Every finding on record at Highland Pines Nursing Home

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication storage rooms. (Storage room [ROOM NUMBER])The facility failed to ensure Resident #95's expired Gabapentin was removed from Storage room [ROOM NUMBER].These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications and inaccurate drug administration.Findings included:Record review of a face sheet, dated 1/14/2026, indicated Resident #95 was a [AGE] year-old male admitted [DATE] with diagnosis of Alzheimer's (a progressive neurodegenerative disorder that primarily affects memory, thinking and behavior), chronic pulmonary edema (occurs when fluid accumulate in the lung's air sacs over an extended period of time), chronic pain syndrome (a complex condition characterized by persistent pain lasting longer than three months), and Parkinson's disease with dyskinesia (degeneration of nerve cells in the brain that produce dopamine, leading to symptoms such as slow movement, tremors, rigidity and balance problems).Record review of a quarterly MDS, dated [DATE], indicated Resident #95 made self-understood and was understood by others. Resident #95 had a BIMS of 5 indicating severe cognitive deficits. The MDS indicated Resident #95 had a feeding tube and was on a mechanically altered diet.Record review of Medication Administration Record, dated 1/1/2026-1/31/2026, indicated Resident #95 was prescribed Gabapentin 100 mg one capsule via G-Tube (a gastrostomy tube is a surgically placed device used to give direct access to stomach for supplemental feeding, hydration or medicine) three times daily for pain.Record review of Care plan, dated 11/1/2023, indicated Resident #95 required tube feeding bolus (a single, concentrated dose of medication or fluid given over a short period) as needed per Physician orders. Interventions included check placement and gastric contents/residual volume per facility protocol and record.During an observation on 1/13/2026 at 10:39 a.m., Storage room [ROOM NUMBER] on 300 hall revealed medication overflow. Observed overflow container of medications for Resident #95 with four blister packets of Gabapentin 100 mg capsules (an anticonvulsant medication used primarily for nerve pain and to manage certain types of seizures) expired. The following blister packets were identified:Gabapentin 100 mg one capsule via G-tube three times daily for pain expiration date: 12/18/2025.Gabapentin 100 mg one capsule via G-tube three times daily for pain expiration date: 12/18/2025.Gabapentin 100 mg one capsule via G-tube three times daily for pain. expiration date: 11/14/2025Gabapentin 100 mg one capsule via G-tube three times daily for pain expiration date: 11/14/2025. During an interview on 1/13/2026 at 10:40 a.m., ADON L said the nurse receiving the medications were responsible for removing expired medications from the overstock. ADON L said if the medication were administered, it may not be as effective. ADON L said the nurses rotated the medication when there was excess and should remove the expired medication. ADON L said it was everyone's responsibility. ADON L said a resident may not have their pain relieved if the medication was not as effective.During an interview on 1/14/2026 at 2:06 p.m., CMA J said the nurses check the medication storage room for expired medications. She said the nurse would be responsible for ensuring the medications were expired. CMA J said she had access to the medication storage room. CMA J said the resident could have a reaction or the medication may not be as effective.During an interview on 1/14/2026 at 2:06 p.m., LVN H said the nurses were responsible for ensuring the medication storage did not have any expired medications. She said when a medication was expired, the nurses would place the medication in a box located in the medication storage room for the ADON to pick up and take to the DON for medication destruction when the Pharmacist visited the facility. LVN H said the properties of the medication could change with expired medications and would not be as effective.During an interview on 1/14/2026 at 2:40 p.m., ADON C said the nurses were responsible for removing expired medications. She said expired medications should not be administered to a resident. She said she did not know what would happen if a resident were administered expired medications. ADON C said she did not think they were bad, but the facility did not want to find out.During an interview on 1/14/2026 at 3:07 p.m., the DON said she expected the medications on the cart to not be expired. She said the facility had a lot of overflow medications. She said the important thing for her was the medication was not on the medication cart. The DON said she was not concerned with the medication in the storage room being expired. She said expired medications were stored in the medication storage room. The DON said as the nurses saw the expired medications, they pulled the medication once a month for medication destruction.During an interview on 1/14/2026 at 3:27 p.m., the ADM said she expected the medication with expirations to be removed from the medication storage room. She said it could cause issues if someone took the expired medications.Record review of the facility's policy titled Medication Destruction for Non-controlled medications revised 08/2020 indicated.Policy.Discontinued medications and medications left in the facility after a resident's discharge that do not qualify for return to the pharmacy for credit are destroyed.1. Unused and non-returnable medications should be removed from their storage area and secured until destroyed.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts (Medication Cart #1) reviewed for pharmacy services.The facility failed to ensure Medication Aide Cart #1 for the 200 short hall was locked when unattended.This failure could place residents at risk of having unauthorized access to medications or lead to harm or drug diversions.Findings included:1. During an observation on 1/13/2026 beginning at 7:25 a.m. revealed medication cart #1 for 200 short hall was unlocked and unattended with no staff within eyesight of the medication cart. The medication cart was found near a resident's room, an elevator, and main sitting area where staff and visitors congregate. There was one resident navigating the hallway in a wheelchair near the unlocked medication cart. CMA J immediately locked medication cart when she returned. At time of observation, the length of time remained unattended and unlocked could not be determined.During an interview on 1/13/2026 at 7:25 a.m., CMA J said she was going to check on a resident and forgot to lock her cart. She said she heard a noise and went to go check on the resident and left her cart unlocked. She said someone could get in her medication cart and could cause counts to be off, cause damage to the cart or an overdose could happen. She said she was responsible for ensuring her medication cart was locked. She said she was in-serviced on medication storage and locking medication carts.During an interview on 1/14/2026 at 1:57 p.m., CMA J said all staff were responsible for ensuring medication carts were locked. CMA J said medication carts were to be locked at all times. She said any residents or staff could open the cart and take something. CMA J said a person would not know what kind of reaction a medication could have on them, or the person could have an allergic reaction.During an interview on 1/14/2026 at 2:06 p.m., LVN H said everyone was responsible for ensuring medication carts were locked and should be locked at all times. LVN H said the cart should be locked when stepping into a resident's room. She said anyone could get in the medication cart and take something that was not prescribed to them. She said it could hurt them, or they could have a drug reaction or overdose. LVN H said a person with dementia could take something not prescribed to them.During an interview on 1/14/2026 at 2:40 p.m., ADON C said the nurse was supposed to keep medication carts locked when they stepped away from the cart. She said someone could get into the medication cart and take a medication that was not prescribed to them. ADON C said it could negatively impact someone who took the medication, and it could cause harm. ADON C said the nurse or staff with the keys to the cart were responsible. ADON C said nursing staff were all responsible if they observed an unlocked cart and should lock it.During an interview on 1/14/2026 at 2:53 p.m., the DON said the medication cart should be locked when no one was around it. The DON said she expected the nurses to keep the medication carts locked when not in use. She said the nurse assigned to the medication cart was responsible for the cart. The DON said if a person took medication not prescribed to them, it could cause harm or have no effect but there were all sorts of potentials.During an interview on 1/14/2026 at 3:07 p.m., the ADM said she expected the medication cart to remain locked when not in use. The ADM said the nurse was responsible for ensuring the medication carts were locked. She said someone could get into the medication cart and take something that was not prescribed to them. She said it could be detrimental.Review of the facility's policy titled Storage of Medications last revised 08-2020 reflected the following: . Policy statement. Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.Procedures. 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aids) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. III. Expiration Dating (Beyond-use dating) indicated .8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

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 for 1 of 1 kitchen reviewed for kitchen sanitation. 1. A sack of flour was not stored six inches off the floor. 2. Raisin bread, sliced cheese, and tortillas were not labeled or dated. These failures could place residents at risk for food borne illness.Findings included: During an observation and interview on 1/12/26 at 8:05 a.m. it was observed during the initial tour of the kitchen that a large sack of flour was lying on the floor of the dry food storage. The Dietary Manager said she needed help lifting the bag as it was too heavy for her. She said it was recently delivered. It was observed that raisin bread stored in the dry food storage, sliced cheese on a preparation table, and tortillas stored in the dry food storage were not labeled and dated. The cheese was stored in a gallon size bag on top of a preparation table that was used recently been recently used. During an interview on 1/14/26 at 1:06 p.m. the Dietary Manager said that food should not be left to sit on the floor as the regulations state it should be stored at least six inches off the floor. She said that it could place food at risk of being contaminated by rodents or pests. She said that food should be labeled or dated. She said that not having labels or dates on food could place residents at risk of foodborne infections. During an interview on 1/14/26 at 1:48 p.m. the Director of Nurses said food should be labeled and dated to ensure old or expired food was not used by kitchen staff to feed residents. She said that feeding a resident expired or old food could place them at risk of foodborne illness. She said that food should not be left on the floor as it could expose it to pests. During an interview on 1/14/26 at 1:58 p.m. the Administrator said that flour or any food should not be left on the floor as it could contaminate the food and encourage rodents. She said that food should also be labeled and dated to prevent residents from eating expired food. She said residents could be placed at risk of illness if they eat expired food. Review of the facility policy, dated 01/01/22, Food Labeling and Dating provided by the Dietary Manager revealed the purpose of this policy was to, To establish guidelines for storing, thawing, and preparing food.Dietary employees will be trained regarding proper food storage procedures, labeling, and dating. The product name will be labeled on food items, including the original packaging, box, zip-lock bag, and storage bin. Label each package, box, can, etc., with the date of receipt. Items stored should be dated upon receipt, unless they contain a manufacturer's use-by, or a date delivered. If the vendor pick stickers have the receive date or delivery date printed on the pick sticker, this can serve as a receiving date labeling. Record review of the FDA Food Code updated in 2022 revealed that, FDA Food Code dry storage requires keeping foods cool, dry (under 60% humidity), and, in many cases, ventilated. Items must be stored at least 6 inches off the floor and away from walls to prevent contamination. Use FIFO (first-in, first-out) inventory rotation, maintain, clean, and secure areas from pests.

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 4 residents (Resident #106) reviewed for infection control practices. The facility failed to ensure LVN A and CNA B utilized enhanced barrier precautions while pulling Resident #106 up in bed on 01/12/2026. This failure could place residents and staff at risk for cross contamination and the spread of infection. The findings included: Record review of the face sheet, dated 01/15/2026, reflected Resident #106 was a [AGE] year-old male who re-admitted to the facility on [DATE] with diagnoses of sepsis due to E. coli (blood infection caused from bacteria), chronic kidney disease (kidneys are damaged and unable to filter blood as well as it should), and obstructive and reflux uropathy (blockage in the urinary tract that causes urine to back flow into the kidneys). Record review of the MDS assessment, dated 01/11/2026, reflected Resident #106 had clear speech, was understood by others, and was able to understand others. Resident #106 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #106 had an indwelling urinary catheter. Resident #106 received hemodialysis (machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) while a resident. Record review of the comprehensive care plan, undated, reflected Resident #106 had an indwelling urinary catheter and required enhanced barrier precautions. The interventions included: Staff members will wear a clean gown and gloves while performing high contact resident care activities . The care plan further revealed Resident #106 received dialysis treatments three times a week. Record review of the order summary report, dated 01/15/2026 reflected, Resident #106 had an order, which started on 01/08/2026, for Enhanced Barrier Precautions [interventions to prevent spread of infection in high-risk residents] related to Indwelling urinary Catheter: Staff members will wear a clean gown and gloves while performing high contact resident care activities. During an observation on 01/12/2026 at 11:16 a.m., LVN A and CNA B walked into Resident #106's room and applied clean gloves. Resident #106 was lying sideways in the bed. LVN A and CNA B pulled Resident #106 up in the bed, lifting and repositioning him by lifting him underneath the legs, near the indwelling urinary catheter. They did not wear an isolation gown. During an attempted telephone interview on 01/14/2026 at 12:47 p.m., LVN A did not answer the phone or return the call upon exit of the facility. During an interview on 01/14/2026 at 1:26 p.m., CNA B stated if a resident was on enhanced barrier precautions, they had a sign outside the door. CNA B stated residents with a indwelling urinary catheter or residents who received dialysis required enhanced barrier precautions during high-contact resident care activities, which included pulling someone up in bed. She said enhanced barrier precautions included gown and gloves. She stated she realized she had not worn a gown after they left Resident #106's room, but should have. She said she was nervous because the state surveyor was watching her, and she was rushed because she had just come out of another room. She said it was important to ensure enhanced barrier precautions were used to protect both the residents and staff and prevent infections. During an interview on 01/14/2026 at 2:10 p.m., the DON stated she expected the nursing staff to ensure that enhanced barrier precautions were being used. The DON stated residents who required an indwelling urinary catheter or residents who received dialysis required enhanced barrier precautions during high-contact resident care activities. She said enhanced barrier precautions included gloves and an isolation gown. The DON stated in-service education was provided to the facility staff on enhanced barrier precautions. She said signage to alert staff was posted on the resident's door and PPE supplies were located in the hallway. The DON stated it was important to ensure staff were using enhanced barrier precautions for high-risk residents to prevent the spread of infection and contamination of open areas or devices. During an interview on 01/14/2026 at 2:13 p.m., ADON C stated she was the infection control preventionist for the facility. She said her role as the infection control preventionist included monitoring infection control practices and teaching facility staff as needed. She stated she provided in-service education that included enhanced barrier precautions and how to put on and take off PPE. She stated she also performed spot checks to random staff and questioned them about infection control practices. She stated enhanced barrier precautions included an isolation gown and gloves while performing high-contact resident care activities. She stated it was important to ensure the staff used enhanced barrier precautions for high-risk residents to prevent infections. During an interview on 01/14/2026 at 2:18 p.m., the Interim Administrator stated she expected the facility staff to use all available PPE as required or indicated. She stated the nursing staff were responsible for monitoring to ensure enhanced barrier precautions were used during high-contact care activities. She said it was important to ensure enhanced barrier precautions were used during high-contact care activities for high-risk residents to prevent cross contamination. Record review of the Standard and Enhanced Precautions policy, implemented on 04/01/2024, reflected Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities that are associated with high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter. vascular catheters.). EBP should be used for any residents who meet the above criteria, wherever they reside in the facility.for residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.

Based on observation, interview, and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment prior to admission for 1 of 5 residents (Residents #60) reviewed for PASRR care and services. The facility failed to ensure Resident #60 had a PASRR evaluation (Level II) completed prior to re-admission from an in-patient psychiatric facility. This failure could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated 01/14/2026, reflected Resident #60 was a [AGE] year-old female who re-admitted to the facility on [DATE] with a diagnosis of bipolar disorder, severe with psychotic features (mental health condition that causes extreme mood swings). Record review of the PASRR Level 1 Screening, dated 11/22/2024, reflected Resident #60 was at a psychiatric hospital and had evidence of mental illness. Record review of the PASRR Evaluation (level II assessment), completed on 11/26/2024, reflected Resident #60 did meet the PASRR definition of mental illness, which indicated she was PASRR positive. It was completed after re-admitting to the nursing facility from a psychiatric hospital. Record review of the comprehensive care plan, dated 09/25/2025, reflected Resident #60 was PASRR positive for mental illness. During an observation and interview on 01/12/2026 at 8:46 a.m., Resident #60 was lying in her bed. She said she had a diagnosis of mental illness and was receiving psychiatric services in the facility. Resident #60 stated she met with PASRR every year but did not want services. During an interview on 01/14/2026 at 1:42 p.m., MDS Coordinator D stated she and the other two MDS Coordinators were responsible for PASRR services. MDS Coordinator D stated Resident #60 re-admitted to the facility from an in-patient psychiatric hospital around November of 2024. MDS Coordinator D stated the in-patient psychiatric hospital was located in another state and the facility had a hard time obtaining the PASRR records at times. MDS Coordinator D stated there have been times when residents were admitted to the facility from a psychiatric hospital with only the PASRR Level 1 Screening completed. She stated she did not have access to see if a PASRR evaluation was completed from another state. She said she was aware a PASRR Evaluation (Level II) should have been completed prior to admission or re-admission from a psychiatric facility. She said it was important to ensure the PASRR Evaluation was completed prior to admitting to the facility to ensure the facility was able to meet the needs of each resident and ensure a nursing facility was the best place for them. During an interview on 01/14/2026 at 2:18 p.m., the Interim Administrator stated she expected the PASRR Level I Screening to have been completed prior to admission. She said Resident #60's PASRR Evaluation (Level II) should have been completed prior to re-admitting to the facility since she was admitted from a psychiatric facility. She stated the MDS nurses were responsible for monitoring to ensure the PASRR requirements were completed at the appropriate timeframes. She stated it was important for continuity of care. Record review of the PASRR policy, undated, reflected If resident is coming from the community or a psychiatric hospital, PE must be completed PRIOR to admission (Do not admit until the PE is showing in Simple [software program used by the facility]) MDS must certify PE prior to admission.

Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 2 (Resident#17 and Resident #31) of 18 residents reviewed for care plans. The facility failed to implement a person-centered care plan for a laceration, received in the facility prior to the initiation of the comprehensive care plan on 01/05/2026, requiring sutures with interventions for Resident #17, to meet medical, nursing, mental and psychosocial needs.The facility did not ensure that Resident #31's care plan had specific triggers for a trauma related problem. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.Findings included: Record review of an undated face sheet revealed Resident #17 was an [AGE] year-old female admitted on [DATE] with the diagnoses of fracture of the left acetabulum (a break in the left hip socket (acetabulum) that typically occurs from high-impact trauma, like car accidents, or falls in older individuals with weakened bones, causing severe hip/groin pain, difficulty walking, and potentially numbness), pulmonary edema (a condition where excess fluid builds up in the lungs' air sacs, making it hard to breathe), and atrial fibrillation (a common type of irregular heartbeat (arrhythmia) where the heart's upper chambers quiver chaotically instead of beating effectively, leading to a rapid, erratic pulse that can feel like fluttering, pounding, or skipped beats, causing symptoms like dizziness, fatigue, shortness of breath, and increasing stroke risk). Record review of an admission MDS assessment, dated 12/29/2025, revealed Resident #17 had a BIMS of 13, which indicated cognitively intact. She required substantial assistance (helper provided over half the help) with ADLs. The MDS revealed the resident had two stage I pressure ulcers, (two) stage II pressure ulcers, and application of ointments and medications other than feet. Record review of Resident #17's care plan indicated two stage I pressure ulcers to bilateral heels and 2 stage III pressure ulcers (one to coccyx and one to left trochanter). No other skin issues were care planned. Record review of Resident #17's nurses notes, dated 12/29/2025 written by LVN M, revealed: 3:09 p.m.,CNA came to the desk and asked me to come look at resident's leg, entered resident room where resident was lying in bed with legs bent. Laceration to left lower extremity approximately 3-4 inches in length noted. Applied pressure dressing, assessed for pain, no complaints of pain at this time. Notified DON and MD and received orders to send out for evaluation and treatment. 5:56 p.m., Resident returned from ER with 9 sutures to left lower extremity due to laceration, with orders to remove in 10 days. Resident has no complaint of pain at this time. During an interview on 01/13/2026 at 1:00 p.m., MDS Coordinator E stated the treatment for the laceration on Resident #17's was on the admission MDS assessment. She stated the laceration should have been care planned with interventions. She stated the treatment nurse normally care planned all of the skin issues. She stated she was unsure how the laceration was missed on the care plan. During an interview on 01/13/2026 at 1:30 p.m., the Treatment Nurse stated she care planned all major skin issues for the residents. She stated Resident #17 had a laceration caused during an incident while a resident at the facility and it should have been care planned with interventions for prevention and interventions for healing. She stated care plans were used to guide staff on individual resident needs. During an interview on 01/13/2026 at 2:00 p.m., the DON stated it was important for all residents to have a care plan. She stated the care plan provided an individualized guide to resident care. She stated that without the care plan everyone received generalized care. The DON stated Resident #17's laceration needed to be care planned so everyone was aware of the treatment. Record review of an undated facility policy titled, Comprehensive Care Planning ,revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life. Record review of Resident #31's face sheet, dated 08/01/13, indicated Resident #31 was a [AGE] year-old female, re-admitted on [DATE] with diagnoses of anxiety disorder (mental health conditions marked by intense, persistent, and excessive worry or fear about everyday situations, leading to significant distress and impairment in daily life, often accompanied by physical symptoms like rapid heart rate, trembling, and shortness of breath, and typically treated effectively with therapy and medication), bi-polar disorder ( mental illness causing extreme shifts in mood, energy, and activity, from manic highs to depressive lows), and polyneuropathy (damage to multiple peripheral nerves, causing symptoms like numbness, tingling, weakness, and burning pain, often starting in the feet and hands and progressing upwards, due to causes like diabetes, autoimmune diseases, infections, toxins, or genetics). Record review of Resident #31's quarterly MDS, dated [DATE], indicated Resident #31 usually understood others and made herself understood. Resident #31 had a BIMS score of 06, which indicated her cognition was severely impaired. Record review of Resident #31's trauma assessment, dated 12/12/24, indicated she had a history of trauma related to the death of a roommate. Record review of Resident #31's comprehensive care plan, dated 01/12/26, revealed the facility did not ensure Resident #31's care plan had specific triggers for a trauma related problem initiated on 12/12/24. The care plan indicated Resident #31 had a history of Trauma and to Create an emotionally and physically safe environment Respond with empathy and respect. The care plan did not address what Resident #31's trauma was from or her triggers. During an interview on 1/13/26 at 2:25 p.m., Resident #31 did not respond to the surveyor's questions regarding her trauma. During an interview on 1/14/26 at 9:57 a.m., LVN H said if a resident was assessed with trauma, she could identify that specific resident's triggers for their trauma by looking at their care plan. She said that she did not know what the triggers were for Resident #31's trauma or what her trauma was. During an interview on 01/14/26 at 1:48 p.m., the Director of Nurses said that residents could be placed at risk for further trauma if their specific triggers were not addressed in their care plan. She said she believed that the residents care plan should address their trauma if they truly have a traumatic event in their lifetime. During an interview on 01/14/26 at 1:58 p.m., the Administrator said that a resident's trauma should be fully described in their care plan so that a staff who was researching a resident's trauma knew what their triggers were. She said that residents could be placed at risk if a trauma is not well documented by potentially triggering their specific trauma. Record review of a facility policy, dated 11/24/22, titled, Care Planning revealed that the purpose of the policy was, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA guidelines. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases.A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 2 of 22 residents reviewed for MDS accuracy. (Resident #12 and Resident #60) The facility failed to accurately code Resident #12's falls within the last 30 days on the admission MDS assessment.The facility failed to ensure Resident #60's Annual MDS assessment accurately reflected her positive PASRR status for mental illness. This failure could place residents at risk of not receiving needed care and services. Findings included: 1.Record review of an undated face sheet revealed Resident #12 was an 83- year-old- female, admitted on [DATE] with the diagnoses CHF (congestive heart failure- is a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and gastritis (a general term for a group of conditions with one thing, inflammation of the lining of the stomach, in common). Record review of an admission MDS assessment, dated 11/28/2025, for Resident #12 revealed a BIMS of 15, which indicated no cognitive impairment. The MDS also revealed Resident #12 required supervision level assistance with bed mobility, eating, transfer, and toileting. The MDS revealed Resident #12 had no history of falls prior to admission and no falls since admission. Record review of a nurse note, dated 11/26/2025 written by LVN G, revealed, At nurse's station heard patient yell out, I need help. Found resident in a sitting position in front of wheelchair. Resident #12 stated she dozed off while leaning on bedside table with brakes on and wheelchair unlocked. Educated patient to keep wheelchair brakes locked when not rolling around. No injury noted. Record review of Resident #12's incident/accident report, dated 11/26/2025 completed by the DON, revealed no added instruction/intervention post fall. During an interview on 01/13/2026 at 3:15 p.m., MDS Coordinator D revealed Resident #12 should have been coded for falls while a resident on the admission MDS, dated [DATE]. She stated because the fall occurred prior to the assessment it should have been coded on the MDS and care planned. She stated it was not coded because of an oversight. MDS Coordinator D stated it was important to accurately code the MDS, so the care plan was developed based on the information on the MDS will be accurate for accurate care for each resident. During an interview on 01/13/2026 at 3:30 p.m., the Regional MDS Nurse stated it was the responsibility of the MDS nurse to ensure accurate MDSs were produced and transmitted to CMS. The Regional MDS Nurse stated the DON or Regional Nurse signed the MDS for completion and the MDS nurses signed it for accuracy. During an interview on 01/14/2026 at 2:00 p.m., the Administrator stated it was the responsibility of the MDS nurse to produce accurate MDSs and care plans. The Administrator stated accuracy was important for revenue as well to ensure the facility was reporting the correct information to CMS on the quality measures. During a record review of the facility's undated Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status. 2. Record review of the face sheet dated 01/14/2026 reflected Resident #60 was a [AGE] year-old female who re-admitted to the facility on [DATE] with a diagnosis of bipolar disorder, severe with psychotic features (mental health condition that causes extreme mood swings). Record review of the PASRR Evaluation (level II assessment), completed on 11/26/2024, reflected Resident #60 did meet the PASRR definition of mental illness, which indicated she was PASRR positive. Record review of the annual MDS assessment, dated 07/24/2025, reflected in the box labeled Section A1500, Resident #60 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, which indicated she was PASRR negative. Record review of the comprehensive care plan, initiated on 09/25/2025, reflected Resident #60 was PASRR positive for mental illness. During an observation and interview on 01/12/2026 at 8:46 a.m., Resident #60 was lying in her bed. She said that she did have diagnosis of mental illness and was receiving psychiatric services in the facility. Resident #60 stated she met with PASRR every year but did not want services. During an interview on 01/14/2026 at 1:52 p.m., MDS Coordinator E stated she was responsible for completing Resident #60's annual MDS assessment. She stated if Resident #60's annual MDS assessment was not marked positive for PASRR then it was marked incorrectly. She stated she reviewed each section of the MDS assessment and must have overlooked that question. MDS Coordinator E stated it was important to ensure Resident #60's annual MDS assessment accurately reflected her positive PASRR status, so the facility had accurate records and information needed to care for the resident. During an interview on 01/14/2026 at 2:18 p.m., the Interim Administrator stated she expected the MDS assessments to accurately reflect the resident's status. She stated the MDS Coordinators were responsible for accurately coding the MDS assessments and the DON was responsible for monitoring to ensure MDS assessments were completed accurately. The Interim Administrator stated it was important to ensure the MDS assessment accurately reflected the resident's status for continuity of care. Record review of the RAI Manual, dated October 2025, reflected A1500: PASRR . code 1, yes: if PASRR Level II screening determined that the resident had a serious mental illness.

Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 2 of 5 residents reviewed for new admissions (Resident #103 and #105). The facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was provided to the resident and/or their representative for Resident #103 and Resident #105. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included: 1.Record review of an undated face sheet revealed Resident #103 was an [AGE] year-old- male, admitted on [DATE] with the diagnoses of Stage III sacral pressure ulcer (a deep, crater-like wound on the tailbone (sacrum) showing full-thickness skin loss, where subcutaneous fat is visible, but muscle, tendon, or bone are not yet exposed, often featuring rolled edges, tunneling, or dead tissue (slough/eschar) and posing serious infection risks), atrial fibrillation (a common type of irregular heartbeat (arrhythmia) where the heart's upper chambers quiver chaotically instead of beating effectively, leading to a rapid, erratic pulse that can feel like fluttering, pounding, or skipped beats, causing symptoms like dizziness, fatigue, shortness of breath, and increasing stroke risk, mycoplasma pneumonia (a common, contagious bacterial lung infection). Record review of Resident #103's EHR on 01/13/2026 revealed no completed MDS assessments, no comprehensive care plan, and no baseline care plans created for Resident #103. During an interview on 01/13/2026 at 10:15 a.m., Resident #103 stated he did not remember the baseline care plan meeting and had no copy of the baseline care plan. He stated he needed to have a baseline care plan meeting because he had questions about why he was in isolation, why he had to do therapy in his room, and what kind of sore he had on his bottom. 2.Record review of an undated face sheet revealed Resident #105 was a [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of diabetes mellitus (condition affecting blood glucose levels), urinary tract infection (a common bacterial infection affecting any part of the urinary system (kidneys, bladder, ureters, urethra), usually occurring when bacteria enter through the urethra, multiply, and cause inflammation, leading to symptoms like painful, frequent urination, cloudy urine, and pelvic pain), and dysphagia (difficulty swallowing, where food or liquids struggle to move from the mouth to the stomach, causing choking, coughing, pain, or a feeling of food getting stuck). Record review of Resident #105's EHR on 01/13/2026 revealed no completed MDS assessments, no comprehensive care plan, and no baseline care plans created for Resident #105. During an interview on 01/13/2026 at 11:30 a.m., Resident #105 stated he had concerns about his discharge he would like to discuss with the discharge planner. He stated his concerns were about what his discharge goals were. He stated he was unsure of what medications he was discharged from the hospital on versus what medications he was receiving at the facility and no one explained it to him. He stated not knowing was making him anxious. During an interview on 01/13/2026 at 2:00 p.m., the MDS Coordinator B stated the baseline care plan was completed by the floor nurse, the social worker, department head nurses, and therapy. The baseline care plan meeting was conducted by the social worker. She stated she was aware the resident was to receive a copy of the baseline care plan. During an interview on 01/14/2026 at 11:00 a.m., the DON said base line care plans were used in place of a comprehensive care plan until one can be developed to direct resident care according to their goals and choices. The DON said the baseline care plan needed to be completed with each department and discussed with the resident and resident representative. The DON said it was her responsibility to inform the IDT of the facility policy on base line care plans and was unsure why the baseline care plans were not completed for Resident #103 and Resident #105. During an interview on 01/14/2026 at 1:45 p.m., the Administrator said the baseline care plans were an interdisciplinary form that was discussed with the residents on admit. The Administrator said it was the DON's responsibility to ensure the MDS nurse and IDT team completed the baseline care plan and provided a copy to the resident and family. Review of an undated facility policy titled Base Line Care Plan revealed .Completion and implementation of the baseline care plan within 48 hours of a resident's admission {was} intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan.

Based on observation, interviews and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident # 1 was free from abuse on 2/20/25 when he was slapped on the top of his hand. The noncompliance was identified as PNC. The noncompliance began on 2/20/25 and ended on 2/20/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: Record Review of Resident #1's face sheet dated 11/20/24 indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), Cognitive Communication Deficit (Cognitive communication is the mental skills used to process information and communicate with others), Mild Cognitive Impairment (a condition characterized by a subtle decline in cognitive abilities, such as memory, attention, and reasoning, that is not severe enough to interfere with daily functioning). Record Review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 usually understood others and usually made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 03, which indicated Resident #1 had severe cognitive impairment. Indicated that Resident #1 never rejected care. Record Review of Resident #1's care plan, dated on 3/03/25, indicated Resident #1 requires tube feeding, is non-compliant with feeding and will eat other resident's food. Resident #1 has impaired cognitive function and has impaired thought processes. Resident #1 has a behavior he will open up his percutaneous endoscopic gastrostomy tube and suck the contents from his stomach. During an interview on 3/3/25 at 3:31 p.m. CNA B said that on 2/20/25 that morning when she was passing breakfast trays, she could hear LVN A being loud in the room with Resident #1. She said she was curious of what was going on and that was when she heard LVN A hit the top of the hands of Resident #1. She said you could hear the skin-on-skin contact. She said she did not lightly tap the hands of Resident #1 but hit them hard like a slap. She said that Resident #1 was not crying and did not appear to be in any distress. She said she asked LVN A what was going on and she said she was trying to get Resident #1 to move his hands so she could feed him. She said that CNA C entered the room also to see what was going on. She said she told CNA C to go report what happened to their supervisor who then told the Administrator what happened. She said she never left Resident #1's side until after management got involved. She said she was trained on abuse and neglect, the timeframes and requirements for reporting abuse and neglect. She said that was how she knew to report and stay with the resident. She said she was then trained again in abuse and neglect after the incident. During an interview on 3/3/25 at 3:40 p.m., the Administrator said that she did not witness the incident, but it was reported that CNA B witnessed LVN A hit the top of the hands of Resident #1 and that CNA C heard the skin on skin contact as well. She said that LVN A did speak loudly but she has never verbally abused anyone. She said LVN A speaks loudly because she was hearing impaired. She said that after the incident LVN A was suspended, a report was made to the Texas Health and Human Services Commission, and Resident #1 was assessed for any physical injury. She said that there was no physical injury, so he was evaluated by a counseling agency to determine if he had any trauma. Resident #1 who has a BIMS of 3 did not recall the incident, said the incident did not happen, and was not in any distress due to the incident. She said that after the incident occurred an investigation was started, and staff were re-trained on abuse and neglect. During an interview on 3/3/25 at 3:54 p.m. Resident #1 was asked questions in an answer question format as he was unable to give full responses. Question: Resident #1 did you know LVN A? Answer: Yes. Question: Did LVN A hit you on the hand? Answer: No. Question: Resident #1 do you feel safe here? Answer: Yes. During an interview on 3/3/25 at 4:05 p.m., CNA C said that on 2/20/25 while breakfast trays were being passed out, she heard a commotion in Resident #1's room. She said before she entered the room, she heard two loud slapping sounds. She said it sounded like skin-on-skin contact. She said when she entered the room CNA B was already inside and she said, She just hit him. She said she saw LVN A sitting with Resident #1 who was being fed. She said LVN A was being loud with the resident saying, Don't do that. She said CNA B said she needed to go get a supervisor. She said she then left the room and told a supervisor. She said she had been trained in abuse and neglect and was trained again after the incident. She said that when abuse or neglect occurs she should report to a supervisor or the Administrator what happened, ensure the resident is safe, and not allow the alleged perpetrator to stay with the resident. During an interview on 3/4/25 at 8:50 a.m., LVN A said that on 2/20/25 she was feeding Resident #1. She said that Resident #1 has a history of interfering when he was being fed and pulling at his Gtube (a feeding tube). She said that on this day he was also pulling at his Gtube. She said she said to him in a loud voice, Stop and Don't do that. She said she did touch Resident #1's hands but it was to move them to his side. She said she did not tap or hit the hands of Resident #1. She said she was only trying to keep him from removing his Gtube. She said that CNA B and CNA C did not see what happened and they were both lying. She said they were both outside in the hallway and neither of them saw or heard her hit Resident #1. During an interview and observation on 3/4/25 at 9:05 a.m. CNA B was asked to demonstrate the force used when she witnessed LVN A hit the top of Resident #1's hands. CNA B demonstrated what she witnessed, and the force used was very strong making aloud slapping noise on the table. She said that LVN A hit the top of Resident #1's hands very hard and it was not a light tap as if a child was being scolded. During multiple staff interviews on 3/4/25 staff were able to identify the elements of abuse and neglect, timeframes for reporting abuse and neglect, who to report to, and that the resident involved should be made safe. Staff were also able to say that the alleged perpetrator should not have access to the alleged victim. During an interview on 3/4/25 at 11:50 a.m., the Director of Nurses said that all newly hired staff and on occasion staff were trained in their abuse and neglect policy. She said staff were trained on when to report, who to report to, and how to protect residents that were suspected of being abused or neglected. She said she expects all her staff to follow facility policy regarding abuse and neglect. She said that a resident was placed at risk of harm if a staff abused them. During an interview on 3/4/25 at 11:55 a.m., the Administrator said that the facility has developed abuse and neglect policies. She said that either herself or the Director of Nurses was to conduct the training. She said that their abuse and neglect policy teach on when to report abuse, who to report abuse to, and how to protect the resident if abuse was suspected or occurred. She said she expects that her staff would intervene if they see or suspect that abuse or neglect occurs. Record review of the facility's provider investigation report dated 2/20/25 revealed that the facility conducted an investigation into the allegations that LVN A physically abused Resident #1 when CNA A observed LVN A hit Resident #1 on the top of his hands while LVN A was feeding the resident. The report showed that the time and date of the incident was 2/20/25 at 8:15 a.m. and that Resident #1 was physically assessed on 2/20/25 at 9:43 a.m. Further review showed that the incident was reported to the Texas Health and Human Services Commission on 2/20/25 at 10:01 a.m. Record review of a skin assessment for Resident #1 dated 2/20/25, indicated that there were no skin impairments. Skin assessment was completed after the incident. Record review of a trauma assessment for Resident #1 dated 2/20/25, indicated that there was no present trauma. Resident # 1 indicated no to the following questions: Has the event caused you to felt very scared, helpless, or horrified Has the event caused you to be constantly on guard, watchful, or easily startled Has the event caused you to feel numb, detached from others, actives, or your surroundings. Record review of facility in-service dated 2/20/25 titled, Abuse and Neglect conducted by the Director of Nurses. In-service training reviewed the facilities abuse and neglect prohibition policy. Policy identified elements of abuse and timeframes for reporting abuse. Record review of LVN A's personnel file on 03/4/25 indicated hire date of 1/15/19. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of LVN A's Corrective Action Memo, dated 2/25/25, indicated she was terminated for misconduct regarding allegations of Abuse. The noncompliance began on 02/20/25 and ended on 02/20/25. The facility had corrected the noncompliance before the investigation began. The surveyor confirmed PNC had been implemented sufficiently to remove the deficiency by: Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. Completion of in-services on abuse. Staff and management recognizing the steps to report abuse and neglect. Termination of confirmed perpetrator. Record Review of facility policy titled, Abuse Prevention and Prohibition dated 8/2020. Policy indicated, To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems.

