Every finding on record at Hewitt Nursing and Rehabilitation

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights , that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #01) reviewed for comprehensive care plans. The facility failed to ensure that Resident #01 had swallowing interventions listed for swallowing problems. This failure could place residents at risk for receiving appropriate care for their health conditions.Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights , that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #01) reviewed for comprehensive care plans. The facility failed to ensure that Resident #01 had swallowing interventions listed for swallowing problems. This failure could place residents at risk for receiving appropriate care for their health conditions. The findings included: Record review of Resident #01's face sheet, dated 08/20/2026, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Atherosclerotic heart disease of native coronary artery without angina pectoris (arteries are narrowed because of plaque buildup), Covid-19 (characterized by fever and cough), muscle weakness (lack of muscle strength), Dementia (progressive memory loss), chronic kidney disease (kidneys are not filtering correctly). Record review of Resident #01's Annual MDS Assessment, dated 07/23/2026, revealed a BIMS score of 04, indicating severe impaired cognition. Residents required supervision for eating. Resident required Maximal assistance for functional transfers. Record review of Resident #01's comprehensive care plan, dated 08/20/2026, revealed it did not address interventions for residents swallowing problem. During an interview on 08/20/2026 at 2:00PM, CNA A said that she looked at the electronic medical record to know how to take care of a resident. She said under the tab Task, it showed a new alert if there was a change on how to take care of a resident. During an interview on 08/20/2026 at 2:15 PM, CNA B said she would look at the electronic medical record or would ask nurse at the desk who would communicate changes with a resident's care. CNA B said the purpose of the Kardex was to know how to take care of the residents. During an interview on 08/20/2026 at 1:00 PM, the DON said the resident's family had been concerned about him having trouble swallowing pills. DON told me the resident is currently on nectar thicken liquids. The DON said that Resident #01's care plan should include interventions for a swallowing problems . The DON said the care plan was an individualized plan to let staff know how to care for the residents. The DON said the interventions were added to the Kardex so the staff would know how to care for the residents. During an interview on 05/30/2025 at 1:30 PM, the Administrator stated the care plan should include everything needed to take care of a resident. He said the care plan should not have any blank sections under interventions. Record review of the facility's policy titled, Care Plans, Comprehensive Person- Centered, dated 2001 and revised December 2016, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Record review of the facility's policy, Physician Orders, dated 02/2025, revealed: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician's orders to ensure the resident receives the necessary care and services. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes, and relevant decision making. a. When possible, interventions address the underlying sources of the problem area not just addressing only symptoms or triggers.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 (Resident #53, Resident # 74, Resident # 83) residents reviewed for care plans. -The facility failed to ensure the care plan for Resident #53 addressed the care needs of the resident with a colostomy regarding her specific stoma care and how often the site is to be changed and cleaned.-The facility failed to ensure the care plan for Resident # 74 and Resident # 83 address the care needs and refusals of the residents regarding nail care. This failure placed the residents at risk of not having their care needs met to maintain health status. Findings include: Record review of Resident # 53's face sheet dated 6/24/2026 reflected resident was a [AGE] year-old female admitted on [DATE] with diagnoses: metabolic encephalopathy (a general term for brain dysfunction caused by chemical imbalances or systemic illnesses in the body), acute kidney failure (the sudden or rapid loss of your kidneys' ability to filter waste products, balance fluids, and regulate electrolytes in the blood), lack of coordination, dysphagia (difficulty swallowing food or liquids), hypokalemia (low blood potassium levels), hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high), cataract, neoplasm of large intestine (cancer of the large intestine), cognitive communication deficit (difficulty exchanging information caused by impaired brain functions like attention, memory, and executive reasoning, rather than a primary language or speech issue), muscle wasting, neutropenia due to infection (a condition characterized by abnormally low levels of neutrophils in the blood), hypo-osmolality (a condition where the concentration of particles such as sodium, potassium , and protein in your blood is abnormally low), hyponatremia (low blood sodium levels). Record review of Resident # 53's care plan dated 6/4/2025 reflected: Resident has an alteration in gastro-intestinal status related to having a Colostomy. Goals: Will remain free from discomfort, complications or s/sx related to gastro-intestinal alterations through review date with target date 5/24/26. Interventions: Avoid activities that involve bending and lifting. Avoid snacks that aggravate the condition. Give medications as ordered. Observe/document side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Resident 53's care plan was incomplete, as it did not include the residents' care needs for their colostomy. Record review of Resident # 53's annual MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognition. The MDS reflected Resident # 53 was independent for toileting hygiene which included wiping the opening of the ostomy (a surgical procedure that creates an artificial opening called a stoma in the abdomen to allow waste or urine to exit the body) but not managing the equipment. Record review of Resident #53's clinical physician orders dated 6/24/26 reflected an order of colostomy change colostomy appliance every 3 days and as needed with a start date of 4/28/26. Order of colostomy care every shift and as needed with a start date of 4/28/26. During an observation and interview on 6/24/26 at 10:20 am with Resident # 53 revealed the resident in her room sitting on the edge of the bed, neatly groomed. Resident # 53 stated the CN has caused her pain 3 times back a couple of months ago while changing her colostomy bag. Resident #53 states the CN pushed down on her stoma (surgically created opening on the surface of the abdomen that connects the bowel or urinary tract to the outside of the body) site when changing the bag. Resident #53 states the CN was cutting the stoma adhesive to small and ignoring the resident. Resident # 53 stated she reported the matter to ADON F and the resident followed up a couple days later at which time ADON F told the resident she had not spoken to the CN yet. Resident # 53 stated she followed up with ADON F a 2nd time to see if the matter had been addressed with the CN. Resident # 53 stated ADON F told her she had not followed up with CN yet. Resident #53 stated after the 2nd time of checking with ADON F, she then reported that the CN had been talked to. Resident # 53 stated she preferred not to have the CN provide her care for her stoma. During an interview on 6/25/26 at 1:15 pm the DON stated the MDS Nurse was responsible for documenting the care plan for overall clinical needs. The DON stated she was responsible for documenting acute care needs such as falls, infections, and antibiotics. The DON stated that if the resident had orders for a colostomy, then the care plan should have at least the care interventions needed to monitor doctor orders. The DON stated the information was obtained from assessing the resident. The DON stated it was the responsibility of the floor nurse completing the assessment to ensure accuracy. The DON stated if information was missing from the care plan it did not necessarily mean the resident was not receiving the proper care because the physician's orders had the needed information and the CNA tasks could also have the needed information and the missing information would not negatively affect the resident. The DON stated the care plan was mainly for MDS purposes and for a care meeting with family to communicate information. The DON stated it as her expectation for care plans and assessments to be accurate. The DON stated assessments were completed to get a better picture of the resident information and document any changes and add the information obtained into the care plan. During an interview on 6/25/26 at 2:02 pm CNA D stated they worked the morning shift 6 AM - 2 PM CNA D stated all trainings were done by in-services. CNA D stated resident care information was in the Plan of Care in the electronic health record under the tab labeled Kardex under care tasks. CNA D stated resident information could also be in the resident care plan if the resident was new or there had been a change in the resident information. During an interview on 6/25/26 at 2:25 pm ADON F said she had received a complaint from Resident # 53 regarding the CN providing ostomy care. ADON F stated she verbally spoke to the CN discussing correct placement of colostomy bags and to be mindful of resident's pain level. The CN verbally walked the ADON F through the steps of what she did during placement. ADON F stated she had not had any other complaints from Resident # 53 since CN was verbally educated. ADON F stated the physician orders have the care needs for Resident #53 colostomy. ADON F did not state if the care plan needed to have the colostomy care needs addressed. During an interview on 6/25/26 at 2:36 pm MDS Nurse stated she had been doing care plans for the last 1 1/2 months prior to that it was the DON and the ADONs. The MDS Nurse stated the resident would need a goal and interventions. MDS Nurse stated each resident is different and therefore all care plans are different. MDS Nurse stated some residents' care needs are more complicated and require step-by-step interventions but that not all residents require these types of interventions. MDS Nurse stated Resident #53's care plan had a goal and an intervention therefore it was sufficient. MDS Nurse stated the care needs for Resident #53's colostomy would be completed by following physician orders. During an interview on 6/25/26 at 2:53 pm ADM stated the MDS Nurse is responsible for completing care plans. ADM stated it was his expectation that care plans are completed accurately, timely, and in their entirety. ADM stated that yes, it could negatively affect a resident if care plans are not completed accurately, timely, and in their entirety. ADM stated the nurse is responsible for completing resident assessments. ADM stated it is the responsibility of DON and ADON to verify the accuracy of the assessments. ADM stated that it could negatively affect a resident if assessments are not accurate. The ADM stated if a resident has a colostomy that is something that would need to be care planned. The ADM stated the purpose of the care plan is to make sure that the facility has a full scope of the resident needs and that the facility can provide those needs. The ADM stated the purpose of resident assessments is to obtain the resident information from evaluating the resident to complete the resident care plans as this provides the information that goes into the care plan. 2.Record review of Resident #72's face sheet dated 6/25/2025 reflected resident was a [AGE] year-old female admitted on [DATE] with diagnoses: paroxysmal atrial fibrillation(the heart's upper chambers (atria) beat chaotically and irregularly for a short period), muscle weakness (a condition where muscles cannot generate normal force, and it can result from temporary fatigue, underlying medical conditions, or neurological issues), hypertension (a chronic condition where the force of blood pushing against artery walls is consistently too high), hypothyroidism (a common condition where the butterfly-shaped gland in your neck doesn't produce enough thyroid hormones), cognitive communication deficit (difficulty exchanging information caused by impaired brain functions like attention, memory, and executive reasoning, rather than a primary language or speech issue). Record review of Resident #72's care plan dated 6/02/2026 reflected: Resident has an ADL self-care performance deficit. Goals: Resident will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score: with target date: 8/11/2026. 8/11/2026. Resident #72's care plan was incomplete, as it did not include the resident's documented refusal of care. Record review of Resident #72's quarterly MDS, dated [DATE], reflected a BIMS score of 08 which indicated moderately impaired cognition. The MDS reflected Resident #72 required supervision or touching assistance for showering, toileting and personal hygiene. During an observation/interview on 6/23/2026 at 1:26 PM Resident #72 stated she refused to allow staff to provide nail care because she preferred to care for her own nails. Observation revealed her fingernails appeared 1/2 inch long past end of the fingertip with a brown substance noted beneath several nails. She did not voice any concerns regarding her nail care and stated that she chose to perform her own nail care. Record review of Resident #83's face sheet dated 6/25/2025 reflected the resident was an [AGE] year-old male admitted on [DATE] with diagnoses: dementia( a loss of memory, thinking, reasoning, and other mental abilities that affects a person's ability to perform everyday activities), chronic obstructive pulmonary disease(is a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), type 2 diabetes(is a chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication), hypertension(a chronic condition where the force of blood pushing against artery walls is consistently too high). Record review of Resident #83's care plan dated 4/28/2026 reflected: Resident has the potential for hypo/hyperglycemia related to Diabetes Mellitus. Goals: Resident will have no complications related to diabetes: with target date: 7/27/2026. Interventions: Discuss with resident the importance of compliance with dietary restrictions, compliance with treatment regimen, adequate sleep, exercise, good hygiene and oral care. Resident #83's care plan was incomplete, as it did not include the resident's documented refusal of care. Record review of Resident #83's MDS dated [DATE] reflected a BIMS score of 10 which indicated moderate cognitive impairment. The MDS reflected Resident #83 required supervision or touching assistance for personal hygiene, was dependent for showering, and partial/moderate assistance for toileting. During observation/interview on 6/23/2026 at 11:56 AM Resident #83 stated he did not like staff to cut his fingernails because he preferred to do it himself. Observation revealed the resident's fingernails appeared 1/2 inch long and jagged from fingertip, with a brown substance noted beneath the nails. The resident did not express any concerns regarding his nail care and stated he preferred to manage it independently. During an interview on 6/25/2026 at 11:40 AM, CNA B stated residents' fingernails were cleaned during showers every other day or as needed. She stated that if a resident's fingernails were dirty, it could cause an infection.During an interview on 6/25/2026 at 11:45 AM, ADON E stated nail care was routinely performed on Sundays. She stated nurses were responsible for providing nail care for residents with diabetes. She stated CNAs clipped and cleaned residents' fingernails during showers or as needed. She stated that failing to clean or clip the residents' fingernails could increase the risk of infection or result in a skin tear. ADON E stated that resident refusals should have been documented in the residents' progress notes and care plan to ensure staff were aware of the refusals and that appropriate interventions were in place. During an interview on 6/25/2026 at 12:00 PM, CNA C stated that CNAs were responsible for ensuring residents' fingernails were kept clean and trimmed. She stated that failing to clean and clip residents' fingernails could increase the risk of infection, skin injury, and the accumulation of dirt and debris beneath the nails.During an interview on 06/25/2026 at 12:20 PM, ADM stated resident fingernails should be checked daily to determine if they need to be clipped or cleaned. He stated that by not clipping or cleaning residents' fingernails this could cause a resident to get an infection. ADM stated that resident refusals should have been documented in the resident progress notes and care plan to ensure staff were aware of the refusals and appropriate interventions were in place.During an interview on 6/25/2026 at 12:45 PM, DON stated resident hands should be washed daily or as needed. She stated residents' fingernails should be checked daily as well. She stated if a resident refused nail care the CNAs should notify the nurse and the refusal should be documented in the resident chart. She stated by not assessing the residents' hands and fingernails each day could result in the resident having dirty hands and fingernails. DON stated that residents' refusals should have been documented in the resident's progress notes and care plan to ensure staff were aware of the refusals and appropriate interventions were in place. Record review of facility Comprehensive Person-Centered Care Plan policy dated 12/2016 reflected under heading policy:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.Under heading policy interpretation and implementation:1.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.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The care planning process will:a. Facilitate resident and/or representative involvement;b. include an assessment of the resident's strengths and needs; andc. Incorporate the resident's personal and cultural preferences in developing the goals of care.8. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;g. Incorporate identified problem areas, incorporate risk factors associated with identified problemsj. Reflect treatments goals, timetables, and objectives in measurable outcomes.9.Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.a. No single discipline can manage an approach in isolation.b. The resident's physician (or primary healthcare provider) is integral to this process.11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.12.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #75) reviewed for resident rights. The facility failed to ensure Resident #75's call light was within reach on 06/23/26. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #75's face sheet dated 06/24/26 reflected a [AGE] year-old-female admitted on [DATE] with diagnoses of cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dysphagia (difficulty in swallowing), diabetes (a group of diseases that result in too much sugar in the blood), and cognitive communication deficit (a communication problem caused by underlying cognitive impairments rather than a primary language or speech deficit)/. Record review of Resident #75's admission MDS assessment dated [DATE] reflected a BIMS score of 08 which indicated Resident #75 was moderately cognitively impaired. The MDS reflected Resident #75 had no impairment in functional limitation in range in motion for upper extremity (shoulder, elbow, wrist, hand). Resident #75 required supervision or touching assistance for eating, substantial/maximal assistance for personal hygiene, and was dependent on staff for toileting and showering. Review of Resident #75's care plan dated 03/31/26 reflected: Resident was was at risk for falls cognitive deficits, debility/generalized weakness. Goals: Resident #75 would be free of falls through the review date with target date: 08/24/26 Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, 03/31/2026. During an interview and observation on 06/23/26 at 2:56 PM, Resident #75 stated she was good so far and all the staff treated her well. She stated she used her call light to call for help when she needed to, and the staff usually responded quickly. Resident #75's call light cord was observed clipped onto her sheet, but the call light button was on the floor on the side of resident's bed. Resident #75 attempted to pull the call light up toward her with the cord to be within her reach where she would have been able to use the call light to call for help if needed. Resident #75's call light cord and clip were stuck in between the bed and bed railing which prevented the call light from moving. Resident #75 was not able to get the call light to be able to call for help if needed. Resident #75 stated she would have yelled for help if she could not have reached her call light. During an interview on 06/23/26 at 3:02 PM, CNA A stated Resident #75 could not have reached her call light where it was at that time. She stated she had been trained on call lights being within residents' reach at all times. She stated if a resident's call light was out of their reach, it could have caused the resident to fall while trying to reach the call light or the resident may have not been able to call for help if needed. During an interview on 06/25/26 at 11:58 AM, the ADM stated it was his expectation that all residents' call lights always be within their reach. He stated staff had been trained on ensuring residents' call lights were always in reach. He stated if a resident's call light was not within their reach, they may not have had their needs met in a timely manner. During an interview on 06/25/26 at 12:10 PM, the DON stated it was her expectation that all residents' call lights always be within their reach. She stated staff had been trained on ensuring residents always had their call lights within their reach. She stated if a resident's call light was not within the resident's reach, the resident would not have been able to call for help if needed. Record review of facility policy titled Answering the Call Light dated 2001 reflected Purpose: The purpose of this procedure is to respond to the resident's requests and needs. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for one(Resident #80) of 1 facility reviewed for ADL care. The facility failed to ensure Resident #80's shower chair did not have yellow-brown discoloration extending across the center of the seat surface and dark black substance near one of the seat drainage holes. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.Findings included:Record review of Resident #80's face sheet dated 6/25/2026 reflected resident was an [AGE] year-old female admitted on [DATE] with diagnoses: myasthenia gravis without (acute) exacerbation metabolic (a chronic, antibody-mediated autoimmune disorder of the neuromuscular junction), sepsis (occurs when the body's response to an infection becomes dysregulated and causes widespread inflammation, leading to organ dysfunction), urinary tract infection(an infection in any part of your urinary system), dementia( a decline in mental ability that is severe enough to interfere with daily life).Record review of Resident 80's care plan dated 5/30/2026 reflected: Resident has (MIXED) bladder incontinence r/t urinary tract infection (UTI), Myasthenia Gravis, High Blood Pressure (HTN), Muscle Weakness, Lack of Coordination, Dementia. Goals: The resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI: with target date: 05/13/2026. Interventions: Observe/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Record review of Resident #80's quarterly MDS, dated [DATE], reflected a BIMS score of 02 which indicated severely impaired cognition. The MDS reflected Resident #80 required substantial/maximal assistance for showering, toileting and personal hygiene. During observation on 6/23/2026 at 11:54 AM, Resident #80's shower chair was observed in the resident bathroom. The seat had what appeared to be yellow-brown discoloration extending across the center of the seat surface and dark black substance near one of the seat drainage holes. During observation/interview on 6/23/2026 at 1:17 PM, Resident #80 was observed sitting up in her wheelchair in the day area. Due to her cognitive impairment, she was unable to participate in an interview. She showed no signs or symptoms of pain.During observation on 06/24/2026 10:00 AM, Resident #80's shower chair was observed in the resident bathroom. The seat had what appeared to be yellow-brown discoloration extending across the center of the seat surface and dark black substance near one of seat the drainage holes. During observation on 06/25/2026 11:35 AM, Resident #80's shower chair was observed in the resident bathroom. The seat had what appeared to be yellow-brown discoloration extending across the center of the seat surface and dark black substance near one of the seat drainage holes. During interview on 6/25/2026 at 11:40 AM, the CNA B stated that CNAs were responsible for cleaning and maintaining residents' shower chairs. She stated shower chairs should be cleaned before and after each use. She stated that failing to clean and disinfect shower chairs could increase the risk of contamination and infection. During interview on 6/25/2026 at 11:45 AM, the ADON stated that CNAs were responsible for cleaning and maintaining shower chairs before and after each use and had been trained on proper cleaning procedures and infection control. She stated that failing to clean and disinfect shower chairs could increase the risk of infection. During interview on 06/25/2026 at 12:20 PM, the ADM stated his expectation were that shower chairs be cleaned and disinfected before and after each use. He stated that CNAs were responsible for cleaning and inspecting shower chairs before transferring a resident onto the shower chair to ensure it was clean and sanitary. He stated failing to clean and disinfect shower chairs could result in an infection control issue and increase a resident's risk of developing an infection. During interview on 6/25/2026 at 12:45 PM, the DON stated that CNAs were responsible for cleaning showers chairs before and after each use. She stated staff had been trained on proper cleaning procedures and infection prevention and control practices. She stated failing to properly clean and disinfect shower chairs could cause infection. Record review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment Policy revised august 2011 reflected the following: Policy Statement:Resident- care equipment including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. 1.The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care:c. Non-critical items are those that come in contact with intact skin but not mucous membranes.(I)Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers.d. Reusable items are cleaned and disinfected between residents (e.g., stethoscopes, durable medical equipment).(1) Single resident-use items are cleaned between uses by a single resident (e.g., bedpans, urinals).3. Durable medical equipment (DME) must be cleaned and disinfected before reused by another resident.4. Reusable resident care equipment will be decontaminated between resident according to manufactures' instructions. Record review of the facility policy Infection Prevention and Control Program Policy revised August 2016 reflected the following:Policy Statement:1.The infection prevention and control program is a facility-wide effort involving all disciplines and indi viduals and is an integral part of the quality assurance and performance improvement program.2.The elements of the infection prevention and control program consist of coordination/oversight, poli cies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.2.Policies and Proceduresa.Policies and procedures are utilized as the standards of the infection prevention and control program.b.The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include:2. Assessment of staff compliance with existing policies and regulations.3.Surveillancea.Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications.6.Outbreak Management(1) determining the presence of an outbreak.(3)preventing the spread to other residents.7.Prevention of Infectiona.Important facets of infection prevention include:(I)identifying possible infections or potential complications of existing infections.(3)educating staff and ensuring that they adhere to proper techniques and procedures.(7) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

Based on observations, interviews, and record reviews, the facility failed to assure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines, for 1 of 3 meals observed. The facility failed to document the substitutions for the lunch menu on 06/23/26. These failures placed the residents at risk of decreased intake, dissatisfaction with their meals, and weight loss. Findings included: A record review on 06/23/26 of the facility's lunch menu on 06/23/26 revealed the following items were to be served for lunch:Beef stroganoffNoodlesSeasoned carrotsWheat rollMargarineBoston cream cakeCoffee or teaMilk sugar, salt, pepper.Nondairy creamerGarnish parsley sprigs. Observation on 06/23/26 at 12:08 PM revealed the residents were served the following for lunch and were also posted on the wall outside of the facility's dining room:Salmon PattyCream style cornSpanish riceRollsPeachesBeverage A record review on 06/25/26 of the facility's menu substitution log for week 3 of June revealed the following:Menu cycle: week 3Food item substituted: salmonFood item omitted: beef stroganoffDay: TuesdayMeal: LunchDate 06/23/26. Record review of the menu substitution log revealed that the following items were not listed as substitutions for week 3 on the menu substitution log: Food items substituted: cream style corn, Spanish rice, rolls, peaches.Food menu items omitted: seasoned carrots, wheat roll, margarine, Boston cream cake, coffee or tea, milk, sugar, salt, pepper, non-dairy creamer, garnish parsley sprigs. During an interview with the DM on 06/25/26 at 8:09 am, she said she kept her menu substitution log in the back of the temperature logbook. The DM said the substitutions were made for the traditional regular menu only. The DM stated that the reason the entree was changed on 06/23/26 was because she ordered the salmon on 06/19/26 and it did not arrive at the facility until the afternoon of 06/22/26, which was too late to prep and serve. She stated that the reason the sides listed on the menu were not served was because the head cook (HC) opened other sides to cook without an explanation or permission. The DM said the kitchen staff were to follow and cook what was listed on the printed menu. The DM said that she started in this position in April 2026 and was not trained on documenting the substitution log. She stated that she thought she was only supposed to document the entree on the log, which would suffice for the menu served for that meal. She said without documentation there was no way to verify that the substituted items provided the same nutritional value, especially for residents with special diets. She also said that it would also help keep track of food that residents did not like. The DM said that moving forward she would document all substitutions on the menu substitution log as required. During an interview with the RD on 06/25/26 at 9:32 AM, she advised that the DM called her when the substitutions were made in menu items but did not know that she did not document all food items substituted and all food items omitted on the menu substitution log as required. The RD said that she may not have gone over this information with the DM because she just recently started working with this facility, but someone should have trained her in this. The RD advised that the DM should have listed all food substitutions on the menu substitution log. The RD said that not documenting substitutions could result in uncertainty about whether residents received the same nutritional value or the ability to track food shortages or foods that residents did not want. She also said that physician-ordered diets could be affected. The RD advised that the DM started her new position 2 or 3 months ago and may not have received all the training she needed. The RD said she would sit down with her as soon as possible and go over the menu substitution log and all it entails.During an interview on 06/25/26 at 2:02 PM, the ADM said he did not complete audits for the substitution logs. He stated the RD audited the DM. He said he was not made aware of the substitutions made daily, but he received a quarterly report. The ADM stated he did not know all the information that had to be on the log, but he knew that changes should be documented in it. The ADM said he was not sure if the substitutions were tracked in monthly QAPI meetings but would double check. The ADM said there were no negative outcomes for the residents because of menu substitutions that he knew of, but the facility would not substitute something that did not fit the residents' diets.During an interview on 06/25/26 at 2:42 PM with the DON, she said to her knowledge no one had complained about the substitutions on the menu on 06/23/26. She stated that the daily menu was posted on the wall in front of the dining room. She stated the nursing staff had to ask the kitchen staff about changes if there were substitutions on the menu. The DON said she checked the lunch tickets on the residents' trays and if there was a substitution made on the menu that the resident could not eat, she would have it changed. She stated that most of the residents, if not all of them, knew what they could and could not eat. The DON said that the kitchen staff was good at ensuring that the residents' menus were posted before they ate. She said an undocumented substitution could result in not knowing if a resident received foods appropriate for allergies, diabetics, renal diets specialized eating plan for people with compromised kidney function), or other therapeutic diets. Record review of the menu policy (undated) revealed the following:A registered dietitian / nutritionist (RDN) or other clinically qualified nutrition professional will review and approve menus. This professional will also adjust individual meal plans based on personal requests, cultural, religious, or ethnic preferences. Professional Review and Approval:Menu integrity:Menus will be served as written unless a substitution is necessary due to preference, unavailability of an item, or a special meal request.Menu substitution log:A log of all menu substitutions will be maintained and kept on file for accountability and future reference.Menu posting:Menus will be prominently posted in the Dietary Services Department dining rooms, and resident/patient care areas for easy access and visibility.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #2) reviewed for infection control practices.The facility failed to ensure Resident #2's soiled wash cloth was removed from the bedside table on 12/22/2025The facility failed to ensure Resident # 2's urinal bottle was emptied on 12/22/2025. This failure placed residents at risk of cross contamination. Findings included:Record review of Resident #2's face sheet dated 12/22/2025 reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had diagnoses which included congestive heart failure(heart can't pump enough oxygen-rich blood to meet the body's need),Type 2 diabetes(body does not make enough insulin)and hypertensive heart disease(heart problems from long term high blood pressure).Record review of Resident #2's care plan dated 12/22/2025, reflected Resident #2 exhibited ADL self-care performance deficit that required assistance with ADL's which included intervention of self-performance extensive support.A record review of Resident #2's Quarterly MDS assessment, dated 10/01/2025, reflected Resident #2 had BIMS score of 15 indicating the resident was cognitively intact. Observation on 12/22/2025 at 9:34 AM., revealed Resident #2's soiled wash cloth was sitting on the bedside table.Observation on 12/22/2025 at 9:34 AM., revealed Resident #2's urinal bottle sitting on bedside table filled to the top of the urinal bottle.During an interview with Resident #2 on 12/22/2025 at 9:35 AM he stated that he used the call light around 6:30 AM this morning and CNA B came in and stated she would be back. Resident # 2 stated that CNA B had not come back, and the soiled washcloth that he used to clean himself with needed to be removed from the bedside table. Resident # 2 stated that he had placed the soiled washcloth on the bedside table so CNA B could take it to the laundry room to be washed. Resident # 2 stated that the urinal was full and needed to be emptied. Resident # 2 stated that he had placed his urinal on the bedside table so it could be emptied by CNA B.During an interview with CNA B on 12/22/2025 at 3:17 PM stated that she was Resident # 2's CNA and she was responsible for removing the soiled washcloth from the bedside table. CNA B stated she answered the call light around 6:30 AM and told Resident # 2 that she would be back. CNA B stated she did not return right then, and she could not recall the time she returned to assist Resident #2. CNA B stated that she was assisting other residents call lights and she totally forgot to return to Resident # 2 to remove the soiled washcloth from the bedside table. CNA B stated it was expected for her to remove Resident # 2's soiled wash cloth he used to clean himself for infection control. CNA B stated that she was assisting other residents call lights and she totally forgot to return to Resident # 2 to empty the urinal. CNA B stated it was expected for her to empty Resident # 2's urinal to prevent from spilling.During an interview with the DON on 12/22/2025 at 4:35 PM, the DON stated it was expected for CNA B to remove the soiled washcloth after each use for infection control purposes. The DON stated it was expected for CNA B to empty Resident #2's urinal. The DON stated rounds were made every two hours and any staff can empty a urinal. The DON stated with the urinal filled it could be knocked off the bedside table and may cause a slip and fall.During an interview with the ADM on 12/22/2025 at 5:19 PM, the ADM stated it was expected for CNA B to have removed the soiled washcloth on the bedside table. It was expected for CNA B to bag the soiled washcloth to be sent to laundry to be washed. the ADM stated it was expected for CNA B to empty Resident # 2's urinal. The ADM stated that a slip and fall could have occurred if the urinal had been knocked over and spilled over on the floor. The ADM stated any staff can empty a urinal when it is full.Review of the facility policy Policies and Practices Infection Control revised 07/2014 reflected This Facility Infection Control policies and practices are intended to facilitate maintaining a safe, sanitary a safe, sanitary and comfortable environment and to help percent and manager transmission of diseases and infections.

