Every finding on record at Houston Heights Nursing and Rehabilitation Center

Based on interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 10 residents (Resident #13 and Resident #28). The facility failed to ensure that PASARR requested therapy services were provided to Resident #13 and Resident #28 in accordance with the PCSP meeting to include Occupational Therapy, Physical Therapy, and Speech Therapy. This failure could result in not receiving the support necessary to maintain stability, function, and safety.Findings included: Record review of Resident #13's undated admission record revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included developmental disorders of speech and language, lack of coordination, muscle wasting and atrophy, swelling, and mass lump right upper limb. Record review of Resident #13's physician orders dated 05/09/2025 revealed Speech Therapy may evaluate and treat as indicated, Physical Therapy may evaluate and treat as indicated, and Occupational Therapy may evaluate and treat as indicated. Record review of Resident #13's PCSP meeting dated 10/31/2025 revealed the following services were requested: Specialized Assessment Occupational Therapy, Specialized Assessment Physical Therapy, Specialized Assessment Speech Therapy, Specialized Occupational Therapy, Specialized Physical Therapy, and Specialized Speech Therapy. Resident #13 did not receive an evaluation for Physical Therapy or receive Physical Therapy services. Record review of Resident #13's Speech Therapy Evaluation & Plan of Treatment dated 11/11/2025-01/09/2026 assessment summary read evaluation completed for habilitative services and patient demonstrated cognitive-communication impairment with deficits in auditory comprehension, verbal expression. Dysarthria (when muscles used for speech are weak or hard to control) affect speech intelligibility. Risk factors read due to documented physical impairments and associated functional deficits; the patient is at risk for further decline in function. Record review of Resident #13's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 03 out of 15 indicating he has severe impairment in cognition. He had no impairment on lower extremity (hip, knee, ankle, foot) and impairment on one side for upper extremity (shoulder, elbow, wrist, hand). Record review of Resident #28's undated admission record revealed [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cellulitis (spreading skin infection) of the lower right limb, intellectual disabilities, dysphagia (difficulty swallowing), parkinsonism (tremors), cognitive communication deficit (trouble participating in conversations), muscle wasting and atrophy right thigh, muscle wasting and atrophy left thigh, left hand contracture, and schizophrenia. Record review of Resident #28's Physical Therapy Evaluation & Plan of Treatment reflected it was completed 06/07/2024, prior to the most recent request of services according to the PCSP meeting. Record review of Resident #28's physician orders dated 05/23/2025 reflected Occupational Therapy may evaluate and treat as indicated, Physical Therapy may evaluate and treat as indicated, Speech Therapy may evaluate and treat as indicated. Physician order review over the phone dated 07/02/2025 indicated to continue ST treatment 24 times in 8 weeks. Record review of Resident #28's Occupational Therapy Evaluation & Plan of Treatment dated 05/28/2025-07/26/2025 recommendations read evaluation assessment summary read patient with decreased tolerance for activities, independence with self-care, and strength of UEs. Risk factors revealed patients have weaknesses and falls. The skilled intervention focus was restoration and compensation. Record review of Resident #28's PCSP meeting on 08/14/2025 revealed the following services were ongoing: Specialized Occupational Therapy, new Physical Therapy, and discontinued Speech Therapy. Record review of Resident #28's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. He had no impairment on upper extremity (shoulder, elbow, wrist, hand) and impairment on one side (hip, knee, ankle, foot). In an interview with LVN M on 03/03/2026 at 2pm stated a meeting is held with the resident or responsible party, care management team of the facility and [NAME] County Health Center staff to conduct the PCSP meeting to develop the needs of therapy services to the resident through the PASARR program. All recommendations and communications are entered into an electronic system accessible to the parties responsible at both the nursing facility and. LVN stated PT services for Resident # 28 were not sent and Resident #13 refused services. LVN M stated she is unsure who is responsible for ensuring that referrals are sent to therapy for completion of the required assessments. LVN M stated the risk of residents not being assessed for PASARR-related services could result in a decline in their condition. In interview with DOR on 03/03/2026 at 2:53pm stated Resident #13 refuses services and would not participate for ST. Resident #13 is not receiving services because he is non-compliant and it was in the best interest to discharge for ST treatment services. Resident #13 was not evaluated for PT or OT services. Resident #28 was receiving ST and OT, but not PT due to having one leg and the other leg was contracted, making him not a good candidate for the program. If no referral is initiated for the residents to receive an assessment, the evaluations are not completed. The DOR stated the care management team is responsible for ensuring all documentation is put into the appropriate electronic system and accessible to all parties involved. The risk of the residents not being assessed for services through PASARR could cause the residents to decline. In an interview with LVN B on 03/04/2026 at 9:30am stated the nursing facility is not responsible for entering information for PASARR II, it is updated by staff. If the referral for an assessment to be completed is not sent, the responsibility falls on staff as they communicate with therapy. LVN B stated Resident #28 should have received an evaluation assessment because it was requested on his PCSP and Resident #13 refuses services, which is why he is not receiving therapy. The risk of the residents not being assessed for services through PASARR could result in the residents not thriving according to their care plan. In an interview with DON on 03/05/2026 at 8:56am stated the procedure for PASARR level II residents is to have a meeting with to review necessary equipment and therapy service or psychiatric services. She stated that she is unsure of the exact process for submitting the requests online, only that the system is electronic. She was unaware that Resident #13 and Resident #28 had not received the services they were approved for through PASARR. She explained that the MDS/Care Management team is responsible for entering and submitting these requests into the system after each meeting. She further stated that if the requests are not entered, the residents will not receive the services they need and have been approved of, which may prevent them from reaching their full potential. In an interview with ADMN on 03/05/2026 at 9:15am stated for PASARR level II residents, the meeting involves participation from [NAME] County Health Center, and on the facility's side, the MDS nurse is typically involved. She was unsure of the specific form names used during the process. If the resident qualifies for and agrees to the recommended services, the required forms are submitted electronically to document the requested services. She reported that she is not fully familiar with PASARR guidelines but does know there is a required timeframe for completing the meeting and entering the information into the portal. She further stated that if the request is not submitted, the residents may miss opportunities to receive needed services and could experience a decline in their quality of life. In an interview with RN N on 03/05/2026 at 9:34am stated during the PASARR level II audits, the facility identified missing information that should have been entered into the electronic portal. If information is not submitted, they must re-enter and resubmit it. He explained that the NFSS is completed based on the building and must be entered within 20 days, then finalized within 30 days from the PCSP meeting. He reported that he was informed by the MDS coordinators of these requirements. He stated that the facility does not have a policy for PASARR level II and instead follows the Texas Health and Human Services guidelines. He further explained that the risk of not submitting the required information is significant, as residents may lose access to needed services, which could negatively impact their health and quality of life. He stated that the facility does not have any policy or procedure specific to level II.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure that Resident #1's care plan included interventions for the contractures to the left elbow, left hand, right knee and left knee.The facility failed to ensure Resident #1's care plan included heel protectors for the potential for the development of pressure ulcers and for the non-pressure wound to the left foot.This deficient practice could place residents at risk of not receiving proper care, pain, reduced mobility and decline in health.Findings included:Record review of Resident #1's face sheet dated 03/04/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. The diagnoses included Hemiplegia (one sided paralysis or severe loss of strength on one side), Hemiparesis (weakness to one side of body), Diabetic neuropathy (affecting peripheral nerves leading to symptoms like pain and numbness), contracture of the left elbow, contracture of the right knee, contracture of the left hand, contracture of the left knee, muscle wasting and dementia (a general term for a group of symptoms that cause a loss of cognitive functioning).Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 out of 15 indicating severely impaired cognition. She had impairment to one side of the upper extremity and to both sides of lower extremity. She was dependent on nursing staff for all ADLs. She was frequently incontinent of urine and always incontinent of bowel. The resident was at risk for pressure ulcers and had pressure reducing device for the bed. Further review revealed she was not receiving any therapy services.Record review of Resident #1's active physician orders as of 03/04/26 revealed an order for a mattress: air pressure reduction every shift, start date on 02/21/25. Further review revealed an order for heel protectors to bilateral feet, daily, start date 11/04/25.Record review of Resident #1's undated care plan revealed Problem - Resident #1 had potential for pressure ulcer development r/t and including limited mobility and contractures. Interventions - did not include heel daily protectors/soft booties to the feet. Further review revealed there was no care plan or interventions for multiple contractures: left elbow, left hand, right and left leg. Observation and interview on 03/04/26 at 5:10 AM during incontinent care for Resident #1 revealed the resident had multiple contractures. Her left elbow was bent close to the chest and left hand was severely contracted at the wrist. The fingers on the left hand were also contracted. Resident #1's right leg and left leg were pulled up towards the chest, bent at the knees with knees touching each other. Resident #1 had a soft boot/heel protector to the left foot. Resident #1 had a low air loss scoop type mattress. During incontinent care, when CNA A turned Resident #1 or attempted to move the knees apart to cleanse the peri area, the resident said it hurt. LVN B entered the room to assist CNA A and attempted to assist by moving Resident #1. Resident #1 said her left leg hurt and that sometimes the right leg would hurt because she had arthritis in that leg. LVN B stated Resident #1 will yell out during incontinent care d/t her contractures and the resident will work herself up at times, so it was best to allow her some time to relax and come back later to finish ADL care which LVN B instructed CNA A to do. CNA A stated she places a pillow between her legs to keep her skin from breaking down. In an interview and observation on 3/4/26 at 8:10 AM, the DOR stated Resident #1 was off Therapy services but would be evaluated this week. The DOR stated the reason for therapy was for contracture management and that therapy included splinting for both upper and lower extremities when she was on service. The DOR stated after discharge from Therapy she was transferred to Nursing care, but the facility no longer had a Restorative Program. The DOR stated for her knees there was a special bolster pillow for behind the knees to prevent flexion, which would help prevent skin breakdown. The DOR stated the special bolster pillow should be in her closet. Observed with the DOR present that the special bolster pillow was in the closet. The DOR stated the special bolster pillow would be put in place by therapy during services. The DOR stated it was also appropriate for nursing staff to use pillows between her legs to help keep contractures from worsening.In a telephone interview on 3/5/26 at 7:00AM, LVN B said she would sometimes place rolled towels for Resident #1's contracted hand to prevent worsening of the contracture and a soft bootie to the left foot to help with contractures to the lower leg. LVN B stated she would find how to address Resident #1's contractures in the resident's chart.In an interview and observation on 3/5/26 at 9:35 AM, CNA C stated she was familiar with Resident #1's care. CNA C stated Resident #1 did have contractures to the left arm and both legs. CNA C stated due to her contractures she would have to turn her a certain way during repositioning otherwise Resident #1's feet would bend and cause pain. CNA C stated she knew Resident #1 needed boots for both feet because it was in the plan of care. CNA C stated Resident #1 had a special bolster pillow for in between the knees. CNA C stated she was aware of how to apply the special bolster pillow because of her experience working with therapy long ago prior to working at the facility. CNA C stated the special pillow was to help prevent pressure sores by reducing skin to skin contact because of her contractures. Resident #1 had the blue bolster pillow in place behind the knees. CNA C stated she did not put the bolster pillow in place and did not know who placed it.In an interview on 3/05/26 at 9:55 AM, LVN D stated Resident #1 cannot move her legs. LVN D stated it was important to address Resident #1's contractures to help prevent contractures from worsening by using pillows. LVN D stated sometimes her legs may separate even a little, which would be important to help keep them from tightening back up and prevent