES REDACTED]. Record review of Resident #30's Progress Note dated 4/8/18 revealed Patient's left hip incision site assessed at this time. A 4x0.1 cm incision with 5 staples noted to be clean and intact. A second [MEDICAL CONDITION] cm incision with 12 staples noted to be clean and intact. Both sites cleansed with normal saline, triple antibiotic ointment applied, and covered with boardered gauze. In an interview on 4/20/18 at 8:00am, Administrator stated an X-ray wasn't ordered because hospice didn't order it. He also stated he has been training staff that hospice doesn't mean denial of treatment. Record review of Facility's Hospice Contract dated 2/12/16 revealed hospice is responsible for providing physician orders [REDACTED]. Record review of Facility's Abuse and Neglect Policy dated (MONTH) 2007 revealed The nurse will assess the individual and document related findings. Assessment data will include Injury assessment Signs of recent fall Pain assessment Current behavior Patient's age and sex All current medications Other platelet inhibitors Vital signs Behavior over last 24 hours . Record review of Facility's CMS 672 revealed 5 residents on hospice.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who required such services, in accordance with their plan of care, for one of three residents (Resident #1) reviewed for pain management. The facility failed to provide effective pain management during wound care for Resident #1 who had a Stage IV pressure ulcer to her left distal foot, and [MEDICAL CONDITION] wound to her left breast. The resident cried out, shed tears and moaned repeatedly when her left leg was touched or moved and when the soiled dressing to her leg was removed. This failure affected one resident and placed 7 other residents with pressure ulcers receiving wound care at risk for pain which could cause unnecessary suffering, depression and a decline in their medical and psychological well-being. Findings include: Intake # 0, 8 & 8 Record Review of Resident #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly review MDS date 7/12/17 revealed the resident was severely impaired for cognition. Further review revealed Resident #1 was dependent with all ADLs, had range of motion limitations on both sides of her upper and lower extremities, was incontinent of bowel and bladder and had one unstageable deep tissue injury. Record review of Resident #1's care plan dated 7/12/17 revealed the resident was at risk for pain and discomfort related to wounds and history of [MEDICAL CONDITION]. The goal was for the resident's pain would be adequately relieved within one hour of intervention through the next review. Interventions included, observe for non-verbal symptoms of pain or discomfort such as grimacing, guarding of different body parts and or moaning, assist her with positioning that provides her with comfort, monitor pain every shift PAINAID, document and notify the physician of any that is not adequately relieved, administer medication as ordered: [MEDICATION NAME] and Tylenol. Record review of Resident #1's MAR dated September 2017 revealed clean left breast wound with normal saline, apply dry, apply alginate and cover with gauze daily. Order dated 8/9/17. Record review of Resident #1's TAR dated 09/14/2017 revealed clean left foot wound with Normal saline, pat dry, apply Santly, [MEDICATION NAME] ointment, alginate and cover with clean dressing daily until healed. Order was dated 9/14/17. Record review of Resident #1's physician wound consult report dated 9/14/17 revealed initial encounter -acute left distal medial foot pressure ulcer with onset date of 9/1/17, measured 3cm in length and 3.5cm width. Further review of this report revealed Resident #1 had a Stage IV pressure injury with moderate exudate, exposed ligament necrosis, exposed bone with necrosis and exposed adipose tissue. Moist yellow slough of 76-100%. Signs of infection present, culture and sensitive pending, and topical antibiotic prescribed. Wound assessment report also revealed fractured bone within wound bed indicates clinical osteo[DIAGNOSES REDACTED]. Record review of Resident #1's physician wound consult report dated 9/14/17 revealed additional orders - give [MEDICATION NAME] 30 minutes prior to dressing changes or planned wound debridement as needed based on previous plan, plan of care discussed with DON- will submit bone fragments from left medial foot wound to the facility's lab for culture for evaluation of osteo[DIAGNOSES REDACTED], plan of care discussed with nurse aide - importance of off -loading and repositioning was emphasized and aide was also asked to convey information to other shift. Follow up in two weeks. Interview on 09/20/2017 at 9:33am, the DON said Resident #1 was medicated already. When asked what medication was offered, the DON said the charge nurse told him when he asked about the resident's medication he was told the resident had a scheduled pain medication. Observation and interview on 09/20/2017 at 9:42am revealed Resident #1 was repositioned in bed and ready for wound care. The DON picked up the resident's left foot and the resident started moaning. The DON continued to reposition Resident #1's leg and then removed the soiled dressing which had a thick, slightly slimy, brownish-yellow drainage. Resident #1 cried louder and had tears in her eyes, she continued to moan non-stop while the DON attempted to pick up her leg and continue wound care. There were two aides assisting with care by holding the resident's leg. Further observation revealed the resident continued to cry out in pain and moan. Surveyor asked DON to stop wound care as it was unbearable to watch. The DON said the resident's pain medication must not have controlled her pain and was unsure what medication was administered to the resident or when. The DON also said the resident's family did not want her to be on be on stronger pain medication due to religious reasons but stated he would discuss it with the resident's doctor to see what other medication could be ordered. Interview on 09/20/17 at 9:54am, LVN #1 said Resident #1 had scheduled [MEDICATION NAME] 50mg as needed for pain. When asked when the medication was last administered LVN #1 said yesterday about 10:30am. LVN #1 was asked what pain medication was administered to the resident today. She looked at the resident's MAR and reported Tylenol #3 was scheduled to be administered every 6 hours via [DEVICE] with last dose given today, 9/20/17 at 6am. Record review of Resident #1's MAR dated September 2017 revealed the following medications: [REDACTED] Tylenol #3 every 6 hours via [DEVICE]. Medication order dated 8/9/17. Medication was given daily at scheduled times of 12am, 6am, 12pm, and 6pm. [MEDICATION NAME] 325mg tablet, give two tablets via [DEVICE] PRN for pain. Medication was ordered 3/22/17. Medication was not documented as administered in the month of September. [MEDICATION NAME] 50mg tablet, give one table by mouth every 6 hours PRN for pain. Medication order date was 6/28/17. Further review of this MAR revealed medication was not documented as administered in the month of September. Record review of Resident #1's pain flow sheet not dated revealed [MEDICATION NAME] 50mg was administered on: 9/14/17 at 9:30am for generalized body aching pain of intensity of 5/10 revealed through facial expression. Precipitating factors were left foot wound and left breast wound. 9/15/17 at 10am for left foot wound 9/19/17 at 10:30am for left breast wound 9/20/17 at 10am, for generalized body pain of 7/10. Record review of Resident #1's TAR dated September 2017 revealed assess patient every shift using PAINAID scale, assess breathing, negative vocalization, facial expression, body language and consolability; 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain, results of 4-7 require documentation. Order was dated 3/22/17. Further review of Resident #1's TAR revealed a pain score of 7 on 09/16, 6 on 09/19 and 7 on 09/20/17 for the morning shift. Other days were documented 0. Pain score of 3 was documented on 09/08/17 and 7 on 09/07/17 for evening shift. Pain scores of 6 were documented on 09/1/17, 09/2/17, 09/04/17, 09/5/17, 09/6/17, 09/7/17 and 09/18/17 for night shift. Pain score of 8 was documented on 09/3/17 for night shift, pain score of 7 on 09/08/17 for night shift. Pain score of 5 was documented on 09/19/17 for night shift. Record review of the facility's policy on pain clinical protocol dated June 2013 revealed the physician and staff will identify individuals who have pain or who are at risk of pain. This includes a review for any treatment that the resident currently is receiving for pain, including complementary (non-pharmacologic) treatment. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review. Whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. The nursing staff will identify any situation or interventions where an increase in the resident's pain may be anticipated for example wound care, ambulation or repositioning .etc. According to the DON, 8 residents had pressure ulcers and were receiving wound care.

Based on observation, record review and interview the facility failed to consult with the physician when there was a change in condition for two of eight residents (Resident #2 and CR #1) on two of four halls (hall 100 and 200) who were reviewed for physician's consultations. Resident # 2 ' s Nurse Practitioner was left four messages from the facility with no return calls and the physician was not consulted by the facility when the resident had episodes of lethargy and an inability to form words over a period of nine hours. The Responsible Party had the facility transfer the resident to the hospital for evaluation due to the change in the resident's condition. CR #1 ' s physician was not consulted when the resident ' s blood pressure medications were held due to low blood pressure eight times over a two month period. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor to ensure physicians were consulted when a resident had a change of condition This failure affected two residents with one of the residents requiring a transfer to the hospital, and placed 29 residents at risk of their physician's not being consulted when they have had change in their conditions which could cause a delay in treatment and a decline in their health. Intake # 7 Findings include: Resident # 2 Record review of Resident # 2 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE], was transferred to the hospital on [DATE] and readmitted back to the facility on [DATE]. Resident #2 had the following diagnoses; [MEDICAL CONDITION], aftercare traumatic [MEDICAL CONDITION], rehabilitation, history of falls, sciatica, pelvic-joint pain, [MEDICAL CONDITION], idiopathic [MEDICAL CONDITION], constipation and general [MEDICAL CONDITION]. Record review of Resident #2 ' s Minimum Data Set ((MDS) dated [DATE] revealed Resident #2' s Brief Interview for Mental Status (BIMS) was four (4) which revealed her cognition was severely impaired. The resident ' s speech pattern was identified as clear, distinct and forming intelligible words. Continued review revealed her ability to make herself understood she expressed ideas and wants. The MDS documented the resident was understood by others. Record review of Resident #2 ' s care plan dated [DATE] revealed the problem: The resident was at risk for injury due to epileptic diagnosis . The care plan goal and target date was: .resident will be monitored for convulsions daily and all convulsions will be reported to the physician through the next review [DATE] .Approaches: administer medications as ordered, monitor laboratory tests and report results to the physician, ensure resident was safe while having a [MEDICAL CONDITION] and floor mat at bedside. Record review of Resident #2 nurse ' s notes dated [DATE] at 9:00 A.M. revealed .resident is alert but lethargic, easily aroused to physical stimuli . 11:30 A.M . resident feels cold, skin is cool to touch .2:45 P.M. Nurse Practitioner (NP) notified of resident ' s current condition today; awaiting return call .5:00 P.M. resident sitting upright in bed eating supper; resident alert with periods of lethargy noted, called and spoke with responsible party (RP) in regards to resident ' s condition 6:30 P.M. resident continued with noted lethargy, remains alert with periods of intermittent periods of lethargy. NP called again no answer. Call placed to the resident ' s RP to update her .she (RP) requested the resident be sent to the hospital for evaluation, DON notified of family request; will reattempt to contact NP again .6:45P.M. call placed to NP . per NP send to hospital for treatment and evaluation for family request . Record review of Resident #2' s physician ' s orders dated [DATE] 7:15 P.M. .send resident to hospital emergency room per family request for treatment and evaluation -altered mental status (AMS) and lethargy . Record review of a statement written by the NP dated [DATE] revealed LVN #1 had spoken to the NP and reported Resident #1's lethargy. The statement goes on to read an order was given to monitor the resident until around 2 P.M. and to call the NP if symptoms did not subside. The statement read the NP spoke to the nurse at 2:08 PM and gave orders. Record review of CR #1 Nurses notes dated [DATE] revealed no documentation of NP contact. Record review of CR#1's physician's orders revealed the only order documented on [DATE] revealed one order for the resident that was timed at 7:15 P.M. which documented family's request to transfer resident to the hospital. Interview on [DATE] at 1:30 P.M. LVN #1 stated she was taking care of Resident #2 on [DATE]. She stated the resident had periods of lethargy that day. At approximately 9:00 A.M. the CNA ' s called her into the resident ' s room. The resident was unable to say the words she wanted to say. As the interview continued she stated approximately between 9:30 A.M. and 9:45 A.M. she put a call in for the NP and she left a message but did not get a response. She continued and stated the resident was alert and talking again a little while later. She did not notice the resident jerking at this time. LVN#1 stated she did not remember reporting to the NP the resident ' s inability to form words. The resident did eat her lunch that day. LVN #1 stated she put a second call in to the NP at approximately 2:00 P.M. She left another message. LVN#1 stated Resident #1 started to have the jerking motions later in the afternoon shift. The LVN stated she put another call in to the NP at approximately 5:00 to 6:00 P.M. but she still did not have an answer so she left another message. LVN #1 stated she notified the resident ' s family member of the changes and was told to send the resident to the hospital for evaluation. LVN#1 stated she told the family member that she would need to check with the resident ' s physician. The LVN stated she called the NP again at approximately 6:30 P.M. and this was the first contact she made with the NP. The NP told her it would be alright to send the resident to the hospital. LVN #1 stated she was not sure how long to wait for the physician or NP to return a call or what to do if they did not return the call. LVN #1 stated she had been trained to call the physician (NP) wait 15 minutes and if no response call again. After another 15 minutes if there was no response she was then to contact the Medical Director. Observation on [DATE] at 1:45 P.M. revealed Resident #2 was sitting in a wheelchair in her room. The resident ' s speech was clear and oriented. As the observation continued the resident ' s bilateral upper extremities jerked up. Interview on [DATE] during the observation at 1:45 P.M. the resident stated she was sorry for the movement but she could not control it. She stated she was not able to identify when it was about to occur and she hated it. CR #1 Record review of CR #1' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE], was readmitted on [DATE] and expired on [DATE]. Resident #1 had the following diagnoses; senile delusion, anxiety, muscle weakness, abnormal gait, history of falls, constipation, chest pain, hypertension, wheezing and [MEDICAL CONDITION]. Record review of CR #1' s MDS dated [DATE] revealed Resident #1' s BIMS was 2 which indicated her cognition was severely impaired. Continued review revealed the residents ambulation required limited assistance of one staff. The MDS revealed the resident did not have behaviors of resisting care required to achieve goals for health and wellbeing;also did not identify shortness of breath or the use of oxygen while a resident within the last 14 days. Record review of CR #1' s consolidated physician ' s orders dated [DATE] revealed the following antihypertensive medications: [REDACTED]< 110 , Diastolic Blood Pressure (DBP) < 60 and [MEDICATION NAME] 25 mg every 12 ours hold for SBP < 110 or heart rate < 60. Record review of CR #1' s Medication Administration Record [REDACTED] [DATE] blood pressure (B/P) ,[DATE] nurse notified. [DATE] BP ,[DATE] nurse notified. Record review of CR #1' s MAR indicated [REDACTED]. Continued review of the back of the MAR indicated [REDACTED] [DATE] at 9:00 A.M. B/P ,[DATE], nurse notified. [DATE] 9:00 A.M. B/P ,[DATE] nurse notified. [DATE] 9:00 P.M. B/P ,[DATE]; B/P rechecked ,[DATE]. [DATE] 9:00 P.M. ,[DATE]. [DATE] 9:00 P.M. B/P ,[DATE] nurse notified. Record review of CR #1' s nurse ' s notes dated [DATE] revealed [MEDICATION NAME] held due to low B/P ,[DATE] and ,[DATE] pulse 97 Attempted to call NP several times no answer. RP aware of low B/P . Record review of CR #1' s MAR indicated [REDACTED] [DATE] at 9:00 A.M. B/P ,[DATE] nurse notified. [DATE] at 9:00 A.M. B/P ,[DATE] nurse notified. [DATE] at 9:00 A.M. B/P ,[DATE] nurse notified. Record review of CR #1' s MAR indicated [REDACTED] [DATE] at 9:00 A.M. B/P ,[DATE] , nurse notified. [DATE] at 9:00 A.M. B/P ,[DATE] initialed and circled to indicate the medication not given. [DATE] at 9:00 P.M. B/P ,[DATE] initialed and circled to indicate the medication not given. [DATE] at 9:00 A.M. B/P ,[DATE] initialed and circled to indicate the medication not given. Record review of CR #1' s pulse rate at 9:00 A.M. revealed: [DATE] was 113. [DATE] was 102. [DATE] was 117. Record review of CR #1' s nurse ' s notes revealed no documentation the physician was notified the blood pressure medications were being held due to low blood pressure on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Continued review of CR #1's physician ' s orders revealed no changes in the antihypertensive medication orders. Interview on [DATE] at 1:00 P.M. LVN#2 stated the physician should have been notified if the blood pressures were too low to administer the medications. Interview on [DATE] at 3:25 P.M. the DON stated this facility was not a hospital or an emergency if someone needed to be sent out they should be sent out. Record review of the facility policy titled Change in a Resident ' s Condition or Status dated 2001 and revised [DATE] revealed .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 .) .The nurse supervisor/charge nurse will notify the resident ' s attending physician or on-call physician when there has been: .A need to alter the resident ' s medical treatment significantly . The facility administrator and DON were notified on ,[DATE]//2015 at 5:16 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of removal of IJ: On [DATE] at 6pm the DON started vital sign and Oxygen Concentration check on every resident in the facility to ensure no conditions existed that would require Physician notification or emergency care. Results: No resident required Physician notification or emergency care. ( ) N.P. was in the facility at 9:20 pm on [DATE], N.P. was asked to review the findings and confirmed no need for interventions or recommendations. At 6 pm on [DATE], the Unit Manager/RN made rounds on each resident in the facility to identify any need for notification of the Physician. No conditions or concerns merited Physician notification or emergency care. The DON conducted patient rounds at 6:30 pm with no need for Physician notification or emergency care noted. Another round was conducted by the DON at 10:10 pm on [DATE] resulting in no negative findings. At 6:30 pm on [DATE] educational training by the DON was started for all nurses regarding timely notification of the Physician for changes in condition; rapid response to critical conditions or assessment findings; and documentation of negative findings and actions taken with subsequent notification of the Physician. The same educational training will be provided to the all nurses prior to assuming their position as charge nurse. At 7 pm on [DATE] the Unit Manager/RN started educational training to all nursing staff (Nurses, MA ' s and CNA ' s) regarding the INTERACT STOP AND WATCH Early Warning Tool for identifying a change while caring or observing a resident. The tool instructs the staff to circle the change and notify the nurse on the following concerns. No concerns were noted by nursing staff. Starting [DATE], the DON/Unit Manager/Designee will daily review the 24 hour reports and conduct patient care rounds to ensure the stability of each resident. PLAN OF REMOVAL MONITORING 1. Reviewed documentation dated [DATE] of the facility Director of Nurses rounds on each resident obtained vital signs and pulse oximetry levels. 2. Reviewed documentation dated [DATE] that all licensed and unlicensed nursing staff were inserviced on the Interact Stop and Watch Early Warning Tool 3. Reviewed documentation dated [DATE] Licensed Nursing Staff were educated on the Timely notification of the physician for changes in condition; rapid response to critical conditions or assessment findings and documentation of negative findings/actions taken with subsequent notification of the physician. 4. Interviews were conducted on [DATE] during two shifts (licensed nursing staff) by the surveyor with the following results: 100% of all licensed nursing staff on 6:00 A.M to 2:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician to return call and how to respond if there was no return call. 100% of all unlicensed nursing staff on 6:00 A.M. to 2:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. One of three Licensed nursing staff on 2:00 P.M. to 10:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician return call and how to respond if there was no return call. Three of nine unlicensed nursing staff 2:00 P.M. to 10:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. Twenty two nursing staff between two shifts were interviewed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as pattern. The facility was continuing to monitor to ensure physicians were consulted when a change in the condition of a resident occurs. The facility roster revealed the census on the 100 and 200 halls was thirty residents.