Based on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for complete and accurate records. The facility failed to ensure Resident #1's nothing by mouth was documented in PCC for December 20th and December 21st on the 10:00 PM -6:00 AM shift. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs. Findings include:A record review of Resident #1's face sheet, dated 12/22/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included type 2 diabetes(body does not make enough insulin), heart failure(heart can't pump enough oxygen-rich blood to meet the body's need), dysphagia(difficulty swallowing food or liquid), and hypertension(high blood pressure).A record review of Resident #1's care plan, dated 12/22/2025, reflected Resident #1 required tube feeding.A record review of Resident #1's Quarterly MDS assessment, dated 09/01/2025, reflected Resident #1 had BIMS score of 99, which indicated unable to complete the interview.A record review of Resident #1's physician's order dated 03/05/2025 reflected NPO every shift start date 03/05/2025.A record review of Resident #1's MAR dated 12/20/2025 and 12/21/2025 reflected NPO was not signed off by LVN A on the 10:00 PM - 6:00 AM shift.Observation of Resident # 1 on 12/22/2025 at 2:00 PM revealed the resident was lying in bed asleep.Attempted an interview with Resident # 1's RP on 12/22/2025 at 12:00 PM, 2:30 PM, and 5:30 PM. Resident # 1's RP was not able to be contacted by exit on 12/22/2025.Attempted an interview with LVN A on 12/22/2025 at 3:38 PM, 4:02 PM, and 5:25 PM. Left LVN A voice messages each attempt and LVN A did not respond back by exit on 12/22/2025.During an interview with the DON on 12/22/2025 at 4:35 PM, the DON stated it was expected for LVN A to have signed off on the MAR on 12/20/2025 and 12/21/2025 on the 10:00 PM- 6:00 AM shift. The DON stated when the MAR was not signed off would indicate it was not done.During an interview with the ADM on 12/22/2025 at 5:19 PM, the ADM stated it was expected for LVN A to have signed off on Resident # 1's MAR to ensure documentation was completed. The ADM stated if the MAR was not signed off on would have indicated that it was not completed and could cause further complications. Record review of the facility's, revised 07/2017, policy titled Charting and Documentation reflected All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response care. 7.Documentation of procedures and treatments will include care-specific details including:A. The date and time the procedure/treatment was providedB. The name and title of the individual(s) who provided the careC. The assessment data and/or any unusual findings obtained during the procedure/treatmentD. How the resident tolerated the procedure/treatmentE. Whether the resident refused the procedure/treatmentF. Notification of family, physician or other staff, if indicated; andG. The signature and title of the individual documenting.

Based on observation, interview, and record review the facility failed to submit a completed and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days from the IDT for 1 of 1 (Resident #1) resident reviewed for delinquent PASARR processes. The facility failed to ensure Resident #1 received the services recommended by the PASARR evaluation when they failed to submit a complete and accurate request for NFSS in the LTC online Portal within 20 business days from the IDT meeting. This failure caused a delay in her Medicaid Entitled Services including physical therapy and occupational therapy. This failure placed Resident #1 at risk of not achieving or maintaining her highest practicable level of physical functioning and could potentially result in increased disability. Findings include: Review of Resident #1's undated face sheet reflected that she was a [AGE] year-old female admitted [DATE] with diagnoses of Mild Intellectual Disabilities, Diabetes Type 2, Hypertension (high blood pressure), chronic kidney disease, stage 5, and Cerebral Infarction (stroke). Review of Resident #1's 6/5/25 Quarterly MDS reflected her BIMS score was 15 which indicated she was cognitively intact. Review of resident #1's 5/5/25 Care Plan reflected a care area initiated 1/23/25 for falls related to poor balance, unrealistic sense of physical abilities with a goal to resume usual activities and interventions including physical therapy. Observation on 6/23/25 at 10:56 AM of Resident #1 revealed her using a manual wheelchair for mobility in the activities/bingo room. Interview attempted on 6/23/25 at 11:14 AM with Resident #1 but she had left the facility for dialysis and was unavailable. In an interview on 6/23/25 at 2:25 PM the MDS-RN stated, the IDT meeting for Resident #1 was held on 4/10/25. She stated that following the meeting NFSS forms were submitted on 4/24/25, 5/7/25, and 5/8/25 for physical and occupational therapy recommendations. She further stated all the forms were rejected with errors and the final form on 5/8/25 was marked as late according to PASARR timelines. In a 2nd interview on 6/23/25 at 3:49 PM the MDS-RN stated, PASARR was important because it provided residents who had intellectual and mental disabilities extra services to help them cope with their disabilities. She stated that she had recently assumed responsibility for the PASARR process and that if PASARR was not done, residents may miss extra therapy and lose strength or independence. In an interview on 6/23/25 at 4:15 PM the DT stated, if PASARR recommended services it was important to do them to maintain a resident's strength, balance, and safety. She stated the MDS-RN was responsible for handling the PASARR processes and that failure to follow the PASARR recommendations could lead to a decline in the resident's function. In an interview on 6/23/25 at 4:27 PM the DON stated, PASARR was important because it allowed residents to get additional services that they needed. She stated, the MDS-RN was responsible for doing PASARR and that if PASARR was not done then residents could miss services and not get as strong as they could. She stated that she and the MDS-RN were immediately setting up a new meeting for Resident #1. In an interview on 6/23/25 at 4:40 PM the ADM stated, PASARR was important to provide residents specialized services to meet their needs. He stated the MDS-RN was responsible for handling PASARR and that the negative outcome to residents if PASARR was not done was that the resident would not improve in areas they could have improved in. Record Review of Resident #1's undated NFSS form reflected: Submission date of 5/7/25. Physical Therapy and Occupational Therapy were requested. Denial date on 5/20/25 for incorrectly completed signature page. Record Review of the facility policy titled, PASRR Clinical Policy and dated May 2014, reflected: The MDS-RN will coordinate and deliver specialized services the facility was responsible for providing. The MDS-RN /DON will initiate delivery of specialized services. The MDS-RN/DON will monitor the LTC portal. The policy did not include a timeline from the IDT meeting.

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident #7 and #34) reviewed for resident rights. The facility failed to ensure Resident's #7's and Resident #34's call lights were within reach on 04/15/25. This failure could place residents at risk of needs not being met. Findings included: 1. Record Review of Resident #7's face sheet dated 04/16/25 reflected the resident was an [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertensive heart disease with heart failure (when high blood pressure (hypertension) weakens the heart over time, leading to heart failure), diabetes (a group of diseases that result in too much sugar in the blood), Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), and heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). Record Review of Resident #7's Annual MDS assessment dated [DATE] reflected Resident #7 was dependent on staff for eating, toileting, bathing, and personal hygiene. MDS reflected Resident #7 had a BIMS score of 06 which indicated Resident #7 was severely cognitively impaired. Record review of Resident #7's care plan dated 10/10/24 reflected: Resident at risk for falls due to weakness. Goal: Resident #7 would not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation and interview on 04/15/25 at 10:38 AM, Resident #7 stated she was doing fine. She stated she could not reach her call light where it was at that time. She stated she usually could reach her call light. She stated the call light could have fallen on the floor but if she needed help, she would yell for someone to come in from the hallway. She stated she had no concerns. Observed Resident #7's call light on the floor beside resident's bed and out of resident's reach. The call light, from the other side of the room, which was intended for use by a roommate if resident had one, was placed in a drawer on the side of residents bed , and was also out of resident's reach. Resident demonstrated that she could not reach either of the call lights. In an observation on 04/15/25 at 11:00 AM, Resident #7's call light remained on the floor beside resident's bed, and the other call light remained in a drawer beside resident's bed and out of Resident #7's reach. 2. Review of Resident #34's quarterly MDS assessment dated [DATE], reflected a [AGE] year-old-female who was admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, end stage renal disease (loss of kidney function), diabetes, high levels of fat stored in the body, morbid obesity, non-Alzheimer's dementia, anxiety (worry), depression (sadness), lupus (when the body's immune system mistakenly attacks its own tissues and organs ), sleep apnea (interruptions in breathing during sleep), chronic pain syndrome, lymphedema (swelling caused by an accumulation of protein-rich fluid), and gout (buildup of uric acid crystals leading to severe pain commonly affecting the big toe). She was dependent on staff for almost all ADL's. She had a BIMS score of 07 indicating severe cognitive impairment. Review of Resident #34's care plan dated last revised 3/27/2025 reflected that she had a behavior problem r/t not using her call light and hollering out for help due to her cognition impairment. Her interventions included making sure her call light was within reach. Observation and interview on 04/15/2025 at 11:15 AM revealed Resident #34 was lying in bed. Her call light was resting on top of her oxygen concentrator approximately 2.5 feet from her bed. When asked, the resident stated she was unable to reach her call light if she needed it to call for help. During the interview, the resident began calling out to staff in pain related to her big toe and requested medication. CNA C entered Resident #34's room in response to the crying out. When asked, CNA C stated she was unaware of why the resident's call light was resting atop the oxygen concentrator and stated it should have been clipped to Resident #34's bed sheet. In an interview on 04/15/25 at 11:03 AM, CNA B stated Resident #7 could not reach her call light where it was at that time. CNA B stated she was going to fix the call light right then. She stated she knew how important it was for the residents to have their call lights and she was just trying to get everyone up and ready for the day. She stated the call light must have fell on the floor. She stated she had been trained on call light placement. She stated lots of things could happen and resident would not be able to call for help if their call light was out of the resident's reach. In an interview on 04/16/25 at 1:45 PM, the ADM stated it was his expectation that all residents' call lights be within reach at all times. He stated staff had been trained on call light placement and ensuring residents had their call light within reach at all times. He stated if a resident's call light was out of their reach, the resident would not have been able to call staff if they needed assistance or it could have caused a delay in care. In an interview on 04/16/25 at 3:24, the DON stated it was her expectation that all residents' call lights be within reach at all times. She stated staff had been trained on call light placement and ensuring residents had their call light within reach at all times. She stated if a residents call light was out of their reach, the resident may not have been able to call for help if they needed something. Interview on 04/17/2025 at 10:40 AM with CNA C revealed that she began working at the facility a couple of months ago and worked the 6am-2pm shift. She stated that Resident #34 could not get out of bed on her own. She stated that she believed that due to Resident #34's diagnosis, that she sometimes forgot how to use her call light and frequently yelled out for help from staff. She stated that the call light was supposed to always be in reach of the resident, but she was aware of times where the resident would throw the call light away from her body/bed. Record review of facility policy titled Answering the Call Light and dated 2001 (revised October 2010) reflected Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #45) reviewed for comprehensive assessments. The facility failed to complete an accurate comprehensive assessment for Resident #45 due to MDS assessment reflected resident received insulin and injections. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. The findings include: Record Review of Resident #45's face sheet dated 04/16/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (a serious condition where the lungs fail to adequately oxygenate the blood, leading to low blood oxygen levels), diabetes (a group of diseases that result in too much sugar in the blood), depression (feelings of severe despondency and dejection), and white matter disease - a progressive disorder that occurs when the white matter in the brain is damaged). Record Review of Resident 45's Annual MDS dated [DATE] reflected Resident #45 required set-up or clean-up assistance for eating, required supervision or touching assistance for toileting and bathing, and required partial or moderate assistance with personal hygiene. MDS reflected Resident #45 had a BIMS score of 13 which indicated Resident #45 was cognitively intact. Record review of Resident #45's Annual MDS assessment dated [DATE], reflected that resident was receiving injections and insulin. Record review of Resident #45's care plan dated 10/26/24 reflected: Resident had Diabetes Mellitus. Goal: Resident #45 would have no complications related to diabetes through the review date. Interventions included: Observe/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (hyperventilating), acetone breath (smells fruity), stupor, coma. Record review of Resident #45's undated Physician's Orders reflected resident had no orders for any type of injection or insulin medications ordered. In an interview on 04/16/25 at 1:06 PM, Resident #45 stated she did not receive insulin injections and she had not ever received insulin that she could remember. She stated she had been diagnosed with pre-diabetes but never required insulin. She stated she was doing well and was on her way to the resident council meeting. In an interview on 04/16/25 at 11:55 AM, LVN A stated she and another staff member were responsible for completing the MDS assessments in the facility. She stated she was trained on completing MDS assessments accurately. She stated she was not sure if Resident #45 received insulin or any injections then or when her last annual MDS was completed on 03/11/25, and she would have to look at the resident's records. She stated she was not sure if Resident #45's MDS dated [DATE] stated resident was receiving insulin or injections or not without looking at the MDS. She stated she had completed Resident #45's MDS dated [DATE]. She stated if a resident was not receiving insulin or any type of injections, it should not have reflected that they did on the MDS. She stated if an MDS assessment was completed inaccurately, it would not affect the resident in any way, but it would have caused the MDS assessment to fall under another RUG level. She stated the RUG score determined the amount of reimbursement the facility received for caring for the residents. In an interview on 04/16/25 at 1:45 PM, the ADM stated it was his expectation that MDS assessments were completed accurately and reflected the resident individually. He stated LVN A was responsible for completing the MDS assessments and she had been trained on completing the MDS assessments accurately as far as he knew. He stated if a resident had not received injections or insulin during the lookback period that the MDS required, the MDS assessment should not have reflected that a resident received insulin or injections he believed. He stated a RUG score was used to determine the amount of reimbursement the facility received for the care they provided to the resident. He stated if an MDS was completed inaccurately, it could have caused an error in billing. In an interview on 04/16/25 at 3:24, the DON stated it was her expectation that MDS assessments were completed to accurately reflect the resident individually. She stated LVN A was responsible for completing the MDS assessments, and LVN A had been trained on completing the MDS assessments accurately. She stated if a resident had not received injections or insulin during the period for coding on an MDS, the MDS assessment should not have reflected that a resident received insulin or injections. She stated a RUG score was used to determine the amount of reimbursement the facility received for the care they provided to the resident. She stated if an MDS was completed inaccurately, it could have caused an inaccurate payment to the facility, but it would not have affected the resident. Record review of the facility's policy titled Resident Assessment Instrument and dated 2001, revised on September 2010 reflected: Policy Statement - A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Policy Interpretation and Implementation - 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. 2. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment. Other assessment forms may be used in addition to the MDS form. 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect, in that: The facility failed to administer Resident #1's Levothyroxine (medication used to treat hypothyroidism) for an unknown period of time at the end of June 2024 and beginning of July 2024. This subsequently led to her TSH (Thyroid Stimulating Hormone) levels elevating to 28.62 (normal range is .450 - 5.330), resulting in a change of condition where she became fatigued, dizzy, and depressed. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not receiving their ordered medications, the loss of the medication's therapeutic benefits, and changes in physical and psychological conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hypothyroidism (a condition resulting from decreased production of thyroid hormones) and a history of thyroid cancer resulting in a thyroidectomy (complete or partial removal of the thyroid gland). Review of Resident #1's quarterly MDS assessment, dated 06/22/24, reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 03/26/24, reflected she had hypothyroidism with an intervention of administering thyroid replacement medication which would help restore the level of thyroid hormone produced by the thyroid gland. Review of Resident #1's physician order, dated 02/09/24, reflected Levothyroxine Sodium Oral Tablet - 150 MCG - one time a day for hypothyroidism. Review of Resident #1's progress notes, dated 06/28/24 and documented by LVN A, reflected the following: [Resident #1] had c/o nausea with small emesis . [Resident #1] was given Zofran and Tylenol for the headache . Review of Resident #1's progress notes, dated 07/09/24 and documented by LVN A , reflected the following: [Resident #1] notified this nurse and aide that she feels like her mental health is going down. She is requesting to see or speak to someone about it. She stated she just wants to give up . Note left in the social worker's office for eval . Review of Resident #1's psychiatric diagnostic assessment, dated 07/10/24, reflected the following: Reason for referral: depression, withdrawal, appetite disturbance, weight loss, refusal/low motivation to participate in rehab therapy . Review of Resident #1's physician order, dated 06/30/24, reflected Remeron Oral Tablet - 15 MG - give 1 tablet by mouth one time a day for depression. Review of Resident #1's physician order, dated 07/10/24, reflected Sertraline HCl Oral Tablet - 50 MG - give 1 tablet by mouth one time a day for depressive symptoms. Review of Resident #1's lab results, dated 07/15/24, reflected a high level of TSH32 - 28.62 (normal range is .450 - 5.330). Review of Resident #1's progress notes, dated 07/15/24 and documented by the NP, reflected the following: [Resident #1] needs to be getting her levothyroxine, spoke with ADON concerning this. Re-check TSH in 4 weeks. During a telephone interview on 07/24/24 with Resident #1's RP, she stated toward the end of June (2024), the noticed Resident #1 had a change in condition. She stated she felt weak, terrible, achy, depressed, and like she wanted to die. She stated it affected her enough that she took herself off therapy (psychological) services. She stated although she was now receiving her thyroid medication , she was still not herself as it would take months to get her levels back to normal. During an interview on 07/24/24 at 12:15 PM, Resident #1's PA stated he saw the residents one time a week and the NP saw the residents the other four days but she was on vacation. He stated he was not aware of the situation where Resident #1 went an experienced extended period of time without her thyroid medication. He stated a negative outcome of not being administered thyroid medication when you had been on it for a long period of time and were dependent on it like someone like Resident #1 could be a thyroid crisis, depression, mood problems, and there could be no thyroid hormones in the body which could cause fatigue. He stated he believed her mood could have been affected. He stated after being without the medication for an extended period of time, it could take up to six months to readjust the TSH levels. He stated checking off in the MAR that the Levothyroxine was given when it actually was not would be a huge medication error. During an interview on 07/24/24 at 1:52 PM, Resident #1 stated she had not been aware she was not receiving her thyroid medication but had noticed how much complications it had caused. She stated about three weeks prior to when they realized she had not been receiving the medication (at the beginning of July 2024, she had become really exhausted, was dizzy, had a loss of appetite, and did not even have the energy to go to therapy. She stated she still felt affected by it as she continued to be fatigued and out of it. She stated it has caused her to be scared to trust the nurses to make sure she was receiving her ordered medications. During an interview on 07/24/24 at 2:32 PM, the ADON stated the NP brought to her attention at the beginning of July (2024) that Resident #1's thyroid level was extremely elevated which indicated she had not been receiving her thyroid medications. She stated Resident #1 had been complaining of feeling down, so she looked at everything. She stated when she looked in the medication cart, she found a blister pack with only four missing pills and she could not find the previous blister back from the month prior (June 2024). She stated it was hard to say how many doses she missed but believed it could have been 5-8 doses. She stated not receiving thyroid medication for an extended period of time could lead to someone not feeling good, tired, and weak. She stated the nurse she believed that was not administering the medication (LVN B ) no longer worked there. She stated she did conduct a full cart audit on that medication cart but none of the other carts. During an interview on 07/24/24 at 4:32 PM, the DON stated on 07/12/24 the NP notified her that there were only two pills missing from Resident #1's thyroid medication blister pack. She stated the ADON looked into it and they had been delivered on 06/28/24. She stated she believed Resident #1 only could have gone 7-12 days without the medication, but it was not guaranteed. She stated a negative outcome of not receiving the medication for an extended period of time could be feeling tired or depression issues but did not believe that was the case for Resident #1 since it could have only been five days that she had gone without. During a telephone interview on 07/29/24 at 11:58 AM, Resident #1's NP stated Resident #1 had been admitted to the facility over five months ago and she was stable until her depression spiked within the last month. She stated Resident #1 was a good historian and told her at the beginning of July (2024) that for the past few weeks she had been feeling more depressed and felt it getting worse and worse. She stated it was to the point where she did not want to get out of bed. She stated once she ordered lab work and her TSH came back extremely high, it was evident that she had not been receiving her thyroid medication, especially with the symptoms she had been experiencing. She stated she could not put a number on how many doses she could have missed because everyone was different, but it had to have been more than a couple of weeks. She stated her TSH could be more normalized with in 4-6 weeks. She stated Resident #1 would not be back at her baseline, but on her medication she will have improved drastically. Review of the facility's Abuse and Neglect Policy, Revised December of 2016, reflected the following: Our residents have the right to be free from abuse, neglect . Review of the facility's Administering Medications Policy, revised December of 2012, reflected the following: Medications shall be administered in a safe and timely manner, and as prescribed. . 3. Medications must be administered in accordance with the orders, including any required time frame. The ADM and ADON were notified on 07/24/24 at 4:50 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 07/27/24 at 12:30 PM: Impact Statement: On 7/24/24 an abbreviated survey was initiated, and the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to not keeping resident free from neglect. How were other residents at risk affected by this deficient practice identified? A. The VP of Clinical in-serviced the DON on audits of thyroid medication orders and the Medication Administration policy and ensuring residents receive their medications on 7/24/24 prior to in servicing staff. B. The facility DON/Designee completed an audit of thyroid medication orders for the residents currently residing in the facility to ensure the residents are receiving their medications. This was completed on 7/24/24. C. An Abuse/Neglect prohibition in-service was conducted by the Administrator with facility staff to include prn staff and newly hired staff on 7/24/24. The facility does not utilize agency. Any staff to include newly hired staff, prn staff not in attendance will be required to receive the in-service prior to working their next scheduled shift. What corrective actions have been implemented for the identified resident? Resident #1 Medication Error report completed, physician and RP notified by the ADON. The DON in-serviced 7/24/24 the licensed nursing staff on Medication Administration. What corrective actions were taken? 1. The following actions were initiated immediately on 7/24/24. a. Initiated in-services on 7/24/24 with licensed nurses to include prn staff and newly hired staff by Director of Nursing on Administering Medications and ensuring residents receive their medications during the hour before to hour after time frame. Newly hired licensed nurses and medication aides, prn staff will be in serviced during the on boarding process by DON/designee on Medication Administration policy. The DON/designee will complete Medication Pass Observations during orientation utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. The facility does not utilize agency. DON/designee will conduct randomized MAR to card audits three times a week for 4 weeks, and then periodically to assure residents are getting medications. 2. The VP of Clinical in-serviced the DON on the Medication Administration policy and ensuring residents receive their medications on 7/24/24. b. On 7/24/24 the DON initiated in-services for the Medication Aides on Administering Medications and ensuring residents receive their medications during the hour before to hour after time frame. The DON/Designee will complete Medication Pass Observations with the licensed nurses and Medication Aides utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. Random Med Pass Observations will be conducted weekly x 4 weeks with the licensed nurses and medication aides to ensure the medication administration policy is followed and that residents are receiving their medication as ordered. If discrepancies are identified, they will be addressed immediately by the DON or ADON. Starting on 7/24/24 DON/designee will conduct randomized MAR to card audits three times a week for 4 weeks, and then periodically to assure residents are getting medications. 3. Newly hired licensed nurses and medication aides, prn staff and agency staff will be in serviced during the on boarding process by DON/designee on Medication Administration policy. The DON/designee will complete Medication Pass Observations during orientation utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. 4. The DON/Designee will complete Medication Pass Observations with the licensed nurses and Medication Aides utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. Random Med Pass Observations will be conducted ongoing weekly with the licensed nurses and medication aides to ensure the medication administration policy is followed and that residents are receiving their medication as ordered. If discrepancies are identified, they will be addressed immediately by the DON or ADON. 5. On 7/24/24 the DON/Designee initiated in-services with licensed nurses and medication aides, on Abuse and Neglect Policy and Procedures with a pre and posttest attached; competency demonstrated as seen by test results. 6. On 7/24/24 the Administrator/Designee initiated life satisfactions surveys with no concerns noted. 7. How will the system be monitored to ensure compliance? A. DON/Administrator will review the results of the Medication Pass Observations that will be completed for the next six weeks. If discrepancies are identified, they will be addressed immediately, and physician notified. Staff will receive further training on our Medication Administration Policy and disciplinary action up to termination. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 7/24/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. The Surveyor monitored the POR on 07/28/24 as followed: During interviews on 07/28/24 from 11:42 AM - 2:32 PM with one RN, three LVNs, two MAs, and three CNAs from different shifts, all stated they were in-serviced before their shift. They all knew who the Abuse and Neglect Coordinator was (the ADM) and gave examples of abuse and neglect such as not changing a resident's brief in a timely manner, verbal, physical, psychosocial, and mental abuse. All stated they would never check off a MAR if they did not administer the medication. All stated the importance of residents receiving their ordered medications. Review of an in-service entitled Medication Administration, dated 07/24/24 and conducted by the VPCS, reflected the DON was reeducated on their Medication Administration policy. Review of in-services entitled Abuse and Neglect, dated 07/24/24 and 07/25/24 and conducted by the ADM, reflected all nursing staff were reeducated on the facility's Abuse and Neglect policy. Review of Abuse and Neglect Post Test Competencies, dated 07/24/24 and 07/25/24, reflected all staff took a post-test after being in-serviced and passed. Review of Life Satisfaction Surveys, dated 07/26/24, reflected all residents were interviewed with no concerns. Review of in-services entitled Medication Administration, dated 07/24/24 and 07/25/24 and conducted by the DON, reflected nurses and medication aides were reeducated on checking the MAR throughout shift for any medications due and checking the MAR/TAR at the end of the shift for any omissions. Review of the facility's Medication MAR to Card Audit, on 7/26/24, reflected the medication carts (four) had been audited on 07/24/24 and 07/25/24 to match the MAR to the medication cards. Review of Medication Pass Observations, dated 07/24/24 - 07/26/24, reflected nurses and medication aides had to conduct a medication pass check-off. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to administer Resident #1's Levothyroxine (medication used to treat hypothyroidism) for an unknown period of time at the end of June 2024 and beginning of July 2024. This subsequently led to her TSH (Thyroid Stimulating Hormone) levels elevating to 28.62 (normal range is .450 - 5.330), resulting in a change of condition where she became fatigued, dizzy, and depressed. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hypothyroidism (a condition resulting from decreased production of thyroid hormones) and a history of thyroid cancer resulting in a thyroidectomy (complete or partial removal of the thyroid gland). Review of Resident #1's quarterly MDS assessment, dated 06/22/24, reflected a BIMS of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 03/26/24, reflected she had hypothyroidism with an intervention of administering thyroid replacement medication which would help restore the level of thyroid hormone produced by the thyroid gland. Review of Resident #1's physician order, dated 02/09/24, reflected Levothyroxine Sodium Oral Tablet - 150 MCG - one time a day for hypothyroidism. Review of Resident #1's progress notes, dated 06/28/24 and documented by LVN A, reflected the following: [Resident #1] had c/o nausea with small emesis . [Resident #1] was given Zofran and Tylenol for the headache . Review of Resident #1's progress notes, dated 07/09/24 and documented by LVN A, reflected the following: [Resident #1] notified this nurse and aide that she feels like her mental health is going down. She is requesting to see or speak to someone about it. She stated she just wants to give up . Note left in the social worker's office for eval . Review of Resident #1's psychiatric diagnostic assessment, dated 07/10/24, reflected the following: Reason for referral: depression, withdrawal, appetite disturbance, weight loss, refusal/low motivation to participate in rehab therapy . Review of Resident #1's physician order, dated 06/30/24, reflected Remeron Oral Tablet - 15 MG - give 1 tablet by mouth one time a day for depression. Review of Resident #1's physician order, dated 07/10/24, reflected Sertraline HCl Oral Tablet - 50 MG - give 1 tablet by mouth one time a day for depressive symptoms. Review of Resident #1's lab results, dated 07/15/24, reflected a high level of TSH32 - 28.62 (normal range is .450 - 5.330). Review of Resident #1's progress notes, dated 07/15/24 and documented by the NP, reflected the following: [Resident #1] needs to be getting her levothyroxine, spoke with ADON concerning this. Re-check TSH in 4 weeks. During a telephone interview on 07/24/24 with Resident #1's RP, she toward the end of June (2024), the noticed Resident #1 had a change in condition. She stated she felt weak, terrible, achy, depressed, and like she wanted to die. She stated it affected her enough that she took herself off therapy services. She stated although she was now receiving her thyroid medication , she was still not herself as it would take months to get her levels back to normal. During an interview on 07/24/24 at 12:15 PM, Resident #1's PA stated he saw the residents one time a week and the NP saw the residents the other four days but she was on vacation. He stated he was not aware of the situation where Resident #1 went an extendedperienced period of time without her thyroid medication. He stated a negative outcome of not being administered thyroid medication when you had been on it for a long period of time and were dependent on it like someone like Resident #1 could be a thyroid crisis, depression, mood problems, and there could be no thyroid hormones in the body which could cause fatigue. He stated he believed her mood could have been affected. He stated after being without the medication for an extended period of time, it could take up to six months to readjust the TSH levels. He stated checking off in the MAR that it was given when it actually was not would be a huge medication error. During an interview on 07/24/24 at 1:52 PM, Resident #1 stated she had not been aware she was not receiving her thyroid medication but had noticed how much complications it had caused. She stated about three weeks prior to when they realized she had not been receiving the medication, she had become really exhausted, was dizzy, had a lost of appetite, and did not even have the energy to go to therapy. She stated she still felt affected by it as she continued to be fatigued and out of it. She stated it has caused her to be scared to trust the nurses to make sure she was receiving her ordered medications. During an interview on 07/24/24 at 2:32 PM, the ADON stated the NP brought to her attention that Resident #1's thyroid level was extremely elevated which indicated she had not been receiving her thyroid medications . She stated Resident #1 had been complaining of feeling down, so she looked at everything. She stated when she looked in the medication cart, she found a blister pack with only four missing pills and she could not find the previous blister back from the month prior (June 2024). She stated it was hard to say how many doses she missed but believed it could have been 5-8 doses. She stated not receiving thyroid medication for an extended period time could lead to someone not feeling good, tired, and weak. She stated the nurse she believed that was not administering the medication (LVN B ) no longer worked there. She stated she did conduct a full cart audit on that medication cart but none of the other carts. During an interview on 07/24/24 at 4:32 PM, the DON stated on 07/12/24 the NP notified her that there were only two pills missing from Resident #1's thyroid medication blister pack. She stated the ADON looked into it and they had been delivered on 06/28/24. She stated she believed Resident #1 only could have gone 7-12 days without the medication, but it was not guaranteed. She stated a negative outcome of not receiving the medication for an extended period of time could be feeling tired or depression issues but did not believe that was the case for Resident #1 since it could have only been five days that she had gone without. During a telephone interview on 07/29/24 at 11:58 AM, Resident #1's NP stated Resident #1 had been admitted to the facility over five months ago and she was stable until her depression spiked within the last month. She stated Resident #1 was a good historian and told her at the beginning of July (2024) that for the past few weeks she had been feeling more depressed and felt it getting worse and worse. She stated it was to the point where she did not want to get out of bed. She stated once she ordered lab work and her TSH came back extremely high, it was evident that she had not been receiving her thyroid medication, especially with the symptoms she had been experiencing. She stated she could not put a number on how many doses she could have missed because everyone was different, but it had to have been more than a couple of weeks. She stated her TSH could be more normalized with 4-6 weeks. She stated Resident #1 would not be back at her baseline, but on her medication she will have improved drastically. Review of the facility's Administering Medications Policy, revised December of 2012, reflected the following: Medications shall be administered in a safe and timely manner, and as prescribed. . 3. Medications must be administered in accordance with the orders, including any required time frame. Review of the Mayo Clinic website, accessed 08/12/24, hypothyroidism that is not treated can lead to goiter (a condition that may cause problems with swallowing or breathing), heart disease and heart failure, and peripheral neuropathy (nerve damage causing pain, numbness, and tingling in the arms and legs). The ADM and ADON were notified on 07/24/24 at 4:50 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 07/27/24 at 12:30 PM: Impact Statement: On 7/24/24 an abbreviated survey was initiated, and the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to not providing pharmaceutical services to meet the needs of a resident. How were other residents at risk affected by this deficient practice identified? D. The VP of Clinical in-serviced the DON on completing an audit on thyroid medication orders and the Medication Administration policy and ensuring residents receive their medications on 7/24/24, prior to in-servicing staff. B. The facility DON/Designee completed an audit of thyroid medication orders for the residents currently residing in the facility to ensure the residents are receiving their medications. This was completed on 7/24/24. What corrective actions have been implemented for the identified resident? Resident #1 Medication Error report completed physician and RP notified by the ADON. Order to recheck thyroid lab on 8/16/24 received. Don/Designee will ensure new order is completed. The DON in-serviced 7/24/24 the licensed nursing staff on Medication Administration. What corrective actions were taken? 8. The following actions were initiated immediately on 7/24/24. c. Initiated in-services on 7/24/24 with licensed nurses by Director of Nursing on Administering Medications and ensuring residents receive their medications during the one hour before and one hour after time frame. Licenses nurses vocalized understanding and signed in-service as confirmation of education and competency. Starting on 7/24/24, DON/designee will conduct randomized MAR to card audits three times a week for 4 weeks, and then periodically to assure residents are getting medications. d. On 7/24/24 The VP of Clinical in serviced the DON on Administering Medications and ensuring residents receive their medications prior to in-servicing staff. e. On 7/24/24 the DON initiated in-services for the Medication Aides on Administering Medications and ensuring residents receive their medications during the one hour before and one hour after time frame. Medication Aides vocalized understanding and signed in-service as confirmation of education and competency. The understanding verification will be completed and documented using a Medication Administration Competency skill check list. f. Newly hired licensed nurses and medication aides will be in serviced during the on boarding process by DON/designee on Medication Administration policy. Licenses nurses and medication aides will vocalize understanding and signed in-service as confirmation of education and competency. The DON/designee will complete a Medication Pass Observation on a competency skill list document during orientation. VP of clinical trained DON on medication administration policy prior to DON in-servicing staff on 7/24/24. g. Starting on 7/25/24 the DON/Designee will complete Medication Pass Observations with the licensed nurses and Medication Aides for four weeks. Random Med Pass Observations will be conducted weekly ongoing thereafter with the licensed nurses and medication aides to ensure the medication administration policy is followed and that residents are receiving their medication as ordered. If discrepancies are identified, the DON and/or ADON will address immediately. 9. How will the system be monitored to ensure compliance? B. DON/Administrator will review the results of the Medication Pass Observations that will be completed for the next four weeks. If discrepancies are identified, they will be addressed immediately, and physician notified. Staff will receive further training on our Medication Administration Policy and disciplinary action up to termination. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 7/24/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. The Surveyor monitored the POR as followed: During interviews on 07/28/24 from 11:42 AM - 2:32 PM with one RN, three LVNs, two MAs, and three CNAs from different shifts, all stated they were in-serviced before their shift. All stated they would never check off a MAR if they did not administer the medication. All stated the importance of residents receiving their ordered medications. Review of an in-serviced entitled Medication Administration, dated 07/24/24 and conducted by the VPCS, reflected the DON was reeducated on their Medication Administration policy. Review of in-services entitled Medication Administration, dated 07/24/25 and 07/25/24 and conducted by the DON, reflected nurses and medication aides were reeducated on checking the MAR throughout shift for any medications due and checking the MAR/TAR at the end of the shift for any omissions. Review of the facility's Medication MAR to Card Audit, on 7/26/24, reflected the medication carts (four) had been audited on 07/24/24 and 07/25/24 to match the MAR to the medication cards. Review of Medication Pass Observations, dated 07/24/24 - 07/26/24, reflected nurses and medication aides had to conduct a medication pass check-off. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern 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 that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for three (Resident #1, Resident #2, and Resident #3) of six residents reviewed for incontinent care. The facility failed to: 1. Change Resident #1's foley catheter after she was diagnosed with a UTI until six days later and failed to ensure the catheter bag was not continuously laying on the ground on 07/24/24. 2. Ensure Resident #2 was provided incontinent care after CNAs E and F removed her dirty brief and put on a clean one. 3. Ensure sanitary infection control practices were used when CNA G provided incontinent care to Resident #3. CNA G also failed to don PPE per EBP protocol as Resident #3 had an indwelling catheter. These failures placed residents at risk of transmission and/or spread of infection or contagious disease which could lead to further infections and hospitalization . Findings included: 1. Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including stroke, hemiplegia (one-sided paralysis), retention of urine, and type II diabetes. Review of Resident #1's quarterly MDS assessment, dated 06/22/24, reflected a BIMS score of 15, indicating she was cognitively intact. Section H (Bladder and Bowel) reflected she had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 03/26/24, reflected she had the inability to control urination and is incontinent with an intervention of observing/reporting to MD and any s/sx of UTI. Review of Resident #1's physician order, dated 07/21/24, reflected Foley Catheter 18 FR 10cc bulb to bedside drainage. Review of Resident #1's progress notes, dated 06/28/24 and documented by the NP, reflected the following: Family requesting UA due to cloudy urine with sediment , nausea, and vomiting . Resident #1 started antibiotics (Cefdinir) on 07/01/24 for a UTI for seven days. Review of Resident #1's physician order, dated 05/30/24, reflected Change Foley Catheter PRN for s/s of infection, obstruction or if closed system is compromised. Review of Resident #1's TAR, July 2024, reflected her foley catheter was changed on 07/07/24 . Observation on 07/24/24 at 12:15 PM revealed Resident #1's foley drainage bag lying flat on the ground under her bed. Observation on 07/24/24 at 12:50 PM revealed Resident #1's foley drainage bag lying flat on the ground under her bed. Observation on 07/24/24 at 1:52 PM revealed Resident #1's foley drainage bag lying flat on the ground under her bed. Observation on 07/24/24 at 3:06 PM revealed Resident #1's foley drainage bag lying flat on the ground under her bed. During a telephone interview on 07/24/24 at 10:28 AM, Resident #1's RP stated she noticed at the end of June (2024), that Resident #1's catheter bag looked yucky and she requested they check for a UTI. She stated she did end up having a UTI and was treated with antibiotics. She stated on 07/06/24 she noticed it was the same catheter and the tubing was full of sediment. She stated she asked for the nurse to put a fresh one in. She stated the nurse tried to flush the tubing and it was so clogged she was not able to. She stated she told the NP who elevated the concern to the ADON. She stated she was a nurse and knew that if someone tested positive for a UTI the catheter needed to be changed to ensure there was no more bacteria. 2. Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, age-related physical debility, and morbid obesity. Review of Resident #2's quarterly MDS assessment, dated 06/27/24, reflected a BIMS score of 7, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff with toileting. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and bowel. Review of Resident #2's quarterly care plan, dated 07/10/24, reflected she was incontinent of bowel and bladder with an intervention of providing prompt incontinent care. Review of video footage of Resident #2, dated 07/18/24 and provided by Resident #2's FM C, revealed CNAs E and F in Resident #2's room about to provide incontinent care. CNAs E and F were both wearing gloves that were not changed during the duration of the footage. CNA E opened the brief then they rolled Resident #2 on her left side and removed the brief and placed it on the floor. Without utilizing wipes or providing any incontinent care, a clean brief was placed on Resident #2. CNA F picked up the dirty brief and bed pad off the floor and used her dirty gloves to open the blinds before leaving the room. CNA E used her dirty gloves to pull Resident #2's blankets up and on top of her. 3. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type II Diabetes, lumbago (lower back pain), and muscle weakness. Review of Resident #3's admission MDS assessment, dated 07/04/24, reflected a BIMS score of 13, indicating a intact cognition. Section GG (Functional Abilities and Goals) reflected she required substantial/maximal assistance with toileting. Section H (Bowel and Bladder) reflected she had an indwelling catheter. Review of Resident #3's admission care plan, dated 07/02/24, reflected no focus areas related to her catheter or ADL assistance. Review of Resident #3's physician order, dated 07/02/24, reflected Foley catheter care Q shift and PRN. During an observation on 07/24/24 at 11:59 AM revealed CNA G performing peri and catheter care on Resident #3. There was not a sign on the door indicating any EBP precautions were required nor was there a PPE cart near the doorway. CNA G told Resident #3 what she was going to do, then went to the bathroom and washed her hands, and donned gloves. She did not don a gown or mask per EBP precautions. She removed the front of the brief which revealed an indwelling catheter was present. CNA G removed one wipe from the package and swiped three areas at the front of the perineum with the same wipe and then threw it away. She grabbed another wipe from the package and swiped the labia twice with the same wipe and threw it away. She then picked up a trash can and placed it closer to her work area. Without changing gloves or performing hand hygiene, she took a wipe from the package and cleaned the indwelling catheter. CNA G repositioned Resident #13 on her right side, removed the soiled brief, and placed it in the trash can. She took a wipe from the package, swiped between the buttocks then folded the stool-soiled wipe and swiped again. She then took two wipes from the package, swiped, folded, and swiped between the buttocks again. She then removed another wipe from the package, swiped between the buttocks, folded the wipe, swiped between the buttocks, then folded the wipe again and swiped a third time. She then doffed soiled gloves, performed hand hygiene, and applied a clean brief. During an interview on 07/24/24 at 12:05 PM, CNA G stated she had recently been in-serviced on infection control. CNA G stated they used EBP for residents with feeding tubes or IV's but not for catheters. She stated if a resident was on precautions, there should be a PPE cart near the door. She stated when she was trained on peri care, they used wash clothes instead of disposable wipes. She stated she figured it was okay to use a couple of wipes at a time so it was thicker (like a washcloth) and then she could fold the wipe and use it more than once. She stated she had never heard of one wipe, one swipe when in-serviced on peri care. During an interview on 07/24/24 at 12:15 PM, the PA stated when performing incontinent care, he expected for the peri area to be cleaned thoroughly. He stated if it was not, it could lead to skin and yeast infections. He stated when going from dirty to clean during peri care changing gloves was best practice . He stated any infection control issues during peri care could increase UTI's. He stated when a resident tested positive for a UTI, the foley catheter should be changed to prevent the reoccurrence of a UTI. During an interview on 07/24/24 at 2:23 PM, the ADON stated a resident should be on EBP precautions (with a sign on their door) when they had a foley catheter, g-tube, or IV. She stated when performing care, staff should be donning a gown, mask, and gloves. She stated a negative outcome of not donning PPE would be the risk of infection and the staff needed to protect themselves as much as they were protecting the residents. She stated the same wipe should never be used more than once during peri care to prevent infection. During an interview on 07/24/24 at 4:23 PM, she DON stated residents with catheters, g-tubes, or IVs should be on EBP when providing care and staff should be donning the proper PPE for infection control. She stated a resident's catheter should only be changed after being diagnosed with a UTI if there was sediment present or if the urine was cloudy. During a telephone interview on 07/29/24 at 11:58 AM, the NP stated if a resident tested positive for a UTI, the catheter must be changed because the bacteria that caused the UTI would still be in there. She stated she was not aware she needed to write an order for that as it was normally facility protocol. She stated a catheter bag should never be left on the ground to prevent contamination or infection. She stated appropriate infection control procedures were important during peri care as it was an easy way to spread infection. She stated it would be unacceptable to use a wipe to swipe more than one time during peri care and would assume staff would be changing clothes gloves between going from dirty to clean. Review of the facility's Infection Control Policy, revised July of 2014, reflected the following: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility's Catheter Care Policy, Revised April of 2010, reflected the following: .b. Be sure the catheter tubing and drainage bag are kept off the floor. .Changing Catheters 1. Changing indwelling catheters: It's recommended to change indwelling catheters and bedside drainage bags as needed for clinical indications such as infection, obstruction, or when closed system is compromised. Review of the facility's Perineal Care Policy, revised December 2011, reflected the following: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: . Do not reuse the same disposable wipe/washcloth or water to clean the urethra or labia. Review of the facility's Enhanced Barrier Precautions Policy, dated 04/01/24, reflected the following: This policy outlines the guidelines and procedures to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff. 'Enhanced Barrier Precautions' (EBP) refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of its residents for one (Resident #2) of five residents reviewed for laboratory services. The facility failed to collect a urine specimen for a UA (urine analysis) for Resident #2 as ordered by the physician on 07/19/24 until 07/24/24 because they were out of UA specimen collection cups. Resident #2 was diagnosed with a UTI on 07/28/24 which required antibiotics for seven days. This failure could place residents with indwelling urinary catheters at risk of infection, renal failure, urinary tract infections, and pain. Findings Included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, age-related physical debility, and morbid obesity. Review of Resident #2's quarterly MDS assessment, dated 06/27/24, reflected a BIMS of 7, indicating a severe cognitive impairment. Section H (Bladder and Bowel) reflected she was always incontinent of bladder. Review of Resident #2's quarterly care plan, dated 07/10/24, reflected she was incontinent of bowel and bladder with an intervention of providing prompt incontinent care. Review of Resident #2's physician order , dated 07/19/24, reflected a STAT UA. Review of Resident #2's physician order, dated 07/22/24, reflected a UA and C&S for UTI. Review of Resident #2's physician order, dated 07/24/24, reflected a UA and C&S for UTI. Review of Resident #2's MAR, July 2024, reflected a urine sample had not been collected for a UA until 07/24/24. Review of Resident #2's physician order, dated 07/28/24, reflected Ciprofloxacin HCl Tablet - 500 MG - Give 1 tablet by mouth every 12 hours for UTI for 7 days. During an interview on 07/24/24 at 12:15 PM, Resident #2's PA stated he saw the residents once a week while the NP saw them the rest of the week. He stated he had not known a UA was ordered for Resident #1 nor that the facility staff had not collected a urine sample. He stated his expectations were if a UA was ordered by either him or the NP that a urine sample be collected the same day for testing. He stated symptoms of a UTI could exacerbate if not caught and treated in an appropriate timeframe. During an interview on 07/24/24 at 2:00 PM, the DON stated they had not received the results of Resident #2's UA from 7/19/24 yet. She then stated Resident #2 was incontinent and the staffthey tried to utilize an in-and-out catheter but there had been no specimen to collect because she had already been incontinent. She stated that was why another order had been written. During an observation and interview on 07/24/24 at 2:05 PM, revealed Resident #2 in her room with FM C and FM D eating food they had brought in for her. FM C stated Resident #2's increased confusion had gotten worse the week prior and that was when she started asking for a UA because something had changed. FM C stated she visited Resident #2 over the weekend (07/20/24 - 07/21/24) and asked staff multiple times about getting the specimen and kept being told, Someone is coming to get it but no one ever came. During an interview on 07/24/24 at 2:32 PM, the ADON stated a UA was ordered for Resident #2 on 07/19/24 due to increased confusion. She stated she did not find out until earlier that week (07/22/24 ) that they were out of UA specimen collection cups and that was why it had not been collected over the weekend. She stated no one told her they were out over the weekend. She stated she then started calling around looking for some. She stated her expectation was that a urine specimen be collected the same day it was ordered. She stated if a resident was symptomatic for a UTI it could lead to a bad infection. During an observation and interview on 07/24/24 at 3:00 PM, revealed the cabinet where the UA specimen cups were stored was empty. The ADON confirmed that was where the cups were normally stored but they were out. The DON joined the conversation and stated they were not out of specimen cups. The ADON stated they had been out for several days but had recently been informed some had been delivered. During a telephone interview on 07/29/24 at 11:58 AM, Resident #2's NP stated she ordered the STAT UA on 07/19/24 due to Resident #2's increased confusion and altered mental status. She stated she was not aware the specimen was not collected until today as she was on vacation last week. She stated it was her expectation that a sample be collected and sent to the lab no longer than six hours after the order is made. She stated going five days without collecting the specimen for testing after being ordered was unacceptable. Review of the facility's Lab and Diagnostic Test Results Policy, revised April 2007, reflected the following: 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care, in that: The facility failed: - To obtain orders for wound care after Resident #1 was found to have several round red areas to his upper bilateral buttocks on 06/30/24. On 07/03/24, one of the areas had opened, measuring 12 mm x 12 mm, causing him pain and a burning sensation for several days. - Ensure the new skin issue, identified 06/30/2024, the wound care nurse was not informed until 07/02/2024, and failure to obtain MD orders for treatment until 07/03/2024 These failures placed residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral palsy (group of movement disorders that appear in early childhood), fusion of spine, contractures of left and right knee, muscle weakness, and quadriplegia (paralysis of all four limbs). Review of Resident #1's quarterly MDS assessment, dated 04/30/24, reflected a BIMS of 15, indicating he had no cognitive impairment. Section M (Skin Conditions) reflected he was at risk of developing pressure ulcers/injuries . Review of Resident #1's quarterly care plan, dated 05/08/24, reflected he had impairment to skin integrity related to fragile skin with an intervention of administering treatment as ordered. Review of Resident #1's Weekly Skin Review, dated 06/30/24, reflected the following: [Resident #1] has several round areas to upper bilateral buttocks, one with small amount of depth, no bleeding noted. Possible pressure injury and needs assessment by wound care . very high upon buttocks, nearly to lower back, each is circular. Review of Resident #1's progress notes, dated 07/01/24 and documented by LVN A, reflected the following: [MA B] came to let me know that she changed [Resident #1]'s brief and that he has redness, possible sores on his bottom, I said yes, the day nurse told me, she had already placed barrier cream on. Will have wound care nurse f/u, he currently does not have any wound care order. Will continue barrier cream for now. Review of Resident #1's progress notes, dated 07/02/24 and documented by LVN C, reflected the following : Advised wound care nurse of areas to L (butt) cheek. Review of Resident #1's progress notes, dated 07/03/24 and documented by LVN D, reflected the following: Cleaned area on left upper buttocks with NS and applied foam dressing. Review of Resident #1's Weekly Skin Review, dated 07/03/24, reflected the following : Left buttock - round red area, blanches upon touch, measures 11 mm x 10 mm; Left buttock - round red area, blanches upon touch, measures 8 mm x 9 mm; Left buttock - 12 mm x 12 mm open red area Review of Resident #1's physician order, dated 07/03/24, reflected treatment to left upper buttock open area: Clean with NS, pat dry, apply collagenase powder and cover with bordered foam dressing two times a day. During an interview on 07/03/24 at 10:10 AM, Resident #1 stated he had redness/burning to his backside for several days. He stated he had not recently been seen by the wound care nurse. He stated he did not know how often they were supposed to be applying cream/treating his backside but it was obviously not enough since it was still there, burning, and causing him pain. During a telephone interview on 07/03/24 at 2:30 PM, LVN A stated MA B informed her about the red areas to Resident #1's buttocks on 06/30/24. She stated she assessed the areas and they were not too major at that point. She stated she applied barrier cream to the area and documented it on her shift report for the oncoming nurse. She stated she worked on 07/01/24 and noted blanchable areas and one of the red spots had a top layer that was gone and it had started to open. She stated she placed a note on her shift report to have the WCN follow up and write orders for treatment. During a telephone interview on 07/03/24 at 2:46 PM, MA B stated she informed LVN A on 06/30/24 about the redness to Resident #1's buttocks. She stated there were at least three small circles that were red and she felt as though they were infected and needed treatment. She stated she was told by LVN A just to apply barrier cream to the areas. During a telephone interview on 07/03/24 at 2:53 PM, LVN C stated she notified the WCN on 07/02/24 about the red areas to Resident #1's buttocks but did not hear back or receive any orders . On 07/03/24 multiple attempts were made to contact the WCN. A returned call was not received prior to exiting. During an interview on 07/03/24 at 3:10 PM, the DON stated her expectations was that any skin integrity issues were documented by the nurses either in the residents' progress notes or by completing a skin assessment. She stated they should notify the WCN and get orders that same day, especially if there was an open area or a pressure injury. She stated LVN D informed her early that morning that it looked like an area to Resident #1's buttocks was opening. She stated the WCN has yet to assess him, but LVN D put in standard wound treatment orders until the WCN could assess him. She stated the nurse that initially identified the open area on Resident #1 should have notified the WCN or doctor. She stated it was not acceptable to just leave it in their shift reports and it did not meet her expectations. She stated areas could become infected or could worsen if treatment orders were not implemented right away . Review of the facility's undated Skin Management Policy, reflected the following: . New Skin Condition: The charge nurse will communicate findings to the RP and MD and obtain an order for treatment/dressing changes.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (Resident #2) of two residents observed for infection control practices. The facility failed to ensure staff (CNA E and CNA F) followed infection control practices while performing peri care on Resident #1. This failure placed residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including stroke, unspecified dementia, age-related osteoporosis (a condition when bone strength weakens and is susceptible to fracture), multiple fractures, and a history of urinary tract infections. Review of Resident #2's quarterly MDS assessment, dated 04/09/24, reflected a BIMS of 00, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was independent for toileting hygiene. Section H (Bladder and Bowel) reflected she was always incontinent of bladder and bowel. Review of Resident #2's quarterly care plan, dated 05/19/24, reflected she had an ADL self-care performance deficit related to weakness and debility with an intervention of requiring 1-2 staff members for assistance with toileting. Observation on 07/03/24 at 1:56 PM, revealed CNA E entering Resident #2's room, pulling gloves out of her pocket, and donned them without washing her hands. CNA F entered the room, washed her hands and donned her gloves. CNA E pulled three wipes from the package and layered them, cleaned Resident #2's left groin, flipped the wipes and cleaned the right groin, and threw the wipes in the trash. She then pulled two wipes from the package and wiped the vaginal area from front to back then threw the wipes away. Resident #2 was turned on her right side with assistance from CNA F and CNA E pulled two wipes from the package and wiped the buttocks, folded the wipes and used them again to wipe the buttocks. The dirty brief was removed by CNA E from behind the resident and a new brief was placed under the resident (without hand hygiene or gloves changed). Resident #2 was rolled onto her back and her brief was secured. CNA E covered Resident #1, picked up oxygen tubing and call light to untangle them while still wearing the soiled gloves She attached the call light to the bed and stated she was going to wash her hands. During an interview on 07/03/24 at 3:10 PM, the DON stated her expectations during peri care were that the staff utilize hand sanitizer or soap and water before donning gloves. She stated they should then remove the dirty brief and don a new pair of gloves. She stated a wipe should never be used more than once; you should wipe once and throw it away before getting a new wipe. She stated when going from dirty to clean, gloves should be changed in between. She stated not changing gloves before going from dirty to clean or utilizing the same wipe more than once would cause opportunities to spread infection . During an interview on 07/03/24 at 3:19 PM, CNA E stated she knew she messed up during peri care with Resident #1. She stated she should not have folded the wipes to reuse them and should have changed gloves in between going from dirty to clean. She stated she knew the policy and procedure said to change gloves from dirty to clean and to utilize hand sanitizer. She stated not changing gloves and reusing wipes while cleaning a resident could lead to infection. Review of a facility in-serviced entitled Peri Care, dated 06/12/24, reflected the aides were reeducated on their Perineal Care Policy. Review of the facility's Perineal Care Policy, revised December 2011, reflected the following: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure: . 