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 6 of 24 residents reviewed for infection control practices (Resident #'s 2, 7, 37, 39, 91, and 100), 1.The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #2. 2. The facility failed to ensure Resident #7 had enhanced barrier precautions sign posted on door with storage container for PPE on 10/14/2024 for resident with a feeding tube. 3. The facility failed to ensure Resident # 37 had enhanced barrier precautions in place with proper PPE storage containers available to care for foley catheter and wound care. 4. The facility failed to ensure Resident # 39 has enhanced barrier precautions in place with PPE containers available for resident with feeding tube. 5. The facility failed to ensure Resident # 91 had enhanced barrier precautions posted and PPE storage containers available for use while performing IV antibiotic therapy. 6. The facility failed to ensure CNA BB and Restorative Aide CC donned PPE (disposable gown and gloves) prior to performing catheter care on Resident #100 on 10/15/24. The resident was on enhanced barrier precautions. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1.Record review of the undated face sheet indicated Resident #2, was a [AGE] year-old female admitted [DATE], and readmitted [DATE]. Record review of the physician's orders dated 10/15/24 indicated Resident #2 had diagnoses that included: Chronic Obstructive Pulmonary Disease (chronic respiratory symptoms with airflow limitation), aphasia (slight or serious difficulty with speech), unspecified dementia with agitation (thinking and social symptoms that interfere with daily functioning with restless, worried and unable to settle down), disorders of bone density and structure (weakened bones and increased risk of fractures). Record review of the significant change MDS dated [DATE] indicated Resident #2 had no speech was rarely or never understood and was rarely or never understood by others. Resident #2 had long-term and short-term memory problems. The MDS indicated she was always incontinent of bowel and bladder. Record review of the undated care plan indicated Resident #2 had impaired cognitive function or impaired thought processes related to dementia and encephalopathy. Resident #2 had episodes of bowel and bladder incontinence. During an observation on 10/16/24 at 9:50 AM, CNA B assisted CNA C to provide incontinent care for Resident #2. CNA B cleaned Resident #2's front area and did not change her gloves before touching Resident #2's bed sheet, gown, draw sheet, and the cast on Resident #2's left leg. CNA B then cleaned her back area. She did not change her gloves or sanitize her hands until she had finished cleaning her back/bottom area. During an interview on 10/16/24 at 10:06 AM, CNA C said she should have changed her gloves after cleaning Resident #2's front area and before touching her sheet, cast, gown, and draw sheet. She said she was taught to change her gloves after a dirty procedure, but she did not do that. She said there was a risk of cross-contamination and infection to the resident. She said she was very nervous because someone was watching her. During an interview on 10/16/24 at 10:08 AM, CNA B said she did not notice that CNA C did not change her gloves after cleaning the front area of Resident #2. She said CNA C should have changed her gloves and cleaned her hands before touching anything. She said touching things with dirty gloves could cause cross-contamination and infection. During an interview on 10/16/24 at 1:29 PM, ADON A said she expected staff to change their gloves and wash or sanitize their hands after a dirty procedure such as incontinent care. She said staff should change their gloves during incontinent care after cleaning the front area and before going to the back area of a resident because cleaning the front area was considered a dirty procedure. She said there was a risk of infection when not changing gloves or washing hands appropriately. During an interview on 10/16/24 at 2:07 PM, the DON said staff should always change their gloves and wash their hands after a dirty procedure. She said CNA C should have changed her gloves and washed or sanitized her hands after cleaning the front area of Resident #2. The DON said CNA C should not have touched anything with her dirty gloves because it was a potential risk of infection to staff and residents. During an interview on 10/16/24 02:23 PM, the ADM said it was a definite no-no for staff to touch a resident or clean items with gloves that were considered dirty and was potentially an infection risk for residents and/or staff. She said CNAs were trained when to changed their gloves. Record review of an Incontinent Care for the Female Resident competency dated 8/28/24 indicated CNA C was competent to perform incontinent care. Record review of a Hand Washing Competency Checklist competency dated 8/28/24 indicated CNA C was competent to perform hand washing. 2. Record review of Resident #7s face sheet, dated 10/16/2024, indicated she was a [AGE] year-old female, who was readmitted to the facility on [DATE], with the diagnoses which included encephalopathy (a medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain), bipolar (a mental health condition that causes extreme mood swings) and anxiety (intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #7's quarterly MDS, dated [DATE], indicated Resident # 7 was rarely or never understood. Record review of Resident #7's care plan, undated indicated the resident had feeding tube related to weight loss due to not eating and dysphagia. Resident #7's care plan indicated she had a deep tissue injury that was resolved on 8/24/2023. During observation on 10/14/2024, Resident # 7 did not have enhanced barrier precautions sign posted on her door. During record review on 10/16/2024, Resident # 7 was on enhanced barrier precautions related to feeding tube and staff members should wear clean gown and gloves while performing high contact activities including dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance and or caring for indwelling medical devices like central lines, catheters, feeding tubes, trach/ventilators. 3. Record review of Resident 37's face sheet, dated 10/15/2024, indicated he was a [AGE] year-old male, who was admitted to the facility on [DATE], with the diagnoses which included metabolic encephalopathy (a change in how your brain works due to an underlying condition that causes confusion, memory loss and loss of consciousness ) , cystitis (infection or inflammation of the urinary bladder or any part of the urinary system caused by a type of bacteria called Escherichia coli (E. coli), sepsis ( an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever.) and dementia (a group of symptoms affecting memory, thinking and social abilities.) Record review of Resident #37's quarterly MDS, dated [DATE], indicated he had a BIMS of 11, which indicated he was moderately impaired cognitively. Resident #37's MDS indicated he had an indwelling catheter related to obstructive uropathy. Record review of Resident #37's undated care plan, indicated Resident # 37 had a focus on history of ESBL and urinary tract infections and foley catheter requiring him to be on enhanced barrier precautions with interventions as follows: o Enhanced Barrier Precautions R/T history of ESBL/UTI/Foley. Staff members will wear clean gown and gloves while performing high contact activities to included: Dressing, Bathing, Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tubes, trach/ventilator. o Monitor/document/report to MD PRN for signs and symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes During an observation on 10/14/2024 at 9:50 AM, Resident # 37 was observed to have a sign posted on door indicating he was on enhanced barrier precautions. Resident # 37 did not have a storage box of personal protective equipment outside his door. Resident # 37 had an indwelling catheter. During an observation on 10/15/2024 at 12:40 PM, Resident # 37 said since when did you start wearing gowns with my wound care. During an interview on 10/17/2024 at 9:30 AM, the Treatment nurse said enhanced barrier precautions were new to her. She said she was required to wear PPE while performing care to residents with wounds, IV, G-tube, foley catheter, dialysis. She said personal protective equipment included gown and gloves and the surgical mask was not required. The Treatment nurse said the facility had multiple containers on the halls with PPE for staff. The Treatment nurse said she was not sure why Resident #37 said that was the first time for seeing staff wearing gowns. She said she always wore the gowns while performing treatment. The Treatment nurse said a staff member could spread infection if not wearing the proper PPE. The Treatment nurse said residents on enhanced barrier precautions should have a sign on their door and the Kardex should have the precautions for the CNA's to be aware when PPE is required. The Treatment nurse said she was not sure who was responsible making sure the signs were on the door or care planned. She said everyone was responsible for ensuring PPE was worn correctly. She said she had educated staff on proper PPE and report any staff not following protocol. 4.Record review of Resident #39' s face sheet, dated 10/16/2024, indicated he was a [AGE] year-old male, who was admitted to the facility on [DATE], with the diagnoses which included cerebral infarction, type II diabetes, GERD, Dysphagia, Cognitive communication disorder. Record review of Resident #39's quarterly MDS, dated [DATE], indicated he was rarely and never understood by others and no BIMS score was conducted. Resident #39's MDS indicated he had a diagnosis of malnutrition requiring feeding tube for nutrition. Record review of Resident #39's undated care plan indicated the resident required tube feeding related to dysphagia secondary to cerebral vascular accident with interventions in place as follows: Check for placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater that 100 cc aspirated. Provide local care to G-tube site as ordered and monitor for signs and symptoms of infection. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. During an interview and observation on 10/15/2024 at 9:15 AM, LVN Y observed administering Resident # 39's medication as ordered through feeding tube only wearing gloves. LVN Y said she was not required to wear PPE while administering medication to Resident # 39's feeding tube. Resident # 39 did not have an enhanced barrier precaution sign on door or storage container with PPE available outside the door. 5.Record review of Resident #91's face sheet, dated 01/00/24, revealed he was an[AGE] year-old male, who was admitted to the facility on [DATE], with the diagnoses which included refsum's disease (a rare genetic disorder that lead to issues with breaking down fat ) , Klebsiella pneumonia (a common type of bacteria found in your intestines ) and diabetes (a group of diseases that affect how the body uses blood sugar (glucose). Record review of Resident #91's admission MDS, dated [DATE], indicated he had a BIMS of 15, which indicated he was cognitively intact. Resident #91's MDS indicated he had an IV Access and was receiving antibiotics for Klebsiella pneumonia. Record review of Resident #91's care plan, undated indicated the resident was on IV antibiotics through PICC line due to Klebsiella pneumonia and refsums disease. Resident #91 did not have a care plan for enhanced barrier precautions. During an observation and interview on 10/15/2024, LVN GG did not don PPE while administering Resident # 91's IV therapy. Resident # 91 did not have an enhanced barrier precaution sign on door. LVN GG said she was not required to wear PPE while administering IV medication to Resident # 91. During an interview on 10/16/2024 at 2:55 PM, CNA HH said she would wear gown, gloves, N95 mask or a surgical mask when providing care. She said residents who received care areas such as bathing, catheter care, perineal care required with residents on EBP. During an interview on 10/16/2024 at 3:14 PM, CNA Q said she would read the EBP sign on a resident door and place on proper PPE such as gowns, gloves, mask (surgical), face shield, shoe covers before entering a resident room to provide care such as bathing, perineal care, and catheter care. During an interview on 10/16/2024 at 3:20 PM, LVN GG said staff should be wearing PPE while providing care to residents who had a posted sign for EBP on door. She said EBP was not required for residents receiving IV antibiotics. During an interview on 10/16/2024 at 3:30 PM, LVN AA said she was an agency nurse and Resident # 39 was currently on EBP precautions due to her feeding tube. LVN AA said PPE should be donned prior to entering the room. LVN AA said LVN said she would place her PPE on even if a resident called for water. LVN said PPE is required for administering resident's medication through feeding tube. LVN AA said PPE included (gown, gloves, surgical mask). LVNAA said the infection control nurse is responsible for ensuring EBP is posted and should be care planned. She said it was a safety measure for the resident and they could get sick from cross contamination. LVN AA said she had not been in-service at the facility on EBP, but she was aware of the precautions. LVN AA said a resident should be on EBP precautions if they are receiving IV therapy. During an interview on 10/17/2024 at 8:43 AM, MDS Coordinator V said the nursing staff completes the EBP precautions for the care plan. MDS Coordinator said any resident who has MRSA, ESLB, or a carrier of infection. The MDS said a resident who was receiving IV therapy should be on EBP precautions. MDS Coordinator V said the staff should be wearing gloves and a gown, but the mask was depended on what type of infection such as droplet precautions if a resident coughed in your face. She said if a resident had an active infection, the staff could potentially cross contaminate. During an observation and interview on 10/17/202 at 4 8:52 AM, Resident # 39 and Resident #91 did not have a sign on the door indicating PPE or EBP cautions. Resident #91 said the nurses only use PPE when changing his PICC line dressing but not when they are admin IV therapy. Resident #91 said the nurse came in today wearing gowns. He said something must have been said. Resident #91 did not have a PPE storage box outside his door or a sign. During an interview on 10/17/2024 at 8:59 AM, LVN DD said she had administered IV antibiotics to Resident # 91 this morning. LVN DD said Resident # 91 was not on any precautions. LVN DD said Resident #91 should be on EBP precautions for IV therapy. LVN DD said residents who receive IV, feedings, foley care should be on EBP precautions. LVN DD said if a nurse assesses a resident and identifies a need for precautions, she said she would report to the DON to see if a resident should be placed on precautions. LVN DD said if a staff was not wearing proper PPE, they could spread infection to other residents. During an interview on 10/17/2024 at 9:50, ADON N said a residents should be on EBP with any wounds, open area, feeding tubes, catheters, and IV therapy. She said any staff member can place EBP precautions on the door. ADON N said PPE should be wearing (gown, gloves, head covers, face shields, or goggles, surgical mask unless covid). ADON N said the staff had been in-serviced on EBP. ADON N said EBP prevented spread of infection protecting the staff and residents. ADON N said the CNAs should check the Kardex with care plans to see if the resident was on EBP precautions and it should be care planned. ADON N said there would be storage carts with PPE at the resident door with signs posted indicating a resident required PPE before providing care. During an interview on 10/17/2024 at 11:30 AM, the Regional Nurse FF said the staff should don PPE for residents who had feeding tube, foley, IV, wound care and MDRO (Multidrug-resistant organism) and colonized. The Regional Nurse FF said PPE (gown, gloves, mask if droplet) should be worn when performing close contact care. She said cross contamination could occur if proper PPE was not worn. Regional Nurse FF said an EBP sign should be posted on the resident door if PPE should be worn while providing care. Regional Nurse FF said EBP should have an order and be on the care plan. She said she had in serviced the EBP and instructed facility staff to review charts and update the orders and proper care plan and PPE in place. She said a container should be outside each door. We can share a container if the rooms are close. During an interview on 10/17/2024 at 11:58 AM, the ADM said the infection control preventionist and the DON are responsible for ensuring the EBP precautions are posted, and care planned. The ADM said there was potential for cross contamination if PPE was not worn for a resident on EBP. She said she expected the nurses to be wearing PPE and stocked. The ADM said PPE containers can be between two rooms and she said she was not sure of what PPE was available in the facility. 6. Record review of a face sheet dated 10/15/24 indicated Resident #100 was a [AGE] year-old male who admitted on [DATE] with the diagnosis of cervical disc disorder with myelopathy, high cervical region (a condition that occurs when the spinal cord in the neck is compressed by a herniated disc or other issue) obstructive and reflux uropathy unspecified (conditions that damage the kidneys and upper urinary tract due to a blockage or other impediment in urine flow) and benign prostatic hyperplasia with lower urinary tract symptoms (needing to urinate frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine). Record review of a comprehensive care plan undated indicated Resident #100 was incontinent of bladder and was dependent for toileting. The care plan interventions for Resident #100 included position catheter bag and tubing below the level of the bladder. Check tubing for kinks and maintain the drainage bag off the floor. Enhanced barrier precautions related to foley catheter care. Staff members will wear clean gown and gloves while performing high contact activities to include: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tubes, trach/ventilator. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for signs and symptoms urinary tract infection: 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 comprehensive care plan undated indicated Resident #100 has a foley catheter and is at risk of multidrug-resistant organism and is on enhanced barrier precautions. The care plan included interventions for enhanced barrier precautions related to multidrug-resistant organism. Staff members will wear clean gown and gloves while performing high contact activities to include: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tubes, trach/ventilator. Monitor/document/report to MD as needed abnormal laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). Record review of the Quarterly MDS dated [DATE] indicated Resident #100 understands and was understood. The MDS indicated Resident #100 had moderate cognitive impairment. The MDS in Section E-Behavior indicated he had not rejected care. The MDS in Section GG-Functional Abilities and Goals indicated Resident #100 was dependent with the helper providing all the effort for toileting. The MDS in Section H-Bladder and Bowel indicated Resident #100 was always incontinent of bowel and had a catheter for bladder. Record review of physician orders dated 5/2/24, enhanced barrier precautions related to foley catheter. Staff members will wear clean gown and gloves while performing high contact activities to include: dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tubes, trach/ventilator. During an observation on 10/15/2024 at 11: 03 a.m., CNA BB and Restorative Aide CC performed catheter care on Resident #100 but did not don their PPE (disposable gown and gloves). There was not a PPE cart outside Resident #100's door, but there was an enhanced barrier precautions sign on the door. During an interview on 10/16/24 at 12:38 P.M., with LVN AA she said staff were supposed to wear PPE when duties were performed with residents on enhanced barrier precautions. She said depending on what the residents are on the enhanced barrier precautions can affect the residents differently. She said wearing PPE can protect the resident and staff from infections. During an interview on 10/16/24 at 12:42 P.M., with Treatment Nurse M she said when a resident was on enhanced barrier precautions staff were supposed to wear their PPE. She said residents with opened wounds, catheters and g-tubes were usually on enhanced barrier precaution residents. She said wearing PPE can protect the resident and staff from infections. During an interview on 10/16/24 at 12:52 P.M., with CNA BB she said she knew she supposed to wear PPE during catheter care. She said the facility informed the staff a while back about enhanced barrier precautions protocol, but when she was doing the catheter care for Resident #100 she forgot. She said enhance barrier precautions was something new. She said CNAs used to only wear PPE when residents were on contact precautions. She said the facility want us to wear PPE to protect staff and the residents from infections. During an interview on 10/16/24 at 1:01 P.M., with Restorative Aide CC she said she knew she was supposed to wear PPE during catheter care. She said she did not remember the date, but remembered an in-service was done over enhanced barrier precautions. She said the enhanced barrier precautions and wearing PPE was to protect the residents and staff from infections. During an interview on 10/16/24 at 1:10 P.M., ADON N she said during any interaction with an enhanced barrier precaution resident CNA's and nurses should be wearing full PPE. She said enhanced barrier precautions resident usually had a catheter, a wound or a peg-tube. She said when staff were to perform catheter care they should be wearing full PPE. She said enhanced barrier precautions was to prevent the residents and staff as well from infections and germs. During an interview on 10/17/24 at 8:40 A.M., with LVN DD she said when CNA's or nurses are performing catheter care they should be washing their hands and wearing gloves along with PPE. She said staff should be wearing PPE for residents that are on enhanced barrier precautions and during catheter care. She said the negative affect on staff not wearing PPE for enhanced barrier precautions can cause infections and cross contamination. During an interview on 10/17/24 at 9:08 A.M., with CNA EE she said when she did catheter care she wore her PPE. She said wearing PPE for enhanced barrier precautions residents was to prevent the spread of infection. She said the negative affect of not wearing PPE on enhanced barrier precaution resident is cross contamination and a system failure. During an interview on 10/17/24 at 10:36 A.M., with ADON A she said I expect the CNAs to wear PPE when performing catheter care, because the residents are very acceptable to get infections. The negative effects of staff not following enhance barrier precautions guidelines, because residents can get infections from staff members and staff can get infections from residents. During an interview on 10/17/24 at 10:54 A.M., with Administrator she said she expected all staff to follow the enhancement barrier precautions guidelines. She said the negative affect on residents if staff do not follow enhanced barrier precautions is a potential for cross contamination. During an interview attempt on 10/17/24 at 12:12 P.M., the DON was called, but no answer. Record review of a facility's Infection Prevention and Control Program policy dated 10/24/2022 indicated .the ensure the facility establishes and maintains an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. Record review of a facility's Perineal Care policy dated revised 6/2020 indicated .purpose, to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown policy . perineal care is provided as [NAME] of a resident's hygienic program a minimum of once daily and per resident need. Procedure .Xll .after peri care, remove gloves. Wash hands or use alcohol-based hand sanitizer. Note: Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call bell, ect.). Xlll .put on clean gloves. XlV .clean and return all equipment to its proper place. XV .place soiled linen in proper container. XVl .remove gloves. XVll .wash hands . Record review of a facility's Catheter-Care of policy revise date 6/2020 indicated . to prevent catheter-associated urinary tract infections while ensuring the residents are not given indwelling catheters unless medically necessary . lll. Proper techniques for urinary catheter maintenance: use standard precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system . Record review of a facility's Standard and Enhanced Precautions policy dated 4/1/2020 indicated .V. Enhanced Barrier Precautions . A. EBP should be used for any residents who meet the criteria, wherever they reside in the facility . the facility has discretion in using EBP for residents who do not have chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC . for residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube and tracheostomy/ventilator. 48958 49019

Based on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 3 of 6 Residents (Resident #21, Resident #51, and Resident #79) whose records were reviewed for skin integrity. The facility failed to ensure Resident #21, Resident #51, and Resident #79's pressure-relieving mattresses (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) were on the correct settings. The facility failed to ensure Resident #79 received and/or documented wound care on 10/05/24, 10/06/24, 10/07/24, 10/10/24, 10/11/24, and 10/13/24. These failures could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings included: 1. Record review of Resident #21's face sheet dated 10/14/24 indicated Resident #21 was a 69-years-old female admitted on [DATE] with diagnoses including need for assistance with personal care, chronic kidney disease (is a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), weakness, pain in right and left shoulder, diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose)), and hidradenitis suppurativa (is a painful, long-term skin condition that causes skin abscesses and scarring on the skin). Record review of Resident #21's quarterly MDS assessment dated [DATE] indicated Resident #21 was understood and understood others. Resident #21 had clear speech, adequate hearing, and adequate vision. Resident #21 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #21 had an indwelling catheter and was always incontinent for bowel. Resident #21 weighed 241 lbs. Resident #21 was at risk of developing pressure ulcers/injuries. Resident #21 had open lesions other than ulcers, rashes, cuts. Resident #21 had a pressure reducing device for bed as a skin and ulcer/injury treatment. Record review of Resident #21's consolidated physician order active as of 10/16/24 indicated may use low air loss mattress. Check settings every shift to ensure settings within therapeutic range. Order date 07/31/23. Record review of Resident #21's undated care plan indicated Resident #21 had the potential for pressure injury development/skin impairment related to disease process, immobility, and incontinence. On 12/07/23, Resident #21 continues to have skin injury to buttocks related to hidradenitis per wound care medical doctor. Intervention included notify nurse immediately of any new areas of skin breakdown. Record review of Resident #21's weight summary dated 10/17/24 indicated: *10/07/24 240.3 lbs. *09/07/24 244.3 lbs. *08/28/24 243.4 lbs. During an observation and interview on 10/15/24 at 8:09 a.m., Resident #21 was lying in bed on a pressure relieving mattress. Resident #21's weight setting was 360 lbs. She said she did not know about the bed settings, but the bed made weird noises. During an observation on 10/16/24 at 3:30 p.m., Resident #21 was lying in bed on a pressure relieving mattress. Resident #21's weight setting was 360 lbs. 2. Record review of Resident #51's face sheet dated 10/15/24 indicated Resident #51 was a 60-years-old female admitted on [DATE] and 12/08/20 with diagnoses including metabolic encephalopathy (is a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), muscle wasting and atrophy (shortening), and protein-calorie malnutrition (is a condition that occurs when someone doesn't get enough calories or the right nutrients). Record review of Resident #51's quarterly MDS assessment dated [DATE] indicated Resident #51 was usually understood and usually understood others. Resident #51 had a BIMS score of 04 which indicated severe cognitive impairment. Resident #51 was dependent for ADL care. Resident #51 was always incontinent for bladder and bowel. Resident #51 weighed 78 lbs. Resident #51 was at risk for developing pressure ulcers/injuries. Resident #51 had pressure reducing device for bed. Record review of Resident #51's consolidated physician order active as of 10/16/24 indicated may use low air loss mattress. Check settings every shift to ensure settings within therapeutic range. Order date 08/07/24. Record review of Resident #51's undated care plan indicated Resident #51 had potential/actual impairment to skin integrity related to fragile skin and scratching buttocks and legs due to itching. Intervention included identify/document potential causative factors and eliminate/resolve where possible. During an observation on 10/14/24 at 2:21 p.m., Resident #51 was lying on a low air loss mattress with boundaries. Resident #51's weight bed setting was 210 lbs. During an observation on 10/15/24 at 10:56 a.m., Resident #51 was lying in bed asleep. Resident #51 was lying on a low air loss mattress with boundaries. Resident #51's weight bed setting was 210 lbs. During an observation on 10/16/24 at 3:10 p.m., Resident #51 was lying in bed asleep. Resident #51 was lying on a low air loss mattress with boundaries. Resident #51's weight bed setting was 210 lbs. 3. Record review of Resident #79's face sheet dated 10/14/24 indicated Resident #79 was a 55-years-old male admitted on [DATE] and 05/01/24 with diagnoses including paraplegia (is paralysis that affects your legs, making it impossible to stand or walk), dependence on renal dialysis, pressure ulcer (are localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) of sacral region (is a skin injury that occurs in the sacral region of the body, near the lower back and spine), Stage 4 (injuries extend to muscle, tendon, or bone), and muscle wasting and atrophy (shortening). Record review of Resident #79's quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. Resident #79 had clear speech, adequate hearing, and adequate vision with corrective lenses. Resident #79 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #79 had an indwelling catheter and was always incontinent of bowel. Resident #79 weighed 125 lbs. Resident #79 had a pressure ulcer/injury and one or more unhealed pressure ulcers/injuries. Resident #79 had two stage 4 pressure ulcers and pressure reducing device for bed and pressure ulcer/injury care for skin and ulcer/injury treatments. Record review of Resident #79's undated care plan indicated: *Resident #79 had stage 4 pressure injury to the sacrum related to immobility and disease process. Interventions included treat wounds as per medical doctor orders and follow facility policies/protocols for the prevention/treatment of skin breakdown. *Resident #79 had a stage 4 pressure injury to his ischium related to disease process, immobility, returned from hospital with pressure injury now unstageable on 05/01/24. Interventions included administer treatments as ordered and monitor for effectiveness and the resident required the use of an air mattress. *Resident #79 had a stage 4 pressure injury to his left ischium from worsening abscess related to disease process, history of ulcers, and immobility. Intervention included administer treatments as ordered and monitor for effectiveness. Record review of Resident #79's consolidated physician order active as of 10/16/24 indicated: *Pressure relieving mattress every shift for preventative. Start date 05/03/24. *Wound care: Cleanse stage 4 pressure injury to left ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered composite dressing. Change every shift and PRN soiling/saturation. Start date 10/15/24. *Wound care: Cleanse stage 4 pressure injury to right ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered composite dressing. Change every shift and PRN soiling/saturation. Start date 10/15/24. *Wound care: Cleanse stage 4 pressure injury to sacrum with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered composite dressing. Change every shift and PRN soiling/saturation. Start date 10/15/24. Record review of Resident #79's MAR dated 10/01/24-10/31/24 indicated: *Wound care: Cleanse stage 4 pressure injury to left ischium with Dakin's or normal saline and pat dry. Fill dead space with calcium alginate. Secure with bordered foam dressing. Change every shift and PRN soiling/saturation, every shift for wound care. Order date 10/05/24. Discontinued 10/13/24. Resident #79's MAR did not have administration of wound care on 10/05/24 (night shift), 10/06/24 (day and night shift), 10/07/24 (night shift), 10/10/24 (day and night shift), 10/11/24 (night shift), and 10/13/24 (night shift) *Wound care: Cleanse stage 4 pressure injury to left ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered waterproof dressing. Change every shift and PRN soiling/saturation. Order date 10/13/24. *Wound care: Cleanse stage 4 pressure injury to right ischium with Dakin's or normal saline and pat dry. Fill dead space with calcium alginate. Secure with bordered foam dressing. Change every shift and PRN soiling/saturation, every shift for wound care. Order date 10/05/24. Discontinued 10/13/24. Resident #79's MAR did not have administration of wound care on 10/05/24 (night shift), 10/06/24 (day and night shift), 10/07/24 (night shift), 10/10/24 (day and night shift), 10/11/24 (night shift), and 10/13/24 (night shift) *Wound care: Cleanse stage 4 pressure injury to right ischium with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered waterproof dressing. Change every shift and PRN soiling/saturation. Order date 10/13/24. *Wound care: Cleanse stage 4 pressure injury to sacrum with Dakin's or normal saline and pat dry. Fill dead space with calcium alginate. Secure with bordered foam dressing. Change every shift and PRN soiling/saturation, every shift for wound care. Order date 10/05/24. Discontinued 10/13/24. Resident #79's MAR did not have administration of wound care on 10/05/24 (night shift), 10/06/24 (day and night shift), 10/07/24 (night shift), 10/10/24 (day and night shift), 10/11/24 (night shift), and 10/13/24 (night shift) *Wound care: Cleanse stage 4 pressure injury to sacrum with Dakin's or normal saline and pat dry. Fill dead space with collagen particles and Dakin's moistened gauze. Secure with bordered waterproof dressing. Change every shift and PRN soiling/saturation. Order date 10/13/24. Record review of Resident #79's progress notes dated 10/10/24 by Wound Care DNP indicated .wound follow up .the following wounds were evaluated .Wound 1 Sacrum, Pressure Injury, Stage 4 .Wound 2 Right Ischium, Pressure Injury, Stage 4 .Wound 4 Left Ischium, Pressure Injury, Stage 4 .wound 1: subsequent- improving .wound 2: subsequent-improving .wound 4: subsequent-improving . Record review of Resident #79's weight summary dated 10/17/24 indicated: *10/16/24 136.8 lbs. *10/09/24 134.6 lbs. *10/04/24 130.67 lbs. *10/02/24 127.2 lbs. During an observation and interview on 10/15/24 at 3:30 p.m., Resident #79 was lying on a LAL mattress after wound care with Treatment Nurse M. Resident #79's weight bed setting was 490 lbs. Resident #79 said he probably weighed about 138 lbs. Treatment Nurse M said she had not noticed Resident #79's weight bed setting being 490 lbs. She said she did not know who was responsible for ensuring the resident's weight settings were accurate. Treatment Nurse M reviewed Resident #79's medical records and said he weighed 134.6 lbs. Resident #79 said sometimes his wound care was not done every day or shift. He said some nurses did not want to mess with it or were too new. He said he mostly missed treatments on the night shift. During an interview on 10/17/24 at 8:15 a.m., RN H said she had been employed at the facility for 3 months. She said she took care of Resident #79. She said Resident #79's wound care was not done sometimes on her shift. She said Treatment Nurse M told her Resident #79's dressing changes were only due on day shift. She said the Treatment Nurse M told her the order only said every shift in case it got soiled or dislodged, there was an order for it. She said Treatment Nurse M told her to only change Resident #79's dressings at night if it got soiled. She said she only changed Resident #79's dressings once on night shift when it got soiled. She said she forgot to document the dressing changes on the TAR. She said she thought she documented the dressing changes on a progress note. She said she did not know she had to document Resident #79's dressing changes on the TAR. She said she should have followed the physicians orders not Treatment Nurse M. She said it was important to follow the physician's order because they ordered it that way for a reason. She said it was important to do the ordered wound care so it could heal faster. She said when wound care was not performed as scheduled, it risked the pressure ulcer not improving and infection. She said she did not know who was responsible for the LAL mattress weight settings. She said the TAR had an order for the resident to have a LAL or pressure relieving mattress but not checking the mattress's settings. She said the mattress settings were important to be set correctly to rotate the pressure off the resident's bony prominences. She said the wrong LAL mattress settings increased the resident's risk of skin breakdown. During an interview on 10/17/24 at 9:34 a.m., Treatment Nurse M said she had been the treatment nurse for a month. She said she did not know who was responsible for checking LAL or pressure relieving mattress settings. She said she would start checking the mattress settings from now on. She said it was important for the mattress settings to be correct to relieve the correct amount of pressure and adjust correctly. She said wrong mattress settings could make pressure ulcers worsen. She said Resident #79's wound care should have been done every shift not once a day. She said she had recently educated the nurses on doing Resident #79's wound care dressing changes every shift. She said she did not remember if she had educated RN F. She said she was responsible for dressing changes Monday-Friday, day shift. She said the weekend supervisor and LVNs were responsible for the night and weekend dressing changes. She said she did not know why there were two day shift days not documented on Resident #79's MAR/TAR. During an interview on 10/17/24 at 10:37 a.m., ADON N said the mattress company set up the resident's LAL or pressure relieving mattress. She said the treatment nurse should be responsible for the resident's weight settings. She said the mattress setting needed to be correct to prevent further pressure ulcer injury. She said wrong mattress setting placed the residents at risk for more damage to the skin and contractures. On 10/17/24 at 11:48 a.m., called and left voicemail for LVN J. A return phone call was not received before or after exit. During an interview on 10/17/24 at 2:05 p.m., Regional RN FF said the treatment nurse should check the resident's pressure relieving mattress settings daily. She said the correct mattress settings were important because there was a reason the resident was on the LAL mattress, and it needed to function correctly. She said the wrong mattress settings could cause skin issues. She said the DON should ensure the treatment nurse was monitoring LAL mattress settings. She said she expected nursing staff to document wound care dressing changes on the MAR/TAR. She said the treatment nurse or charge nurse should perform the dressing changes every shift or as ordered. She said if the treatment was not documented on the MAR/TAR, it could imply, it was not done. She said not performing wound care as ordered could lead to decreased wound healing, infection, and delayed wound healing. She said the DON should review the MAR/TARs daily to ensure the residents with wounds had scheduled wound care done. During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said the wound care nurse or LVNs should perform the resident's ordered wound care treatment. She said the treatment should be documented on the MAR/TAR by the treatment nurse or LVN. She said if the treatment was not documented, it was not done. She said not doing a resident's ordered treatments could cause infection, poor healing, and possible loss of a limb. She said the DON should be monitoring documentation. She said the treatment nurse or LVNs should check the resident's mattress settings for the current weight of the resident. She said the correct weight setting was important to protect the wound and better healing. She said when the resident had incorrect mattress settings, more skin breakdown could happen, or the pressure ulcer would not heal properly. She said the DON should be doing visual checks and reviewing the charts. Record review of a facility's Wound Management revised date 06/2020 indicated .a resident who has a wound will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure injuries from developing . Review of Evaluation of a low-air-loss mattress system in the treatment of patients with pressure ulcers (1995) by M A [NAME], J Oldenbrook, C [NAME], www.pubmed.ncbi.nlm.nih.gov/7612140 was accessed on 10/22/2024 indicated .our observation indicate that use of the low-air-loss mattress system reduces the size and facilitates the healing of previously stable, chronic pressure ulcers .