Based on record review and interview, the facility failed to implement their policies and procedures that prohibit neglect for one of eight resident's on one of four halls (Hall 200 the secured unit) reviewed for neglect (CR #1) when the facility staff did not ensure CR #1's, who had a compromised respiratory status, oxygen administration and saturation (level of oxygen saturation in the blood) was monitored. The facility failed to monitor CR #1 ' s oxygen use prior to being discovered by a family member in respiratory distress with cyanotic fingers and lips. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure residents who were on the secured unit who were assessed with [REDACTED]. This failure affected one resident who was transferred in respiratory distress to the hospital, and placed 13 residents at risk of neglect, and delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 7 CR #1 ' s Record review of CR #1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE], readmitted to the facility on [DATE] on hospice and died on [DATE]. CR #1 had the following diagnoses; senile delusion, anxiety, muscle weakness, abnormal gait, history of falls, constipation, chest pain, hypertension, wheezing and [MEDICAL CONDITION]. Record review of CR #1's nurse's notes dated May through [DATE] revealed no complaints or changes in resident's condition documented. Record review of CR #1 ' s telephone physician's order [REDACTED].continuous oxygen ,[DATE] liters as needed titrate oxygen as needed less than (<) 92% indication were [MEDICAL CONDITION] and shortness of breath (SOB). Record review of CR #1 ' s care plan dated [DATE] revealed the problem .Has oxygen and nebulizer treatments due to SOB .approaches: #4 .check resident frequently to ensure oxygen was in use as needed . Record review of CR #1 ' s MDS dated [DATE] revealed the resident ' s BIMS was 2 which indicated her cognition was severely impaired. Continued review revealed the resident ' s ambulation required limited assistance of one staff. The MDS revealed the resident did not have behaviors of resisting care required to achieve goals for health and wellbeing; also it did not identify shortness of breath or the use of oxygen within the last 14 days. Record review of the chest radiology report dated [DATE] revealed .Impression .Large focal patchy infiltration in the right upper lobe, likely a large mass versus lobar pneumonia . Record review of CR #1 ' s nurse ' s notes dated [DATE] to [DATE] revealed oxygen saturation was monitored on [DATE] without oxygen and it was 97%. On [DATE] at 2:00 P.M. CR #1 ' s oxygen saturation was 94%. Record review of CR #1 ' s treatment record dated [DATE] revealed the resident ' s oxygen saturation was checked on the following dates with the following results: [DATE] at 9:00 A.M. result 87 % oxygen 2 liters. [DATE] at 9:20 A.M. oxygen saturation 88%-94% fluctuating oxygen 2 liters. [DATE] at 9:30 A.M oxygen saturation 89% connected 3 liters. Review of CR #1's medical record revealed there was no consistent area where oxygen saturation was documented nor if the oxygen saturation was monitored more then one time a day after the physician ordered oxygen to be administered if oxygen saturation below 92% on [DATE]. Record review of the chest radiology report dated [DATE] revealed comparison to [DATE] .Large consolidation in the right upper lobe is worsening .could be pneumonia or enlarged mass . Record review of CR #1's care plan revealed no changes in resident's care after x-ray results were received. Record review of CR #1 ' s nurse ' s notes dated [DATE] at 11:40 A.M. revealed .called to the room by the resident ' s (family member) to assess his concerns over resident ' s labored breathing. Resident noted attempting to sit up and moving constantly. Stating she could not breath. Oxygen was in place respirations labored and rapid oxygen saturation 70%, skin pale with extremities cyanotic. Blood Pressure ,[DATE]; pulse 97. (Family member) requested resident be transferred to the emergency room via Emergency Medical Services (EMS) at this time. Called and left a message for NP. Assisted the resident to breathe deeply and raised the head of the bed. EMS requested by the (family member) and arrived at facility. Resident was placed on an oxygen mask . The U.S. National Library of Medicine, updated [DATE], defined cyanosis as a bluish color to the skin or mucus membranes that is usually due to a lack of oxygen in the blood. Further record review revealed the next entry in CR #1 ' s nurse ' s notes dated [DATE] at 9:00 A.M. (late entry) Resident awake and alert . vital signs B/P ,[DATE], pulse 89, respirations 20, temperature 98.9 in bed head of the bed elevated 45 degrees, oxygen connected at 2 liters per doctors order, pulled out her Intravenous . continue to monitor behavior and for SOB .oxygen saturation 89% prior to oxygen now 94% monitor closely . Record review of the Patient Care Report from City of Katy EMS dated [DATE] revealed .the EMS arrived at the resident bedside at 11:59 A.M. the level of care was advanced life support, condition was urgent required immediate care ., breathing labored and mechanically assisted by [MEDICAL CONDITION] (continuous positive airway pressure machine); at 12:00 the resident ' s blood pressure was ,[DATE] heart rate ,[DATE], respirations 30 oxygen saturation 67% .indications for [MEDICAL CONDITION] was Severe Respiratory Distress Oxygen saturation at 12:05 P.M. was 70%, at 12:10 P.M. 58% and at 12:15 P.M. 84% . Continued review revealed the EMS narrative read .arrived found [AGE] year old female in bed seems to be in severe respiratory distress. ( family member) by her side and stated she had gotten progressively sicker in the past couple of days, resident extremely tired and cannot breathe, speaks in three (3 ) word sentences and has to pause for a breath . Record review of the facility complaint/grievance report dated [DATE] revealed .(family member) stated he came in at 11:30 A.M. and (resident)was in respiratory distress and did not have her oxygen on . Continued review of the facility complaint in the investigation section revealed interviews with two aides stated the resident CR#1 would remove the oxygen mask when she wanted to. Interview on [DATE] at 10:10 A.M. EMS #1 stated when he arrived CR #1 was in severe respiratory distress and she needed assistance to breath. Interview on [DATE] at 5:07 P.M. LVN #3 stated she was not the resident ' s nurse. She stated she did not know where the resident ' s nurse was perhaps at lunch. The staff said the family member had questions about his mom. She was the closest nurse around so she went to the room around 11:40 A.M. She stated when she arrived in the room the resident was in severe respiratory distress. The resident had stated at that time to the nurse she could not get enough air. The LVN stated she left the family member in the room to get her equipment to get vital signs on the resident and she put a page in for the doctor. The resident was sitting in high fowler ' s position ( head of the bed elevated to sitting up straight) with her oxygen on. LVN #3 stated the family member wanted 911 called. The LVN stated she needed to call the NP, assess the resident and get her vital signs. LVN #3 stated she knew she needed more help in the room so she poked her head in the hall and got the weekend supervisor. As the interview continued she stated by that time the family member had called 911. The family member stated he could get them there faster. The nurse stated the family member worked with the local EMS services. Interview on [DATE] at 10:44 A.M. CR #1 ' s family member and Responsible Party (RP) stated he arrived at the facility at approximately 11:30 A.M. on [DATE]. He found the resident in the tripod position He continued and stated his problem was what he found when he arrived at the facility that morning and saw the resident. Not because the resident had pneumonia but the acute state she was in when he arrived. The pneumonia did not suddenly come on that morning like a [MEDICAL CONDITION] embolism (PE) would have. He stated the resident did not have her oxygen on when he arrived. He stated he put it on her. She could not breathe so he helped her to sit back with the head of the bed up. He looked out in to the hall and found some staff. He asked them to get the nurse to come in. The nurse came in and saw right away the resident was in distress. The nurse began to get vital signs. He continued and stated he said for her to call 911 she said she would have to call the physician to get approval. He stated he told her he would have to override that and he called 911. Review of the medical dictionary website defined the tripod position as a position adopted by a patient with extreme respiratory distress, who sits upright and leans forward, resting his or her hands on her knees. The U.S. National Library of Medicine updated [DATE] defined [MEDICAL CONDITION] embolism as blood clots in the lung. Interview on [DATE] at 1:00 P.M. LVN #2 stated she was working as a medication aide the day CR #1 went to the hospital. She stated she mainly just gave her medications and really did not notice any of the nursing issues. She did remember CR #1 took her medications fine. The resident was not short of breath nor did she notice any discoloration. LVN #2 stated this was at approximately 9:15 A.M. to 9:30 A.M. on [DATE]. She stated she did not see CR #1 again before she was transferred to the hospital. As the interview continued she stated staff was to always get an order to transfer out residents even in an emergency situation. Interview on [DATE] at 1:11 P.M. CNA #1 stated she cared for CR #1 and she gave her a shower the day the resident went to the hospital. CNA #1 stated she showered the resident at approximately 9:00 A.M. She stated the resident looked alright and she did not notice any changes in her skin color. The nurse fed her breakfast and she hardly ate anything that morning. After the shower the CNA stated she took her back to bed. She stated the resident did not have any oxygen on when she took her to the shower and she did not remember who put the oxygen on her after the shower. She stated maybe it was the nurse, but she was not sure. CNA #1 stated she saw the resident walking to the bathroom around 10:30 AM and the resident did not have her oxygen on. She stated that was the last time she saw her was when she was going to the bathroom by herself. CNA #1 did not state any specific instructions relayed to her by the nurse concerning monitoring the resident. Interview on [DATE] at 3:00 P.M. RN #1 stated she was called into the room for CR #1 by LVN #3 (around 11:40 A.M.) RN #1 stated the family member told her the resident was cyanotic. She stated when she arrived the resident ' s oxygen saturation was ,[DATE]% and EMS arrived. Interview on [DATE] at 3:18 P.M. LVN #4 stated she was CR #1's nurse and she checked on her in the morning. The resident ' s appetite was poor that morning. The resident had needed to be fed over the past week. LVN#4 stated CR #1 had been declining over the past ,[DATE] days with a decrease appetite and increased fatigue ever since the chest X-Ray . LVN#4 stated she saw the resident before the shower and CR #1 was not cyanotic. She stated she did not see CR #1 again before she was transferred to the hospital and she was not aware of the family member coming in. She stated the resident needed to be watch closely. Interview on [DATE] at 4:00 P.M. LVN #5 stated she arrived in the resident ' s room just before EMS arrived. She stated RN #1 and LVN #3 were in the room along with the family member. LVN#5 stated the resident had her oxygen on. Interview on [DATE] at 4:03 P.M. the DON stated everything happened very quickly with CR #1. She stated the family member said he would call 911 because he could get them faster. She stated CR #1 was good and they did everything they could for her. Interview on [DATE] at 4:38 P.M. LVN #4 stated she saw CR #1 at approximately 9:30 A.M. - 9:45 A.M. on [DATE] then she went to another hall for about 1 ,[DATE] - 2 hours. She stated one nurse works two halls and the CNA ' s watch the resident ' s when the nurse was not on that particular hall. Interview on [DATE] at 5:00 P.M. the DON stated if a change was seen in the resident or if the resident was in distress she was not real sure of the policy. She stated she would expect an ambulance called first. The DON stated she was pretty sure the family member offered to call the EMS because he was the fire chief and could get them here faster. Interview on [DATE] at 3:25 P.M. the DON stated this facility was not a hospital or an emergency room and if someone needed to be sent out they should be sent out. A policy for monitoring residents was requested but not provided prior to exit. Record review of the facility abuse and neglect policy dated [DATE] did not address neglect of staff providing care but did reveal Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation cause by another person must report the abuse, neglect or exploitation. The facility administrator and DON were notified on ,[DATE]//2015 at 5:16 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ On [DATE] at 6pm the DON started vital sign and Oxygen Concentration check on every resident in the facility to ensure no conditions existed that would require Physician notification or emergency care. Results: No resident required Physician notification or emergency care. ( ) N.P. was in the facility at 9:20 pm on [DATE], N.P. was asked to review the findings and confirmed no need for interventions or recommendations. At 6 pm on [DATE], the Unit Manager/RN made rounds on each resident in the facility to identify any need for notification of the Physician. No conditions or concerns merited Physician notification or emergency care. The DON conducted patient rounds at 6:30 pm with no need for Physician notification or emergency care noted. Another round was conducted by the DON at 10:10 pm on [DATE] resulting in no negative findings. At 6:30 pm on [DATE] educational training by the DON was started for all nurses regarding timely notification of the Physician for changes in condition; rapid response to critical conditions or assessment findings; and documentation of negative findings and actions taken with subsequent notification of the Physician. The same educational training will be provided to the all nurses prior to assuming their position as charge nurse. At 7 pm on [DATE] the Unit Manager/RN started educational training to all nursing staff (Nurses, MA ' s and CNA ' s) regarding the INTERACT STOP AND WATCH Early Warning Tool for identifying a change while caring or observing a resident. The tool instructs the staff to circle the change and notify the nurse on the following concerns. No concerns were noted by nursing staff. Starting [DATE], the DON/Unit Manager/Designee will daily review the 24 hour reports and conduct patient care rounds to ensure the stability of each resident. PLAN OF REMOVAL MONITORING 1. Reviewed documentation dated [DATE] of the facility Director of Nurses rounds on each resident obtained vital signs and pulse oximetry levels. 2. Reviewed documentation dated [DATE] that all licensed and unlicensed nursing staff were inserviced on the Interact Stop and Watch Early Warning Tool 3. Reviewed documentation dated [DATE] Licensed Nursing Staff were educated on the Timely notification of the physician for changes in condition; rapid response to critical conditions or assessment findings and documentation of negative findings/actions taken with subsequent notification of the physician. 4. Interviews were conducted on [DATE] during two shifts (licensed nursing staff) by the surveyor with the following results: 100% of all licensed nursing staff on 6:00 A.M to 2:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician to return call and how to respond if there was no return call. 100% of all unlicensed nursing staff on 6:00 A.M. to 2:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. One of three licensed nursing staff on 2:00 P.M. to 10:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician return call and how to respond if there was no return call. Three of nine unlicensed nursing staff 2:00 P.M. to 10:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. Twenty two nursing staff between two shifts was interviewed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure residents who were on the secured unit who were assessed with [REDACTED]. Facility roster revealed the census on hall 200 the secured unit was 13 residents

Based on record review and interview, the facility failed to implement their written policies and procedures that prohibit neglect for one of eight resident's on one of four halls (Hall 200 the secured unit) reviewed for neglect (CR #1) when the facility staff did not ensure CR #1's, who had a compromised respiratory status, oxygen administration and saturation (level of oxygen saturation in the blood) was monitored. The facility failed to monitor CR #1 ' s oxygen use prior to being discovered by a family member in respiratory distress with cyanotic fingers and lips. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure residents who were on the secured unit who were assessed with [REDACTED]. This failure affected one resident who was transferred in respiratory distress to the hospital, and placed 13 residents at risk of neglect, and delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 7 Record review of the facility abuse and neglect policy dated [DATE] did not address neglect of staff providing care but did reveal Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation cause by another person must report the abuse, neglect or exploitation. CR #1 ' s Record review of CR #1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE], readmitted to the facility on [DATE] on hospice and died on [DATE]. CR #1 had the following diagnoses; senile delusion, anxiety, muscle weakness, abnormal gait, history of falls, constipation, chest pain, hypertension, wheezing and [MEDICAL CONDITION]. Record review of CR #1's nurse's notes dated May through [DATE] revealed no complaints or changes in resident's condition documented. Record review of CR #1 ' s telephone physician's order [REDACTED].continuous oxygen ,[DATE] liters as needed titrate oxygen as needed less than (<) 92% indication were [MEDICAL CONDITION] and shortness of breath (SOB). Record review of CR #1 ' s care plan dated [DATE] revealed the problem .Has oxygen and nebulizer treatments due to SOB .approaches: #4 .check resident frequently to ensure oxygen was in use as needed . Record review of CR #1 ' s MDS dated [DATE] revealed the resident ' s BIMS was 2 which indicated her cognition was severely impaired. Continued review revealed the resident ' s ambulation required limited assistance of one staff. The MDS revealed the resident did not have behaviors of resisting care required to achieve goals for health and wellbeing; also it did not identify shortness of breath or the use of oxygen within the last 14 days. Record review of the chest radiology report dated [DATE] revealed .Impression .Large focal patchy infiltration in the right upper lobe, likely a large mass versus lobar pneumonia . Record review of CR #1 ' s nurse ' s notes dated [DATE] to [DATE] revealed oxygen saturation was monitored on [DATE] without oxygen and it was 97%. On [DATE] at 2:00 P.M. CR #1 ' s oxygen saturation was 94%. Record review of CR #1 ' s treatment record dated [DATE] revealed the resident ' s oxygen saturation was checked on the following dates with the following results: [DATE] at 9:00 A.M. result 87 % oxygen 2 liters. [DATE] at 9:20 A.M. oxygen saturation 88%-94% fluctuating oxygen 2 liters. [DATE] at 9:30 A.M oxygen saturation 89% connected 3 liters. Review of CR #1's medical record revealed there was no consistent area where oxygen saturation was documented nor if the oxygen saturation was monitored more then one time a day after the physician ordered oxygen to be administered if oxygen saturation below 92% on [DATE]. Record review of the chest radiology report dated [DATE] revealed comparison to [DATE] .Large consolidation in the right upper lobe is worsening .could be pneumonia or enlarged mass . Record review of CR #1's care plan revealed no changes in resident's care after x-ray results were received. Record review of CR #1 ' s nurse ' s notes dated [DATE] at 11:40 A.M. revealed .called to the room by the resident ' s (family member) to assess his concerns over resident ' s labored breathing. Resident noted attempting to sit up and moving constantly. Stating she could not breath. Oxygen was in place respirations labored and rapid oxygen saturation 70%, skin pale with extremities cyanotic Blood Pressure ,[DATE]; pulse 97. (Family member) requested resident be transferred to the emergency room via Emergency Medical Services (EMS) at this time. Called and left a message for NP. Assisted the resident to breathe deeply and raised the head of the bed. EMS requested by the (family member) and arrived at facility. Resident was placed on an oxygen mask . The U.S. National Library of Medicine, updated [DATE], defined cyanosis as a bluish color to the skin or mucus membranes that is usually due to a lack of oxygen in the blood Further record review revealed the next entry in CR #1 ' s nurse ' s notes dated [DATE] at 9:00 A.M. (late entry) Resident awake and alert . vital signs B/P ,[DATE], pulse 89, respirations 20, temperature 98.9 in bed head of the bed elevated 45 degrees, oxygen connected at 2 liters per doctors order, pulled out her Intravenous . continue to monitor behavior and for SOB .oxygen saturation 89% prior to oxygen now 94% monitor closely . Record review of the Patient Care Report from City of Katy EMS dated [DATE] revealed .the EMS arrived at the resident bedside at 11:59 A.M. the level of care was advanced life support, condition was urgent required immediate care ., breathing labored and mechanically assisted by [MEDICAL CONDITION] (continuous positive airway pressure machine); at 12:00 the resident ' s blood pressure was ,[DATE] heart rate ,[DATE], respirations 30 oxygen saturation 67% .indications for [MEDICAL CONDITION] was Severe Respiratory Distress Oxygen saturation at 12:05 P.M. was 70%, at 12:10 P.M. 58% and at 12:15 P.M. 84% . Continued review revealed the EMS narrative read .arrived found [AGE] year old female in bed seems to be in severe respiratory distress. ( family member) by her side and stated she had gotten progressively sicker in the past couple of days, resident extremely tired and cannot breathe, speaks in three (3 ) word sentences and has to pause for a breath . Record review of the facility complaint/grievance report dated [DATE] revealed .(family member) stated he came in at 11:30 A.M. and (resident)was in respiratory distress and did not have her oxygen on . Continued review of the facility complaint in the investigation section revealed interviews with two aides stated the resident CR#1 would remove the oxygen mask when she wanted to. Interview on [DATE] at 10:10 A.M. EMS #1 stated when he arrived CR #1 was in severe respiratory distress and she needed assistance to breath. Interview on [DATE] at 5:07 P.M. LVN #3 stated she was not the resident ' s nurse. She stated she did not know where the resident ' s nurse was perhaps at lunch. The staff said the family member had questions about his mom. She was the closest nurse around so she went to the room around 11:40 A.M. She stated when she arrived in the room the resident was in severe respiratory distress. The resident had stated at that time to the nurse she could not get enough air. The LVN stated she left the family member in the room to get her equipment to get vital signs on the resident and she put a page in for the doctor. The resident was sitting in high fowler ' s position ( head of the bed elevated to sitting up straight) with her oxygen on. LVN #3 stated the family member wanted 911 called. The LVN stated she needed to call the NP, assess the resident and get her vital signs. LVN #3 stated she knew she needed more help in the room so she poked her head in the hall and got the weekend supervisor. As the interview continued she stated by that time the family member had called 911. The family member stated he could get them there faster. The nurse stated the family member worked with the local EMS services. Interview on [DATE] at 10:44 A.M. CR #1 ' s family member and Responsible Party (RP) stated he arrived at the facility at approximately 11:30 A.M. on [DATE]. He found the resident in the tripod position He continued and stated his problem was what he found when he arrived at the facility that morning and saw the resident. Not because the resident had pneumonia but the acute state she was in when he arrived. The pneumonia did not suddenly come on that morning like a [MEDICAL CONDITION] embolism (PE) would have. He stated the resident did not have her oxygen on when he arrived. He stated he put it on her. She could not breathe so he helped her to sit back with the head of the bed up. He looked out in to the hall and found some staff. He asked them to get the nurse to come in. The nurse came in and saw right away the resident was in distress. The nurse began to get vital signs. He continued and stated he said for her to call 911 she said she would have to call the physician to get approval. He stated he told her he would have to override that and he called 911. The medical dictionary website defined the tripod position as a position adopted by a patient with extreme respiratory distress, who sits upright and leans forward, resting his or her hands on her knees. The U.S. National Library of Medicine updated [DATE] defined [MEDICAL CONDITION] embolism as blood clots in the lung. Interview on [DATE] at 1:00 P.M. LVN #2 stated she was working as a medication aide the day CR #1 went to the hospital. She stated she mainly just gave her medications and really did not notice any of the nursing issues. She did remember CR #1 took her medications fine. The resident was not short of breath nor did she notice any discoloration. LVN #2 stated this was at approximately 9:15 A.M. to 9:30 A.M. on [DATE]. She stated she did not see CR #1 again before she was transferred to the hospital. As the interview continued she stated staff was to always get an order to transfer out residents even in an emergency situation. Interview on [DATE] at 1:11 P.M. CNA #1 stated she cared for CR #1 and she gave her a shower the day the resident went to the hospital. CNA #1 stated she showered the resident at approximately 9:00 A.M. She stated the resident looked alright and she did not notice any changes in her skin color. The nurse fed her breakfast and she hardly ate anything that morning. After the shower the CNA stated she took her back to bed. She stated the resident did not have any oxygen on when she took her to the shower and she did not remember who put the oxygen on her after the shower. She stated maybe it was the nurse, but she was not sure. CNA #1 stated she saw the resident walking to the bathroom around 10:30 AM and the resident did not have her oxygen on. She stated that was the last time she saw her was when she was going to the bathroom by herself. CNA #1 did not state any specific instructions relayed to her by the nurse concerning monitoring the resident. Interview on [DATE] at 3:00 P.M. RN #1 stated she was called into the room for CR #1 by LVN #3 (around 11:40 A.M.) RN #1 stated the family member told her the resident was cyanotic. She stated when she arrived the resident ' s oxygen saturation was ,[DATE]% and EMS arrived. Interview on [DATE] at 3:18 P.M. LVN #4 stated she was CR #1's nurse and she checked on her in the morning. The resident ' s appetite was poor that morning. The resident had needed to be fed over the past week. LVN#4 stated CR #1 had been declining over the past ,[DATE] days with a decrease appetite and increased fatigue ever since the chest X-Ray . LVN#4 stated she saw the resident before the shower and CR #1 was not cyanotic. She stated she did not see CR #1 again before she was transferred to the hospital and she was not aware of the family member coming in. She stated the resident needed to be watch closely. Interview on [DATE] at 4:00 P.M. LVN #5 stated she arrived in the resident ' s room just before EMS arrived. She stated RN #1 and LVN #3 were in the room along with the family member. LVN#5 stated the resident had her oxygen on. Interview on [DATE] at 4:03 P.M. the DON stated everything happened very quickly with CR #1. She stated the family member said he would call 911 because he could get them faster. She stated CR #1 was good and they did everything they could for her. Interview on [DATE] at 4:38 P.M. LVN #4 stated she saw CR #1 at approximately 9:30 A.M. - 9:45 A.M. on [DATE] then she went to another hall for about 1 ,[DATE] - 2 hours. She stated one nurse works two halls and the CNA ' s watch the resident ' s when the nurse was not on that particular hall. Interview on [DATE] at 5:00 P.M. the DON stated if a change was seen in the resident or if the resident was in distress she was not real sure of the policy. She stated she would expect an ambulance called first. The DON stated she was pretty sure the family member offered to call the EMS because he was the fire chief and could get them here faster. Interview on [DATE] at 3:25 P.M. the DON stated this facility was not a hospital or an emergency room and if someone needed to be sent out they should be sent out. A policy for monitoring residents was requested but not provided prior to exit. The facility administrator and DON were notified on ,[DATE]//2015 at 5:16 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ On [DATE] at 6pm the DON started vital sign and Oxygen Concentration check on every resident in the facility to ensure no conditions existed that would require Physician notification or emergency care. Results: No resident required Physician notification or emergency care. ( ) N.P. was in the facility at 9:20 pm on [DATE], N.P. was asked to review the findings and confirmed no need for interventions or recommendations. At 6 pm on [DATE], the Unit Manager/RN made rounds on each resident in the facility to identify any need for notification of the Physician. No conditions or concerns merited Physician notification or emergency care. The DON conducted patient rounds at 6:30 pm with no need for Physician notification or emergency care noted. Another round was conducted by the DON at 10:10 pm on [DATE] resulting in no negative findings. At 6:30 pm on [DATE] educational training by the DON was started for all nurses regarding timely notification of the Physician for changes in condition; rapid response to critical conditions or assessment findings; and documentation of negative findings and actions taken with subsequent notification of the Physician. The same educational training will be provided to the all nurses prior to assuming their position as charge nurse. At 7 pm on [DATE] the Unit Manager/RN started educational training to all nursing staff (Nurses, MA ' s and CNA ' s) regarding the INTERACT STOP AND WATCH Early Warning Tool for identifying a change while caring or observing a resident. The tool instructs the staff to circle the change and notify the nurse on the following concerns. No concerns were noted by nursing staff. Starting [DATE], the DON/Unit Manager/Designee will daily review the 24 hour reports and conduct patient care rounds to ensure the stability of each resident. PLAN OF REMOVAL MONITORING 1. Reviewed documentation dated [DATE] of the facility Director of Nurses rounds on each resident obtained vital signs and pulse oximetry levels. 2. Reviewed documentation dated [DATE] that all licensed and unlicensed nursing staff were inserviced on the Interact Stop and Watch Early Warning Tool 3. Reviewed documentation dated [DATE] Licensed Nursing Staff were educated on the Timely notification of the physician for changes in condition; rapid response to critical conditions or assessment findings and documentation of negative findings/actions taken with subsequent notification of the physician. 4. Interviews were conducted on [DATE] during two shifts (licensed nursing staff) by the surveyor with the following results: 100% of all licensed nursing staff on 6:00 A.M to 2:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician to return call and how to respond if there was no return call. 100% of all unlicensed nursing staff on 6:00 A.M. to 2:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. One of three licensed nursing staff on 2:00 P.M. to 10:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician return call and how to respond if there was no return call. Three of nine unlicensed nursing staff 2:00 P.M. to 10:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. Twenty two nursing staff between two shifts was interviewed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure residents who were on the secured unit who were assessed with [REDACTED]. Facility roster revealed the census on hall 200 the secured unit was 13 residents