2. Wash and dry your hands thoroughly. . Do not reuse the same disposable wipe/washcloth or water to clean the urethra or labia. . 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Put on clean gloves and place new brief and secure in place.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice for 2 of 6 residents (Residents #1 and Resident #2) reviewed for respiratory care. 1. The facility failed to ensure Resident #1 received weekly filter cleanings for her BiPAP machine (A BiPAP Machine is a respiratory machine used to provide positive airway pressure through a mask, worn while sleeping, to provide airway pressure during inhalation and exhalation to keep the user's throat open from collapsing.). 2. The facility failed to ensure Resident #2 received weekly filter cleanings for her CPAP machine (A CPAP Machine was a respiratory machine used to provide positive airway pressure through a mask, worn while sleeping, to provide airway pressure during inhalation and exhalation to keep the user's throat open from collapsing.) An IJ was identified on 5/9/2024. The IJ Template was provided to the facility on [DATE] at 6:01 PM. While the IJ was removed on 5/10/2024, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of isolated because all staff had not been trained on the POR. This placed residents receiving BiPAP/CPAP therapy at risk for infection and exacerbation of respiratory distress. Findings included: 1. Record review of Resident #1's Quarterly MDS, dated [DATE], indicated the resident was a [AGE] year-old female that admitted to the facility on [DATE]. She was diagnosed with both Acute, and Chronic, Respiratory failure with hypoxia (which was a life-threatening condition where the lungs could not provide enough oxygen to the body) and Obstructive Sleep Apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway while sleeping.) Section C., Cognitive Patterns: Resident #1 had a BIMS Score of 14. A BIMS Score of 14 indicated the resident did not have cognitive impairment. Resident # 1 was not coded as a having a BiPAP. Record review of Resident #1's CP reflected a [Focus] area, revised 3/18/2024, evidenced by the resident having utilized a BiPAP Machine and was high-risk for infection and aspiration. The [Goal,] revised on 3/18/2024, indicated the resident would not show signs of infection. An intervention for nursing staff, initiated on 6/15/2023, indicated nursing staff was to wake resident to make sure the BiPAP was on. An [Intervention] for nursing staff, initiated on 5/31/2023, indicated staff was to ensure the BiPAP Machine was at the correct settings, per order. Record review of Resident #1's Order Summary Report, dated 5/9/2024, indicated an order, made 12/23/2023, to change BiPAP tubing every 3 months. Record review of Resident #1's vital signs in PCC at the facility, dated 3/4/2024, indicated Resident #1's O2 saturations (the amount of oxygen in her blood) was 82%. Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 3/4/2024 to 3/14/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident was admitted to the ICU and was intubated (a tube placed through the resident's airway to breathe.) She was extubated (removal of the tube placed in resident's airway) on 3/5/2024 and discharged to a regular hospital bed on 3/6/2024. The resident received her BiPAP machine, from the nursing facility, and the machine had performed well. Resident was diagnosed with pneumonia (which was an infection in the lungs caused by bacteria, viruses, or fungi) on 3/7/2024. The hospital summary stated the resident's responsible parties [alleged the nursing facility had not been successful in the correct placement of the resident's BiPAP mask.] Record review of Resident #1's Order Summary indicated an order, revised on 3/18/2024 to start 3/24/2024, to clean BiPAP mask, tubing, filter, and water canister weekly every night shift on Sunday. An order, revised on 3/18/2024 to start on 3/24/2024, indicated the residents BiPAP machine settings were supposed to be 15 IPAP and 4 EPAP. (These setting controlled positive airway pressure for inhaling and exhaling, respectfully.) Record review of Resident #1's treatment record, March 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 3/24/2024 (documented complete by LVN A.) Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 3/27/2024 to 3/30/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident expressed SOB. Her O2 saturations (the amount of oxygen in her blood) was 89 %. Resident was intubated on 3/27/2024 in the emergency room . Record review of Resident #1's treatment record, March 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 3/31/2024 (documented by LVN E). Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 4/6/2024 to 4/16/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident expressed SOB. Her O2 saturations were 78 % on the way to the hospital. Having arrived, her O2 saturations were 49%. She was noted to be cyanotic (blue or purplish skin due to deficient levels of oxygen in the blood) at the face, lips, and ears. Resident was intubated for concern for severe hypercapnia (elevated carbon dioxide.) The hospital summary indicated the resident had active bilateral pneumonia. Record review of Resident #1's treatment record, April 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 4/7/2024 (documented by LVN A,) 4/14/2024 (documented by LVN E,) 4/21/2024 (documented by LVN F,) and 4/28/2024 (documented by LVN G.) Record review of Resident #1's treatment record, May 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 5/5/2024 (documented by LVN E.) Interview and observations on 5/9/2024 at 9:30 AM with Resident #1 revealed her in bed, the back of the bed was elevated at a 45-degree angle, and she had continuous oxygen via nasal canula (oxygen delivery through a tube inserted in each nostril.) Resident # 1 stated she had been to the hospital 3 times in the last 3 months due to respiratory distress. She stated the reason for the hospitalization s was due to inconsistent use of her BiPAP mask; and that staff had not made sure she was wearing it like she should. She went to the hospital on 3/4/2024 due to low oxygen levels, while there, an RP brought her BiPAP machine from the nursing facility to the hospital. The hospital staff changed the settings and utilized the resident utilized the BiPAP machine while there. She stated she had to go to the hospital two more times due to similar instances of respiratory distress. She denied having seen nursing staff clean her BiPAP Machine or change the filter. She did not know how to check the settings on the machine, and she was not sure who to ask to make sure the settings were correct. The filter for her BiPAP Machine, which was a small rectangular mesh cloth, was designed to fit in a small rectangular compartment on the back side of the machine. The filter was designed to clean room air going into the machine used to produce the proper air pressure flow. The filter was black with discoloration. The settings on the BIPAP were 16 IPAP (Inhale) and 8 EPAP (Exhale.) She did not have any filters, masks, or tubing in her room or in her possession. Phone interview on 5/9/2024 at 11:00 AM with the facility's MD revealed Resident #1 had been to the hospital on 3 separate occasions since 3/4/2024. Her diagnoses were Pneumonia, Congestive Heart Failure (which was a long-term condition that happened when the heart could not pump blood well enough to give your body a normal supply,) and Chronic Obstructive Pulmonary Disease (COPD, which was a respiratory condition characterized by persistent breathlessness and cough.). The MD stated dirty BiPAP filters were most likely not the sole reason that was causing Resident #1's exacerbated shortness of breath and respiratory distress, but more than likely a contributor. Interview on 5/9/2024 at 12:10 PM with MSMR revealed that any replacement materials for Resident #1's BiPAP machine would come from the local BiPAP/CPAP machine company. She stated she did not have any masks, tubing, or filters on hand. She stated she had not ordered any filters. The company did come to the facility to size Resident #1 for the right mask size, but the topic of filters never came up. The facility did not have any supplies for Resident #1's BiPAP Machine on hand. Interview and observation on 5/9/2024 at 12:35 PM with the ADON in Resident #1's room revealed the BiPAP Machine filter was very dirty and did not appear to have been changed weekly. The IPAP 16 (Inhale) and EPAP 8 (Exhale) were not congruent with the orders listed in PCC. The ADON stated the orders to clean BiPAP mask, tubing, filter, and water canister weekly every night shift on Sunday were located on the treatment record but was unable to verbalize the location of the replacement filters. The ADON stated the new filters should have been requested through MSMR in medical supply. 2. Record reviews of Resident #2's Quarterly MDS, dated [DATE] indicated the resident was a [AGE] year-old female that admitted to the facility on [DATE]. She was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) (which was a respiratory condition characterized by persistent breathlessness and cough,) and Obstructive Sleep Apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway.) Section C., Cognitive Patterns: Resident #2 had a BIMS Score of 14. A BIMS Score of 14 indicated the resident did not have cognitive impairment. Resident #2 was not coded as wearing a CPAP. Record review of Resident #2's CP reflected a [Focus] area, revised 12/14/2023, evidenced by having been at risk for ineffective airway clearance D/T COPD and Sleep Apnea. The [Goal,] revised on 12/12/2023, indicated the resident would display normal breathing. An intervention for nursing staff, initiated on 12/14/2023, indicated staff was supposed to maintain CPAP per orders. Record review of Resident #2's May 2024 treatment record, under the heading of [Schedule for May 2024,] Resident #2 was ordered to have her mask cleaned, tubing cleaned, filter cleaned, and water chamber weekly. The start date of the scheduled treatment began on 12/17/2023. Record review or Resident #2's treatment record, dated March 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 3/3/2024 (documented by LVN H,) 3/10/2024 (documented by LVN I,) 3/17/2024 (documented by LVN H,) 3/24/2024 (documented by LVN I,) and 3/31/2024 (documented by LVN H.) Record review or Resident #2's treatment record, dated April 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 4/7/2024 (documented by LVN I,) 4/14/2024 (documented by LVN J,) 4/21/2024 (documented by LVN I,) and 4/28/2024 (documented by LVN H.) Record review or Resident #2's treatment record, dated May 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 5/5/2024 (documented by LVN I.) Interview and observation on 5/9/2024 at 3:34 PM with Resident #2 revealed her lying in her bed watching television. She stated she utilized a CPAP machine daily and pointed to it on a table next to her bed. The filter for her CPAP Machine, which was supposed to be a small rectangular mesh cloth, was designed to fit in a small rectangular compartment on the back side of the machine. The filter was designed to clean room air going into the machine used to produce the proper positive airway pressure flow. When the compartment was opened, there was not a filter in the required location. Resident #2 stated she had not observed staff having cleaned her CPAP machine or having changed the filter weekly. Resident #2 denied any exacerbation of her COPD or problems with the sleep apnea. Record review of the facility's BIPAP/CPAP policy, dated April 2010, indicated BiPAP/CPAP were used to provide the spontaneously breathing resident with continuous positive airway pressure, with or without supplemented oxygen. To improve arterial oxidization in residents with respiratory insufficiencies, obstructive sleep apneas, and restrictive/obstructive lung diseases. The purpose is to promote resident comfort and safety. Review the physician's order to determine the oxygen concentration and flow, and the pressure, such as CPAP, IPAP, and EPAP. The policy indicated filters were required for BIPAP/CPAP supply. Record review on 5/20/2024 of URL: Sleepfoundation.org; BiPAP/ CPAP machines were both forms of positive airway pressure therapy, which used compressed air to open and support the upper airway during sleep. A portable machine generated the pressurized air and directed it to the user's airway via a hose and mask system. Both systems used similar masks, hoses, and other accessories. The machines were humid and often warm, having made them the perfect home for mold, bacteria, viruses, and other harmful microbes. Having cleaned your machine components regularly washed these microbes away and prevented them from reaching dangerous levels, but having neglected your machine's hygiene could have led to both acute and chronic respiratory illnesses. Record review on 5/20/2024 of URL: National Library of Medicine, Pulse Oximetry-Stat Pearls (on-line school for physicians) - NCBI Bookshelf (nih.gov), the normal oxygen levels displayed on a pulse oximeter (a tool to measure the oxygen in the blood) were commonly supposed to range from 95% to 100%. Oxygen saturation was an essential element of patient care. Oxygen was tightly regulated within the body because hypoxemia (low levels of oxygen) could have led to many acute adverse effects on individual organ systems. These included the brain, heart, and kidneys. Interview on 5/9/2024 at 6:01 PM with the ADM revealed that Resident #1 and Resident #2 had not been receiving respiratory care per physician orders. Neither Resident #1, nor Resident #2, had been receiving BiPAP or CPAP care per physician orders. The facility did not possess replacement filters for either CPAP or BiPAP equipment, but the nursing staff was checking off treatments on the nurse's treatment record for Resident #1 and Resident #2, having indicated they had been changed/cleaned. Resident #1 had been hospitalized on [DATE] for respiratory distress, 3/27/2024 for respiratory distress, and 4/6/2024 for respiratory distress. All of which, a contributing factor could have been the result of dirty respiratory care equipment. It was determined that criteria had been met to initiate an IJ. The IJ was called and the administer was presented with the IJ template at 6:01 PM. The following POR by the facility was accepted on 5/10/2024 at 1:14 PM. The notification of IJ states as follows: Statement of deficient practice: F695: The facility failed to ensure its BiPAP/CPAP users received respiratory care in accordance with highest professional standards which placed Resident #1 at risk of exacerbation of her SOB, having resulted in Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Impact Statement: On 5/09/24 an abbreviated survey was initiated on 5/09/24 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to a significant medication error. 1. How were other residents at risk affected by this deficient practice identified? The facility Administrator, DON/Designee completed an audit of all Residents with BiPAP/CPAP orders ordered in the last 30 days to ensure the residents have not had an adverse effect from their normal baseline 5/09/24. Residents with BiPAP/CPAP orders have the potential to be affected by this deficient practice, 2 of the residents who were identified as having BiPAP/CPAP orders were not affected. 2. What corrective actions have been implemented for the identified resident? Resident #1's BiPAP settings were adjusted by the BiPAP/CPAP company technician, to meet physician orders, BiPAP machine filter was cleaned by facility ADON, along with the tubing. Resident #1 is currently in the facility and stable condition as of 5/9/24. On 5/9/24, replacement filters were obtained from facility DME company by central supply clerk, who will also monitor inventory of filters weekly to ensure facility has adequate stock. Regional [NAME] President in-serviced Administrator and DON/Designee on the identification of new BiPAP orders and verification of settings, as well as the proper cleaning methods and frequency of cleaning of BiPAP equipment on 5/9/24. On 5/9/24, Administrator, DON/Designee in-serviced the licensed nursing staff on the identification of new BiPAP orders and verification of settings, as well as the proper cleaning methods and frequency of cleaning of BiPAP equipment. What corrective actions were taken? 3. The following actions were initiated immediately on 5/09/2024. a. Nursing management was educated on 5/09/2024 by the Administrator, on identifying and reviewing all new orders for BiPAP/CPAP machines, during daily clinical meeting, to ensure BiPAP orders are followed per physician orders. b. Initiated in-services on 5/09/24 with licensed nurses, by Administrator, on proper cleaning methods of BiPAP equipment (masks, hoses, filters) and frequency of weekly filter changes, both to be completed by licensed nurses. c. Newly hired licensed nurses will be in serviced during the onboarding process by DON on identifying and reviewing all new orders to ensure BiPAP settings are being followed and set appropriately on BiPAP equipment. d. PRN and Agency nurses will be in-serviced by DON/Designee, prior to working designated shifts, on identifying and reviewing all new orders to ensure BiPAP settings are being followed and filters are being cleaned weekly. 4. How will the system be monitored to ensure compliance? a. DON/Designee Will review the Order List Report for newly received orders and compare it to resident new BiPAP orders daily for 4 weeks. If discrepancies are identified, we will notify the physician immediately for clarification, Quality Assurance An impromptu Quality Assurance and Performance Improvement review (quick meeting) of the plan of removal was completed on 5/09/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. Monitoring began 5/10/2024 at 1:14 PM. Interview on 5/10/2024 at 1:50 PM with LVN B revealed nursing staff was made aware of BiPAP/CPAP orders when new residents come to the facility with their orders, or they have had a sleep study while a resident. New orders were under the orders tab in PCC. Settings were found on the machine and staff needed to confirm they match the orders. Tubing and masks get cleaned every week by taking the masks apart and rinsing it. Tubing and masks get cleaned one time a week: the filter and water container 1 x week. The facility has the equipment they needed to maintain the machines. LVN B attended an in-service on 5/10/2024 given by the ADON. Interview on 5/10/2024 at 2:05 PM with LVN C revealed the nursing staff was made aware of new BiPAP/CPAP orders through PCC or paper orders. New orders in PCC would be highlighted in red. The machine had buttons for setting and those settings were supposed to match those on the orders. Nursing staff checked orders for treatments each week. Nursing staff cleaned the mask with soap and water each week and let air dry. Cleaning consisted of having disconnected the tubing from them machine and having washed it with warm soapy water weekly. The filter was rinsed and placed between two paper towels to dry. Wet filters did not go back into the machine, which would be bad. LVN C attended an in-service today, 5/10/2024 for BiPAP/CPAP care by the ADON. Day shift started cleaning the BiPAP/CPAP during the day on Tuesday. Interview on 5/10/2024 at 2:15PM with LVN D revealed nursing staff was made aware of BiPAP/CPAP orders when a resident arrived from the hospital, admitted , if ordered by the medical director, or ordered by the nurse practitioner. New orders were found in PCC; PCC to be checked daily for new orders. The settings for the BiPAP/CPAP machine were found on the machine and the settings needed to match what was in the orders. Masks were supposed to be cleaned each week with soap and water. The tubing was supposed to be rest with water each week and the filter was rinsed with water each week. The mask and the tubing were supposed to be exchanged once a month. LVN D attended an in-service earlier this week on BiPAP/CPAP care. The DON provided the training. Interview on 5/10/2024 at 2:25 PM with the RN revealed new BiPAP/CPAP orders would show up on the administration record, under new orders, or pop up under the To Do List. The settings on the BiPAP/CPAP were accessible from the machine itself. Those numbers had to match what was on the orders. Every week, nursing staff was supposed to clean the mask, the tubing, and the filter. All items needed to be air dried. The RN stated she attended an in-service today, 5/10/2024, presented by the ADON. Interview on 5/10/2024 at 2:40 PM with the ADON revealed all new BiPAP/CPAP orders were supposed to be listed on the 24-hour report, which was a report having pertained residents' medical changes. New BiPAP/CPAP users also could have had orders when they returned from the hospital or having had seen the doctor. Those new orders were listed in PCC. New orders needed confirmation, so they needed follow up. BiPAP/CPAP settings were found on the machine. New admissions were asked for paperwork regarding their BiPAP/CPAP settings. The settings on the machine needed to match those on the orders. The hoses, the mask, in the filters needed to be cleaned with soap and water weekly; and air dried as much as possible. The ADON was briefed on the BiPAP/CPAP policies by the DON; The ADON in-serviced the staff. Interview on 5/10/2024 at 2:55 PM with the DON revealed new BiPAP/CPAP orders were found on the 24-hour report, put into PCC, and flagged for confirmation and items needed to be completed while on shift. The machine settings were found on the machine itself, and those settings needed to match those that were in the order. Once a week, she cleaned the mask with soap and water. The filters were rinsed with water weekly also and patted dry before having placed them back in the machine. The DON attended an in-service for BiPAP/CPAP yesterday, 5/9/2024, by the RVP. Interview and observation on 5/10/2024 at 5:05 PM with the MRMS revealed he monitored the respiratory supplies daily and weekly. The O2 company came to the facility and serviced the machines once a month. The MRMS displayed the supply of BiPAP/CPAP hoses and various other tubing for respiratory equipment. She stated the BiPAP/CPAP filters were delivered on 5/9/2024. Record review of BiPAP/CPAP in-service, performed by the ADM to the ADONs on 5/9/2024, for BiPAP/CPAP: Identify and review all new BiPAP/CPAP orders. Record review of BiPAP/CPAP in-service performed by the ADM and the ADON to the Licensed Nursing Staff, performed on 5/9/2024, for BiPAP/CPAP: Identify and review all new orders. Cleaning. Replacement supplies. Record review of BiPAP/CPAP invoice, dated 5/9/2024 and 5/10/2024, delivering BiPAP/CPAP tubing and filters. Record review of BiPAP/CPAP in-service performed by the RVP to the ADM and DON, dated 5/9/2024. New orders, settings, cleaning, and filter replacement. Record review of ADON confirmation of cleaning Resident #1's machine, dated 5/9/2024. Record review of ADON confirmation of audit for BiPAP/CPAP filters, dated 5/14/2024. Record review of DON plans, undated, for new hires, shift workers, and PRN staff. Record review of the QAPI Team members email review, dated 5/92024, having discussed the F695 POR. Interview and observation on 5/10/2024 at 5:10 PM with Resident #1 revealed she was in bed, clean, and in no distress. The BiPAP machine was a new device; hose and mask were clean placed in a plastic bag. Resident voiced no complaints and stated she was pleased with having clean equipment now. The ADM was informed the Immediate Jeopardy was removed on 5/10/2024 at 5:30 PM. The facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Interview and record review on 5/13/2024 at 4:20 PM with LVN A revealed she had signed off treatment for Resident #1's BiPAP on 3/24/2024 and 4/7/2024. She stated the order to clean the machine, and change the filter out weekly, were on the nurse's treatment record. She recalled checking off the treatments and recalled not having clean filters to exchange. She stated she had informed the ADON. There were no filters on hand to change out the old. Interview and observation on 5/14/2024 at 11:15 AM with Resident #2 revealed she had a new CPAP machine, and the machine had a clean filter in place. She was getting used to the new mask. Interview on 5/14/2024 at 2:25 PM with the DON revealed cleaning masks, tubing, and changing filters were important to keep BiPAP/CPAP therapy equipment clean. Clean equipment reduced the risk of infection and kept the air flow optimum. The facility had a policy covering the BIPAP/CPAP therapy and the nursing staff was not following the facility policy. The residents who were using BiPAP/CPAP treatments were placed at risk for portals for infection.

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (Resident #234) reviewed for medication errors. The facility failed to accurately transcribe amitriptyline 10mg by mouth at bedtime and instead transcribed amitriptyline 300mg by mouth twice daily. The facility administered 300mg of amitriptyline to Resident #234 which caused an overdose that sent the resident to the hospital with abnormal labs and cardiac arrhythmia. This failure could place residents at risk for complications and possible death. This failure resulted in an identification of an Immediate Jeopardy (IJ) On 2/21/2024 @ 5:25pm. While the IJ was removed on 02 /24/24 @ 6:10 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The findings include: Record review of Resident #234's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #234 had diagnoses which included NSTEMI (heart attack), metabolic encephalopathy (a chemical imbalance of the brain causing confusion), anemia (low red blood cells), dementia, and type 2 diabetes (elevated blood sugar). Record review of Resident #234 admission MDS assessment, dated 2/5/24, reflected Resident #234 had a BIMS score of 8, which indicated Resident #234 was cognitively impaired. Resident #234 required substantial max assistance with personal hygiene upper and lower body dressing. Record review of a progress note dated 2/5/24 at 9:30 AM, by LVN W, reflected Resident #234's family member brought a medication list from home and requested Amitriptyline (an antidepressant) be given as he had previously been on medication at home. Record review of Resident #234's order recap report, dated 2/1/24-2/22/24, reflected the resident had an order received 2/5/24 by LVN W for Amitriptyline Oral Tablet 150 MG (Amitriptyline) Give 2 tablets to equal 300mg by mouth every morning and at bedtime for depression. Record review of the Medication Administration log for February 2024 reflected Resident #234 received 300mg of amitriptyline by mouth on 2/6/24 at 9 am. Record review of the facility progress notes, dated 2/6/24 at 1:30 by LVN W, reflected the resident was found slow to respond, drowsy and lethargic. The Nurse Practitioner was notified, and an order was given to transport Resident #234 to the hospital. Record review of Resident #234 census reflected the resident was sent to the hospital on 2/6/24 and readmitted [DATE]. Record review of hospital records, dated 2/6/24, reflected Resident #234 presented to the ER with an accidental drug overdose when a transcription error was created unintentionally at the nursing facility transcribing amitriptyline 300 mg by mouth twice daily. Resident #234 appeared drowsy, and speech slurred. Per records his family members stated he was finally seeming like his old self until he received his medication around 10:30 AM. Following this he became progressively somnolent and eventually slumped over. Initial assessment Resident #234 was hypertensive (elevated blood pressure) and drowsy with slurred speech with abnormal EKG . Poison control was contacted, and the resident required 2 ampules of bicarb (a medication used to assist the body in disposing of the excessive medication) and repeated EKGs and orders to maintain potassium level greater than 4. Record review of hospital labs, dated 2/6/24, reflected: potassium level of 3.4 (low level causing heart irregularity), glucose level of 171(high blood sugar), carbon dioxide level of 21 (Meaning the blood is too acidic). Hospital vital signs reflected Resident #234 had elevated blood pressure and elevated respirations. Record review of hospital medication administration, dated 2/6/24, reflected Resident #234 required potassium chloride drip via IV to maintain his potassium level greater than 4, and supplemental bicarb also IV, to counter act the effects of the amitriptyline. In a record review of hospitals After Visit Summary, dated 2/13/24, reflected Resident #234's hospital admitting diagnosis was acute drug overdose, accidental or unintentional initial encounter. The Hospital instructions were to stop amitriptyline 10mg and the medication was discontinued. During an observation on 2/21/24 at 10:10 AM revealed Resident #234's was lying in bed and was sleepy and confused Resident #234 was not interview able. In an interview on 02/21/24 at 10:32 AM with the NP revealed the facility notified the NP of a concern due to Resident #234's increased lethargy. The NP stated Resident #234s family member had concerns the resident was over sedated. The NP stated she asked if Resident #234 had his morning medications. The NP stated she pulled Resident #234's medication profile and reviewed his medications, she questioned the orders that were input on 2/5/24 for Amitriptyline 150mg 2 tabs bid. The NP stated the order should have been for 10mg by mouth at bedtime as she had given the verbal order. Resident #234 received 1 dose of 300mg of amitriptyline on 2/6/24. The NP stated she ordered the resident to be sent to the hospital for evaluation of adverse effects related to medications error. An interview was attempted with LVN W by phone on 02/21/24 at 10:45 AM was unsuccessful. In an interview on 02/21/24 at 11:15 AM with LVN X, the former ADON, she reported on February 6th Resident #234 received a dose of amitriptyline 300mg as the order was reading from the medication administration record. LVN X reported Resident #234 became lethargic and LVN W, who was on duty, notified the NP. At that time, the NP reviewed medications, she noted the amitriptyline correctly transcribed. LVN X stated Resident #234 was lethargic. The NP gave orders to send Resident #234 to the hospital. EMS was notified and the resident went to the hospital via ambulance. The Family was notified of the incident and the DON was notified of the incident. There was an internal investigation she is not sure where it is. LVN X explained the process for checking orders included checking the 24-hour report. She reported there was no order reports that they were aware of that were ran. LVN X reported occasionally nurse managers work the floor. The new admissions were double checked by another nurse not necessarily a nurse manager, but just a second set of eyes on new admit orders, there was a clinical follow up sheet where they notify the nurses of missing assessments but not necessarily orders. LVN X stated the negative effects for not checking orders would include a risk of overdose causing altered mental status hospitalization or even worse. In an interview with Resident #234s' family, on 2/21/24 at 2:29 PM revealed on 2/5/24 Resident #234 was given a new order for amitriptyline 10mg 1 tab by mouth at bedtime. On 2/6/24 Resident #234 took his morning medications and within 30 minutes became lethargic and weak. Upon notification of the Nurse Practitioner, it was discovered Resident #234 was given 300mg of amitriptyline. Resident #234 was sent to the hospital and admitted with accidental drug overdose. During an interview on 02/21/24 at 2:34 PM with the DON, she stated typically a nurse manager should review orders in the computer. There was an order listing report that could be ran for 24 hours daily to review the previous days orders and double check for correctness or clarification of orders if needed. This order report should be reviewed by nurse managers, the practitioners had the capability to input their own orders into the computer and the facility was stressing the importance of this to avoid this type of medication error Both ADONs were new, and the Administrator were new as well, the negative outcome would depend on the medications. During an interview with the Administrator n 02/21/24 at 2:48 PM, he stated he was aware of the incident with Resident #234. He stated he understood there was an investigation completed. He was not sure where the report or investigation was. He stated he was not a clinician so he was not sure what kind of negative outcome there would have been for the medication error. He stated he did not feel qualified to answer that question. Record review of a medication error report, dated 2/6/24, reflected the following corrective actions were taken: 1) An Inservice was completed to ensure verbal orders are read back for accuracy. 2) to put in orders nursing administration to check orders daily. Record review of an unsigned in service, dated 02/6/24, reflected the staff were educated in handwritten in-services with the following directions: 1) Ensure verbal orders are read back for accuracy. 