Based on interviews and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #21, Resident #50, and Resident #74) reviewed for abuse. The facility failed to ensure Resident #21 did not feel abused during bathing by CNA P in September and October 2024. The facility failed to ensure Resident #50 did not experience abuse by Resident #70 on 10/06/24. The facility failed to ensure Resident # 74 (victim) was free from undesired touching by Resident #77 (alleged perpetrator) on 10/5/2024. These failures could place resident at risk for emotional distress and further abuse. Findings included: 1. Record review of Resident #21's face sheet dated 10/14/24 indicated Resident #21 was a 69-years-old female admitted on [DATE] with diagnoses including need for assistance with personal care, chronic kidney disease (is a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), weakness, pain in right and left shoulder, diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose)), and hidradenitis suppurativa (is a painful, long-term skin condition that causes skin abscesses and scarring on the skin). Record review of Resident #21's quarterly MDS assessment dated [DATE] indicated Resident #21 was understood and understood others. Resident #21 had clear speech, adequate hearing, and adequate vision. Resident #21 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #21 was dependent for shower/bathe self and personal hygiene. Record review of Resident #21's undated care plan indicated Resident #21 had an ADL self-care performance deficit. Interventions included bathing: shower at least once a week and as needed per CNA. Resident #21 was dependent for bathing. Bed mobility: assist resident to turn and reposition at least once every 2 hours. Roll left and right, sit to lying, and lying to sitting substantial/maximal assist. Record review of Resident #21's shower sheets, provided by the ADM on 10/16/24, indicated: *09/19/24 Received bed bath by CNA P *09/24/24 Received bed bath by CNA P *09/28/24 Received bed bath by CNA P Record review of Resident #35's face sheet dated 10/14/24 indicated Resident #35 was a 65-years-old female admitted on [DATE] and 09/11/23 with diagnoses including Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and need for assistance with personal care. Record review of Resident #35's quarterly MDS assessment dated [DATE] indicated Resident #35 was understood and understood others. Resident #35 had adequate hearing, clear speech, and adequate vision. Resident #35 had a BIMS score of 15 which indicated intact cognition. During an interview on 10/14/24 at 10:05 a.m., Resident #21 said she was supposed to get a bed bath every night because her sores oozed and smelled. She said CNA P was really rough during care. She said it always seemed like CNA P did not want to assist her. During an interview on 10/14/24 at 10:07 a.m., Resident #35, roommate of Resident #21, said CNA P did not abuse her because she knew better. She said CNA P did not answer call lights or brought things you asked for during her shift. She said it always seemed like CNA P had a bad attitude about doing care like bathing. During an interview on 10/15/24 at 11:10 a.m., Resident #21 said CNA P was rough when turning and cleaning her during bed baths. She said CNA P was rough with her every time she gave her a bath except for the last bath she got. She said it had been happening for a while but, definitely the last two months. She said CNA P did not like giving her bed baths, but the nurses would make her. She said then CNA P would be mad at her and take it out on her during the baths. She said when CNA P was rough with her, it made her feel bad and in more pain. She said she told a night shift nurse about CNA P not wanting to give her a bath and being mad about it. She said she could not remember the nurse's real name because she went by a different name. She said the nurse did not work at the facility anymore. She said she felt like she was being abuse by CNA P during care. During an interview on 10/15/24 at 11:12 a.m., Resident #35 said when CNA P was giving Resident #21 a bed bath, she would hear Resident #21 tell CNA P she was hurting her. On 10/15/24 at 1:21 p.m., call CNA P and left a voice mail. On 10/15/24 at 3:04 p.m., call CNA P and left a voice mail. On 10/17/24 at 11:47 a.m., called CNA P and left a voice mail. CNA P did not return phone call before or after exit. 2. Record review of Resident #50's face sheet dated 10/14/24 indicated Resident #50 was a 68-years-old male admitted on [DATE], 01/08/22, and 03/14/23 with diagnoses including type 2 diabetes mellitus (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), vascular dementia (is a type of dementia that occurs when blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior), generalized anxiety disorder (is a mental health condition that causes people to experience excessive and persistent worry about everyday things), depression (is a serious mood disorder that affects a person's thoughts, feelings, behavior, and sense of well-being), and acquired absence of left and right leg below knee. Record review of Resident #50's annual MDS assessment dated [DATE] indicated Resident #50 was understood and understood others. Resident #50 had a BIMS score of 08 which indicated moderate cognitive impairment. Record review of Resident #50's undated care plan indicated Resident #50 had potential to demonstrate physical behaviors related to when he gets upset. 10/06/24: Resident #50 hit/curse at CNA staff. Intervention included intervene before agitation escalates. Record review of Resident #50's physical aggression received incident report dated 10/06/24 indicated .Resident #50 .Incident location: Resident's room .Nursing description: Resident #50 was in the hallway by his room when another resident [Resident #70] came in down the hallway and hit .had hit a staff member .Resident description: was sitting in wheelchair when the other resident rolled down the hallway and hit me .mental status: oriented to person and impulsiveness .predisposing physiological factors: confused, incontinent, and impaired memory . Record review of Resident #70's face sheet dated 10/14/24 indicated Resident #70 was a 64-years-old, male admitted on [DATE] with diagnoses including Alzheimer's disease (is a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), Parkinson's disease (is a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and personal history of transient ischemic attack (is a brief episode of stroke-like symptoms caused by a temporary lack of blood flow to the brain) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of Resident #70's quarterly MDS assessment dated [DATE] indicated Resident #70 was understood and understood others. Resident #70 had a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #70's undated care plan indicated Resident #70 had the potential to demonstrate physical/verbal behaviors related to anger. Resident #70 would slam against the nurses' cart and yell at staff when something set him off. On 10/4/24, aggression episode towards staff. On 10/06/24, aggression episode towards resident (slap resident on face) and staff (threatened/hit/verbally abuse). Intervention included monitor/document observed behaviors and attempted interventions in behavior log. Record review of Resident #70's physical aggression initiated, dated 10/06/24 indicated .Resident #70 .Incident location: hallway .Nursing description: Resident [Resident #70] rolled down the hallway where another resident was sitting in her wheelchair .the other resident exchange an altercation with a staff member .This resident [Resident #70] rolled up the other resident unprovoked .Resident [Resident #70] stated I got tired of his mouth, and he put his hands on the nurses .mental status: oriented to person, oriented to place, oriented to time, oriented to situation, and impulsiveness . Record review of the facility's incident self-report dated 10/06/24 indicated .10/06/24 at 3:30 p.m .Resident #50 was heard calling out for help in the dining room .when the weekend RN supervisor [RN F] responded, she witnessed Resident #70 standing in front of Resident #50 and Resident #70 was slapping Resident #50 in the face .Resident #70 was aggressive towards the weekend supervisor [RN F] during the separation of the two residents . Record review of the provider investigation report dated 10/11/24 indicated .10/06/24 at 3:20 p.m .location of incident: dining room .alleged perpetrator: Resident #70 .Resident #50 was being belligerent to aides and nurses in the dining room .Resident #70 told him [Resident #50] to stop being mean to the staff and go get cleaned up .Resident #50 allegedly said no and Resident #70 slapped him across the face .Resident #70 was determined to be taking up for the facility staff due to his perception that Resident #50 was constantly being mean and nasty towards them .Resident #70 stated he told Resident #50 to stop being mean and then just slapped him to make his point .Facility Investigation Findings: Confirmed . Record review of an undated witness statement by RN F indicated .I [RN F] was getting off of elevator and I could hear someone screaming 'help me' .I [RN F] walked into the dining room and I observed both residents sitting in their wheelchairs at dining room table .Resident #70 was holding Resident #50's right hand down on the table as he was slapping Resident #50's face on the right side .I [RN F] then asked Resident #70 to stop as I was approaching the table to separate the two residents .I [RN F] then made it to the table to redirect and separate the two at that time Resident #70 became more aggressive and was trying to strike Resident #50 again .[LVN L] then was trying to assist me calming the resident [Resident #70] down .Resident #70 then began to rise out of his wheelchair at this nurse .I [RN F] had to physically put my hands up in front of the charge nurse [LVN L] and resident [Resident #70] to prevent him from striking her .Resident #70 had calmed down as I [RN F] propelled his wheelchair to his room .I then asked Resident #70 what happened to cause him to strike Resident #50 .Resident #70 said that Resident #50 is always talking 'ugly' to the staff and he was tired of it and he was going to 'teach him a lesson' . Record review of Resident #42's face sheet dated 10/17/24 indicated Resident #42 was a 48-years-old female admitted on [DATE] with diagnosis including multiple sclerosis (is a chronic autoimmune disease that affects the central nervous system (CNS)). Record review of Resident #42's quarterly MDS assessment dated [DATE] indicated Resident #42 was understood and understood others. Resident #42 had clear speech, adequate hearing, and adequate vision. Resident #42 had a BIMS score of 15 which indicated intact cognition. During an interview on 10/14/24 at 11:08 a.m., Resident #59 said Resident #70 never hit him. He said the staff at the facility was lying. During an interview on 10/14/24 at 12:07 p.m., Resident #42 said Resident #50 hit CNA Q in the hallway over being out of something. She said Resident #70 heard Resident #50 cussing at CNA Q. She said Resident #70 and Resident #50 got into it in the hallway. She said she was not in the dining room when the other incident happened. She said she heard Resident #70 hit Resident #50 because he hits the CNAs. She said Resident #70 was normally not aggressive but Resident #50 was. She said she did not think it was fair Resident #70 got in trouble for hitting Resident #50 because he was sticking up for the CNAs. During an interview on 10/14/24 at 2:38 p.m., Resident #70 said he never hit anybody. He said he did not remember hitting Resident #50. During an interview on 10/15/24 at 2:32 p.m., RN F said she was coming off the elevator near the dining room when she heard Resident #50 screaming out for help. She said she arrived in the dining room and saw Resident #70 open hand slapping Resident #50 in the face and holding Resident #50's hand down on the table. She said she immediately separated the residents. She said Resident #70 was so angry, he was trying to stand up out of his wheelchair to reach Resident #50. She said Resident #70 said Resident #50 was saying bad things and he was tired of it. She said Resident #50 was sitting in his wheelchair with a shocked look on his face. She said that she was aware of, this was the first altercation between Resident #50 and Resident #70. She said this incident was the first time Resident #70 had been aggressive towards a resident. She said LVN L tried to help during the altercation and Resident #70 tried to hit her too. She said Resident #70 was placed on 1:1 monitoring, and the ADM and the DON were notified. She said the facility called an ambulance but Resident #70 refused to leave for the evaluation. She said Resident #70 also refused an inpatient behavioral referral. She said after the incident, Resident #50 seemed fine the rest of the day. She said Resident #70 eventually calmed down. She said Resident #70 was cognitive enough to know what he was doing. She said she would consider Resident #70 slapping Resident #50 abuse. During an interview on 10/15/24 at 3:18 p.m., LVN L said Resident #50 was upset and hit CNA Q on her arm. She said Resident #70 saw Resident #50 hit CNA Q. She said Resident #70 wheeled himself to Resident #50's room and grabbed him by the arm. She said when she went to separate Resident #50 and Resident #70, Resident #70 tried to hit her too. She said after the hallway incident, Resident #70 went into his room and Resident #50 went to the dining room. She said she notified RN F about the hallway incident between Resident #50 and Resident #70. She said she thought everything was okay between the residents. She said she went to smoke and walked back into RN F trying the separate Resident #50 and Resident #70. She said the residents were separated and Resident #70 placed on 1:1. She said Resident #70 refused to go with emergency medical service. She said the police were also called and they spoke with Resident #70. She said Resident #70 was placed on 1:1 for 3 days until he was released by the NP. She said Resident #70 could sometimes get violent if he did not get his way. During an interview on 10/16/24 at 2:45 p.m., CNA Q said Resident #50 came out of his room for a towel and got upset there were none available. She said Resident #50 was already agitated from a visit with his. She said Resident #50 swung and hit her on the arm. She said Resident #70 was in his doorway and saw it happen. She said Resident #70 came out of his room and approached Resident #50. She said Resident #70 started swinging at Resident #50 and hit him. She said she and LVN L separated the residents. She said they wheeled Resident #50 to the dining room and Resident #70 to his room. She said Resident #70 tried to stand out of his wheelchair during the argument and tried to hit LVN L. She said that was the first time she had seen Resident #70 and Resident #50 interact. During an interview on 10/17/24 at 2:05 p.m., Regional RN FF, acting DON, said staff being rough during care was not appropriate. She said if a staff member abused a resident, then the resident would not want to receive care from the abuser. She said the resident needed to voice their concerns to the nursing staff and the abuse coordinator. She said residents should be educated on reporting mistreatment or abuse in resident council meetings and a letter sent out to the residents and resident's family about reporting abuse and who the abuse coordinator was. She said the Interim ADM was the abuse coordinator. She said she was not too familiar with the incident between Resident #70 and Resident #50. She said she would consider the incident between the resident abuse because they touched. She said the residents should have been separated, monitored, and psychological evaluation ordered. She said Resident #70 refused to go to a behavioral hospital. She said she did not think upper management knew about the hallway incident that happened before the dining room altercation. During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said she had not interviewed Resident #35 yet. She said she was working on the investigation since the abuse allegations were made 10/15/24. She said CNA P did not return the phone calls made to her by the facility but texted the facility asking what was going on. She said CNA P denied the allegation and claimed Resident #35 refused bed baths. She said CNA P said she did not know Resident #35 had issues with her. She said CNA P was suspended pending investigation. She said she expected staff to treat residents with respect. She said she expected staff to introduce themselves to residents, explain what they were going to do, and provide the assistance the resident needed. She said residents should be informed of who the abuse coordinator was and how to report abuse by the abuse coordinator during visits with the residents. She said she had only been at the facility for a few days. She said the social worker should also have conversations with the residents on abuse and reporting. She said during activities, the Activity Director should also be educating resident on how to file a complaint and who the abuse coordinator was. She said if a staff member was being rough during care including bathing, it would be considered abuse. She said if a resident was abused, they could feel neglected, frightened, depressed, and treated unfairly. She said the residents could also feel like staff did not like them and were being treated bad as a form of retaliation. She said she would consider Resident #70 slapping Resident #50 as abuse. She said anyone getting slapped would be upset about it. She said it depended on the resident's BIMS score on their reaction and lasting effect on being slapped. She said when resident to resident altercations happened, they should be separated and monitored 1:1 to help prevent it from happening again 3. Record review of Resident #74's face sheet, dated 10/14/2024, indicated she was a [AGE] year-old female, who was readmitted to the facility on [DATE] with the diagnoses which included Guillain-Barre syndrome (a condition in which the body's immune system attacks the nerves), muscle wasting and atrophy (wasting or thinning of muscle mass), difficulty walking, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest ) Record review of Resident #74's quarterly MDS, dated [DATE], indicated she had a BIMS score of 15, which indicated she was cognitively intact. Resident #74's MDS indicated she was understood and understands others. Resident #74 was dependent for most ADL's such as toileting hygiene, showering, dressing upper and lower body, putting on and taking off footwear, and she required substantial assistance with personal hygiene. Record review of Resident #74's undated care plan, indicated a focus on Resident #74 required antidepressant medication for a diagnosis of depression with interventions for following: o Educated the resident and family about risks, benefits, and the side effects and or toxic symptoms of anti-depressant drugs given. o Give antidepressant medications as ordered by the physician. Monitor and document side effects and effectiveness. Side effects: dry mouth, dry eyes, constipation, urinary retention, and suicidal ideations. o Monitor, document, and report to physician as needed ongoing signs or symptoms of depression unaltered by antidepressant medications such as: sadness, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideation, negative mood or comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight and appetite, fear or being alone or with others, unrealistic fears, attention seeking, concern with body function, anxiety and constant reassurance. Record review of Resident #77 s face sheet, dated 10/14/2024, revealed he was a [AGE] year-old female, who was admitted to the facility on [DATE], with the diagnoses which included Parkinson's disease (a movement disorder of the nervous system that worsens over time), schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania, and a milder form of mania called hypomania), mild cognitive impairment (the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia), and cerebrovascular disease (a term for conditions that affect blood flow to your brain ). Record review of Resident #77's quarterly MDS, dated [DATE], indicated she had a BIMS score of 12, which indicated she was moderately cognitively impaired. Resident #77's MDS did not indicate resident hallucinated or delusions during the look back period. Record review of Resident #77's undated care plan indicated, Resident #77 was sexually inappropriate as evidenced by Resident #77 taking her clothes off and began to rub on her roommate leg and made statement that she needed some loving and was making in appropriate remarks. Interventions included: o Evaluate the resident's ability to understand behavior and the consequences of that behavior. o Psychiatric services consult as needed. o Reinforce with staff that clear, firm limits are healthy, and required when resident makes inappropriate gestures and statements. o Report incidents of target behavior to charge nurse. o Resident was placed on one-on-one until sent out to psychiatric hospital. During an interview on 10/15/2024 at 11:06 AM, Resident # 74 said on 10/5/2024 that Resident #77 (perpetrator) was naked in her wheelchair and wheeled herself to her bedside and started rubbing all over me and touched my leg. Resident #74 said her roommate attempted to ease up on her bed and she pushed her back. Resident #74 said her roommate Resident #77 attempted to grab her hand to prevent her from grabbing her call light. Resident #74 said a CNA came in and saw Resident #77 (perpetrator) next to her bed naked and placed the resident back in her bed. Resident #74 said she felt nervous but fell back asleep and Resident #77 (perpetrator) did not bother her again throughout the night. She said she reported it and was interviewed by the weekend supervisor. The police were called, and a statement was given. Resident #74 said no administrative staff interviewed her. During an interview on 10/15/2024 at 12:53 PM CNA LL said she worked the 6 PM to 6 AM shift on 10/5/2024. CNA LL said she went in Resident # 74's room because her call light was on. She said Resident #74 was sitting up in her bed and Resident #77 (perpetrator) was naked in her wheelchair next to Resident #74's bed. CNA LL said Resident #77 (perpetrator) was not touching Resident #74 when she turned on the light. CNA LL said she assisted Resident #77 (perpetrator) back to her side of the room, dressed her, and placed her back in her bed. CNA LL said she immediately reported to the incident to ADON N who was working the unit. CNA LL said she left the door to Resident # 74's room open and made rounds. CNA said the next day when she returned to the unit, Resident #77 (perpetrator) was on 1 on 1 care. She said Resident #74 was not harmed. CNA LL said she did not know if the abuse coordinator was notified. CNA LL said she was not aware the resident had been touched or hurt. She just observed Resident #77 (perpetrator) naked, so she continued to check on them. During an interview on 10/15/2024 at 2:15 PM, RN F said she came in that morning about 9 AM and said the charge nurse was ADON N. RN F said LVN L said she needed to talk to me and reported Resident #74's roommate Resident #77 (perpetrator) was inappropriate with her. RN F said ADON N did not know anything about the incident and Resident #74 had told LVN L what happened. RN F said ADON N said she was only aware that the roommate was naked. RN F said Resident #74 did not voice to the CNA what had occurred. RN F said Resident #77 (perpetrator) had never been inappropriate prior to the allegation and was not sure how long they had been roommates. RN F said she did not feel the CNA was aware of the allegations and did appropriate care for both residents. During an interview on 10/16/2024 at 3:06 PM, CNA Q said Resident #74 had told her that Resident #77 (perpetrator) was touching on her and saying sexual things toward her. CNA Q said she was told the incident happened on a night shift and Resident #74 told her she reported it to the CNA. CNA Q said CNA LL did not report because she knew Resident #77 (perpetrator). CNA Q said Resident #77 (perpetrator) did have episodes of behaviors where she would lay down in her bed and not move and reported Resident #77 (perpetrator) did not like help. CNA Q said Resident #77 (perpetrator) would have episodes where she would not sleep for days. CNA Q said Resident #74 did not verbalize feeling scared or afraid. CNA Q said she would report immediately to the nurse if allegations were reported to her and said the abuse coordinator was the ADM. CNA Q said unwanted touching was considered abuse. During an interview on 10/17/2024 at 9:11 AM, Social worker E said the perpetrator never had any previous behaviors. Social worker E said the perpetrator transferred to the hospital and was currently receiving psychiatric care. Social worker E said Resident #77 (perpetrator) was having manic behaviors which included restless, not sleeping at night, and wheeling herself all over the facility. Social worker E said Resident #77 (perpetrator) was on medication and she started attending out-patient behavioral therapy approximately 1 week prior to incident. Social worker E said Resident #74 was not fearful or scared and was understanding of the situation. Social worker E said she had completed a trauma screen assessment on Resident #74 for 3 days in a row. She said the facility was not planning on returning Resident #77 (perpetrator) to the room. Social worker E said Resident #74 was receiving in-house psychiatric services and no concerns had been reported to facility since incident. During an interview on 10/17/2024 at 9:45 AM, ADON N said she had only been at the facility for 2 weeks. ADON N said Resident #74 had intermittent confusion. She said Resident #74 had never made any previous allegations. ADON N said she was not made aware of the allegations that night and made aware the next morning during report. ADON N said she was on call the night of the allegation and did not receive any calls. ADON N said Resident #77 (perpetrator) was removed from Resident #74's room and was in the dining area most of the day. ADON N said Resident #77 (perpetrator) had some behaviors which included yelling, wandering, demanding, and cussing. ADON N said Resident #77 (perpetrator) had to be redirected often. ADON N said Resident #77 (perpetrator) was removed from room and placed on 1:1 care on a different unit. During an interview on 10/17/2024 at 11:31 AM, the Regional Nurse FF said the DON reported the incident. She said she expected the nurses and staff to report any abuse concerns to the ADM even on the weekends. The Regional nurse said the on-call nurse would be available if the ADM was not available. She said she expected an intervention to be in place to keep residents safe. The Regional Nurse FF said the abuse coordinator, the DON, and the Social worker were responsible for conducting a thorough investigation. The Regional Nurse FF said if Resident #77 (perpetrator) was not removed from the victim, the victim could continue to be harmed. During record review of police report dated 10/6/2024 indicated an indecent exposure occurred during unknown hours of 11 PM and 2 AM on 10/5/2024. The police report indicated Resident #77 (perpetrator) was in the lobby in a counseling room to discuss events. The report indicated Resident #77 (perpetrator) was masturbating in her bed and got up to Resident #74's bedside to see if she wanted to join her. Resident #77 (perpetrator) reported to police she was masturbating next to Resident #74's bed and touching her leg and she wanted to touch her vagina. Resident #77 (perpetrator) reported to the police she did not touch Resident #74's vagina and only rubbed her legs. The perpetrator told police a nurse came into the room and told her to leave Resident #74 alone and she was taken to another room for some pills and went to sleep. Record review of police report dated 10/6/2024 indicated interview with Resident #74 said she woke up because she heard a lot of stuff fall. Resident #74 said Resident #77 (perpetrator) had pushed her tray over and was beside her bed naked and rubbing on her leg asking if she wanted to make love with her. Resident #74 told Resident #77 (perpetrator) no and to get back to bed. Resident #74 said Resident #77 (perpetrator) told her she wanted to touch her vagina. Resident #74 pushed the nursing help button, and Resident #77 (perpetrator) grabbed her hand and started rubbing it. Resident #74 said the nurse came into the room and removed Resident #77 (perpetrator). Resident #74 told police Resident #77 (perpetrator) only rubbed her leg that was protected by the cover and rubbed her hand when she pushed the button. The police were informed Resident #77 (perpetrator) would not be returning to the facility and was getting transported to an in-patient psychiatric hospital. Record review of a facility's, Violence Between Residents policy revised date 08/2020 indicated .the facility acts promptly and conscientiously to prevent and address between residents .facility staff monitors resident for aggressive or inappropriate behaviors toward other residents . Record review of a facility's Abuse Prevention and Prohibition Program policy revised date 10/24/22 indicated .each resident has the right to be free from mistreatment, neglect, abuse .staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment .the facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents . 49019

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 5 residents (Resident #25, Resident #16, and Resident #15) reviewed for respiratory care and services. 1. The facility failed to obtain a physician's order for Resident #25's oxygen, prior to surveyor intervention. 2. The facility failed to ensure Resident #25's oxygen concentrator was clean and free of gray/black debris. 3. The facility failed to ensure Resident #15's CPAP mask was stored in bag and oxygen concentrator had a filter on 10/14/24-10/17/24. 4. The facility failed to ensure Resident #16's oxygen concentrator filter was free from gray, fuzzy particles on 10/14/24-10/16/24. These failures could place residents who receive oxygen at risk for developing respiratory complications. Findings included: 1. Record review of Resident #25's face sheet, dated 10/15/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs can't exchange oxygen and carbon dioxide properly), heart failure (a serious condition that occurs when the heart can't pump enough blood and oxygen to meet the body's needs), chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe) and chronic pulmonary edema (fluid buildup in the lungs over time). Record review of Resident #25's quarterly MDS, dated [DATE], indicated he was able to make himself understood and he was able to understand others. His BIMS score was 11, which indicated moderately impaired cognition. Record review of a screenshot of Resident #25's physician's orders, taken on 10/15/24 at 2:10 PM, indicated the resident did not have an order for oxygen. Record review of a printed copy of Resident #25's physician's orders, provided by ADON A on 10/15/24 at 3:44 PM, and further dated for 10/15/24 at 03:06 PM, indicated these orders: *Change respiratory tubing, mask, bottled water, clean filter every 7 days as needed. The start date was 08/06/24. *Change respiratory tubing, mask, bottled water, clean filter every 7 days, every night shift every Wednesday. The start date was 08/07/24. *Oxygen at 2-4 liters per minute via nasal cannula every shift. The start date was 10/15/24. Record review of Resident #25's undated care plan indicated the care plan did not address his oxygen use. During an observation on 10/14/24 at 10:19 AM, Resident #25 was lying in bed watching TV in his room. He had oxygen in place via nasal cannula. The oxygen concentrator was set at 2.5LPM. The oxygen concentrator filter was dirty and was covered with gray debris, with black debris at the bottom of the filter. During an observation on 10/14/24 at 2:17 PM, Resident #25 was lying in bed watching TV in his room. He had oxygen in place via nasal cannula. The filter in the oxygen concentrator was dirty and had gray debris, with black debris at the bottom of the filter. During an observation on 10/15/24 at 08:47 AM, Resident #25 was in his room lying in bed. He had oxygen in place via nasal cannula. The filter in the oxygen concentrator was dirty and had gray debris, with black debris at the bottom of the filter. During an interview on 10/15/24 at 03:44 PM, ADON A said Resident #25 did not have an order for oxygen. She said she obtained the order after this surveyor pointed out the missing order to her, and then entered it into the resident's orders. She said the facility did not have a standing order for continuous oxygen use. During an interview on 10/16/24 at 02:01 PM, ADON A said she was not aware of the filter that this surveyor pointed out was dirty. She said the nursing staff check and clean the filters on Wednesdays on night shift. She said she checks the filters herself on Thursday mornings. She said the risk to the resident was potential infection. During an interview on 10/16/24 at 02:20 PM, the DON said the night nurse was responsible for changing the filters on Wednesdays. She said the ADONs were supposed to check, follow up, and ensure completion. She said the risk to the resident was potential infection. During an interview on 10/16/24 at 02:34 PM, the Interim Administrator said the oxygen concentrator filters should be cleaned as needed. She said the risk to the resident was a potential infection. 44933 2. Record review of Resident #15's face sheet dated 10/17/24 indicated Resident #15 was a 96-years-old female admitted on [DATE] and 03/03/19 with diagnoses including respiratory disorders in disease, shortness of breath, chronic obstructive pulmonary disease (is a common lung disease causing restricted airflow and breathing problems), and obstructive sleep apnea (is a common sleep disorder that causes the upper airway to partially or completely collapse during sleep, leading to reduced or absent breathing). Record review of Resident #15's annual MDS assessment dated [DATE] indicated Resident #15 was understood and understood others. Resident #15 had a BIMS score of 15 which indicated intact cognition. Resident #15 received oxygen therapy within the last 14 days. Record review of Resident #15's undated care plan indicated: *Resident #15 had oxygen therapy as needed related to shortness of breath. Intervention included oxygen via nasal prongs as needed. *Resident #15 had altered respiratory status/difficulty breathing related to sleep apnea. Intervention included CPAP settings 10/5 cm via nasal pillow at hour of sleep and PRN. Record review of Resident #15's consolidated physician order active as of 10/17/24 indicated: *CPAP 10/5 cm water heated humidifier via medium size nasal mask at hour of sleep for diagnosis of obstructive sleep apnea. Ordered date 12/15/22. *Oxygen at 2 liters per minute via nasal cannula, every 4 hours as needed, as needed every shift. Ordered date 02/27/24. During an observation on 10/14/24 at 11:40 a.m., Resident #15 was asleep in her recliner. Resident #15's CPAP mask was laying on the machine. Resident #15's mask was not stored in a bag. Resident #15's oxygen concentrator did not have a filter in the compartment. During an observation on 10/15/24 at 8:39 a.m., Resident #15 was asleep in her recliner. Resident #15's CPAP mask was laying on the machine. Resident #15's mask was not stored in a bag. Resident #15's oxygen concentrator did not have a filter in the compartment. 3. Record review of Resident #16's face sheet dated 10/17/24 indicated Resident #16 was a 71-years-old female admitted on [DATE] and 12/08/20 with diagnoses including shortness of breath and congestive heart failure (is a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 was understood and understood others. Resident #16 had a BIMS score of 13 which indicated intact cognition. Record review of Resident #16's undated care plan indicated Resident #16 had oxygen therapy related to congestive heart failure and shortness of breath. Intervention included to provide oxygen as needed at 2-5 liters per minute via nasal cannula PRN for shortness of breath. Record review of Resident #16's consolidated physician order active as of 10/17/24 indicated: *Change respiratory tubing, mask, bottled water, clean filter every 7 days every night every Wednesday. Change all O2 tubing and nasal cannula every Sunday on night shift. Ordered date 06/25/24. *Oxygen at 2-5 liters per minute via nasal cannula every 24 hours as needed for shortness of breath. Ordered date 07/21/23. Record review of Resident #16's MAR dated 10/01/24-10/31/24 indicated: *Change respiratory tubing, mask, bottled water, clean filter every 7 days every night every Wednesday. Change all O2 tubing and nasal cannula every Sunday on night shift. Ordered date 06-25-24. The MAR indicated administration on 10/09/24 (LVN Z) and 10/16/24 (RN H). *Oxygen at 2-5 liters per minute via nasal cannula every 24 hours as needed for shortness of breath. Ordered date 07/21/23. During an observation on 10/14/24 at 11:38 a.m., Resident #16 was lying in bed reading a book. She said she only used her oxygen at night. Resident #16's oxygen concentrator filter had a moderate amount of gray, fuzzy material on it. During an interview and observation on 10/15/24 at 8:37 a.m., Resident #16 was lying in her bed. Resident #16's oxygen concentrator filter had a moderate amount of gray, fuzzy material on it. Resident #16 said staff cleaned the filter sometimes, but they were human and forgot sometimes. During an interview on 10/16/24 at 2:10 p.m., LVN R said night shift nurses on Wednesdays and Sundays were supposed to change oxygen tubing and label and date the tubing. She said the night shift nurses were also supposed to clean the concentrator filters. She said it was also important for infection control. She said when a filter had gray, fuzzy material on it, it affects the oxygenation to the resident and may not work correctly. She said the nurse who took the CPAP mask off the resident, should make sure it was stored correctly. She said the CPAP mask was supposed to be stored in a clear bag when not in use for infection control. She said when a CPAP mask was not stored correctly, it could affect the amount of oxygen the resident received, caused a stuffy nose and risk of infection. During an interview on 10/17/24 at 8:15 a.m., RN H said she worked night shift on the 300 hall. She said she had only been employed at the facility for 3 months. She said she did not know who was responsible for storing a resident's CPAP mask in bag. She said Resident #15 did not use her CPAP machine at night, but the CPAP mask still should be stored in a bag. She said resident's oxygen concentrator filters should be cleaned once a week. She said dust particles could affect the resident oxygen flow to the nasal cannula and back the machine up. She said it was important to label and date oxygen tubing, store oxygen equipment not in use, in a bag and clean filters for infection control. She said the oxygen tubing could grow bacteria when it was not changed weekly. During an interview and observation on 10/17/24 at 10:28 a.m., ADON A said Resident #15's CPAP mask was currently stored in a bag. ADON A and Surveyor went to Resident #15's room. ADON A found Resident #15's missing filter in the resident's bathroom. ADON A said she did not know who was responsible for the internal filter on the oxygen concentrators. She said normally, the oxygen concentrators were only cleaned or swapped out if the resident was discharged . She said she did not know if a service company was supposed to come out and service the oxygen concentrators with interval filters. During an interview on 10/17/24 at 2:05 p.m., Regional RN FF said the nurses were responsible for cleaning and storing resident's oxygen equipment. She said the nursing staff were supposed to do it once a week or every 7 days. She said it was important to clean filters, and store equipment properly for infection control. She said the nurse who cleaned the filter, should make sure to put it back. She said nursing management should be ensuring the nurses are managing resident's oxygen equipment by rounding. She said residents were at risk for respiratory infections when oxygen equipment was not stored correctly or not cleaned properly. During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said nurses were responsible for respiratory equipment. She said the ADON and DON should ensure nursing staff were storing and cleaning equipment. She said if those things were not done, it placed residents at risk for possible infection. She said residents could experience respiratory distress, lung infection, and sinus infection. She said the internal filters on the oxygen concentrator should be handled by trained personnel. Record review of the facility's policy Oxygen Administration, last revised June 2020, stated: .A physician's order is required to initiate oxygen therapy, except in an emergency situation .oxygen items will be stored in plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use .document in patient's record .date and time oxygen is being used . The policy did not address oxygen concentrator filters.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 5 of 24 resident personal refrigerators reviewed for food safety (Resident #42, Resident #49, Resident #51, Resident #72, and Resident #81). 1.The facility failed to ensure the refrigerator for Resident #72 was cleaned, clutter free and free from meat with green mold. 2.The facility failed to ensure Resident #42, Resident #49, Resident #51, and Resident #81's refrigerator temperature was checked and logged daily. These failures could place resident at risk for food borne illnesses. The Findings were: 1.Record review of Resident #72's face sheet, dated [DATE] revealed a [AGE] year old male admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a serious, long-term condition that makes it difficult to breathe and exchange oxygen and carbon dioxide in the body), unspecified protein-calorie malnutrition (a condition that occurs when a person does not get enough calories or the right amount of nutrients, such as proteins, carbohydrates, fats, vitamins, and minerals), mild cognitive impairment of uncertain or unknown etiology (the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia), pulmonary fibrosis unspecified (a condition in which the lungs become scarred over time) and chronic obstructive pulmonary disease, unspecified(a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #72's quarterly MDS assessment, dated [DATE]. The MDS indicated a BIMS score of 15 indicating Resident #72's cognition was intact. The MDS indicated Resident #72 was independent with activities of daily living. Record review of Resident #72's Comprehensive Care Plan undated revealed that Resident #72 had impaired cognitive function or impaired thought processes. Is able to make his own decisions although he does not always make wise choices. During an observation on [DATE] at 10:01 A.M., in Resident #72's personal refrigerator was observed not clean, cluttered and had meat with green mold. The top of Resident's #72's refrigerator had ice build-up in to top. During an observation on [DATE] at 8:33 A.M., in Resident #72's personal refrigerator had ice build-up in the top, cluttered, not clean and had meat with green mold . During an interview on [DATE] at 12:28 P.M., with LVN R she said she thought all the food probably came from when Resident #72's wife was here, because he does not go to the store and she did, but she passed a couple weeks ago . She said she never went into Resident #72's refrigerator. She said she was not sure who was responsible for checking and cleaning the resident's refrigerators. She said she was sure he would not eat the molded food. She said it looked like everything in the refrigerator needed to be thrown away. She said the negative effects of Resident #72 having a nasty refrigerator with molded items in it was he could get sick from ingesting the molded food. During an interview on [DATE] at 1:01 P.M., with Restorative Aide CC she said housekeeping was responsible for keeping the resident's refrigerators clean. She said Resident #72's refrigerator looked nasty. She said the molded meat could affect everything in Resident #72's refrigerator and make him sick. She said she would not want any molded items in her refrigerator. During an interview on [DATE] at 1:10 P.M., with ADON N she said as an ADON we were supposed to be doing ambassador rounds, such as checking the resident's rooms. She said there was no excuse for Resident #72's refrigerator to look like that. She said any staff member can check temps and clean refrigerators. She said the facility would follow up on Resident #72's refrigerator and buckle down on staff to make sure the refrigerators in resident's rooms are cleaned and checked. During an interview on [DATE] at 2:57 P.M., with Housekeeping JJ she said housekeeping was responsible for making sure the resident's refrigerators were clean. She said they was supposed to clean the resident's refrigerators every day and do the temperature logs. She said the pictures of Resident #72's refrigerator looked nasty. She said they was supposed to notify their supervisor if we had any issues with refrigerators. She said the molded items in the refrigerator could have made the resident very sick, cause vomiting, diarrhea or maybe a trip to the hospital. During an interview on [DATE] at 8:40 A.M., with LVN DD she said the nurses and CNAs were responsible for checking and cleaning the resident's refrigerators. She said Resident #72's refrigerator looked nasty. She said consuming the molded meat could be an upper respiratory issue, possibly food poisoning and could make the resident sick. During an interview on [DATE] at 9:00 A.M., with Housekeeping KK she said housekeeping was responsible for keeping the resident's refrigerators clean and checking the temperatures. She said the residents usually told staff if their refrigerators were dirty. She said the negative affect of the items in the refrigerator could have on the resident if he ate them was, they could make the resident sick. She said the refrigerator was unacceptable. During an interview on [DATE] 09:08 A.M., with CNA EE she said she was not sure who is responsible for making sure the resident's refrigerators were cleaned. During an interview on [DATE] at 10:36 A.M., with ADON A she said sometimes she left things too long in her refrigerator at home. She said housekeeping were supposed to be cleaning and monitoring the resident's refrigerators, but the facility was going to change the monitoring process to prevent that from happening again. She said the negative effects that could had happened to Resident #72 for having molded items in his refrigerator would be it would make him sick if he was to eat it, it could cause nausea and vomiting or food poisoning. During an interview on [DATE] at 10:54 A.M., with the Administrator she said who was responsible for the resident's refrigerator depend on who the facility decided who was responsible for cleaning and monitoring the refrigerators. She said she was not sure exactly who was responsible or who is required to make sure the refrigerator was cleaned. She said the negative effects of Resident #72's refrigerator was a potential for food poisoning. 2. During an observation and interview on [DATE] at 10:49 a.m., Resident #49 was lying in bed. Resident #49's refrigerator temperature log sheet had a temperature only on [DATE]. Resident #49 said he did not know about the refrigerator log. Resident #49 said he was in a hospital and did not know what was going on. Resident #49 was only oriented to person but not place or time. Resident #49 was not interviewable. During an interview and observation on [DATE] at 12:07 p.m., Resident #42 was in her room. Resident #42's refrigerator log sheet was missing temperatures from [DATE]-[DATE]. Resident #42 said she saw staff occasionally check the temperature. During an interview and observation on [DATE] at 2:21 p.m., Resident #51 was laying in her bed cursing with delusions of being pregnant. Resident #51 was not interviewable. Resident #51's refrigerator log sheet was missing temperatures from [DATE]-[DATE]. During an interview on [DATE] at 8:33 a.m., Resident #81 was lying in her bed. Resident #81 said staff did not check her personal refrigerator every day. She said Housekeeping Supervisor T came yesterday to check the refrigerator temperature and logged a bunch of temps. Resident #81's refrigerator log sheet had documented temps from [DATE]-[DATE] all by Housekeeping Supervisor T. During an interview on [DATE] at 2:10 p.m., LVN R said housekeeping was responsible for checking resident's personal fridge and log temperature daily. She said housekeeping was supposed to check the fridge for expired foods and make sure the freezer section was good. She said when housekeeping did not check resident's fridges, the resident's food could spoil if it was too warm. She said the resident's food could also get freezer burned if the freezer was too cold. She said residents could get sick and possible have diarrhea. During an interview on [DATE] at 3:10 p.m., Housekeeper S said housekeeping was responsible for resident's refrigerator logs. She said the logs should be completed daily. She said she checked the refrigerators every day on the rooms she cleaned. She said she sometimes did not put the temperatures on the log sheet but on a piece a paper. She said she was supposed to put the temperatures on the log sheet every day. She said it was important to check resident's fridge temps and put the temperature on the log sheet to see if the food stayed good and not bad. During an interview on [DATE] at 9:10 a.m., the Housekeeping Supervisor T said housekeeping was responsible for checking resident's personal fridges daily. She said the temperatures should be documented on the log sheet which was normally on the fridge or the wall above the fridge. She said she went to rooms daily for ambassador rounds and checked the fridge log sheets to ensure it was being done. She said she had been working 7 days a week due to short staffing. She said Resident #81's fridge log had been done. She said Resident #49's fridge had been locked and the key was lost. She said Resident #49's fridge had been recently opened so the temperatures should have been done for the last few days. She said Resident #51 was missing temps on the log sheet. She said Resident #42's temperatures were written on pieces of paper instead of the log sheet. She said she had lost Resident #42's temperatures on the pieces of paper. She said checking temperatures on resident's fridges was important to make sure they do not go out, check to make sure the freezer did not need to be thawed out. She said staff and residents would not know and the food would go bad. During an interview on [DATE] at 10:15 a.m., CNA O said housekeeping was responsible for the resident's refrigerator logs. She said housekeeping was supposed to do it daily. She said the fridges needed to be checked daily to make sure food did not go bad. She said the bad food could make the resident's sick. During an interview on [DATE] at 10:28 a.m., ADON N said resident's fridges needed to be checked and temperatures logged daily. She said during ambassador rounds, those staff members should be making sure temperatures were logged or fill out the log themselves. She said anyone who viewed the log sheet could fill it out. She said the nurses, housekeeping supervisor, and ambassadors should be ensuring the temps were done daily. She said it was important to check and document the temperatures daily to ensure food was not spoiled. She said residents had the potential to get sick for eating spoiled food. During an interview on [DATE] at 2:05 p.m., the Regional Nurse FF, acting DON, said housekeeping was responsible for resident's refrigerator log sheets. She said the log sheets could also be completed by the nursing staff. She said the log sheets should be completed daily. She said the Housekeeping Supervisor and ambassadors should be ensuring staff completed the log sheets daily. She said it was important to document the refrigerator logs daily to make sure things were kept at the right temperature and food did not go bad. She said residents were at risk for food poisoning. During an interview on [DATE] at 2:58 p.m., the interim ADM said she had only been at the facility for a few days. She said she would think maintenance, housekeeping, and ambassadors were responsible for personal fridge temperature logs. She said those staff members should log temperatures daily on the log sheets. She said temperatures logs needed to be completed daily to make sure the refrigerator worked so the resident's food did not get spoiled. She said if a resident ate spoiled food, they could get a stomach virus or food poisoning. Record review of a facility's Refrigerator/Freezer Temperature Records policy revised date ,d+[DATE] indicated .a daily temperature record is to be kept for refrigerated and frozen storage areas . Record review of a facility's Refrigerator-Personal policy dated ,d+[DATE] indicated .it is the policy of this home that resident's refrigerators will be checked weekly for cleanliness and remaining sanitary. Procedure: the housekeeping Supervisor/designee will monitor resident's refrigerators weekly . inform resident prior to checking fridge . clean and remove expired food as needed . keep thermometer in refrigerator and maintain at 41 degrees or below . log temperature weekly when checked . notify ADM/ DON/ Designee of any issues for immediate intervention . notify family of concern/ issues . 44933