Based on interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the assessment for one of 8 residents (CR #1) reviewed for care. The facility failed to monitor CR #1 ' s oxygen use prior to being discovered by a family member in respiratory distress with cyanotic fingers and lips. CR #1 ' s physician was not consulted when the resident ' s blood pressure medications where held due to low blood pressure eight times over a two month period (July and [DATE]). CR # 1 's physician was not promptly consulted of her abnormal Complete Blood Count (CBC) results. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure residents who were on the secured unit who were assessed with [REDACTED]. This failure affected one resident who was transferred in respiratory distress to the hospital, and placed 13 residents at risk of neglect, and delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 7 CR #1 ' s Record review of CR #1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE], readmitted to the facility on [DATE] on hospice and expired on [DATE]. CR #1 had the following diagnoses; senile delusion, anxiety, muscle weakness, abnormal gait, history of falls, constipation, chest pain, hypertension, wheezing and [MEDICAL CONDITION]. Record review of CR #1 ' s MDS dated [DATE] revealed the resident ' s BIMS was 2 which indicated her cognition was severely impaired. Continued review revealed the resident ' s ambulation required limited assistance of one staff. The MDS revealed the resident did not have behaviors of resisting care required to achieve goals for health and wellbeing;also did not identify shortness of breath or the use of oxygen while a resident within the last 14 days. Record review of CR #1 ' s telephone physician's order [REDACTED].continuous oxygen ,[DATE] liters as needed titrate oxygen as needed less than (<) 92% indication were [MEDICAL CONDITION] and shortness of breath (SOB). Record review of CR #1 ' s care plan dated [DATE] revealed the problem .Has oxygen and nebulizer treatments due to SOB .approaches: #4 .check resident frequently to ensure oxygen was in use as needed . Record review of the chest radiology report dated [DATE] revealed .Impression .Large focal patchy infiltration in the right upper lobe, likely a large mass versus lobar pneumonia . Record review of CR #1 ' s nurse ' s notes dated [DATE] to [DATE] revealed oxygen saturation was monitored on [DATE] without oxygen and it was 97%. On [DATE] at 2:00 P.M. CR #1 ' s oxygen saturation was 94%. Record review of the chest radiology report dated [DATE] revealed comparison to [DATE] .Large consolidation in the right upper lobe is worsening .could be pneumonia or enlarged mass . Record review of CR #1 ' s treatment record dated [DATE] revealed the resident ' s oxygen saturation was checked on the following dates with the following results: [DATE] at 9:00 A.M. result 87 % oxygen 2 liters. [DATE] at 9:20 A.M. oxygen saturation 88%-94% fluctuating oxygen 2 liters. [DATE] at 9:30 A.M oxygen saturation 89% connected 3 liters. Record review of CR #1 ' s nurse ' s notes dated [DATE] at 11:40 A.M. revealed .called to the room by the resident ' s (family member) to assess his concerns over resident ' s labored breathing. Resident noted attempting to sit up and moving constantly. Stating she could not breath. Oxygen was in place respirations labored and rapid oxygen saturation 70%, skin pale with extremities cyanotic Blood Pressure ,[DATE]; pulse 97. (Family member) requested resident be transferred to the emergency room via Emergency Medical Services (EMS) at this time. Called and left a message for NP. Assisted the resident to breathe deeply and raised the head of the bed. EMS requested by the (family member) and arrived at facility. Resident was placed on an oxygen mask . The U.S. National Library of Medicine, updated [DATE], defined cyanosis as a bluish color to the skin or mucus membranes that is usually due to a lack of oxygen in the blood. Further record review revealed the next entry in CR #1 ' s nurse ' s notes dated [DATE] at 9:00 A.M. (late entry) Resident awake and alert . vital signs B/P ,[DATE], pulse 89, respirations 20, temperature 98.9 in bed head of the bed elevated 45 degrees, oxygen connected at 2 liters per doctors order, pulled out her Intravenous . continue to monitor behavior and for SOB .oxygen saturation 89% prior to oxygen now 94% monitor closely . Record review of the Patient Care Report from City of Katy EMS dated [DATE] revealed .the EMS arrived at the resident bedside at 11:59 A.M. the level of care was advanced life support, condition was urgent required immediate care ., breathing labored and mechanically assisted by [MEDICAL CONDITION] (continuous positive airway pressure machine); at 12:00 the resident ' s blood pressure was ,[DATE] heart rate ,[DATE], respirations 30 oxygen saturation 67% .indications for [MEDICAL CONDITION] was Severe Respiratory Distress Oxygen saturation at 12:05 P.M. was 70%, at 12:10 P.M. 58% and at 12:15 P.M. 84% . Continued review revealed the EMS narrative read .arrived found [AGE] year old female in bed seems to be in severe respiratory distress. ( family member) by her side and stated she had gotten progressively sicker in the past couple of days, resident extremely tired and cannot breathe, speaks in three (3 ) word sentences and has to pause for a breath . Record review of the facility complaint/grievance report dated [DATE] revealed .(family member) stated he came in at 11:30 A.M. and (resident)was in respiratory distress and did not have her oxygen on . Continued review of the facility complaint investigation revealed from the Aides unnamed .Oxygen ? - she takes it off . Interview on [DATE] at 10:10 A.M. EMS #1 stated when he arrived CR #1 was in severe respiratory distress and she needed assistance to breath. Interview on [DATE] at 5:07 P.M. LVN #3 stated she was not the resident ' s nurse. She stated she did not know where the resident ' s nurse was perhaps at lunch. The staff said the family member had questions about his mom. She was the closest nurse around so she went to the room. She stated when she arrived in the room the resident was in severe respiratory distress. The resident had stated at that time to the nurse she could not get enough air. The LVN stated she left the family member in the room to get her equipment to get vital signs on the resident and she put a page in for the doctor. The resident was sitting in high fowler ' s position ( head of the bed elevated to sitting up straight) with her oxygen on. LVN #3 stated the family member wanted 911 called. The LVN stated she needed to call the NP, assess the resident and get her vital signs. LVN #3 stated she knew she needed more help in the room so she poked her head in the hall and got the weekend supervisor. As the interview continued she stated by that time the family member had called 911. The family member stated he could get them there faster. The nurse stated the family member worked with the local EMS services. Interview on [DATE] at 10:44 A.M. CR #1 ' s family member and Responsible Party (RP) stated he arrived at the facility at approximately 11:30 A.M. on [DATE]. He found the resident in the tripod position He continued and stated his problem was what he found when he arrived at the facility that morning and saw the resident. Not because the resident had pneumonia but the acute state she was in when he arrived. The pneumonia did not suddenly come on that morning like a [MEDICAL CONDITION] embolism (PE) would have. He stated the resident did not have her oxygen on when he arrived. He stated he put it on her. She could not breathe so he helped her to sit back with the head of the bed up. He looked out in to the hall and found some staff. He asked them to get the nurse to come in. The nurse came in and saw right away the resident was in distress. The nurse began to get vital signs. He continued and stated he said for her to call 911 she said she would have to call the physician to get approval. He stated he told her he would have to override that and he called 911. The medical dictionary website defined the tripod position as a position adopted by a patient with extreme respiratory distress, who sits upright and leans forward, resting his or her hands on her knees. The U.S. National Library of Medicine updated [DATE] defined [MEDICAL CONDITION] embolism as blood clots in the lung. Interview on [DATE] at 1:00 P.M. LVN #2 stated she was working as a medication aide the day CR #1 went to the hospital. She stated she mainly just gave her medications and really did not notice any of the nursing issues. She did remember CR #1 took her medications fine. The resident was not short of breath nor did she notice any discoloration. LVN #2 stated this was at approximately 9:15 A.M. to 9:30 A.M. on [DATE]. She stated she did not see CR #1 again before she was transferred to the hospital. As the interview continued she stated staff was to always get an order to transfer out residents even in an emergency situation. Interview on [DATE] at 1:11 P.M. CNA #1 stated she cared for CR #1 and she gave her a shower the day the resident went to the hospital. CNA #1 stated she showered the resident at approximately 9:00 A.M. She stated the resident looked alright and she did not notice any changes in her color. The nurse fed her breakfast and she hardly ate anything that morning. After the shower the CNA stated she took her back to bed. She stated the resident did not have any oxygen on in the shower and she did not remember who put the oxygen on her after the shower. She stated maybe it was the nurse, but she was not sure. CNA #1 stated the resident had her oxygen off and was in the bathroom at approximately 10:30 A.M. She stated she did not see the resident again. Interview on [DATE] at 3:00 P.M. RN #1 stated she was called into the room for CR #1 . RN #1 stated the family member told her the resident was cyanotic. She stated when she arrived the resident ' s oxygen saturation was ,[DATE]% and EMS arrived. Interview on [DATE] at 3:18 P.M. LVN #4 stated she was CR #1's nurse and she checked on her in the morning. The resident ' s appetite was poor that morning. The resident had needed to be fed over the past week. LVN#4 stated CR #1 had been declining over the past ,[DATE] days with a decrease appetite and increased fatigue ever since the chest X-Ray . LVN #4 stated she saw the resident before the shower and CR #1 was not cyanotic. She stated she did not see CR #1 again before she was transferred to the hospital and she was not aware of the family member coming in. She stated the resident needed to be watch closely. Interview on [DATE] at 4:00 P.M. LVN #5 stated she arrived in the resident ' s room just before EMS arrived. She stated RN #1 and LVN #3 were in the room along with the family member. LVN#5 stated the resident had her oxygen on. Interview on [DATE] at 4:03 P.M. the DON stated everything happened very quickly with CR #1. She stated the family member said he would call 911 because he could get them faster. She stated CR #1 was good and they did everything they could for her. Interview on [DATE] at 4:38 P.M. LVN #4 stated she saw CR #1 at approximately 9:30 A.M. - 9:45 A.M. on [DATE] then she went to another hall for about 1 ,[DATE] - 2 hours. She stated one nurse works two halls and the CNA ' s watch the resident ' s when the nurse was not on that particular hall. Interview on [DATE] at 5:00 P.M. the DON stated if a change was seen in the resident or if the resident was in distress she was not real sure of the policy. She stated she would expect an ambulance called first. The DON stated she was pretty sure the family member offered to call the EMS because he was the fire chief and could get them here faster. Interview on [DATE] at 3:25 P.M. the DON stated this facility was not a hospital or an emergency room and if someone needed to be sent out they should be sent out. Consulting physician concerning holding blood pressure medications: [REDACTED] Record review of CR #1' s consolidated physician's order [REDACTED].< 110 , Diastolic Blood Pressure (DBP) < 60 and [MEDICATION NAME] 25 mg every 12 ours hold for SBP < 110 or heart rate < 60. Record review of CR #1' s Medication Administration Record [REDACTED] [DATE] blood pressure (B/P) ,[DATE] nurse notified. [DATE] BP ,[DATE] nurse notified. Record review of CR #1' s MAR indicated [REDACTED]. Continued review of the back of the MAR indicated [REDACTED] [DATE] at 9:00 A.M. B/P ,[DATE], nurse notified. [DATE] 9:00 A.M. B/P ,[DATE] nurse notified. [DATE] 9:00 P.M. B/P ,[DATE]; B/P rechecked ,[DATE]. [DATE] 9:00 P.M. ,[DATE]. [DATE] 9:00 P.M. B/P ,[DATE] nurse notified. Record review of CR #1' s nurse ' s notes dated [DATE] revealed [MEDICATION NAME] held due to low B/P ,[DATE] and ,[DATE] pulse 97 Attempted to call NP several times no answer. RP aware of low B/P . Record review of CR #1' s MAR indicated [REDACTED] [DATE] at 9:00 A.M. B/P ,[DATE] nurse notified. [DATE] at 9:00 A.M. B/P ,[DATE] nurse notified. [DATE] at 9:00 A.M. B/P ,[DATE] nurse notified. Record review of CR #1' s MAR indicated [REDACTED] [DATE] at 9:00 A.M. B/P ,[DATE] , nurse notified. [DATE] at 9:00 A.M. B/P ,[DATE] initialed and circled to indicate the medication not given. [DATE] at 9:00 P.M. B/P ,[DATE] initialed and circled to indicate the medication not given. [DATE] at 9:00 A.M. B/P ,[DATE] initialed and circled to indicate the medication not given. Record review of CR #1' s pulse rate at 9:00 A.M. revealed: [DATE] was 113. [DATE] was 102. [DATE] was 117. Record review of CR #1' s nurse ' s notes revealed no documentation the physician was notified the blood pressure medications were being held due to low blood pressure on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Continued review of CR #1's physician's order [REDACTED]. Interview on [DATE] at 1:00 P.M. LVN#2 stated the physician should have been notified if the blood pressures were too low to administer the medications. Reporting CR #1's laboratory results to the physician: Record review of CR # 1' s CBC results dated [DATE] revealed the resident ' s white blood count was 24 thousand (24,000) (Reference range 3XXX,[DATE].1 thousand). Continued review of the laboratory result revealed it was initialed as seen by the physician/NP on [DATE]. Record review of CR # 1's physician's progress notes dated [DATE] revealed chief Complaint/ History of Present Illness .follow up pneumonia versus mass, temperature slightly elevated, dry cough, not eating lab results reviewed . Record review of CR #1's physician's orders [REDACTED]. Repeat chest xray. CT scan [DIAGNOSES REDACTED]. Tylenol 650 milligrams by mouth every 6 hours as needed for elevated temperature. Interview on [DATE] at 1:00 P.M. LVN #2 stated a white blood count of 24,000 should have been called in to the physician. Interview on [DATE] at 1:30 P.M. LVN #1 stated the physician should have been notified immediate for an abnormal lab result like a high white blood count. Interview on [DATE] at 3:25 P.M. the DON stated she started to audit the labs and she noticed a lot of duplicated results. No policy for laboratory services or notifying the physician was provided prior to exit. A policy for monitoring residents was requested but not provided prior to exit. Record review of the facility abuse and neglect policy dated [DATE] did not address neglect of a resident. The facility administrator and DON were notified on ,[DATE]//2015 at 5:16 P.M. that an Immediate Jeopardy situation had been identified due to the above failures. Plan of Removal of the IJ On [DATE] at 6pm the DON started vital sign and Oxygen Concentration check on every resident in the facility to ensure no conditions existed that would require Physician notification or emergency care. Results: No resident required Physician notification or emergency care. ( ) N.P. was in the facility at 9:20 pm on [DATE], N.P. was asked to review the findings and confirmed no need for interventions or recommendations. At 6 pm on [DATE], the Unit Manager/RN made rounds on each resident in the facility to identify any need for notification of the Physician. No conditions or concerns merited Physician notification or emergency care. The DON conducted patient rounds at 6:30 pm with no need for Physician notification or emergency care noted. Another round was conducted by the DON at 10:10 pm on [DATE] resulting in no negative findings. At 6:30 pm on [DATE] educational training by the DON was started for all nurses regarding timely notification of the Physician for changes in condition; rapid response to critical conditions or assessment findings; and documentation of negative findings and actions taken with subsequent notification of the Physician. The same educational training will be provided to the all nurses prior to assuming their position as charge nurse. At 7 pm on [DATE] the Unit Manager/RN started educational training to all nursing staff (Nurses, MA ' s and CNA ' s) regarding the INTERACT STOP AND WATCH Early Warning Tool for identifying a change while caring or observing a resident. The tool instructs the staff to circle the change and notify the nurse on the following concerns. No concerns were noted by nursing staff. Starting [DATE], the DON/Unit Manager/Designee will daily review the 24 hour reports and conduct patient care rounds to ensure the stability of each resident. PLAN OF REMOVAL MONITORING 1. Reviewed documentation dated [DATE] of the facility Director of Nurses rounds on each resident obtained vital signs and pulse oximetry levels. 2. Reviewed documentation dated [DATE] that all licensed and unlicensed nursing staff were inserviced on the Interact Stop and Watch Early Warning Tool 3. Reviewed documentation dated [DATE] Licensed Nursing Staff were educated on the Timely notification of the physician for changes in condition; rapid response to critical conditions or assessment findings and documentation of negative findings/actions taken with subsequent notification of the physician. 4. Interviews were conducted on [DATE] during two shifts (licensed nursing staff) by the surveyor with the following results: 100% of all licensed nursing staff on 6:00 A.M to 2:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician to return call and how to respond if there was no return call. 100% of all unlicensed nursing staff on 6:00 A.M. to 2:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. One of three licensed nursing staff on 2:00 P.M. to 10:00 P.M. shift identified when to call 911, the Stop and Watch Early Warning Tool, how long to wait for the physician return call and how to respond if there was no return call. Three of nine unlicensed nursing staff 2:00 P.M. to 10:00 P.M. identified what resident changes to report to the nurse and how to complete the Interact Stop and Watch Early Warning Tool , where to find the form and who to notify when one is completed. Twenty two nursing staff between two shifts was interviewed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at actual harm with a scope identified as isolated. The facility was continuing to monitor to ensure residents who were on the secured unit who were assessed with [REDACTED]. Facility roster revealed the census on hall 200 the secured unit was 13 residents

Based on record review and interview, the facility failed to implement their policies and procedures that prohibit neglect when the facility did not enforce the smoking and retention of non allowable items policies for one of five residents, (CR #1) reviewed for neglect. CR #1 ignited herself when smoking unsupervised and expired twelve hours later from her injuries. The facility failed to intervene and stop CR #1 from violating these policies when they saw her using Febreze and possessing smoking materials at non designated times. The facility failed to retrieve non allowable items and smoking material from CR #1 when they witnessed her violating the facility's policies. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility needed additional time to evaluate the effectiveness of their plan. This failure affected one resident by causing severe injuries, pain and death and placed four current residents who smoke at risk of serious injury and death from accidental hazards. Findings include: Incident # 4 Record review revealed that CR #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. She was life-flighted from the facility to a local emergency roiagnom on [DATE] and expired 12 hours later on [DATE] Record review of CR #1's quarterly MDS dated [DATE] revealed the resident had the behavior of [MEDICAL CONDITION] which fluctuated (comes and goes) and disorganized thinking which fluctuated. Record review of CR #1's care plans, updated on [DATE], revealed a problem of Resident Smokes. The goal documented was the resident would comply with the facility policy. Approaches listed revealed the charge nurse was to complete a safe smoking assessments quarterly. CR #1's care plan, updated [DATE], revealed a problem of a potential for impaired thought process, long and short term memory loss, secondary to Alzheimer Disease. Approaches included monitor resident for needs and assist as needed and follow consistent routine, explain reasons for nursing home routines. Record review of CR#1's safe smoking evaluations dated [DATE], [DATE], [DATE] [DATE] and [DATE] revealed the resident was alert and oriented and can consistently perform safe smoking techniques. Resident was able to communicate the risks associated with smoking. CR #1 was assessed as being able to light cigarette safely with a lighter, smoke the cigarette safely and was able to extinguish cigarette safely and completely. Continued review of the safe smoking evaluations revealed all nursing staff who had assessed the resident documented CR #1 could smoke independently and unsupervised in the designated smoking area. The evaluations also revealed the resident must request smoking materials from staff and that the resident had been informed of the smoking policies/procedures. The acknowledgment that the family/responsible party had been informed of the policies/procedures had been crossed out signifying they had not been informed. In the comment section of the form dated [DATE] it was documented RP(responsible party) and son aware of smoking habit of resident. Record review of the facility's Provider Investigation Report, dated, [DATE], revealed on [DATE], at 7:10 p.m., CR #1 was in a designated smoking area when a visitor passing by the facility saw the resident standing with flames coming from her clothing. The visitor immediately reported the observation to the charge nurse inside the facility. Upon staff observation, the resident was soaked with water from the sprinkler system and her clothing was burned. Her physician was at the building at the time of the incident and assessed her at that time as having suffered third [MEDICAL CONDITION] ,[DATE]% of her body from a clothing fire. The physician cut off the resident's clothing and rinsed debris from her body using the activated sprinkler system. The resident was life-flighted to a local hospital at 7:32 p.m. and died at 7:43 a.m. on [DATE]. The facility staff had reviewed the facility's camera video footage which revealed CR #1 did not request a cigarette or a lighter from a nurse immediately prior to the incident. The documentation revealed CR #1 was known to use a great deal of perfume and would spray her clothing with Febreze to eliminate any smoke odor because her daughter did not want her to smoke. A search of her room on [DATE] revealed a pack of cigarettes and a lighter in a pair of pants hanging on the back of a chair and more cigarettes in a small gold case in the top dresser drawer. Record review of CR #1's progress note dated [DATE] written by the Nurse Practitioner revealed .The fire alarm came on and we stood up to see where the fire was, a boy ran in front door to say a woman was outside and on fire. I left the nurse's station and as was walking toward the door, called 911. Immediately then asked the kids that reported the incident to pull the resident out of the water and nurse brought scissors to cut off clothing .patient was talking, alert and oriented X3 and called me by name .pain ,[DATE] .pt (patient) has a burn third degree on breast, abdomen, legs, hair approximately 85% .Assessment Burn involving 80 -89% of body surface with ,[DATE]% third degree . Record review of facility document, Investigation RE: CR #1, dated, [DATE], 11:00 p.m., revealed , .When interviewing staff, no one gave the resident cigarettes or a lighter. The Aides did report that the daughter did not want the resident to smoke, but the son and other family members were supplying cigarettes and mailing her packages with unknown contents . Record review of the facility's undated document, Smoking Times, revealed that it read in part, Smoking Times: 6:00 am, 10:00 am, 1:00 pm, 4:00 pm, 6:00 pm, Last smoke break no exceptions @ 10 pm. Residents are to receive only 2 cigarettes and lighter at each smoke break. Residents personal lighter must be returned to the nurses station at the end of each smoke break . Record review of CR#1's care plans dated [DATE] revealed there was no care plan to address the resident was not compliant with the facility's smoking policy, or that she hid smoking paraphernalia, that she received smoking supplies and other unallowables in the mail, or that she was known to spray her clothing with air freshener from an aerosol can. In an interview on [DATE] at 6:00 p.m., the facility's DON stated CR #1 had gone out alone the night before, [DATE], to smoke. She stated they (the facility) suspected the son was providing the resident with cigarettes and they had spoken to him about bringing her cigarettes. She stated families were given a list of allowable and unallowable items upon admission (Facility Do's & Do Not's). Record review of an undated facility document, entitled, Facility Do's & Do Not's, revealed, .Residents may not bring: (Any product labeled Keep Out Of Reach Of Children) .Any aerosol spray containers .Any container labeled with a Hazardous Warning .Anything that has alcohol content . In an interview on [DATE] at 6:14 p.m., the facility's Administrator stated the staff were aware that CR #1 sprayed herself with Febreze and perfume because she did not like to smell like smoke. The Administrator stated she kept those items in her rolling walker. During an interview on [DATE] at 6:25 P.M. the facility's Administrator stated the facility just became a smoking facility at the first of the year (2015). The facility was aware at that time that CR #1 was sneaking off and smoking with another resident and the facility feared they would hurt themselves so they changed the facility's policy from being a non smoking facility. She continued and stated the facility thought CR #1 would get cigarettes into the facility thru packages she received. In an interview on [DATE], at 1:50 p.m., the facility's QA Nurse and Nurse Supervisor stated they both smoked and would go out and smoke with the residents. They said they had observed CR #1 spray herself with Febreze and she kept the aerosol can in the basket seat of her rolling walker. They stated residents were not allowed to have Febreze in the building and when staff conducted room searches they would take the resident's Febreze. In continued interview, they stated CR #1 was not compliant with not having unallowables in her room and the staff had to do frequent room searches. Both stated they felt the son was bringing in some of the unallowable items. Continued interview the facility's QA Nurse and Nurse Supervisor stated the cigarettes of the residents had always been kept in the medication room and the charge nurse was the one who would distribute the two cigarettes and lighters to the residents at smoking times. The residents would return the lighters to the same charge nurse at the end of the cigarette break. They stated now the residents must be supervised by staff when they smoke. In an interview on [DATE] at 2:30 p.m., LVN A stated she would sometimes go out with CR #1 to evaluate her for smoking safety. She stated she observed the resident spray herself with Febreze ,[DATE] times although she was not supposed to have Febreze. Staff would do room searches and take the cans of Febreze from her room frequently. She stated she did not know if anyone had ever searched the resident's rolling walker. Record review of CR #1's safe smoking assessment dated [DATE] revealed LVN A had conducted the assessment. The assessment also revealed LVN A assessed CR #1 a safe smoker and she could smoke independently and unsupervised in the designated smoking area. In an interview on [DATE] at 3:00 p.m., CNA B stated CR #1 was not compliant to the facility's designated smoking times. She stated she did what she wanted to do. CNA B stated on the morning of the incident, [DATE], she observed the resident outside smoking on the porch while she was inside giving another resident a shower. She observed CR #1 spray her clothing with what she thought was perfume from a smaller bottle than a Febreze can. CNA B stated staff had previously taken cans of Febreze, cigarettes, and lighters from CR #1, but the resident would somehow get a new supply. CNA B said the residents were not supposed to have Febreze or perfumes because they were flammable. She stated all staff were to do room searches and remove unallowable items. In an interview on [DATE] at 4:00 p.m., the Administrator stated she doubted if any staff had ever searched CR #1's rolling walker for the Febreze because she always had it with her. When asked how staff were monitored to ensure effectiveness of facility's policies she stated compliance rounds were made. She stated rounds were made every one to two hours and all halls were monitored by cameras. She stated she would also question staff and observe them. She stated she was aware the resident went outside sometimes. She also stated she was aware the resident would spray herself with Febreze. In an interview on [DATE], at 2:00 p.m., the facility's DON stated she had observed CR #1 with Febreze in her rolling walker. She said that honestly, she should have taken the Febreze but never did. She never observed the resident spray herself but had heard that she did through the grapevine from other staff. She stated the staff did at least monthly and sometimes more often, resident room checks and would take the unallowable items. Record review of the facility's Smoking Procedures, not dated revealed the resident's cigarettes and lighter or other smoking materials must be kept at the nurse's station. Record review of the facility's Abuse Policy and Procedure revealed Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation cause by another person must report the abuse, neglect or exploitation. Record review of an Internet search of the U.S. Department of Health & Human Services' Household Products Database revealed that Febreze Air Aerosol Air Refresher had the following warning label on the back panel: Caution .Keep Out Of Reach Of Children The Flammability rating was 2 moderate (on a scale from 0 - 4 with 4 being severe) and it had an alcohol content of 3.0 - 7.0%. The handling precautions also read .Do not expose to heat or open flame or store at room temperatures above 120 F . The facility Administrator was notified on [DATE] at 3:47 p.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. Immediate Jeopardy Plan of Removal 1) On [DATE] at 4:05 pm Activity Director met with each resident and reviewed the list of the facility un-allowed items. All residents in the facility re-signed the acknowledgement of the facility Do's and Don'ts. 2) On [DATE] at 4:05 pm the Business Office Manager contacted family members and/or responsible parties to review the facility Do's and Don'ts and contacted them to pick up the unallowable items. 3) On [DATE] at 4:30 pm Maintenance started a room search, with the resident's permission, to remove all un-allowed items from each resident's possession. The unallowable items were marked, stored and placed in a safe place where the residents can use or the family members/responsible party can pick up the items. Items not allowed in resident's possession in their rooms or bathrooms are the following: Cigarettes, lighters or any smoking paraphernalia. microwaves cleaning supplies cooking equipment wax candles with wicks normal saline hydrogen peroxide cough drops anything that has alcohol content or container labeled with a Hazardous warning or keep out of reach of children hair dryers,curling irons, or other heat producing items; shampoo/hair conditioner (that states keep out of reach of children) Ointment/Medications Potpourri other than [MEDICATION NAME] any glass containers any aerosol spray cans safety razors extension cords hampers/laundry baskets that are not completely enclosed non-electric razors over the counter medications heating pads or electric blankets. Weekly, an assigned housekeeper will help each resident check and compare items to the Unallowable list ensuring continued compliance. 4) On [DATE] at 4:05 pm, RN in-serviced all staff that during their daily tasks, note any item that is on the non-allowable list or that places the resident at risk for harm or injury and immediately report to the Administrator. 5) On [DATE] at 4:15 pm, RN in-serviced all staff to report to the Administrator all behaviors that may pose a risk for harm or injury. 6) All staff were in serviced by the Administrator on [DATE] that no resident would be allowed to smoke unattended. Nurses were in-serviced that at anytime a smoking resident unstable or disoriented, a smoking apron would be given to the Ambassador and placed on the resident while smoking. 7) On [DATE], after the incident, the smoking policy was reviewed and revised to include an assigned smoking ambassador for each smoking time. The smoking policy times were modified per the resident's request and times/assignments are as follows: 6:30 am Laundry Ambassador 8:30 am Activity Ambassador 1:30 pm Activity Ambassador 6:30 pm Laundry Ambassador 8:30 pm Laundry Ambassador All smoking paraphernalia, cigarettes, lighters and/or tobacco will continue to be maintained in the Medication room where only the charge nurse has access to these items. The implemented change is that no resident can smoke unattended, the assigned smoking ambassador will obtain 2 cigarettes for each resident and a lighter from the charge nurse, which will remain in her possession until smoking time has finished, at which time the ambassador will return the cigarette lighter to the charge nurse. Times will be re-evaluated at resident's request. 8) On [DATE] at 4:00 pm a revised lists of unallowable items were posted at the nurses stations, in the ADL books, shower rooms and the shower assignment books. Monitoring of plan: Observation on [DATE] at 1:15 P.M. revealed a staff member and one resident in the designated smoking area. The resident had a lit cigarette and was visiting with the staff member. Staff member had a lighter in her hand. Staff stayed with resident while she smoked two cigarettes and then entered the facility with the staff members assistance. Record review of in-service dated [DATE] at 7:45 P.M. and continue to day shift on [DATE] revealed thirty staff members had been in-serviced on re-assessing existing residents who smoked and new smoking policy including where no residents can smoke unattended. Policy also covered the use of the apron on residents who appeared unstable or not oriented to surroundings. Record review of in-service [DATE] revealed 42 staff members had been trained on non-allowable personal items. What they should be observant of in resident rooms and who to report to if unallowable found in resident ' s rooms. Record review of in-service conducted [DATE] revealed 42 staff members were in-serviced on reporting change of conditions in resident ' s behaviors. Record review of new smoking policy for the facility revealed residents were not allowed to smoke unsupervised. Interview with two supervisors revealed all staff had been in-serviced on policy and that residents had also been informed. Both supervisors stated staff were educating families as they came in and also business office was calling each family to inform them of the allowable and unallowable items. On [DATE] reviewed the smoking assessments on three of the four still existing smokers and compared assessments with current MDS and care plan. The fourth resident who still smoked does so only when family were present. The facility does not supervise or have any smoking materials for this resident. On [DATE] observation tour was conducted on halls 400 and 300 revealed no unallowable products or items noted in resident rooms. Interviews with three CNA's who worked two different shifts and one housekeeping staff revealed they were all able to list items that were unallowable and what to do with the items if found. Observation on [DATE] of the secured unit revealed staff locked unallowable items in the shower room closet. Interviews with two staff members revealed they were able to verbalize unallowable items in resident rooms. Observation at nurse ' s station (centralized for all halls) revealed postings of smoking times with reminders to staff as to which department would provide the ambassador designated to be supervising the residents who smoked. The postings were on the outside of the desk on all sides and in the main hallway entering the facility. Observation of the nurse ' s station on [DATE] revealed a list of the unallowable products staff were to monitor resident's rooms for. Interviewed two residents on [DATE] on each hall except the secured unit, concerning items they were allowed and not allowed in their rooms. Residents were able to voice what items they would not be allowed in their rooms. All residents appeared to understand the reason and rationale behind why they were not to keep certain items in their rooms. Interviewed three residents on [DATE] - [DATE] who were documented as safe smokers concerning the new smoking policy. All acknowledge they were very much aware of the changes and though not happy about the changes would comply. Interviews conducted between [DATE] and [DATE] with 16 staff from all departments revealed staff were aware of the smoking policy and smoking times. They also acknowledged what item residents were allowed and not allowed and who the smoking ambassadors were. All staff interviewed relayed their responsibility of removing unallowable items from the resident's rooms, reporting the items to the charge nurse and securing the items for resident usage when asked. Observations conducted between [DATE] and [DATE] revealed nursing supervisors explaining the smoking policy changes and having the residents and their Responsible party/family sign the acknowledgment form. Smoking signs were posted and cigarettes were provided to the smoking ambassadors who then took them to the residents in the smoking area and remained with them while they were smoked. After monitoring the implementation of the plan and confirming the implementation of the new smoking policy, the IJ was removed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed . However the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility was continuing to monitor the plan to ensure compliance with all policies. According to the facility's roster, the census was 97. The facility staff reported there were four residents who smoked in the facility.