2) Pay attention to what you are doing (avoid distractions) 3) Look at order being placed at a minimum of two times (when put into system and before sending to pharmacy) 4) All and any questions related to dosage ASK! In a record review of the facility policy Adverse Consequences and Medication Errors reflected a Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's order, manufacturers specifications or accepted professional standards and principles of the professionals' providing services. An example of medication error would include e) wrong dosage . This was determined to be an Immediate Jeopardy (IJ) on 02/22/24 at 5:25 PM. The ADM and DON were notified. The ADM was provided with the IJ template on 02/22/24 at 5:25 PM. The following Plan of Removal submitted by the facility was accepted on 02/23/24 at 1:08 PM : Impact Statement: On 2/21/24 an abbreviated survey was initiated on 2/21/24 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to a significant medication error. How were other residents at risk affected by this deficient practice identified? The facility DON/Designee completed an audit of all new medication orders ordered in the last 30 days to ensure the residents have not had an adverse effect from their normal baseline 2/21/22. Residents with new medication orders have the potential to be affected by this deficient practice, 68 of the residents who were identified as having new medication orders were not affected. What corrective actions have been implemented for the identified resident? Resident #234 was sent to the hospital on 2/6/24 for evaluation. Resident #234 was readmitted to the facility on [DATE] in stable condition. The previous DON in-serviced 2/6/22 the licensed nursing staff on accurate drug transcription and dosage identification when new orders are received for antidepressant medications completed 2/21/24. What corrective actions were taken? 1. The following actions were initiated immediately on 2/21/2024. a. Director of Nursing was educated on 2/21/2024 by Clinical Services Director on identifying and reviewing all new orders daily to ensure drug transcription and dosage are within the recommended range. Completed 2/21/24. b. Initiated in-services on 2/21/24 with licensed nurses by Director of Nursing identifying and reviewing all new medication orders to ensure drug transcription and dosage are within the recommended range. Completed 2/21/24. c. On 2/21/24 the DON in-serviced all Medication Aides on notifying charge nurse if discrepancies in dosages verses written orders with medications are identified and reviewing all new orders to include antidepressant medication to ensure drug transcription and dosage are within the recommended range and medication administration medications, encompassing a comprehensive review of correct medication dosages cross-referenced with orders. Completed 2/21/24. d. Newly hired licensed nurses and medication aides will be in serviced during the on boarding process by DON on identifying and reviewing all new orders to include antidepressant medication to ensure drug transcription and dosage are within the recommended range and medication administration medications, encompassing a comprehensive review of correct medication dosages cross-referenced with orders. Completion- Ongoing Licensed nurses and medication aides in serviced by DON/ Designee on Medication administration. Reviewing all new orders to include antidepressant medication to ensure drug transcription and dosage are within the recommended range and medication administration medications, encompassing a comprehensive review of correct medication dosages cross-referenced with orders prior to administering. Completed 2/21/24. 2. How will the system be monitored to ensure compliance? A. DON/Designee Will review the Order List Report for all Newly received orders and compare it to resident for 4 weeks . If discrepancies are identified, we will notify the physician immediately for clarification before administering. Staff will receive further training on our Medication Administration Policy and disciplinary action up to termination. When discrepancies with medications are identified, the CMA will notify the charge nurse, the charge nurse will notify the physician if no response from the physician within two hours, then we will notify medical director prior to medication administration. Completion- Ongoing Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 2/21/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. Monitoring of the POR included the following: Interview and record review on 2/24/2024 at 1:00 PM with the DON revealed she and the CSD provided in-service trainings to the CMAs, RNs, and the LVNs on 2/21/2024. The in-service trainings were conducted face to face, or over the telephone. The trainings covered the facility's Administering Medication Policy as well as special instructions to ensure verbal orders were verified before entering them into the MAR and the NMAR. The DON stated she was trained one-to-one by the CSD to ensure approval orders were repeated back to the giver for verification before inputting the order into the computer. Nurses were supposed to ask questions of the provider if they did not understand the order, the order dosage, or if it looked inappropriate. New orders were supposed to be documented in the residence chart. The documentation was supposed to contain the order, who gave the order, who took the order, and that a family member, or responsible party, was notified. Lastly, the nurse was supposed to provide follow up visits for three days and document those findings in the residence medical record. Interview and record review on 2/24/2024 at 1:15 PM with CMA R, revealed she worked a 6:00 AM to 2:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, the medication aide was to alert charge nurse for clarification. CMA R stated the training pertained to bring any discrepancy with a medication dosage, versus the written order, to the attention of the charge nurse for clarification. She was directed to question any new medication order that looked out of the ordinary. She was re-trained to verify the medication packaging was for the right resident, right medication, right dosage, right time, and right route before being administered. She was educated to report observations of lethargic residents, or residents who displayed unusual behaviors, to the nursing staff immediately. CMA R's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 1:35 PM with CMA Q, revealed she worked a 6:00 AM to 2:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert the charge nurse for clarification. CMA Q stated she was instructed to report any discrepancies with medication, or medication dosages to the charge nurse. She was re-trained to make sure the medication orders on the MAR matched the medication packaging for the right resident, the right dosage, right time, and right route before being administered. Nursing staff needed to be informed immediately if a resident was lethargic residents or displayed unusual behaviors. CMA Q's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 2:15 PM with CMA S, revealed she worked a 2:00 PM to 10:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. CMA S stated she was supposed to question any medication order that did not look right, or had an unusual dosage, and bring that to the attention of the charge nurse for clarification. Each medication administration was supposed to be checked 3 times for the right resident, right medication, right dosage, right time, and right route before being administered. CMA S's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 2:30 PM with CMA T, revealed she worked a 2:00 PM to 10:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. Any issue or concerns with a medication, or medication dosage were supposed to be brought to the attention of the charge nurse for clarification. Any observations of lethargic residents, or overly medicated residents, were to be reported the nursing staff immediately. CMA T's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 3:00 PM with LVN K, revealed she worked both 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM shifts on a PRN basis. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN K stated the training covered medication transcription and that she was supposed to read back and verify all orders were correct before putting them into the computer. She was instructed to ask questions of the provider if she did not understand the order, or if the order and dosage did not look appropriate. The entry into the computer would state the order, who took the order, who gave the order, and that the responsible party was notified. Follow up visits for residents with new medication were to take place for three days and each follow-up needed to be documented in the resident's chart. If they had questions about a medication and were unable to contact the provider after 2 hours of attempts, she was told she could call the medical director directly. Interview and record review on 2/24/2024 at 3:27 PM with LVN L, revealed he worked 6:00 AM to 6:00 PM shifts on a PRN basis. He participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN L stated the training pertained to verifying orders by repeating them back to the provider for clarification before entering them into the computer. If an order did not look correct, or if the dosage appeared to be wrong, he was instructed to ask questions to make sure. All new orders were to be documented in the resident's chart with the order itself, the person who gave the order, the person who took the order, and that the responsible party was informed. Follow-up visits were to be conducted, and documented, for residents who received [NAME] medications for 3 days. LVN L's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 3:51 PM with RN C revealed she worked the 6:00 AM to 6:00 PM. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. Orders were supposed to be repeated back to the provider to make sure the order was correct before putting it into the computer. If a medication, or dosage, did not look correct, she was supposed to ask for verification from the provider. All medication orders received were supposed to be documented in the resident's chart and were to state the order itself, the person who gave the order, the person who took the order, and that the responsible party was informed. Each resident, who received a new medication, received a follow up visit for three days to document the medication and its effects. If she were unable to contact a provider with questions about medications after two hours, she was told she could contact the medical director. RN C's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:05 PM with CMA U, revealed she worked a 6:00 AM to 2:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. CMA U stated the training instructed her to let the nursing staff know if she thought a medication, or a medication dose, did not look correct. She was supposed to review the medication package and verify it 3 times with the resident to make sure of the right resident, right medication, right dosage, right time, and right route before being administered. Residents who appeared lethargic or overly medicated were supposed to be reported to the charge nurse immediately. CMA U's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:31 PM with LVN J revealed, he worked 6:00 PM to 6:00 AM shifts. He participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN J explained that he was supposed to listen to the order, write it down, and repeat it back to the provider before entering it into the computer. It was ok to ask questions if he did not understand the order of if it did not make sense. New medication orders were supposed to be entered into the resident's chart and contain the order, who gave the order, who took the order, and that the family was notified. Each resident who received a new medication was supposed to receive follow-up visits for 3 days and each visit was supposed to be supported with documentation in the resident's chart. If he had a question about an order and could not reach the provider, he was told to reach to to the medical director for help. LVN J's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:38 PM with LVN I, revealed she worked 6:00 PM to 6:00 AM shifts. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN I stated the training covered medication order transcription and how to repeat the order to the provider for confirmation before entering it into the computer. The training instructed her to ask questions of the provider if they did not understand the order, or if the order and dosage did not look appropriate. New medication orders were documented in the residence chart and were supposed to include the order, who gave the order, who took the order, and that a family member was notified. Each resident received 3 days of follow-up visits and each visit was supposed to be documented on the medication and how it was working. If she had a question about a medication and could not reach the provider, she was instructed to reach out to the medical director for assistance. LVN I's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:50 PM with CMA V, revealed she worked a 2:00 PM to 10:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. CMA V stated she was trained to question any medication order that did not look correct, or any dosage that seemed too high. Any issue or concerns with medications were supposed to be reported to the charge nurse immediately. CMA V stated she checked medications 3 times to make sure they were the right resident, right medication, right dosage, right time, and right route before being administered. Any resident who appeared groggy, or behaved out of character, was supposed to be reported to the nursing staff immediately. CMA V's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 5:50 PM with LVN G, revealed she worked 6:00 PM to 6:00 AM shifts. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN G stated the training directed nursing staff to repeat medication orders and confirm they were correct before placing them into the computer. If something did not seem right, they were supposed to question the order for accuracy. All new orders were supposed to be entered in the resident's chart to include the order, who took the order, who gave the order, and that the family was notified. Resident with new medication orders received 3 days of follow-up visits, all documented, to check on the resident and how the medication was working. If a nurse could not reach a provider for a question about a medication, she was told to call the medical director for assistance. LVN G's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 6:00 PM with LVN H, revealed she worked 6:00 PM to 6:00 AM shifts. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN H was trained to read back and verify medication orders before having placed them into the computer. Ask questions to the provider or if they did not understand the order, or if the order and dosage did not look appropriate; Document new orders in the residence chart to clarify which nurse received the order, who gave the order, the written order itself, and having notified the family or responsible party. Conduct follow up visits for residents for residents with new medication for 3 days and document those follow-up visits in the residence chart. If they were unable to contact a provider with questions about medications, they were instructed to reach out to the medical director. LVN H's name was annotated on the in-service document. While the IJ was removed on 02 /24/24 @ 6:10 PM, The facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interviews, and record review, the facility failed to ensure residents received quality care and quality treatment in accordance with professional standards of practice for 1 of 8 residents (Resident #25) reviewed for quality of care. The facility failed to apply an anti-fungal cream, per medical orders 2/14/2024 through 2/21/2024, which resulted in itching, intermittent burning, annoyance, and anger. This failure placed the residents at the facility at risk of having their needs not met. Findings included: Record review of Resident #25's AR, dated 2/21/2024, reflected a [AGE] year-old, who was admitted to the facility on [DATE]. He was diagnosed with Cerebral Palsy, Unspecified (a group of conditions that effected movement and posture caused through damage of the developing brain;) Major Depression (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts;) and, congenital hydrocephalus, unspecified (a medical diagnosis marked by malformations, deformations, and chromosomal abnormalities.) Record review of Resident #25's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #25 had a BIMS Score of 15. A BIMS Score of 15 indicated Resident #25 had no cognitive impairment. Section GG., Functional Abilities and Goals: Resident had no impairment with both sides of their upper extremities (shoulder, elbow, wrist, and hand.) Resident had impairment on both sides of their lower extremities (hip, knee, ankle, and foot.) Resident #25 utilized a wheelchair. Resident #25 was [Dependent] upon staff for: Toileting Hygiene, Shower/Bathe Self, and Personal Hygiene. With Resident #25 [Dependent] on staff, the helper did all of the effort. Section H., Bladder and Bowel indicated Resident #25 was always incontinent of bladder and bowel. Record review of Resident #25's CP reflected a [Focus] area for actual skin impairment, initiated on 1/10/2024, evidenced by fragile skin. The [Goal], initiated on 1/24/2024, stated the resident's skin would be healed by the next review. The [Intervention], initiated 1/24/2024, delegated CNA staff to observe skin injury for abnormalities, failures to heal, infections, and to report to changes to the physician. Record review of Resident #25's medical order, dated 2/13/2024, reflected an order for application of an anti-fungal cream to begin on 2/14/2024. The orders were to apply to skin every shift for 7 days, which was until 2/21/2024. The document indicated the medication was [on hand] in house stock and [on order] at the pharmacy. The order was confirmed by LVN X. Record review of Resident #25's [Weekly Skin Review,] dated 2/15/2024 at 9:25 PM, reflected redness to left flank (side)- treatment orders in place. NP aware. Record review of Resident #25's progress notes, dated 2/17/2024 at 5:14 PM, written by LVN D indicated the pharmacy did not provide the anti-fungal cream, because it was something that could be purchased OTC. Record review of Resident #25's progress notes, dated 2/18/2024 at 2:23 PM, written by LVN J indicated facility was waiting on the pharmacy to provide the anti-fungal cream. Record review of Resident #25's progress notes, dated 2/18/2024 at 5:12 PM, written by LVN D indicated the pharmacy did not provide the anti-fungal cream, because it was something that could be purchased OTC. Record review of Resident #25's progress notes, dated 2/18/2024 at 9:09 PM, written by LVN J indicated the anti-fungal cream was out of stock. Record review of Resident #25's medical order, dated 2/21/2024, reflected an order for application of an anti-fungal cream to begin on 2/22/2024. The orders were to apply to skin every shift for 7 days. Interview on 2/20/2024 at 10:24 AM with Resident #25 revealed he had a fungal infection on his left side that was supposed to be treated with an anti-fungal cream. He did not get the cream like ordered and did was not offered an alternative treatment. He stated the infection itched and burned constantly after he had an incident of incontinence. Interview and observation on 2/21/2024 at 7:51 AM with LVN D revealed the anti-fungal cream, which was ordered to begin on 2/14/2024 through 2/21/2024, had not yet begun. LVN D reviewed her nursing documentation and stated the pharmacy did not fill the medication, but it was supposed to be from house stock. LVN D's nursing cart did not contain the anti-fungal cream. LVN D stated she messaged LVN X about the anti-fungal cream on 2/18/2024, but she had not heard back. She stated she had been off the last 2 days and referenced her progress note on 2/17/2024 at 5:14 PM and 2/18/2024 at 5:12 PM, which indicated the pharmacy did not provide the anti-fungal cream, because it was something that could be purchased OTC. If the anti-fungal cream were in house, it would have been stored on the medical closet. During the interview, LVN D checked the number in her phone, and she messaged the wrong contact, not LVN X, about the anti-fungal cream. She stated she felt terrible. Interview on 2/21/2024 at 8:45 AM with LVN D revealed she called the NP and reinstated a new order for the anti-fungal cream to begin on 2/22/2024 for 7 days. She stated she retrieved the anti-fungal cream from the medical supply closet. He had already had an application of the anti-fungal cream to his left flank. Interview on 2/21/2024 at 10:00 AM with Resident #25 revealed he received an application of the anti-fungal cream to his left flank and received relief from the itching and burning. Interview on 02/22/24 at 9:41 AM with Resident #25 revealed staff had been aware of the order for the anti-fungal cream since 2/14/2024, but they did apply the anti-fungal cream per the written order. He was angry and annoyed he had to wait for the treatment. He felt relief with the start of the anti-fungal cream and was not itching or burning near as much. Interview on 2/22/2024 at 10:01 AM with LVN D reveled the reason Resident #25 he had not gotten the anti-fungal cream as ordered was because of the confusion about the medication coming from the pharmacy or from the medical closet. She stated, in good faith, that she had reached out to LVN X on 2/18/2024, but the number was incorrect, and the request was never received. She wished she had reached out the NP, since she did not get a response from LVN X. She acquired the anti-fungal cream, on 2/21/2024, from the medical closet, which was where OTC medications were stored. Interview on 2/23/2024 at 4:36 PM with MRS revealed the medication closet contained OTC medications utilized in the facility, one of which was the anti-fungal cream. She provided anti-fungal cream to LVN D on 2/21/2024 for Resident #25. She had not received any requests for the anti-fungal cream until 2/21/2024. She had not received a request for the anti-fungal cream from the time it was ordered, which was 2/14/2024, until 2/21/2024 at 8:30 AM. Interview on 2/24/2024 at 10:58 AM with ADON B revealed it was important to make sure residents get intended medication to address their medical need. OTC remedies were medical orders. When the pharmacy and OTC issues arose, the change nurse should have called someone and waited for a response. Simply charting the discrepancy in a progress note, was not effective communication. The failure for Resident #25 having not received his medication as ordered was the nurse failed to follow through with the communication. Interview on 2/22/2024 at 10:15 AM with the ADM revealed that issues or concerns with OTC and pharmacy medications were not addressed in morning report. Usually, issues with OTC and pharmacy medications were resolved with nursing staff. The failure in Resident #25 not receiving his anti-fungal cream was a failure for staff to follow up on organization and communication. Record review of the facility's [Administering Medication] Policy, dated December 2012, reflected (2) the DON would supervise and direct all nursing personnel who administered medications or had a medication related function; and (3) medications were administered in accordance with the orders, which included any required time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 2) Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 02/20/2024 at 08:37 AM the following was observed: The walk-in freezer contained a bag labeled ravioli in a clear plastic bag with no dates documented. The walk-in freezer contained a bag labeled hamburger patties in a clear plastic bag with no dates documented. The walk-in refrigerator contained a bag labeled shredded cheese in a clear plastic bag with a prepared date of 02/16/24 with no use by date documented. The walk-in refrigerator contained a bag labeled mozzarella cheese in a clear plastic bag that was loosely opened and exposed to the air. Interview with the Dietary Manager on 02/20/24 at 9:00 AM, the dietary manager stated the cooks knew to discard opened items within 3 days of opening them. The Dietary Manager stated if food was not dated the food would be compromised. The Dietary Manager stated food items could be old, be molded, or smell if not appropriately labeled with a received, opened, and used by dates. The Dietary Manager stated the cooks were responsible for appropriately labeling the opened with items with a received, opened, and used by dates. The Dietary manager stated the walk-in refrigerator/freezer had signage instructing staff to not leave food in it opened over 3 days . Interview with [NAME] A on 02/20/24 at 9:05 AM, [NAME] A stated if items were opened, the item should be placed in a ziploc bag and labeled with an opened date and used by date. [NAME] A stated opened items should be discarded after 3 days. [NAME] A said food items that did not have a received, opened, and used by date should be thrown away. [NAME] A stated if the food items were not labeled with dates, then the food could be spoiled or old. [NAME] A stated if residents were served old food, they could get sick. [NAME] A stated it was the kitchen staff's responsibility to make sure food was labeled with the received, opened, and used by dates . Interview with the ADM on 02/23/24 at 3:20 PM, the ADM stated foods in the refrigerator and freezer should have been labeled appropriately with the received by, opened, and used by dates. The ADM said if food was not labeled appropriately then the food could be spoiled, and the facility could possibly serve spoiled food to the residents. The ADM stated whoever opened the items should appropriately date and label it. Record review of the facility's Food Storage: Cold Foods, dated 04/2018, reflected All time/temperature control for Safety (TCS ) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 5. All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . A record review of the FDA's 2022 Food Code reflected the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based on observation, interview, and record review, the facility failed to implement procedures that prohibit neglect and abuse for one (1) of three (3) residents reviewed for change in condition. (Resident #20) The facility failed to supervise and monitor Resident #20 every 2 hours per his plan of care. CNA D checked on Resident #20 only 1 time (at 11:30 PM) during her 10:00 PM to 6:00 AM shift. Her charge nurse, Registered Nurse (RN) E failed to monitor and supervise CNA D's performance during this shift. CNA D had previously been disciplined twice for failing to provide every 2 hour turning/positioning and/or incontinent care for residents. RN E had previously been disciplined for failure to closely monitor/supervise the CNA staff, and she failed to assess Resident #20 after another resident reported a fall. Resident #20 was found cold, stiff, unresponsive and with an unexplained wound to his head by day shift staff on [DATE] at 6:15 AM. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of Actual Harm with a scope identified as a pattern. This deficient practice placed 45 residents who reside on Halls 100 and 200 where CNA D and RN E were assigned to provide care at risk for not receiving supervision and treatment in a timely manner in the event of a change in condition. Findings Include: Review of Resident #20's Admission Face Sheet dated [DATE] was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 received rehabilitative therapy from a Physical Therapists, Occupational Therapists and Speech, Language Pathologists 3 to 5 days a week, with a goal of returning home. Resident #20's Minimum Data Set Assessment (MDS) dated [DATE] revealed the following: Cognitive Patterns: Score of 15 (,[DATE] interpreted as cognitively intact). Functional Status: (1) Self performance, (2) Support provided by staff. Bed Mobility- (1) Extensive assistance, staff provide weight bearing. (2) Requires 2 person physical assist. Transfer- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Walk in Room- (1) Supervision, oversight. (2) Requires one person physical assist. Locomotion on Unit- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Toilet Use- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Balance: Walking, turning around, moving on and off toilet, and surface to surface transfer- Not steady, only able to stabilize with staff assistance. Mobility Devices: Walker and Wheelchair checked. Urinary Continence- Occasionally incontinent. Bowel Continence- Frequently incontinent. Health Conditions: Short of breath, trouble breathing- with exertion, sitting at rest and while lying flat checked. Fall history- Fall during month before admission, no falls since admission. Review of Resident #20's Care Plan conference summary dated [DATE] revealed the following topics were discussed: Cognitive: Alert and oriented to person, place and time. Falls/Safety: At risk. Resident #20's Care Plan revealed problem/needs identified as follows: Problem onset: [DATE] Potential for impaired skin integrity related to immobility, incontinent at times. Approaches included: Check every 2 hours for incontinence and provide cleansing as needed. Turn and reposition every 2 hours. Roles responsible: NNA (Nursing and Nurse Aides). Review of a facility form titled AccuNurse (used by CNA's to document the level of assistance provided for residents to complete their ADL's) revealed CNA D documented the care she provided to Resident #20 for the night shift (10 PM to 6 AM) on [DATE] into [DATE] as follows: Locomotion: Did not occur. Transfer: Did not occur. Urine: Did not occur. Position: Bed: Did not occur. BM: Did not occur. CNA D documented the above activity on [DATE] at 5:01 AM, that Resident #20 had not been checked during the night, nor had he been assisted with locomotion, transfers, incontinent checks for urine or bowel movements, nor had she assisted with repositioning him in bed. Interview with the Corporate Nurse RN F on [DATE] at 9:40 AM revealed that CNA D stated she last checked Resident #20 at 11:30 PM on [DATE]. Interview on [DATE] at 10:25 AM with Unit Manager, LVN C revealed: "The NNA on the care plan stands for Nurse and Nurse Aide. If the care plan approach says to check every 2 hours, or turn every 2 hours it is the responsibility of the CNA to check or turn the resident every 2 hours. It is the responsibility of the charge nurse to delegate the task to the CNA and to supervise to ensure the CNA is performing the task." Attempts by the surveyor to reach CNA D by telephone were ineffective, as the voice mail box was full. Interview on [DATE] at 2:40 PM with a Sergeant with the local Police Department revealed that his department is treating Resident #20's death as a homicide. The Sergeant had also made attempts to reach CNA D without success, but in his initial interview with her, she stated she had not checked on Resident #20 after 11:30 PM. Observation on [DATE] at 10:30 AM revealed housekeeping staff cleaning the mattress in room [ROOM NUMBER], which had been occupied by Resident #20 until [DATE]. There was an area on the mattress where the resident's head would lay, approximately 14 inches in diameter with dried red stains. The housekeeper stated it was dried blood. She stated the sheets she had removed also had the same area of dried blood. Interview on [DATE] at 9:40 AM with the Corporate Nurse, Registered Nurse (RN) F revealed the following: Medication Aide (MA) K found Resident #20 cold on [DATE] at 6:15 AM. She called for help and nursing staff responded finding him cold and non-responsive. They initiated Cardiopulmonary Resusitation (CPR), and called for emergency medical transport (EMT). When EMT arrived, resuscitation efforts were ceased. The police allowed me to enter Resident #20's room briefly. I observed that he was lying flat, with a wound to the left side of his forehead. It was approximately 3 to 4 centimeters long above the eyebrow, and about ? to ? cm open. There was a small pool of dried blood, approximately 3 to 4 inches in diameter on the sheets next to his head. There was some mottling and pooling on his left side and left thigh area. Other than the crash cart, there was nothing out of place in the room. There was no blood anyplace in the room where he may have fallen. The police felt it strange that there was no blood in the room. I interviewed everybody that worked the night shift. The CNA (D) assigned to the 200 hall (Resident #20 was in room [ROOM NUMBER]) said she last saw him at 11:30 PM, and she did not check on him after that. The charge nurse (RN E) assigned to the 100 and 200 halls, said she saw him about midnight and again between 3:45 AM and 4:30 AM, when she peeked in on him, and saw him breathing with his chest moving. She checked in because the resident in room [ROOM NUMBER] had come out to report a man fell in her room. So RN E took that resident to 3 rooms on the 200 hall (including Resident #20's room) to reassure her no one was on the floor. RN E reported that she had to look for CNA D between 12:20 PM and 1:00 AM, and again between 3:15 AM and 4:00 AM. Other CNA's interviewed stated they searched for CNA D without success, when they needed assistance with transfers. One CNA said she found her working in the room across the hall from Resident #20 at about 4:00 AM. We do not have a policy that staff check on residents every 2 hours, but it is our expectation that the CNA's make rounds and check residents every 2 hours." Interview with the Director of Nurses (DON) on [DATE] at 9:50 AM revealed: "Staff should check on residents every 2 hours. We have staff peek in so they don't wake the residents and check for breathing. Our nurses do walking rounds (oncoming and off going nurses check every resident) at change of shift. The charge nurses were counting (controlled substances) and would have done the walking rounds when done with the count. They count with the Medication Aide first, so she can start the morning medication pass. Resident #20 could not, and never tried to get out of bed on his own. He had [MEDICAL CONDITION] ([MEDICAL CONDITION]- lung disease causing difficulty breathing and shortness of breath). He would take 2 to 3 steps and his oxygen saturation rate would drop down to 76% (Normal is above 95%), and get extremely short of breath and have to sit." Interview on [DATE] at 12:55 PM with MA K revealed: "I went to Resident #20's room to administer morning medications at 6:15 AM. I knocked and there was no response, which was not usual. So I went into the room. I thought maybe he was sleeping soundly, so I tried to move his shoulder to wake him. When I moved his shoulder, his whole body moved. He was stiff and cold. He was not breathing. His teeth (dentures) were