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 3 of 7 residents (Resident #52, Resident #79, and Resident #88) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #52, Resident #79, and Resident #88's indwelling catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor catheter to their legs on 10/14/24, 10/15/24, and 10/16/24. The facility failed to ensure Treatment Nurse M did not place Resident #79's catheter bag on the bed during wound care on 10/15/24. Theses failures could place residents at risk for urinary tract infections. Findings included: 1. Record review of Resident #52's face sheet dated 10/17/24 indicated Resident #52 was a 77-years-old male admitted on [DATE] with diagnosis including obstructive and reflux uropathy (is a general term for a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally). Record review of Resident #52's quarterly MDS assessment dated [DATE] indicated Resident #52 was understood and understood others. Resident #52's BIMS score was 12 which indicated moderate cognitive impairment. Resident #52 had an indwelling catheter and frequently incontinent for bowel. Record review of Resident #52's undated care plan indicated Resident #52 had indwelling foley catheter related to stricture (obstructive uropathy). Intervention included position catheter bag and tubing below the level of the bladder. During an observation and interview on 10/14/24 at 10:49 a.m., Resident #52 was lying in his bed. Resident #52 said he did not have anything on his leg to hold his catheter tubing. Resident #52 did not have an anchoring device on either thigh. During an observation on 10/15/24 at 8:39 a.m., Resident #52 was sitting in his wheelchair eating breakfast in a t-shirt and brief. Resident #52 did not have an anchoring device on either thigh. During an observation on 10/16/24 at 3:00 p.m., Resident #52 was sitting in his wheelchair wearing shorts. Resident #52's catheter tubing could be visualized. Resident #52 did not have an anchoring device on either thigh. 2. Record review of Resident #79's face sheet dated 10/14/24 indicated Resident #79 was a 55-years-old male admitted on [DATE] and 05/01/24 with diagnoses including paraplegia (is paralysis that affects your legs, making it impossible to stand or walk), dependence on renal dialysis, pressure ulcer (are localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) of sacral region (is a skin injury that occurs in the sacral region of the body, near the lower back and spine), Stage 4 (injuries extend to muscle, tendon, or bone.), and obstructive and reflux uropathy (is a general term for a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally). Record review of Resident #79's quarterly MDS assessment dated [DATE] indicated Resident #79 was understood and understood others. Resident #79 had clear speech, adequate hearing, and adequate vision with corrective lenses. Resident #79 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #79 had an indwelling catheter and was always incontinent of bowel. Record review of Resident #79's undated care plan indicated Resident #79 had indwelling catheter related to obstructive and reflux uropathy. Intervention included position catheter bag and tubing below the level of the bladder. During an interview and observation on 10/15/24 at 3:30 p.m., Resident #79 was lying in bed waiting on wound care to be started by Treatment Nurse M. Treatment Nurse M moved Resident #79's indwelling catheter bag from the left side of the bed and laid it flat on the right side of the resident, on the bed. Resident #79's anchor device was around the catheter tubing near the catheter, not attached to Resident #79. Treatment Nurse M completed three wound care treatments then placed Resident #79's catheter bag back on the hooks, on the left side of the bed. After the wound care treatment, Resident #79 said he had an anchoring device to thigh sometimes, but it did not always stay stuck to his leg. 3. Record review of Resident #88 face sheet dated 10/16/24 indicated Resident #88 was a 59-years-old male admitted on [DATE] and 09/09/24 for diagnoses including Asperger's syndrome (is a neurodevelopmental disorder that is part of the autism spectrum and is characterized by difficulties with social interaction and communication, as well as repetitive behaviors and interests), retention of urine, obstructive and reflux uropathy (is a general term for a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally), and need for assistance with personal care. Record review of Resident #88's annual MDS assessment dated [DATE] indicated Resident #88 had unclear speech, adequate hearing, and impaired vision. Resident #88 was sometimes understood and sometimes understood others. Resident #88 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #88 had an indwelling catheter and always incontinent for bowel. Record review of Resident #88 undated care plan indicated Resident #88 had an indwelling catheter for diagnosis of obstructive uropathy. Intervention included apply catheter secure device to thigh to decrease the risk of foley tubing pulling. Record review of Resident #88's consolidated physician order active as of 10/15/24 indicated check the catheter securement device each shift and prn for placement, every shift for preventative. Ordered date 08/03/23. Record review of Resident #88's MAR dated 10/01/24-10/31/24, printed 10/16/24 indicated check the securement device each shift and PRN for placement, every shift for preventative. Ordered date 08/03/23. The MAR indicated administration on 10/14/24 (RN Y, LVN Z), 10/15/24 (LVN L, RN H). During an observation and interview on 10/14/24 at 11:17 a.m., Resident #88 was lying in bed with a catheter bag hanging on the right side of his bed. Resident #88 said no he did not have anything on his leg holding his catheter tubing. Resident #88 lifted his gown to the top of his thighs. Resident #88 did not have an anchoring device on his thighs. During an observation on 10/15/24 at 11:01 a.m., a therapist was working with Resident #89's legs. Resident #88 did not have an anchoring device on his thighs. During an interview on 10/17/24 at 8:15 a.m., RN H said the nurses were responsible for ensuring residents with catheters had an anchoring device. She said the anchoring device was important to hold the catheter tubing in place. She said Resident #52 had an anchoring device last week but did not check to see if he had one last night (10/16/24). She said Resident #88 did not have an anchoring device on last night. She said she thought Resident #79 had one on last night but was not for sure. She said when the residents did not have an anchoring device, it placed them at risk for pain in the urethra and bladder. She said the residents could experience irritation and bleeding. During an interview on 10/17/24 at 9:34 a.m., the Treatment Nurse M said Resident #79's catheter bag should have been hung on the other side of the bed, not laid down on the bed. She said the bag should not have been placed on the bed due to infection control and the catheter bag was not below Resident #79's bladder. She said when the catheter bag was not below the bladder, the urine could go back in the bladder and cause an infection. During an interview on 10/17/24 at 10:15 a.m., CNA O said the LVNs were responsible for the anchoring devices for resident's catheters. She said if she noticed a resident did not have one on, she notified the nurse. She said an anchoring device was important so the tubing would not get hung on things and pulled. She said the anchoring device helped the catheter tubing stay in place and secured. She said when a resident did not have an anchoring device it could get pulled out. During an interview on 10/17/24 at 10:37 a.m., ADON N said a catheter bag should not be placed on the bed. She said it was not good practice due to infection control and risk of spillage. She said that also risked the urine going back up to the bladder and causing an infection and pain. During an interview on 10/17/24 at 2:05 p.m., Regional RN FF said the nurses were responsible for the residents with indwelling catheters to also have an anchoring device. She said the residents should have an order to check for an anchoring device. She said the nurses had to sign off the observation on the MAR/TAR. She said the anchoring device prevented tugging which could cause trauma. She said the nurses should be checking for an anchoring device every shift. She said the ADONs, and DON should ensure the LVNs were monitoring anchoring devices. She said a resident's catheter bag should never be placed on the bed. She said the resident's catheter bag should be hooked on either side of the bed. She said this should not be done for infection control and the potential for urine backflow. She said the backflow of the urine, to the resident's bladder could cause a urinary tract infection. During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said the nurses were responsible for ensuring residents with foley catheters had an anchoring device. She said the LVNs should be checking for an anchoring device every shift. She said the anchoring device made sure the tubing was not moved and tugged. She said when the residents did not have an anchoring device, it placed residents at risk for the catheter getting pulled out and skin tear. She said the residents could experience bleeding if the catheter was pulled out. She said she expected staff to place the catheter bags on the sides of the beds, not in the bed. She said it was an infection control issue and could irritant the bladder. She said the residents were at risk for bladder infections. Record review of a facility's Catheter-Care of policy revised date 06/2020 indicated .each resident who is incontinent of urine is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible .a resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible .anchor the catheter with a leg strap to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter .collection bags should always be kept below the level of the bladder .catheter tubing should be secured to prevent dependent loops .

Based on interviews and record review the facility failed to ensure each resident was informed before or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #274, and Resident #275) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #274, and Resident #275 were given a SNF ABN (a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk for not being aware of changes to provided services. Findings included: 1. Record review of Resident #274's face sheet, dated 10/15/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included embolism and thrombosis of arteries of the upper extremities (a condition where blood clots form in the arms), and type 2 diabetes (a chronic condition where the levels of sugar, or glucose, build up in the body). Record review of Resident #274's quarterly MDS assessment, dated 09/26/24, indicated she was able to make herself understood, and able to understand others. She had a BIMS score of 14, which indicated she had intact cognition. Record review of the SNF Beneficiary Notification Review indicated Resident #274 received Medicare Part A skilled services on 11/22/23 and the last covered day of Part A was 07/01/24. The SNF Beneficiary Notification Review indicated the facility/provider notified the Resident of discharge from Medicare Part A services with a NOMNC form on 06/28/24. The review further did not contain a SNF ABN for Resident #274. 2. Record review of Resident #275's face sheet, dated 10/15/24, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects brain function), and chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe). Record review of Resident #275's admission MDS assessment, dated 03/14/24, indicated she was able to make herself understood, and was able to understand others. She had a BIMS score of 15, which indicated intact cognition. Record review of the SNF Beneficiary Notification Review indicated Resident #275 received Medicare Part A skilled services on 03/12/24 and the last covered day of Part A was 05/13/24. The SNF Beneficiary Notification Review indicated the facility / provider notified the Resident of discharge from Medicare Part A services with a NOMNC form on 05/08/24. The review further did not contain a SNF ABN for Resident #275. During an interview on 10/15/24 at 11:50 AM, SW E said that an ABN form was not provided to Resident #275. She did not realize the form was required to be given to the resident and stated it should have been provided. During an interview on 10/15/24 at 12:20 PM, SW E said an ABN form was not provided to Resident #274. She said it was not provided for the same reason as Resident #275. During an interview on 10/16/24 at 02:28 PM, SW E said Resident #275 and Resident #274 should have been provided an ABN form. She said it was important for them to receive the form because it was required by regulation. She said the ABN form should have been issued at the same time as the NOMNC. She said the risk was that the resident may not be aware of out-of-pocket costs after being discharged from Part A services. During an interview on 10/16/24 at 02:34 PM, the Interim Administrator said Residents #274 and #275 should have received the ABN form. She said it was important for the residents to receive the form because it would have helped the residents understand the cost of their services if they stayed in the facility after they ran out of Part A days. She said the risk was they could be charged and not know the cost of their stay. She said it could also cause the resident to have increased anxiety. Record review of the facility's policy, Beneficiary Notice Policy, effective 04/20/23, stated: .A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay . .Deadline for providing ANB/NOMNC to resident or guardian: 48 hours before services are set to expire . .The Social Service department is responsible for completing and issuing these forms to the resident and/or family to be signed .

Based on interviews and record review, the facility failed to report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report regarding Resident#1's incident with Resident #26, dated 09/12/24 was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1. This failure could place residents at risk for abuse and neglect. Findings included: 1. Record review of Resident #1's face sheet, dated 10/14/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (a group of symptoms that affect a person's memory, thinking, and social abilities), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about various aspects of daily life), and chronic obstructive pulmonary disease (a group of progressive lung diseases that cause obstructed airflow from the lungs and make breathing difficult). Record review of Resident #1's quarterly MDS assessment, dated 08/30/24, indicated she was able to make herself understood and understand others. She had a BIMS score of 9, indicating moderate cognitive impairment. Record review of the facility's provider investigation report for the reported incident for Resident #1, dated 9/12/24 (date facility made aware of incident), indicated that Resident #1 alleged that Resident #26 hit her on the back after an argument over the television and other belongings in the room. Resident #1 cannot recall when the incident occurred but thinks it may have happened on 09/11/24 at an unknown time, but she was not sure. Head-to-toe skin assessment performed, and no injury noted to Resident #1's back. The residents were immediately separated. Resident #26 was moved to a different room on the 200 hall and both residents were interviewed. Staff increased supervision of both residents to ensure no emotional distress for either. Neither resident could remember the details of the events or dates they occurred. Both were extremely confused and poor historians. No injuries to either resident was noted during head-to-toe assessments. Resident #26 had bruising from falls that were in the healing process at the time of the head-to -toe assessment. Ultimately, the facility's investigation concluded that the allegation of abuse was inconclusive. In-services were conducted with facility staff on the prevention of abuse and neglect and in-service on de-escalation. The allegation was reported to the state survey agency on 09/12/24 . During an interview on 10/15/24 at 12:41 PM, the Administrator she said the provider investigation report for incident 531976 was not turned into the state. She said it should have been turned into the state within 5 days of the report. During an interview on 10/15/24 at 12:43 PM, the Administrator provided an email dated 10/01/24 indicating the PIR was submitted on 10/01/24. She said it was submitted in 6 days and it should have been submitted in 5 days or less. During an interview on 10/15/24 at 12:54 PM, the Administrator said the facility did not have a policy other than the abuse policy for turning in a PIR in 5 days. During an interview on 10/17/24 at 12:20 PM, the Administrator said, I cannot tell you why the provider investigation report was not turned in to HHSC for Resident #1, because that was before I got here. The Administrator said the provider investigation report should have been turned in to HHSC within 5 working days of the investigation. She said she was the Administrator and her first day was 10/14/24 . Record review of the facility's undated policy, Abuse/Neglect, stated: .IX. Reporting/Response . .D iv. The administrator will provide the state survey agency, law enforcement and the Ombudsman with a copy of the investigative report within 5 days of the incident .

Based on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 24 resident reviewed for assessments. (Resident #49 and Resident #88) The facility failed to ensure Resident #49's MDS dated [DATE], was not inaccurately coded for being on an antipsychotic medication (are a class of psychotropic medication primarily used to manage psychosis). The facility failed to ensure Resident #49's MDS dated [DATE], was not inaccurately coded as having a diagnosis of bipolar (is a mental illness that causes extreme shifts in mood, energy, and activity levels) instead of mood disorder. The facility failed to ensure Resident #88's MDS dated [DATE] was coded for being PASRR (is a federally mandated review process, requiring all people seeking Medicaid-certified nursing facilities admissions to be screened for mental illness or intellectual and developmental disability regardless of funding source or age) positive for development disability/intellectual disability. These failures could place residents at risk of not having individual needs met. Findings included: 1. Record review of Resident #49's face sheet dated 10/14/24 indicated Resident #49 was a 54-years-old male admitted on [DATE] and 09/18/23 with diagnoses including mood disorder (is a mental health condition that primarily affects your emotional state) and vascular dementia (is a type of dementia that occurs when blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior), severe, with mood disturbance (is a general term for a range of psychiatric conditions that affect a person's emotional state). Record review of Resident #49's quarterly MDS assessment dated [DATE] indicated Resident #49 was understood and understood others. Resident #49 had a BIMS score of 05 which indicated severe cognitive impairment. The MDS indicated Resident #49 had diagnoses including depression and bipolar disorder. The MDS indicated Resident #49 had received an antipsychotic during the last 7 days of the assessment period. Record review of Resident #49's consolidated physician orders active as of 10/15/24 indicated Depakote Oral Tablets Delayed Release (Divalproex Sodium) (is an anticonvulsant), give 125 mg by mouth in the morning for [sic]. Start date 01/11/24. Resident #49's consolidated physician orders did not reflect an antipsychotic medication. Record review of Resident #49's undated care plan indicated: *Resident #49 had history of behavioral problems. On 09/18/23, Resident #49 returned from an inpatient stay at a behavioral unit with a new diagnosis of mood disorder due to known physiological condition with manic features. Intervention administer medication as ordered. *Resident #49 required antidepressant medication for diagnosis of depression and mood disorder. Intervention included give antidepressant medications ordered by physician. Record review of Resident #49's psychiatric subsequent assessment dated [DATE] indicated . Resident #49 had primary treating diagnosis: other specified depressive episodes, secondary treating diagnosis: other psychoactive substance dependence with psychoactive substance-induce mood disorder, tertiary treating diagnosis: vascular dementia, severe, with mood disturbance, diagnosis treating: other seizures (is a temporary, abnormal burst of electrical activity in the brain) .history of presenting illness .depression . Resident #49 psychiatric subsequent assessment did not reflect a diagnosis of bipolar disorder. During an interview on 10/15/24 at 10:18 a.m., MDS Coordinator W said she completed Resident #49's MDS assessment. She said Resident #49 was on Depakote, an anticonvulsant, but it was prescribed for his mood disorder. She said she classified the Depakote as an antipsychotic because until October 1, 2024, an anticonvulsant option was not available. She said Resident #49 had a mood disorder, so she coded it as bipolar disorder. She said there was no documentation stating Resident #49's mood disorder was bipolar. During an interview on 10/15/24 at 10:30 a.m., MDS Coordinator W said she was new to the facility and stated she was still learning. She said the Regional MDS Coordinator had educated her on how to correctly code anticonvulsants and mood disorders. 2. Record review of Resident #88's face sheet dated 10/16/24 indicated Resident #88 was a 59-years-old male admitted on [DATE] and 09/09/24 for diagnoses including Asperger's syndrome (is a neurodevelopmental disorder that is part of the autism spectrum and is characterized by difficulties with social interaction and communication, as well as repetitive behaviors and interests), limitation of activities due to disability, need for assistance with personal care, obstructive and reflux uropathy (is a general term for a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally), and retention of urine (is the inability to empty the bladder). Record review of Resident #88's annual MDS assessment dated [DATE] indicated Resident #88 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #88 had unclear speech, adequate hearing, and impaired vision. Resident #88 was sometimes understood and sometimes understood others. Resident #88 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #88 admission performance was substantial/maximal assistance for oral hygiene and dependent for chair/bed-to-chair transfer. Resident #88 had an indwelling catheter and always incontinent for bowel. Record review of Resident #88's undated care plan indicated Resident #88 was PASRR positive and receiving specialized services. Intervention included will continue to monitor PASRR services were ordered. Record review of Resident #88's PASRR Evaluation (Level II) dated 05/21/24 indicated Resident #88 had a developmental disability other than an intellectual disability that manifested before the age of 22. During an interview on 10/17/24 at 10:05 a.m., MDS Coordinator W said if Resident #88 was PASRR positive, it should have been coded on his annual MDS. She said she had not completed Resident #88's MDS. She said MDS Coordinator V had done Resident #88's annual MDS assessment. During an interview on 10/17/24 at 10:45 a.m., MDS Coordinator V said she completed Resident #88's annual MDS assessment. She said Resident #88 was PASRR positive for development disability and received services. She said Resident #88's PASRR status should have been coded on his MDS assessment. She said it was a data entry error on her part. She said the Corporate MDS Coordinator spot checked the facilities submitted MDS assessments. She said it was important for Resident #88's PASRR status to be on his MDS to make sure he was getting services and it was part of his clinical record. She said a resident's MDS assessment should be accurate to know the resident's status and what the facility was doing for them. During an interview on 10/17/24 at 11:00 a.m., the Regional MDS Coordinator X said a resident's PASRR positive status should be reflected on their annual MDS. She said Depakote was an anticonvulsant not an antipsychotic. She said after October 1, 2024, the MDSs had an anticonvulsant coding option. She said medications should be coded as their drug classification not how they were being used. She said Resident #49's mood disorder should have been added on additional diagnoses not coded as bipolar. She said it was important for a MDS assessment to be accurate because it reflected the resident's care during the assessment period and identified needs. She said the MDS assessments should always be coded correctly per the RAI. She said she audited the facility's MDS assessments last month and tried to do them quarterly. During an interview on 10/17/24 at 2:05 p.m., the Regional RN FF said the MDS Coordinator was responsible for accurate MDS assessments. She said she expected resident's MDS assessment to be accurate. She said the DON signed the MDS assessment indicating it had been reviewed and was accurate. She said the RN who signed the resident's MDS assessment was responsible for ensuring the MDS Coordinator coded the resident's information correctly. She said Depakote was an anticonvulsant not an antipsychotic. She said a mood disorder should not automatically be coded as bipolar disorder. She said positive PASRR status should be reflected on the resident's MDS assessment. She said if the MDS was not accurate, it did not reflect the resident's plan of care accurately. During an interview on 10/17/24 at 2:58 p.m., the Interim ADM said the MDS Coordinator was responsible for accurate MDS assessments. She said when the RN signed the MDS assessment, it implied it was ready to be closed. She said the Regional MDS Coordinator or RN, who signed the MDS assessment should ensure the MDS Coordinator submitted accurate MDS assessments. She said it was important for MDS assessments to be accurate because the information was how the facility cared for the resident and showed the level of care they would be receiving. She said if the MDS assessment was not accurate, the resident was at risk for not receiving accurate care. She said a resident's PASRR positive status should be on their MDS assessment. She said only documented diagnoses should be coded on the MDS assessment. Record review of an undated facility's Minimum Data Set policy indicated .the facility will follow RAI guideline for all areas related to MDS process .to utilize the most current version of the RAI manual to guide all IDT members on the proper procedure for coding items on MDS assessment .

Based on interviews and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 13 residents (Resident #97) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #97. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #97's face sheet, dated 10/14/2024, revealed he was a [AGE] year-old male, who was readmitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (symptom that involves one-sided paralysis after blood flow to the brain is blocked or reduced), obstructive and reflux uropathy (when your urine can't flow (either partially or completely) through your ureter, bladder, or urethra due to some type of obstruction), and schizophrenia ( mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #97's quarterly MDS, dated [DATE], indicated he had a BIMS score of 15, which indicated he was cognitively intact. Resident #97's MDS revealed an active diagnosis of Schizophrenia. Record review of Resident # 97's PASARR level L1 dated 8/2/2023 indicated Resident #97 did not have a mental illness. Record review of Resident #97's care plan, undated revealed Resident #97 required psychotropic medication for diagnosis of Schizophrenia. Resident #97's care plan did not indicate he was PASRR positive or negative. Record review of Resident #97's PASRR Level 1 Screening, dated 08/03/2023, indicated in Section C Mental Illness was marked as no, which indicated Resident #97 did not have a mental illness. During an interview on 10/17/2024 at 9:08 AM Social worker E said she does not complete any of the PASSR level one screenings or PASSR. Social worker E said she attends the meetings for care plans. Social worker E said she was not sure which residents were receiving PASSR services. She said she was aware that residents with mental illness and do not have dementia can qualify for services and those residents with intellectual disabilities. During an interview on 10/17/2024 at 8:34 AM, MDS Coordinator V said all residents should have a PASSR level one. She said if a resident had a diagnosis of a mental illness or intellectual disability, they would be positive. She said there were 2 authorities depending on if the resident had mental illness or intellectual disabilities. MDS Coordinator V said she would be aware if a resident qualified if they received a negative letter. MDS Coordinator V said if the resident was positive, then the facility would schedule a meeting and the facility only care plans if a resident was positive. MDS Coordinate V said Resident # 97 had come to the facility with a diagnosis of schizophrenia and said the hospital incorrectly marked mental illness as no. MDS Coordinator said she had completed the form 1012 on 10/17/2024 and the local authority had already requested records. MDS Coordinator V said Resident #97 had already been receiving psychiatric services since 8/2/2023. During an interview on 10/17/2024 at 9:33 AM, ADON N said she was not sure about PASRR. During an interview on 10/17/2024 at 11:31 AM, Regional Nurse FF said the MDS nurse was responsible for ensuring the PASARR forms were completed. She said the resident's PASARR should have been positive with a diagnosis of schizophrenia. Regional Nurse FF said the MDS nurse should have identified the diagnosis and referred PASARR evaluation. She said she expected the nurses to complete the form 1012 when identified a resident had a mental illness. Regional Nurse FF said if the resident has proper orders in place, the care was coordinated to receive services. During an interview on 10/17/2024 at 11:55 AM, the ADM said she had been the ADM since Monday. The ADM said a resident who had a mental illness should be evaluated for a positive PASSR. She said the resident could qualify for additional services. Record review of the facility's policy, undated and titled Pre-Admission Screening Resident Review (PASRR) stated: To ensure that all Facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated. PASARR is a federal requirement .A. PASSR level I screening is to be completed before the individual is admitted .B. All first-time applicants to the facility, regardless of Medicaid status or payor .ii. The state is responsible for providing specialized services to residents with MD/ID residing in Medicaid certified facilities .

Based on interviews and record review the facility failed to notify the State Mental Health Authority to inform them of a significant change in mental condition for 1 of 5 (Residents #93) residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR). 1. The facility failed to notify the SMHA to ensure Resident #93 received a new PASRR level 1 screening following identification of his diagnosis of post-traumatic stress disorder on 01/25/24. This failure could affect residents who may have a mental disorder diagnosis by placing them at risk for not receiving the necessary services that may benefit them daily. Findings included: Record review of Resident #93's face sheet, dated 10/14/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included post-traumatic stress disorder (a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), encephalopathy (a broad term for any brain disease that alters brain function or structure) and other specified depressive episodes (a diagnosis for a person who has symptoms of a depressive disorder but doesn't meet the full criteria for a specific depressive disorder). Record review of Resident #93's quarterly MDS assessment, dated 9/20/24. The MDS indicated a BIMS score of 12 indicating Resident #93's cognition was moderately impaired. The MDS indicated Resident #93 was independent with activities of daily living. Record review of Resident #93's admission record, dated 05/05/23, reflected his diagnoses included encephalopathy unspecified, onset date 05/05/23; and other specified depressive episodes, onset date 05/05/23. Record review of Resident #93's face dated 10/14/24, indicated she had a diagnosis that included post-traumatic stress disorder. Record review of Resident #93's PASRR Level 1 Screening, dated 05/05/23, indicated the resident did not have mental illness, intellectual disability, or developmental disability. Record review of Resident #93's PASRR Level 1 Screening, dated on 01/25/24 or after PTSD diagnosis was not indicated, the resident did not have a PASRR Level 1 Screening. Record review of Resident #'s Order Summary Report, dated 07/09/24, reflected: 1. Venlafaxine HCL 50 mg, two times daily for depression During an interview on 10/15/24 at 8:35 A.M., with Resident #93 she said the facility was treating her depression and PTSD with medications and counseling. During an interview on 10/15/24 at 2:37 P.M., with Regional MDS Coordinator X she said PTSD was not a diagnosis for a positive PASRR. During an interview on 10/15/24 at 2:44 P.M., with MDS Coordinator V said she had not heard PTSD was a diagnosis for a positive PASRR. She said normally the residents have another diagnosis to go with PTSD for a positive PASRR. During an interview on 10/15/24 at 3:58 P.M., Regional MDS Coordinator X notified the State Surveyor that they were going to do a 1012 Form for Resident #93 and they were going to get the doctor to sign the order tonight. She said they were going to enter the form in the portal and that will trigger PASRR to complete a PASRR level 1 evaluation. She said the facility would have an in-service for our MDS nurses for PASRR positive diagnosis. Regional MDS Coordinator X said after Resident #93 received the PTSD diagnosis she was supposed to have a PASRR Level 1 evaluation. During an interview on 10/16/24 at 9:41 A.M., with Regional MDS Coordinator notified the state surveyor that 1012 was filed for Resident #93 and the facility was waiting for PASRR for an evaluation. During an interview on 10/17/24 at 9:27 A.M., with MDS Coordinator V she said Resident #93 should have had a new PASRR eval done after she received a new diagnosis of PTSD. She said the PASRR eval was not done after the state surveyor intervention. She said the facility had filed a 1012 and called the MD. She said she had requested the PL1 and requested the records from the state. She said the negative effects of a resident not receiving PASRR services was residents with mental illness could miss out on counseling services and other services that could be offered. During an interview on 10/17/24 at 10:54 A.M., with the Administrator she said she expected for residents to have an accurate PASRR assessment. She said the negative effects on residents not having an accurate PASRR evaluation could affect the resident's health and they could be paying for services that the PASRR benefits could cover. Record review of facility's Pre-Admission Screening Resident Review (PASRR) policy indicated . the facility also conducts a Level 1 screening for current residents who experience a significant change in their condition based on MDS 3.0 guidelines . a Level 1 PASRR is completed each time a resident is hospitalized and readmitted if there has been a significant change in condition .