Based on record review and interview, the facility failed to implement their policies and procedures that prohibit neglect when the facility did not enforce the smoking and retention of non allowable items policies for one of five residents, (CR #1) reviewed for neglect. CR #1 ignited herself when smoking unsupervised and expired twelve hours later from her injuries. The facility failed to intervene and stop CR #1 from violating these policies when they saw her using Febreze and possessing smoking materials at non designated times. The facility failed to retrieve non allowable items and smoking material from CR #1 when they witnessed her violating the facility's policies. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility needed additional time to evaluate the effectiveness of their plan. This failure affected one resident by causing severe injuries, pain and death and placed four current residents who smoke at risk of serious injury and death from accidental hazards. Findings include: Incident # 4 Record review of the facility's Abuse Policy and Procedure revealed Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation cause by another person must report the abuse, neglect or exploitation. Record review revealed that CR #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. She was life-flighted from the facility to a local emergency roiagnom on [DATE] and expired 12 hours later on [DATE] Record review of CR #1's quarterly MDS dated [DATE] revealed the resident had the behavior of [MEDICAL CONDITION] which fluctuated (comes and goes) and disorganized thinking which fluctuated. Record review of CR #1's care plans, updated on [DATE], revealed a problem of Resident Smokes. The goal documented was the resident would comply with the facility policy. Approaches listed revealed the charge nurse was to complete a safe smoking assessments quarterly. CR #1's care plan, updated [DATE], revealed a problem of a potential for impaired thought process, long and short term memory loss, secondary to Alzheimer Disease. Approaches included monitor resident for needs and assist as needed and follow consistent routine, explain reasons for nursing home routines. Record review of CR#1's safe smoking evaluations dated [DATE], [DATE], [DATE] [DATE] and [DATE] revealed the resident was alert and oriented and can consistently perform safe smoking techniques. Resident was able to communicate the risks associated with smoking. CR #1 was assessed as being able to light cigarette safely with a lighter, smoke the cigarette safely and was able to extinguish cigarette safely and completely. Continued review of the safe smoking evaluations revealed all nursing staff who had assessed the resident documented CR #1 could smoke independently and unsupervised in the designated smoking area. The evaluations also revealed the resident must request smoking materials from staff and that the resident had been informed of the smoking policies/procedures. The acknowledgment that the family/responsible party had been informed of the policies/procedures had been crossed out signifying they had not been informed. In the comment section of the form dated [DATE] it was documented RP(responsible party) and son aware of smoking habit of resident. Record review of the facility's Provider Investigation Report, dated, [DATE], revealed on [DATE], at 7:10 p.m., CR #1 was in a designated smoking area when a visitor passing by the facility saw the resident standing with flames coming from her clothing. The visitor immediately reported the observation to the charge nurse inside the facility. Upon staff observation, the resident was soaked with water from the sprinkler system and her clothing was burned. Her physician was at the building at the time of the incident and assessed her at that time as having suffered third [MEDICAL CONDITION] ,[DATE]% of her body from a clothing fire. The physician cut off the resident's clothing and rinsed debris from her body using the activated sprinkler system. The resident was life-flighted to a local hospital at 7:32 p.m. and died at 7:43 a.m. on [DATE]. The facility staff had reviewed the facility's camera video footage which revealed CR #1 did not request a cigarette or a lighter from a nurse immediately prior to the incident. The documentation revealed CR #1 was known to use a great deal of perfume and would spray her clothing with Febreze to eliminate any smoke odor because her daughter did not want her to smoke. A search of her room on [DATE] revealed a pack of cigarettes and a lighter in a pair of pants hanging on the back of a chair and more cigarettes in a small gold case in the top dresser drawer. Record review of CR #1's progress note dated [DATE] written by the Nurse Practitioner revealed .The fire alarm came on and we stood up to see where the fire was, a boy ran in front door to say a woman was outside and on fire. I left the nurse's station and as was walking toward the door, called 911. Immediately then asked the kids that reported the incident to pull the resident out of the water and nurse brought scissors to cut off clothing .patient was talking, alert and oriented X3 and called me by name .pain ,[DATE] .pt (patient) has a burn third degree on breast, abdomen, legs, hair approximately 85% .Assessment Burn involving 80 -89% of body surface with ,[DATE]% third degree . Record review of facility document, Investigation RE: CR #1, dated, [DATE], 11:00 p.m., revealed , .When interviewing staff, no one gave the resident cigarettes or a lighter. The Aides did report that the daughter did not want the resident to smoke, but the son and other family members were supplying cigarettes and mailing her packages with unknown contents . Record review of the facility's undated document, Smoking Times, revealed that it read in part, Smoking Times: 6:00 am, 10:00 am, 1:00 pm, 4:00 pm, 6:00 pm, Last smoke break no exceptions @ 10 pm. Residents are to receive only 2 cigarettes and lighter at each smoke break. Residents personal lighter must be returned to the nurses station at the end of each smoke break . Record review of CR#1's care plans dated [DATE] revealed there was no care plan to address the resident was not compliant with the facility's smoking policy, or that she hid smoking paraphernalia, that she received smoking supplies and other unallowables in the mail, or that she was known to spray her clothing with air freshener from an aerosol can. In an interview on [DATE] at 6:00 p.m., the facility's DON stated CR #1 had gone out alone the night before, [DATE], to smoke. She stated they (the facility) suspected the son was providing the resident with cigarettes and they had spoken to him about bringing her cigarettes. She stated families were given a list of allowable and unallowable items upon admission (Facility Do's & Do Not's). Record review of an undated facility document, entitled, Facility Do's & Do Not's, revealed, .Residents may not bring: (Any product labeled Keep Out Of Reach Of Children) .Any aerosol spray containers .Any container labeled with a Hazardous Warning .Anything that has alcohol content . In an interview on [DATE] at 6:14 p.m., the facility's Administrator stated the staff were aware that CR #1 sprayed herself with Febreze and perfume because she did not like to smell like smoke. The Administrator stated she kept those items in her rolling walker. During an interview on [DATE] at 6:25 P.M. the facility's Administrator stated the facility just became a smoking facility at the first of the year (2015). The facility was aware at that time that CR #1 was sneaking off and smoking with another resident and the facility feared they would hurt themselves so they changed the facility's policy from being a non smoking facility. She continued and stated the facility thought CR #1 would get cigarettes into the facility thru packages she received. In an interview on [DATE], at 1:50 p.m., the facility's QA Nurse and Nurse Supervisor stated they both smoked and would go out and smoke with the residents. They said they had observed CR #1 spray herself with Febreze and she kept the aerosol can in the basket seat of her rolling walker. They stated residents were not allowed to have Febreze in the building and when staff conducted room searches they would take the resident's Febreze. In continued interview, they stated CR #1 was not compliant with not having unallowables in her room and the staff had to do frequent room searches. Both stated they felt the son was bringing in some of the unallowable items. Continued interview the facility's QA Nurse and Nurse Supervisor stated the cigarettes of the residents had always been kept in the medication room and the charge nurse was the one who would distribute the two cigarettes and lighters to the residents at smoking times. The residents would return the lighters to the same charge nurse at the end of the cigarette break. They stated now the residents must be supervised by staff when they smoke. In an interview on [DATE] at 2:30 p.m., LVN A stated she would sometimes go out with CR #1 to evaluate her for smoking safety. She stated she observed the resident spray herself with Febreze ,[DATE] times although she was not supposed to have Febreze. Staff would do room searches and take the cans of Febreze from her room frequently. She stated she did not know if anyone had ever searched the resident's rolling walker. Record review of CR #1's safe smoking assessment dated [DATE] revealed LVN A had conducted the assessment. The assessment also revealed LVN A assessed CR #1 a safe smoker and she could smoke independently and unsupervised in the designated smoking area. In an interview on [DATE] at 3:00 p.m., CNA B stated CR #1 was not compliant to the facility's designated smoking times. She stated she did what she wanted to do. CNA B stated on the morning of the incident, [DATE], she observed the resident outside smoking on the porch while she was inside giving another resident a shower. She observed CR #1 spray her clothing with what she thought was perfume from a smaller bottle than a Febreze can. CNA B stated staff had previously taken cans of Febreze, cigarettes, and lighters from CR #1, but the resident would somehow get a new supply. CNA B said the residents were not supposed to have Febreze or perfumes because they were flammable. She stated all staff were to do room searches and remove unallowable items. In an interview on [DATE] at 4:00 p.m., the Administrator stated she doubted if any staff had ever searched CR #1's rolling walker for the Febreze because she always had it with her. When asked how staff were monitored to ensure effectiveness of facility's policies she stated compliance rounds were made. She stated rounds were made every one to two hours and all halls were monitored by cameras. She stated she would also question staff and observe them. She stated she was aware the resident went outside sometimes. She also stated she was aware the resident would spray herself with Febreze. In an interview on [DATE], at 2:00 p.m., the facility's DON stated she had observed CR #1 with Febreze in her rolling walker. She said that honestly, she should have taken the Febreze but never did. She never observed the resident spray herself but had heard that she did through the grapevine from other staff. She stated the staff did at least monthly and sometimes more often, resident room checks and would take the unallowable items. Record review of the facility's Smoking Procedures, not dated revealed the resident's cigarettes and lighter or other smoking materials must be kept at the nurse's station. Record review of an Internet search of the U.S. Department of Health & Human Services' Household Products Database revealed that Febreze Air Aerosol Air Refresher had the following warning label on the back panel: Caution .Keep Out Of Reach Of Children The Flammability rating was 2 moderate (on a scale from 0 - 4 with 4 being severe) and it had an alcohol content of 3.0 - 7.0%. The handling precautions also read .Do not expose to heat or open flame or store at room temperatures above 120 F . The facility Administrator was notified on [DATE] at 3:47 p.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. Immediate Jeopardy Plan of Removal 1) On [DATE] at 4:05 pm Activity Director met with each resident and reviewed the list of the facility un-allowed items. All residents in the facility re-signed the acknowledgement of the facility Do's and Don'ts. 2) On [DATE] at 4:05 pm the Business Office Manager contacted family members and/or responsible parties to review the facility Do's and Don'ts and contacted them to pick up the unallowable items. 3) On [DATE] at 4:30 pm Maintenance started a room search, with the resident's permission, to remove all un-allowed items from each resident's possession. The unallowable items were marked, stored and placed in a safe place where the residents can use or the family members/responsible party can pick up the items. Items not allowed in resident's possession in their rooms or bathrooms are the following: Cigarettes, lighters or any smoking paraphernalia. microwaves cleaning supplies cooking equipment wax candles with wicks normal saline hydrogen peroxide cough drops anything that has alcohol content or container labeled with a Hazardous warning or keep out of reach of children hair dryers,curling irons, or other heat producing items; shampoo/hair conditioner (that states keep out of reach of children) Ointment/Medications Potpourri other than [MEDICATION NAME] any glass containers any aerosol spray cans safety razors extension cords hampers/laundry baskets that are not completely enclosed non-electric razors over the counter medications heating pads or electric blankets. Weekly, an assigned housekeeper will help each resident check and compare items to the Unallowable list ensuring continued compliance. 4) On [DATE] at 4:05 pm, RN in-serviced all staff that during their daily tasks, note any item that is on the non-allowable list or that places the resident at risk for harm or injury and immediately report to the Administrator. 5) On [DATE] at 4:15 pm, RN in-serviced all staff to report to the Administrator all behaviors that may pose a risk for harm or injury. 6) All staff were in serviced by the Administrator on [DATE] that no resident would be allowed to smoke unattended. Nurses were in-serviced that at anytime a smoking resident unstable or disoriented, a smoking apron would be given to the Ambassador and placed on the resident while smoking. 7) On [DATE], after the incident, the smoking policy was reviewed and revised to include an assigned smoking ambassador for each smoking time. The smoking policy times were modified per the resident's request and times/assignments are as follows: 6:30 am Laundry Ambassador 8:30 am Activity Ambassador 1:30 pm Activity Ambassador 6:30 pm Laundry Ambassador 8:30 pm Laundry Ambassador All smoking paraphernalia, cigarettes, lighters and/or tobacco will continue to be maintained in the Medication room where only the charge nurse has access to these items. The implemented change is that no resident can smoke unattended, the assigned smoking ambassador will obtain 2 cigarettes for each resident and a lighter from the charge nurse, which will remain in her possession until smoking time has finished, at which time the ambassador will return the cigarette lighter to the charge nurse. Times will be re-evaluated at resident's request. 8) On [DATE] at 4:00 pm a revised lists of unallowable items were posted at the nurses stations, in the ADL books, shower rooms and the shower assignment books. Monitoring of plan: Observation on [DATE] at 1:15 P.M. revealed a staff member and one resident in the designated smoking area. The resident had a lit cigarette and was visiting with the staff member. Staff member had a lighter in her hand. Staff stayed with resident while she smoked two cigarettes and then entered the facility with the staff members assistance. Record review of in-service dated [DATE] at 7:45 P.M. and continue to day shift on [DATE] revealed thirty staff members had been in-serviced on re-assessing existing residents who smoked and new smoking policy including where no residents can smoke unattended. Policy also covered the use of the apron on residents who appeared unstable or not oriented to surroundings. Record review of in-service [DATE] revealed 42 staff members had been trained on non-allowable personal items. What they should be observant of in resident rooms and who to report to if unallowable found in resident ' s rooms. Record review of in-service conducted [DATE] revealed 42 staff members were in-serviced on reporting change of conditions in resident ' s behaviors. Record review of new smoking policy for the facility revealed residents were not allowed to smoke unsupervised. Interview with two supervisors revealed all staff had been in-serviced on policy and that residents had also been informed. Both supervisors stated staff were educating families as they came in and also business office was calling each family to inform them of the allowable and unallowable items. On [DATE] reviewed the smoking assessments on three of the four still existing smokers and compared assessments with current MDS and care plan. The fourth resident who still smoked does so only when family were present. The facility does not supervise or have any smoking materials for this resident. On [DATE] observation tour was conducted on halls 400 and 300 revealed no unallowable products or items noted in resident rooms. Interviews with three CNA's who worked two different shifts and one housekeeping staff revealed they were all able to list items that were unallowable and what to do with the items if found. Observation on [DATE] of the secured unit revealed staff locked unallowable items in the shower room closet. Interviews with two staff members revealed they were able to verbalize unallowable items in resident rooms. Observation at nurse ' s station (centralized for all halls) revealed postings of smoking times with reminders to staff as to which department would provide the ambassador designated to be supervising the residents who smoked. The postings were on the outside of the desk on all sides and in the main hallway entering the facility. Observation of the nurse ' s station on [DATE] revealed a list of the unallowable products staff were to monitor resident's rooms for. Interviewed two residents on [DATE] on each hall except the secured unit, concerning items they were allowed and not allowed in their rooms. Residents were able to voice what items they would not be allowed in their rooms. All residents appeared to understand the reason and rationale behind why they were not to keep certain items in their rooms. Interviewed three residents on [DATE] - [DATE] who were documented as safe smokers concerning the new smoking policy. All acknowledge they were very much aware of the changes and though not happy about the changes would comply. Interviews conducted between [DATE] and [DATE] with 16 staff from all departments revealed staff were aware of the smoking policy and smoking times. They also acknowledged what item residents were allowed and not allowed and who the smoking ambassadors were. All staff interviewed relayed their responsibility of removing unallowable items from the resident's rooms, reporting the items to the charge nurse and securing the items for resident usage when asked. Observations conducted between [DATE] and [DATE] revealed nursing supervisors explaining the smoking policy changes and having the residents and their Responsible party/family sign the acknowledgment form. Smoking signs were posted and cigarettes were provided to the smoking ambassadors who then took them to the residents in the smoking area and remained with them while they were smoked. After monitoring the implementation of the plan and confirming the implementation of the new smoking policy, the IJ was removed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed . However the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility was continuing to monitor the plan to ensure compliance with all policies. According to the facility's roster, the census was 97. The facility staff reported there were four residents who smoked in the facility.

Based on record review and interview, the facility failed to ensure the environment remained as free of accident hazards as possible and residents received adequate supervision to prevent accidents for one of five residents (CR #1) reviewed for accidents. CR #1 ignited herself when smoking unsupervised and expired twelve hours later from her injuries. The facility failed to remove non allowable items such as Febreze and lighters from CR #1 when she was visualized using the items. The facility failed to supervise CR #1 when smoking after CR #1 had been witnessed not adhering to the facility's smoking policy by retaining lighters and cigarettes and smoking at other times then the facility's designated smoke times. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility was continuing to monitor to ensure policies concerning non allowables and smoking were being followed . This failure affected one resident by causing severe injuries, pain and death and placed four current residents who smoke at risk of serious injury and death from accidental hazards. Findings include: Incident # 4 Record review revealed that CR #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. She was life-flighted from the facility to a local emergency roiagnom on [DATE] and expired from burn injuries on [DATE]. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident had the behavior of delirium which fluctuated (comes and goes) and disorganized thinking which fluctuated. Record review of CR #1's care plans, updated on [DATE], revealed a problem of Resident Smokes. The goal documented was the resident would comply with the facility policy. Approaches listed revealed the charge nurse was to complete a safe smoking assessments quarterly. CR #1's care plan, updated [DATE], revealed a problem of a potential for impaired thought process, long and short term memory loss, secondary to Alzheimer Disease. Approaches included monitor resident for needs and assist as needed and follow consistent routine, explain reasons for nursing home routines. Record review of CR#1's safe smoking evaluations dated [DATE], [DATE], [DATE] [DATE] and [DATE] revealed the resident was alert and oriented and can consistently perform safe smoking techniques. Resident was able to communicate the risks associated with smoking. CR #1 was assessed as being able to light cigarette safely with a lighter, smoke the cigarette safely and was able to extinguish cigarette safely and completely. Continued review of the safe smoking evaluations revealed all nursing staff who had assessed the resident documented CR #1 could smoke independently and unsupervised in the designated smoking area. The evaluations also revealed the resident must request smoking materials from staff and that the resident had been informed of the smoking policies/procedures. The acknowledgment that the family/responsible party had been informed of the policies/procedures had been crossed out signifying they had not been informed. In the comment section of the form dated [DATE] it was documented RP(responsible party) and son aware of smoking habit of resident. Record review of the facility's Provider Investigation Report, dated, [DATE], revealed on [DATE], at 7:10 p.m., CR #1 was in a designated smoking area when a visitor passing by the facility saw the resident standing with flames coming from her clothing. The resident was life-flighted to a local hospital at 7:32 p.m. and died at 7:43 a.m. on [DATE]. The facility staff had reviewed the facility's camera video footage which revealed CR #1 did not request a cigarette or a lighter from a nurse immediately prior to the incident. The documentation revealed CR #1 was known to use a great deal of perfume and would spray her clothing with Febreze to eliminate any smoke odor because her daughter did not want her to smoke. A search of her room on [DATE] revealed a pack of cigarettes and a lighter in a pair of pants hanging on the back of a chair and more cigarettes in a small gold case in the top dresser drawer. Record review of facility document, Investigation RE: CR #1, dated, [DATE], 11:00 p.m., revealed , .When interviewing staff, no one gave the resident cigarettes or a lighter. The Aides did report that the daughter did not want the resident to smoke, but the son and other family members were supplying cigarettes and mailing her packages with unknown contents . Record review of the facility's undated document, Smoking Times, revealed that it read in part, Smoking Times: 6:00 am, 10:00 am, 1:00 pm, 4:00 pm, 6:00 pm, Last smoke break no exceptions @ 10 pm. Residents are to receive only 2 cigarettes and lighter at each smoke break. Residents personal lighter must be returned to the nurses station at the end of each smoke break . Record review of CR#1's care plans dated [DATE] revealed there was no care plan to address the resident was not compliant with the facility's smoking policy, or that she hid smoking paraphernalia, that she received smoking supplies and other unallowables in the mail, or that she was known to spray her clothing with air freshener from an aerosol can. In an interview on [DATE] at 6:00 p.m., the facility's DON stated CR #1 had gone out alone the night before, [DATE], to smoke. She stated they (the facility) suspected the son was providing the resident with cigarettes and they had spoken to him about bringing her cigarettes. She stated families were given a list of allowable and unallowable items upon admission (Facility Do's & Do Not's). Record review of an undated facility document, entitled, Facility Do's & Do Not's, revealed, .Residents may not bring: (Any product labeled Keep Out Of Reach Of Children) .Any aerosol spray containers .Any container labeled with a Hazardous Warning .Anything that has alcohol content . In an interview on [DATE] at 6:14 p.m., the facility's Administrator stated the staff were aware that CR #1 sprayed herself with Febreze and perfume because she did not like to smell like smoke. The Administrator stated she kept those items in her rolling walker. During an interview on [DATE] at 6:25 P.M. the facility's Administrator stated the facility just became a smoking facility at the first of the year (2015). The facility was aware at that time that CR #1 was sneaking off and smoking with another resident and the facility feared they would hurt themselves so they changed the facility's policy from being a non smoking facility. She continued and stated the facility thought CR #1 would get cigarettes into the facility thru packages she received. In an interview on [DATE], at 1:50 p.m., the facility's QA Nurse and Nurse Supervisor stated they were both smokers and would go out and smoke with the residents. They said they had observed CR #1 spray herself with Febreze and she kept the aerosol can in the basket seat of her rolling walker. They stated residents were not allowed to have Febreze in the building and when staff conducted room searches they would take the resident's Febreze. In continued interview, they stated CR #1 was not compliant with not having unallowables in her room and the staff had to do frequent room searches. Both stated they felt the son was bringing in some of the unallowable items. Continued interview with the facility's QA Nurse and Nurse Supervisor they stated the cigarettes of the residents had always and were kept in the medication room and the charge nurse was the one who would distribute the two cigarettes and lighters to the residents at smoking times. Then the residents would return the lighters to the same charge nurse at the end of the cigarette break. They stated now the residents must be supervised when they smoke. In an interview on [DATE] at 2:30 p.m., LVN A stated she would sometimes go out with CR #1 to evaluate her for smoking safety. She stated she observed the resident spray herself with Febreze ,[DATE] times although she was not supposed to have Febreze. Staff would do room searches and take the cans of Febreze from her room frequently. She stated she did not know if anyone had ever searched the resident's rolling walker. Record review of CR #1's safe smoking assessment dated [DATE] revealed LVN A had conducted the assessment. The assessment also revealed LVN A assessed CR #1 a safe smoker and she could smoke independently and unsupervised in the designated smoking area. In an interview on [DATE] at 3:00 p.m., CNA B stated CR #1 was not compliant to the facility's designated smoking times. She stated she did what she wanted to do. CNA B stated on the morning of the incident, [DATE], she observed the resident outside smoking on the porch while she was inside giving another resident a shower. She observed CR #1 spray her clothing with what she thought was perfume from a smaller bottle than a Febreze can. CNA B stated staff had previously taken cans of Febreze, cigarettes, and lighters from CR #1, but the resident would somehow get a new supply. CNA B said the residents were not supposed to have Febreze or perfumes because they were flammable. She stated all staff were to do room searches and remove unallowable items. In an interview on [DATE] at 4:00 p.m., the Administrator stated she doubted if any staff had ever searched CR #1's rolling walker for the Febreze because she always had it with her. When asked how staff were monitored to ensure effectiveness of facility's policies she stated compliance rounds were made. She stated rounds were made every one to two hours and all halls were monitored by cameras. She stated she would also question staff and observe them. She stated she was aware the resident went outside sometimes. She also stated she was aware the resident would spray herself with Febreze. In an interview on [DATE], at 2:00 p.m., the facility's DON stated she had observed CR #1 with Febreze in her rolling walker. She said that honestly, she should have taken the Febreze but never did. She never observed the resident spray herself but had heard that she did through the grapevine from other staff. She stated the staff did monthly and more room checks and would take the unallowable items. Record review of the facility's Smoking Procedures, not dated revealed the resident's cigarettes and lighter or other smoking materials must be kept at the nurse's station. Record review of an Internet search of the U.S. Department of Health & Human Services' Household Products Database revealed that Febreze Air Aerosol Air Refresher had the following warning label on the back panel: Caution .Keep Out Of Reach Of Children The Flammability rating was 2 moderate (on a scale from 0 - 4 with 4 being severe) and it had an alcohol content of 3.0 - 7.0%. The handling precautions also read .Do not expose to heat or open flame or store at room temperatures above 120 F . The facility Administrator was notified on [DATE] at 3:47 p.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. Immediate Jeopardy Plan of Removal · On [DATE] at 4:05 pm Activity Director met with each resident and reviewed the list of the facility un-allowed items. All residents in the facility re-signed the acknowledgement of the facility Do's and Don'ts. · On [DATE] at 4:05 pm the Business Office Manager contacted family members and/or responsible parties to review the facility Do's and Don'ts and contacted them to pick up the unallowable items. · On [DATE] at 4:30 pm Maintenance started a room search, with the resident's permission, to remove all un-allowed items from each resident's possession. The unallowable items were marked, stored and placed in a safe place where the residents can use or the family members/responsible party can pick up the items. Items not allowed in resident's possession in their rooms or bathrooms are the following: Cigarettes, lighters or any smoking paraphernalia. microwaves cleaning supplies cooking equipment wax candles with wicks normal saline hydrogen peroxide cough drops anything that has alcohol content or container labeled with a Hazardous warning or keep out of reach of children hair dryers,curling irons, or other heat producing items; shampoo/hair conditioner (that states keep out of reach of children) Ointment/Medications Potpourri other than sachet any glass containers any aerosol spray cans safety razors extension cords hampers/laundry baskets that are not completely enclosed non-electric razors over the counter medications heating pads or electric blankets. Weekly, an assigned housekeeper will help each resident check and compare items to the Unallowable list ensuring continued compliance. · On [DATE] at 4:05 pm, RN in-serviced all staff that during their daily tasks, note any item that is on the non-allowable list or that places the resident at risk for harm or injury and immediately report to the Administrator . · All staff were in serviced by the Administrator on [DATE] that no resident would be allowed to smoke unattended. Nurses were in-serviced that at anytime a smoking resident unstable or disoriented, a smoking apron would be given to the Ambassador and placed on the resident while smoking. · On [DATE], after the incident, the smoking policy was reviewed and revised to include an assigned smoking ambassador for each smoking time. The smoking policy times were modified per the resident's request and times/assignments are as follows: 6:30 am Laundry Ambassador 8:30 am Activity Ambassador 1:30 pm Activity Ambassador 6:30 pm Laundry Ambassador 8:30 pm Laundry Ambassador All smoking paraphernalia, cigarettes, lighters and/or tobacco will continue to be maintained in the Medication room where only the charge nurse has access to these items. The implemented change is that no resident can smoke unattended, the assigned smoking ambassador will obtain 2 cigarettes for each resident and a lighter from the charge nurse, which will remain in her possession until smoking time has finished, at which time the ambassador will return the cigarette lighter to the charge nurse. Times will be re-evaluated at resident's request. · On [DATE] at 4:00 pm a revised lists of unallowable items were posted at the nurses stations, in the ADL books, shower rooms and the shower assignment books. Monitoring of plan: Observation on [DATE] at 1:15 P.M. revealed a staff member and one resident in the designated smoking area. The resident had a lit cigarette and was visiting with the staff member. Staff member had a lighter in her hand. Staff stayed with resident while she smoked two cigarettes and then entered the facility with the staff members assistance. Record review of in-service dated [DATE] at 7:45 P.M. and continue to day shift on [DATE] revealed thirty staff members had been in-serviced on re-assessing existing residents who smoked and new smoking policy including where no residents can smoke unattended. Policy also covered the use of the apron on residents who appeared unstable or not oriented to surroundings. Record review of in-service [DATE] revealed 42 staff members had been trained on non-allowable personal items. What they should be observant of in resident rooms and who to report to if unallowable found in resident ' s rooms. Record review of in-service conducted [DATE] revealed 42 staff members were in-serviced on reporting change of conditions in resident ' s behaviors. Record review of new smoking policy for the facility revealed residents were not allowed to smoke unsupervised. Interview with two supervisors revealed all staff had been in-serviced on policy and that residents had also been informed. Both supervisors stated staff were educating families as they came in and also business office was calling each family to inform them of the allowable and unallowable items. On [DATE] reviewed the smoking assessments on three of the four still existing smokers and compared assessments with current MDS and care plan. The fourth resident who still smoked does so only when family were present. The facility does not supervise or have any smoking materials for this resident. On [DATE] observation tour was conducted on halls 400 and 300 revealed no unallowable products or items noted in resident rooms. Interviews with three CNA's who worked two different shifts and one housekeeping staff revealed they were all able to list items that were unallowable and what to do with the items if found. Observation on [DATE] of the secured unit revealed staff locked unallowable items in the shower room closet. Interviews with two staff members revealed they were able to verbalize unallowable items in resident rooms. Observation at nurse ' s station (centralized for all halls) revealed postings of smoking times with reminders to staff as to which department would provide the ambassador designated to be supervising the residents who smoked. The postings were on the outside of the desk on all sides and in the main hallway entering the facility. Observation of the nurse ' s station on [DATE] revealed a list of the unallowable products staff were to monitor resident's rooms for. Interviewed two residents on [DATE] on each hall except the secured unit, concerning items they were allowed and not allowed in their rooms. Residents were able to voice what items they would not be allowed in their rooms. All residents appeared to understand the reason and rationale behind why they were not to keep certain items in their rooms. Interviewed three residents on [DATE] - [DATE] who were documented as safe smokers concerning the new smoking policy. All acknowledge they were very much aware of the changes and though not happy about the changes would comply. Interviews conducted between [DATE] and [DATE] with 16 staff from all departments revealed staff were aware of the smoking policy and smoking times. They also acknowledged what item residents were allowed and not allowed and who the smoking ambassadors were. All staff interviewed relayed their responsibility of removing unallowable items from the resident's rooms, reporting the items to the charge nurse and securing the items for resident usage when asked. Observations conducted between [DATE] and [DATE] revealed nursing supervisors explaining the smoking policy changes and having the residents and their Responsible party/family sign the acknowledgment form. Smoking signs were posted and cigarettes were provided to the smoking ambassadors who then took them to the residents in the smoking area and remained with them while they were smoked. After monitoring the implementation of the plan and confirming the implementation of the new smoking policy, the IJ was removed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed . However the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility was continuing to monitor the plan to ensure compliance with all policies. According to the facility's roster, the census was 97. The facility staff reported there were four residents who smoked in the facility.