half way out of his mouth and his head was slumped over to the left side. I ran out and called for help." Interview with RN E on [DATE] at 10:00 AM revealed the following: "I was the charge nurse on 100 and 200 halls on [DATE] into [DATE]. MA K went in to give Resident #20 his medications about 6:15 AM (on [DATE]), and called for help. Licensed Vocational Nurse (LVN) G went down to check him, and came out calling for the crash cart. I was sitting at the station, charting. All of the nurses ran down to his room, and assisted with the CPR. When I went in to help, I saw Resident #20 on his right side, with his dentures out of place (half out of his mouth). His right side was mottled and he was not breathing. We rolled him onto a back board, and started the CPR. LVN J was doing the chest compressions and looked down and noticed a wound to Resident #20's head. I had not noticed the wound before LVN J saw it. I saw him about 12:00 AM and he was laying in bed. Then, between 3:45 AM and 4:30 AM, Resident #9, who was in room [ROOM NUMBER] (adjacent to Resident #20 in room [ROOM NUMBER]), came walking down the hall with her walker. She got half way down the hall and I intercepted her because she was on contact isolation and I wanted to get her back to her room to cover her wound. She said a man fell in her room. I checked her room; there was no one there. I took her with me to Resident #20's room. We stood at the door (I was concerned about going into the room with her due to her contact isolation). The lights were off; I used a flashlight and saw Resident #20 was in bed on his left side (facing the window) and breathing. I did not go in to assess him, or count his respirations. His head was turned away from me so I did not see his forehead or if there was a wound there. We went to three (3) other rooms to show her they (residents) were all fine. I reassured Resident #9 that no one was on the floor and she went back to bed. I think Resident #9 saw or heard something that awakened her; something happened. She usually slept through the night. But Resident #20 usually slept on his left side, so I didn't think to assess him further." RN E continued her interview: Resident #20 usually called for help (call light) whenever he needed anything. I did see call lights going off down the 200 hall during the night, but I couldn't tell you for sure if any were from Resident #20's room. He was on the light a lot and always called for help. I had to talk to CNA D a few times because she had a habit of visiting/talking with staff and not taking care of business. I had to look for her that night and could not find her to take care of the residents. Most of the time she would do her job, but she had an attitude and I felt I had to check up on her. In the last few weeks, I noticed her attitude about her job was worse, and I gave her a verbal warning. The CNA's should do every 2 hour rounds (checks) on residents and the nurses should do every 2 hour checks on them (CNA's)." Interview with LVN G on [DATE] at 10:45 AM revealed: "MA K called me at 6:15 AM to Resident #20's room. I walked in and Resident #20 was sitting up in bed, with the head of his bed elevated to about 45 degrees. He was on his back, but leaning to the left side with his head slumped to the left. His feet were elevated (bed with knee section up to support resident). His eyes were fixed open, and his dentures half out of his mouth. His skin was cool. I ran down the hall for the crash cart and other nurses came in to assist me. LVN J and I started CPR. LVN J saw the wound to his forehead then. Resident #20 was stiff, and there was a gash on his forehead. The top of it was open about an inch wide and the edges of the skin was rolled up. The blood in the wound was coagulated (dried) and dark. There was no other blood in the room where he may have hurt himself. We continued CPR until the EMT's took over. Resident #20 always put the call light on, he would not attempt anything by himself because he was so short of breath. He used a pull-up (brief) during the day, and an incontinent brief at night. He even put on his light to get staff to help get his brief down to use the urinal in bed. I have never seen him get up on his own. Even if he got out of bed, he could not have gotten himself back in bed due to his shortness of breath." Interview on [DATE] at 12:40 PM with LVN J revealed: "I went down to help when they took the crash cart to Resident #20's room. When I entered, the head of his bed was elevated, and his head and shoulder was slumped to the left side. His oxygen was on, because I had to remove the nasal cannula (tubing) so LVN G could place the ambu bag (bag used to deliver breaths manually) on him. We lowered the bed so we could put the back board under him. His eyes were fixed, he was cold to touch, and stiff. We had to put pressure on his chest to make him lay flat on the back board. I started the compressions and then I saw the wound. No one had noticed it before. It was on the left forehead, about mid eyebrow to the end of the eyebrow. It was 3 and ? to 4 cm long and 1 and ? to 2 cm in width. It was not bleeding. There was dried blood at the top of the wound. There was no blood on his face, his sheet, or on his gown. He was on a blood thinner which should have caused a lot of bleeding. When I started the chest compressions, a small trickle of blood came out and I placed a 4 x 4 (gauze dressing) on it. He would not have attempted to get out of bed by himself, because he was short of breath with the least exertion. Because of that, he was constantly on his call light . Interview on [DATE] at 11:00 AM with Certified Occupational Therapy Assistant (COTA) H revealed: I worked with Resident #20 to strengthen his arms, on standing balance and mouth training to help with his breathing. He would not attempt to get out of bed on his own; he would not do something where he might get hurt. He made his needs known, either on the call light or he would just holler out for help. If he had fallen out of bed, he could not have gotten back in bed. Review of a current (undated) facility job description for the CNA revealed the following elements: 2. Check and reposition residents every 2 hours or more frequently as instructed. 7. Observe all residents and report anything unusual or abnormal to Charge Nurse. 8. Provide a supportive, protective, and safe environment for residents Review of a current (undated) job description for the Charge Nurse revealed the following elements: 13. Records vital signs, notes changes, and pursues more specific investigation as needed. 14. Assesses for and notifies physician and other appropriate parties of change in condition. 16. Uses care plans as a basis for providing safe and therapeutic care to patients. 18. Accepts accountability for clinical care of assigned patients, including supervision of non-professional personnel. Review of CNA D's personnel record revealed the following disciplinary events: -[DATE]: Separation report for involuntary separation (termination). CNA reports rounds not made on patient after 11:30 PM on 10:00 PM to 6:00 AM shift. - [DATE]: Correction action form. Areas that need improvement: Turn and reposition total care residents every 2 hours. Notify nurse if you leave your hall unattended for any reason. Only allowed behind nurse's desk at nurses request, or for silverchair (training). - [DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Transferred patient without using gait belt. - [DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Check and change (incontinent care) will be done and documented on all incontinent patients every 2 hours. Review of RN E's personnel record revealed the following disciplinary events: - [DATE]: Corrective Action form. Policy violation or performance issue: Not monitoring, turning and repositioning of at risk patients. Conduct substantiated: Patient in room [ROOM NUMBER] developed deep tissue injury (DTI-injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). Patient in room [ROOM NUMBER] developed deep tissue injury. Areas that need improvement: Knowing residents at risk for skin breakdown and closely monitoring CNA during shift for positioning and changing patients and floating heels. - [DATE]: Corrective Action form for unsatisfactory performance. 6:00 AM weights not done on heart failure patients, or documented. Head to Toe Assessments not done on [DATE]. Breathing treatments not done as ordered; no documentation, and time management. Offered to change to different shift, night shift accepted. Review of the facility's current (undated) Abuse Prevention Policy from the Operational/Resident Care Policies reflected the following elements: Prevention: The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, and misappropriation of resident property. Through the facility's Mission Statement each employee is expected to act in such a manner as to reflect the Mission Statement of this corporation. Each employee receives the "Employee standards of conduct", which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. Staff treatment of [REDACTED]. The facility prohibits mistreatment, neglect, and abuse of residents and misappropriation of resident's property. All employees are trained through orientation and ongoing sessions on issues related to facility abuse prohibition policies and procedures which cover prevention, identification, investigation, protection and reporting. IJ COMPONENTS: The facility Administrator, DON, and RN F were notified on [DATE] at 5:12 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. The following Plan of Removal was submitted by RN F on [DATE] at 8:20 AM. The final Plan of Removal was accepted by the investigator on [DATE] at 10:37 AM. PLAN OF REMOVAL FOR Neglect: PROBLEM: Neglect failing to properly investigate and assess residents after a resident said they heard someone fall. GOAL: To ensure that any time a resident or anyone else says they heard someone fall they are taken seriously & an investigation is done to ensure all resident in the vicinity of the noise are assessed to ensure no one is injured. INTERVENTION: All Staff will be inserviced on following up and investigating anytime a resident or anyone else says they heard someone fall. All nursing staff will be inserviced on making every 2 hour rounds to ensure they are looking at every resident to ensure they are not in distress. Someone from Nursing Administration will be at the facility to ensure that every 2 hour rounds are completed. Administrative staff will conduct random interviews during Quality of Life rounds with residents to ensure they are being checked on at least every 2 hours. CNA (D)that was assigned to 200 Hall was immediately terminated. Charge Nurse (RN E) that was assigned to 200 Hall was suspended immediately. RESPONSIBLE PERSON: Nursing Administration or designee/Administrator or Designee. DATE OF COMPLETION: Inservicing begin (sic) on [DATE] & will continue until all staff have been inserviced. All new hires will be inserviced and a competency completed prior to working the floor. Any employee on vacation or PRN will be inserviced and a competency completed prior to working. Results of inservices and competency will be taken to QAPI monthly and results reviewed. Results of Quality of Life rounds will be taken to QAPI monthly and results reviewed. The investigator monitored the current plan of removal as follows: Record review of facility inservices dated [DATE], [DATE] and [DATE] revealed all staff, including contracted rehabilitation therapy, housekeeping and dietary staff were trained on how to respond to reports of accident or incident. Nursing staff (CNA and charge nurses) are to conduct physical checks of residents every 2 hours. Review of competency skills check offs revealed that administrative staff are performing mock incident scenarios to all staff, who in turn must demonstrate that they have a complete understanding and can execute instructions to ensure resident safety. During interviews on [DATE] between 8:30 AM and 10:45 AM with CNA's, Charge Nurses, Medication Aides, Housekeepers, and Physical Therapy Staff, all were able to verbally repeat instructions from the inservices, as well as physically demonstrate how to enter a resident's room, ensuring adequate lighting to monitor for resident safety. On [DATE] at 11:00 AM, the facility was informed the IJ was lowered due to facility inservices on follow-up and investigation of reports of falls, and scheduled rounds every two (2) hours to ensure residents are not in distress and are safe. However, the facility remained out of compliance at a severity level of Actual Harm at a scope of a pattern because the facility Administrator and staff need time to monitor their plan of removal for effectiveness. Unit Manager LVN C identified two (2) additional residents with recent changes in condition, and a facility census dated [DATE] reflected 45 patients residing on the 100 and 200 halls.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect and abuse for one (1) of three (3) residents reviewed for change in condition. (Resident #20) The facility failed to supervise and monitor Resident #20 every 2 hours per his plan of care. CNA D checked on Resident #20 only 1 time (at 11:30 PM) during her 10:00 PM to 6:00 AM shift. Her charge nurse, Registered Nurse (RN) E failed to monitor and supervise CNA D's performance during this shift. CNA D had previously been disciplined twice for failing to provide every 2 hour turning/positioning and/or incontinent care for residents. RN E had previously been disciplined for failure to closely monitor/supervise the CNA staff, and she failed to assess Resident #20 after another resident reported a fall. Resident #20 was found cold, stiff, unresponsive and with an unexplained wound to his head by day shift staff on [DATE] at 6:15 AM. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of Actual Harm with a scope identified as a pattern. This deficient practice placed 45 residents who reside on Halls 100 and 200 where CNA D and RN E were assigned to provide care at risk for not receiving supervision and treatment in a timely manner in the event of a change in condition. Findings Include: Review of the facility's current (undated) Abuse Prevention Policy from the Operational/Resident Care Policies reflected the following elements: Prevention: The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, and misappropriation of resident property. Through the facility's Mission Statement each employee is expected to act in such a manner as to reflect the Mission Statement of this corporation. Each employee receives the "Employee standards of conduct", which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a resident. Staff treatment of [REDACTED]. The facility prohibits mistreatment, neglect, and abuse of residents and misappropriation of resident's property. All employees are trained through orientation and ongoing sessions on issues related to facility abuse prohibition policies and procedures which cover prevention, identification, investigation, protection and reporting. Review of Resident #20's Admission Face Sheet dated [DATE] was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 received rehabilitative therapy from a Physical Therapists, Occupational Therapists and Speech, Language Pathologists 3 to 5 days a week, with a goal of returning home. Resident #20's Minimum Data Set Assessment (MDS) dated [DATE] revealed the following: Cognitive Patterns: Score of 15 (,[DATE] interpreted as cognitively intact). Functional Status: (1) Self performance, (2) Support provided by staff. Bed Mobility- (1) Extensive assistance, staff provide weight bearing. (2) Requires 2 person physical assist. Transfer- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Walk in Room- (1) Supervision, oversight. (2) Requires one person physical assist. Locomotion on Unit- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Toilet Use- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Balance: Walking, turning around, moving on and off toilet, and surface to surface transfer- Not steady, only able to stabilize with staff assistance. Mobility Devices: Walker and Wheelchair checked. Urinary Continence- Occasionally incontinent. Bowel Continence- Frequently incontinent. Health Conditions: Short of breath, trouble breathing- with exertion, sitting at rest and while lying flat checked. Fall history- Fall during month before admission, no falls since admission. Review of Resident #20's Care Plan conference summary dated [DATE] revealed the following topics were discussed: Cognitive: Alert and oriented to person, place and time. Falls/Safety: At risk. Resident #20's Care Plan revealed problem/needs identified as follows: Problem onset: [DATE] Potential for impaired skin integrity related to immobility, incontinent at times. Approaches included: Check every 2 hours for incontinence and provide cleansing as needed. Turn and reposition every 2 hours. Roles responsible: NNA (Nursing and Nurse Aides). Review of a facility form titled AccuNurse (used by CNA's to document the level of assistance provided for residents to complete their ADL's) revealed CNA D documented the care she provided to Resident #20 for the night shift (10 PM to 6 AM) on [DATE] into [DATE] as follows: Locomotion: Did not occur. Transfer: Did not occur. Urine: Did not occur. Position: Bed: Did not occur. BM: Did not occur. CNA D documented the above activity on [DATE] at 5:01 AM, that Resident #20 had not been checked during the night, nor had he been assisted with locomotion, transfers, incontinent checks for urine or bowel movements, nor had she assisted with repositioning him in bed. Interview with the Corporate Nurse RN F on [DATE] at 9:40 AM revealed that CNA D stated she last checked Resident #20 at 11:30 PM on [DATE]. Interview on [DATE] at 10:25 AM with Unit Manager, LVN C revealed: "The NNA on the care plan stands for Nurse and Nurse Aide. If the care plan approach says to check every 2 hours, or turn every 2 hours it is the responsibility of the CNA to check or turn the resident every 2 hours. It is the responsibility of the charge nurse to delegate the task to the CNA and to supervise to ensure the CNA is performing the task." Attempts by the surveyor to reach CNA D by telephone were ineffective, as the voice mail box was full. Interview on [DATE] at 2:40 PM with a Sergeant with the local Police Department revealed that his department is treating Resident #20's death as a homicide. The Sergeant had also made attempts to reach CNA D without success, but in his initial interview with her, she stated she had not checked on Resident #20 after 11:30 PM. Observation on [DATE] at 10:30 AM revealed housekeeping staff cleaning the mattress in room [ROOM NUMBER], which had been occupied by Resident #20 until [DATE]. There was an area on the mattress where the resident's head would lay, approximately 14 inches in diameter with dried red stains. The housekeeper stated it was dried blood. She stated the sheets she had removed also had the same area of dried blood. Interview on [DATE] at 9:40 AM with the Corporate Nurse, Registered Nurse (RN) F revealed the following: Medication Aide (MA) K found Resident #20 cold on [DATE] at 6:15 AM. She called for help and nursing staff responded finding him cold and non-responsive. They initiated Cardiopulmonary Resusitation (CPR), and called for emergency medical transport (EMT). When EMT arrived, resuscitation efforts were ceased. The police allowed me to enter Resident #20's room briefly. I observed that he was lying flat, with a wound to the left side of his forehead. It was approximately 3 to 4 centimeters long above the eyebrow, and about ? to ? cm open. There was a small pool of dried blood, approximately 3 to 4 inches in diameter on the sheets next to his head. There was some mottling and pooling on his left side and left thigh area. Other than the crash cart, there was nothing out of place in the room. There was no blood anyplace in the room where he may have fallen. The police felt it strange that there was no blood in the room. I interviewed everybody that worked the night shift. The CNA (D) assigned to the 200 hall (Resident #20 was in room [ROOM NUMBER]) said she last saw him at 11:30 PM, and she did not check on him after that. The charge nurse (RN E) assigned to the 100 and 200 halls, said she saw him about midnight and again between 3:45 AM and 4:30 AM, when she peeked in on him, and saw him breathing with his chest moving. She checked in because the resident in room [ROOM NUMBER] had come out to report a man fell in her room. So RN E took that resident to 3 rooms on the 200 hall (including Resident #20's room) to reassure her no one was on the floor. RN E reported that she had to look for CNA D between 12:20 PM and 1:00 AM, and again between 3:15 AM and 4:00 AM. Other CNA's interviewed stated they searched for CNA D without success, when they needed assistance with transfers. One CNA said she found her working in the room across the hall from Resident #20 at about 4:00 AM. We do not have a policy that staff check on residents every 2 hours, but it is our expectation that the CNA's make rounds and check residents every 2 hours." Interview with the Director of Nurses (DON) on [DATE] at 9:50 AM revealed: "Staff should check on residents every 2 hours. We have staff peek in so they don't wake the residents and check for breathing. Our nurses do walking rounds (oncoming and off going nurses check every resident) at change of shift. The charge nurses were counting (controlled substances) and would have done the walking rounds when done with the count. They count with the Medication Aide first, so she can start the morning medication pass. Resident #20 could not, and never tried to get out of bed on his own. He had [MEDICAL CONDITION] ([MEDICAL CONDITION]- lung disease causing difficulty breathing and shortness of breath). He would take 2 to 3 steps and his oxygen saturation rate would drop down to 76% (Normal is above 95%), and get extremely short of breath and have to sit." Interview on [DATE] at 12:55 PM with MA K revealed: "I went to Resident #20's room to administer morning medications at 6:15 AM. I knocked and there was no response, which was not usual. So I went into the room. I thought maybe he was sleeping soundly, so I tried to move his shoulder to wake him. When I moved his shoulder, his whole body moved. He was stiff and cold. He was not breathing. His teeth (dentures) were half way out of his mouth and his head was slumped over to the left side. I ran out and called for help." Interview with RN E on [DATE] at 10:00 AM revealed the following: "I was the charge nurse on 100 and 200 halls on [DATE] into [DATE]. MA K went in to give Resident #20 his medications about 6:15 AM (on [DATE]), and called for help. Licensed Vocational Nurse (LVN) G went down to check him, and came out calling for the crash cart. I was sitting at the station, charting. All of the nurses ran down to his room, and assisted with the CPR. When I went in to help, I saw Resident #20 on his right side, with his dentures out of place (half out of his mouth). His right side was mottled and he was not breathing. We rolled him onto a back board, and started the CPR. LVN J was doing the chest compressions and looked down and noticed a wound to Resident #20's head. I had not noticed the wound before LVN J saw it. I saw him about 12:00 AM and he was laying in bed. Then, between 3:45 AM and 4:30 AM, Resident #9, who was in room [ROOM NUMBER] (adjacent to Resident #20 in room [ROOM NUMBER]), came walking down the hall with her walker. She got half way down the hall and I intercepted her because she was on contact isolation and I wanted to get her back to her room to cover her wound. She said a man fell in her room. I checked her room; there was no one there. I took her with me to Resident #20's room. We stood at the door (I was concerned about going into the room with her due to her contact isolation). The lights were off; I used a flashlight and saw Resident #20 was in bed on his left side (facing the window) and breathing. I did not go in to assess him, or count his respirations. His head was turned away from me so I did not see his forehead or if there was a wound there. We went to three (3) other rooms to show her they (residents) were all fine. I reassured Resident #9 that no one was on the floor and she went back to bed. I think Resident #9 saw or heard something that awakened her; something happened. She usually slept through the night. But Resident #20 usually slept on his left side, so I didn't think to assess him further." RN E continued her interview: Resident #20 usually called for help (call light) whenever he needed anything. I did see call lights going off down the 200 hall during the night, but I couldn't tell you for sure if any were from Resident #20's room. He was on the light a lot and always called for help. I had to talk to CNA D a few times because she had a habit of visiting/talking with staff and not taking care of business. I had to look for her that night and could not find her to take care of the residents. Most of the time she would do her job, but she had an attitude and I felt I had to check up on her. In the last few weeks, I noticed her attitude about her job was worse, and I gave her a verbal warning. The CNA's should do every 2 hour rounds (checks) on residents and the nurses should do every 2 hour checks on them (CNA's)." Interview with LVN G on [DATE] at 10:45 AM revealed: "MA K called me at 6:15 AM to Resident #20's room. I walked in and Resident #20 was sitting up in bed, with the head of his bed elevated to about 45 degrees. He was on his back, but leaning to the left side with his head slumped to the left. His feet were elevated (bed with knee section up to support resident). His eyes were fixed open, and his dentures half out of his mouth. His skin was cool. I ran down the hall for the crash cart and other nurses came in to assist me. LVN J and I started CPR. LVN J saw the wound to his forehead then. Resident #20 was stiff, and there was a gash on his forehead. The top of it was open about an inch wide and the edges of the skin was rolled up. The blood in the wound was coagulated (dried) and dark. There was no other blood in the room where he may have hurt himself. We continued CPR until the EMT's took over. Resident #20 always put the call light on, he would not attempt anything by himself because he was so short of breath. He used a pull-up (brief) during the day, and an incontinent brief at night. He even put on his light to get staff to help get his brief down to use the urinal in bed. I have never seen him get up on his own. Even if he got out of bed, he could not have gotten himself back in bed due to his shortness of breath." Interview on [DATE] at 12:40 PM with LVN J revealed: "I went down to help when they took the crash cart to Resident #20's room. When I entered, the head of his bed was elevated, and his head and shoulder was slumped to the left side. His oxygen was on, because I had to remove the nasal cannula (tubing) so LVN G could place the ambu bag (bag used to deliver breaths manually) on him. We lowered the bed so we could put the back board under him. His eyes were fixed, he was cold to touch, and stiff. We had to put pressure on his chest to make him lay flat on the back board. I started the compressions and then I saw the wound. No one had noticed it before. It was on the left forehead, about mid eyebrow to the end of the eyebrow. It was 3 and ? to 4 cm long and 1 and ? to 2 cm in width. It was not bleeding. There was dried blood at the top of the wound. There was no blood on his face, his sheet, or on his gown. He was on a blood thinner which should have caused a lot of bleeding. When I started the chest compressions, a small trickle of blood came out and I placed a 4 x 4 (gauze dressing) on it. He would not have attempted to get out of bed by himself, because he was short of breath with the least exertion. Because of that, he was constantly on his call light . Interview on [DATE] at 11:00 AM with Certified Occupational Therapy Assistant (COTA) H revealed: I worked with Resident #20 to strengthen his arms, on standing balance and mouth training to help with his breathing. He would not attempt to get out of bed on his own; he would not do something where he might get hurt. He made his needs known, either on the call light or he would just holler out for help. If he had fallen out of bed, he could not have gotten back in bed. Review of a current (undated) facility job description for the CNA revealed the following elements: 2. Check and reposition residents every 2 hours or more frequently as instructed. 7. Observe all residents and report anything unusual or abnormal to Charge Nurse. 8. Provide a supportive, protective, and safe environment for residents Review of a current (undated) job description for the Charge Nurse revealed the following elements: 13. Records vital signs, notes changes, and pursues more specific investigation as needed. 14. Assesses for and notifies physician and other appropriate parties of change in condition. 16. Uses care plans as a basis for providing safe and therapeutic care to patients. 18. Accepts accountability for clinical care of assigned patients, including supervision of non-professional personnel. Review of CNA D's personnel record revealed the following disciplinary events: - [DATE]: Separation report for involuntary separation (termination). CNA reports rounds not made on patient after 11:30 PM on 10:00 PM to 6:00 AM shift. - [DATE]: Correction action form. Areas that need improvement: Turn and reposition total care residents every 2 hours. Notify nurse if you leave your hall unattended for any reason. Only allowed behind nurse's desk at nurses request, or for silverchair (training). - [DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Transferred patient without using gait belt. - [DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Check and change (incontinent care) will be done and documented on all incontinent patients every 2 hours. Review of RN E's personnel record revealed the following disciplinary events: - [DATE]: Corrective Action form. Policy violation or performance issue: Not monitoring, turning and repositioning of at risk patients. Conduct substantiated: Patient in room [ROOM NUMBER] developed deep tissue injury (DTI-injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). Patient in room [ROOM NUMBER] developed deep tissue injury. Areas that need improvement: Knowing residents at risk for skin breakdown and closely monitoring CNA during shift for positioning and changing patients and floating heels. - [DATE]: Corrective Action form for unsatisfactory performance. 6:00 AM weights not done on heart failure patients, or documented. Head to Toe Assessments not done on [DATE]. Breathing treatments not done as ordered; no documentation, and time management. Offered to change to different shift, night shift accepted. IJ COMPONENTS: The facility Administrator, DON, and RN F were notified on [DATE] at 5:12 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. The following Plan of Removal was submitted by RN F on [DATE] at 8:20 AM. The final Plan of Removal was accepted by the investigator on [DATE] at 10:37 AM. PLAN OF REMOVAL FOR Neglect: PROBLEM: Neglect failing to properly investigate and assess residents after a resident said they heard someone fall. GOAL: To ensure that any time a resident or anyone else says they heard someone fall they are taken seriously & an investigation is done to ensure all resident in the vicinity of the noise are assessed to ensure no one is injured. INTERVENTION: All Staff will be inserviced on following up and investigating anytime a resident or anyone else says they heard someone fall. All nursing staff will be inserviced on making every 2 hour rounds to ensure they are looking at every resident to ensure they are not in distress. Someone from Nursing Administration will be at the facility to ensure that every 2 hour rounds are completed. Administrative staff will conduct random interviews during Quality of Life rounds with residents to ensure they are being checked on at least every 2 hours. CNA (D) that was assigned to 200 Hall was immediately terminated. Charge Nurse (RN E) that was assigned to 200 Hall was suspended immediately. RESPONSIBLE PERSON: Nursing Administration or designee/Administrator or Designee. DATE OF COMPLETION:Inservicing begin (sic) on [DATE] & will continue until all staff have been inserviced. All new hires will be inserviced and a competency completed prior to working the floor. Any employee on vacation or PRN will be inserviced and a competency completed prior to working. Results of inservices and competency will be taken to QAPI monthly and results reviewed. Results of Quality of Life rounds will be taken to QAPI monthly and results reviewed. The investigator monitored the current plan of removal as follows: Record review of facility inservices dated [DATE], [DATE] and [DATE] revealed all staff, including contracted rehabilitation therapy, housekeeping and dietary staff were trained on how to respond to reports of accident or incident. Nursing staff (CNA and charge nurses) are to conduct physical checks of residents every 2 hours. Review of competency skills check offs revealed that administrative staff are performing mock incident scenarios to all staff, who in turn must demonstrate that they have a complete understanding and can execute instructions to ensure resident safety. During interviews on [DATE] between 8:30 AM and 10:45 AM with CNA's, Charge Nurses, Medication Aides, Housekeepers, and Physical Therapy Staff, all were able to verbally repeat instructions from the inservices, as well as physically demonstrate how to enter a resident's room, ensuring adequate lighting to monitor for resident safety. On [DATE] at 11:00 AM, the facility was informed the IJ was lowered due to facility inservices on follow-up and investigation of reports of falls, and scheduled rounds every two (2) hours to ensure residents are not in distress and are safe. However, the facility remained out of compliance at a severity level of Actual Harm at a scope of a pattern because the facility Administrator and staff need time to monitor their plan of removal for effectiveness. Unit Manager LVN C identified two (2) additional residents with recent changes in condition, and a facility census dated [DATE] reflected 45 patients residing on the 100 and 200 halls.