Based on observations, interviews, and record review the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #1). The facility failed to ensure Resident #1 who was identified as confused and a wanderer and had increased confusion was monitored more closely. Resident#1 was found on a high traffic street in a wheelchair in the street, with no sidewalk and a few inches for a holder on 7/27/24. The facility staff did not know the resident had eloped, or exactly how he left the facility. An Immediate Jeopardy (IJ) was identified on 07/31/24. While the IJ was removed on 08/01/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could result in serious harm and possible death of a resident. Findings included: Record review of Resident #1's face sheet dated 7/30/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were cognitive communication deficit, muscle weakness, unsteadiness on feet, lack of coordination, and stroke. Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 3 (severely cognitively impaired.) The MDS did not indicate any memory problems, mood issues or behavioral symptoms. The resident required partial to moderate assist with the helper doing less than half the effort for transfers and sit to stand. Record review of Resident #1's care plan dated 2/28/24 and last revised on 5/28/24 indicated a Focus area of impaired cognitive function or impaired thought process related to a stroke. He wandered into other resident rooms and used the bathroom. He urinated on his jacket and would not allow it to be cleaned. One of the interventions was to redirect the resident when he wandered into other rooms. A Focused area dated 7/27/24 and last revised 7/30/24 indicated Resident #1 was at risk for elopement related to Elopement Risk sore. He had a wander guard in place. Some of the interventions were engage the resident in activities of his choice. Report to MD factors for potential elopement such as wandering, repeated request to leave the facility, and attempts to leave. Ensure the wander guard was in place. Record review of Resident #1's Elopement Risk Evaluation dated 5/19/24 indicated a score of 1 with no risk of elopement. The form indicated if there was a yes to question 1 or 2 then the form was complete. Question one indicated the resident was able to make decisions regarding task of daily living and decisions were consistent and reasonable. The question was answered yes. However, additional information indicated the resident was at risk for elopement related to Elopement Evaluation risk score, the goals were he would remain safe within the facility unless accompanied by staff or authorized persons. The intervention was to engage the resident in actives of his choice. Record review of Resident #1's Elopement Risk Evaluation dated 7/27/24 indicated a score of 15 (imminent Risk for elopement.) The form indicated Resident #1 was unable to make decisions regarding task of daily living, and he was unable to ambulate. The patient was cognitively impaired and had a history of leaving the community without informing staff. Additional information the resident is an elopement risk related to Elopement Evaluation risk score. Record review of Resident #1's nursing note dated 7/27/24 at 12:37 a.m. indicated the resident continued day 10 of 10 of an antibiotic for UTI. He was pleasantly confused and was out of bed and self-propelling using his lower extremities about the facility. He had his clothes piled up in his wheelchair and was sitting on them as if they were a cushion. It was difficult to re-direct the resident, and he did not know what time it was. He was also redirected due to the fact that he would stand and attempt to walk, and it looked like he was having balance issues. He was frequently reminded to sit in his wheelchair. Will continue to monitor. Record review of Resident #1's History for Police Event (#242090341) indicated on 7/27/24 at 4:18 p.m. they received a call a resident had rolled away from the nursing home. At 4:19 p.m. the caller said the resident is in the middle of the street and they are trying to get him out of the roadway. They have blocked traffic to get him moved. At 4:31 the patent was rolled back to the location by staff who did not know he had even left. At 4:33 p.m. Resident #1 said he was out to see a friend at the apartments next door. He was advised that it was dangerous out on the roadway with vehicles. He was assisted back to facility. The resident said he would never do that again and that it was scary. Record review of an incident report dated 7/27/24 at 4:28 p.m. indicated Resident #1 was reported by and off duty staff member to be outside in the area adjacent to the facility in his wheelchair rolling himself with his feet. The resident was returned to the facility by law enforcement and wheeled to his room. The resident was asked how he was able to leave the facility and he stated he just went out the door himself. When the resident was asked how he opened the door he said you do not need a code to open the door from the inside. When the resident was asked what door, he went out. He said he went out the front door. When the resident was asked how he got down the stairs he said he did not go down any starts he was on the ground floor, the resident was confused and not aware of the current situation. The form indicated the resident was oriented to person, impulsive with a lack of safety awareness. Predisposing environmental factors were recent illness, confusion, and impaired memory. Predisposing situational factors where the resident was a wanderer. Record review of a one-to-one activity dated 7/27/24 at 4:30p.m. indicated Resident #1 was paced on one-to-one observation for 24 hours after eloping. Record review of a nursing note dated 7/27/24 at 5:00 p.m. indicated Resident #1 had a skin assessment completed upon return to the facility, there was no bruising, no abrasions noted, and no signs and symptoms of injury or trauma. Record review of Resident #1's computerized physician orders dated 7/27/24 indicated, may have wander guard due to potential elopement. Record review of a nursing note dated 7/27/24 at 10:50 p.m. indicated the resident was sitting on the side of the bed pleasantly confused. He was one on one active with wander guard to the right ankle in place. There had been no attempts to elope at that time. Record review of Resident #1's nursing note indicated it was created on 7/30/24 at 10:09 a.m. the effective date was 7/27/24 at 6:00 p.m. The note indicated at approximately 4:10 p.m. to 4:15 p.m. the resident was observed by CNA wheeling himself down the hall passed the nurses station toward the common area of the 200 hall. At approximately 4:30 p.m. he was returned to the facility and assessed. The patient remained in the building with no further incidents. Signed by LVN A. Record review of statements dated 7/27/24 from CNA I and CNA L that placed the resident in and around the 200 hall about 4:15 p.m. The facility provided a timeline for their investigation 8/1/24 at 12:30 p.m. with no date. The typed form indicated on 7/27/24 at 4:15 CNA I noted Resident #1 self-propelling self in wheelchair in hallway. At 4:18 p.m. CNA L noted Resident #1 sitting at the dining room table. Between 4:10 p.m. and 4:20 p.m. the family of another resident was noted in and out of the 300-hall door moving a resident belonging. At 4:26 p.m. Resident #1 was brought back to the facility by the police. With no signature. During an interview on 7/30/24 at 9:28 a.m. the ADON P said Resident #1 was the resident that the police bought back on 7/27/24 and he was just on the side of the building. She said to the best of what they could figure out there was a family in the building picking up a resident's belonging, she said they felt like Resident #1 had gone out the door by kitchen/ nurses' station with those family members on 300 hall. She said Resident #1 was not considered at risk for wandering until 7/27/24. She said Resident #1 was confused at times but had never tried to leave. She said the nurse on duty LVN A said the police brought the resident back and only waved at her. The nurse said the floor tech brought Resident #1 back into to the facility. During an interview on 7/30/24 at 9:45 a.m. Resident #1 said he did not remember leaving the facility on 7/27/24. He could not say where he lived now or where he used to live. He only said, I live here. He did say he used to go fishing every day and told fish stories. He was confused. During an interview on 7/30/24 at 9:55 a.m. LVN B said Resident #1 was confused. She said she had never heard him say he was going to leave. She said a while back he thought his family was coming to take him home. He would pack his clothes and say he was waiting on his family to come and get him. She said he would place his clothes in the chair behind him. However recently he had not said anything about leaving. During a telephone interview on 7/30/24 at 10:47 a.m. LVN A said on 7/27/24 around 4:00 p.m. LVN A said she was doing last med pass. She saw Resident # 1, he had been up and down the hallway all day, and she kept an eye on him due to his increased confusion. LVN A said Resident #1 had a UTI and had just finished antibiotics. She said he was wandering up and down the halls more than usual. LVN A said a group of family came to get another resident's belonging. She said Resident #1 had gone to the common area and the several members of a family walked in from the 300-hall. The LVN said she did not hear any alarms going off. She said the family members had been in and out of the facility multiple times. She said the doors were all locked and it was not easy to get out of the facility. She said another nurse called and said Resident #1 was outside about 4:28 p.m. She said she left by the side door of the 200-hall floor. LVN A said when she saw Resident #1, he was between the building parking lot and the apartment building across the street. She said when she saw him, he was being wheeled up the ramp by Floor Tech C. LVN A said the Police had him and the floor tech went and got him. She said the police did not ask her name or speak to her, they only waved and left. She said she had tried to complete a skin assessment on Resident #1 but as soon as she removed one piece of clothing, he was putting another piece of clothes on. She said Resident #1 did not complain of any pain to her. She said Resident #1 told her he went out the ground floor. However, he could not because there were steps down to the ground level on the first floor. She said he exit to parking lot on the 300-hall looked like it is at the ground level. She said the family removed a lot of stuff, gave two big boxes and a couple of trash bags, and their hands were full. LVN A said they may not have seen the resident exit the facility with them. She said that was the way the staff pieced together Resident #1's possible exit. LVN A said she had texted ADON P to let her know the family had come to get the resident things at 4:17 right before the family left. She said she received a call on 7/27/24 at 4:28 p.m. and was notified Resident #1 was missing and outside with the police. She said that either way he went out the door would have been downhill. She said she had never seen him stand or walk. During an interview on 7/30/24 at 12:25 p.m. the Administrator said he knew Resident #1 had left the faciity on [DATE]. He said they had come to the conclusion he was not trying to elope. He said no staff he interviewed had seen him exit the building, but they felt he had got caught up in the traffic of the family leaving the facility. The Administrator said they did not think Resident #1 was trying to elope, and he was found by the apartments across the street. He said the staff did not know he was gone. He said he was not aware of the police saying anything about where he was found but they believed from what the nurse said he was just across the street and not on the main street in front of the facility. The Administrator said he was the abuse coordinator. He said they deliberated calling Resident #1's elopement, but Resident #1 did not have an intent to leave and he was only gone a short time. He said Resident #1 was only gone about 10 minutes as best they could determine with staff interviews. So he had not reported the incident to the State agency. He said he had not talked to Floor Tech C. During a telephone interview on 7/30/24 at 12:35 p.m. Floor Tech C said he was upstairs on the second floor on 7/27/24. He said he was not sure of the time, but he was looking out the patio doors and he saw several police cars. He said a female officer was approaching the front door and he went down to answer the door. He said there were 3 police cars and one emergency vehicle parked by the corner of the facility. He said the officer wanted to know if Resident #1 was their resident. He said they wanted someone to escort Resident #1 back in the building. He said when he saw Resident #1, he was on the major street by the facility. Floor Tech C said Resident #1 said he hurt his hand because he could not stop his wheelchair from going down the hill so fast. He said the resident had passed the facility, crossed the street on the same side of the street, and had rolled down to almost the next street. He said he had turned around somehow but he was in the street because there was no sidewalk. Floor Tech C said Resident #1 said he was glad he did not get by car. He said Resident #1 said he was glad they had come to get him because he was scared a car was going to hit him. The Floor Tech said Resident # 1 was trying to figure out why so many police were there. He said he had wheeled Resident #1 back into the facility from the wheelchair access on the side of the building. He said no one had asked him where the resident was located when he got him from the police. During an interview on 7/31/24 at 10:58 a.m. the Administrator said he had done an investigation regarding Resident # 1 leaving the facility. He said that he had interviewed staff on duty, and they were very direct on the time that they had last seen the resident. He said he did not interview the Floor Tech C, no one had told him was really involved with the incident. He was told a Floor Tech brought Resident # 1 back into the facility. He said CNA I said that she had last seen the resident between 4:10 p.m. and 4:15 p.m. He said LVN A said that she had gotten a call at 4:28 saying that the police had the resident outside. The Administrator said he said that he had not attempted to contact the family because they had just lost a relative. He said that he felt that Resident #1 had got caught up in the door when the family was leaving. He said the family should not have had a code and he does not know who let them in and who let them out or who let the resident out of the facility. During a telephone interview on 7/27/24 at 12:50 p.m. the family member of another resident said they were at the facility on 7/27/24 to pick up their family members belongings. The family member said they did not see a resident go out of the facility with them. She said they did not have a code for the doors, she said a facility staff had to let them in and out of the facility. She said Resident #1 was on the highway when they were leaving the facility. She said when they saw him his wheelchair appeared to be stuck in a rut. She said he could not move, and a family member had called the police. The family member said Resident #1 was down the street with no sidewalk. The family member said when they asked him where he was going, he said he just left and did not want to get hit by a car because they were driving by fast. The family member said about 3 officers and EMS showed up. The family member said Resident #1 told one of the officers watch his leg because he had fallen. During an interview on 7/31/24 at 11:20 a.m. the DON said Resident #1 was more confused since he had a UTI. During an interview on 8/1/24 at 12:30 p.m. the Administrator he had not called the incident in regarding Resident #1, but he realized it should have been called into the state. He said he realized also that he did not take all the steps to complete a thorough investigation. He said from his initial reports it appeared the resident only made it across the street to the apartments and did not get to the stop sign on the main street. During an interview on 7/31/24 at 9:20 a.m. LVN F said she worked at the facility 5 years. She said the door by the nurse's station on the 300 hall was always locked. She said she had never given out the code to any family members. The LVN F said she had worked on 7/27/24 on the 300 hall. She did not see anyone coming or going. She said around 4:00 p.m. to 4:30 p.m. she was down the hall passing medications. She said on 7/27/24 they had two nurses and three aides. She said she did not see a family come in, she did not let them in, and she did not see them leave. She said she did not hear any alarms. When the door is opened it will alarm. She said she did not see any residents exiting the door either. During an observation and interview on 07/31/24 at 9:30 a.m., the Maintenance Supervisor showed the exits on the first floor required walking down stairs or exit into a courtyard. The exits on the second floor required walking downstairs or using the elevator to get downstairs to the first floor. The exit in the dining room that went to the smoke break area opened into a courtyard that was gated. Observation of the 300 hall showed all three exit doors had coded locks on the doors. The door to the parking lot right beside the nurse's station was the most used according to the Maintenance supervisor. He said the door to the west end of the hall was used mostly by laundry because that was where it exited to. The door to the East end of the hall was used mostly by maintenance. The door by the 3d floor nursing station was used by families and staff to enter and exit and that door required a code. The outside of the facility revealed the facility sat at the corner of an intersection. The facility sat on a hill so the driveway to get to the street and the sidewalk on the side of the facility were both downhill. The side of the facility faced a busy street with 3 lanes of traffic and a speed limit of 40 miles an hour. The facility was between two hospitals, it has a highway to the south and the cities loop to the north. The street was crowed with physician offices and business. The front of the facility faced a side street and across that street were some apartments. The front of those apartments also faced the street with the high-volume traffic and there was no sidewalk in front of the apartments and only a 21-inch shoulder. The Maintenance Supervisor said most wheelchairs were 22 inches wide. The side of the facility with the busy street had a sidewalk that measured 4 feet 10 inches at the widest and 3 feet 11 inches where an electric pole took up part of the sidewalk. At the end of the sidewalk, it measured 4 feet 1 inch. The drop off from the sidewalk to the street was 11 inches at the steepest point and 5 inches at the shortest point. If the resident had rolled down hill, he would have had to come off the sidewalk and cross the two-lane residential street. Once he crossed that street there was no more sidewalk. According to interview and a picture taken by a passerby, Resident #1 had rolled his 22-inch wheelchair down a 21-inch shoulder about 125 yards (same size block as the facility- about the length of a football field) and turned around somehow and was headed back toward the facility. During an interview on 7/31/24 at 9:50 a.m. CNA H said that Resident #1 was not on any kind of monitoring prior to 7/27/24 She said that he would get his clothes and sit on them. She said he would go another residence rooms and sometimes. CNA H said Resident #1 would say that he was going to leave on occasion. She said he was confused and would call her his granddaughter. During an interview on 7/31/24 at 10:05 a.m. LVN E said she had worked at the facility on 7/27/24. She said she knew about 4:00 p.m. she started medication pass. She said at that time the family was at the facility to get the belongings of a resident. She said she saw Resident #1 in the sitting area talking to another resident and it was not 15 minutes later that they got the notification he was outside. She said that the family was there, and they were going in and out gathering a resident's things and Resident #1 may have gone out with them. LVN E said Resident #1 had just stopped taking antibiotics for UTI. She said he had intermittent confusion. During an interview on 7/31/24 at 10:58 a.m. the Administrator said he had done an investigation regarding Resident # 1 leaving the facility. He said that he had interviewed staff on duty, and they were very direct on the time that they had last seen the resident. He said he did not interview Floor Tech C, no one had told him that he was really involved with the incident. He was told a Floor Tech brought Resident # 1 back into the facility. He said CNA I said that she had last seen the resident between 4:10 p.m. and 4:15 p.m. He said LVN A said that she had gotten a call at 4:28 saying that the police had the resident outside. The Administrator said that he had not attempted to contact the family because they had just lost a relative. He said that he felt that Resident #1 had got caught up in the door when the family was leaving. He said the family should not have had a code and he does not know who let them in and who let them out or who let the resident out of the facility. During an interview on 7/31/24 at 11:20 the DON said she thought the family that was moving a former residents' things had the code to the door because the family would come up to the facility at all hours of the night. She said she was not certain, but she also did not know how Resident #1 got out of the facility. The DON said Resident #1 was more confused since he had a UTI. During an interview on 7/31/24 at 12:55 p.m. LVN E on the 200 hall said the Elopement Book at the nurses station on 2nd floor did not have Resident #1's information but it would only take her a few minutes to put it in the book. On 7/31/24 at 3:50 p.m. the DON said Resident #1's Elopement assessment dated [DATE] was incomplete and inaccurate. She said the former interim DON had not filled the form out incorrectly. She said the form should be filled out according to the actions of the resident actively trying to exit the facility. The DON said the form should not be filled out because the resident wandered through out the facility. She said Resident #1 had a history of wandering into other residents rooms but not exit seeking behaviors. During an interview on 8/1/24 at 1:50 p.m. LVN R said she worked on 7/27/24 and was down the hall passing medications around 4:00 p.m. She said she did not see Resident #1. She did not let anyone in or out and she did not hear the door beeping. During an interview on 8/1/24 at 2:02 p.m. CNA S said she worked on 7/27/24 and did not see a family coming in and out. She did not see Resident# 1 and she did not let anyone in or out. During an interview on 8/1/24 at 2:28 p.m. CNA L said she worked on 7/27/24. She saw Resident #1 sitting at the table in the dining room between the 200 hall and 300 hall around 4:15 p.m. She said she knew it was about that time because she had come back off her break. She said she had gone to laundry on 300 hall and had to put the code in the door to exit and enter the door. She said when she came back through Resident #1 was just sitting there. She said he was sitting on some clothes and maybe a blanket. The Family of another resident had come in to get some things and it was 4 or 5 family members. She said she saw LVN A standing down the 200 hall around that time. She said she did not know how Resident #1 got out. During an interview on 8/1/24 at 2:43 p.m. CNA I said she worked on 7/27/24 and saw Resident #1 around 4:15 p.m. by the nurse's station on the 200 hall. She said Resident #1 said earlier in the day he was going to get his kids some school clothes. She said he was confused but he appeared to be okay. She said Resident #1 had confused some visitors with his grandchildren. She said when they brought him back from being outside Resident #1 said he left to go to the hospital. She said Resident #1 said he had burned his hands trying to stop the wheelchair from going downhill to fast, but she did not see anything. Record Review of the facility's Wandering and Elopement policy last revised 8/2020 Indicated the facility would identify residents at risk for elopement and minimize any possible injury because of elopement the procedure was licensed nurses would assess residents upon admission, readmission and quarterly and upon identification of a significant change in condition to determine their risk of wandering/elopement. Residents with a history of wander or who the IDT have assessed to be at risk for wandering or elopement would have a photograph maintained in their medical record and the Elopement /Wandering Risk binder. The Administrator and DON were notified on 07/31/24 at 4:20 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/31/24 at 4:20 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 08/01/24 at 10:23 a.m. and included: [F689- Supervision to Prevent Accidents 1. The facility failed to put interventions in place to prevent Resident #1, who was confused from eloping. 2. The facility failed to follow their elopement policy 3. The facility failed to determine how Resident #1 eloped Identify residents who could be affected All residents have the potential to be affected. Identify responsible staff/ what immediate action taken 1. Resident #1 elopement assessment and care plan was audited on 7/31/24. 2. Initiated staff interviews and established a timeline of the sequence of events. 3. The DON and Administrator received a 1:1 re-education by the Regional Nurse Consultant on the facility policy and procedure on supervision of a cognitively impaired resident assessed to be at risk for elopement on 7/31/24. 4. Audit Elopement assessments on all residents currently in the facility completed on 07.31.2024. 5. Elopement assessments have been reviewed and or revised and deemed appropriate by the IDT on 7/31/24. 6. All residents triggering at risk for elopement were added to the elopement Book that is kept at each nurse's station. The elopement Book includes the resident's picture and face sheet completed on 7/31/24 7. Staff received re-education by the DON on the facility policy and procedure when resident exhibits exit seeking behavior on 7/31/24. 8. Staff received re-education by the DON on the facility policy and procedure in the event of a missing/wandering resident on 7/31/24. 9. Licensed Nurse and CNAs will complete an exit seeking behavior resident questionnaire starting on 7/31/24 and must complete prior to returning to work. If CNA observes resident exhibiting exit seeking behaviors, CNA will report to charge nurse. 10. The maintenance director has assessed all Exit doors in the facility to ensure that each are operating as manufacture recommendation. 11. Facility IDT has audited all key padded doors, changed codes, and areas of egress to ensure latching and lock functions are operable as designed on 7/31/24 12. Elopement assessments have been reviewed and or revised and deemed appropriate by the IDT. 13. Cameras were installed on the 300 hall exits on 7/31/24 14. A sign was placed at all exit doors reminding visitors to use the main entrance, ensure the doors are closed securely behind them. A sign was placed at all exit doors reminding visitors to use the main entrance, and ensure the doors are closed securely behind them. Staff educated not to give code out to any visitors and redirect family to use main entrance only. Charge nurses to remind families and visitors not allow residents to exit the facility with them and to notify staff if a resident is trying to leave? In-Service conducted In-service was conducted by Director of Nursing 7/31/24. The in-service is on Resident Supervision. The details of the in-service include: ? Walking Rounds ? Visualizing each resident during rounds ? Rounding every 2 hours ? Exit seeking behavior notification to DON and/or Administrator. ? 24hrs report sign off by outgoing nurse and incoming nurse. ? Immediately search the facility, rooms, common areas, perimeter of the building. ? Elopement binders ? Educate weekend supervisor on admission completion and necessary care planning. ? Proper completion of elopement assessments for charge nurses and ADON The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistants, Qualified medication tech, Housekeepers, Maintenance, Kitchen Staff. Staff members who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service was initiated on 7/31/24 and completed on 8/1/24. Implementation of Changes The changes were started by the Director of Nursing. The changes were implemented effective on 7/31/24 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and completion of returned questionnaire. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 7/31/24. ? The Administrator/Director of Nursing/Designee will monitor/review each shift change report for signature validation daily x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI ? Director of Nursing/Designee will conduct a daily audit of Elopement assessment x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI ? Residents will be monitored by staff every shift for any exit seeking behaviors. Any changes will be reported to the Administrator Director of Nursing/Designee immediately for appropriate action. ? DON/Designee new admissions audit within 24hrs for admission for completion and necessary care plan. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 7/31/24 and conducted an Ad HOC QAPI regarding Resident #1. The Medical Director was notified about the immediate Jeopardy on 7/31/24, the Plan of removal was reviewed and accepted by the Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 7/31/24. Who is responsible for implementation of process? The Director of Nursing will be responsible for implementation of New Process. The New Process/ system was started on 7/31/24.] Record review of in-service training report dated 7/31/24 indicated the subject was Supervision of Cognitively Impaired Residents (Wandering /Elopement) by the RNC. Attendees were the Administrator and the DON. They were in serviced on the elopement policy and Elopement assessments. Record review of in services dated 7/31/24 indicated the facility staff were educated on Elopement prevention and procedures to include, walking [NAME] [TRUNCATED]

Based on interview and record review the facility failed to provide care in accordance with resident's comprehensive assessment and failed to ensure resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 8 residents reviewed for quality of care. (Resident #1) The facility did not monitor the condition of Resident #1's feet. Resident #1 developed gangrene (Gangrene is death of body tissue due to a lack of blood flow or a serious bacterial infection.) in his right great toe. Seven days later he was admitted to the hospital and had surgery to amputate all five toes on his right foot. An Immediate Jeopardy (IJ) was identified on at 2:40 p.m. on 04/14/2022. While the IJ was removed on 04/15/2022, the facility remained out of compliance at a scope of isolation and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective plan. These failures could place residents at risk for failing to obtain their highest practicable physical and mental well-being and place them at risk for serious harm, hospitalization , or death. Findings included: Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was to go to [CONDITION(S)] three times a week on Monday, Wednesday, and Friday, and Bacteremia (The presence of viable bacteria in the circulating blood). There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of a MDS dated [DATE] indicated Resident #1 had a BIMS score of 15 which showed he was mentally intact and alert to person, place, and time. Resident #1 required two-person extensive physical assistance for bed mobility, transfer, and toilet use. Resident #1 required limited one-person assistance with personal hygiene and limited two-person assistance with dressing. Resident #1 was always continent to bladder and always incontinent to bowel. Record Review of a comprehensive care plan for Resident #1, dated 03/01/2022 indicated nursing staff are to inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] (swelling), or redness. Resident #1 was to go to [CONDITION(S)] three times a week on Monday, Wednesday, and Friday. Record Review of a Routine Foot Care form completed by a Podiatrist and dated 03/28/2022 indicated resident was seen at the facility. Notation on the form showed Dry gangrene noted to right first toe. No infection. The form was not provided to the facility until 4/5/22 after request by the facility. (Podiatrist office alleged a broken fax machine.) Record Review of a skin assessment on admitted d 2/18/2022 showed skin to bottom and top of bilateral feet extremely dry and cracked. Prescription lotion scheduled Q-shift. Review of other weekly skin assessments dated 02/25/2022, 3/4/2022, 03/11/2022, 03/18/2022, 03/29/2022 and 04/01/2022 showed no skin impairments. Record Review of a progress note dated 04/03/2022 at 9:00 p.m. showed LVN B was called to Resident #1's room by Resident #1 to look at his feet. LVN B assessed Resident #1's right foot and documented all the toes on Resident #1's right foot was black with necrotic tissue. Necrotic (dead cells) tissue noted on the right lateral side of the foot and the whole circumference of the bottom of the right heal was black with necrotic tissue. Pictures were taken by LVN B and sent to Medical Director, nurse practitioner and assistant director of nursing (LVN A) were notifying of the change in condition. Resident #1 notified his sister on personal cell phone. Record Review of a progress note entered by LVN C dated 04/04/2022 at 8:05 a.m. showed nurse practitioner was in the facility making rounds. Nurse Practitioner ordered STAT (Immediate) doppler scan. (A scan to assess blood flow) Facility was unable to schedule scan as ordered, so Resident #1 was transported to the hospital via ambulance for evaluation and treatment. Record Review of hospital records dated 04/04/2022 showed Resident #1 chief complaint was gangrene right foot. Resident had gangrene from the tips of digits 1 through 5 proximally to the metatarsal phalangeal (toe) joints. Resident #1 also had necrosis spanning along the lateral aspect of the foot in the heel. Resident #1 told hospital staff the foot turned black about a week ago. Record Review of hospital records dated 04/06/2022 showed Resident #1 received a partial amputation of his right foot with wound vac placement. Resident #1 was a [AGE] year-old male who comes from a nursing home with gangrenous changes to the right foot. Doctors amputated all five toes down to the phalangeal (toe) joints on Resident #1's right foot. Records showed the area of the foot which was amputated was gangrenous and mummified. According to the hospital documentation the foot was partially covered by a black-tan skin with a large amount of necrosis and mumification. During an interview on 04/13/2022 at 9:45 a.m. LVN B said the last time she saw Resident #1 was 04/01/22 during her 6:00 a.m. to 6:00 p.m. shift. LVN B said she completed a skin assessment on Resident #1 on 04/01/2022, but she did not look at his feet. LVN B said she did not know Resident #1 had gangrene on his toe. LVN B said Resident #1 goes to [CONDITION(S)] at noon and returned about 5:45 p.m. LVN B said the darker a person's skin the harder it is to assess changes in condition. LVN B said Resident #1 did not like for her to turn the light or open to blinds on the windows. LVN B said Resident #1 had dark skin, which made it harder to see his skin. LVN B said she had not had any specialize training on assessing darker skin. During an interview on 04/13/2022 at 9:45 a.m. the DON said LVN B did not follow facility protocol when completing the skin assessment for Resident #1. The DON said any changes in the color of skin should been documented on the weekly skin assessment and the doctor notified of the change in condition. The DON said a skin assessment should be head-to-toe and LVN B should have looked at all areas of Resident #1's body, which included both feet. During an Interview on 04/08/2022 at 11:55 a.m., Resident #1's family member said Resident #1 was brought to the facility on [DATE] for rehabilitation services. She said Resident #1 told her that the podiatrist had seen him a week before he went to the hospital and trimmed his toenails. She said when he was admitted to the facility, he was on the first floor. She said the facility moved him to the second floor and she did not think they were providing adequate care, because when he was sent to the hospital on 04/04/2022 he arrived dirty, and it was obvious he had not been bathed. She said Resident #1 will not be returning to the facility and she would find another facility that will provide better care. During an interview on 04/08/2022 at 12:50 p.m. the Social Worker said on 04/04/2022 Resident #1's family member complained about the facility not taking good care of Resident #1. The Social Worker said she discussed the complaint with the Administrator. The Social Worker said the family member said the facility was not giving Resident #1 showers as needed. During a telephone interview on 4/11/22 at 4:28 p.m. with the Medical Assistant for the Podiatrist for Resident #1. She said there was not treatment needed on 03/28/22 because there was no sign of injection. She said the gangrene was dry and no treatment was needed at the time. (Podiatrist unavailable) During a telephone interview on 04/13/2022 at 10:46 a.m. Resident #1 said he had been released from the hospital and now was in another facility and receiving good care. Resident #1 said he was not pleased with the care provided when at the facility and the quality of care was very poor. Resident #1 said he normally wore socks on his feet which were changed every other day when he went to [CONDITION(S)]. He said staff had to help him change his socks because he could not do it without help. Resident #1 said he did not notice his feet turning black until after the podiatrist saw him. Resident #1 said he told CNA B a couple days after the podiatrist left about his foot turning black. Resident #1 said CNA B said she would tell the nurse, but the nurse did not come. Resident #1 said a couple days later he told CNA B again about his foot turning black. Resident #1 said after he told the CNA B the second time the nurse came and looked at his foot. Resident #1 said the nurse told him the doctor would look at his foot the next day. Resident #1 said the next morning the doctor looked at his foot and he was sent to the hospital and all the toes and part of his right foot were amputated. Resident #1 said it hurts him physically and emotionally to lose his toes and is afraid losing part of his foot will hinder him from being able to walk again. During an interview on 04/14/2022 at 10:27 a.m. CNA B said she worked the morning shift and would help Resident #1 to get ready to go to [CONDITION(S)]. CNA B said Resident #1 insisted on keeping his socks on and did not say anything about his feet being sore. CNA B said on the day before Resident #1 went to the hospital, she saw his foot and it looked dead. CNA B said she reported it to LVN C. CNA B said, Since he (resident #1) was a diabetic, we are supposed to look for things like that. During an interview on 04/14/2022 at 2:11 p.m. LVN C said on 04/03/2022 around the end of her shift at 6:00 p.m., CNA B asked her to look at Resident #1's feet. LVN C said she was not aware of any skin issues with Resident #1. LVN C said she was not familiar with Resident skin issues and asked LVN B to look at Resident #1's feet when she came to work at 6:00 p.m. LVN C said Resident #1 said he could not feel anything in his right foot. During an interview on 04/14/2022 at 9:44 a.m. LVN B said she was the charge nurse on 04/03/2022 during the evening shift. LVN B said when she arrived at work at 6:00 p.m., LVN C asked her to look at Resident #1 feet. LVN B said when she looked at Resident #1's feet, she noticed all the toes on his right foot were black in color and there was necrotic tissue from his pinky toe all the way down to his heel. LVN said she took pictures of Resident #1's feet and sent to the medical director, NP and LVN A. LVN B said Resident #1 always wore socks on his feet. LVN B said Resident #1 needed help to put on his socks. LVN B said CNAs did not report any change in the condition of Resident #1's feet to her. LVN B said the first time she noticed a change in the condition of Resident #1's foot was on 04/03/2022. During an interview on 04/14/2022 at 1:25 p.m. the nurse practitioner (NP) said he saw Resident #1 on 03/14/2022 and Resident #1 did not have any skin issues. The NP said the last time he saw Resident #1 was 04/04/2022. The NP said he was told the issue with Resident #1's foot started a day or two ago. The NP said the issue with Resident #1's feet could have progressed in one or two days, but the main thing was to receive a doppler and restore circulation to his leg. The NP said the doppler was needed ASAP to prevent amputation. During an interview on 04/14/2022 at 9:00 a.m. CNA A said she provided care to Resident #1. CNA A said she would give Resident #1 a bed bath, and get ready to go to [CONDITION(S)] on Monday, Wednesday, and Friday. CNA A said she rubbed lotion on his feet, and he told her the bottom of his feet were tender. CNA A said one of Resident #1's feet were darker than the other. CNA A said she reported Resident #1's complaint of a tender feet to LVN A. CNA A said all the CNAs and nurses knew about Resident #1's feet. Record review of a wound care management policy dated 06/2020 showed .A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. Definitions: Arterial Ulcer-an ulceration that occurs as the result of arterial occlusive disease when no pressure related disruption or blockage of the arterial blood flow to an area causes tissue necrosis .usually occurs in the distal portion of the lower extremity and may be over the ankle or boney areas of the foot. A licensed nurse will perform a skin assessment upon admission, readmission, weekly and as needed for each resident.D. Licensed nurse will document effectiveness of current treatment in the resident's medical record on a weekly basis .E. Document notifications following a change in the resident's skin condition. F. Update the resident's care plan as necessary. The Administrator was notified on 4/14/2022 at 2:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 4/14/2022 at 2:40 p.m. The facility's Plan of Removal was accepted on 4/15/2022 at 10:10 a.m. and included: Quality of Care. The facility failed to provide care and services for a resident which led to amputation. Identify residents who could be affected. All Residents have the potential to be affected. Identify responsible staff/what action taken. *Regional Nurse Consultant and Director of Nursing initiated in-service for all licensed nurses (Registered Nurses and Licensed Vocational Nurses) on following: i. Policy and procedure regarding skin assessment: Skill assessment to be completed on admission, re-admission, weekly and as needed. ii. Following resident care plan for residents with skin impairment or risk for skin impairment. iii. Education on how to assess dark pigmented and complicated skin. iv. Education/notes immediately after assessment/visits. * Skin assessments completed on 04/13/2022 for 104 residents with no adverse effects or issues noted. * Skin assessments completed including a head-to-toe assessment with emphasis on residents with dark pigmented and complicated skin. * CNA's will be in-serviced on identification of skin issues while providing ADL care including peri care and bathing. Negative findings will be documented on the Stop and Watch form and/or shower sheets and reported to charge nurse. Charge nurse will report findings to Director of Nursing. * The administrator communicated/educated the podiatrist on 04/13/2022 to ensure that after every resident visit/assessment, findings from the visit is communicated to the staff immediately. In-Service conducted Regional Nurse Consultant and Director of Nursing initiated in-service on: I. Policy and procedure regarding skin assessment: Skin assessment to be completed on admission, readmission, weekly and as needed. II. Following resident's care plan. III. Education on how to assess dark pigmented and complicated skin. IV. Education/training with nursing staff and podiatrist to obtain podiatry assessment/notes immediately after assessment/visits. * Resident skin assessment will be completed upon admission, readmission and as needed thereafter, Skin assessments will consist of head-to-toe assessment that will check for normal or any skin impairment. * Competing weekly skin assessments as designated on all residents and ensuring that residents with dark pigmented and complicated skin are provided necessary care and services to precent skin injury. Findings of weekly skin assessments will be documented in PCC. * Expected completion date will be 04/15/2022. * Staff who have not been trained on I. Policy and procedure regarding skin assessment: Skin assessment to be completed on admission, readmission, weekly and as needed. II. Following resident's care plan. III. Education on how to assess dark pigmented and complicated skin. IV. Education/training with nursing staff and podiatrist to obtain podiatry assessment/notes immediately after assessment/visits will not be allowed to work until they have undergone training. The staff that will be trained are the Licensed nursing staff: Licensed vocational nurse, Registered nurses, and certified nursing assistants. A comprehensive list of all the licensed nurses and certified nursing assistants that work in the facility will be used to ensure that they are trained. Implementation of Changes Director of Nursing will round weekly with charge nurse and/or treatment nurse and review wound care physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon identification of a new or worsening wound, physician will be notified to promptly obtain an appropriate treatment. Resident representative will be notified. Rehabilitation will be consulted for pressure related devices. Resident care plan will be updated based on dietary, rehabilitation and physician recommendations and updated as needed. Nursing will initiate treatment per physician orders, implement nutritional and pressure relieving recommendations. Monitoring * Director of Nursing, Assistant Director of Nursing, and charge nurse and/or treatment nurse will review and verify skin assessments for all new admissions, readmissions, and new findings from weekly skin sweeps. * Regional Nurse Consultant will review weekly pressure injuries and non-pressure injury report and round one time monthly with Director of Nursing and charge nurse and/or treatment nurse. * Any negative outcomes will be reported to QAPI committee. Involvement of Medical Director The Medical Director as notified about the immediate jeopardy on 04/14/2022. Involvement of QA An ad hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 04/14/2022. Who is responsible for implementation of Process? The Director of Nursing will be responsible for implementation of new process. The process/system will be started on 04/14/2022. Please accept this letter as our plan of removal for the determination of revised immediate jeopardy issued on 04/14/2022. During an interview on 04/15/2022 the administrator said the issue of the Immediate Jeopardy and the quality-of-care issues were reported and addressed by the special called QAPI committee on 04/14/2022 and these issues will continue to be monitored by the QAPI to ensure the facility provides the best possible care to residents. Those in attendance included: Medical Director, DON, Administrator and Social Work. Interviews on 4/15/2022 between 11:50 a.m. to 3:30 p.m. with nursing staff (4-nurses on the 06:00 a.m.-06:00 p.m. shift; 2 -nurses on the 6:00 p.m. to 6:00 a.m. shift, 3-CNAs on the 08:00 a.m.-02:00 p.m. shift; 2-CNAs on the 02:00 p.m.-10:00 p.m. shift were performed. The staff were able to express understanding of the in-services provided by the facility. Record Review of training sign-in sheets dated 04/14/2022 and 04/15/2022 showed nursing staff including nurse and CNAs had received training on skin assessments, reporting change in condition and monitoring darker-pigmented skin on all shifts. Record Review of an email dated 04/13/2022 from the podiatrist to the DON stated, Yes, we will recommit to update you on all patients we see at your nursing facility on the same day we see them. On 4/15/2022 at 3:30 p.m., the Administrator was informed the IJ was removed, while the IJ was removed on 4/15/2022, the facility remained out of compliance at a scope of isolation and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was provided for the facility regarding COVID 19. The facility did not follow CDC guidelines and restrict LVN A from working for 14 days after being exposed to Resident #1 who displayed symptoms of COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older). LVN A provided an aerosolized nebulizer treatment (used to turn liquid medicine into a very fine mist that is inhaled into the lungs) to Resident #1 without an N95 mask, eye protection, and gown. Resident #1 was diagnosed with [REDACTED]. LVN A continued to work her scheduled shifts on Hall 300 after being exposed to COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/25/20. While the IJ was removed on 4/26/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for the transmission of COVID-19 and death. Findings included: An undated admission record dated 4/26/20 indicated Resident #1 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. The order summary report dated 4/19/20 indicated an order with a start date of 9/18/19 for [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) MG/ML 1 vial inhale orally every 4 hours as needed for shortness of breath and wheezing. The MDS dated [DATE] indicated Resident #1 had intact cognition and used oxygen therapy. A care plan with a revision date of 9/19/19 indicated Resident #1 had shortness of breath, was a smoker, was receiving oxygen therapy, had altered respiratory status, and had asthma. The nurse administration record dated 4/19/20 indicated Resident #1 was to receive [MEDICATION NAME]-[MEDICATION NAME] (a medication used for the treatment of [REDACTED]. A nursing note dated 4/19/20 at 9:48 a.m. indicated LVN A found Resident #1 lethargic and short of breath in his room. LVN A checked Resident #1's oxygen saturation and found it to be 80% (normal range 95-100%) while on 2 liters of oxygen. The note indicted LVN A provided a breathing treatment and rechecked his oxygen saturation and there was no change. The note indicated LVN A increased his oxygen to 3 liters and there was no change in his oxygen saturation. The note indicated LVN A notified the nurse practitioner and the resident was sent to the hospital. During an interview on 4/27/20 at 3:51 p.m., LVN A said on 4/19/20 she entered Resident #1's room and found him lethargic. She said his oxygen level was between 80-85% and he was on 2 liters of oxygen. She said she gave him a breathing treatment through his nebulizer and stayed in the room with him for about 15 minutes. She said she wore a surgical mask and gloves and was within 3 to 5 feet of him during his breathing treatment. She said she notified the nurse practitioner of the resident's condition and sent him to the hospital. LVN A said on 4/20/20 she was notified by the facility of Resident #1's positive COVID-19 result. She said she was tested a couple of days ago and was taken off the schedule. She said there were 41 residents on the 300 hall and because she was the charge nurse, she gave direct care to all of them after her exposure to COVID-19. She said after Resident #1 was found to be positive for COVID-19, her temperature was taken every day while she was at work and the DON asked her if she was feeling well and if she was showing any signs or symptoms of COVID-19. An employee time sheet dated 4/16/20 through 4/30/20, indicated LVN A worked the day shift on 4/19/20, 4/20/20, 4/23/20 and 4/24/20. A handwritten timeline completed by the DON dated 4/20/20 at 3:25 p.m. indicated the facility received a call from the local hospital notifying Resident #1 tested positive for COVID-19. During an interview on 4/25/20 at 1:30 p.m., the DON said Resident #1 had been in the hospital since 4/19/20. She said Resident #1 was tested for COVID-19 on 4/20/20 and the positive result was sent to the facility on [DATE]. The DON said the change in Resident #1's condition happened quickly, and the facility had no reason to believe he had COVID-19 because he had no cough or fever. She said LVN A gave Resident #1 an aerosol breathing treatment and per facility policy should have stayed in the room with the resident for the entire 15-minute treatment. She said LVN A was wearing a surgical mask during the care of Resident #1, and during his breathing treatment administration. She said after the facility received Resident #1's positive COVID-19 test results from the hospital the facility requested the hospital do a blood test on Resident #1. She said the facility did not believe the resident was really positive because he had no symptoms while at the facility. She said the hospital refused to do a blood test, but the facility medical director would be calling the hospital to request a blood test for Resident #1. During an interview on 4/25/20 at 6:00 p.m., the DON said the health department was notified of Resident #1's positive result and was consulted regarding testing LVN A and Resident #1's roommate. The DON said the facility was told not to test LVN A or Resident #1's roommate because neither person was symptomatic for COVID-19. She said the health department did not suggest quarantining LVN A and said the only changes to make were increased PPE in isolation rooms. She said trainings from the facility's corporate office stated to follow health department guidance and guidelines. During an interview on 4/25/20 at 7:00 p.m., the DON said the facility was receiving guidance from the CDC from their corporate office. She said she was not aware of the CDC guidance regarding high risk exposures. A COVID Action Plan, with a revision date of 4/21/20 indicated the following: If a staff member is exposed to the COVID 19: - The employee must inform the administrator immediately - The administrator will immediately notify SVP of Operations, SVPC, VP-Regulatory Compliance - If the employee has reported to work and they are at the screening station, they must leave the facility immediately and not return for recheck for 14 days. - If the employee is at home and report, they are not to enter the facility for 14 days and will be rescreened at that time. - If the staff member becomes ill, they must report to the facility immediately with signs and symptoms (if they mimic COVID 19, contact Local Health Department) If a staff member has presumed or confirmed COVID: - If the employee is not at work, they will be instructed to contact the local health department and will remain away from work for 14 days and the will be re-screened before returning to work. If the employee is at work, they must don a mask and leave immediately - The administrator will contact the local health department for direction. - All staff who has come in contact with this presumed or confirmed COVID staff member will have to be self-quarantined for 14 days before being rescreened. - All residents will be assessed with [REDACTED]. - Group dining will be stopped, and staff will be delivering meals to the resident rooms. - All group activities will stop until further notice. - If confirmed, admission of other potential residents will stop. The website https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#take_precautions accessed on 4/28/20 indicated: .4. Take precautions when performing aerosol generating procedures. If performed, the following should occur: HCP in the room should wear N95 or higher-level respirator .eye protection, gloves, and a gown. The website https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, updated by the CDC on 4/15/20 and accessed 4/25/20 indicated the following: . high-risk exposures refer to HCP being present in the room for procedures that generate aerosols or during which respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, [MEDICATION NAME], nebulizer therapy, sputum induction) on patients with COVID-19 (beginning 48 hours before onset of symptoms) when the healthcare providers' eyes, nose, or mouth were not protected .III. Recommendations for Monitoring Based on COVID-19 Exposure Risk 1. High- or Medium-risk Exposure Category .HCP should undergo active monitoring, including restriction from work in any healthcare setting until 14 days after their last exposure . The administrator and DON were notified on 4/25/20 at 7:00 p.m. an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 4/26/20 at 2:01 p.m and included: .A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: 1. On 4/19/20 the day shift LVN was exposed to COVID- 19 through providing an aerosolized breathing treatment to an unresponsive resident while she wore a surgical mask. The resident was sent to the hospital and tested on [DATE]. Positive results were received on 04/20/2020 and the facility was notified. The LVN has since worked 3 shifts after the resident was found positive and she has not been tested 2. The LVN continued to report to work providing care to other residents and potentially exposing the residents under her care to COVID- 19 as well as other staff members which could lead to harm or death 3. The LVN in question was potentially infected with COVID-19 during the aerosolized breathing treatment that was given to the resident. The LVN has now potentially exposed the residents under her care and other staff members to COVID-19 Identify residents who could be affected Residents who were provided care for by the LVN on 300 Hall. All the residents in the 300 Hall on 04.25.2020 were assessed by the Charge Nurses and Nursing Supervisor. No resident presented with any respiratory change in condition. Identify responsible staff/ what action taken LVN was removed from the schedule on 04/25/2020. LVN has gone to the hospital on [DATE] to be tested . LVN will not be allowed back to work until test result is out and quarantined for 14 days All residents on hall 300 will be tested for COVID-19 on 4/27/2020. In-Service conducted In-service was conducted by Director of Nursing and Assistant Director of Nursing on 04.25.2020. The in-service is on Infection Control. The details of the in-service include: If a nurse must give a breathing treatment to a resident the nurse will wear an N95 Mask and be the only one in the room with door closed. Full PPE will be donned on Hall 300 Proper handwashing technique CDC risk categories regarding facility staff. The in-service was attended by licensed nurses which include; Registered Nurse, Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide, Respiratory Therapy and Licensed Therapists which include; Physical Therapist, Occupational Therapist and Speech therapist. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. This in-service will be started on 04.25.20 Implementation of Changes The changes were initiated by the Director of Nursing. The changes will be implemented effective on 04.25.20 and will be ongoing until all staff are in serviced. The Director of Nursing will ensure competency through verbalization of understanding by staff. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 04.25.2020. The Administrator/Director of Nursing/Assistant Director of Nursing will assess all staff members who have potentially been exposed to a suspected resident and determine the proper risk of the employee daily. Director of Nursing/Assistant Director of Nursing will monitor the administration of breathing treatments when they are deemed necessary to make sure the proper procedure daily. Administrator/Director of Nursing will consultant with the Vice President of Clinical, Vice President of Operations, Vice President of compliance and the Regional Nurse Consultant on any potential exposure related to any staff member/resident and CDC and state guidelines will be reviewed daily on the daily end of day call for 21 days after the last confirmed case. Residents will be monitored every shift for any changes of condition. Any changes of condition will be reported to the Director of Nursing and Assistant Director of Nursing immediately. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 04.25.2020. The Medical Director will be meeting with the Interdisciplinary team on 04.26.2020 to discuss more about the immediate Jeopardy and ways to address the alleged deficient practice. Involvement of QA An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal. Who is responsible for implementation of process? The Director of Nursing will be responsible for implementation of New Process. The New Process/ system will be started on 04.25.2020 and no employee be able to return to work until they complete the in-service. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 04.25.2020. On 4/26/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 4/25/20 at 5:05 p.m., the administrator and DON said after the facility received the positive test results for Resident #1, the staff wore N95 masks and gowns into isolation rooms, per health department recommendations. She said Resident #1's roommate was isolated and tested for COVID-19. His results were negative. During an interview on 4/25/20 at 6:00 p.m., the DON said direct care staff that previously worked on Resident #1's hall had been dedicated to that hall and would not be moved. During an observation on 4/26/20 at 11:50 a.m., an N95 mask was provided for the surveyor for entry to 300 hall. The DON and front desk staff member were wearing N95 masks. During an observation on 4/26/20 at 11:55 a.m., the DON and administrator were wearing N95 masks. During an interview on 4/26/20 at 12:00 p.m., the DON and administrator said LVN A went to the hospital on the night of 4/25/20 to be tested for COVID-19. LVN A was removed from the schedule on 4/25/20. In-services were created and staff were being trained upon arrival to work. Staff in the building were trained before clocking in, and the new rotation would be trained on 4/27/20 before clocking in. The administrator said the testing of residents would begin on the morning of 4/27/20. An untitled in-service dated 4/25/20 indicated: Food carts would be covered when delivered through the third floor, ensure masks were worn at all times and doors to kitchen were kept closed at all times. Staff were not to go onto unit 3 to retrieve carts. The carts would be delivered to the dining room for the other floors to pick up. An untitled in-service dated 4/25/20 indicated: Handwashing was the best prevention for spread of virus/disease. Staff were expected to use appropriate handwashing technique before and after any and all patient care, when entering and exiting patient care areas. When donning and doffing PPE. An untitled in-service dated 4/25/20 indicated: Respiratory assessments were to be performed in PCC per shift by the charge nurses. Temperatures and oxygen saturations were to be completed a second time per shift and entered into PCC on the weight/vital signs page. Respiratory therapy assessments were separate from this and did not count towards completion. An untitled in-service dated 4/25/20 indicated: 300 hall staff would wear full PPE for each resident's care throughout the 14 day quarantine. An untitled in-service dated 4/25/20 indicated: If a breathing treatment was given- the nurse must wear an N95 mask, be in the same room alone and have the door closed throughout the treatment. An untitled in-service dated 4/25/20 indicated: Per CDC guidelines, the facility would follow the protocol of risk categories: low, medium and high. During a record review on 4/26/20 at 1:00 p.m., Resident #s 2, 3, 4, 5, 6, and 7 had respiratory assessments performed in accordance with the facility's plan of removal on 4/25/20 and 4/26/20. Temperatures and oxygen saturations were recorded appropriately by nursing staff. During an interview on 4/26/20 at 1:10 p.m., RN B was wearing an N95 mask at the nursing station and said she had received training that morning that included usage of PPE (gloves, gowns, shoe covers) and wearing N95 masks while on the 300 hall. The facility would continue screening at the front door and taking temperatures. Nursing staff would be conducting respiratory charting twice a shift for all residents which included temperatures and oxygen saturations. She said only nurses could go into COVID pending rooms and must wear full PPE, such as gowns, gloves, and masks. During an interview on 4/26/20 at 1:15 p.m., CNA C and CNA D were both wearing N95 masks and said they had received training that morning on wearing N95 masks while in the building. They said they were also trained that when giving breathing treatments to residents, the nurses were to wear an N95 mask, be the only staff member present in the room, and have the door shut. Any staff providing care on the 300 hall would wear full PPE, such as gowns, gloves and masks. Training also included handwashing being the best way to prevent the spread of infections and to wash hands before and after resident care. During an interview on 4/26/20 at 1:25 p.m., RN D was wearing an N95 mask and said she was trained that morning on staff not being allowed on the 300 hall unless they were scheduled to work there, and those employees were to wear full PPE. She said new N95 masks were handed out by administrative staff and they were to wear those while in the building. She said if a nurse was giving a breathing treatment, only the nurse could be in the room and would wear full PPE, with the door closed. She said training covered handwashing being the best prevention for spread of viruses and staff were to wash their hands before and after any patient care. She said she received training on documentation of resident respiratory assessments, which would include temperatures and oxygen saturations. During an interview on 4/26/20 at 1:34 p.m., the RT was wearing an N95 mask and said she was trained that morning on nebulizer treatments and that the nurse, or RT, and resident were to be the only people in the room, with the door closed. She said the CDC guidelines and protocols were to be followed now because they were stricter than the health department's guidelines and protocols. She said training indicated 300 hall would be completely isolated to all staff that were not designated to work there. She said changes were made to food dispersal through the 300 hall and carts would be covered when delivered through the 300 hall and masks were to be worn. During an interview on 4/26/20 at 1:40 p.m., LVN E, who worked on hall 300, was wearing an N95 mask and said she was trained that morning on wearing masks and PPE in every room that staff would enter. She said the meal service changed, and the kitchen would start putting meals right outside of the doors to the kitchen. She said staff could not go back and forth between the 300 hall and the rest of the building. She said staff had been given paper forms for clocking in and out and were not able to visit the time clock. She said administration had provided staff with paper bags to place an uncompromised N95 in at the end of their shift and were overnighting more gowns to the facility. She said the nursing staff were performing respiratory treatments to the entire 300 hall and were getting oxygen saturations and temperatures twice a day. She said she was also given training on handwashing being performed before and after resident care and when donning/doffing PPE. She said when giving breathing treatments, the nurse was to be the only person in the room with the resident, in full PPE, with the door closed. During an interview on 4/26/20 at 1:45 p.m., CMA F, who worked on the 300 hall, was wearing an N95 mask and said she was trained that morning on reporting to the 300 hall and not being able to leave to other parts of the building. She said the facility was still taking the temperatures of staff and residents. She said training included handwashing and washing hands before and after resident care. She said the facility was still encouraging social distancing between staff and residents. During an observation on 4/26/20 at 1:50 p.m., an aide performing resident care on the 300 hall, was wearing a gown, gloves, an N95 mask and eye protection. On 4/26/20 at 2:01 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents was provided for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not safely transfer Resident #1 who required the assistance of 2 people for transfers and bed mobility. CNA A transferred the resident without assistance of any other staff, using a Hoyer lift, and repositioned Resident #1 by herself. Resident #1 sustained a shoulder fracture. This failure placed residents requiring assistance with transfers and positioning at risk of injury. Findings included: A face sheet dated 09/01/19 indicated Resident #1 was a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 required at least two people to physically assist with transfers and total dependent with two- person physical assistance with mobility. Resident #1 had functional limitations to both legs. A care plan dated 02/04/17 revised on 06/14/18 indicated Resident #1 had an alteration in his musculoskeletal status related to extremely severe osteopenia. Resident #1's goal was to remain free of injuries or complications related to severe [MEDICAL CONDITION]. Resident #1 had an ADL self-care performance deficit related to [MEDICAL CONDITION]. The care plan for indicated Resident #1 was totally dependent on staff times 2 for repositioning and turning in bed. Resident #1 required the mechanical aid-sling with staff x 2 for transfers. A nursing note written by RN B, dated 08/31/19 at 10:45 p.m., indicated Resident #1 complained of right shoulder pain rated at 9 on a scale of 1 to 10 after CNA A completed the resident's shower and repositioned the resident back in bed. The note indicated the resident reported CNA A pulled Resident #1 back over to the middle of the bed and Resident #1 heard a few popping sounds and had shoulder pain. An x-ray report dated 09/04/19 indicated Resident #1 had a humeral head fracture ([MEDICAL CONDITION] area). Three in-service training sign in sheets dated 09/01/19 indicated 11 staff signed the sheet to indicate they received training on transfers, bed mobility and the facility's kardex system. One of the signatures was from a nurse who worked the 10:00 p.m. to 6:00 a.m. shift. No signature was provided from any CNA who worked the 10:00 p.m. to 6:00 a.m. shift. A provider investigation report dated 09/05/19 indicated CNA A did not follow Resident #1's care plan while transferring the resident using the Hoyer lift, tried to stabilize resident and fractured his shoulder. During an interview on 09/12/19 at 9:30 a.m., the interim DON said CNA A knew the policy on Hoyer transfers and also knew Resident #1 required 2 people for transfers and positioning. The interim DON said CNA A said she got tired of waiting for help and transferred and positioned Resident #1 without assistance. The interim DON said there were 3 people working on the hall at the time of the incident and they denied being asked for assistance. The interim DON said CNA A was terminated. A witness statement dated 8/31/19 completed by CNA A indicated CNA A put Resident #1 in bed unassisted then turned him to remove the Hoyer lift pad from under him. Resident #1 began to go over too far in the bed and CNA A grabbed Resident #1's chest area, when Resident #1 said his arm popped. A CNA proficiency audit dated 02/07/19 indicated CNA A had satisfactory completion on skills training for skills regarding 2- person assist with transfers and turns and repositioning residents correctly. A Hoyer lift competency checklist dated 2/07/19 indicated CNA A demonstrated competency in all skills on 2/07/17. The competency checklist included the instruction (#2 a) ensures two caregivers are present. A policy and procedure for mechanical lift dated 05/2017 indicated lifting a resident with a mechanical lift is always a two-person procedure.