Based on observation, interview and record review, the facility's Administration failed to administer the facility in a manner that enabled it to use its resources effectively to maintain the highest practicable physical, mental and psychosocial wellbeing of one of one of five residents (CR #1) the supervision and resources to smoke safely. CR #1 ignited herself when smoking unsupervised and expired twelve hours later from her injuries. The facility's Administrator and DON failed to remove non allowable items when CR #1 was witnessed using them, to prevent her from smoking other then at the designated times. The facility's Administrator and DON failed to remove non allowable combustible and flammable sprays when CR #1 was witnessed using them. The facility's Administrator and DON failed to train staff to intervene when residents were witnessed not adhering to the smoking policy. The facility's Administrator and DON failed to train staff to intervene when residents/family members were not compliant with the facility's policy on non-allowable items. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility was continuing to monitor to ensure policies concerning non allowables and smoking were being followed . This failure affected one resident CR #1 who sustained third [MEDICAL CONDITION] 80 % of her body and expired and placed 97 residents at risk of serious injury due to staff not being effectively trained and supervised to ensure the adherence to facility policies. Findings include: Incident # 4 Record review revealed that CR #1 was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. She was life-flighted from the facility to a local emergency roiagnom on [DATE] and expired from burn injuries on [DATE]. Record review of the facility's Provider Investigation Report, dated, [DATE], revealed on [DATE], at 7:10 p.m., CR #1 was in a designated smoking area when a visitor passing by the facility saw the resident standing with flames coming from her clothing. The resident was life-flighted to a local hospital at 7:32 p.m. and died at 7:43 a.m. on [DATE]. The facility staff had reviewed the facility's camera video footage which revealed CR #1 did not request a cigarette or a lighter from a nurse immediately prior to the incident. The documentation revealed CR #1 was known to use a great deal of perfume and would spray her clothing with Febreze to eliminate any smoke odor because her daughter did not want her to smoke. A search of her room on [DATE] revealed a pack of cigarettes and a lighter in a pair of pants hanging on the back of a chair and more cigarettes in a small gold case in the top dresser drawer. Please refer to this CMS form 2567 dated [DATE] F 224 and 323 for the evidence of the deficient practice. In an interview with the facility's Administrator on [DATE], at 6:14 p.m., she stated staff were aware that CR #1 sprayed herself with Febreze and perfume because she did not like to smell like smoke. She kept those things in her rolling walker. During an interview on [DATE] at 6:25 P.M. the facility's Administrator stated the facility just became a smoking facility at the first of the year (2015). The facility was aware at that time that CR #1 was sneaking off and smoking with another resident and the facility feared they would hurt themselves so they changed the facility's policy from being a non smoking facility. She continued and stated the facility thought CR #1 would get cigarettes into the facility thru packages she received. Interview on [DATE] at 2:30 pm the DON stated the resident had gone outside on [DATE] between ,[DATE]:30 pm alone to smoke unsupervised. She stated the nurses pass medications at that time, so she walked out un-noticed. In continued interview, the DON was asked how did she think this incident came about and she stated she did not know if the ashes blew on her but the resident made a comment at the hospital that the lighter exploded. The DON stated she did not know if the resident was grasping for an explanation when she (the resident) made that comment. The facility staff suspected the son was providing the resident with cigarettes. Families are given a list of allowable upon admission. Staff had spoken to the son about bringing her cigarettes. In the same interview with the DON she was asked what resources were available for her to use to assist her and the staff and she replied the policies and procedures. Also there were outside speakers and the staff did routine fire drills. She stated she would like to contact the Fire Marshall to give and in-service on safety. She stated the staff did monthly and more room checks and would take the unallowable items. In an interview on [DATE] at 2:45 pm the Administrator , when asked how do you think this IJ occurred, she stated, I do not think we did anything wrong. The resident got the cigarettes from somewhere, it was just a freak accident. She stated the resident was still able to communicate after the fire and while at the hospital, prior to her expiring, she stated to a family member the lighter blew up. In continued interview, the Administrator stated she was aware the resident went out alone to smoke and sprayed herself with Febreze at times; but Febreze was not flammable. In an interview on [DATE] at 4:00 p.m., the Administrator stated she doubted if any staff had ever searched CR #1's rolling walker for the Febreze because she always had it with her. When asked how staff were monitored to ensure effectiveness of facility's policies she stated compliance rounds were made. She stated rounds were made every one to two hours by supervisors and all halls were monitored by cameras. She stated she would also question staff and observe them. She stated she was aware the resident went outside sometimes. She also stated she was aware the resident would spray herself with Febreze. In the same interview the Administrator when asked what kind of resources were available to train and monitor effectiveness of staff she stated the corporation had consultants that were utilized. She also stated a Social Worker was offering counseling to the residents and staff. In an interview on [DATE], at 2:00 p.m., the facility's DON stated she had observed CR #1 with Febreze in her rolling walker. She said that honestly, she should have taken the Febreze but never did. She never observed the resident spray herself but had heard that she did through the grapevine from other staff. Record review of an Internet search of the U.S. Department of Health & Human Services' Household Products Database revealed that Febreze Air Aerosol Air Refresher had the following warning label on the back panel: Caution .Keep Out Of Reach Of Children The Flammability rating was 2 moderate (on a scale from 0 - 4 with 4 being severe) and it had an alcohol content of 3.0 - 7.0%. The handling precautions also read .Do not expose to heat or open flame or store at room temperatures above 120 F . The facility Administrator was notified on [DATE] at 3:47 p.m. that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. Immediate Jeopardy Plan of Removal 1) On [DATE] at 4:05 pm Activity Director met with each resident and reviewed the list of the facility un-allowed items. All residents in the facility re-signed the acknowledgement of the facility Do's and Don'ts. 2) On [DATE] at 4:05 pm the Business Office Manager contacted family members and/or responsible parties to review the facility Do's and Don'ts and contacted them to pick up the unallowable items. 3) On [DATE] at 4:30 pm Maintenance started a room search, with the resident's permission, to remove all un-allowed items from each resident's possession. The unallowable items were marked, stored and placed in a safe place where the residents can use or the family members/responsible party can pick up the items. Items not allowed in resident's possession in their rooms or bathrooms are the following: Cigarettes, lighters or any smoking paraphernalia. microwaves cleaning supplies cooking equipment wax candles with wicks normal saline hydrogen peroxide cough drops anything that has alcohol content or container labeled with a Hazardous warning or keep out of reach of children hair dryers,curling irons, or other heat producing items; shampoo/hair conditioner (that states keep out of reach of children) Ointment/Medications Potpourri other than [MEDICATION NAME] any glass containers any aerosol spray cans safety razors extension cords hampers/laundry baskets that are not completely enclosed non-electric razors over the counter medications heating pads or electric blankets. Weekly, an assigned housekeeper will help each resident check and compare items to the Unallowable list ensuring continued compliance. 4) On [DATE] at 4:05 pm, RN in-serviced all staff that during their daily tasks, note any item that is on the non-allowable list or that places the resident at risk for harm or injury and immediately report to the Administrator. 5) On [DATE] at 4:15 pm, RN in-serviced all staff to report to the Administrator all behaviors that may pose a risk for harm or injury. 6) All staff were in serviced by the Administrator on [DATE] that no resident would be allowed to smoke unattended. Nurses were in-serviced that at anytime a smoking resident unstable or disoriented, a smoking apron would be given to the Ambassador and placed on the resident while smoking. 7) On [DATE], after the incident, the smoking policy was reviewed and revised to include an assigned smoking ambassador for each smoking time. The smoking policy times were modified per the resident's request and times/assignments are as follows: 6:30 am Laundry Ambassador 8:30 am Activity Ambassador 1:30 pm Activity Ambassador 6:30 pm Laundry Ambassador 8:30 pm Laundry Ambassador All smoking paraphernalia, cigarettes, lighters and/or tobacco will continue to be maintained in the Medication room where only the charge nurse has access to these items. The implemented change is that no resident can smoke unattended, the assigned smoking ambassador will obtain 2 cigarettes for each resident and a lighter from the charge nurse, which will remain in her possession until smoking time has finished, at which time the ambassador will return the cigarette lighter to the charge nurse. Times will be re-evaluated at resident's request. 8) On [DATE] at 4:00 pm a revised lists of unallowable items were posted at the nurses stations, in the ADL books, shower rooms and the shower assignment books. Monitoring of plan: Observation on [DATE] at 1:15 P.M. revealed a staff member and one resident in the designated smoking area. The resident had a lit cigarette and was visiting with the staff member. Staff member had a lighter in her hand. Staff stayed with resident while she smoked two cigarettes and then entered the facility with the staff members assistance. Record review of in-service dated [DATE] at 7:45 P.M. and continue to day shift on [DATE] revealed thirty staff members had been in-serviced on re-assessing existing residents who smoked and new smoking policy including where no residents can smoke unattended. Policy also covered the use of the apron on residents who appeared unstable or not oriented to surroundings. Record review of in-service [DATE] revealed 42 staff members had been trained on non-allowable personal items. What they should be observant of in resident rooms and who to report to if unallowable found in resident ' s rooms. Record review of in-service conducted [DATE] revealed 42 staff members were in-serviced on reporting change of conditions in resident ' s behaviors. Record review of new smoking policy for the facility revealed residents were not allowed to smoke unsupervised. Interview with two supervisors revealed all staff had been in-serviced on policy and that residents had also been informed. Both supervisors stated staff were educating families as they came in and also business office was calling each family to inform them of the allowable and unallowable items. On [DATE] reviewed the smoking assessments on three of the four still existing smokers and compared assessments with current MDS and care plan. The fourth resident who still smoked does so only when family were present. The facility does not supervise or have any smoking materials for this resident. On [DATE] observation tour was conducted on halls 400 and 300 revealed no unallowable products or items noted in resident rooms. Interviews with three CNA's who worked two different shifts and one housekeeping staff revealed they were all able to list items that were unallowable and what to do with the items if found. Observation on [DATE] of the secured unit revealed staff locked unallowable items in the shower room closet. Interviews with two staff members revealed they were able to verbalize unallowable items in resident rooms. Observation at nurse ' s station (centralized for all halls) revealed postings of smoking times with reminders to staff as to which department would provide the ambassador designated to be supervising the residents who smoked. The postings were on the outside of the desk on all sides and in the main hallway entering the facility. Observation of the nurse ' s station on [DATE] revealed a list of the unallowable products staff were to monitor resident's rooms for. Interviewed two residents on [DATE] on each hall except the secured unit, concerning items they were allowed and not allowed in their rooms. Residents were able to voice what items they would not be allowed in their rooms. All residents appeared to understand the reason and rationale behind why they were not to keep certain items in their rooms. Interviewed three residents on [DATE] - [DATE] who were documented as safe smokers concerning the new smoking policy. All acknowledge they were very much aware of the changes and though not happy about the changes would comply. Interviews conducted between [DATE] and [DATE] with 16 staff from all departments revealed staff were aware of the smoking policy and smoking times. They also acknowledged what item residents were allowed and not allowed and who the smoking ambassadors were. All staff interviewed relayed their responsibility of removing unallowable items from the resident's rooms, reporting the items to the charge nurse and securing the items for resident usage when asked. Observations conducted between [DATE] and [DATE] revealed nursing supervisors explaining the smoking policy changes and having the residents and their Responsible party/family sign the acknowledgment form. Smoking signs were posted and cigarettes were provided to the smoking ambassadors who then took them to the residents in the smoking area and remained with them while they were smoked. After monitoring the implementation of the plan and confirming the implementation of the new smoking policy, the IJ was removed. On [DATE] at 2:20 P.M. the Administrator was informed the IJ was removed. However the facility remained out of compliance at actual harm that was not Immediate Jeopardy with a scope identified as isolated. The facility was continuing to monitor the plan to ensure compliance with all policies. According to the facility's roster, the census was 97.