Based on observation, interview, and record review, the facility failed to provide services including every 2 hour checks in accordance with one (1) of three (3) resident's plan of care who experienced a change of condition. (Resident #20) The facility failed to supervise and monitor Resident #20 every 2 hours per his plan of care. CNA D checked on Resident #20 only 1 time (at 11:30 PM) during her 10:00 PM to 6:00 AM shift. Her charge nurse, Registered Nurse (RN) E failed to monitor and supervise CNA D's performance during this shift. CNA D had previously been disciplined twice for failing to provide every 2 hour turning/positioning and/or incontinent care for residents. RN E had previously been disciplined for failure to closely monitor/supervise the CNA staff, and she failed to assess Resident #20 after another resident reported a fall. Resident #20 was found cold, stiff, unresponsive and with an unexplained wound to his head by day shift staff on [DATE] at 6:15 AM. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of Actual Harm with a scope identified as a pattern. This deficient practice placed 45 residents who reside on Halls 100 and 200 where CNA D and RN E were assigned to provide care at risk for not receiving supervision and treatment in a timely manner in the event of a change in condition. Findings Include: Review of Resident #20's Admission Face Sheet dated [DATE] was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 received rehabilitative therapy from a Physical Therapists, Occupational Therapists and Speech, Language Pathologists 3 to 5 days a week, with a goal of returning home. Resident #20's Minimum Data Set Assessment (MDS) dated [DATE] revealed the following: Cognitive Patterns: Score of 15 (,[DATE] interpreted as cognitively intact). Functional Status: (1) Self performance, (2) Support provided by staff. Bed Mobility- (1) Extensive assistance, staff provide weight bearing. (2) Requires 2 person physical assist. Transfer- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Walk in Room- (1) Supervision, oversight. (2) Requires one person physical assist. Locomotion on Unit- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Toilet Use- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Balance: Walking, turning around, moving on and off toilet, and surface to surface transfer- Not steady, only able to stabilize with staff assistance. Mobility Devices: Walker and Wheelchair checked. Urinary Continence- Occasionally incontinent. Bowel Continence- Frequently incontinent. Health Conditions: Short of breath, trouble breathing- with exertion, sitting at rest and while lying flat checked. Fall history- Fall during month before admission, no falls since admission. Review of Resident #20's Care Plan conference summary dated [DATE] revealed the following topics were discussed: Cognitive: Alert and oriented to person, place and time. Falls/Safety: At risk. Resident #20's Care Plan revealed problem/needs identified as follows: Problem onset: [DATE] Potential for impaired skin integrity related to immobility, incontinent at times. Approaches included: Check every 2 hours for incontinence and provide cleansing as needed. Turn and reposition every 2 hours. Roles responsible: NNA (Nursing and Nurse Aides). Review of a facility form titled AccuNurse (used by CNA's to document the level of assistance provided for residents to complete their ADL's) revealed CNA D documented the care she provided to Resident #20 for the night shift (10 PM to 6 AM) on [DATE] into [DATE] as follows: Locomotion: Did not occur. Transfer: Did not occur. Urine: Did not occur. Position: Bed: Did not occur. BM: Did not occur. CNA D documented the above activity on [DATE] at 5:01 AM, that Resident #20 had not been checked during the night, nor had he been assisted with locomotion, transfers, incontinent checks for urine or bowel movements, nor had she assisted with repositioning him in bed. Interview with the Corporate Nurse RN F on [DATE] at 9:40 AM revealed that CNA D stated she last checked Resident #20 at 11:30 PM on [DATE]. Interview on [DATE] at 10:25 AM with Unit Manager, LVN C revealed: "The NNA on the care plan stands for Nurse and Nurse Aide. If the care plan approach says to check every 2 hours, or turn every 2 hours it is the responsibility of the CNA to check or turn the resident every 2 hours. It is the responsibility of the charge nurse to delegate the task to the CNA and to supervise to ensure the CNA is performing the task." Attempts by the surveyor to reach CNA D by telephone were ineffective, as the voice mail box was full. Interview on [DATE] at 2:40 PM with a Sergeant with the local Police Department revealed that his department is treating Resident #20's death as a homicide. The Sergeant had also made attempts to reach CNA D without success, but in his initial interview with her, she stated she had not checked on Resident #20 after 11:30 PM. Observation on [DATE] at 10:30 AM revealed housekeeping staff cleaning the mattress in room [ROOM NUMBER], which had been occupied by Resident #20 until [DATE]. There was an area on the mattress where the resident's head would lay, approximately 14 inches in diameter with dried red stains. The housekeeper stated it was dried blood. She stated the sheets she had removed also had the same area of dried blood. Interview on [DATE] at 9:40 AM with the Corporate Nurse, Registered Nurse (RN) F revealed the following: Medication Aide (MA) K found Resident #20 cold on [DATE] at 6:15 AM. She called for help and nursing staff responded finding him cold and non-responsive. They initiated Cardiopulmonary Resusitation (CPR), and called for emergency medical transport (EMT). When EMT arrived, resuscitation efforts were ceased. The police allowed me to enter Resident #20's room briefly. I observed that he was lying flat, with a wound to the left side of his forehead. It was approximately 3 to 4 centimeters long above the eyebrow, and about ? to ? cm open. There was a small pool of dried blood, approximately 3 to 4 inches in diameter on the sheets next to his head. There was some mottling and pooling on his left side and left thigh area. Other than the crash cart, there was nothing out of place in the room. There was no blood anyplace in the room where he may have fallen. The police felt it strange that there was no blood in the room. I interviewed everybody that worked the night shift. The CNA (D) assigned to the 200 hall (Resident #20 was in room [ROOM NUMBER]) said she last saw him at 11:30 PM, and she did not check on him after that. The charge nurse (RN E) assigned to the 100 and 200 halls, said she saw him about midnight and again between 3:45 AM and 4:30 AM, when she peeked in on him, and saw him breathing with his chest moving. She checked in because the resident in room [ROOM NUMBER] had come out to report a man fell in her room. So RN E took that resident to 3 rooms on the 200 hall (including Resident #20's room) to reassure her no one was on the floor. RN E reported that she had to look for CNA D between 12:20 PM and 1:00 AM, and again between 3:15 AM and 4:00 AM. Other CNA's interviewed stated they searched for CNA D without success, when they needed assistance with transfers. One CNA said she found her working in the room across the hall from Resident #20 at about 4:00 AM. We do not have a policy that staff check on residents every 2 hours, but it is our expectation that the CNA's make rounds and check residents every 2 hours." Interview with the Director of Nurses (DON) on [DATE] at 9:50 AM revealed: "Staff should check on residents every 2 hours. We have staff peek in so they don't wake the residents and check for breathing. Our nurses do walking rounds (oncoming and off going nurses check every resident) at change of shift. The charge nurses were counting (controlled substances) and would have done the walking rounds when done with the count. They count with the Medication Aide first, so she can start the morning medication pass. Resident #20 could not, and never tried to get out of bed on his own. He had [MEDICAL CONDITION] ([MEDICAL CONDITION]- lung disease causing difficulty breathing and shortness of breath). He would take 2 to 3 steps and his oxygen saturation rate would drop down to 76% (Normal is above 95%), and get extremely short of breath and have to sit." Interview on [DATE] at 12:55 PM with MA K revealed: "I went to Resident #20's room to administer morning medications at 6:15 AM. I knocked and there was no response, which was not usual. So I went into the room. I thought maybe he was sleeping soundly, so I tried to move his shoulder to wake him. When I moved his shoulder, his whole body moved. He was stiff and cold. He was not breathing. His teeth (dentures) were half way out of his mouth and his head was slumped over to the left side. I ran out and called for help." Interview with RN E on [DATE] at 10:00 AM revealed the following: "I was the charge nurse on 100 and 200 halls on [DATE] into [DATE]. MA K went in to give Resident #20 his medications about 6:15 AM (on [DATE]), and called for help. Licensed Vocational Nurse (LVN) G went down to check him, and came out calling for the crash cart. I was sitting at the station, charting. All of the nurses ran down to his room, and assisted with the CPR. When I went in to help, I saw Resident #20 on his right side, with his dentures out of place (half out of his mouth). His right side was mottled and he was not breathing. We rolled him onto a back board, and started the CPR. LVN J was doing the chest compressions and looked down and noticed a wound to Resident #20's head. I had not noticed the wound before LVN J saw it. I saw him about 12:00 AM and he was laying in bed. Then, between 3:45 AM and 4:30 AM, Resident #9, who was in room [ROOM NUMBER] (adjacent to Resident #20 in room [ROOM NUMBER]), came walking down the hall with her walker. She got half way down the hall and I intercepted her because she was on contact isolation and I wanted to get her back to her room to cover her wound. She said a man fell in her room. I checked her room; there was no one there. I took her with me to Resident #20's room. We stood at the door (I was concerned about going into the room with her due to her contact isolation). The lights were off; I used a flashlight and saw Resident #20 was in bed on his left side (facing the window) and breathing. I did not go in to assess him, or count his respirations. His head was turned away from me so I did not see his forehead or if there was a wound there. We went to three (3) other rooms to show her they (residents) were all fine. I reassured Resident #9 that no one was on the floor and she went back to bed. I think Resident #9 saw or heard something that awakened her; something happened. She usually slept through the night. But Resident #20 usually slept on his left side, so I didn't think to assess him further." RN E continued her interview: Resident #20 usually called for help (call light) whenever he needed anything. I did see call lights going off down the 200 hall during the night, but I couldn't tell you for sure if any were from Resident #20's room. He was on the light a lot and always called for help. I had to talk to CNA D a few times because she had a habit of visiting/talking with staff and not taking care of business. I had to look for her that night and could not find her to take care of the residents. Most of the time she would do her job, but she had an attitude and I felt I had to check up on her. In the last few weeks, I noticed her attitude about her job was worse, and I gave her a verbal warning. The CNA's should do every 2 hour rounds (checks) on residents and the nurses should do every 2 hour checks on them (CNA's)." Interview with LVN G on [DATE] at 10:45 AM revealed: "MA K called me at 6:15 AM to Resident #20's room. I walked in and Resident #20 was sitting up in bed, with the head of his bed elevated to about 45 degrees. He was on his back, but leaning to the left side with his head slumped to the left. His feet were elevated (bed with knee section up to support resident). His eyes were fixed open, and his dentures half out of his mouth. His skin was cool. I ran down the hall for the crash cart and other nurses came in to assist me. LVN J and I started CPR. LVN J saw the wound to his forehead then. Resident #20 was stiff, and there was a gash on his forehead. The top of it was open about an inch wide and the edges of the skin was rolled up. The blood in the wound was coagulated (dried) and dark. There was no other blood in the room where he may have hurt himself. We continued CPR until the EMT's took over. Resident #20 always put the call light on, he would not attempt anything by himself because he was so short of breath. He used a pull-up (brief) during the day, and an incontinent brief at night. He even put on his light to get staff to help get his brief down to use the urinal in bed. I have never seen him get up on his own. Even if he got out of bed, he could not have gotten himself back in bed due to his shortness of breath." Interview on [DATE] at 12:40 PM with LVN J revealed: "I went down to help when they took the crash cart to Resident #20's room. When I entered, the head of his bed was elevated, and his head and shoulder was slumped to the left side. His oxygen was on, because I had to remove the nasal cannula (tubing) so LVN G could place the ambu bag (bag used to deliver breaths manually) on him. We lowered the bed so we could put the back board under him. His eyes were fixed, he was cold to touch, and stiff. We had to put pressure on his chest to make him lay flat on the back board. I started the compressions and then I saw the wound. No one had noticed it before. It was on the left forehead, about mid eyebrow to the end of the eyebrow. It was 3 and ? to 4 cm long and 1 and ? to 2 cm in width. It was not bleeding. There was dried blood at the top of the wound. There was no blood on his face, his sheet, or on his gown. He was on a blood thinner which should have caused a lot of bleeding. When I started the chest compressions, a small trickle of blood came out and I placed a 4 x 4 (gauze dressing) on it. He would not have attempted to get out of bed by himself, because he was short of breath with the least exertion. Because of that, he was constantly on his call light . Interview on [DATE] at 11:00 AM with Certified Occupational Therapy Assistant (COTA) H revealed: I worked with Resident #20 to strengthen his arms, on standing balance and mouth training to help with his breathing. He would not attempt to get out of bed on his own; he would not do something where he might get hurt. He made his needs known, either on the call light or he would just holler out for help. If he had fallen out of bed, he could not have gotten back in bed. Review of a current (undated) facility job description for the CNA revealed the following elements: 2. Check and reposition residents every 2 hours or more frequently as instructed. 7. Observe all residents and report anything unusual or abnormal to Charge Nurse. 8. Provide a supportive, protective, and safe environment for residents Review of a current (undated) job description for the Charge Nurse revealed the following elements: 13. Records vital signs, notes changes, and pursues more specific investigation as needed. 14. Assesses for and notifies physician and other appropriate parties of change in condition. 16. Uses care plans as a basis for providing safe and therapeutic care to patients. 18. Accepts accountability for clinical care of assigned patients, including supervision of non-professional personnel. Review of CNA D's personnel record revealed the following disciplinary events: - [DATE]: Separation report for involuntary separation (termination). CNA reports rounds not made on patient after 11:30 PM on 10:00 PM to 6:00 AM shift. - [DATE]: Correction action form. Areas that need improvement: Turn and reposition total care residents every 2 hours. Notify nurse if you leave your hall unattended for any reason. Only allowed behind nurse's desk at nurses request, or for silverchair (training). - [DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Transferred patient without using gait belt. - [DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Check and change (incontinent care) will be done and documented on all incontinent patients every 2 hours. Review of RN E's personnel record revealed the following disciplinary events: - [DATE]: Corrective Action form. Policy violation or performance issue: Not monitoring, turning and repositioning of at risk patients. Conduct substantiated: Patient in room [ROOM NUMBER] developed deep tissue injury (DTI-injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). Patient in room [ROOM NUMBER] developed deep tissue injury. Areas that need improvement: Knowing residents at risk for skin breakdown and closely monitoring CNA during shift for positioning and changing patients and floating heels. - [DATE]: Corrective Action form for unsatisfactory performance. 6:00 AM weights not done on heart failure patients, or documented. Head to Toe Assessments not done on [DATE]. Breathing treatments not done as ordered; no documentation, and time management. Offered to change to different shift, night shift accepted. IJ COMPONENTS: The facility Administrator, DON, and RN F were notified on [DATE] at 5:12 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. The following Plan of Removal was submitted by RN F on [DATE] at 8:20 AM. The final Plan of Removal was accepted by the investigator on [DATE] at 10:37 AM. PLAN OF REMOVAL FOR Neglect: PROBLEM: Neglect failing to properly investigate and assess residents after a resident said they heard someone fall. GOAL: To ensure that any time a resident or anyone else says they heard someone fall they are taken seriously & an investigation is done to ensure all resident in the vicinity of the noise are assessed to ensure no one is injured. INTERVENTION: All Staff will be inserviced on following up and investigating anytime a resident or anyone else says they heard someone fall. All nursing staff will be inserviced on making every 2 hour rounds to ensure they are looking at every resident to ensure they are not in distress. Someone from Nursing Administration will be at the facility to ensure that every 2 hour rounds are completed. Administrative staff will conduct random interviews during Quality of Life rounds with residents to ensure they are being checked on at least every 2 hours. CNA (D) that was assigned to 200 Hall was immediately terminated. Charge Nurse (RN E) that was assigned to 200 Hall was suspended immediately. RESPONSIBLE PERSON: Nursing Administration or designee/Administrator or Designee. DATE OF COMPLETION:Inservicing begin (sic) on [DATE] & will continue until all staff have been inserviced. All new hires will be inserviced and a competency completed prior to working the floor. Any employee on vacation or PRN will be inserviced and a competency completed prior to working. Results of inservices and competency will be taken to QAPI monthly and results reviewed. Results of Quality of Life rounds will be taken to QAPI monthly and results reviewed. The investigator monitored the current plan of removal as follows: Record review of facility inservices dated [DATE], [DATE] and [DATE] revealed all staff, including contracted rehabilitation therapy, housekeeping and dietary staff were trained on how to respond to reports of accident or incident. Nursing staff (CNA and charge nurses) are to conduct physical checks of residents every 2 hours. Review of competency skills check offs revealed that administrative staff are performing mock incident scenarios to all staff, who in turn must demonstrate that they have a complete understanding and can execute instructions to ensure resident safety. During interviews on [DATE] between 8:30 AM and 10:45 AM with CNA's, Charge Nurses, Medication Aides, Housekeepers, and Physical Therapy Staff, all were able to verbally repeat instructions from the inservices, as well as physically demonstrate how to enter a resident's room, ensuring adequate lighting to monitor for resident safety. On [DATE] at 11:00 AM, the facility was informed the IJ was lowered due to facility inservices on follow-up and investigation of reports of falls, and scheduled rounds every two (2) hours to ensure residents are not in distress and are safe. However, the facility remained out of compliance at a severity level of Actual Harm at a scope of a pattern because the facility Administrator and staff need time to monitor their plan of removal for effectiveness. Unit Manager LVN C identified two (2) additional residents with recent changes in condition, and a facility census dated [DATE] reflected 45 patients residing on the 100 and 200 halls.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for change in condition. (Resident #20) The facility failed to supervise and monitor Resident #20 every 2 hours per his plan of care. CNA D checked on Resident #20 only 1 time (at 11:30 PM) during her 10:00 PM to 6:00 AM shift. Her charge nurse, Registered Nurse (RN) E failed to monitor and supervise CNA D's performance during this shift. CNA D had previously been disciplined twice for failing to provide every 2 hour turning/positioning and/or incontinent care for residents. RN E had previously been disciplined for failure to closely monitor/supervise the CNA staff, and she failed to assess Resident #20 after another resident reported a fall. Resident #20 was found cold, stiff, unresponsive and with an unexplained wound to his head by day shift staff on [DATE] at 6:15 AM. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of Actual Harm with a scope identified as a pattern. This deficient practice placed 45 residents who reside on Halls 100 and 200 where CNA D and RN E were assigned to provide care at risk for not receiving supervision and treatment in a timely manner in the event of a change in condition. Findings Include: Review of Resident #20's Admission Face Sheet dated [DATE] was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 received rehabilitative therapy from a Physical Therapists, Occupational Therapists and Speech, Language Pathologists 3 to 5 days a week, with a goal of returning home. Resident #20's Minimum Data Set Assessment (MDS) dated [DATE] revealed the following: Cognitive Patterns: Score of 15 (,[DATE] interpreted as cognitively intact). Functional Status: (1) Self performance, (2) Support provided by staff. Bed Mobility- (1) Extensive assistance, staff provide weight bearing. (2) Requires 2 person physical assist. Transfer- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Walk in Room- (1) Supervision, oversight. (2) Requires one person physical assist. Locomotion on Unit- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Toilet Use- (1) Extensive assistance, staff provide weight bearing. (2) Requires 1 person physical assist. Balance: Walking, turning around, moving on and off toilet, and surface to surface transfer- Not steady, only able to stabilize with staff assistance. Mobility Devices: Walker and Wheelchair checked. Urinary Continence- Occasionally incontinent. Bowel Continence- Frequently incontinent. Health Conditions: Short of breath, trouble breathing- with exertion, sitting at rest and while lying flat checked. Fall history- Fall during month before admission, no falls since admission. Review of Resident #20's Care Plan conference summary dated [DATE] revealed the following topics were discussed: Cognitive: Alert and oriented to person, place and time. Falls/Safety: At risk. Resident #20's Care Plan revealed problem/needs identified as follows: Problem onset: [DATE] Potential for impaired skin integrity related to immobility, incontinent at times. Approaches included: Check every 2 hours for incontinence and provide cleansing as needed. Turn and reposition every 2 hours. Roles responsible: NNA (Nursing and Nurse Aides). Review of a facility form titled AccuNurse (used by CNA's to document the level of assistance provided for residents to complete their ADL's) revealed CNA D documented the care she provided to Resident #20 for the night shift (10 PM to 6 AM) on [DATE] into [DATE] as follows: Locomotion: Did not occur. Transfer: Did not occur. Urine: Did not occur. Position: Bed: Did not occur. BM: Did not occur. CNA D documented the above activity on [DATE] at 5:01 AM, that Resident #20 had not been checked during the night, nor had he been assisted with locomotion, transfers, incontinent checks for urine or bowel movements, nor had she assisted with repositioning him in bed. Interview with the Corporate Nurse RN F on [DATE] at 9:40 AM revealed that CNA D stated she last checked Resident #20 at 11:30 PM on [DATE]. Interview on [DATE] at 10:25 AM with Unit Manager, LVN C revealed: "The NNA on the care plan stands for Nurse and Nurse Aide. If the care plan approach says to check every 2 hours, or turn every 2 hours it is the responsibility of the CNA to check or turn the resident every 2 hours. It is the responsibility of the charge nurse to delegate the task to the CNA and to supervise to ensure the CNA is performing the task." Attempts by the surveyor to reach CNA D by telephone were ineffective, as the voice mail box was full. Interview on [DATE] at 2:40 PM with a Sergeant with the local Police Department revealed that his department is treating Resident #20's death as a homicide. The Sergeant had also made attempts to reach CNA D without success, but in his initial interview with her, she stated she had not checked on Resident #20 after 11:30 PM. Observation on [DATE] at 10:30 AM revealed housekeeping staff cleaning the mattress in room 213, which had been occupied by Resident #20 until [DATE]. There was an area on the mattress where the resident's head would lay, approximately 14 inches in diameter with dried red stains. The housekeeper stated it was dried blood. She stated the sheets she had removed also had the same area of dried blood. Interview on [DATE] at 9:40 AM with the Corporate Nurse, Registered Nurse (RN) F revealed the following: Medication Aide (MA) K found Resident #20 cold on [DATE] at 6:15 AM. She called for help and nursing staff responded finding him cold and non-responsive. They initiated Cardiopulmonary Resusitation (CPR), and called for emergency medical transport (EMT). When EMT arrived, resuscitation efforts were ceased. The police allowed me to enter Resident #20's room briefly. I observed that he was lying flat, with a wound to the left side of his forehead. It was approximately 3 to 4 centimeters long above the eyebrow, and about ? to ? cm open. There was a small pool of dried blood, approximately 3 to 4 inches in diameter on the sheets next to his head. There was some mottling and pooling on his left side and left thigh area. Other than the crash cart, there was nothing out of place in the room. There was no blood anyplace in the room where he may have fallen. The police felt it strange that there was no blood in the room. I interviewed everybody that worked the night shift. The CNA (D) assigned to the 200 hall (Resident #20 was in room 213) said she last saw him at 11:30 PM, and she did not check on him after that. The charge nurse (RN E) assigned to the 100 and 200 halls, said she saw him about midnight and again between 3:45 AM and 4:30 AM, when she peeked in on him, and saw him breathing with his chest moving. She checked in because the resident in room 211 had come out to report a man fell in her room. So RN E took that resident to 3 rooms on the 200 hall (including Resident #20's room) to reassure her no one was on the floor. RN E reported that she had to look for CNA D between 12:20 PM and 1:00 AM, and again between 3:15 AM and 4:00 AM. Other CNA's interviewed stated they searched for CNA D without success, when they needed assistance with transfers. One CNA said she found her working in the room across the hall from Resident #20 at about 4:00 AM. We do not have a policy that staff check on residents every 2 hours, but it is our expectation that the CNA's make rounds and check residents every 2 hours." Interview with the Director of Nurses (DON) on [DATE] at 9:50 AM revealed: "Staff should check on residents every 2 hours. We have staff peek in so they don't wake the residents and check for breathing. Our nurses do walking rounds (oncoming and off going nurses check every resident) at change of shift. The charge nurses were counting (controlled substances) and would have done the walking rounds when done with the count. They count with the Medication Aide first, so she can start the morning medication pass. Resident #20 could not, and never tried to get out of bed on his own. He had COPD (Chronic Obstructive Pulmonary Disease- lung disease causing difficulty breathing and shortness of breath). He would take 2 to 3 steps and his oxygen saturation rate would drop down to 76% (Normal is above 95%), and get extremely short of breath and have to sit." Interview on [DATE] at 12:55 PM with MA K revealed: "I went to Resident #20's room to administer morning medications at 6:15 AM. I knocked and there was no response, which was not usual. So I went into the room. I thought maybe he was sleeping soundly, so I tried to move his shoulder to wake him. When I moved his shoulder, his whole body moved. He was stiff and cold. He was not breathing. His teeth (dentures) were half way out of his mouth and his head was slumped over to the left side. I ran out and called for help." Interview with RN E on [DATE] at 10:00 AM revealed the following: "I was the charge nurse on 100 and 200 halls on [DATE] into [DATE]. MA K went in to give Resident #20 his medications about 6:15 AM (on [DATE]), and called for help. Licensed Vocational Nurse (LVN) G went down to check him, and came out calling for the crash cart. I was sitting at the station, charting. All of the nurses ran down to his room, and assisted with the CPR. When I went in to help, I saw Resident #20 on his right side, with his dentures out of place (half out of his mouth). His right side was mottled and he was not breathing. We rolled him onto a back board, and started the CPR. LVN J was doing the chest compressions and looked down and noticed a wound to Resident #20's head. I had not noticed the wound before LVN J saw it. I saw him about 12:00 AM and he was laying in bed. Then, between 3:45 AM and 4:30 AM, Resident #9, who was in room 211 (adjacent to Resident #20 in room 213), came walking down the hall with her walker. She got half way down the hall and I intercepted her because she was on contact isolation and I wanted to get her back to her room to cover her wound. She said a man fell in her room. I checked her room; there was no one there. I took her with me to Resident #20's room. We stood at the door (I was concerned about going into the room with her due to her contact isolation). The lights were off; I used a flashlight and saw Resident #20 was in bed on his left side (facing the window) and breathing. I did not go in to assess him, or count his respirations. His head was turned away from me so I did not see his forehead or if there was a wound there. We went to three (3) other rooms to show her they (residents) were all fine. I reassured Resident #9 that no one was on the floor and she went back to bed. I think Resident #9 saw or heard something that awakened her; something happened. She usually slept through the night. But Resident #20 usually slept on his left side, so I didn't think to assess him further." RN E continued her interview: Resident #20 usually called for help (call light) whenever he needed anything. I did see call lights going off down the 200 hall during the night, but I couldn't tell you for sure if any were from Resident #20's room. He was on the light a lot and always called for help. I had to talk to CNA D a few times because she had a habit of visiting/talking with staff and not taking care of business. I had to look for her that night and could not find her to take care of the residents. Most of the time she would do her job, but she had an attitude and I felt I had to check up on her. In the last few weeks, I noticed her attitude about her job was worse, and I gave her a verbal warning. The CNA's should do every 2 hour rounds (checks) on residents and the nurses should do every 2 hour checks on them (CNA's)." Interview with LVN G on [DATE] at 10:45 AM revealed: "MA K called me at 6:15 AM to Resident #20's room. I walked in and Resident #20 was sitting up in bed, with the head of his bed elevated to about 45 degrees. He was on his back, but leaning to the left side with his head slumped to the left. His feet were elevated (bed with knee section up to support resident). His eyes were fixed open, and his dentures half out of his mouth. His skin was cool. I ran down the hall for the crash cart and other nurses came in to assist me. LVN J and I started CPR. LVN J saw the wound to his forehead then. Resident #20 was stiff, and there was a gash on his forehead. The top of it was open about an inch wide and the edges of the skin was rolled up. The blood in the wound was coagulated (dried) and dark. There was no other blood in the room where he may have hurt himself. We continued CPR until the EMT's took over. Resident #20 always put the call light on, he would not attempt anything by himself because he was so short of breath. He used a pull-up (brief) during the day, and an incontinent brief at night. He even put on his light to get staff to help get his brief down to use the urinal in bed. I have never seen him get up on his own. Even if he got out of bed, he could not have gotten himself back in bed due to his shortness of breath." Interview on [DATE] at 12:40 PM with LVN J revealed: "I went down to help when they took the crash cart to Resident #20's room. When I entered, the head of his bed was elevated, and his head and shoulder was slumped to the left side. His oxygen was on, because I had to remove the nasal cannula (tubing) so LVN G could place the ambu bag (bag used to deliver breaths manually) on him. We lowered the bed so we could put the back board under him. His eyes were fixed, he was cold to touch, and stiff. We had to put pressure on his chest to make him lay flat on the back board. I started the compressions and then I saw the wound. No one had noticed it before. It was on the left forehead, about mid eyebrow to the end of the eyebrow. It was 3 and ? to 4 cm long and 1 and ? to 2 cm in width. It was not bleeding. There was dried blood at the top of the wound. There was no blood on his face, his sheet, or on his gown. He was on a blood thinner which should have caused a lot of bleeding. When I started the chest compressions, a small trickle of blood came out and I placed a 4 x 4 (gauze dressing) on it. He would not have attempted to get out of bed by himself, because he was short of breath with the least exertion. Because of that, he was constantly on his call light . Interview on [DATE] at 11:00 AM with Certified Occupational Therapy Assistant (COTA) H revealed: I worked with Resident #20 to strengthen his arms, on standing balance and mouth training to help with his breathing. He would not attempt to get out of bed on his own; he would not do something where he might get hurt. He made his needs known, either on the call light or he would just holler out for help. If he had fallen out of bed, he could not have gotten back in bed. Review of a current (undated) facility job description for the CNA revealed the following elements: 2. Check and reposition residents every 2 hours or more frequently as instructed. 7. Observe all residents and report anything unusual or abnormal to Charge Nurse. 8. Provide a supportive, protective, and safe environment for residents Review of a current (undated) job description for the Charge Nurse revealed the following elements: 13. Records vital signs, notes changes, and pursues more specific investigation as needed. 14. Assesses for and notifies physician and other appropriate parties of change in condition. 16. Uses care plans as a basis for providing safe and therapeutic care to patients. 18. Accepts accountability for clinical care of assigned patients, including supervision of non-professional personnel. Review of CNA D's personnel record revealed the following disciplinary events: -[DATE]: Separation report for involuntary separation (termination). CNA reports rounds not made on patient after 11:30 PM on 10:00 PM to 6:00 AM shift. -[DATE]: Correction action form. Areas that need improvement: Turn and reposition total care residents every 2 hours. Notify nurse if you leave your hall unattended for any reason. Only allowed behind nurse's desk at nurses request, or for silverchair (training). -[DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Transferred patient without using gait belt. -[DATE]: Correction action form for Unsatisfactory Performance. Areas that need improvement: Check and change (incontinent care) will be done and documented on all incontinent patients every 2 hours. Review of RN E's personnel record revealed the following disciplinary events: -[DATE]: Corrective Action form. Policy violation or performance issue: Not monitoring, turning and repositioning of at risk patients. Conduct substantiated: Patient in room 311 developed deep tissue injury (DTI-injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body). Patient in room 201 developed deep tissue injury. Areas that need improvement: Knowing residents at risk for skin breakdown and closely monitoring CNA during shift for positioning and changing patients and floating heels. -[DATE]: Corrective Action form for unsatisfactory performance. 