Based on interview and record review, the facility failed to immediately consult with the physician when there was a significiant change of condition for 1 of 8 residents reviewed for resident rights. (Resident #1) The facility did not ensure all pertinent information was given to Resident #1's physician or nurse practitioner when the resident, who had a history of [REDACTED]. Approximately 21 hours later, Resident #1 was transferred to the hospital where he was diagnosed with [REDACTED]. An Immediate Jeopardy situation was identified on 8/29/19. The Immediate Jeopardy was removed on 8/30/19. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place other residents with a change in condition at risk for delayed medical evaluation, serious impairment, and death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, was readmitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognition was intact. Resident #1 received limited assistance with transfers, and extensive assistance with most other ADLs. A care plan initiated 2/17/19 indicated Resident #1 had a history of [REDACTED]. A late entry nursing note dated 8/12/19 at 1:30 p.m. indicated Resident #1 returned inside from a smoke break with slurred speech. The note indicated the writer observed a second nurse assess the resident and noted Resident #1 had left sided weakness. Vitals were obtained and were within normal limits. Resident #1 complained of being dizzy. The second nurse notified the nurse practitioner and was told she was instructed to continue to monitor the resident for other changes, that the resident had a stoke in the past and left sided weakness was already present. The writer assisted the second nurse transfer Resident #1 into bed. During an interview on 8/28/19 at 1:30 p.m., Resident #1 said he went outside to smoke on 8/12/19 around 3:30 p.m. He said he got overheated, so he came inside and complained to the nurse he felt dizzy. He said he was having weakness on his left side and some nurses and other residents told him his speech was slurred. Resident #1 said he told staff members he thought he was having a stroke. He said he did not recall which staff members he told, but he said he did not tell his nurse. He said the facility sent him to the hospital the following day (8/13/19). He said at the hospital, he was told he had another mild stroke. He said after his stroke on 8/12/19, he had trouble swallowing, and got orders for a pureed diet with thickened liquids and his medications had to be crushed. During an interview on 8/29/19 at 12:55 p.m., LVN B said on 8/12/19 around 3:30 p.m., Resident #1 came inside from smoking and was talking a little slower, but not real slow. She said Resident #1 did not have slurred speech. She said she initially thought the resident was overheated and took his vitals, which were normal, and gave the resident a glass a water. She said she gave the resident the cup in his right hand. She said Resident #1 reported his left hand was a little weak. She said she called the nurse practitioner, notified her of the resident talking slower and the left-sided weakness, and the nurse practitioner told her due to the resident's history of [MEDICAL CONDITION], he already had left-sided weakness and to monitor the resident throughout the remainder of her shift. LVN B said she suspected Resident #1 was having a stroke. LVN B said after around 3:40 p.m., Resident #1 said he wanted to go lay down so she took him to his room and helped lay him down. She did not recall if anyone assisted LVN B transfer Resident #1 to bed. LVN B said Resident #1 did not normally require her assistance with transfers, but he did that day. LVN B said that was a change for the resident, and she did not call the nurse practitioner back and notify her of that change and probably should have. LVN B said she did not notice any other changes with Resident #1 during the remainder of her shift. LVN B said she should have went with her gut instinct that the resident was having a stroke and she should have fought harder to send him out. During an interview on 8/28/19 at 2:47 p.m., LVN A said LVN B was assigned to Resident #1 on 8/12/19. She said around on 8/12/19 around 1:30 p.m., someone came up to the nursing station with Resident #1 and notified LVN B Resident #1's speech was slurred. LVN A witnessed LVN B take Resident #1's vital signs and talk to Resident #1. Resident #1's speech was usually clear, but at this time it was slurred. Resident #1 exhibited some left-sided weakness, and complained of being dizzy. LVN A said she told LVN B she should notify the nurse practitioner. LVN A said she went down the hall to provide care for another resident, and when she came back minutes later, LVN B said the nurse practitioner told her to continue to monitor Resident #1 for other changes, to watch for facial drooping, and to monitor the resident's vital signs. LVN A said around 3:00 p.m., LVN B asked her to assist with transferring Resident #1 to bed. LVN B said Resident #1 usually needed standby assistance to guide him during transfers, but at this time, he required extensive assistance of LVN A and B to lift the resident with the gait belt and transfer him into the bed. LVN A said she told LVN B it seemed as if Resident #1 had a stroke, and LVN B told LVN A she informed the nurse practitioner of the resident's changes in condition after the resident was assessed at 1:30 p.m. LVN A said she told LVN B she thought she should call the nurse practitioner again and explain Resident #1's symptoms. During an interview on 8/28/19 at 3:21 p.m., CNA C said she was assigned to Resident #1 on 8/12/19 from 3:00 p.m. until 11:00 p.m. CNA C said on 8/12/19 between 3:00 p.m. and 3:30 p.m., she saw LVN B examine Resident #1 at the nursing station. She said LVN B had Resident #1 squeeze her hands, and then had him bring a cup to his mouth with his left hand. CNA C said the resident was barely able to move it to his mouth. LVN B moved the cup to his right hand, and he was able to move it straight to his mouth. CNA C said this was a change for the resident, because he normally was able to use both his arms without difficulty. CNA C said Resident #1 also had slurred speech, which was not normal for him. CNA C said LVN B called someone who was over her, but she did not know who. CNA C said LVN B said whoever she called said Resident #1 had left-sided weakness anyways and did not recommend the resident be sent to the hospital. CNA C said the resident had left-sided weakness prior to this day, but it was much worse. CNA C said she heard LVN say she suspected Resident #1 was having a TIA (mini stroke). CNA C said Resident #1 could usually stand with a walker, and needed standby assistance of 1 staff to transfer him to bed. She said a gait belt was not normally necessary because the resident was fully able to bear weight and was steady during his transfers. CNA C said on 8/12/19, LVN B said it took both nurses to get Resident #1 into bed. CNA C said since Resident #1 came back from the hospital, he was now transferred with a Hoyer lift because he was no longer independent. A nursing note dated 8/13/19 at 10:06 a.m. indicated Resident #1 continued to have slurred speech and had increased weakness to his left upper extremity and inability to grasp items. His left arm was noted to be drooping. It was noted the nurse practitioner was notified, and the nurse would continue to monitor for other changes. During an interview on 8/28/19 at 2:47 p.m., LVN A said she suspected Resident #1 was having a stroke when she saw him on 8/12/19. LVN A said on 8/13/19, Resident #1's speech was still slurred, it took LVN A and a CNA to transfer the resident out of bed with extensive assistance that morning, and the resident's left-sided weakness had increased. LVN A said she told ADON D about Resident #1's symptoms and explained to her LVN B notified the nurse practitioner the day before. LVN A said ADON D told her she would contact the nurse practitioner. LVN A said based on the nurse practitioner's assessment, LVN A notified 911 and Resident #1 went to the hospital around 12:40 p.m. on 8/13/19, (21 hours after presenting with slurred speech). A nursing note dated 8/13/19 at 12:40 p.m. indicated Resident #1 was sent to the hospital for a change in condition. The resident was noted with a functional decline (worsening function and/or mobility) Stroke/[MEDICAL CONDITION]/TIA/new neurological signs. The nurse practitioner's progress note dated 8/13/19 indicated she saw Resident #1 on 8/13/19 for slurred speech, numbness of the resident's left arm and leg, and weakness in the resident's left upper extremity which started earlier that morning. Resident #1 was noted with a history of a stroke with residual right sided weakness. It was noted the resident's speech sounded slurred in comparison to normal. It was noted the resident was sent to the emergency room for further evaluation. During a telephone interview on 8/28/19 at 3:53 p.m., the nurse practitioner said she received a call during the evening of 8/12/19 that Resident #1 was not acting like himself. She said the nurse informed her the resident's speech was a little slurred and the resident had a new onset of weakness (but did not say it affected his left-side). She said due to Resident #1's history of a previous stroke, it was difficult to assess for new signs of a stroke based on the changes reported by the nurse. She said she asked the nurse to monitor the resident closely and notify her of any other changes. She said Resident #1 mentation was affected after his first stroke, although the resident could communicate fairly well. The nurse practitioner said the previous stroke impacted his right side. The nurse practitioner said the nurse did not report Resident #1 had left-sided weakness, he had a decreased ability to transfer, or that she suspected the resident was having a stroke or TI[NAME] The nurse practitioner said if she would have been notified of those symptoms, she would have recommended to send the resident out to the hospital for further evaluation. The nurse practitioner said the following morning around 10:45 a.m., she went into Resident #1's room after ADON D notified her the resident needed to be assessed. The nurse practitioner said when she saw Resident #1, there was a definite impairment noted. She said his speech was slurred and he had left-sided weakness. She said she recommended he be sent out to the hospital at that time. A hospital discharge summary dated 8/18/19 indicated Resident #1's discharge [DIAGNOSES REDACTED]. It was noted the resident was advised after a swallow study to have a mechanical soft diet, however the resident was choking a lot and was put on a pureed diet with nectar thick liquids. It was also noted Resident #1's neurological exam showed left-sided weakness and pronator drift (indicates a possible neurological disorder). During an interview on 8/28/19 at 4:14 p.m., the DON said she first learned of Resident #1 's change of condition on 8/13/19, when the resident was sent out to the hospital. The DON said she was not aware of Resident #1's change in condition on 8/12/19 until she reviewed the nursing notes. The DON said the nurse practitioner was notified of the residents left sided weakness and slurred speech and said to continue to monitor the resident. The DON said the nurse practitioner told LVN B because the resident had a previous stroke, it would be difficult to recognize new symptoms and based on LVN B's assessment of Resident #1, it did not appear Resident #1 had a change in condition. The DON said if LVN B suspected Resident #1 was having a stroke, that should have been communicated to the nurse practitioner. During an interview on 8/28/19 at 4:32 p.m., the administrator said Resident #1 came back inside after a smoke break on 8/12/19 and looked different than usual. The administrator said the nurse assessed the resident, and reported what she saw to the nurse practitioner, who said continue to monitor the resident. The administrator said he was not aware the resident was experiencing left-sided weakness, slurred speech, or an inability to grasp with his left hand. The administrator said he spoke to the nurse practitioner a couple days after the resident was sent out to the hospital, and the nurse practitioner reported to him the resident had a history of [REDACTED]. The administrator said it was the nurse practitioner's responsibility to send the resident to the hospital. He said Resident #1's decreased ability to transfer should have been reported to the nurse practitioner so she had a full understanding of each of Resident #1's changes in condition. A Change of Condition policy dated (MONTH) (YEAR) required the resident's physician be notified of a significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications or when there was a need to alter treatment significantly. The policy indicated if necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation. The CDC website <https://www.cdc.gov/stroke/signs_symptoms.htm> accessed 9/3/19 indicated: During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women oSudden numbness or weakness in the face, arm, or leg, especially on one side of the body oSudden confusion, trouble speaking, or difficulty understanding speech oSudden trouble seeing in one or both eyes oSudden trouble walking, dizziness, loss of balance, or lack of coordination oSudden severe headache with no known cause Call 9-1-1 right away if you or someone else has any of these symptoms. Acting F.[NAME]S.T. Is Key for Stroke Acting F.[NAME]S.T. can help stroke patients get the treatments they desperately need. The stroke treatments that work best are available only if the stroke is recognized and diagnosed with [REDACTED]. Stroke patients may not be eligible for these if they don't arrive at the hospital in time. If you think someone may be having a stroke, act F.[NAME]S.T. and do the following simple test: F-Face: Ask the person to smile. Does one side of the face droop? A-Arms: Ask the person to raise both arms. Does one arm drift downward? S-Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange? T-Time: If you see any of these signs, call 9-1-1 right away. The administrator, DON, and ADON D were notified on 8/29/19 at 2:29 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 8/30/19 at 9:55 a.m. and included: 1. (Resident #1) was assessed by the Assistant Director with no change in condition on stroke like symptoms noted on 8/29/19. a. All the residents in the facility on 08.29.19 with a [DIAGNOSES REDACTED]. No resident presented with a change in condition. 2. (LVN B) was interviewed by the Administrator and Director of Nursing and was placed on immediate suspension for failure to assess properly 3. In-service was conducted by Director of Nursing, Assistant Director of Nursing and MDS Nurse on 08.29.19. The in-service is on Assessment, change in condition, and stroke signs and symptoms. a. The in-service was attended by licensed nurses which include; Registered Nurse and Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide and Licensed Therapists which include; Physical Therapist, Occupational Therapist and Speech therapist. The in-service has been completed for Registered Nurses, Licensed Vocational Nurses, Certified Nursing Assistants, Certified Medication Aide, Physical Therapists, Occupational Therapists and Speech Therapists working on 7a-7p and 7p-7a shift on 08.29.19. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. The in-service for the Licensed Nurses and Certified Nursing Assistance will be completed on 08.30.19 b. The details of the in-service information include, assessment of change in condition, notifying/reporting all change of condition- Stroke like symptoms immediately to physician, family and Director of Nursing/ADON, use of STOP AND WATCH in notification of change in condition, documentation of change in condition. Also, on recognizing Signs and Symptoms of Stroke according to CDC Guidelines (which include) Sudden numbness in the face and arm or leg, especially on one side of the body, Sudden confusion, trouble speaking or difficulty understanding speech. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance, or lack of coordination, Sudden and severe headache with no known cause (CDC 24/7 Saving Lives, Protecting People) will also be trained on the CDC Acronym F.[NAME]S.T. F-Face: Ask the person to smile. Does one side of the face droop? A-Arms: Ask the person to raise both arms, does arm drift downward? S-Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange? T-Time: If you see any of these signs, call 9-1-1 right away. On 8/30/19 surveyor confirmed the facility implemented their plan of removal to sufficiently to remove the Immediate Jeopardy by: Four CNAs (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift), 1 CMA (7 a.m. to 7 p.m. shift) and 1 PTA said they were in-serviced on changes of condition and signs of a stroke. They were able to identify signs of a stroke and said they would report any changes of condition or signs of a stroke to the resident's charge nurse. They said if a resident had signs of a stroke and the charge nurse did not send the resident to the hospital, they would report the signs of a stroke to the ADON, DON, and then administrator until the resident was sent to the hospital. The CNA's said they would also document the change of condition using their stop and watch system. Three charge nurses (7 a.m. to 7 p.m. shift) said they were in-serviced on changes of condition and signs of a stroke. They said if a resident presented with signs of a stroke, they would report it to the nurse practitioner, and if the nurse practitioner did not recommend the resident be sent out, they would notify then notify the physician. The charge nurses said they would document any changes of condition in the resident's clinical record, and notify the resident's family, physician, and the DON or ADON. The charge nurses said they would send the resident to the hospital if the resident had a change of condition and stroke like symptoms. A list of 24 residents with a history [MEDICAL CONDITION] reviewed. This list indicated each resident was assessed for a change in condition on 8/29/19 between 4:00 p.m. and 6:30 p.m. There was no evidence of a change in condition for any of the 24 residents with a history of [MEDICAL CONDITION]. On 8/30/19 at 12:03 p.m., the administrator, senior vice president of operations, and vice president of clinical services were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 1 of 8 residents reviewed for assessments. (Resident #1) The facility did not immediately send Resident #1 to the hospital for emergency care when he experienced stroke like symptoms that consisted of slurred speech, left sided weakness, dizziness, and a decreased ability to transfer. Resident #1 was not sent to the hospital for approximately 21 hours where he was diagnosed with [REDACTED]. An Immediate Jeopardy situation was identified on 8/29/19. The Immediate Jeopardy was removed on 8/30/19. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place other residents with a change in condition at risk for not receiving care and services to meet their needs, serious impairment, and death. Findings included: The most recent physician orders [REDACTED].#1 was [AGE] years old, was readmitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1's cognition was intact. Resident #1 received limited assistance with transfers, and extensive assistance with most other ADLs. A care plan initiated 2/17/19 indicated Resident #1 had a history of [REDACTED]. A late entry nursing note dated 8/12/19 at 1:30 p.m. indicated Resident #1 returned inside from a smoke break with slurred speech reported to the nurse. The note indicated the writer observed a second nurse assess the resident and noted Resident #1 had left sided weakness. Vitals were obtained and were within normal limits. Resident #1 complained of being dizzy. The second nurse notified the nurse practitioner and was instructed to continue to monitor the resident for other changes, that the resident had a stroke in the past and left sided weakness was already present. The writer assisted the second nurse transfer Resident #1 into bed. During an interview on 8/28/19 at 1:30 p.m., Resident #1 said he went outside to smoke on 8/12/19 around 3:30 p.m. He said he got overheated, so he came inside and complained to the nurse he felt dizzy. He said he was having weakness on his left side and some nurses and other residents told him his speech was slurred. Resident #1 said he told staff members he thought he was having a stroke. He did not recall which staff members he told, but he said he did not tell his nurse. He said his weakness on his left side continued to get worse and he was not able to grab items. The facility sent him to the hospital on [DATE]. He said at the hospital, he was told he had another mild stroke. He said after his stroke 0n 8/12/19, he had trouble swallowing and got orders for a pureed diet with thickened liquids and his medications had to be crushed. He said he still had some left sided weakness, but it was improving. During an interview on 8/29/19 at 12:55 p.m., LVN B said on 8/12/19 around 3:30 p.m., Resident #1 came inside from smoking and was talking a little slower, but not real slow. She said Resident #1 did not have slurred speech. She said she initially thought the resident was overheated and took his vitals, which were normal, and gave the resident a glass a water. She said she gave the resident the cup in his right hand. She said Resident #1 reported his left hand was a little weak, so she moved the cup to his left hand and he was able to hold it and was able to bring it to his mouth slowly. LVN B said she noticed Resident #1's left hand was a little weak. She said she called the nurse practitioner, notified her of the resident talking slower and the left-sided weakness, and the nurse practitioner told her due to the resident's history of [MEDICAL CONDITION], he already had left-sided weakness and to monitor the resident throughout the remainder of her shift. LVN B said she suspected Resident #1 was having a stroke. LVN B said after around 3:40 p.m., Resident #1 said he wanted to go lay down so she took him to his room and helped lay him down. She did not recall if anyone assisted LVN B transfer Resident #1 to bed. LVN B said Resident #1 did not normally require her assistance with transfers, but he did that day. LVN B said that was a change for the resident, and she did not call the nurse practitioner back and notify her of that change and probably should have. LVN B said she did not notice any other changes with Resident #1 during the remainder of her shift. LVN B said she should have went with her gut instinct that the resident was having a stroke and she should have fought harder to send him out. During an interview on 8/28/19 at 2:47 p.m., LVN A said LVN B was assigned to Resident #1 on 8/12/19. She said around on 8/12/19 around 1:30 p.m., someone came up to the nursing station with Resident #1 and notified LVN B Resident #1's speech was slurred. LVN A witnessed LVN B take Resident #1's vital signs and talk to Resident #1. Resident #1's speech was usually clear, but at this time it was slurred. Resident #1 exhibited some left-sided weakness, and complained of being dizzy. LVN A said she told LVN B she should notify the nurse practitioner. LVN A said she went down the hall to provide care for another resident, and when she came back minutes later, LVN B said the nurse practitioner told her to continue to monitor Resident #1 for other changes, to watch for facial drooping, and to monitor the resident's vital signs. LVN A said around 3:00 p.m., LVN B asked her to assist with transferring Resident #1 to bed. LVN B said Resident #1 usually needed standby assistance to guide him during transfers, but at this time, he required extensive assistance of LVN A and B to lift the resident with the gait belt and transfer him into the bed. LVN A said she told LVN B it seemed as if Resident #1 had a stroke, and LVN B told LVN A she informed the nurse practitioner of the resident's changes in condition after the resident was assessed at 1:30 p.m. LVN A said she told LVN B she thought she should call the nurse practitioner again and explain Resident #1's symptoms. During an interview on 8/28/19 at 3:21 p.m., CNA C said she was assigned to Resident #1 on 8/12/19 from 3:00 p.m. until 11:00 p.m. CNA C said on 8/12/19 between 3:00 p.m. and 3:30 p.m., she saw LVN B examine Resident #1 at the nursing station. She said LVN B had Resident #1 squeeze her hands, and then had him bring a cup to his mouth with his left hand. CNA C said the resident was barely able to move it to his mouth. LVN B moved the cup to his right hand, and he was able to move it straight to his mouth. CNA C said this was a change for the resident, because he normally was able to use both his arms without difficulty. CNA C said Resident #1 also had slurred speech, which was not normal for him. CNA C said LVN B called someone who was over her, but she did not know who. CNA C said LVN B said whoever she called said Resident #1 had left-sided weakness anyways and did not recommend the resident be sent to the hospital. CNA C said the resident had left-sided weakness prior to this day, but it was much worse. CNA C said she heard LVN say she suspected Resident #1 was having a TIA (mini stroke). CNA C said Resident #1 could usually stand with a walker, and needed standby assistance of 1 staff to transfer him to bed. She said a gait belt was not normally necessary because the resident was fully able to bear weight and was steady during his transfers. CNA C said on 8/12/19, LVN B said it took both nurses to get Resident #1 into bed. CNA C said since Resident #1 came back from the hospital, he was now transferred with a Hoyer lift. A nursing note dated 8/13/19 at 10:06 a.m. indicated Resident #1 continued to have slurred speech and had increased weakness to his left upper extremity and inability to grasp items. His left arm was noted to be drooping. It was noted the nurse practitioner was notified, and the nurse would continue to monitor for other changes. During an interview on 8/28/19 at 2:47 p.m., LVN A said she suspected Resident #1 was having a stroke when she saw him on 8/12/19. LVN A said on 8/13/19, Resident #1's speech was still slurred, it took LVN A and a CNA to transfer the resident out of bed with extensive assistance that morning, and the resident's left-sided weakness had increased. LVN A said she told ADON D about Resident #1's symptoms and explained to her LVN B notified the nurse practitioner the day before. LVN A said ADON D told her she would contact the nurse practitioner. LVN A said based on the nurse practitioner's assessment, LVN A notified 911 and Resident #1 went to the hospital around 12:40 p.m. on 8/13/19, (21 hours after presenting with slurred speech). A nursing note dated 8/13/19 at 12:40 p.m. indicated Resident #1 was sent to the hospital for a change in condition. The resident was noted with a functional decline (worsening function and/or mobility) Stroke/[MEDICAL CONDITION]/TIA/new neurological signs. The nurse practitioner's progress note dated 8/13/19 indicated Resident #1 was seen by the nurse practitioner on 8/13/19 for slurred speech, numbness of the resident's left arm and leg, and weakness in the resident's left upper extremity which started earlier that morning. The progress note and left-sided weakness and numbness. Resident #1 was noted with a history of a stroke with residual right sided weakness. It was noted the resident's speech sounded slurred in comparison to normal. It was noted the resident was sent to the emergency room for further evaluation. During a telephone interview on 8/28/19 at 3:53 p.m., the nurse practitioner said she received a call during the evening of 8/12/19 that Resident #1 was not acting like himself. She said the nurse informed her the resident's speech was a little slurred and the resident had a new onset of weakness (but did not say it affected his left-side). She said due to Resident #1's history of a previous stroke, it was difficult to assess for new signs of a stroke based on the changes reported by the nurse. She said she asked the nurse to monitor the resident closely and notify her of any other changes. She said Resident #1 mentation was affected after his first stroke, although the resident could communicate fairly well. The nurse practitioner said the previous stroke impacted his right side. The nurse practitioner said the nurse did not report Resident #1 had left-sided weakness, he had a decreased ability to transfer, or that she suspected the resident was having a stroke or TI[NAME] The nurse practitioner said if she would have been notified of the symptoms, she would have recommended to send the resident out to the hospital for further evaluation. The nurse practitioner said the following morning around 10:45 a.m., she went into Resident #1's room after ADON D notified her the resident needed to be assessed. The nurse practitioner said when she saw Resident #1, there was a definite impairment noted. She said his speech was slurred and he had left-sided weakness. She said she recommended he be sent out to the hospital at that time. A hospital discharge summary dated 8/18/19 indicated Resident #1's discharge [DIAGNOSES REDACTED]. It was noted the resident was advised after a swallow study to have a mechanical soft diet, however the resident was choking a lot and was put on a pureed diet with nectar thick liquids. It was also noted Resident #1's neurological exam showed left-sided weakness and pronator drift (indicates a possible neurological disorder). A speech therapy evaluation dated 8/22/19 indicated Resident #1 was referred to speech therapy due to a new onset of oral/pharyngeal function, risk for aspiration, risk for dehydration and risk for weight loss. The evaluation indicated Resident #1 swallowing was impaired and he was ordered a pureed diet with nectar thick liquids. The evaluation indicated Resident #1 previously consumed a regular consistency diet with thin liquids. During an interview on 8/29/19 at 12:42 p.m., the speech therapist said Resident #1 was on a regular diet with thin consistency, until he returned to the facility on [DATE] after the stroke on 8/12/19 when the resident was put on a pureed diet with nectar thick liquids. She said Resident #1 previously had no swallowing difficulties, but said since his stroke, she observed the resident pocketing his food and keeping a mouthful of food in his mouth before he swallows. The speech therapist the pocketing was probably related to the stroke. The speech therapist said Resident #1 was now a choke risk. During an interview on 8/28/19 at 4:14 p.m., the DON said she first learned of Resident #1 's change of condition on 8/13/19, when the resident was sent out to the hospital. The DON said she was not aware of Resident #1's change in condition on 8/12/19 until she reviewed the nursing notes. The DON said the nurse practitioner was notified of the residents left sided weakness and slurred speech and said to continue to monitor the resident. The DON said the nurse practitioner told LVN B because the resident had a previous stroke, it would be difficult to recognize new symptoms and based on LVN B's assessment of Resident #1, it did not appear Resident #1 had a change in condition. The DON said if LVN B suspected Resident #1 was having a stroke, that should have been communicated to the nurse practitioner. During an interview on 8/28/19 at 4:32 p.m., the administrator said on 8/12/19, Resident #1 came back inside after a smoke break and looked different than usual. The administrator said the nurse assessed the resident, and reported what she saw to the nurse practitioner, who said continue to monitor the resident. The administrator said he was not aware the resident was experiencing left-sided weakness, slurred speech, or an inability to grasp with his left hand. The administrator said he spoke to the nurse practitioner a couple days after the resident was sent out to the hospital, and the nurse practitioner reported to him the resident had a history of [REDACTED]. The administrator said it was the nurse practitioner's responsibility to send the resident to the hospital. He said Resident #1's decreased ability to transfer should have been reported to the nurse practitioner so she had a full understanding of each of Resident #1's changes in condition. A Change of Condition policy dated (MONTH) (YEAR) required the resident's physician be notified of a significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications or when there was a need to alter treatment significantly. The policy indicated if necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation. The CDC website <https://www.cdc.gov/stroke/signs_symptoms.htm> accessed 9/3/19 indicated: During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women oSudden numbness or weakness in the face, arm, or leg, especially on one side of the body oSudden confusion, trouble speaking, or difficulty understanding speech oSudden trouble seeing in one or both eyes oSudden trouble walking, dizziness, loss of balance, or lack of coordination oSudden severe headache with no known cause Call 9-1-1 right away if you or someone else has any of these symptoms. Acting F.[NAME]S.T. Is Key for Stroke Acting F.[NAME]S.T. can help stroke patients get the treatments they desperately need. The stroke treatments that work best are available only if the stroke is recognized and diagnosed with [REDACTED]. Stroke patients may not be eligible for these if they don't arrive at the hospital in time. If you think someone may be having a stroke, act F.[NAME]S.T. and do the following simple test: F-Face: Ask the person to smile. Does one side of the face droop? A-Arms: Ask the person to raise both arms. Does one arm drift downward? S-Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange? T-Time: If you see any of these signs, call 9-1-1 right away. The administrator, DON, and ADON D were notified on 8/29/19 at 2:29 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 8/30/19 at 9:55 a.m. and included: 1. (Resident #1) was assessed by the Assistant Director with no change in condition on stroke like symptoms noted on 8/29/19. a. All the residents in the facility on 08.29.19 with a [DIAGNOSES REDACTED]. No resident presented with a change in condition. 2. (LVN B) was interviewed by the Administrator and Director of Nursing and was placed on immediate suspension for failure to assess properly 3. In-service was conducted by Director of Nursing, Assistant Director of Nursing and MDS Nurse on 08.29.19. The in-service is on Assessment, change in condition, and stroke signs and symptoms. a. The in-service was attended by licensed nurses which include; Registered Nurse and Licensed Vocational Nurse, Certified Nursing Assistants, Certified Medication Aide and Licensed Therapists which include; Physical Therapist, Occupational Therapist and Speech therapist. The in-service has been completed for Registered Nurses, Licensed Vocational Nurses, Certified Nursing Assistants, Certified Medication Aide, Physical Therapists, Occupational Therapists and Speech Therapists working on 7a-7p and 7p-7a shift on 08.29.19. For licensed staff who are unavailable for training on this date, they will not be allowed to return to work until training is complete. The in-service for the Licensed Nurses and Certified Nursing Assistance will be completed on 08.30.19 b. The details of the in-service information include, assessment of change in condition, notifying/reporting all change of condition- Stroke like symptoms immediately to physician, family and Director of Nursing/ADON, use of STOP AND WATCH in notification of change in condition, documentation of change in condition. Also, on recognizing Signs and Symptoms of Stroke according to CDC Guidelines (which include) Sudden numbness in the face and arm or leg, especially on one side of the body, Sudden confusion, trouble speaking or difficulty understanding speech. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance, or lack of coordination, Sudden and severe headache with no known cause (CDC 24/7 Saving Lives, Protecting People) will also be trained on the CDC Acronym F.[NAME]S.T. F-Face: Ask the person to smile. Does one side of the face droop? A-Arms: Ask the person to raise both arms, does arm drift downward? S-Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange? T-Time: If you see any of these signs, call 9-1-1 right away. On 8/30/19 surveyor confirmed the facility implemented their plan of removal to sufficiently to remove the Immediate Jeopardy by: Four CNAs (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift), 1 CMA (7 a.m. to 7 p.m. shift) and 1 PTA said they were in-serviced on changes of condition and signs of a stroke. They were able to identify signs of a stroke and said they would report any changes of condition or signs of a stroke to the resident's charge nurse. They said if a resident had signs of a stroke and the charge nurse did not send the resident to the hospital, they would report the signs of a stroke to the ADON, DON, and then administrator until the resident was sent to the hospital. The CNA's said they would also document the change of condition using their stop and watch system. Three charge nurses (7 a.m. to 7 p.m. shift) said they were in-serviced on changes of condition and signs of a stroke. They said if a resident presented with signs of a stroke, they would report it to the nurse practitioner, and if the nurse practitioner did not recommend the resident be sent out, they would notify then notify the physician. The charge nurses said they would document any changes of condition in the resident's clinical record, and notify the resident's family, physician, and the DON or ADON. The charge nurses said they would send the resident to the hospital if the resident had a change of condition and stroke like symptoms. A list of 24 residents with a history [MEDICAL CONDITION] reviewed. This list indicated each resident was assessed for a change in condition on 8/29/19 between 4:00 p.m. and 6:30 p.m. There was no evidence of a change in condition for any of the 24 residents with a history of [MEDICAL CONDITION]. On 8/30/19 at 12:03 p.m., the administrator, senior vice president of operations, and vice president of clinical services were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and based on the comprehensive assessment for 1 of 1 resident reviewed for assessments. (Resident #1) LVN C did not complete an assessment of Resident #1's leg when staff reported to her Resident #1's complaints of leg pain on 1/16/19. On 1/17/19 Resident #1 was found to have fracture to her distal left femur (thighbone) that resulted from an injury of unknown origin. This failure contributed to a delay in treatment for [REDACTED]. This failure could place residents at risk of receiving delayed medical care and services. Findings included: An admission record dated 2/14/2019 indicated Resident #1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 had severely impaired cognition. The MDS indicated she required extensive assistance with ADLs. The care plan dated 12/11/18 indicated Resident #1 had risk for falls. The care plan indicated Resident #1 had a communication deficit and required extensive 1- person assistance with dressing and bathing. Resident #1 required total assistance with transfers. An incident report dated 1/17/19 indicated CNA B reported Resident #1 had pain to her left leg when touched. The report indicated LVN A assessed the area. Resident #1 was unable to tell staff what happened. The incident report indicated Resident #1's lower left leg area was sore to touch. The left thigh area was also painful to touch. The physician was notified and ordered an x-ray of the left extremity. A radiology report dated 1/17/19 at 11:33 a.m., indicated Resident #1 had a [MEDICAL CONDITION] left femur. (thighbone) A skilled nursing note dated 1/21/19 at 8:25 p.m., indicated Resident #1 returned from the hospital with [DIAGNOSES REDACTED]. There was a dressing to her left knee with 23 staples in place. During an observation on 2/14/19 at 9:39 a.m., Resident #1 was laying in her bed. She was unable to answer questions or get out of bed. During an interview on 2/14/19 at 9:45 a.m., LVN A said she worked on 1/17/19 when the fracture to Resident #1's femur was discovered. LVN A said CNA B reported to her that something was wrong with Resident #1's leg. LVN A said she completed a skin assessment and noticed Resident #1's leg looked abnormal. LVN A said, a bone was sticking out. LVN A said she notified Resident #1's physician and received an order for [REDACTED].#1's physician and the resident was sent to the hospital for evaluation and treatment. LVN A said Resident #1 had not fallen and had not had any accident to cause the fracture that she knew of. LVN A said she did not know what caused the fracture. During an interview on 2/14/19 at 11:26 a.m., CNA B said she provided care for Resident #1. CNA B said after lunch on 1/16/19 she noticed something was wrong with Resident #1's leg. She said Resident #1's leg was swollen and at an angle and she reported it to LVN C. CNA B said on 01/17/19 she knew something was not right because Resident #1 was yelling out more than usual during care. CNA B said Resident #1 was saying mommy broke her leg, and her leg looked weird. She said Resident #1 was a 2- person transfer prior to her injury. CNA B said Resident #1 now required the use of the Hoyer lift for transfers. During an interview on 2/14/19 at 11:57 a.m., LVN C said CNA B reported to her that something was wrong with Resident #1's leg on 01/16/19. LVN C said she looked at Resident #1's leg and did not see anything wrong. LVN C said Resident #1's leg was swollen but did not think it was swollen more than usual. LVN C said Resident #1 always yelled out you are killing me. LVN C said she did not do a full assessment because she did not think it was anything different. LVN C said Resident #1 spit out her pain medications on 01/16/19 and that was why she thought Resident #1 had an increase in pain. LVN C said she called ADON D and asked her if she had noticed anything different with Resident #1's leg and she said no. LVN C said she did not do anything after that. LVN C said looking back at the situation she should have done a more thorough assessment because she did not do a full assessment, nor did she write anything down. LVN C said she only looked at Resident #1's leg.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing for 2 of 12 residents reviewed for pressure injuries. (Resident #s 71 and 86) The facility did not assess new facility acquired pressure injuries identified on Resident #86's right and left buttock and left ankle until 2 days after they were first identified, did not notify the physician of the new areas, and did not implement treatments for the 3 new areas until 2 days later upon surveyor intervention. Resident #86 was identified to be at a high risk for developing pressure injuries and had an unstageable pressure injury on her heel. She was not provided a pressure redistribution mattress until after she developed an unstageable on her right buttock and left ankle and a stage 2 on her left buttock. The facility did not assess a new facility acquired stage 2 pressure injury identified on Resident #71's sacral area (coccyx area), did not notify the physician, and did not obtain and provide treatment until 2 days after it was first identified and upon surveyor intervention. This failure could place 85 residents receiving preventive skin care at risk for developing new pressure injuries and 16 residents with existing pressure injuries at risk for a decline in existing pressure injuries and/or developing new pressure injuries. Finding included: 1. Physician orders [REDACTED].#86 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. A Braden scale risk assessment dated [DATE] indicated Resident #86 was at high risk for pressure injuries. There were no other Braden skin assessments. The most recent MDS dated [DATE] indicated Resident #86 had moderate cognitive impairment, clear speech, and understood others and was understood by others. Resident #86 required the extensive assistance of 2 staff for bed mobility and transfers. Resident #86 had a stage 1 or greater pressure injury, a scar over a bony prominence, or a non-removable dressing/device. The MDS indicated he was at risk of developing pressure injuries and had an unhealed pressure injury that was a stage 1or higher. The MDS indicated he had 1 stage 4 pressure injury. The MDS indicated Resident #86 received hospice care and had a pressure reducing device for his bed. The care plan dated 6/27/18 indicated Resident #86 a potential for pressure injury development related to having history of pressure injuries and daily incontinence. The care plan indicated Resident #86 had a DTI (deep tissue injury) pressure injury on his left heel with a recommendation for a Prevalon boot. It indicated the resident refused to wear the boot. The care plan indicated his heels should be floated with the use of pillows. The care plan did not address any other pressure injuries or open areas. The care plan indicated Resident #86 had a Foley catheter and was on hospice care. A weekly skin assessment for Resident #86 indicated: *7/8/18 - Other skin findings section was blank. A weekly skin pressure injury report dated 7/10/18 indicated Resident #86 had a stage 4 pressure injury on his left heel. The report did not identify any other pressure injuries. A weekly skin assessment for Resident #86 indicated: *7/15/18 Other skin findings: Pressure area to left heel and to coccyx. There were no measurements of the wounds. This was the first note of a coccyx wound. The RN hospice notes for Resident #86 indicated the following: *7/16/18 .Wounds to coccyx noted and treatment nurse notified. There were no measurements of the wounds. *7/16/18 a stage 4 pressure ulcer to his left ankle was noted. Treatment nurse notified and will initiate treatment to coccyx area. Will continue to monitor and coordinate with facility treatment nurse. The note indicated a low air loss mattress had been ordered. There was no order or any assessment of the coccyx (sacral area.) During an observation and interview on 7/18/18 at 10:58 a.m., the treatment nurse said the wound care physician did not see Resident #86 yesterday when he was in the building. Resident #86 was lying on a regular scoop mattress. He had a boot on his left leg. He had a pressure injury on his left ankle that was open to air. The hospice aide said the area on the resident's left ankle was there on Monday (7/16/18) The treatment nurse said the left ankle pressure injury was new and was unstageable. She said she did not know if the left ankle pressure injury developed when she was on vacation (the week of 7/9/18) last week. She said there were no orders in place to treat the left ankle pressure injury. The treatment nurse said, I don't remember if I ever saw it (pressure ulcer on his left ankle) or not, it is a blur. The treatment nurse measured the Resident #86's left ankle pressure injury to be 0.7 x 0.7 cm. She said it was unstageable and had 100% eschar. The wound care nurse checked Resident #86's bottom after assisting him to turn over. She said Resident #86 had a new stage 2 pressure injury on his left buttock that measured 1 cm x 1 cm x less than 0.1 cm. She said he had a new unstageable pressure injury on his right buttock that measured 7.5 cm x 5 cm. The wound was on his middle right buttock. She said the wound was unstageable because of the slough and she could not see the wound bed. She said while she was on vacation last week she did not know if the facility found these pressure injuries on his buttocks or not. She said there were no treatment orders for the wounds on Resident #86's buttocks. During an interview on 7/18/18 1:03 p.m., the hospice nurse said on Monday 7/16/18 she observed the new pressure injuries on Resident #86's right and left buttocks and left ankle. She said she noted the pressure injuries did not have treatment orders. She said she told the treatment nurse about Resident #86's ankle and the wounds on both buttocks on Monday (7/16/18). She said his left ankle had a bandage on it on Monday. She said she looked at his skin prior to Monday but did not remember any areas on his ankles or buttocks before Monday. She said upon admission (6/24/18), he had an area on his bottom that was an old incision, right in the split in his crack and a DTI on his heel. The hospice nurse said Resident #86 did not have open areas on his bottom or ankles on 7/13/18. During an observation and interview on 7/18/18 at 2:00 p.m., Resident #86 was on a scoop mattress and the facility was changing him to a low air loss mattress. CNA A said he was getting up now for one meal per day but used to get up 3 times per day. CNA B said she did not think he had been up in his Geri chair this week. She said he got up out of the bed less than he used to because he has hemorrhoids that bothered him. During an interview on 7/18/18 at 2:19 p.m., ADON C said Resident #86 was on a regular scoop mattress, not a pressure relieving mattress. She said he was being changed to a low air loss mattress. During an interview on 7/18/18 at 2:42 p.m., CNA A said she provided incontinent care for Resident #86 on Monday (7/16). She said she had not done incontinent care for him before because she had not worked there long and said she just changed shifts. She said he had a red area on his right buttock on Monday. She said she saw his right buttock today and it was redder now. During an interview on 7/18/18 at 2:45 p.m., the corporate nurse said she thought the wound care physician saw Resident #86 on 7/17/18. She said she thought the new pressure injuries on his buttocks were from scratching. She said there was not a note or documentation from the wound care physician indicating he saw Resident #86 on 7/17/18. She said she did not know if the wound care physician saw Resident #86, but she said he said the new area was not pressure wounds. A call was placed to the wound care physician on 7/18/18 at 2:49 p.m., and 7/19/18 at 12:24 p.m. with no answer; a message was left. No return call was received. During an interview on 7/18/18 at 2:51 p.m., CNA B said she provided incontinent care for Resident #86 on Wednesday (7/11/18) and he had some redness from scratching on his upper right buttock. After the observation with the treatment nurse on 7/18/18 at 10:58 a.m., the following physician's orders [REDACTED]. *a physician order [REDACTED].#86 indicated to cleanse the wound to his left buttock with wound cleanser, pat dry, apply silver [MEDICATION NAME] to the wound bed, cover with dry protective dressing daily and as needed for dressing dislodgement/soilage as needed. *a physician order [REDACTED].#86 indicated to cleanse the wound to his right buttock with wound cleanser, pat dry, apply silver [MEDICATION NAME] to the wound bed, cover with dry protective dressing daily and as needed for dressing dislodgement/soilage as needed. *a physician order [REDACTED].#86 indicated to paint the wound to left lateral ankle with [MEDICATION NAME]-iodine every other day and as needed. During an interview 7/20/18 at 2:46 p.m., while the DON was present, the treatment nurse said she could not provide a copy of the TAR regarding treatment for [REDACTED]. During an interview on 7/19/18 at 1:31 p.m., the corporate nurse said Resident #86's last Braden scale risk assessment was 2/7/18. She said she expected the Braden scale risk assessment to be done quarterly. A multi wound chart details note for Resident #86,dated 7/18/18, received 7/23/18, from the wound care physician indicated: *Left heel, stage 4 pressure injury, moderate amount of exudate, no odor 40% slough, 50% [MEDICATION NAME] and 10% grandulation. *Right buttock, self inflicted scratches, 7.5 x 5 x 0.3 cm., 30% slough, 20% eschar, 30% epithelizlization, 20% grandulation. *Left buttock, pressure ulcer, 1 x 1 x 0.2 cm, 100% epithelizlization. The wound care physician note did not address the unstageable pressure injury on Resident #86's left ankle. 2. An admission record dated 7/19/18 indicated Resident #71 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A care plan updated on 6/30/18 indicated Resident #71 had bowel incontinence related to immobility and impaired cognitive status. Interventions included to check the resident every 2 hours and assist with toileting as needed and provide peri-care after each incontinent episode. The care plan did not address risk for pressure injuries or interventions to prevent pressure injuries A weekly skin report dated 7/5/18 indicated Resident #71 previously had a stage 2 pressure injury on his coccyx and a stage 2 on his sacrum and both had resolved on 7/2/18. The most recent MDS dated [DATE] indicated Resident #71 was cognitively intact and was totally dependent upon staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #71 had an indwelling urinary device, was incontinent of bowel, and had a feeding tube. The MDS indicated Resident #71 was at risk for developing pressure injuries and had no unhealed pressure ulcers. The MDS indicated Resident #71 was on a pressure reducing device for the bed, nutrition and hydration intervention to manage skin problems, and was receiving applications of ointments/medications other than to feet. An admission/readmission assessment dated [DATE] indicated Resident #71 did not have a pressure injury upon readmission from an acute care facility. A Braden scale dated 7/19/18 indicated Resident #71 was at high risk for developing pressure injuries. During an observation and interview on 7/18/18 at 10:29 a.m., Resident #71 was noted to have a stage 2 pressure injury on his sacrum the approximate size of a dime. The area was red with macerated edges and had no drainage. CNA B and CNA R indicated they were not assigned to Resident #71 the previous day. CNA B and CNA R said they did not know Resident #71 had an open area on his bottom prior to today. During an interview on 7/18/18 at 10:52 a.m., RN G said skin assessments were completed weekly on each resident. She said the nurse would notify the treatment nurse if a resident had a new open area. RN G said if the treatment nurse was already seeing the resident for a wound, the treatment nurse would complete the weekly skin assessment. She indicated if the treatment nurse was not present, the charge nurse would complete the treatment and skin assessment. RN G provided the names of residents assigned to her that had pressure injuries and Resident #71 was not included. During an interview on 7/18/18 at 1:27 p.m., the treatment nurse said every resident received a weekly skin assessment. She said she completed the weekly skin assessments if she was already providing wound care for a resident, otherwise, the charge nurse completed the skin assessment. The treatment nurse said Resident #71 previously had two small pressure injuries on his sacral area that were healed. The treatment nurse said no one had reported to her that Resident #71 had a new pressure injury. The treatment nurse stated, This is the first I have heard of it. During an interview on 7/18/18 at 2:49 p.m., CNA R said when an open area was found on a resident she would report it to the charge nurse immediately. She said she had reported the open area on Resident #71's bottom to the charge nurse, RN G that morning (7/18/18) as soon as it was identified. During an interview on 7/18/18 at 3:05 p.m. RN G said CNA R had reported the open area to her that morning. She indicated she did not remember the exact time it was reported. During an interview on 7/19/18 at 2:50 p.m., the DON said if a CNA noticed an open area on a resident it should be reported to the charge nurse or treatment nurse immediately. She said any change in a resident's skin should be assessed immediately or as soon as possible by the charge nurse or treatment nurse. During an interview on 7/19/18 at 3:09 p.m., the treatment nurse said she had not yet looked at Resident #71's skin and did not know if anyone else had looked at the open area on his bottom. A nursing note dated 7/19/18 at 5:44 p.m. indicated RN C and another nurse went into Resident #71's room to complete the weekly skin assessment but was unable to look at Resident #71's back side because Resident #71's spouse requested they come back at another time. A weekly skin assessment dated [DATE] at 6:48 p.m. indicated Resident #71 had redness on his buttocks and an open area noted on his coccyx measuring 1.5cm x 0.5cm x 0.5cm. A nursing noted dated 7/19/18 at 7:24 p.m. indicated the following documentation by LVN D: This nurse assessed resident skin with an open area noted to his coccyx. Treatment nurse in the facility and aware of skin concern. Wound assessed at this time with a treatment put in place. MD (medical director) notified. Wife in the facility and aware. Will monitor. During an interview on 7/20/18 at 9:25 a.m., the treatment nurse said when a pressure injury was reported to her she would assess the resident as soon as she could get to them. She indicated she assessed Resident #71 on 7/19/18 and put a treatment in place. She said a nurse had attempted to assess Resident #71 on 7/19/18, but the resident refused. She indicated she was working on getting the documentation in the electronic medical record but had been busy doing treatments A weekly skin pressure injury assessment dated [DATE] and completed by the treatment nurse on 7/20/18 indicated Resident #71 had a stage 2 on his sacrum measuring 1.5cm x 0.5cm x 0.75cm that was identified on 7/18/18. The assessment indicated the wound was open, the wound bed color was pink and red, the area around the wound was clear and there was a light amount of pink drainage. The assessment indicated the current wound treatment was [MEDICATION NAME] every other day and as needed A nursing policy and procedure with the subject of skin integrity monitoring system dated 5/2017 indicated the following: .2. Residents will be screened daily through direct care provided and any deficits identified will be reported. 4. When a pressure injury is identified, treatment orders are obtained from physician. 5. When a pressure injury is identified, treatment orders are obtained from physician. 7. When a pressure injury is identified, the interdisciplinary care plan and CNA care plan are to be updated to communicate changes to all care givers Procedure. 5. Treatment is completed and documented. The Skin Integrity Monitoring System dated 5/2017 indicated: Risk assessment: .3. A resident will have a new risk assessment no less than quarterly. When a pressure injury is identified: .3. Treatment orders are secured and noted on the Treatment Administration Record (TAR). Treatment is completed and documented on the Skin assessment Flow Sheet - Pressure Injury form and Nursing Assistant Daily Body Observation Form. According to the NPUAP (National Pressure Ulcer Advisory Panel) website, http://www.npuap.org/resources/educational-and-clinical-resources, accessed 07/25/18, the following was indicated: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . The CMS-672 dated 7/16/18 indicated 16 residents had pressure ulcers and 85 residents were receiving preventative skin care.