Based on observation, interview, and record review, the facility failed to provide services according to the physician's order [REDACTED].#66 #40, #93, #12, #17, and #18) reviewed for physician's order [REDACTED]. The facility failed to provide: Resident #66 with her three blood pressure medicines as ordered by the physician. One of the medications she received only one third the dose (25 mg instead of 75 mg), when her blood pressure was 232/93. Resident #40, and #93' s blood pressure medication when their blood pressures were below the parameters the physician had set and had ordered the medication to be held. Resident #12's medications without monitoring the resident's blood pressure and pulse as ordered by the physician. Resident #17's medication [MEDICATION NAME] when the resident's pulse was below 60 and the physician ordered the medication to be held. Resident #18's with the treatment of [REDACTED]. An immediate jeopardy (IJ) was identified on 6/11/15. While the IJ was removed on 6/16/15, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. This placed one resident at risk of a [MEDICAL CONDITION] (stroke) , five residents at risks of their conditions worsening and 91 residents of not receiving care and services as ordered by the physician and as planned which could cause a decline in their overall health and well-being. Findings include: Resident # 66 Record review of Resident # 66 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #66 ' s admission assessment dated [DATE] revealed the resident came from another nursing home facility. Her vital signs upon admission included a B/P of 134/68 and a pulse of 50. Her weight was 124 pounds. She was alert and oriented to person, place and time. She had no behaviors and reported her usual time to awake was 6:00 a.m. Observation on 6/10/15 at 9:39 a.m., revealed MA# 7 checked Resident # 66 ' s blood pressure using a wrist cuff apparatus and got a reading of 232/93 mm Hg. MA#7 at this time stated Resident # 66 ' s blood pressure was usually high and proceeded to prepare her morning medications. Observation on 6/10/15 at 9:42 a.m., MA # 7 prepared the resident's A.M. medications to include: One 25 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 0.2 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 12.5 mg tablet of Carvedilol (used to treat high blood pressure). One 40 mg tablet of Isosprbide [MEDICATION NAME] ER (used to treat [MEDICAL CONDITION] by dialtating arteries and veins ). One 150 mg tablet of Irbesartan (used to treat high blood pressure). One 10 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). Observation on 6/10/15 at 10:13 a.m., MA# 7 administered a total of 14 tablets/medications by mouth to Resident # 66, which included only one tablet of the [MEDICATION NAME]. MA #7 did not notify the resident ' s nurse concerning Resident #66's elevated blood pressure of 232/93. Record review of Resident # 66 ' s admission orders [REDACTED] [MEDICATION NAME] HCL 25 mg PO, give 3 tablets TID (three times a day) . [MEDICATION NAME] 40 mg PO daily [MEDICATION NAME] 0.2 mg tablet PO every 12 hours Carvedilol 12.5 mg PO every 12 hours Irbesartan 150 mg tablet PO daily. [MEDICATION NAME] 10 mg tablet PO daily. Interview on 6/10/15 at 2:05 p.m., MA # 7 stated thank you so much for pointing that out to me because I did not realize that it should be 3 tablets . She further reviewed the MAR and said it does say 3 tablets but I guess I focused on the 25 mg only. MA# 7 said she had been giving Resident # 66 her medications but had no response when asked how many she had been giving her. Interview on 6/11/15 at 12:47 p.m., the DON said medications should be administered as ordered by the MD and any discrepancy/confusions should be reported to the charge nurse or DON immediately. She said the aides were trained to correctly administer mediations. The DON said upon resuming the DON position three weeks ago, she conducted competency checks on licensed nurses and medications aides to ensure they were adequately trained to perform duties. Resident #40 Record review of Resident #40 ' s face sheet, revealed she was admitted to the facility on [DATE] and was readmitted on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Record review of Resident #40 ' s physician's order [REDACTED]. [MEDICATION NAME] 12.5 mg, by mouth, twice daily with parameters of the heart rate less than 60 to hold the medication with the original start date of 2/6/15. Record review of Resident #40 ' s MAR, dated 6/2015, revealed documentation that the resident was administered [MEDICATION NAME] 12.5 mg, when the heart rate was below the parameter on: 6/2/15 at 9:00 AM: Heart Rate was 52; 6/6/15 at 9:00 PM: Heart Rate was 54; 6/7/15 at 9:00 PM: Heart Rate was 54; Interview on 6/12/15 at 11:00 AM, Resident #40 stated she did not always get all her morning medications. She stated she was aware how many medications she was supposed to receive in the AM dose and did not get that many pills on three different occasions. She stated she counted the number of pills given to her and told the medication aide it was not the correct amount of pills. She stated the unidentified medication aide went to the medication cart and brought more pills. She stated she counts her medications pills to ensure she was getting the right medications. Resident #93 Record review of Resident #93 ' s face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Record review of Resident #93 ' s physician's order [REDACTED]. Record review of Resident #93 ' s MAR, dated 6/2015, revealed documentation that she was administered [MEDICATION NAME] 25 mg, when the blood pressure was outside the parameters on: 6/2/15 at 8:00 AM: Blood Pressure was 139/60; 6/3/15 at 8:00 AM: Blood Pressure was 129/79; at 8:00 PM: Blood Pressure was 134/76; 6/4/15 at 8:00 AM: Blood Pressure was 120/70; at 8:00 PM: Blood Pressure was 132/71; 6/5/15 at 8:00 PM: Blood Pressure was 139/77; 6/6/15 at 8:00 PM: Blood Pressure was 136/78; 6/7/15 at 8:00 AM: Blood Pressure was 131/71; at 8:00 PM: Blood Pressure was 118/79; 6/8/15 at 8:00 AM: Blood Pressure was 139/77; at 8:00 PM: Blood Pressure was 130/74; 6/9/15 at 8:00 AM: Blood Pressure was 130/64; at 8:00 PM: Blood Pressure was 135/78; 6/10/15 at 8:00 AM: Blood Pressure was 144/66; at 8:00 PM: Blood Pressure was 131/74; 6/11/15 at 8:00 PM: Blood Pressure was 138/75; Interview on 6/15/15 at 6:00 PM; the DON stated the blood pressure medication should be held and documented when the blood pressure reading was outside the parameters. She further stated that the doctor should have been notified when the blood pressure medication was held for more than three doses. Resident # 12 Record review of Resident # 12 ' s face sheet revealed an [AGE] year old female admitted the facility on 5/21/15. Her [DIAGNOSES REDACTED]. Record review of Resident # 12 ' s care plan dated 5/21/15 revealed the resident was at risk of irregular pulse, chest pains, and hypo/hypertensive episodes due to history of [MEDICAL CONDITION]. Goal was the charge nurse would ensure that hypertensive medications were administered as ordered and any changes in blood pressure would be reported to the MD through the next review. Approaches included: monitor for chest pain, abnormal pulse and report to MD. Record review of Resident # 12 ' s physician's orders [REDACTED]. [MEDICATION NAME] 50 mg tablet, one by mouth daily. [MEDICATION NAME] 5 mg tablet, one by mouth daily. Document blood pressure and pulse daily . Further review of Resident # 12 ' s MAR dated June 2015 revealed the resident received the medications as ordered. The MAR had no record of the blood pressure and pulse as ordered. Further review of Resident #12's medical record revealed no record of the resident's blood pressure and pulse being monitored as ordered. Resident # 17 Record review of Resident # 17's record revealed a [AGE] year old male admitted the facility on 5/29/15. His [DIAGNOSES REDACTED]. Record review of Resident # 17's physician's orders [REDACTED]. Further review of Resident # 17 ' s MAR dated June 2015 revealed the [MEDICATION NAME] medication was documented as administered on the following dates with a recorded pulse of less than 60; On 6/7/15 at 8:00 a.m., pulse was 52 and at 4:00 p.m., pulse was 51. Resident #18 Record review of Resident # 18 ' s face sheet revealed he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 18 ' s physician's order [REDACTED]. Record review of Resident # 18 ' s MAR dated June 2015 revealed order to offload left lower extremity while in bed. Designated shift was 6-2 and order was initialed by staff as implemented from 6/1- 6/11/15. Further review of Resident # 18 ' s MAR dated June 2015 revealed the order for fluid restriction of 1500 ml per day. The fluids consumed were documented for 6-2 , 2-10 and 10-6 shifts respectively on the MAR with totals documented for each shift. Further review of Resident # 18 ' s record revealed implementation of the above order on 1500 ml per day fluid restriction did not include the resident ' s total fluid intake including fluid served with meals and with medications. Interview on 6/10/15 at 1:15 p.m., LVN # 6 stated the resident had a water pitcher by his bedside which was measured to ensure he was not drinking more fluids than required. LVN#6 said the resident's meals and fluids from the kitchen were not added to the total fluids as well as the water used for drug administration. LVN # 6 stated she would send a communication to both the medication aides and the dietary department to ensure the physician's orders [REDACTED]. Observation on 6/9/15 at 5:25 p.m., Resident # 18 was in bed with his legs not offloaded. Observation on 6/10/15 at 3:38 p.m., Resident # 18 ' s legs were not offloaded as ordered. Observation on 6/11/15 at 10:10 a.m., Resident #18 was in bed and his legs were not offloaded. Interview on 6/11/15 about 2:00 p.m., LVN #6 said Resident #18 had a physician's orders [REDACTED]. She said she instructed the aides to keep watch when they make rounds. Interview on 6/11/15 at 4:15 p.m., the DON said she had initiated in-services on following the physician's orders [REDACTED]. The DON said she would continue to enforce the order. Record review of facility policy on medication administration dated 09/08 revealed that prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged the prescriber's orders are checked for the correct dosage schedule. The same policy revealed the medications were administered in accordance with the written physician order. On 6/11/2015 at 6:55 pm an IJ was identified and the Administrator was notified. The IJ was removed on 6/16/2015. The facility submitted and implemented the following plan to remove the IJ on 6/12/2015. Plan to remove immediacy: On 6/11/2015 at 8:00 pm the Charge nurse checked the vital signs for Resident #66 and observed resident for signs/symptoms of hypertension, headache, flushed cheeks and/or blurred vision. On 6/11/15 at 8:15 pm the DON rechecked resident #66 ' s B/P and it was noted to be 154/73. At 8:30 pm on 6/11/15 the Physician of Resident #66 ' s was notified of the B/P findings and the medication discrepancies. The resident ' s medication [MEDICATION NAME] was increased to 100 mg every 8 hours. On 6/11/15 at 8:00 pm, facility nurses began checking Resident #66 ' s B/P every 4 hours for the next 24 hours to monitor outcomes. On 6/11/15 at 8:30 pm the DON completed medication error reports on the [MEDICATION NAME] and Imdur. At 8:45 pm on 6/11/15 the Medical Director was notified and family was called 2 times, message was left with no return call. On 6/11/15 at 8:30 pm the Medication Aide (MA), was terminated for her performance. At 8:30 pm on 6/11/15 B/Ps and Pulses were obtained on all 96 residents in the facility to ensure no other problem existed with other residents. This was completed on 6/11/2015 at 9:30 pm. On 6/11/15 at 8:45 pm the MA's were in-serviced by the DON on reporting B/Ps that are above 180 or below 120. On 6/11/15 at 9:30 pm and again on 6/12/15 at 8:00 am the DON in-serviced the charge nurses on reporting to the physicians B/P above 180 at the time the vital sign is obtained. On 6/11/15 at 9:00 pm the DON started Med pass checks with the MA ' s on the 2-10 shift for skills performance by observing and verifying the MA followed the 7 rights for each medication x 15 meds on the evening medication pass and again on 6/12/15 at 8:30 am for the 6-2 shift. All MA's must complete and pass the Skills Check by 6/15/15 before they are allowed to pass medications. On 6/11/15 at 9:30 pm and again at 8:00 am on 6/12/15 the DON in-serviced the MA ' s on the rights of Medication Administration 1) Patient 2) Time 3) Medication 4) Dose 5) Route 6) Parameter and 7) Documentation. On 6/11/15 at 9:30 pm and again on 6/12/15 at 7:30 am the DON in-serviced the charge nurses to notify the physicians at the time an abnormal B/P is obtained and notify the RN if the physician does not answer or return calls within 30 minutes. On 6/11/15 at 8:30 pm the DON started Med Administration observations with the MAs on the 2-10 shift for random observations which will be conducted for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 7:30 am the DON stated random observations with the 6-2 MAs which will continue for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 8:30 am the Pharmacy Consultant was contacted by the Administrator to conduct a complete medication pass audit. The audit is scheduled to be conducted on Monday June 15, 2015. The Medical Director was contacted 6/12/15 at 9:00 am regarding the occurrence and parameters were given to notify physicians of any B/P above 180. IJ plan of removal addendum revealed additional corrective actions added 6/14/2015 by the facility were: On June 13 2015 a RN Clinical Consultant and a facility RN completed chart audits on 100 % of the active residents with orders for cardiac medications. On June 13, 2015 audits of Medication Administration Sheets for 100% of the active residents was completed by RN Clinical Consultant and a facility RN to identify residents who have/need vital sign parameters for per administration actions related to cardiac medication orders. Attending MD /designee was notified and parameters for pre administration of cardiac medications was obtained on June 13/2015 Education was provided by RN Clinical Consultant to MA and charge nurses on 6/13/2015 and 6/14/2015 on Medication Administration, MA guidelines , common cardiovascular medications, medications that affect the cardiovascular system, documentation related to vital sign parameters, change sticker usage, drug reference books usage, notification procedures relating to change of conditions, medication administration and parameters. Pre and Post tests were provided for the educational in-service. IJ plan of removal addendum revealed additional corrective actions added 6/16/2015 by the facility were: Residents identified during the monitoring process on 6/15/2015 were audited and the missing medications on the cart were restocked. Residents identified during the monitoring process on 6/15/2015 had full chart reviews with attention focused on physician's order [REDACTED]. All medication carts were compared to the current residents MARs to ensure drug availability on 6/15/2015. Education was provided on 6/16/2015 to all MAs and LVNs concerning medication ordering and reordering by the DON. Starting 6/16/2015 the DON/designee will conduct compliance monitoring through a review of the physician's order [REDACTED]. Monitoring of the plan to remove the immediate jeopardy: Monitoring began on 6/12/15. LVNs and MA were interviewed on three of three shifts concerning medication administration, documentation, and physician notification. Record review of the facility In-Services revealed: 6/11/15-- Eight staff members trained on staff reporting all negative findings to the charge nurse; and the 7 rights of medication administration. 12 staff members trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, Recommendation) tool. 6/12/15- Ten staff members were trained on parameters of systolic blood pressure over 180 or below 120. Ten staff members were trained on medication [MEDICATION NAME] must take medication with food or milk and the benefits of the medication. 6/13/15-6/14/15-Fourteen staff members were trained by the nurse consultant on medications that affect the cardiovascular system, common cardiovascular medications, medication administration documentation related to vital sign parameters, direction changes and the use of sticker use, and utilizing Drug Reference books for any vital signs monitoring prior to administration of medications. Also seven staff were in-serviced on administering oral medications, documentation of medication administration, and medication aide/LVN guidelines of general medication administration. Interview on 6/14/15 at 3:59 PM, the RN Nurse Consultant stated she did chart audits and found 60 residents did not have any blood pressure parameters and contacted the physicians to get parameters. She stated she rewrote all the cardiac medication orders, updated the resident ' s MAR and highlighted discontinued medications in yellow. She further stated she had completed in-services on documentation, problem solving, and handed out handouts to the staff, and administered a Pre/Post test over common medications. Observation on 6/15/15 at 4:45 PM, during a medication cart review with the DON that was conducted on RN #6 ' s cart revealed five discrepancies of medication for Resident #22. The findings included: Vitamin C and [MEDICATION NAME] 160 mg/15 mL, liquid multivitamin, and Sugar Free Protast, were not found on the cart. Resident #22 was receiving ProMod Liquid Protein that had 13 grams of sugar. [MEDICATION NAME] was not found for Resident #22 in the medication refrigerator. Record review of the contracted Pharmacist review, dated 6/15/15, revealed the Pharmacist had performed four observations of medication administrations with two LVNs and two MAs. Her findings included: found discrepancies between the medication in the cart compared to the Resident ' s MAR. She further documented that she recommended the staff ensure proper hand washing/sanitizing between each resident and ensuring medication was available in the cart. Record review of Medication Pass In-service, dated 6/15/15 through 6/16/15 revealed five staff members were trained on proper hand-sanitizing and washing techniques, importance of reconciling medication in the cart with the resident's MAR and to use change of directions stickers or notify nurse of any necessary updated to the MAR, and proper documentation on MAR immediately after medication was administered. Record review of In-service, dated 6/16/15, the DON trained five staff members on reordering of scheduled medications and PRN (as needed ) medications, and notifying the DON immediately of non-available medications for follow-up to ensure medications were available at all times. Observation with two different medication aides, the DON, and QA nurse (LVN 7) on 6/16/2015 from 4:25 P.M. to 5:15 P.M. revealed the medication carts reviewed on the 100, 200, 300, and 400 halls had all the medications available for the medication administration for the entire day for the six residents reviewed. Interviews with three MAs, and two LVNs on 6/16/15 between 4:25 P.M. and 5:15 P.M. during the medication cart reviews revealed they all had knowledge and could verbalize the medication pass verifications which must be completed with each resident with each administration including the 7 rights they had recently been in-serviced on. Record review of the in-service forms provided by the Administrator dated 6/11/15, 6/13/15, 6/14/15 and 6/16/15 revealed in-services concerning the reordering of medications, the availability of medications for residents, the rights of the medication administration, and medications concerning the cardiovascular system and the importance of vital sign parameters. Interview on 6/16/2015 at 5:20 P.M. the pharmacy consultant stated she had conducted a medication pass with two MAs and three LVNs and had no medication errors identified. Record review of the pharmacy consultant report dated 6/16/2015 revealed the findings from the medication pass conducted with the MAs and LVNs which revealed no issues noted. Interview on 6/16/2015 at 5:25 P.M. the DON stated she would be continuing to do medication verification audits every morning with her staff. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on 6/16/2015 at 5:30 P.M. While the IJ was removed on 6/16/2015 the facility remained out of compliance at a scope of pattern at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents with hypertension were receiving physician ordered medications , treatments and consultations as their condition requires. The facility CMS form 2567 revealed a census of 97 residents.

Based on observation, interview and record review the facility failed to ensure that one of seven residents observed during medication administration (Resident # 66) was free of significant medication errors. Resident # 66's blood pressure reading was 232/95. MA#7 failed to administer Resident #66's was administered 25 mg of [MEDICATION NAME] instead of 75 mg the physician ordered by MA #7 and Resident #66 was administered Carvedilol 12.5 mg (used to treat hypertension) without food as recommended by the manufacturer. Resident # 66 ' s blood pressure prior to administration of the medications was 232 /95. Resident #66's medication [MEDICATION NAME] 40 mg tablet (used to manage [MEDICAL CONDITION] disorders) was not administered upon arising as ordered. An immediate jeopardy (IJ) was identified on 6/11/15. While the IJ was removed on 6/16/15, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. This failure affected one resident by placing her at risk for a [MEDICAL CONDITION] (stroke) and placed an additional 77 residents in the facility with [DIAGNOSES REDACTED]. Findings Include: Resident # 66 Record review of Resident # 66 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #66 ' s admission assessment dated [DATE] revealed the resident came from another nursing home facility. Her vital signs upon admission included a B/P of 134/68 and a pulse of 50. Her weight was 124 pounds. She was alert and oriented to person, place and time. She had no behaviors and reported her usual time to awake was 6:00 a.m. Record review of Resident # 66 ' s admission physician's orders [REDACTED]. [MEDICATION NAME] HCL 25 mg PO, give 3 tablets three times daily. [MEDICATION NAME] 40 mg PO daily. [MEDICATION NAME] 0.2. mg tablet PO every 12 hours. Carvedilol 12.5 mg PO every 12 hours. Irbesartan 150 mg tablet PO daily. [MEDICATION NAME] 10 mg tablet PO daily. [MEDICATION NAME] tablet 1 mg PO daily. [MEDICATION NAME] tablet 10 mg PO daily. [MEDICATION NAME] 300 mg tablet, PO three times daily. Pantoprazole 40 mg tablet PO daily. [MEDICATION NAME] sulfate 325 mg tablet, PO daily. Sennosides 8.6-50 mg PO twice daily. [MEDICATION NAME] sodium 100 mg tablet PO twice daily. [MEDICATION NAME] 750 mg tablet PO every 12 hours. Observation on 6/10/15 at 9:42 a.m., MA # 7 prepared the resident's A.M. medications which included: One 25 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 0.2 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 12.5 mg tablet of Carvedilol (used to treat high blood pressure). One 40 mg tablet of Isosprbide [MEDICATION NAME] ER (used to treat [MEDICAL CONDITION] by dilating arteries and veins ). One 150 mg tablet of Irbesartan (used to treat high blood pressure). One 10 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). Observation on 6/10/15 at 10:13 a.m., MA# 7 administered a total of 14 tablets/medications by mouth to Resident # 66, which included only one tablet of the [MEDICATION NAME] 25 mg. Interview on 6/10/15 at 2:05 p.m., when questioned concerning the dosage of [MEDICATION NAME] MA # 7 stated thank you so much for pointing that out to me because I did not realize that it should be three tablets . She further reviewed the MAR and said it does say three tablets but I guess I focused on the 25 mg only. MA# 7 said she had been giving Resident # 66 her medications but had no response when asked how many tablets she had been giving her each day. MA# 7 pulled up one of the blister packages of the above medication administered and requested to be shown where the instructions were written. When the label was shown to her, she stated now I see, thank you. As MA #7 reviewed the MAR she stated Resident #66 recieved medications at 6 a.m. that morning ([MEDICATION NAME]). Interview on 6/11/15 at 12:47 p.m., the DON said medications should be administered as ordered by the MD and any discrepancy/confusions should be reported to the charge nurse or DON immediately. She said the medication aides had been trained to correctly administer medications in the past. The DON said upon resuming the DON position three weeks ago, she conducted competency checks on licensed nurses and medications aides to ensure they were adequately trained to perform duties. The DON stated the medication aide would be re-trained immediately. Record review of facility policy on medication administration dated 09/08 revealed that prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged the prescriber's orders are checked for the correct dosage schedule. The same policy revealed the medications were administered in accordance with the written physician order. Record review of the Drug Information Handbook for Nursing dated 2007 revealed the medication Carvedilol should be taken with food to minimize the risk of orthostatic [MEDICAL CONDITION]. On 6/11/2015 at 6:55 pm an IJ was identified and the Administrator was notified. The IJ was removed on 6/16/2015. The facility submitted and implemented the following plan to remove the IJ on 6/12/2015. Plan to remove immediacy: On 6/11/2015 at 8:00 pm the Charge nurse checked the vital signs for Resident #66 and observed resident for signs/symptoms of hypertension, headache, flushed cheeks and/or blurred vision. On 6/11/15 at 8:15 pm the DON rechecked resident #66 ' s B/P and it was noted to be 154/73. At 8:30 pm on 6/11/15 the Physician of Resident #66 ' s was notified of the B/P findings and the medication discrepancies. The resident ' s medication [MEDICATION NAME] was increased to 100 mg every 8 hours. On 6/11/15 at 8:00 pm, facility nurses began checking Resident #66 ' s B/P every 4 hours for the next 24 hours to monitor outcomes. On 6/11/15 at 8:30 pm the DON completed medication error reports on the [MEDICATION NAME] and Imdur. At 8:45 pm on 6/11/15 the Medical Director was notified and family was called 2 times, message was left with no return call. On 6/11/15 at 8:30 pm the Medication Aide (MA), was terminated for her performance. At 8:30 pm on 6/11/15 B/Ps and Pulses were obtained on all 96 residents in the facility to ensure no other problem existed with other residents. This was completed on 6/11/2015 at 9:30 pm. On 6/11/15 at 8:45 pm the MA's were in-serviced by the DON on reporting B/Ps that are above 180 or below 120. On 6/11/15 at 9:30 pm and again on 6/12/15 at 8:00 am the DON in-serviced the charge nurses on reporting to the physicians B/P above 180 at the time the vital sign is obtained. On 6/11/15 at 9:00 pm the DON started Med pass checks with the MA ' s on the 2-10 shift for skills performance by observing and verifying the MA followed the 7 rights for each medication x 15 meds on the evening medication pass and again on 6/12/15 at 8:30 am for the 6-2 shift. All MA's must complete and pass the Skills Check by 6/15/15 before they are allowed to pass medications. On 6/11/15 at 9:30 pm and again at 8:00 am on 6/12/15 the DON in-serviced the MA ' s on the rights of Medication Administration 1) Patient 2) Time 3) Medication 4) Dose 5) Route 6) Parameter and 7) Documentation. On 6/11/15 at 9:30 pm and again on 6/12/15 at 7:30 am the DON in-serviced the charge nurses to notify the physicians at the time an abnormal B/P is obtained and notify the RN if the physician does not answer or return calls within 30 minutes. On 6/11/15 at 8:30 pm the DON started Med Administration observations with the MAs on the 2-10 shift for random observations which will be conducted for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 7:30 am the DON stated random observations with the 6-2 MAs which will continue for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 8:30 am the Pharmacy Consultant was contacted by the Administrator to conduct a complete medication pass audit. The audit is scheduled to be conducted on Monday June 15, 2015. The Medical Director was contacted 6/12/15 at 9:00 am regarding the occurrence and parameters were given to notify physicians of any B/P above 180. IJ plan of removal addendum revealed additional corrective actions added 6/14/2015 by the facility were: On June 13 2015 a RN Clinical Consultant and a facility RN completed chart audits on 100 % of the active residents with orders for cardiac medications. On June 13, 2015 audits of Medication Administration Sheets for 100% of the active residents was completed by RN Clinical Consultant and a facility RN to identify residents who have/need vital sign parameters for per administration actions related to cardiac medication orders. Attending MD /designee was notified and parameters for pre administration of cardiac medications was obtained on June 13/2015 Education was provided by RN Clinical Consultant to MA and charge nurses on 6/13/2015 and 6/14/2015 on Medication Administration, MA guidelines , common cardiovascular medications, medications that affect the cardiovascular system, documentation related to vital sign parameters, change sticker usage, drug reference books usage, notification procedures relating to change of conditions, medication administration and parameters. Pre and Post tests were provided for the educational in-service. IJ plan of removal addendum revealed additional corrective actions added 6/16/2015 by the facility were: Residents identified during the monitoring process on 6/15/2015 were audited and the missing medications on the cart were restocked. Residents identified during the monitoring process on 6/15/2015 had full chart reviews with attention focused on physician's order [REDACTED]. All medication carts were compared to the current residents MARs to ensure drug availability on 6/15/2015. Education was provided on 6/16/2015 to all MAs and LVNs concerning medication ordering and reordering by the DON. Starting 6/16/2015 the DON/designee will conduct compliance monitoring through a review of the physician's order [REDACTED]. Monitoring of the plan to remove the immediate jeopardy: Monitoring began on 6/12/15. LVNs and MA were interviewed on three of three shifts concerning medication administration, documentation, and physician notification. Record review of the facility In-Services revealed: 6/11/15-- Eight staff members trained on staff reporting all negative findings to the charge nurse; and the 7 rights of medication administration. 12 staff members trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, Recommendation) tool. 6/12/15- Ten staff members were trained on parameters of systolic blood pressure over 180 or below 120. Ten staff members were trained on medication [MEDICATION NAME] must take medication with food or milk and the benefits of the medication. 6/13/15-6/14/15-Fourteen staff members were trained by the nurse consultant on medications that affect the cardiovascular system, common cardiovascular medications, medication administration documentation related to vital sign parameters, direction changes and the use of sticker use, and utilizing Drug Reference books for any vital signs monitoring prior to administration of medications. Also seven staff were in-serviced on administering oral medications, documentation of medication administration, and medication aide/LVN guidelines of general medication administration. Interview on 6/14/15 at 3:59 PM, the RN Nurse Consultant stated she did chart audits and found 60 residents did not have any blood pressure parameters and contacted the physicians to get parameters. She stated she rewrote all the cardiac medication orders, updated the resident ' s MAR and highlighted discontinued medications in yellow. She further stated she had completed in-services on documentation, problem solving, and handed out handouts to the staff, and administered a Pre/Post test over common medications. Observation on 6/15/15 at 4:45 PM, during a medication cart review with the DON that was conducted on RN #6 ' s cart revealed five discrepancies of medication for Resident #22. The findings included: Vitamin C and [MEDICATION NAME] 160 mg/15 mL, liquid multivitamin, and Sugar Free Protast, were not found on the cart. Resident #22 was receiving ProMod Liquid Protein that had 13 grams of sugar. [MEDICATION NAME] was not found for Resident #22 in the medication refrigerator. Record review of the contracted Pharmacist review, dated 6/15/15, revealed the Pharmacist had performed four observations of medication administrations with two LVN and two MA. Her findings included: found discrepancies between the medication in the cart compared to the Resident ' s MAR. She further documented that she recommended the staff ensure proper hand washing/sanitizing between each resident and ensuring medication was available in the cart. Record review of Medication Pass In-service, dated 6/15/15 through 6/16/15 revealed five staff members were trained on proper hand-sanitizing and washing techniques, importance of reconciling medication in the cart with the resident's MAR and to use change of directions stickers or notify nurse of any necessary updated to the MAR, and proper documentation on MAR immediately after medication was administered. Record review of In-service, dated 6/16/15, the DON trained five staff members on reordering of scheduled medications and PRN (as needed ) medications, and notifying the DON immediately of non-available medications for follow-up to ensure medications were available at all times. Observation with two different medication aides, the DON, and QA nurse (LVN 7) on 6/16/2015 from 4:25 P.M. to 5:15 P.M. revealed the medication carts reviewed on the 100, 200, 300, and 400 halls had all the medications available for the medication administration for the entire day for the six residents reviewed. Interviews with three MAs, and two LVNs on 6/16/15 between 4:25 P.M. and 5:15 P.M. during the medication cart reviews revealed they all had knowledge and could verbalize the medication pass verifications which must be completed with each resident with each administration including the 7 rights they had recently been in-serviced on. Record review of the in-service forms provided by the Administrator dated 6/11/15, 6/13/15, 6/14/15 and 6/16/15 revealed in-services concerning the reordering of medications, the availability of medications for residents, the rights of the medication administration, and medications concerning the cardiovascular system and the importance of vital sign parameters. Interview on 6/16/2015 at 5:20 P.M. the pharmacy consultant stated she had conducted a medication pass with two MAs and three LVNs and had no medication errors identified. Record review of the pharmacy consultant report dated 6/16/2015 revealed the findings from the medication pass conducted with the MAs and LVNs which revealed no issues noted. Interview on 6/16/2015 at 5:25 P.M. the DON stated she would be continuing to do medication verification audits every morning with her staff. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on 6/16/2015 at 5:30 P.M. While the IJ was removed on 6/16/2015 the facility remained out of compliance at a scope of pattern at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents with hypertension were receiving physician ordered medications , treatments and consultations as their condition requires. The DON reported there were 78 residents in the facility with [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility's Administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical wellbeing of one of 17 residents (Resident #66) reviewed for their highest practicable well-being. The facility ' s Administrator failed to supervise the DON on training the nursing staff on consulting with the physician when Resident #66 ' s blood pressure was elevated to 232/97. The facility ' s Administrator failed to supervise the DON on training the nursing staff on assessing and treating residents who were experiencing abnormal blood pressures. The facility's Administrator failed to supervise the DON on training the nursing staff on the administration of medications as ordered by the physician. The facility's DON failed to train and monitor the nursing staff on consulting physician's concerning abnormal blood pressure. The facility's DON failed to train and monitor the nursing staff on assessing, treating and managing residents with abnormal blood pressure. An immediate jeopardy (IJ) was identified on 6/11/15. While the IJ was removed on 6/16/15, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. These failures affected one residents causing them abnormally blood pressure which could cause a cardiovascular accident (stroke) and placed an additional 77 residents at risk of pain, headaches, and stroke; and not having the physician consulted when their blood pressure elevated and was not managed effectively. Findings Include: Record review of Resident #66 ' s admission assessment dated [DATE] revealed the resident came from another nursing home facility. Her vital signs upon admission included a B/P of 134/68 and a pulse of 50. Her weight was 124 pounds. She was alert and oriented to person, place and time. She had no behaviors and reported her usual time to awake was 6:00 a.m. Resident #66 blood pressure was 232/93 on 6/10/15 at 9:39 AM. She was ordered to have Hydralizine 75 mg, but was administered 25 mg. Her medication [MEDICATION NAME] 12.5 mg was to be given with food and was given at 10:13 AM without food.[MEDICATION NAME][MEDICATION NAME] 40 mg extended release (ER) was ordered to be taken upon rising, it was administered at 10:13 AM. MA#7 did not report to the charge nurse until after 11:00 AM. Resident #66's blood pressure of 232/93. LVN #14 reassessed Resident #66's blood pressure to be 185/85, but did not consult the physician. Please refer to this CMS form 2567, dated 6/17/2015, tags F157, F282, F309 and F333 for the evidence of the deficient practices. Interview on 6/11/15 at 2:50 PM, the Administrator was interviewed concerning the Quality Assurance Committee. She stated the committee included the DON and all the department heads and met at least quarterly. She stated the last meeting was held on 5/29/15 and issues were identified with notifying families and physicians of a change in resident ' s conditions. She stated that was an ongoing issue that had not been resolved. She further stated the DON was responsible for implementing orders by the physicians. She stated the previous DON was not holding the staff responsible for their actions and the current DON was counseling staff and issuing write-ups concerning their job performances. The Administrator stated she meets with the DON daily to assess effectiveness of the nursing care or to discuss resident issues and nursing interventions. Interview on 6/11/15 at 6:55 PM, the Administrator and DON stated they were unaware of the facility's system failure with medication administration and assessment documentation. They were aware and the QA committee was acting on the physician notification system. They both stated the facility staff was working diligently to enforce the policy and procedures concerning residents with blood pressure issues, documentation, and physician notification. Record review of the DON ' s employee file revealed she had previously been the DON of the facility (dates not specific) and was rehired on 5/18/15. Record review of MA #7 ' s employee file revealed she was hired on 11/19/13 as a medication aide and was terminated on 6/11/15. She had an active MA certificate that would expire on 9/22/15 and active CNA license that did not expire until 11/26/16. Further review revealed she was previously counseled by the current DON ong 9/15/14 for not performing required narcotic counts and on 1/21/15 for not giving medications correctlly for medication errors and failure to document medications during administration. Record review of RN #6 ' s employee file revealed he was hired on 6/14/12 and was the weekend RN supervisor. Further review revealed he was previously hired as the facility ' s DON. His RN license was current and did not expire until 11/30/15. Record review of LVN #14 ' s employee file revealed she was hired on 4/29/15 and had an active LVN license that did not expire until 12/31/16. Further review revealed she had previously been counseled on 6/4/15 by the current DON for failure to notify the family of resident changes and charge nurse duties. Record review of the facility ' s Administering Oral Medications policy, dated 4/2007, revealed the steps included selecting the drug from the unit dose drawer or stock supply, check the label on the medication and confirm the medication name and dose with the MAR. Check the expiration date on the medication. Return any expired medications to the pharmacy. Check the medication dose. Re-check to confirm the proper dose. Prepare the correct dose of medication. Confirm the identity of the resident. Explain the procedure to the resident. Record review of the facility ' s Documentation of Medication policy, dated 4/2007, revealed the nurse or medication aide shall document all medication administered to each resident on the resident ' s MAR and must be documented immediately after (never before) it was given. On 6/11/2015 at 6:55 pm an IJ was identified and the Administrator was notified. The IJ was removed on 6/16/2015. The facility submitted and implemented the following plan to remove the IJ on 6/12/2015. Plan to remove immediacy: On 6/11/2015 at 8:00 pm the Charge nurse checked the vital signs for Resident #66 and observed resident for signs/symptoms of hypertension, headache, flushed cheeks and/or blurred vision. On 6/11/15 at 8:15 pm the DON rechecked resident #66 ' s B/P and it was noted to be 154/73. At 8:30 pm on 6/11/15 the Physician of Resident #66 ' s was notified of the B/P findings and the medication discrepancies. The resident ' s medication [MEDICATION NAME] was increased to 100 mg every 8 hours. On 6/11/15 at 8:00 pm, facility nurses began checking Resident #66 ' s B/P every 4 hours for the next 24 hours to monitor outcomes. On 6/11/15 at 8:30 pm the DON completed medication error reports on the [MEDICATION NAME] and Imdur. At 8:45 pm on 6/11/15 the Medical Director was notified and family was called 2 times, message was left with no return call. On 6/11/15 at 8:30 pm the Medication Aide (MA), was terminated for her performance. At 8:30 pm on 6/11/15 B/Ps and Pulses were obtained on all 96 residents in the facility to ensure no other problem existed with other residents. This was completed on 6/11/2015 at 9:30 pm. On 6/11/15 at 8:45 pm the MA's were in-serviced by the DON on reporting B/Ps that are above 180 or below 120. On 6/11/15 at 9:30 pm and again on 6/12/15 at 8:00 am the DON in-serviced the charge nurses on reporting to the physicians B/P above 180 at the time the vital sign is obtained. On 6/11/15 at 9:00 pm the DON started Med pass checks with the MA ' s on the 2-10 shift for skills performance by observing and verifying the MA followed the 7 rights for each medication x 15 meds on the evening medication pass and again on 6/12/15 at 8:30 am for the 6-2 shift. All MA's must complete and pass the Skills Check by 6/15/15 before they are allowed to pass medications. On 6/11/15 at 9:30 pm and again at 8:00 am on 6/12/15 the DON in-serviced the MA ' s on the rights of Medication Administration 1) Patient 2) Time 3) Medication 4) Dose 5) Route 6) Parameter and 7) Documentation. On 6/11/15 at 9:30 pm and again on 6/12/15 at 7:30 am the DON in-serviced the charge nurses to notify the physicians at the time an abnormal B/P is obtained and notify the RN if the physician does not answer or return calls within 30 minutes. On 6/11/15 at 8:30 pm the DON started Med Administration observations with the MAs on the 2-10 shift for random observations which will be conducted for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 7:30 am the DON stated random observations with the 6-2 MAs which will continue for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 8:30 am the Pharmacy Consultant was contacted by the Administrator to conduct a complete medication pass audit. The audit is scheduled to be conducted on Monday June 15, 2015. The Medical Director was contacted 6/12/15 at 9:00 am regarding the occurrence and parameters were given to notify physicians of any B/P above 180. IJ plan of removal addendum revealed additional corrective actions added 6/14/2015 by the facility were: On June 13 2015 a RN Clinical Consultant and a facility RN completed chart audits on 100 % of the active residents with orders for cardiac medications. On June 13, 2015 audits of Medication Administration Sheets for 100% of the active residents was completed by RN Clinical Consultant and a facility RN to identify residents who have/need vital sign parameters for per administration actions related to cardiac medication orders. Attending MD /designee was notified and parameters for pre administration of cardiac medications was obtained on June 13/2015 Education was provided by RN Clinical Consultant to MA and charge nurses on 6/13/2015 and 6/14/2015 on Medication Administration, MA guidelines , common cardiovascular medications, medications that affect the cardiovascular system, documentation related to vital sign parameters, change sticker usage, drug reference books usage, notification procedures relating to change of conditions, medication administration and parameters. Pre and Post tests were provided for the educational in-service. IJ plan of removal addendum revealed additional corrective actions added 6/16/2015 by the facility were: Residents identified during the monitoring process on 6/15/2015 were audited and the missing medications on the cart were restocked. Residents identified during the monitoring process on 6/15/2015 had full chart reviews with attention focused on physician's order [REDACTED]. All medication carts were compared to the current residents MARs to ensure drug availability on 6/15/2015. Education was provided on 6/16/2015 to all MAs and LVNs concerning medication ordering and reordering by the DON. Starting 6/16/2015 the DON/designee will conduct compliance monitoring through a review of the physician's order [REDACTED]. Monitoring of the plan to remove the immediate jeopardy: Monitoring began on 6/12/15. LVNs and MA were interviewed on three of three shifts concerning medication administration, documentation, and physician notification. Record review of the facility In-Services revealed: 6/11/15-- Eight staff members trained on staff reporting all negative findings to the charge nurse; and the 7 rights of medication administration. 12 staff members trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, Recommendation) tool. 6/12/15- Ten staff members were trained on parameters of systolic blood pressure over 180 or below 120. Ten staff members were trained on medication [MEDICATION NAME] must take medication with food or milk and the benefits of the medication. 6/13/15-6/14/15-Fourteen staff members were trained by the nurse consultant on medications that affect the cardiovascular system, common cardiovascular medications, medication administration documentation related to vital sign parameters, direction changes and the use of sticker use, and utilizing Drug Reference books for any vital signs monitoring prior to administration of medications. Also seven staff were in-serviced on administering oral medications, documentation of medication administration, and medication aide/LVN guidelines of general medication administration. Interview on 6/14/15 at 3:59 PM, the RN Nurse Consultant stated she did chart audits and found 60 residents did not have any blood pressure parameters and contacted the physicians to get parameters. She stated she rewrote all the cardiac medication orders, updated the resident ' s MAR and highlighted discontinued medications in yellow. She further stated she had completed in-services on documentation, problem solving, and handed out handouts to the staff, and administered a Pre/Post test over common medications. Observation on 6/15/15 at 4:45 PM, during a medication cart review with the DON that was conducted on RN #6 ' s cart revealed five discrepancies of medication for Resident #22. The findings included: Vitamin C and [MEDICATION NAME] 160 mg/15 mL, liquid multivitamin, and Sugar Free Protast, were not found on the cart. Resident #22 was receiving ProMod Liquid Protein that had 13 grams of sugar. [MEDICATION NAME] was not found for Resident #22 in the medication refrigerator. Record review of the contracted Pharmacist review, dated 6/15/15, revealed the Pharmacist had performed four observations of medication administrations with two LVN and two MA. Her findings included: found discrepancies between the medication in the cart compared to the Resident ' s MAR. She further documented that she recommended the staff ensure proper hand washing/sanitizing between each resident and ensuring medication was available in the cart. Record review of Medication Pass In-service, dated 6/15/15 through 6/16/15 revealed five staff members were trained on proper hand-sanitizing and washing techniques, importance of reconciling medication in the cart with the resident's MAR and to use change of directions stickers or notify nurse of any necessary updated to the MAR, and proper documentation on MAR immediately after medication was administered. Record review of In-service, dated 6/16/15, the DON trained five staff members on reordering of scheduled medications and PRN (as needed ) medications, and notifying the DON immediately of non-available medications for follow-up to ensure medications were available at all times. Observation with two different medication aides, the DON, and QA nurse (LVN 7) on 6/16/2015 from 4:25 P.M. to 5:15 P.M. revealed the medication carts reviewed on the 100, 200, 300, and 400 halls had all the medications available for the medication administration for the entire day for the six residents reviewed. Interviews with three MAs, and two LVNs on 6/16/15 between 4:25 P.M. and 5:15 P.M. during the medication cart reviews revealed they all had knowledge and could verbalize the medication pass verifications which must be completed with each resident with each administration including the 7 rights they had recently been in-serviced on. Record review of the in-service forms provided by the Administrator dated 6/11/15, 6/13/15, 6/14/15 and 6/16/15 revealed in-services concerning the reordering of medications, the availability of medications for residents, the rights of the medication administration, and medications concerning the cardiovascular system and the importance of vital sign parameters. Interview on 6/16/2015 at 5:20 P.M. the pharmacy consultant stated she had conducted a medication pass with two MAs and three LVNs and had no medication errors identified. Record review of the pharmacy consultant report dated 6/16/2015 revealed the findings from the medication pass conducted with the MAs and LVNs which revealed no issues noted. Interview on 6/16/2015 at 5:25 P.M. the DON stated she would be continuing to do medication verification audits every morning with her staff. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on 6/16/2015 at 5:30 P.M. While the IJ was removed on 6/16/2015 the facility remained out of compliance at a scope of pattern at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents with hypertension were receiving physician ordered medications , treatments and consultations as their condition requires. The facility CMS form 2567 revealed a census of 97 residents.

Based on observation, interview, and record review, the facility failed to consult with the physician when a change of condition occurred for one of 17 residents (Residents # 66) reviewed for changes in conditions. Resident #66 ' s physician was not promptly consulted when the resident's blood pressure elevated to 232/93 on 6/10/15. An immediate jeopardy (IJ) was identified on 6/11/15. While the IJ was removed on 6/16/15, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a isolated. This failure affected one resident by causing a delay in treatment placing her at risk of a cerbrovascular accident (stroke) and placed 77 residents with [DIAGNOSES REDACTED]. Findings include: Resident #66 Record review of Resident # 66 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #66 ' s admission assessment dated [DATE] revealed the resident came from another nursing home facility. Her vital signs upon admission included a B/P of 134/68 and a pulse of 50. Her weight was 124 pounds. She was alert and oriented to person, place and time. She had no behaviors and reported her usual time to awake was 6:00 a.m. Observation and interview on 6/10/15 at 9:39 a.m., revealed MA# 7 checked Resident # 66 ' s blood pressure using a wrist cuff apparatus and obtained a reading of 232/93 mm Hg. MA#7 at this time stated Resident # 66 ' s blood pressure was usually high and proceeded to prepare her morning medications. Observation on 6/10/15 at 9:42 a.m., MA # 7 prepared the resident's A.M. medications to include: One 25 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 0.2 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 12.5 mg tablet of Carvedilol (used to treat high blood pressure). One 40 mg tablet of Isosprbide [MEDICATION NAME] ER (used to treat [MEDICAL CONDITION] by dialtating arteries and veins ). One 150 mg tablet of Irbesartan (used to treat high blood pressure). One 10 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). Observation on 6/10/15 at 10:13 a.m., MA# 7 administered a total of 14 tablets/medications by mouth to Resident # 66, which included only one tablet of the [MEDICATION NAME]. MA #7 did not notify the resident ' s nurse concerning Resident #66's elevated blood pressure of 232/93. Record review of Resident # 66 ' s admission orders [REDACTED] [MEDICATION NAME] HCL 25 mg PO, give 3 tablets TID (three times a day) . [MEDICATION NAME] 40 mg PO daily [MEDICATION NAME] 0.2 mg tablet PO every 12 hours Carvedilol 12.5 mg PO every 12 hours Irbesartan 150 mg tablet PO daily. [MEDICATION NAME] 10 mg tablet PO daily. Record review of Resident #66 ' s MAR dated June 2015 also revealed the same medications as the admission orders [REDACTED] Review of Resident #66 ' s MAR dated June 2015 revealed blood pressure records at 9 a.m. as ; 6/4/15- 167/79 6/5/15- 167/unreadable 6/6/15 -154/74 6/7/15-153/65 6/8 and 6/9/15 were unreadable 6/10/15 -232/93 Interview following the observation on 6/10/15 at 10:13 a.m., , MA # 7 when asked what she was required to do following obtaining an elevated blood pressure reading on a resident, stated she would notify the nurse. When asked what she considered to be a high blood pressure she stated it depended on the resident. Interview on 6/10/15 at 2:00 p.m., LVN #14 said MA # 7 informed her of Resident # 66 ' s blood pressure reading was 232/93 a little after 11:00 a.m., LVN # 14 said she checked Resident # 66 ' s blood pressure again and it was 185/85. LVN # 14 stated she did not see the need to call the physician because the resident had a [DIAGNOSES REDACTED]. LVN # 14 also said Resident # 66 ' s blood pressure was usually high. Record review of Resident # 66 ' s nurses ' notes dated 6/10/15 for 6-2 shift ( no time) revealed staff reported that resident ' s blood pressure was very high when checked. Blood pressure reassessed by this nurse at 185/85, heart rate 80, respiration 18 and temperature 98.2. Respiration was even and unlabored , skin dry and warm to touch, drank water and call light at reach . Note was written by LVN # 14. A request was made for a policy concerning consulting a physician upon changes of resident's conditions but none was provided prior to exit. On 6/11/2015 at 6:55 pm an IJ was identified and the Administrator was notified. The IJ was removed on 6/16/2015. The facility submitted and implemented the following plan to remove the IJ on 6/12/2015. Plan to remove immediacy: On 6/11/2015 at 8:00 pm the Charge nurse checked the vital signs for Resident #66 and observed resident for signs/symptoms of hypertension, headache, flushed cheeks and/or blurred vision. On 6/11/15 at 8:15 pm the DON rechecked resident #66 ' s B/P and it was noted to be 154/73. At 8:30 pm on 6/11/15 the Physician of Resident #66 ' s was notified of the B/P findings and the medication discrepancies. The resident ' s medication [MEDICATION NAME] was increased to 100 mg every 8 hours. On 6/11/15 at 8:00 pm, facility nurses began checking Resident #66 ' s B/P every 4 hours for the next 24 hours to monitor outcomes. On 6/11/15 at 8:30 pm the DON completed medication error reports on the [MEDICATION NAME] and Isosprbide [MEDICATION NAME] ER . At 8:45 pm on 6/11/15 the Medical Director was notified and family was called 2 times, message was left with no return call. On 6/11/15 at 8:30 pm the Medication Aide (MA), was terminated for her performance. At 8:30 pm on 6/11/15 B/Ps and Pulses were obtained on all 96 residents in the facility to ensure no other problem existed with other residents. This was completed on 6/11/2015 at 9:30 pm. On 6/11/15 at 8:45 pm the MA's were in-serviced by the DON on reporting B/Ps that are above 180 or below 120. On 6/11/15 at 9:30 pm and again on 6/12/15 at 8:00 am the DON in-serviced the charge nurses on reporting to the physicians B/P above 180 at the time the vital sign is obtained. On 6/11/15 at 9:00 pm the DON started Med pass checks with the MA ' s on the 2-10 shift for skills performance by observing and verifying the MA followed the 7 rights for each medication x 15 meds on the evening medication pass and again on 6/12/15 at 8:30 am for the 6-2 shift. All MA's must complete and pass the Skills Check by 6/15/15 before they are allowed to pass medications. On 6/11/15 at 9:30 pm and again at 8:00 am on 6/12/15 the DON in-serviced the MA ' s on the rights of Medication Administration 1) Patient 2) Time 3) Medication 4) Dose 5) Route 6) Parameter and 7) Documentation. On 6/11/15 at 9:30 pm and again on 6/12/15 at 7:30 am the DON in-serviced the charge nurses to notify the physicians at the time an abnormal B/P is obtained and notify the RN if the physician does not answer or return calls within 30 minutes. On 6/11/15 at 8:30 pm the DON started Med Administration observations with the MAs on the 2-10 shift for random observations which will be conducted for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 7:30 am the DON stated random observations with the 6-2 MAs which will continue for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 8:30 am the Pharmacy Consultant was contacted by the Administrator to conduct a complete medication pass audit. The audit is scheduled to be conducted on Monday June 15, 2015. The Medical Director was contacted 6/12/15 at 9:00 am regarding the occurrence and parameters were given to notify physicians of any B/P above 180. IJ plan of removal addendum revealed additional corrective actions added 6/14/2015 by the facility were: On June 13 2015 a RN Clinical Consultant and a facility RN completed chart audits on 100 % of the active residents with orders for cardiac medications. On June 13, 2015 audits of Medication Administration Sheets for 100% of the active residents was completed by RN Clinical Consultant and a facility RN to identify residents who have/need vital sign parameters for per administration actions related to cardiac medication orders. Attending MD /designee was notified and parameters for pre administration of cardiac medications was obtained on June 13/2015 Education was provided by RN Clinical Consultant to MA and charge nurses on 6/13/2015 and 6/14/2015 on Medication Administration, MA guidelines , common cardiovascular medications, medications that affect the cardiovascular system, documentation related to vital sign parameters, change sticker usage, drug reference books usage, notification procedures relating to change of conditions, medication administration and parameters. Pre and Post tests were provided for the educational in-service. IJ plan of removal addendum revealed additional corrective actions added 6/16/2015 by the facility were: Residents identified during the monitoring process on 6/15/2015 were audited and the missing medications on the cart were restocked. Residents identified during the monitoring process on 6/15/2015 had full chart reviews with attention focused on physician's order [REDACTED]. All medication carts were compared to the current residents MARs to ensure drug availability on 6/15/2015. Education was provided on 6/16/2015 to all MAs and LVNs concerning medication ordering and reordering by the DON. Starting 6/16/2015 the DON/designee will conduct compliance monitoring through a review of the physician's order [REDACTED]. Monitoring of the plan to remove the immediate jeopardy: Monitoring began on 6/12/15. LVNs and MAs were interviewed on three of three shifts concerning medication administration, documentation, and physician notification. Record review of the facility In-Services revealed: 6/11/15-- Eight staff members trained on staff reporting all negative findings to the charge nurse; and the 7 rights of medication administration. 12 staff members trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, Recommendation) tool. 6/12/15- Ten staff members were trained on parameters of systolic blood pressure over 180 or below 120. Ten staff members were trained on medication [MEDICATION NAME] must take medication with food or milk and the benefits of the medication. 6/13/15-6/14/15-Fourteen staff members were trained by the nurse consultant on medications that affect the cardiovascular system, common cardiovascular medications, medication administration documentation related to vital sign parameters, direction changes and the use of sticker use, and utilizing Drug Reference books for any vital signs monitoring prior to administration of medications. Also seven staff were in-serviced on administering oral medications, documentation of medication administration, and medication aide/LVN guidelines of general medication administration. Interview on 6/14/15 at 3:59 PM, the RN Nurse Consultant stated she did chart audits and found 60 residents did not have any blood pressure parameters and contacted the physicians to get parameters. She stated she rewrote all the cardiac medication orders, updated the resident ' s MAR and highlighted discontinued medications in yellow. She further stated she had completed in-services on documentation, problem solving, and handed out handouts to the staff, and administered a Pre/Post test over common medications. Observation on 6/15/15 at 4:45 PM, during a medication cart review with the DON that was conducted on RN #6 ' s cart revealed five discrepancies of medication for Resident #22. The findings included: Vitamin C and [MEDICATION NAME] 160 mg/15 mL, liquid multivitamin, and Sugar Free Protast, were not found on the cart. Resident #22 was receiving ProMod Liquid Protein that had 13 grams of sugar. [MEDICATION NAME] was not found for Resident #22 in the medication refrigerator. Record review of the contracted Pharmacist review, dated 6/15/15, revealed the Pharmacist had performed four observations of medication administrations with two LVN and two MA. Her findings included: found discrepancies between the medication in the cart compared to the Resident ' s MAR. She further documented that she recommended the staff ensure proper hand washing/sanitizing between each resident and ensuring medication was available in the cart. Record review of Medication Pass In-service, dated 6/15/15 through 6/16/15 revealed five staff members were trained on proper hand-sanitizing and washing techniques, importance of reconciling medication in the cart with the resident's MAR and to use change of directions stickers or notify nurse of any necessary updated to the MAR, and proper documentation on MAR immediately after medication was administered. Record review of In-service, dated 6/16/15, the DON trained five staff members on reordering of scheduled medications and PRN (as needed ) medications, and notifying the DON immediately of non-available medications for follow-up to ensure medications were available at all times. Observation with two different medication aides, the DON, and QA nurse (LVN 7) on 6/16/2015 from 4:25 P.M. to 5:15 P.M. revealed the medication carts reviewed on the 100, 200, 300, and 400 halls had all the medications available for the medication administration for the entire day for the six residents reviewed. Interviews with three MAs, and two LVNs on 6/16/15 between 4:25 P.M. and 5:15 P.M. during the medication cart reviews revealed they all had knowledge and could verbalize the medication pass verifications which must be completed with each resident with each administration including the 7 rights they had recently been in-serviced on. Record review of the in-service forms provided by the Administrator dated 6/11/15, 6/13/15, 6/14/15 and 6/16/15 revealed in-services concerning the reordering of medications, the availability of medications for residents, the rights of the medication administration, and medications concerning the cardiovascular system and the importance of vital sign parameters. Interview on 6/16/2015 at 5:20 P.M. the pharmacy consultant stated she had conducted a medication pass with two MAs and three LVNs and had no medication errors identified. Record review of the pharmacy consultant report dated 6/16/2015 revealed the findings from the medication pass conducted with the MAs and LVNs which revealed no issues noted. Interview on 6/16/2015 at 5:25 P.M. the DON stated she would be continuing to do medication verification audits every morning with her staff. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on 6/16/2015 at 5:30 P.M. While the IJ was removed on 6/16/2015 the facility remained out of compliance at a scope of isolated at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents with hypertension were receiving physician ordered medications , treatments and consultations as their condition requires. The facility reported 78 residents with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the assessment for one of 24 residents (Resident #66) reviewed for care. The facility failed to Promptly notify the charge nurse of Resident # 66 ' s elevated blood pressure of 232/93 when taken by MA#7. Promptly notify Resident #66 ' s MD of the elevated blood pressure of 232/93 or LVN #14's assessment of 185/85 one hour later. Administer to Resident #66 the antihyptertensive [MEDICATION NAME] 75 mg. medication as ordered. The resident received only 25 mg of the medication when Resident # 66's blood pressure was 232/93. An immediate jeopardy (IJ) was identified on 6/11/15. While the IJ was removed on 6/16/15, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a isolated. This failure affected one resident whose hypertension was not managed and placed her at risk for a cerbrovascular accident (stroke) and placed 77 residents in the facility with hypertension at risk of poor quality of care and life. These failures could cause the residents to have a rapid decline in health due to [MEDICAL CONDITION]. Findings include: Record review of Resident # 66 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #66 ' s admission assessment dated [DATE] revealed the resident came from another nursing home facility. Her vital signs upon admission included a B/P of 134/68 and a pulse of 50. Her weight was 124 pounds. She was alert and oriented to person, place and time. She had no behaviors and reported her usual time to awake was 6:00 a.m. Observation on 6/10/15 at 9:39 a.m., revealed MA# 7 checked Resident # 66 ' s blood pressure using a wrist cuff apparatus and obtained a reading of 232/93 mm Hg. MA#7 at this time stated Resident # 66 ' s blood pressure was usually high and proceeded to prepare her morning medications. Observation on 6/10/15 at 9:42 a.m., MA # 7 prepared the resident's A.M. medications to include: One 25 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 0.2 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). One 12.5 mg tablet of Carvedilol (used to treat high blood pressure). One 40 mg tablet of Isosprbide [MEDICATION NAME] ER (used to treat [MEDICAL CONDITION] by dialtating arteries and veins ). One 150 mg tablet of Irbesartan (used to treat high blood pressure). One 10 mg tablet of [MEDICATION NAME] (used to treat high blood pressure). Observation on 6/10/15 at 10:13 a.m., MA# 7 administered a total of 14 tablets/medications by mouth to Resident # 66, which included only one tablet of the [MEDICATION NAME]. MA #7 did not notify the resident ' s nurse concerning Resident #66's elevated blood pressure of 232/93. Record review of Resident # 66 ' s admission ordered dated 6/3/15 reveled the following: [MEDICATION NAME] HCL 25 mg PO, give 3 tablets. [MEDICATION NAME] 40 mg PO daily. [MEDICATION NAME] 0.2 mg tablet PO every 12 hours. Carvedilol 12.5 mg PO every 12 hours. Irbesartan 150 mg tablet PO daily. [MEDICATION NAME] 10 mg tablet PO daily. Record review of Resident #66 ' s MAR dated June 2015 also revealed the same physician admission orders [REDACTED] Further review of Resident #66 ' s MAR dated June 2015 revealed the resident's blood pressure record at 9 am; 6/4/15- 167/79 6/5/15- 167/unreadable 6/6/15 -154/74 6/7/15-153/65 6/8 and 6/9/15 were unreadable 6/10/15 -232/93 Interview on 6/10/15 at 10:13 a.m., , MA # 7 when asked what she was required to do following elevated blood pressure readings, MA#7 stated she would notify the nurse. Interview on 6/10/15 at 2:00 p.m., LVN #14 said MA # 7 informed her of Resident # 66 ' s blood pressure reading of 232/93 a little after 11:00 a.m. LVN # 14 said she checked Resident # 66 ' s blood pressure again and it was 185/85. LVN # 14 stated she did not see the need to call the physician because the resident had a [DIAGNOSES REDACTED].# 14 also said Resident # 66 ' s blood pressure was usually high. Record review of Resident # 66 ' s nurses ' notes dated 6/10/15 for 6-2 shift ( no time) revealed staff reported that resident ' s blood pressure was very high when checked. Blood pressure reassessed by this nurse at 185/85, heart rate 80, respiration 18 and temperature 98.2. Respiration was even and unlabored , skin dry and warm to touch, drank water and call light at reach . Note was written by LVN # 14. Interview on 6/11/15 at 12:47 p.m., the DON said medications should be administered as ordered by the MD and any discrepancy/confusions should be reported to the charge nurse or DON immediately. She said the aides were trained to correctly administer mediations. The DON said upon resuming the DON position three weeks ago, she conducted competency checks on licensed nurses and medications aides to ensure they were adequately trained to perform duties. The DON said she expected the medication aide to notify the charge nurse of Resident # 66 ' s elevated blood pressure immediately before administering her medications. The DON also agreed the charge nurse should have contacted the resident ' s physician immediately. Record review of facility policy on medication administration dated 09/08 revealed that prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged the prescriber's orders are checked for the correct dosage schedule. The same policy revealed the medications were administered in accordance with the written physician order. A request was made for a policy concerning identifying/treating resident's change of conditions but was not provided prior to exit. On 6/11/2015 at 6:55 pm an IJ was identified and the Administrator was notified. The IJ was removed on 6/16/2015. The facility submitted and implemented the following plan to remove the IJ on 6/12/2015. Plan to remove immediacy: On 6/11/2015 at 8:00 pm the Charge nurse checked the vital signs for Resident #66 and observed resident for signs/symptoms of hypertension, headache, flushed cheeks and/or blurred vision. On 6/11/15 at 8:15 pm the DON rechecked resident #66 ' s B/P and it was noted to be 154/73. At 8:30 pm on 6/11/15 the Physician of Resident #66 ' s was notified of the B/P findings and the medication discrepancies. The resident ' s medication [MEDICATION NAME] was increased to 100 mg every 8 hours. On 6/11/15 at 8:00 pm, facility nurses began checking Resident #66 ' s B/P every 4 hours for the next 24 hours to monitor outcomes. On 6/11/15 at 8:30 pm the DON completed medication error reports on the [MEDICATION NAME] and Imdur. At 8:45 pm on 6/11/15 the Medical Director was notified and family was called 2 times, message was left with no return call. On 6/11/15 at 8:30 pm the Medication Aide (MA), was terminated for her performance. At 8:30 pm on 6/11/15 B/Ps and Pulses were obtained on all 96 residents in the facility to ensure no other problem existed with other residents. This was completed on 6/11/2015 at 9:30 pm. On 6/11/15 at 8:45 pm the MA's were in-serviced by the DON on reporting B/Ps that are above 180 or below 120. On 6/11/15 at 9:30 pm and again on 6/12/15 at 8:00 am the DON in-serviced the charge nurses on reporting to the physicians B/P above 180 at the time the vital sign is obtained. On 6/11/15 at 9:00 pm the DON started Med pass checks with the MA ' s on the 2-10 shift for skills performance by observing and verifying the MA followed the 7 rights for each medication x 15 meds on the evening medication pass and again on 6/12/15 at 8:30 am for the 6-2 shift. All MA's must complete and pass the Skills Check by 6/15/15 before they are allowed to pass medications. On 6/11/15 at 9:30 pm and again at 8:00 am on 6/12/15 the DON in-serviced the MA ' s on the rights of Medication Administration 1) Patient 2) Time 3) Medication 4) Dose 5) Route 6) Parameter and 7) Documentation. On 6/11/15 at 9:30 pm and again on 6/12/15 at 7:30 am the DON in-serviced the charge nurses to notify the physicians at the time an abnormal B/P is obtained and notify the RN if the physician does not answer or return calls within 30 minutes. On 6/11/15 at 8:30 pm the DON started Med Administration observations with the MAs on the 2-10 shift for random observations which will be conducted for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 7:30 am the DON stated random observations with the 6-2 MAs which will continue for the next 72 hours to ensure the adherence to physician's order [REDACTED]. On 6/12/15 at 8:30 am the Pharmacy Consultant was contacted by the Administrator to conduct a complete medication pass audit. The audit is scheduled to be conducted on Monday June 15, 2015. The Medical Director was contacted 6/12/15 at 9:00 am regarding the occurrence and parameters were given to notify physicians of any B/P above 180. IJ plan of removal addendum revealed additional corrective actions added 6/14/2015 by the facility were: On June 13 2015 a RN Clinical Consultant and a facility RN completed chart audits on 100 % of the active residents with orders for cardiac medications. On June 13, 2015 audits of Medication Administration Sheets for 100% of the active residents was completed by RN Clinical Consultant and a facility RN to identify residents who have/need vital sign parameters for per administration actions related to cardiac medication orders. Attending MD /designee was notified and parameters for pre administration of cardiac medications was obtained on June 13/2015 Education was provided by RN Clinical Consultant to MA and charge nurses on 6/13/2015 and 6/14/2015 on Medication Administration, MA guidelines , common cardiovascular medications, medications that affect the cardiovascular system, documentation related to vital sign parameters, change sticker usage, drug reference books usage, notification procedures relating to change of conditions, medication administration and parameters. Pre and Post tests were provided for the educational in-service. IJ plan of removal addendum revealed additional corrective actions added 6/16/2015 by the facility were: Residents identified during the monitoring process on 6/15/2015 were audited and the missing medications on the cart were restocked. Residents identified during the monitoring process on 6/15/2015 had full chart reviews with attention focused on physician's order [REDACTED]. All medication carts were compared to the current residents MARs to ensure drug availability on 6/15/2015. Education was provided on 6/16/2015 to all MAs and LVNs concerning medication ordering and reordering by the DON. Starting 6/16/2015 the DON/designee will conduct compliance monitoring through a review of the physician's order [REDACTED]. Monitoring of the plan to remove the immediate jeopardy: Monitoring began on 6/12/15. LVNs and MA were interviewed on three of three shifts concerning medication administration, documentation, and physician notification. Record review of the facility In-Services revealed: 6/11/15-- Eight staff members trained on staff reporting all negative findings to the charge nurse; and the 7 rights of medication administration. 12 staff members trained on physician notification of any resident with a change in condition and using the SBAR (Situation, Background, Assessment, Recommendation) tool. 6/12/15- Ten staff members were trained on parameters of systolic blood pressure over 180 or below 120. Ten staff members were trained on medication [MEDICATION NAME] must take medication with food or milk and the benefits of the medication. 6/13/15-6/14/15-Fourteen staff members were trained by the nurse consultant on medications that affect the cardiovascular system, common cardiovascular medications, medication administration documentation related to vital sign parameters, direction changes and the use of sticker use, and utilizing Drug Reference books for any vital signs monitoring prior to administration of medications. Also seven staff were in-serviced on administering oral medications, documentation of medication administration, and medication aide/LVN guidelines of general medication administration. Interview on 6/14/15 at 3:59 PM, the RN Nurse Consultant stated she did chart audits and found 60 residents did not have any blood pressure parameters and contacted the physicians to get parameters. She stated she rewrote all the cardiac medication orders, updated the resident ' s MAR and highlighted discontinued medications in yellow. She further stated she had completed in-services on documentation, problem solving, and handed out handouts to the staff, and administered a Pre/Post test over common medications. Observation on 6/15/15 at 4:45 PM, during a medication cart review with the DON that was conducted on RN #6 ' s cart revealed five discrepancies of medication for Resident #22. The findings included: Vitamin C and [MEDICATION NAME] 160 mg/15 mL, liquid multivitamin, and Sugar Free Protast, were not found on the cart. Resident #22 was receiving ProMod Liquid Protein that had 13 grams of sugar. [MEDICATION NAME] was not found for Resident #22 in the medication refrigerator. Record review of the contracted Pharmacist review, dated 6/15/15, revealed the Pharmacist had performed four observations of medication administrations with two LVN and two MA. Her findings included: found discrepancies between the medication in the cart compared to the Resident ' s MAR. She further documented that she recommended the staff ensure proper hand washing/sanitizing between each resident and ensuring medication was available in the cart. Record review of Medication Pass In-service, dated 6/15/15 through 6/16/15 revealed five staff members were trained on proper hand-sanitizing and washing techniques, importance of reconciling medication in the cart with the resident's MAR and to use change of directions stickers or notify nurse of any necessary updated to the MAR, and proper documentation on MAR immediately after medication was administered. Record review of In-service, dated 6/16/15, the DON trained five staff members on reordering of scheduled medications and PRN (as needed ) medications, and notifying the DON immediately of non-available medications for follow-up to ensure medications were available at all times. Observation with two different medication aides, the DON, and QA nurse (LVN 7) on 6/16/2015 from 4:25 P.M. to 5:15 P.M. revealed the medication carts reviewed on the 100, 200, 300, and 400 halls had all the medications available for the medication administration for the entire day for the six residents reviewed. Interviews with three MAs, and two LVNs on 6/16/15 between 4:25 P.M. and 5:15 P.M. during the medication cart reviews revealed they all had knowledge and could verbalize the medication pass verifications which must be completed with each resident with each administration including the 7 rights they had recently been in-serviced on. Record review of the in-service forms provided by the Administrator dated 6/11/15, 6/13/15, 6/14/15 and 6/16/15 revealed in-services concerning the reordering of medications, the availability of medications for residents, the rights of the medication administration, and medications concerning the cardiovascular system and the importance of vital sign parameters. Interview on 6/16/2015 at 5:20 P.M. the pharmacy consultant stated she had conducted a medication pass with two MAs and three LVNs and had no medication errors identified. Record review of the pharmacy consultant report dated 6/16/2015 revealed the findings from the medication pass conducted with the MAs and LVNs which revealed no issues noted. Interview on 6/16/2015 at 5:25 P.M. the DON stated she would be continuing to do medication verification audits every morning with her staff. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on 6/16/2015 at 5:30 P.M. While the IJ was removed on 6/16/2015 the facility remained out of compliance at a scope of isolated at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents with hypertension were receiving physician ordered medications , treatments and consultations as their condition requires. The DON reported there were 78 residents in the facility with [DIAGNOSES REDACTED].

Based on interviews and record reviews, the facility failed to provide the necessary care and services to 1 of 9 sampled residents (#1) who sustained a fall with injuries. The facility failed to conduct comprehensive and follow-up assessments, to include neuro checks, and document the condition of Resident #1 after she sustained an unwitnessed fall with head injuries on 9/19/11. Four days later, Resident #1 was transferred and admitted to the hospital with [REDACTED]. This failure caused Resident #1 to have delayed treatment for [REDACTED]. Intake # 5 Findings Include: Record review of the clinical record face sheet revealed Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The medications included: [MEDICATION NAME], Carvedil, and [MEDICATION NAME]. The resident was discharged and transferred to the hospital on [DATE]. Resident #1 remained in the hospital as of 10/14/11. Record review of the Radiology Report from the hospital dated 9/24/11 revealed Resident #1 had an acute mixed intra and extra-cranial hemorrhage. The largest blood collection was within the left temporal lobe and measured 4.1 x 4.2 cm. Further review revealed: "There was resultant effacement of the left lateral ventricle and approximately 7 to 8 mm of rightward midline shift." Record review of the Progress Records from the hospital dated 9/24/11 revealed the resident arrived to the hospital with altered mental status, fever, and [MEDICAL CONDITION] Physical examination of Resident #1 revealed a bruise on the right side of the face, around the right eye, and a bruise on the left abdomen. Review of the Emergency Department Nursing Notes from the hospital dated 9/24/11 revealed that Resident #1 was transferred to another hospital for a higher level of care related to the intracranial bleed. Record review of the facility Resident Incident Report dated 9/19/11 revealed: " Resident (#1) was wheeled into her room...when CNA's exited room resident alarm sounded...resident sitting on the floor by bed." Further review of the form revealed that Resident #1 sustained an hematoma to the right brow and under right chin and that ice to the brow was applied. Further review of the facility Resident Incident Follow-Up Report, which was on the reverse side of the Resident Incident Report, revealed the form was not completed. The section titled 24 Hour Follow-Up was blank. Also, the additional follow-ups sections, which were dated 9/20/11, 9/21/11, 9/22/11, and 9/23/11 were also blank. Further review of Resident #1' incident report revealed a neurological assessment was not conducted. Record review of the Daily Skilled Nurse's Notes from 9/19/11 through 9/24/11 did not reveal neurological checks or follow up assessments were conducted after the unwitnessed fall. Further review of the Daily Skilled Nurse's Notes for 9/24/11 revealed that Resident #1's family member called the nurse to the room because she was concerned about the resident's condition. It stated the nurse practioner was called at the family member's request. At that time, the notes revealed an order was received to send the resident to the emergency room for evaluation and treatment. Record review of Resident #1's Fall assessment dated [DATE] revealed the resident scored a 22 and was considered a high fall risk. Record review of the Admission Care Plan dated 8/30/11 and updated on 9/19/11 after the fall, revealed the resident was care planned for falls and safety risk. The approaches included: keeping the call light within reach, using a mobility alarm, and not leaving the resident alone in the room while sitting up in the wheelchair. Record review of the admission MDS dated [DATE] revealed that Resident #1 had moderately impaired decision making skills, functional status included ambulatory with a walker, was independant for bed mobility and required extensive assistance of one person for transfers, walking in room and corridor. Interview on 10/13/11 at 12:00 pm, the Assistant Director of Nursing stated neurological checks were conducted when a resident hits their head and/or has an unwitnessed fall. Interview on 10/13/11 at 4:00 pm, the Assistant Director of Nursing stated the Incident/Accident reports were immediately filled out after an incident. She stated the residents were assessed for at least 72 hours, but their policy included an additional six days of observations. During the interview on 10/14/11 at 5:00 pm with the Assistant Administrator, Director of Nursing, and Assistant Director of Nursing, they were unable to provide any documentation or verification to prove that Resident #1 was assessed and neurological checks were performed after the unwitnessed fall on 9/19/11. Interview on 10/14/11 at 5:00 pm, the Director of Nursing stated that the gap in communication on when to use the follow-up assessment form probably occurred when the facility was transferring over to a new documentation system. Review of the facility's Instructions for Completing The Accident/Incident Investigation dated 2/1/09 revealed, "72 Hours Follow-Up: The nursing staff should document on the resident each shift for 72 hours after a fall. This area is for a summary of that documentation addressing the resident's condition and any further treatment was necessary." Review of the facility's policy on Incident/Accident Reporting dated 6/2009 revealed "5...Vital signs, including neurological checks, must be recorded every shift and resident's condition described for at least 72 hours, or longer as appropriate, following an incident/accident where there is a possibility of a head injury. This will include all unwitnessed falls. (Note: Subdural hematomas can present up to six (6) weeks post trauma." The Administrator stated the facility census was 91.

Based on observation, record review and interview, the facility failed to ensure that adequate supervision was provided for one of three sampled residents on a pureed diet, (Resident #1) to prevent accidental choking. Resident #1 had a history of [REDACTED]. Resident #1 consumed a piece of hot dog on [DATE] and required transfer to the emergency room . The hot dog was removed from her trachea in the hospital. She expired on [DATE]. This failure resulted in Resident #1's emergency transfer to the hospital where a piece of sausage was removed from her throat, subsequent brain damage and death. Failure to supervise residents during meal times placed eight residents at risk of choking and/or aspiration. Findings include: Incient # 4 Review of Resident #1's information sheet revealed she was [AGE] years old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident's quarterly MDS(Minimum Data Set) assessment dated [DATE] revealed that in the Making Self Understood section, the resident was assessed as could sometimes be understood. Her ability was limited to making concrete requests. The same MDS, section Ability to Understand others revealed the resident was assessed as sometimes understood and responded adequately to simple, direct communication. MDS section marked Eating revealed she required total dependence, full staff performance of the activity, from at least one staff member. Review of the resident's Care Plan dated [DATE] revealed, "problem potential for aspiration related to history of choking. Goal: Minimize risk of choking episodes while eating ... Intervention: Mechanically altered diet: Puree Honey Thick Liq ... Supervise during meal service ..." Another Care Plan with the same date revealed "resident has chewing/swallowing difficulty, is at risk for aspiration ...13. Review seating assignment/consider seating with other residents on puree diet ( Resident refused to move) 14. Continue to monitor during meals 15. Clear away left overs promptly." Review of the resident's Care Plan dated [DATE] revealed a problem, Noncompliance resists care and for approaches, "... Res reach into other tray and attempt to get others food re-directed on several occasions ... Res gets agitated when staff assisting in dining. Rolling eye @ staff call names ... Redirect when necessary ... choking episode assist by staff Heimlich maneuver." Review of Resident #1's Nurses' notes dated [DATE] revealed "Res in D/R @ supper Res noted choking lips blue Heimlich Maneuver performed ... removed slice of pear from resident's mouth". Review of another Nurses' notes dated [DATE] revealed "res lunch res choking Heimlich Maneuver performed charge nurse present, assists with Heimlich x2 unable to clear airway completely finger sweep x 2 ... " Review of the resident's Care Plan dated [DATE] problem revealed resident was on altered diet (pureed) resident required set up assistance. The approaches documented for this problem included for staff to check on resident regularly during meal service to assess for signs and symptoms of choking, meal tolerance. Review of Resident #1's Nurse's Note dated [DATE] at 7:30 P.M. revealed "Resident in w/c (wheelchair), setting away from dinner table. Food had been picked up. Had observed resident 10 minutes prior awake & alert without s/s (signs or symptoms) of distress. Resident non-responsive. Faint carotid pulse felt. Non-responsive to sternal stimuli. No respirations noted. Resident place on bed to initiate CPR Chest compresssions initiated & respirations via face mask ambu bag continuous." Review revealed the Nurse's Note was signed by RN #1. Review of the facility's incident report regarding Resident # 1 dated [DATE] revealed that Resident #1 was found to be unresponsive in her wheelchair seated at a table in the dining room around 7:30 PM on [DATE]. The review revealed that facility staff administered CPR, contacted 911 and that Resident #1 was transferred to the emergency room . Review of the hospital emergency room records dated [DATE] for Resident #1 revealed the physician, while attempting to intubate, discovered and removed a piece of sausage from her throat. The resident was admitted to the hospital with [REDACTED]. Further review of the Intensive Care Unit notes revealed she was removed from a ventilator and expired on [DATE]. Observation and interview on [DATE] at 5:50 P.M. the Administrator pointed out the table where Resident #1 ate all her meals. At the table sat three residents. The Administrator pointed out to the sureveyor that only two of the residents, Resident #5 and #10 shared the table with Resident #1 and that the other resident was a new resident to the faclity who just started sitting at that table that day. Interview on [DATE] at 5:55 P.M. Resident #5 stated she had been at the facilty for approximately 3 years. She stated that she enjoyed her meals and usually ate 100% of her meals. Observation at this time revealed Resident #5 had been served a regular diet and had consumed approximatedly 80% of her meal. Interview on [DATE] at 6:00 P.M. Resident #10 stated that she was not happy with her meal but did not want anything else to eat. Observation at this time revealed that the resident had been served a regular diet and had consumed approximately 30% of the meal. The resident had pushed the plate away from her place and the plate was setting at the unoccupied space on the table. Interview on [DATE] at 6:10 P.M. the Dietary Manager stated that Resident #1 had been served a pureed diet for the four months he had been at the facility. He stated that he would circulate in the dining room Monday through Friday to offer substitutes to residents. He stated he had just spoken to Resident #10 and that she did not want anything else to eat. He said it was not unusual for her not to eat much of her meals and that often only had soup. He stated he did not know if Resident #1 had a habit of taking food off of others' plates or if she would ask others for food. He then stated he was not working on the day Resident #1's incident occurred. Interview on [DATE] at 6:20 A.M. Food Service Worker A stated that on [DATE] Resident #1 was served a pureed pasta diet on a divided tray. She stated that she had worked for the facility for 9 months. She had never witnessed the resident take food off others' plates nor had she seen other residents ever offer her food. She stated that between 7:20 and 7:30 P.M. she saw CNA A pushing Resident #1 to her room. She followed and learned that resident was unresponsive. She assisted in transferring resident to bed and participated in CPR along with CNA A. Interveiw on [DATE] RN #1 stated that the last time she had spoken to Resident #1 was on [DATE]. She stated that Resident #1 was alert and responsive at that time. On [DATE] RN #1 stated she was on the locked unit admitting a new resident and entered the main dining room around 7:20 P.M. She said at that time the dining room tables had been cleared by dietary staff and that the resident was not sitting at her dining table. She went to do something and when she came back into the dining area around 7:30 P.M. a staff member yelled for her to assist with Resident #1 because she was unresponsive. There was no choking or movement from Resident #1. CPR was initiated and 911 was called. She stated that on that evening there had been four aides in the dining room to assist residents. Interview on [DATE] at 6:55 P.M. the ADON stated she had been working at the facility since [DATE] and been promoted to ADON aproximately two weeks prior. She stated that she worked on the locked unit the evening of Resident #1's incident and was not aware of what happened until the ambulance arrived. She stated that the nurses reported to her that they found the resident unresponsive around 7:30 P.M. and started CPR. They notified 911, physician and family. She stated that supper was usually served around 5:30 P.M. and that the dining room tables were usually cleaned by 7:00 P.M. She stated that Resident #1 was alert and had no behavior problems. She stated she had never seen her take food off of another resident's plate. She went on to say that Resident #10 usually did not eat much and would push her plate away. She stated often Resident #10 would ask for soup or "magic cup" (a frozen dietary supplement). She said that Residents #5 and #10 were both alert and oriented. Observation on [DATE] at 7:00 P.M. revealed two dietary staff cleaning the last table in the dining room. No residents were present in the dining room. Charge nurse was at the nurse's station that faced the dining area. Interview on [DATE] at 7:15 P.M. the DON stated that Resident #1 had been alert and oriented and had no behavior problems. She stated that the resident had a stroke in the past which caused swallowing problems. She stated Resident #1 never complained about the pureed diet that was prescribed for her. She stated the night of the incident she was out of town. She received a call from staff stating that Resident #1 had been found in the dining room, not at her table, in her wheelchair unresponsive. She stated she did not learn until the Medical Examiner called the facility on Monday night that the hospital had reported to him that the resident had choked on a hot dog. Once she learned this she stated she immediately started an investigation and checked the other residents who received pureed diets. She stated that her investigation revealed that all the tables had been cleaned before staff left the dining room that evening. Review of the typed statement of CNA A dated [DATE] revealed that CNA A had spoken to Resident #1 at approximately 7:00 P.M. on [DATE] in the dining room. The resident had requested iced tea. CNA informed resident he needed to answer a call light and that he would be back to make her some tea. Upon return CNA revealed that he saw Resident #1 in the dining room, unresponsive with a glass of thickened tea at the table. The statement then revealed that he took resident to the room and started CPR because there were other residents in the dining area. The statement also stated that Resident #1 had been served a pureed diet that evening and that he was the CNA who delivered the meal to the resident. Interview on [DATE] at 10:50 AM CNA A stated that he discovered Resident #1 seated in her wheelchair at a table in the dining room around 7:30 PM on [DATE]. CNA A stated that Resident #1 looked like she was asleep but that her "color was wrong." He stated that the resident's head was to the side. She had her left hand on her chest and a cup in her right hand. He stated that he checked and found no pulse. CNA A and 2 additional staff members transported her to her room where they administered CPR. Interview on [DATE] at 1:55 P.M. the DON stated that they had requested Resident #1 change tables in the dining room due to her behavior of trying to take food off other resident's plates but that the resident refused to be moved and wanted to remain seated with the same table mates. CNA A stated that he was present in the dining room during the evening meal and that Resident #1 had sent back her pureed meal of which the entree was a pureed hot dog. She received an alternate meal of pasta. Interview on [DATE] at 11:10 AM Food Service Worker A stated Resident #1 received and consumed her pureed meal at dinner that evening. She stated that Resident #1 always received a pureed diet and that she always consumed all of her meal. She stated that Resident #1 was seated at her usual table and that her tablemates, two ladies, received a regular diet. She stated that the main dish served for the regular diets on [DATE] was hot dogs. Interview on [DATE] at 11:16 AM Resident #5, who was one of two residents that shared table with Resident #1, stated that she always sat at the same table with Resident #1 during meals. She stated that she was on a regular diet and could not recall how long ago it had been that she was served hot dog at a meal. Resident #5 stated, "I can't stand hot dogs. If they serve me something I don't like, I just leave it sitting there and don't touch it. Hot dogs are for younger people." According to the DON, eight residents were presently receiving a pureed diet.