6:00 AM weights not done on heart failure patients, or documented. Head to Toe Assessments not done on [DATE]. Breathing treatments not done as ordered; no documentation, and time management. Offered to change to different shift, night shift accepted. IJ COMPONENTS: The facility Administrator, DON, and RN F were notified on [DATE] at 5:12 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. The following Plan of Removal was submitted by RN F on [DATE] at 8:20 AM. The final Plan of Removal was accepted by the investigator on [DATE] at 10:37 AM. PLAN OF REMOVAL FOR Neglect: PROBLEM: Neglect failing to properly investigate and assess residents after a resident said they heard someone fall. GOAL: To ensure that any time a resident or anyone else says they heard someone fall they are taken seriously & an investigation is done to ensure all resident in the vicinity of the noise are assessed to ensure no one is injured. INTERVENTION: All Staff will be inserviced on following up and investigating anytime a resident or anyone else says they heard someone fall. All nursing staff will be inserviced on making every 2 hour rounds to ensure they are looking at every resident to ensure they are not in distress. Someone from Nursing Administration will be at the facility to ensure that every 2 hour rounds are completed. Administrative staff will conduct random interviews during Quality of Life rounds with residents to ensure they are being checked on at least every 2 hours. CNA (D) that was assigned to 200 Hall was immediately terminated. Charge Nurse (RN E) that was assigned to 200 Hall was suspended immediately. RESPONSIBLE PERSON: Nursing Administration or designee/Administrator or Designee. DATE OF COMPLETION:Inservicing begin (sic) on [DATE] & will continue until all staff have been inserviced. All new hires will be inserviced and a competency completed prior to working the floor. Any employee on vacation or PRN will be inserviced and a competency completed prior to working. Results of inservices and competency will be taken to QAPI monthly and results reviewed. Results of Quality of Life rounds will be taken to QAPI monthly and results reviewed. The investigator monitored the current plan of removal as follows: Record review of facility inservices dated [DATE], [DATE] and [DATE] revealed all staff, including contracted rehabilitation therapy, housekeeping and dietary staff were trained on how to respond to reports of accident or incident. Nursing staff (CNA and charge nurses) are to conduct physical checks of residents every 2 hours. Review of competency skills check offs revealed that administrative staff are performing mock incident scenarios to all staff, who in turn must demonstrate that they have a complete understanding and can execute instructions to ensure resident safety. During interviews on [DATE] between 8:30 AM and 10:45 AM with CNA's, Charge Nurses, Medication Aides, Housekeepers, and Physical Therapy Staff, all were able to verbally repeat instructions from the inservices, as well as physically demonstrate how to enter a resident's room, ensuring adequate lighting to monitor for resident safety. On [DATE] at 11:00 AM, the facility was informed the IJ was lowered due to facility inservices on follow-up and investigation of reports of falls, and scheduled rounds every two (2) hours to ensure residents are not in distress and are safe. However, the facility remained out of compliance at a severity level of Actual Harm at a scope of a pattern because the facility Administrator and staff need time to monitor their plan of removal for effectiveness. Unit Manager LVN C identified two (2) additional residents with recent changes in condition, and a facility census dated [DATE] reflected 45 patients residing on the 100 and 200 halls.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of two (2) residents (Resident #4) observed for wound care. Resident #4 was not offered pain medication when Licensed Vocational Nurse (LVN J) performed a dressing change although the resident voiced pain. This deficient practice contributed to pain and discomfort for Resident #4. Findings include: During observation of wound care on 6/5/13 at 3:15 PM, LVN J and Certified Nurse Aide (CNA) O entered Resident #4's room to perform wound care. LVN J removed a gauze wrapping from Resident #4's left foot, then started to remove the gauze treatment pad from his heel. The gauze pad was stuck to the heel with dried, reddish exudate. Without benefit of applying moisture to gently loosen the gauze pad, LVN J pulled the gauze off the resident's heel. Resident #4 moaned out loud and said, 'Ow'. While proceeding to clean the left heel wound bed with Normal Saline (NS) wet cleansing pads, LVN J stated to the surveyor that the doctor had debrided (surgical removal of dead tissue) the heel yesterday (6/4/13). LVN J asked Resident #4 if he was having pain on the scale of 1-10, (10 being the worst). Resident #4 voiced a pain level of 8 (severe pain). LVN J applied Santyl ointment to a clean gauze dressing to the heel, and proceeded to continue the wound care to the other three wounds on his left foot and heel. Resident #4 was saying 'Ow' throughout the treatment. LVN J did not offer any pain medication to Resident #4, and then stated that she would start the wound care on Resident #4's right foot. Observation of the diabetic wound to the bottom of Resident #4's right foot under the toes on the right side revealed an approximate 2 centimeter (cm) x 2 cm area that had been debrided by the podiatrist on 6/4/13, exposing the tendon. As LVN J cleaned the area, Resident #4 was moaning and saying, 'Ow'. LVN J asked the resident if he was having pain on a scale of 1-10. The resident stated an "8" again and LVN J told CNA O to go tell the resident's nurse he needed a pain pill. LVN J continued dressing the foot wound and an area on top of the foot. Upon completion of the treatment and leaving the room, a second nurse was observed entering Resident #4's room with medication. The nurse told the surveyor she was giving Resident #4 [MEDICATION NAME] (narcotic pain medication), (forty minutes after the wound care had begun). During an interview on 6/5/12 at 3:55 PM, LVN J was asked if Resident #4 always had this much pain during wound care. She stated, "Sometimes it hurts, sometimes it doesn't" When asked if the resident had pain medication scheduled before wound care, she stated, "No, but he has scheduled pain medication." Review of Resident #4's Recap Physician order [REDACTED]. Review of Resident #4's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 6/6/13 at 10:00 AM, LVN J stated that it had been awhile since the resident had pain during wound care, and she had never known him to need pain medication. She stated that she had been the wound care nurse since May 2013. When asked, "Since you knew that one of the wounds had been debrided down to the tendon by the podiatrist yesterday, did you think that Resident #4 might have more pain?" She stated, "Yes, I will call the doctor to get an order for [REDACTED]. During an interview on 6/6/13 at 1:30 PM, the Director of Nurses (DON) stated that if Resident #4 was in pain she would have expected the nurse to stop the wound care treatment, medicate him for pain and come back and finish the treatment. Review of the current (undated) facility procedure for wound care titled, "Treatment Nurse Competency Check Off" revealed the following element: *Made resident comfortable The facility completed CMS 672 form identified 6 residents with pressure ulcers.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) residents reviewed for accidents (Resident #1), when Resident #1 did not receive physician ordered pain medication following an accident with a malfunctioning Hoyer Lift (mechanical lift). This deficient practice affected Resident #1 whose pain was not controlled timely, resulting in the resident being sent to the hospital emergency room where he received [MEDICATION NAME] (narcotic pain reliever) intraveneously (IV). Findings include: Review of Resident #1's face sheet revealed he is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set assessment dated [DATE] revealed that he required extensive physical assistance of two persons for bed mobility and transfers, and he had impaired range of motion on one side. Observation on 4/4/13 at 2:30 PM revealed Resident #1 resting in bed. He declined to answer any questions. Review of the Nurse ' s Notes dated 4/2/13 on Resident #1's chart revealed the following: 1530 (3:30 PM) Aides were transferring resident to wheelchair in Hoyer Lift, bolt came out of the Hoyer and dropped resident on floor. Skin tear to right forearm, skin tear to left knee, bruise on back right elbow. Bruises and swelling to [MEDICATION NAME] back and sacrum and coccyx. Nurse Practitioner gave new order for [MEDICATION NAME] 5/325 milligrams (narcotic pain medication) every six hours as needed, times 14 days. During an interview on 4/4/13 at 3:30 PM, Licensed Vocational Nurse (LVN A) stated, "Someone hollered for me and I went into Resident #1's room and saw him lying on the legs of the Hoyer Lift with the bar (cradle assembly that holds the sling, and swivels to lift and move patient from one place to another, such as from bed to wheelchair) across his chest. We assessed him for injury. He had skin tears to his right forearm and left knee. He denied any pain. I checked his pupils, responses and range of motion. They were all normal. He was still in the sling, so four staff picked up the corners of the sling and transferred him into his bed. I checked his back, and it was red along his rib cage and on the middle of his back, but he still denied pain. Everything else looked good. I talked him into taking a [MEDICATION NAME] ([MEDICATION NAME] pain medication to treat moderate to severe pain) as a precaution, since he had an order for [REDACTED]. I could see his back was starting to bruise. That was well after 5:00 PM, because meal trays come out at 5:00 PM, and we had already passed them out. I called his doctor, and the Nurse Practitioner and got orders for x-rays and [MEDICATION NAME] (narcotic pain medication). I kept going in to check on him and he kept saying his back hurt. I faxed the order to our pharmacy and got the Assistant Director of Nurses (ADON) to assist me by calling the pharmacist to request a stat (immediate) delivery of the pain medication from the local pharmacy. At first Resident #1 was saying no, he didn't want pain medication, then he started asking for it. The mobile x-ray company was here at 8:00 PM, and reported no new fractures. Resident #1 ' s son came in about then, and after x-rays were completed, he said he wanted him transferred to the hospital. I sent him out about 10:30 PM to the hospital, and he really hollered out when they transferred him to the stretcher. His ([MEDICATION NAME]) pain medication had not come in by then." During an interview on 4/5/13 at ll:45 AM, the Director of Nurses (DON) stated, "The medication had been delivered at 8:32 PM from our local pharmacy. Another nurse accepted and signed for the stat delivery of the medication. She was busy and failed to communicate to Resident #1's nurse that the medication was available. She was counseled and received disciplinary action. When she received the stat delivery, she should have taken it to the nurse on that resident's hall." Review of a facility pharmacy Stat Delivery Sheet dated 4/2/13 revealed the following: Call Time: 7:50 PM Pick-up Time: 8:16 PM Delivery Time: 8:32 PM Review of current (undated) facility pharmacy policy reflected the following elements: Medication Ordering: Stat Orders: Please call any Stat orders directly into the pharmacy and fax the orders immediately thereafter to ensure the medications will be delivered within the required time period. Review of Resident #1's Nurses Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Pain Assessment. Document level of pain from 0-10, and scale used to determine (1) Verbal, or (2) Non-Verbal or Cognitively Impaired. Assessment completed for 4/2/13 for evening (2:00 PM to 10:00 PM) shift revealed pain was rated at a 5 on the verbal scale. Review of Resident #1's Emergency Department Physician Record dated 4/2/13 revealed he was assessed at 2355 (11:55 PM) with moderate pain to his back. [MEDICATION NAME] 0.25 milligram (a narcotic pain medication that is commonly used in hospitals and clinics to treat moderate to severe pain) was administered via an intravenous (infusion of medication directly into a vein) line on 4/3/13 at 0025 (12:25 AM) to treat his pain. During a telephone interview on 4/4/13 at 7:15 PM, Resident #1's primary care physician stated, "I would expect medications should be available within a few hours, especially pain and antibiotic medications. If you have to wait more than a few hours to treat pain, it can be torture. If you have to wait to treat an infection, it could become septic." Review of a facility completed CMS 672 Form idenified 94 residents on a pain management program.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit possible neglect of residents for 1 (Resident #1) of 4 residents reviewed for insulin dependent medications when they failed to report a substantiated incident to the state agency, DADS (Department of Aging and Disability Services). The facility failed to implement procedures and did not investigate or report when Resident #1 was injected with an unknown amount of insulin and developed [DIAGNOSES REDACTED] and altered mental status resulting in hospitalization . This failure to report caused Resident #1 anxiety, discomfort, and unwarranted hospitalization . Findings include: Review of the facility policy Resident Behavior and Facility Practices Policy (undated) reflected the following: "Investigation: The administrator or his/her designee will report allegation of abuse immediately to the state agency (DADS) and to the proper local authorities. The director of nursing will ensure that facility completes the appropriate investigated forms and forwards a copy of the investigation to DADS within 5 working days. " "Reporting /Response: The facility policy and procedure on reporting is to follow state guidelines as outlined in the TDADS Provider letter #06-43-Guidelines for Reporting Incidents and to answer all questions as outlined in TDADS letter dated January 3, 2007. Upon completion of the investigation, the Provider Investigation Report will be faxed or mailed to TDADS within 5 working days" Review of a facility policy Medication Errors (undated) reflected the following: "Medications are administered to residents according to all Federal and State requirements. Procedures are established to assure that significant medication errors that cause the resident discomfort or jeopardize his/her health or safety do not occur." "Drug Administration: the facility has established drug administration procedures to ensure: 1. drugs being administered are checked against the physicians orders; 2. the resident is identified prior to administering the drug; 3. each resident has an individual medication record where doses of drugs administered can be recorded by the person administering the drug; 4. drugs and biological's are administered by the same person; and 5. drugs prescribed for one resident are not administered to any other resident." All drug errors and adverse drug reactions will be reported to the resident's physician in a timely manner and recorded in the resident's record. An incident report will be completed. If the incident appears to be serious, it will be investigated by the director of nursing and the administrator. In addition, special reporting to DADS will be done immediately." Review of a Medication Error Report dated 4/29/12 reflected the following: time of error: 8:00 pm-Medication as ordered "no insulin ordered".-Description of error "resident notified family and family notified nurse that resident had received insulin. Assessed resident, noted possible finger stick mark to left index finger. Educated resident of signs of [DIAGNOSES REDACTED], notified physician of resident possibly receiving non-ordered insulin. Received order to recheck blood sugar at 10:00 pm if below 100 recheck at 12:00 pm and if above 100 at 6:30 am." Measures taken to prevent recurrence: "nurse suspended for further investigation, inservices to nurses on rights of medication, check off on giving insulin, inservice on who to report med errors to." Review of Resident #1's physician orders dated May 2012 reflected an [AGE] year old originally admitted to the facility on 1/29/10 and readmitted on [DATE] with [DIAGNOSES REDACTED]. There were no prescribed diabetic medications on Resident #1's physician orders. Review of Resident #1's MAR (medication administration record) dated April 2012 reflected no diabetic medication.(insulin). Review of Resident #1's clinical hospital note dated 12/8/11 reflected "This is an [AGE] year old presenting to the clinic to follow up from the nursing home. She recently had some blood work done which showed good control of her diabetes." Review of Resident #1's annual MDS (minimum date set) dated 2/13/12 reflected a BIMs (brief interview for mental status) score of 14 (cognitively intact) Active [DIAGNOSES REDACTED]. In an interview on 5/14/12 at 4:15 pm, Resident #1 stated I was laying in bed, this nurse came in and never said a word. She came back and gave me a shot in the stomach. I don't remember well enough to tell you exactly what I said, I did tell her I don't understand this, I never had to do this before. I don't ever take shots for anything. I said to her "are you sure this is for me? (stating her name)" She never said a word, she just left. At first I didn't feel any different, I don't know how long after, apparently I lost consciousness. I don't remember anything until they were putting me in the ambulance. When asked by the surveyor how this incident made her feel, Resident #1 stated " I wanted to choke her! She just blatantly screwed up. I think she was new here, I had never seen her before." In an interview on 5/15/12 at 11:00 am, Resident #1's family member stated he was on the phone with Resident #1 the evening of 4/29/12 when he heard Resident #1 say "here comes the nurse." The family member stated he heard the nurse say I have your insulin shot for you and Resident #1 answer her "are you sure this is for me?" (stating her name). The family member stated he thought it was strange because he knows Resident #1 does not have diabetes, so he contacted another family member to report the incident. In an interview on 5/14/12 at 9:30 am, Resident #1's responsible party (RP) stated on 4/29/12, she received a call from her brother informing her he was talking on the phone to Resident #1 when he overheard a nurse come in and tell her" I'm going to give you your insulin." The RP stated Resident #1 is not diabetic and does not receive insulin. The RP stated she went to the facility and was told the nurse denied she had given the insulin. The RP stated while visiting with Resident #1 following the incident she observed a moist alcohol swab with a small amount of blood and a lancet in the trash can next to Resident #1's bed. In an interview on 5/14/12 at 10:55 am, the Director of Nurses (DON) stated licensed vocational nurse (LVN) A had been working at the facility for 4 days. The DON stated LVN A had trained for 2 nights with another nurse. The DON stated this is usual policy as a nurse should know the basics of administering medications. The DON stated there were no concerns with LVN A's performance. The DON stated LVN A stuck Resident #1's finger and then gave her a shot of insulin. The DON stated LVN A adamantly denied giving the insulin to the wrong resident and insisted she gave the insulin to the resident across the hall. The DON stated Resident #1's RP found a lancet in the trash. The DON stated she did not report the error to DADS because she thought that only medication errors resulting in severe reactions or death had to be reported. The DON stated Resident #1 did not have any adverse harm from the shot. The DON stated Resident #1 moaned and became unresponsive and was sent out to the hospital and admitted for observations and testing. The DON stated LVN A should have identified the resident prior to giving the medication. The DON stated LVN A was suspended and terminated following the investigation and did not return to the facility after the incident. The DON stated all residents with an order for [REDACTED]. The DON stated the facility will be referring LVN A to the Texas Board of Nursing. In an interview on 5/14/12 at 12:15 pm, the Administrator stated at first he thought the incident was not reportable because there was no harm, but once Resident #1 was admitted to the hospital, he realized it should have been re-evaluated and reported. The Administrator stated "I don't disagree, it should have been reported." Review of Resident #1's Physician's Telephone Order dated 4/29/12 reflected 1. Recheck blood sugar at 2200 (10:00 pm) if below 100 recheck at midnight. if not below 100 recheck in am then discontinue accucheck. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"4/29/12 10:00 pm 160- 12:00 pm no check-6:30 am 49. Review of Resident #1's nurses notes dated 4/29/12 reflected: " 8:45- received phone call from resident's daughter at 8:00 pm reporting that resident had called and said she had received an accucheck and insulin at 7:45 pm. Spoke with resident and she was certain she had received insulin. Was unable to contact Resident #1's 's physician. Spoke with the medical director and received orders to recheck blood sugar at 10:00 pm and if below 100 recheck at 12:00 midnight and and if not recheck at 6:30 am. Daughter present a this time and explained monitoring. Blood sugar at 8:15 pm was 139. resident states she feels fine. Instructed her if she felt light headed or clammy to notify the nurse immediately. Daughter and resident satisfied with intervention. Notified DON of complaint. Will monitor resident" The note was signed by LVN B Review of Resident #1's nurses notes dated 4/30/12 reflected the following: "6:30 am Resident snoring very loudly. Knocked on door. Called resident's name and turned on light. Resident in bed eyes wide open, blank look on her face. Called residents name again. No response. Shook resident. No response. Sternal rub resident and still no response. Resident diaphoretic, pupils non-reactive to light, body limp, watering of both eyes, drooling from mouth. Called for help. Night nurse came in to help. Check blood sugar and it was 49. [MEDICATION NAME] 1mg IM (intramuscular)injection in deltoid. Recheck blood sugar. Now blood sugar 59. EMS (emergency medical service) called to send resident out. Vital signs, blood pressure 160/80, respirations 22, pulse 95, temperature 97.6. Raise head of bed and apply oxygen via nasal canula at 2 liters. Resident still snoring very loudly. resident went back out. Resident arm warm to touch, legs cool to touch. Resident still has no verbal response. EMS arrived and took over. Notified RP and physician." Review of a resident transfer form dated 4/30/12 reflected reason for transfer: low blood sugar 59. Review of Resident #1's hospital record notes dated 4/30/12 reflect "The patient is sent from facility for [DIAGNOSES REDACTED] and altered mental status." "History of present illness: Her medical history is quite limited. she does have hypertension, diastolic heart failure and DJD ([MEDICAL CONDITION] joint disease) the patient does not have any history of diabetes. As per daughter who is at bedside the patient was by mistake given insulin last night. This morning the patient was confused and sweaty. She was found to be delirious and poorly responsive. A blood sugar was checked and this was in the 30s. The patient was given glycogen and EMS was called. When EMS arrived the patients blood sugar was in the 50s and the patient was transported to the ER.(emergency room ) [MEDICATION NAME] 50% was also given prior to her arrival. The most recent blood sugar checked was about 187 at 9:00 am." "She was found to be hypothermic in the ER with her rectal temperature being 91. She does currently have a Bair Hugger (warning device) and her temperature is still about a 92. Hence I was called for admitting her." In an interview on 5/14/12 at 3:30 pm, LVN B stated she was the charge nurse on duty the evening of the incident. LVN B stated Resident #1 informed her of the incident, she looked for evidence of a finger stick or shot to stomach and could not find anything. LVN B stated she confronted LVN A who insisted she did not perform a finger stick or inject insulin to Resident #1. LVN B stated the physician was contacted and an order was obtained to check Resident #1's blood sugar. LVN B stated Resident #1's RP found an alcohol pad and a lancet in the trash in Resident #1's trash. LVN B stated lancettes should be placed in the sharps containers, never in the trash. LVN B stated she assumed LVN A documented the medication in the MAR (medication administration record) but there was no way to know the amount given because LVN A denied giving it. LVN B stated she removed LVN A from resident contact, notified the physician, DON and responsible party. In an interview on 5/14/12 at 2:00 pm the Medical Director (MD) stated Resident #1 went out to the hospital and stayed for 2 days. The MD stated if a resident's sugar is low they run the risk of hallucinations, becoming lethargic and confused and possible [MEDICAL CONDITION]. The MD stated he would expect a nurse to make sure they know the resident before administering a medication. The MD stated the resident told the nurse she was not diabetic. The MD stated if the resident had not let someone know of the incident, they would not have had any reason to monitor her and it could have had worst consequences. The MD stated Resident #1 certainly had some discomfort and he would be concerned of the long term emotional effects from getting a shot she did not need. In an interview on 5/14/12 at 5:30 pm, LVN A stated "I made a med error. I did not think so at first, but after thinking about it I know I must have. I was giving the resident across the hall a breathing treatment, I had the insulin in my hand, and I guess I just gave it to Resident #1. I should have followed the 5 R's identified the resident and double checked the room". LVN A stated she assumes she gave Resident #1 30 cc's of insulin. A facility acquired list dated 5/14/12 identified 19 residents receiving insulin.

Based on interview and record review the facility failed to ensure that residents are free of any significant medication error for 1 (Resident #1) of 4 residents reviewed for medications. Resident #1 was injected with an unknown amount of insulin and developed [DIAGNOSES REDACTED] and altered mental status resulting in hospitalization . This failure caused Resident #1 anxiety and discomfort resulting in unwarranted hospitalization . Findings include: Review of Resident #1's physician orders [REDACTED]. There were no prescribed diabetic medications on Resident #1's physician orders. Review of Resident #1's MAR (medication administration record) dated April 2012 reflected no diabetic medication.(insulin). Review of Resident #1's clinical hospital note dated 12/8/11 reflected "This is an [AGE] year old presenting to the clinic to follow up from the nursing home. She recently had some blood work done which showed good control of her diabetes." Review of Resident #1's annual MDS (minimum date set) dated 2/13/12 reflected a BIMs (brief interview for mental status) score of 14 (cognitively intact) Active [DIAGNOSES REDACTED]. In an interview on 5/14/12 at 4:15 pm, Resident #1 stated I was laying in bed, this nurse came in and never said a word. She came back and gave me a shot in the stomach. I don't remember well enough to tell you exactly what I said, I did tell her I don't understand this, I never had to do this before. I don't ever take shots for anything. I said to her "are you sure this is for me? (stating her name)" She never said a word, she just left. At first I didn't feel any different, I don't know how long after, apparently I lost consciousness. I don't remember anything until they were putting me in the ambulance. When asked by the surveyor how this incident made her feel, Resident #1 stated " I wanted to choke her! She just blatantly screwed up. I think she was new here, I had never seen her before." In an interview on 5/15/12 at 11:00 am, Resident #1's family member stated he was on the phone with Resident #1 the evening of 4/29/12 when he heard Resident #1 say "here comes the nurse." The family member stated he heard the nurse say I have your insulin shot for you and Resident #1 answer her "are you sure this is for me?" (stating her name). The family member stated he thought it was strange because he knows Resident #1 does not have diabetes, so he contacted another family member to report the incident. In an interview on 5/14/12 at 9:30 am, Resident #1's responsible party (RP) stated on 4/29/12, she received a call from her brother informing her he was talking on the phone to Resident #1 when he overheard a nurse come in and tell her" I'm going to give you your insulin." The RP stated Resident #1 is not diabetic and does not receive insulin. The RP stated she went to the facility and was told the nurse denied she had given the insulin. The RP stated while visiting with Resident #1 following the incident she observed a moist alcohol swab with a small amount of blood and a lancet in the trash can next to Resident #1's bed. In an interview on 5/14/12 at 10:55 am, the Director of Nurses (DON) stated licensed vocational nurse (LVN) A had been working at the facility for 4 days. The DON stated LVN A had trained for 2 nights with another nurse. The DON stated this is usual policy as a nurse should know the basics of administering medications. The DON stated there were no concerns with LVN A's performance. The DON stated LVN A stuck Resident #1's finger and then gave her a shot of insulin. The DON stated LVN A adamantly denied giving the insulin to the wrong resident and insisted she gave the insulin to the resident across the hall. The DON stated Resident #1's RP found a lancet in the trash. The DON stated she did not report the error to DADS because she thought that only medication errors resulting in severe reactions or death had to be reported. The DON stated Resident #1 did not have any adverse harm from the shot. The DON stated Resident #1 moaned and became unresponsive and was sent out to the hospital and admitted for observations and testing. The DON stated LVN A should have identified the resident prior to giving the medication. The DON stated LVN A was suspended and terminated following the investigation and did not return to the facility after the incident. The DON stated all residents with an order for [REDACTED]. The DON stated the facility will be referring LVN A to the Texas Board of Nursing. Review of Resident #1's Physician's Telephone Order dated 4/29/12 reflected 1. Recheck blood sugar at 2200 (10:00 pm) if below 100 recheck at midnight. if not below 100 recheck in am then discontinue accucheck. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"4/29/12 10:00 pm 160- 12:00 pm no check-6:30 am 49. Review of Resident #1's nurses notes dated 4/29/12 reflected: " 8:45- received phone call from resident's daughter at 8:00 pm reporting that resident had called and said she had received an accucheck and insulin at 7:45 pm. Spoke with resident and she was certain she had received insulin. Was unable to contact Resident #1's 's physician. Spoke with the medical director and received orders to recheck blood sugar at 10:00 pm and if below 100 recheck at 12:00 midnight and and if not recheck at 6:30 am. Daughter present a this time and explained monitoring. Blood sugar at 8:15 pm was 139. resident states she feels fine. Instructed her if she felt light headed or clammy to notify the nurse immediately. Daughter and resident satisfied with intervention. Notified DON of complaint. Will monitor resident." The note was signed by LVN B. Review of Resident #1's nurses notes dated 4/30/12 reflected the following: "6:30 am Resident snoring very loudly. Knocked on door. Called resident's name and turned on light. Resident in bed eyes wide open, blank look on her face. Called residents name again. No response. Shook resident. No response. Sternal rub resident and still no response. Resident diaphoretic, pupils non-reactive to light, body limp, watering of both eyes, drooling from mouth. Called for help. Night nurse came in to help. Check blood sugar and it was 49. [MEDICATION NAME] 1 mg IM (intramuscular) injection in deltoid. Recheck blood sugar. Now blood sugar 59. EMS (emergency medical service) called to send resident out. Vital signs, blood pressure 160/80, respirations 22, pulse 95, temperature 97.6. Raise head of bed and apply oxygen via nasal canula at 2 liters. Resident still snoring very loudly. resident went back out. Resident arm warm to touch, legs cool to touch. Resident still has no verbal response. EMS arrived and took over. Notified RP and physician." Review of a resident transfer form dated 4/30/12 reflected reason for transfer: low blood sugar 59. Review of Resident #1's hospital record notes dated 4/30/12 reflect "The patient is sent from facility for [DIAGNOSES REDACTED] and altered mental status." "History of present illness: Her medical history is quite limited. she does have hypertension, diastolic heart failure and DJD ([MEDICAL CONDITION] joint disease) the patient does not have any history of diabetes. As per daughter who is at bedside the patient was by mistake given insulin last night. This morning the patient was confused and sweaty. She was found to be delirious and poorly responsive. A blood sugar was checked and this was in the 30s.. The patient was given glycogen and EMS was called. When EMS arrived the patients blood sugar was in the 50s and the patient was transported to the ER.(emergency room ) [MEDICATION NAME] 50% was also given prior to her arrival. The most recent blood sugar checked was about 187 at 9:00 am." "She was found to be hypothermic in the ER with her rectal temperature being 91. She does currently have a Bair Hugger (warning device) and her temperature is still about a 92. Hence I was called for admitting her." In an interview on 5/14/12 at 3:30 pm, LVN B stated she was the charge nurse on duty the evening of the incident. LVN B stated Resident #1 informed her of the incident, she looked for evidence of a finger stick or shot to stomach and could not find anything. LVN B stated she confronted LVN A who insisted she did not perform a finger stick or inject insulin to Resident #1. LVN B stated the physician was contacted and an order was obtained to check Resident #1's blood sugar. LVN B stated Resident #1's RP found an alcohol pad and a lancet in the trash in Resident #1's trash. LVN B stated lancettes should be placed in the sharps containers, never in the trash. LVN B stated she assumed LVN A documented the medication in the MAR (medication administration record) but there was no way to know the amount given because LVN A denied giving it. LVN B stated she removed LVN A from resident contact, notified the physician, DON and responsible party. In an interview on 5/14/12 at 2:00 pm the Medical Director (MD) stated Resident #1 went out to the hospital and stayed for 2 days. The MD stated if a Resident's sugar is low they run the risk of hallucinations, becoming lethargic and confused and possible [MEDICAL CONDITION]. The MD stated he would expect a nurse to make sure they know the resident before administering a medication. The MD stated the resident told the nurse she was not diabetic. The MD stated if the resident had not let someone know of the incident, they would not have had any reason to monitor her and it could have had worst consequences. The MD stated Resident #1 certainly had some discomfort and he would be concerned of the long term emotional effects from getting a shot she did not need. In an interview on 5/14/12 at 5:30 pm, LVN A stated "I made a med error. I did not think so at first, but after thinking about it I know I must have. I was giving the resident across the hall a breathing treatment, I had the insulin in my hand, and I guess I just gave it to Resident #1. I should have followed the 5 R's identified the resident and double checked the room". LVN A stated she assumes she gave Resident #1 30 cc's of insulin. Review of a Medication Error Report dated 4/29/12 reflected the following: time of error: 8:00 pm-Medication as ordered "no insulin ordered".-Description of error "resident notified family and family notified nurse that resident had received insulin. Assessed resident, noted possible finger stick mark to left index finger. Educated resident of signs of [DIAGNOSES REDACTED], notified physician of resident possibly receiving non-ordered insulin. Received order to recheck blood sugar at 10:00 pm if below 100 recheck at 12:00 pm and if above 100 at 6:30 am." Measures taken to prevent recurrence: "nurse suspended for further investigation, inservices to nurses on rights of medication, check off on giving insulin, inservice on who to report med errors to." Review of a facility policy Medication Errors (undated) reflected the following: "Medications are administered to residents according to all Federal and State requirements. Procedures are established to assure that significant medication errors that cause the resident discomfort or jeopardize his/her health or safety do not occur." "Drug Administration: the facility has established drug administration procedures to ensure: 1. drugs being administered are checked against the physicians orders; 2. the resident is identified prior to administering the drug; 3. each resident has an individual medication record where doses of drugs administered can be recorded by the person administering the drug; 4. drugs and biological's are administered by the same person; and 5. drugs prescribed for one resident are not administered to any other resident." All drug errors and adverse drug reactions will be reported to the resident's physician in a timely manner and recorded in the resident's record. An incident report will be completed. If the incident appears to be serious, it will be investigated by the director of nursing and the administrator. In addition, special reporting to DADS will be done immediately." A facility acquired list dated 5/14/12 identified 19 residents receiving insulin.