Based on observation, interview, and record review, the facility failed to ensure nursing staff with the appropriate competencies and skills sets were provided to assure the safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being as determined by assessments and individual plans of care for 8 of 39 residents reviewed for sufficient staffing. (Resident #s 29, 33, 45, 67, 71, 86, 90, and 352) The facility did not assess new facility acquired pressure injuries identified on Resident #86's right and left buttock and left ankle until 2 days after they were first identified, did not notify the physician of the new areas, and did not implement treatments for the 3 new areas until 2 days later upon surveyor intervention. Resident #86 was identified to be at a high risk for developing pressure injuries and had an unstageable pressure injury on her heel. She was not provided a pressure redistribution mattress until after she developed an unstageable on her right buttock and left ankle and a stage 2 on her left buttock. The facility did not assess a new facility acquired stage 2 pressure injury identified on Resident #71's sacral area (coccyx area), did not notify the physician, and did not obtain and provide treatment until 2 days after it was first identified and upon surveyor intervention. The facility did not provide timely pain management for Resident #352's complaint of severe left hip pain. The resident was not administered pain medication until approximately 2 hours after she initially called for it. The facility did not respond timely to Resident #90's complaint of pain or provide an accurate assessment of pain. The resident was not administered pain medication until approximately 1 hour and 30 minutes after she initially called for it. The facility did not administer Resident #33's 6 a.m., 8 a.m., 8:30 a.m., and 9 a.m. medications timely, within the one-hour time frame. LVN P was administering morning medications approximately 1 hour and 45 minutes to 4 hours and 45 minutes late. The facility did not provide Resident #45 with timely incontinent care. The resident and her bed linens were soiled and saturated in urine. Incontinent care was provided, after surveyor intervention. The facility did not provide Resident #29 timely incontinent care. The resident was soiled with bowel movement and requested incontinent care and staff did not return. Therapy was delayed because facility staff did not provide timely care. The facility did not provide Resident #67, who was continent of bowel, with timely incontinent care. The resident called for assistance and soiled her brief when staff did not come to assist her to the toilet. The facility did not answer call lights timely for Resident #s 20, 23, 29, and 4. This failure could place the census of 100 at risk for unnecessary pain, discomfort, not receiving medications as prescribed, decreased quality of life, skin breakdown, loss of bowel continence, and psychosocial harm. Findings included: 1. Physician orders [REDACTED].#86 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. A Braden scale risk assessment dated [DATE] indicated Resident #86 was at high risk for pressure injuries. There were no other Braden skin assessments. The most recent MDS dated [DATE] indicated Resident #86 had moderate cognitive impairment, clear speech, and understood others and was understood by others. Resident #86 required the extensive assistance of 2 staff for bed mobility and transfers. Resident #86 had a stage 1 or greater pressure injury, a scar over a bony prominence, or a non-removable dressing/device. The MDS indicated he was at risk of developing pressure injuries and had an unhealed pressure injury that was a stage 1or higher. The MDS indicated he had 1 stage 4 pressure injury. The MDS indicated Resident #86 received hospice care and had a pressure reducing device for his bed. The care plan dated 6/27/18 indicated Resident #86 a potential for pressure injury development related to having history of pressure injuries and daily incontinence. The care plan indicated Resident #86 had a DTI (deep tissue injury) pressure injury on his left heel with a recommendation for a Prevalon boot. It indicated the resident refused to wear the boot. The care plan indicated his heels should be floated with the use of pillows. The care plan did not address any other pressure injuries or open areas. The care plan indicated Resident #86 had a Foley catheter and was on hospice care. A weekly skin assessment for Resident #86 indicated: *7/8/18 - Other skin findings section was blank. A weekly skin pressure injury report dated 7/10/18 indicated Resident #86 had a stage 4 pressure injury on his left heel. The report did not identify any other pressure injuries. A weekly skin assessment for Resident #86 indicated: *7/15/18 Other skin findings: Pressure area to left heel and to coccyx. There were no measurements of the wounds. This was the first note of a coccyx wound. The RN hospice notes for Resident #86 indicated the following: *7/16/18 .Wounds to coccyx noted and treatment nurse notified. There were no measurements of the wounds. *7/16/18 a stage 4 pressure ulcer to his left ankle was noted. Treatment nurse notified and will initiate treatment to coccyx area. Will continue to monitor and coordinate with facility treatment nurse. The note indicated a low air loss mattress had been ordered. There was no order or any assessment of the coccyx (sacral area.) During an observation and interview on 7/18/18 at 10:58 a.m., the treatment nurse said the wound care physician did not see Resident #86 yesterday when he was in the building. Resident #86 was lying on a regular scoop mattress. He had a boot on his left leg. He had a pressure injury on his left ankle that was open to air. The hospice aide said the area on the resident's left ankle was there on Monday (7/16/18) The treatment nurse said the left ankle pressure injury was new and was unstageable. She said she did not know if the left ankle pressure injury developed when she was on vacation (the week of 7/9/18) last week. She said there were no orders in place to treat the left ankle pressure injury. The treatment nurse said, I don't remember if I ever saw it (pressure ulcer on his left ankle) or not, it is a blur. The treatment nurse measured the Resident #86's left ankle pressure injury to be 0.7 x 0.7 cm. She said it was unstageable and had 100% eschar. The wound care nurse checked Resident #86's bottom after assisting him to turn over. She said Resident #86 had a new stage 2 pressure injury on his left buttock that measured 1 cm x 1 cm x less than 0.1 cm. She said he had a new unstageable pressure injury on his right buttock that measured 7.5 cm x 5 cm. The wound was on his middle right buttock. She said the wound was unstageable because of the slough and she could not see the wound bed. She said while she was on vacation last week she did not know if the facility found these pressure injuries on his buttocks or not. She said there were no treatment orders for the wounds on Resident #86's buttocks. During an interview on 7/18/18 1:03 p.m., the hospice nurse said on Monday 7/16/18 she observed the new pressure injuries on Resident #86's right and left buttocks and left ankle. She said she noted the pressure injuries did not have treatment orders. She said she told the treatment nurse about Resident #86's ankle and the wounds on both buttocks on Monday (7/16/18). She said his left ankle had a bandage on it on Monday. She said she looked at his skin prior to Monday but did not remember any areas on his ankles or buttocks before Monday. She said upon admission (6/24/18), he had an area on his bottom that was an old incision, right in the split in his crack and a DTI on his heel. The hospice nurse said Resident #86 did not have open areas on his bottom or ankles on 7/13/18. During an observation and interview on 7/18/18 at 2:00 p.m., Resident #86 was on a scoop mattress and the facility was changing him to a low air loss mattress. CNA A said he was getting up now for one meal per day but used to get up 3 times per day. CNA B said she did not think he had been up in his Geri chair this week. She said he got up out of the bed less than he used to because he has hemorrhoids that bothered him. During an interview on 7/18/18 at 2:19 p.m., ADON C said Resident #86 was on a regular scoop mattress, not a pressure relieving mattress. She said he was being changed to a low air loss mattress. During an interview on 7/18/18 at 2:42 p.m., CNA A said she provided incontinent care for Resident #86 on Monday (7/16). She said she had not done incontinent care for him before because she had not worked there long and said she just changed shifts. She said he had a red area on his right buttock on Monday. She said she saw his right buttock today and it was redder now. During an interview on 7/18/18 at 2:45 p.m., the corporate nurse said she thought the wound care physician saw Resident #86 on 7/17/18. She said she thought the new pressure injuries on his buttocks were from scratching. She said there was not a note or documentation from the wound care physician indicating he saw Resident #86 on 7/17/18. She said she did not know if the wound care physician saw Resident #86, but she said he said the new area was not pressure wounds. A call was placed to the wound care physician on 7/18/18 at 2:49 p.m., and 7/19/18 at 12:24 p.m. with no answer; a message was left. No return call was received. During an interview on 7/18/18 at 2:51 p.m., CNA B said she provided incontinent care for Resident #86 on Wednesday (7/11/18) and he had some redness from scratching on his upper right buttock. After the observation with the treatment nurse on 7/18/18 at 10:58 a.m., the following physician's orders [REDACTED]. *a physician order [REDACTED].#86 indicated to cleanse the wound to his left buttock with wound cleanser, pat dry, apply silver [MEDICATION NAME] to the wound bed, cover with dry protective dressing daily and as needed for dressing dislodgement/soilage as needed. *a physician order [REDACTED].#86 indicated to cleanse the wound to his right buttock with wound cleanser, pat dry, apply silver [MEDICATION NAME] to the wound bed, cover with dry protective dressing daily and as needed for dressing dislodgement/soilage as needed. *a physician order [REDACTED].#86 indicated to paint the wound to left lateral ankle with [MEDICATION NAME]-iodine every other day and as needed. During an interview 7/20/18 at 2:46 p.m., while the DON was present, the treatment nurse said she could not provide a copy of the TAR regarding treatment for [REDACTED]. During an interview on 7/19/18 at 1:31 p.m., the corporate nurse said Resident #86's last Braden scale risk assessment was 2/7/18. She said she expected the Braden scale risk assessment to be done quarterly. A multi wound chart details note for Resident #86,dated 7/18/18, received 7/23/18, from the wound care physician indicated: *Left heel, stage 4 pressure injury, moderate amount of exudate, no odor 40% slough, 50% [MEDICATION NAME] and 10% grandulation. *Right buttock, self inflicted scratches, 7.5 x 5 x 0.3 cm., 30% slough, 20% eschar, 30% epithelizlization, 20% grandulation. *Left buttock, pressure ulcer, 1 x 1 x 0.2 cm, 100% epithelizlization. The wound care physician note did not address the unstageable pressure injury on Resident #86's left ankle. 2. An admission record dated 7/19/18 indicated Resident #71 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A care plan updated on 6/30/18 indicated Resident #71 had bowel incontinence related to immobility and impaired cognitive status. Interventions included to check the resident every 2 hours and assist with toileting as needed and provide peri-care after each incontinent episode. The care plan did not address risk for pressure injuries or interventions to prevent pressure injuries A weekly skin report dated 7/5/18 indicated Resident #71 previously had a stage 2 pressure injury on his coccyx and a stage 2 on his sacrum and both had resolved on 7/2/18. The most recent MDS dated [DATE] indicated Resident #71 was cognitively intact and was totally dependent upon staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #71 had an indwelling urinary device, was incontinent of bowel, and had a feeding tube. The MDS indicated Resident #71 was at risk for developing pressure injuries and had no unhealed pressure ulcers. The MDS indicated Resident #71 was on a pressure reducing device for the bed, nutrition and hydration intervention to manage skin problems, and was receiving applications of ointments/medications other than to feet. An admission/readmission assessment dated [DATE] indicated Resident #71 did not have a pressure injury upon readmission from an acute care facility. A Braden scale dated 7/19/18 indicated Resident #71 was at high risk for developing pressure injuries. During an observation and interview on 7/18/18 at 10:29 a.m., Resident #71 was noted to have a stage 2 pressure injury on his sacrum the approximate size of a dime. The area was red with macerated edges and had no drainage. CNA B and CNA R indicated they were not assigned to Resident #71 the previous day. CNA B and CNA R said they did not know Resident #71 had an open area on his bottom prior to today. During an interview on 7/18/18 at 10:52 a.m., RN G said skin assessments were completed weekly on each resident. She said the nurse would notify the treatment nurse if a resident had a new open area. RN G said if the treatment nurse was already seeing the resident for a wound, the treatment nurse would complete the weekly skin assessment. She indicated if the treatment nurse was not present, the charge nurse would complete the treatment and skin assessment. RN G provided the names of residents assigned to her that had pressure injuries and Resident #71 was not included. During an interview on 7/18/18 at 1:27 p.m., the treatment nurse said every resident received a weekly skin assessment. She said she completed the weekly skin assessments if she was already providing wound care for a resident, otherwise, the charge nurse completed the skin assessment. The treatment nurse said Resident #71 previously had two small pressure injuries on his sacral area that were healed. The treatment nurse said no one had reported to her that Resident #71 had a new pressure injury. The treatment nurse stated, This is the first I have heard of it. During an interview on 7/18/18 at 2:49 p.m., CNA R said when an open area was found on a resident she would report it to the charge nurse immediately. She said she had reported the open area on Resident #71's bottom to the charge nurse, RN G that morning (7/18/18) as soon as it was identified. During an interview on 7/18/18 at 3:05 p.m. RN G said CNA R had reported the open area to her that morning. She indicated she did not remember the exact time it was reported. During an interview on 7/19/18 at 2:50 p.m., the DON said if a CNA noticed an open area on a resident it should be reported to the charge nurse or treatment nurse immediately. She said any change in a resident's skin should be assessed immediately or as soon as possible by the charge nurse or treatment nurse. During an interview on 7/19/18 at 3:09 p.m., the treatment nurse said she had not yet looked at Resident #71's skin and did not know if anyone else had looked at the open area on his bottom. A nursing note dated 7/19/18 at 5:44 p.m. indicated RN C and another nurse went into Resident #71's room to complete the weekly skin assessment but was unable to look at Resident #71's back side because Resident #71's spouse requested they come back at another time. A weekly skin assessment dated [DATE] at 6:48 p.m. indicated Resident #71 had redness on his buttocks and an open area noted on his coccyx measuring 1.5cm x 0.5cm x 0.5cm. A nursing noted dated 7/19/18 at 7:24 p.m. indicated the following documentation by LVN D: This nurse assessed resident skin with an open area noted to his coccyx. Treatment nurse in the facility and aware of skin concern. Wound assessed at this time with a treatment put in place. MD (medical director) notified. Wife in the facility and aware. Will monitor. During an interview on 7/20/18 at 9:25 a.m., the treatment nurse said when a pressure injury was reported to her she would assess the resident as soon as she could get to them. She indicated she assessed Resident #71 on 7/19/18 and put a treatment in place. She said a nurse had attempted to assess Resident #71 on 7/19/18, but the resident refused. She indicated she was working on getting the documentation in the electronic medical record but had been busy doing treatments A weekly skin pressure injury assessment dated [DATE] and completed by the treatment nurse on 7/20/18 indicated Resident #71 had a stage 2 on his sacrum measuring 1.5cm x 0.5cm x 0.75cm that was identified on 7/18/18. The assessment indicated the wound was open, the wound bed color was pink and red, the area around the wound was clear and there was a light amount of pink drainage. The assessment indicated the current wound treatment was [MEDICATION NAME] every other day and as needed During an interview on 7/20/18 at 11:08 a,m. the treatment nurse indicated she had missing measurements of residents' wound during the week of 7/9/18. The treatment nurse said she did not measure the wound that week because did not have time. She indicated she was busy doing treatments and could not always get to the documentation. The treatment nurse said she did not feel she had the time to do her job adequately. She indicated documentation of wound care was a full-time job alone and hands on treatment and documentation at the facility was too much for one nurse. The treatment nurse said the facility had a second treatment nurse, but she walked out a couple of months ago and had not been replaced. A nursing policy and procedure with the subject of skin integrity monitoring system dated 5/2017 indicated the following: .2. Residents will be screened daily through direct care provided and any deficits identified will be reported. 4. When a pressure injury is identified, treatment orders are obtained from physician. 5. When a pressure injury is identified, treatment orders are obtained from physician. 7. When a pressure injury is identified, the interdisciplinary care plan and CNA care plan are to be updated to communicate changes to all care givers Procedure. 5. Treatment is completed and documented. The Skin Integrity Monitoring System dated 5/2017 indicated: Risk assessment: .3. A resident will have a new risk assessment no less than quarterly. When a pressure injury is identified: .3. Treatment orders are secured and noted on the Treatment Administration Record (TAR). Treatment is completed and documented on the Skin assessment Flow Sheet - Pressure Injury form and Nursing Assistant Daily Body Observation Form. 3. An admission record dated (MONTH) 20, (YEAR) indicated Resident #352 admitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#352 was to have a pain assessment and utilize the 0-10 pain scale before and after prn (as needed) medications. The orders indicated to maintain hip precautions every shift and listed the following orders for pain medications: [REDACTED] *Administer [MEDICATION NAME]-[MEDICATION NAME] #3 tablet 300-30mg, one tablet by mouth every 6 hours as needed for mild/moderate pain and two tablets by mouth every 6 hours for moderate to severe pain, *[MEDICATION NAME] tablet 50 mg every 6 hours as needed for mild pain. An Admission assessment dated [DATE] at 12:19 p.m. indicated Resident #352 was alert and oriented to person, place, time and situation and had appropriate verbal response. She had clear speech and was understood and understood others. Resident #352 had bruising to the left hip related to surgical site. During an observation on 7/20/18 at 8:20 a.m., Resident #352's call light was activated. During an observation and interview on 7/20/18 at 8:32 a.m., Resident #352's call light remained on and surveyor asked Resident #352 if she was okay. Resident #352's body was shaking she had a startled look on her face and stated, No I am not okay, I asked for a pain pill at 6:30 a.m. and again at 7:30 a.m. and still have not received anything, the pain is worse now and she scaled it at 9 out of 10 on a pain scale of 0-10 (with 10 being the worst pain). She said she would not be able to participate in therapy if the pain did not get better. Resident #352 said she admitted yesterday (July 19, (YEAR)) after a hip replacement and said the pain in her left hip was now radiating down her buttock and left leg. She said she asked a staff member who entered her room at 6:30 a.m. for something for pain. She said the PT came in at 7:30 a.m. and she told him she had asked for pain medication at 6:30 a.m. and she had not received it. She said the PT told her he would report it to the nurse. During an observation and interview on 7/20/18 at 8:34 a.m., LVN N entered Resident #352's room to answer the resident's call light. LVN N said Resident #352 requested pain medication. LVN N said no one told her Resident #352 asked for medication at 6:30 a.m. or 7:30 a.m. and there were no entries on the 24 hour report regarding pain symptoms. During an observation on 7/20/18 8:43 a.m. LVN N returned to Resident #352's room with her pain medication. Resident #352 told the nurse she had been trying to get a pain pill since 6:30 a.m. and scaled her pain as 9 out of 10. LVN N asked Resident #352 if she would like an ice pack and Resident #352 said yes, but it took them 2 hours last night to bring me one. She said the PT was in her room at 7:30 a.m. and she told him she had been waiting for an hour at that time. The resident said now it had been over 2 hours since she first asked for the pain medication. A MAR indicated [REDACTED]. There were no other entries that indicated Resident #352 had received pain medication since her admission on (MONTH) 19, (YEAR). During a telephone interview on 7/20/18 at 9:18 a.m., PT M said he checked on Resident #352 at 7:30 a.m. and she reported pain in her hip. He said the resident scaled the pain as an 8 out 10 at that time. PT M said he did not see a nurse when he left Resident #352's room. He said a MA could not prescribe medication (indicating the nurse had to perform an assessment)-so he thought he would try to provide pain modalities during her therapy. During an interview on 7/20/18 at 08:56 a.m., the corporate nurse said unless the surveyor observed a resident asking for a pain medication at a specific time, then we could not verify they did. She did not give a parameter of how quickly staff were expected to respond to a resident's request for pain medication. During an interview on 7/20/18 at 08:58 a.m., MA O said she had not seen Resident #352 since she arrived on duty at 7:00 a.m. She said she could not say anything else concerning Resident #352's request for pain medication this morning. 4. An Admission Record dated (MONTH) 20, (YEAR) indicated Resident #90 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #90 had intact cognition, adequate hearing, clear speech, and was understood and able to understand others. Her pain management included scheduled pain medication and prn medications. Resident #90 was assessed to have occasional pain with the highest intensity of 6 out of 10 on pain scale of 0-10. A care plan initiated 7/18/18 and revised on 7/18/18 indicated Resident #90 required pain management due to acute pain related to a right total knee replacement and migraines. Interventions included anticipate resident's need for pain relief and respond immediately to any complaint of pain. A MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an observation on 7/18/18 at 12:54 p.m., Resident #90's call light was ringing. During an observation and interview on 7/18/18 at 1:10 p.m., Resident #90's call light continued to ring and surveyor asked resident if she was okay. Resident #90 said she needed a [MEDICATION NAME] to curtail her pain before she did therapy. She scaled her pain as 6 out of 10 in her right knee. During an interview on 7/18/18 at 1:15 p.m., surveyor informed nurses at nursing station Resident #90's call light had been ringing for over 15 minutes. The ADON left the nurses station and said she would answer the call light. During an observation 7/18/18 at 2:00 p.m., Resident #90's call light was ringing. During an observation and interview on 7/18/18 at 2:18 p.m. Resident #90's call light continued to ring. She said a staff member answered her call light after 1:00 p.m. and she had been waiting for the pain pill for over 45 minutes. During an observation and interview on 7/18/18 at 2:20 p.m., the administrator answered Resident #90's call light and she- said she had been waiting for 45 minutes to get a pain pill. During an interview on 7/18/18 at 2:30 p.m. LVN P said she was not told by RN Q who answered Resident #90's call light at 1:15 p.m. that she requested a pain pill. During an interview on 7/18/18 at 3:05 p.m. RN Q said she answered Resident #90's call light. She said she told the ADON she would take care of it. RN Q said she told LVN P, Resident #90 needed a pain pill. RN Q said pain medications should be given promptly upon a resident's request. The progress notes did not address Resident #90's complaints of pain voiced by Resident on 7/18/18 at 12:54 and again at 2:20 p.m. During an interview on 7/20/18 at 1:24 p.m., Resident #90 said during her stay, her daughter filed a grievance on her behalf with the administrator because she was not receiving her pain medications timely. A review of grievances on 7/20/18 at 1:30 p.m. did not contain a grievance by Resident #90's daughter concerning pain management. A Pain Management policy and procedure dated (MONTH) (YEAR) indicated the following: It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life .2. The home promotes residents self-reporting as the most reliable indicator of pain. 3. The home recognizes that a resident's response to pain is subjective and individual . 5. Physician consolidated orders dated (MONTH) 20, (YEAR) for Resident #33 indicated she was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. The resident had order for the following medications: [REDACTED] *[MEDICATION NAME] Sodium tablet 125 mg 1 tablet by mouth one time a day. *[MEDICATION NAME] tablet 30mg 1 tablet by mouth one time a day. *[MEDICATION NAME]-[MEDICATION NAME] tablet 25-100mg 1 tablet by mouth three times a day. *[MEDICATION NAME] capsule 100mg 2 capsules by mouth three times a day. *Tylenol with [MEDICATION NAME] #4 tablet 1 by mouth two times a day. *[MEDICATION NAME] Tablet 10 mg 1 tablet by mouth one time a day. *Aspirin tablet 81 mg by mouth 1 tablet by mouth one time a day. *[MEDICATION NAME] tablet 325 mg t tablet by mouth one time a day. *[MEDICATION NAME] tablet 75mg 1 tablet by mouth one time a day. *Eliquis 2.5 mg 1 tablet by mouth two times a day. *[MEDICATION NAME] tablet delayed release 40 mg by mouth two times a day. *[MEDICATION NAME] tablet 0.5 mg 1 tablet by mouth three times a day. The MAR indicated [REDACTED]#33: *6:00 a.m. -[MEDICATION NAME] Sodium tablet 125 mg 1 tablet. *8:00 a.m. -[MEDICATION NAME] tablet 30mg 1 tablet by mouth. -[MEDICATION NAME]-[MEDICATION NAME] tablet 25-100mg 1 tablet by mouth. *8:30 a.m. -[MEDICATION NAME] capsule 100mg 2 capsules by mouth. *9:00 a.m. -Tylenol with [MEDICATION NAME] #4 tablet 1 by mouth. -[MEDICATION NAME] Tablet 10 mg 1 tablet by mouth -Aspirin tablet 81 mg by mouth -[MEDICATION NAME] tablet 325 mg t tablet by mouth -[MEDICATION NAME] tablet 75mg 1 tablet by mouth -Eliquis 2.5 mg 1 tablet by mouth -[MEDICATION NAME] tablet delayed release 40 mg by mouth -[MEDICATION NAME] tablet 0.5 mg 1 tablet by mouth During an observation and interview on 7/19/18 at 10:45 a.m., LVN P prepared to administer medications on Hall 200. LVN P said she had not given Resident #33's medications that were due at earlier that morning (6 a.m., 8 a.m., 8:30 a.m. and 9 a.m.) She said she was behind and still had 13-15 residents left to complete her morning medication pass. During an interview on 7/19/18 at 11:00 a.m., the corporate nurse said LVN P should administer prescribed medication within a one-hour window before and after the designated administration times. 6. Physician orders [REDACTED].#45 admitted [DATE], was [AGE] years old and had [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #45 had clear speech, was usually understood and usually understood others, and had severe impaired cognition. She required extensive assistance of 2 staff for bed mobility, extensive assistance of staff for toileting and hygiene, and could not ambulate. She was always incontinent of bowel and bladder. A care plan with a revision date of 6/19/18 indicated Resident #45 had functional bladder and bowel incontinence, interventions included check resident and provide incontinent care as needed and change brief every 2 hours and as needed. During an observation on 7/19/18 at 4:32 p.m., Resident #45's call light was activated. There were no staff viewed in the hall way. During an observation and interview on 7/19/18 at 4:49 p.m., Resident #45 called out to surveyor from behind her privacy curtain. There was a noticeable urine and fecal odor in the room. She said she had been trying to get staff into her room since 3:30 p.m. and no one would answer the light. She said she was wet and needed to be changed. She said her sheets were wet. She looked at the clock on her wall and said it was 4:50 p.m. During an observation on 7/19/18 at 4:51 LVN S remained at the nurse's station and CNA T came out of a room. During an observation and interview on 7/19/18 at 4:52 CNA T said she made here initial rounds at the beginning of her shift, I looked in on everybody to see if they were breathin (TRUNCATED)

Based on observation, 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 2 of 5 residents reviewed for indwelling urinary catheters. (Resident #s 1 and 2) 1. Resident #1 had an indwelling urinary catheter with the incorrect bulb size inserted, causing bleeding from his penis. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1's gross hematuria (blood in the urine that can be seen with the naked eye) was thought to be secondary to indwelling urinary catheter trauma. He received 2 units of blood due to acute blood loss per urethra. 2. The facility did not properly insert Resident #2's indwelling urinary catheter, resulting in bleeding due to traumatic urethral injury. This failure could place 12 residents with indwelling urinary catheters at risk of pain, injury, and infection. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had an order for [REDACTED]. A care plan dated 11/16/17 indicated Resident #1 had an indwelling urinary catheter. Interventions listed included .Staff should monitor and document for pain or discomfort due to catheter . A MDS dated [DATE] indicated Resident #1 understood others and usually made his needs known. He was dependent on staff for ADLs. He had an indwelling urinary catheter and was incontinent of bowel. The nursing note for Resident #1 dated 12/16/17 at 3:05 a.m., indicated the resident requested catheter change at 11:30 p.m. .With a 10 cc syringe, old bulb deflated by removing sterile water. New 22 French foley catheter was inserted with 30 cc bulb with no urine return. At 1:00 a.m., checked resident's output and he did not have any return. Catheter bulb was deflated by 15cc with a small amount of bloody return to catheter line. Resident complained of discomfort as though he needed to void. Catheter was removed and blood spewed out of tip of penis, pressure applied to penis. Resident's blood pressure was 167/100, pulse 78, and respirations 22 . The note indicated 911 was called and Resident #1 was transferred to the emergency room (ER) at 1:15 a.m. The hospital records dated 12/16/17 indicated Resident #1 arrived at the ER with a pain level of 8/10 and bleeding from his penis. Resident #1 was .initially unstable with systolic blood pressure dropping to 60. Resident #1 received fluids and a 16 French coude catheter was inserted and the new catheter tamponaded the bleeding . Resident #1 was admitted to the hospital for .traumatic catheter placement and [MEDICAL CONDITION] . Resident #1's .gross hematuria was thought to be secondary to Foley catheter trauma . The hospital records dated 12/21/17 indicated Resident #1 was found with normocytic [MEDICAL CONDITION] secondary to acute blood loss per urethra and Resident #1 was transfused with 2 units of blood. Resident #1's hemoglobin improved. During an observation and interview on 12/28/17 at 5:20 p.m., Resident #1 was lying in his bed with an indwelling urinary catheter bag secured to the side of his bed. He said he asked RN A to change out his catheter because he felt like he needed to void. He said that he was quadriplegic and normally did not feel the urge to urinate. He said RN A removed his old catheter with no problems. He said when RN A inserted the new catheter he had a headache with severe pain. Resident #1 said he did not remember much after that and did not know how much blood he lost. He said he went to the hospital and was septic and had an injury from the indwelling urinary catheter placement. He said he had not had any problems with catheter insertion before RN A inserted his catheter on 12/16/17. During an interview on 12/28/17 at 5:16 p.m., RN D said he worked 12/16/17 from 7:00 a.m. to 7:00 p.m. He said about 20 minutes before his shift ended, Resident #1 told him that he felt like he needed to void. He said Resident #1 was quadriplegic and had not said anything to him before about feeling an urge to void. He said he told RN A about Resident #1's urge to void during report at shift change. During an interview on 12/28/17 at 3:39 p.m., RN A said on 12/16/17, Resident #1 asked her to change his indwelling urinary catheter because he felt the urge to urinate. She said she did not want to change his indwelling urinary catheter, but Resident #1 wanted her to so she did. She said she looked at the physician order [REDACTED].#1 was ordered a 22 French 30 cc bulb indwelling urinary catheter. She said she removed 30 cc of saline out of the old catheter bulb and the catheter came out with no issues. She said she inserted the new indwelling urinary catheter and met no resistance. She said she inflated 30 cc of saline into the new bulb. She said there was no urine return. RN A said she left the room and came back about an hour later and there was still no urine in the bag. She said she removed 15 cc of saline from the bulb and there was a small amount of dark blood in the catheter line. She said Resident #1 said he continued to feel like he needed to void. She said she removed the other 15 cc of saline from the bulb and removed the indwelling urinary catheter and Resident #1 began bleeding bright red blood from his penis. RN A said she held pressure to Resident #1's penis while another nurse called 911. She said Resident #1's blood pressure was high and then dropped low. She said the ambulance was at the facility within 15 minutes and EMS transferred Resident #1 to the hospital. She said she called the hospital to check on Resident #1 and the ER nurse said Resident #1 had a puncture to his urethra. She said she was not in-serviced on catheter insertion since being hired in July 2017. She said she did not know if the facility had indwelling urinary catheters with 10 cc bulbs. 2. Physician orders [REDACTED].#2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had an order for [REDACTED]. The nursing notes indicated the following for Resident #2: *12/12/17 at 4:08 a.m.-order for indwelling urinary catheter noted, 16 French catheter with 30 cc bulb instilled, resident tolerated well. Urine is clear yellow and draining to bedside drainage bag. *12/13/17 at 5:15 p.m.-resident's wife requested foley catheter to be removed due to blood in catheter bag and wife thought resident was in pain. Removed 30 cc from catheter bulb, catheter slid out easily, then followed by frank bleeding from meatus. Bleeding continued and was unable to be controlled and resident was sent to ER. During an interview on 12/28/17 at 4:38 p.m., RN B said Resident #2's order was for a 16 French 30 cc bulb indwelling urinary catheter. She said she did not remember seeing an order with a 10 cc bulb. She said she inserted Resident #2's catheter and met no resistance. She said there was urine return with possible a little blood. She said she instilled 30 cc of saline into the bulb. She said Resident #2 attempted to grab at the catheter tubing but Resident #2's hands were unable to grab the tubing. She said RN C was the oncoming nurse and she was notified about the blood in the catheter bag. She said she has not been in-serviced on catheter insertion. She said she did not know if the facility had urinary catheters with 10 cc bulbs. During an interview on 12/28/17 at 4:49 p.m., RN C said she was in Resident #2's room on 12/13/17 at 2:30 p.m. to perform wound care. She said Resident #2 pushed his hands down towards the indwelling urinary catheter tubing. She said a CNA redirected Resident #2's hands, but Resident #2 continued to push his hands onto the catheter tubing. RN C said at 5:00 p.m., she entered Resident #2's room and Resident #2 attempted to push his hands onto the catheter tubing. She said Resident #2's wife was in the room and said Resident #2 appeared to be in pain and wanted the indwelling urinary catheter removed. RN C said there was blood in the catheter tubing and bag. The hospital records dated 12/13/17 indicated Resident #2 arrived at the ER with bleeding to his penis after nursing home staff placed an indwelling urinary catheter. Resident #2 did not have blood in his urine prior to the catheter being placed. Hospital staff attempted to place the indwelling urinary catheter with no success. There was resistance when attempting to insert catheter. Resident #2 was seen by urology and a catheter was placed. Hospital records indicated Resident #2 could have a .urethral stricture of false passage with bulbar disruption . An urethrogram dated 12/13/17 indicated Resident #2 had a urethral injury along the inferior surface of the base of the penile urethra. A MDS dated [DATE] indicated Resident #2 did not understand others and did not make his needs known. Resident #2 was dependent on staff for ADLs. He was incontinent of bowel and bladder. The MDS did not indicate that Resident #2 had an indwelling urinary catheter. A care plan dated 12/14/17 was revised on 12/28/17 to include Resident #2's indwelling urinary catheter. Interventions included .Staff should monitor and document for pain or discomfort due to catheter . During an observation on 12/28/17 at 12:45 p.m., Resident #2 was lying in bed with an indwelling urinary catheter secured to his left thigh. A catheter bag was hanging on the bed frame. He was unable to answer questions due to his cognition. During an interview on 12/28/17 at 5:38 p.m., the Regional Consultant Nurse said all nurses will be in-serviced and perform a skills check off on indwelling catheter insertion before performing indwelling urinary catheter care. The facility's catheter policy dated May 2017 indicated .it is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications. Physician order [REDACTED]. Order should contain the following: type of catheter, size of catheter and size of bulb . According to www.ncbi.nlm.nih.gov, accessed 01/05/18, .Proper placement technique is critical, as failed attempts at catheterization may lead to iatrogenic injury. Forcing a catheter past the point of resistance can cause injuries ranging from a mucosal tear to more serious false passages (perforations), which are associated with infection, urethral stricture, and subsequent surgical management. In turn, urethral stricture may make future catheterizations problematic. The most common injury sites are the posterior and bulbous urethra. The most frequent injuries are false passages created by forceful catheterization, as well as mucosal and submucosal tissue tears caused by balloon inflation in an improper position in the urethra. Bleeding typically is the first sign that an injury has occurred. Besides making manual catheterization more difficult, bleeding also complicates subsequent endoscopic procedures that may be required . The CMS 672 indicated 12 residents had indwelling urinary catheters.

Based on interview and record review the facility failed to ensure care and services were provided in accordance with the comprehensive assessment and plan of care to maintain the highest practicable well-being for 1 of 9 residents reviewed for change in condition. (Resident #2) Resident #2 experienced a change in condition in the early morning hours of [DATE]. The nurse on duty did not perform an accurate assessment or provide care at this time. Four and a half hours later, the resident was found unresponsive and, although two nurses were notified of her condition, she was not assessed for over an hour at which time emergency medical service (EMS) was called. Upon arrival at the emergency room (ER), she had a [MEDICAL CONDITION]. Her [DIAGNOSES REDACTED]. She was placed on hospice and died 26 days later. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to the hospitalization and death of Resident #2. This failure could place the 48 residents residing on the 2nd floor at risk for not receiving timely assessments which could result in harm or death. Findings included: A computerized physician order [REDACTED].#2 was a [AGE] year old female admitted [DATE]. Her [DIAGNOSES REDACTED]. There were orders for [MEDICATION NAME] solution ([MEDICATION NAME] sulfate and [MEDICATION NAME] inhaler used to relax and widen the airways in the lungs ) every 4 hours as needed for shortness of breath (SOB) and wheezing. These orders required staff to complete a respiratory evaluation before and after treatment [MEDICATION NAME], including pulse, respirations, and oxygen saturation levels. The staff was also to indicate if the lungs were clear, crackles, rhonchi, or wheezing, and the location of any [MEDICAL CONDITION] abnormalities. She also had a routine order for [MEDICATION NAME] 0.5 milligram (mg)/2 (milliliter) ml suspension (used to control and prevent symptoms (wheezing and SOB) 2 times daily and an order for [REDACTED]. A MDS dated [DATE] Indicated Resident #2 was severely cognitively impaired. She had behaviors of physical and verbal symptoms directed toward others 4 to 6 days a week. She was totally dependent on staff for assistance with all ADLs with one person and two persons for transfers. A care plan dated ,[DATE] indicated Resident #2 had problems with resistance of care and SOB on exertion and activity. The approaches for her SOB were to administer oxygen, obtain and record the resident oxygen saturation levels, and assess her respiratory status. A nursing note dated [DATE] at 2:00 a.m., indicated Resident #2 had no signs and symptoms of respiratory distress or SOB. She was offered fluids and would continue to be monitored. The note was signed by RN E. An oxygen treatment MAR for [DATE] indicated Resident #2 could have oxygen at 2 liters per nasal cannula for shortness of breath as needed, but there was no indication oxygen was provided. The oxygen saturation level was to be checked each shift. On [DATE], on the night shift, Resident # 2's oxygen saturation level was noted to be 94 (,[DATE] percent (%) normal range). The MAR indicated [REDACTED]. There was no documentation of the required respiratory assessment. During a telephone interview on [DATE] at 9:00 a.m., CNA H said Resident #2 was normally up most of the night and would smile, make noises, and grab your hand. She said she worked on [DATE] during the 10 p.m.-6 a.m. shift , and checked on Resident #2 about midnight ([DATE]) and found her unresponsive. She said Resident #2 would not respond to her name and had her eyes closed. CNA H said she picked up Resident #2's arm and it just fell back to the bed, it was like she was dead weight. CNA H said she told RN E, Resident #2 was non-responsive. The nurse said she was going to check on her. She said she asked RN E about Resident #2 at approximately 1:30 a.m. or 2:00 a.m., and was told the resident had an asthma flair up. CNA H said RN E said the weather was bad and Resident #2 drank milk which contributed to her breathing problem. She said RN E said she gave Resident #2 a couple of breathing treatments and the resident was fine. CNA H said she checked on Resident #2 at approximately 3:00 a.m., and she was still unresponsive. CNA H said she told RN E, Resident #2 was still non-responsive. She said at approximately 6:50 a.m., during rounds she requested CNA B to accompany her to check on Resident #2 and found her to be unresponsive, not responding to her name being called and eyes closed. She said Resident #2 was much the same as she had been all night. CNA H said CNA B reported to RN E and LVN F, resident was still unresponsive. CNA H said her shift ended at 7:00 a.m., on [DATE] and she left. During an interview on [DATE] at 7:22 a.m., RN E said she worked on [DATE] during the 10 p.m.-6 a.m. shift. Resident #2 was in respiratory distress, around midnight. She said she took her oxygen saturation levels and administered breathing treatments.. RN E said that was the last time she remembered seeing Resident #2. She said on [DATE], during morning report, a CNA came to the nursing station and reported Resident #2 was not doing well. RN E said LVN F, day shift nurse, said she would check on her. RN E said Resident #2, " was a young lady with classic Down's Syndrome who always had respiratory issues." A nursing note dated [DATE] at 8:00 a.m., indicated Resident #2 was lying in bed in respiratory distress. She was breathing short, rapid breaths at a rate of 24 per minute (,[DATE] normal range), oxygen was initiated, and oxygen saturation was 76% (,[DATE]% normal range). A [MEDICATION NAME] nebulizer treatment was initiated in accordance with the physician orders. Her blood pressure was ,[DATE] (,[DATE] normal range for women) and heart rate 68 (60 -80 normal range). Her skin was warm and dry to touch and eyes were at a blank stare. Resdient # 2 was not responsive to sternal rub. A call was placed to 911 for transport to the hospital. At 8:10a.m., EMS arrived and transported Resident #2. Hospital emergency room records dated [DATE] indicated Resident #2 arrived at the hospital at 8:43 a.m. and was unresponsive. Upon her arrival at the ER, she had a [MEDICAL CONDITION] and was intubated. Her diagnoses, after testing, included an acute [MEDICAL CONDITION] and a stroke. Nursing notes dated [DATE] indicated that Resident #2 was returned to the facility on hospice services on [DATE]. She remained unresponsive and died on January , 2015. During an interview on [DATE] at 6:58 a.m., CNA B said she worked on [DATE] during the 10 p.m.-6 a.m. shift. on [DATE] she clocked in about 6:50 a.m., and found Resident #2 unresponsive. She said Resident #2's eyes were half opened, her breath was raspy and she would not even move her head. CNA B said normally when she would wash Resident #2's face, the resident would hit at her. She said Resident #2 did not do anything except lay there. CNA B said she told RN E and LVN F, that Resident #2 was not right, she was unresponsive, her eyes were half opened, and she was having hard time breathing. RN E said she knew about it. RN E said Resident #2 had an asthma attack earlier and administered her two breathing treatments and she was fine. RN E said bad weather caused Resident #2 to have asthma attacks. CNA B said she told the nurses, " I know she has asthma attacks, but this is different. " LVN F said she would check on the resident when she finished with morning report. CNA B said she did not see LVN F go into the room until after breakfast approximately 8:30 or so. During an interview on [DATE] at 7:31 a.m., LVN F said [DATE] she worked on [DATE] during the 6 a.m. - 2 p.m. shift. She said during morning report with RN E at approximately 6:45 a.m.,CNA B reported that something was wrong with Resident #2. RN E said she had given Resident #2 a breathing treatment and she was just asleep, and the resident was fine. LVN F said she finished getting report, stocked her cart, and began passing medications. She said CNA G came from Resident #2 ' s room and said something was wrong with Resident #2. LVN F said she was not sure how long it had been since the CNA B reported the concern at the nursing station. LVN F said she found Resident #2 having breathing difficulties, gasping for breath, and her eyes were " bucked." She said she did not remember Resident #2's oxygen saturation, but she called 911 and the resident was taken to the hospital. During an interview on [DATE] at 9:17 a.m., LVN F said on [DATE], RN E said she had given Resident #2 a breathing treatment and she was fine. She said she did not ask RN E how long it had been since the breathing treatment had been given. LVN F said she just assumed it was recent. She said Resident #2 sometimes slept with her eyes open, and made noises when she slept. LVN F said she had taken report from RN E, set up her cart, and started her medication pass on the other end of the hall. She said CNA G had alerted her Resident #2 was not doing well. She said she found Resident #2 receiving oxygen, but in obvious respiratory distress. LVN F said she called 911. She said she did not remember the exact times. During an interview [DATE] at 8:15 a.m., CNA G said she knew CNA B tried to get RN E to go and check on Resident #2, but no one had come. She said she passed all the breakfast trays and went into Resident #2's room at approximately 8:20 a.m. and found Resident #2 lying on her back breathing really hard. CNA G said Resident #2 did not respond when she tried to awaken her. She said she informed LVN F, Resident #2 was in bad shape. CNA G said CNA H, complained that Resident #2 was not doing well during her shift (10 p.m.-6 a.m.). During an interview on [DATE] at 10:00 a.m., the administrator said they were doing one on one in-service with the aides and the nurses about reporting changes in condition of residents that started on [DATE] after surveyor intervention. She said they were not aware of the incident with Resident #2 until [DATE]. A facility policy on charting and documentation revised [DATE] indicated, " ... all services provided to the resident or any changes in the residents ' medical or mental conditions shall be documented in the resident's medical record. Documentation for procedures and treatments shall include care-specific details and shall include: the assessment data, any unusual findings obtained during the procedure/treatment, and how the resident tolerated the procedure /treatment... " The policy and procedure revised February 2014 indicated the policy of this facility was, "The nurse Supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: ...d. A significant change in the resident's physical/emotional/mental condition ...Except in medical emergencies, notifications will be made within twenty-four (24) hours of the change occurring in the resident ' s medical/mental condition status. ...A significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 3. Unless otherwise instructed by the residents, the nurse supervisor/charge nurse will notify the resident's family of representative when ...b. There is a significant change in the resident's physical, mental, or psychosocial status. " The administrator and DON were notified on [DATE] at 10:02 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 2:45 p.m. and included: "...Licensed Nurses will be in-serviced on the following: ...A " significant change " of condition is a decline or improvement in the resident ' s status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions b) impacts more than one area of the resident ' s health status; and c) requires interdisciplinary review and/or revision to the care plan... Regardless of the resident ' s current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status... Any resident who was discharged to an acute care hospital will have their chart reviewed and audited by the Nursing Administration team on the next business day. Any issues noted with timely assessment will be reported to the QAPI team for recommendations of changes to the current process or education requirements. ... On [DATE] the facility scheduled an in-service for all nursing staff to be done on [DATE] at 1:30pm and 3:30pm. On [DATE] Facility initiated an in-service on a new process for notification of resident condition changes from the CNA to the Nurse using an Interact Version 4.0 "Stop and Watch Early Warning Tool" which allows the CNA to communicate a suspected change of condition of a resident to a charge nurse for further assessment. 12 Full Time Nurses have been in-serviced. 10 full time nurses are left to be in-serviced. 5 PRN nurses are left to be in-serviced and will be in-serviced before they return to work. 26 Full Time CNA/CMA were in-serviced [DATE] & [DATE]. 13 Full Time CNA/CMA are left to be in-serviced. 9 PRN CNA/CMA are left to be in-serviced. On [DATE] the administrator in-serviced the DON and ADONs on the following: "Daily Unit Management Tool", which is used to verify change of conditions have been documented, communicated to the physician, and communicated to the responsible party, are to be completed for each unit each day. In addition, a "Change of Condition Audit", which is a log to track the changes of condition of residents and notification of that change to the physician and responsible party, and the completion of ordered lab, X-ray, and neurological assessments, is to be completed daily by the ADON daily. "Telephone Order Audits", which are used to track the documentation of the physician's orders [REDACTED]. These processes is to be monitored by the DON and Administrator Monday through Friday daily during morning meetings and daily Monday through Friday at end of day meetings. On the weekend and/or holidays this process will be monitored through charge nurse notification to the Director of Nurses and/or designee that a "SBAR" has been initiated. Any noncompliance will be reported to the QAPI team monthly x3 months." On [DATE] The Administrator added an addendum to the Action Plan dated [DATE] to include Notification of change to the charge nurse from the CNA and timely follow up by the Licensed Nurse. This addendum included: "Licensed Nursing Staff and CNAs/CMAs were/will be in-serviced on the below process: The CNA is to complete a Stop and Watch Early Warning Tool, as previously describe in Number 7 above, when they suspect a change with a resident. The CNA is to enter the Name of the resident, the name of the nurse, and the time the Stop and Watch was given to the nurse. The CNA will then give a copy of the Stop and Watch Tool to the charge nurse for follow-up. The charge nurse is to review the Stop and Watch Tool and assess/collect data on the resident. Once the charge nurse has completed the face to face with the resident the Stop and Watch Tool is to be completed by the Charge Nurse and returned to the binder for completed tools and to make an entry in the log. The Charge Nurse is to complete an SBAR if there is a change in condition, notify the Physician, notify the responsible party and resident, then notify the DON/ADON that an SBAR was initiated. The ADON/DON is to review the Stop and Watch Early Warning Tools each day to ensure the changes in the resident which were suspected were addressed timely. Stop and Watch Tools will be reviewed in each morning meeting and at each stand-down meeting by the DON, ADON, and Administrator." On [DATE], at 10:55 a.m. the survey team confirmed the Plan of Removal (POR) had been implemented sufficiently to remove the IJ as evidenced by: Review of employee training roster provided by the administrator dated [DATE] indicated all available nursing staff had been in-serviced on the plan of removal. During interviews on [DATE] four (4) CNAs said they had been trained on reporting change in condition and how to document on the "Stop and Watch" form. They were able to demonstrate the procedure and explain their responsibility in reporting change in condition to the charge nurse. During interviews on [DATE] with two LVN charge nurses said they had been trained on reporting change in condition and how to document on the "Stop and Watch" form. They were able to demonstrate the procedure and explain their responsibility in timely assessment, reporting change in condition to the physician, responsible party and DON. They were not aware of any recent changes in condition. The "Stop and Watch" log located at the nurse's desk on the first and second floors indicated one change in condition was reported on [DATE] at 9:23 p.m. The charge nurse completed face to face assessment with the resident at 9:50 p.m. The change in condition was reported to the responsible party and the physician was aware of the change. The log was reviewed on [DATE] by the administrator. On [DATE] at 10:55 a.m., the administrator was informed the IJ was removed: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS form 672 dated [DATE] indicated 48 residents on the 2nd floor.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #1) Resident #1 fell from a mechanical lift during a transfer that resulted in a fractured leg and three ribs. Staff did not provide the required supervision or appropriate sling size for the resident during the transfer to prevent falls. This failure contributed to Resident #1 sustaining a fractured leg and 3 fractured ribs. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 9 residents, requiring mechanical lift transfers, at risk of injuries due to falls. Findings included: Physician orders, dated 09/05/14, indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent Risk Analysis Worksheet, dated 09/05/14, indicated Resident #1 was at high risk for falls, was non-ambulatory, and had a history of [REDACTED]. An initial care plan, dated 09/05/14, indicated Resident #1 required a 2 person mechanical lift for transfers. An Incident Report dated 09/29/14 at 11:30 a.m., indicated RN C witnessed Resident #1 lying on her left side on the floor of the resident's room yelling out in pain. Resident #1 was assessed with [REDACTED]. During an interview on 10/08/14 at 8:05 a.m. Resident #1's family member said the facility called and notified her that Resident #1 fell from a mechanical lift when CNA A attempted to transfer the resident without a second staff present. Resident #1's family member said Resident #1 was sent to the emergency room for evaluation and diagnosed with [REDACTED]. During an interview on 10/08/14 at 10:40 a.m., CNA A said on 09/29/14 at approximately 11:00 a.m. RN C told her to get Resident #1 up. CNA A said the other CNA on duty was busy and she did not want to ask RN C for assistance so she transferred Resident #1 with a mechanical lift without a second staff present. CNA A said she found a lift sling in Resident #1's room that looked too small for Resident #1, but she used it to transfer the resident anyway. She said she lifted Resident #1 off the bed using the mechanical lift and began to pull the lift toward the wheelchair when Resident #1 panicked and said "no, no, no". CNA A said Resident #1 slipped from the sling and the resident's feet touched the floor. She said she attempted to catch Resident #1, but the resident fell on the floor on her left side. CNA A said she yelled for help and LVN B and RN C came to the room. She said RN C assessed Resident #1 and called for emergency transport to the hospital. CNA A said she was trained on using a mechanical lift and knew she should not use a mechanical lift to transfer a resident without a second staff present. She said she knew Resident #1 required a large lift sling and she used a medium sized sling when the incident occurred. During an interview on 10/08/14 at 9:25 a.m., RN C said she was at the nursing station when she heard the wound care nurse and CNA A calling for help. She said she went to Resident #1's room, saw the resident on the floor with a bump below her left knee, and called for emergency transport to the hospital. RN C said CNA A told her she used a mechanical lift to transfer Resident #1 without a second staff present. She said all staff were trained to have 2 staff present when using a mechanical lift. She said there were 4 other staff on the hall at the time of the incident who could have assisted CNA A with the mechanical lift transfer. During an interview on 10/08/14 at 9:40 a.m., LVN B said she was in another resident's room when she heard CNA A call for help. She said she went to Resident #1's room and saw the resident on the floor crying in pain. LVN B said a mechanical lift was nearby, but no other staff was present in the room except CNA A. She said they called RN C to the room. LVN B said RN C assessed Resident #1 and called for emergency transport to the hospital. She said all staff were trained to have 2 staff present when using a mechanical lift. She said 4 other staff on the hall at the time of the incident could have assisted CNA A with the mechanical lift transfer. During an interview on 10/08/14 at 9:55 a.m., the DON said CNA A transferred Resident #1 using a mechanical lift without a second staff present. She said all staff including CNA A were trained to have 2 staff present when using a mechanical lift. The policy titled "Using a Portable Lifting Machine", dated February 2014, indicated 2 nursing assistants were required to operate a mechanical lift. The in-services records indicated staff, including CNA A, were trained on 06/06/11 regarding using a mechanical lift. The facility took the following actions to correct the non-compliance on 09/29/14. *Staff were trained regarding the correct procedures for 2 staff to transfer residents with the mechanical lift and correct sling size again on 09/29/14. *A list of residents transferred by the mechanical lift with the size of the sling each resident required was available to staff on the ADL book During an interview on 10/08/14 at 9:55 a.m., the DON said all staff were trained again on the procedure for transferring residents using a mechanical lift and provided a list of residents who use mechanical lift and their required sling size. She said CNA A was suspended while the incident was investigated then terminated. During an interview on 10/08/14 at 9:25 a.m., RN C said all staff were trained again after the incident to have 2 staff present when using a mechanical lift. She said a list of residents who required a mechanical lift for transfers with the size of sling required was listed in the ADL book. She said CNA A was suspended while the incident was investigated then terminated. During an interview on 10/08/14 at 9:40 a.m., LVN B said staff were re-inserviced on having 2 staff transfer residents with a mechanical lift. During an interview on 10/08/14 at 10:05 a.m., CNA B said after the incident a new list was created and placed in the ADL book listing residents requiring mechanical lift and their required sling size on the same page. During an interview on 10/08/14 at 9:15 a.m., CNA E said prior to the incident with Resident #1 there was a list of residents requiring mechanical lift in the ADL book. CNA B said after the incident a new list was created and placed in the ADL book listing residents requiring mechanical lift and their required sling size on the same page. The DON provided a list on 10/08/14 at 8:30 a.m. that indicated 9 residents required mechanical lift for transfers.

Based on observation, interview, and record review, the facility failed to ensure CNA A demonstrated competency in techniques to care for 1 of 10 residents reviewed for transfers. (Resident #1) Resident #1 fell from a mechanical lift during a transfer that resulted in a fractured leg and three ribs. Staff did not provide the required supervision or appropriate sling size for the resident during the transfer to prevent falls. This failure contributed to Resident #1 sustaining a fractured leg and 3 fractured ribs. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 9 facility residents, requiring mechanical lift transfers, at risk of injuries due to falls. Findings included: Physician orders, dated 09/05/14, indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent Risk Analysis Worksheet, dated 09/05/14, indicated Resident #1 was at high risk for falls, was non-ambulatory, and had a history of [REDACTED]. An initial care plan, dated 09/05/14, indicated Resident #1 required a 2 person mechanical lift for transfers. An Incident Report dated 09/29/14 at 11:30 a.m., indicated RN C witnessed Resident #1 lying on her left side on the floor of the resident's room yelling out in pain. Resident #1 was assessed with [REDACTED]. During an interview on 10/08/14 at 8:05 a.m. Resident #1's family member said the facility called and notified her that Resident #1 fell from a mechanical lift when CNA A attempted to transfer the resident without a second staff present. Resident #1's family member said Resident #1 was sent to the emergency room for evaluation and diagnosed with [REDACTED]. During an interview on 10/08/14 at 10:40 a.m., CNA A said on 09/29/14 at approximately 11:00 a.m. RN C told her to get Resident #1 up. CNA A said the other CNA on duty was busy and she did not want to ask RN C for assistance so she transferred Resident #1 with a mechanical lift without a second staff present. CNA A said she found a lift sling in Resident #1's room that looked too small for Resident #1, but she used it to transfer the resident anyway. She said she lifted Resident #1 off the bed using the mechanical lift and began to pull the lift toward the wheelchair when Resident #1 panicked and said "no, no, no". CNA A said Resident #1 slipped from the sling and the resident's feet touched the floor. She said she attempted to catch Resident #1, but the resident fell on the floor on her left side. CNA A said she yelled for help and LVN B and RN C came to the room. She said RN C assessed Resident #1 and called for emergency transport to the hospital. CNA A said she was trained on using a mechanical lift and knew she should not use a mechanical lift to transfer a resident without a second staff present. She said she knew Resident #1 required a large lift sling and she used a medium sized sling when the incident occurred. During an interview on 10/08/14 at 9:25 a.m., RN C said she was at the nursing station when she heard the wound care nurse and CNA A calling for help. She said she went to Resident #1's room, saw the resident on the floor with a bump below her left knee, and called for emergency transport to the hospital. RN C said CNA A told her she used a mechanical lift to transfer Resident #1 without a second staff present. She said all staff were trained to have 2 staff present when using a mechanical lift. She said there were 4 other staff on the hall at the time of the incident who could have assisted CNA A with the mechanical lift transfer. During an interview on 10/08/14 at 9:40 a.m., LVN B said she was in another resident's room when she heard CNA A call for help. She said she went to Resident #1's room and saw the resident on the floor crying in pain. LVN B said a mechanical lift was nearby, but no other staff was present in the room except CNA A. She said they called RN C to the room. LVN B said RN C assessed Resident #1 and called for emergency transport to the hospital. She said all staff were trained to have 2 staff present when using a mechanical lift. She said 4 other staff on the hall at the time of the incident could have assisted CNA A with the mechanical lift transfer. During an interview on 10/08/14 at 9:55 a.m., the DON said CNA A transferred Resident #1 using a mechanical lift without a second staff present. She said all staff including CNA A were trained to have 2 staff present when using a mechanical lift. The policy titled "Using a Portable Lifting Machine", dated February 2014, indicated 2 nursing assistants were required to operate a mechanical lift. The in-services records indicated staff, including CNA A, were trained on 06/06/11 regarding using a mechanical lift. The facility took the following actions to correct the non-compliance on 09/29/14. *Staff were trained regarding the correct procedures for 2 staff to transfer residents with the mechanical lift and correct sling size again on 09/29/14. *A list of residents transferred by the mechanical lift with the size of the sling each resident required was available to staff on the ADL book During an interview on 10/08/14 at 9:55 a.m., the DON said all staff were trained again on the procedure for transferring residents using a mechanical lift and provided a list of residents who use mechanical lift and their required sling size. She said CNA A was suspended while the incident was investigated then terminated. During an interview on 10/08/14 at 9:25 a.m., RN C said all staff were trained again after the incident to have 2 staff present when using a mechanical lift. She said a list of residents who required a mechanical lift for transfers with the size of sling required was listed in the ADL book. She said CNA A was suspended while the incident was investigated then terminated. During an interview on 10/08/14 at 9:40 a.m., LVN B said staff were re-inserviced on having 2 staff transfer residents with a mechanical lift. During an interview on 10/08/14 at 10:05 a.m., CNA B said after the incident a new list was created and placed in the ADL book listing residents requiring mechanical lift and their required sling size on the same page. During an interview on 10/08/14 at 9:15 a.m., CNA E said prior to the incident with Resident #1 there was a list of residents requiring mechanical lift in the ADL book. CNA B said after the incident a new list was created and placed in the ADL book listing residents requiring mechanical lift and their required sling size on the same page. The DON provided a list on 10/08/14 at 8:30 a.m. that indicated 9 residents required mechanical lift for transfers.