skin breakdown as well.In an interview on 3/06/26 at 8:15 AM, the DOR stated Resident #1 would be in pain with every little movement when he worked with her in the past due to her severe contractures. The DOR stated she did receive pain medication at the time but thought her issues were more to do with anxiety. The DOR stated management of contractures had to do with improving a resident's mobility and if the resident was unable then it would just be for maintaining their abilities to the point where mobility would not get worse. The DOR stated he was the one who placed the blue bolster pillow in place.In an interview on 03/06/26 at 8:50 AM, LVN E and LVN M (who were both MDS nurses) stated the purpose of the care plan was to reflect the residents' care, needs, goals and interventions. LVN E and LVN M stated the care plan was the responsibility of the IDT team which included nursing, dietary, social services and MDS. LVN E and LVN M stated if a resident's contracture was an active issue and documented then it would be care planned. LVN E and LVN M stated the purpose of interventions was to prevent any decline, maintain and meet the residents' needs. LVN E and LVN M stated that nursing staff had access to interventions in the care plan and the information would cross over into the Kardex (essentially a care plan chart or template).In an interview on 03/06/26 at 9:05 AM, the DON stated the purpose of the care plan was to provide a big picture of the residents' care and that it should be resident centered. The DON stated the IDT team was responsible for the accuracy of the care plan. The DON stated nursing tasks would transfer from the care plan to the Kardex, and the expectation would be that CNAs review the Kardex before providing care. The DON stated Resident #1's contractures should have been care planned as well as for all residents with contractures. The DON stated she did not know why Resident #1's contractures were not in the care plan and that the MDS nurses had a different system before she started working at the facility as DON.Record review of the facility's policy for Comprehensive Care Plans dated 10/24/22 read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing and mental and psychosocial needs.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.f. Resident specific interventions that reflect the resident's needs.as indicated.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed.

Based on interviews and record review failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision, in that: CR #1 eloped from the facility on 6/21/25 after being let out of the building by the Receptionist. CR #1 was found by another staff member on the sidewalk near the carwash which was next door to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/21/25 and ended on 06/21/25. The facility corrected the non-compliance before the survey and investigation began on 06/24/25. The IJ template was sent to Administrator on 06/26/25 at 11:40a.m. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included: Record review of CR #1 face sheet dated 06/25/35 revealed a [AGE] year-old male who admitted to the facility on [DATE] and discharged to a secure facility on 6/21/25. His diagnosis included: hemiplegia (severe weakness on side of the body) and hemiparesis (weakness affecting one side of the body, often the arm, leg, and sometimes the face) following cerebral infarction (part of the brain dies because it did not get enough blood or oxygen) affecting right dominant side, major depressive disorder(mood disorder that causes a feeling of sadness or loss of interest), atrial fibrillation(upper chambers of the heart beats very fast), and hypertension(when the pressure in the blood vessels is too high). Record review of CR #1 99 MDS assessment dated [DATE] revealed CR #1 was admitted to the facility on [DATE]. CR #1 was a admit. Record review of CR #'s initial baseline/advanced care plan dated 06/20/25 read in part . CR #1 required assistance with ADLs, and he was not at risk for elopement . Record review of CR #1's initial nursing evaluation dated 06/19/25 indicated he was alert to person and place and had difficulty expressing/pronouncing words. Record review of CR#1 BIMS assessment conducted twice on 06/21/25 revealed results were 0 out of 15 which indicated severe cognitive impairment. Record review of CR#1's BIMS assessment conducted on 06/21/25 result was 2 out of 15 which indicated severe cognition impairment. Record review of CR#1 initial wandering dated 06/19/25 25 indicated he was not a wandering risk. He used a manual wheelchair for ambulation. Record review of CR #1's nursing note dated 6/21/25 indicated the resident was noted outside the building by staff who was let out by the receptionist. The nurse brought the resident back in the facility and a head-to-toe assessment was done. There were no skin issues, and the facility started 1:1 monitoring. A new order was received from the MD to transfer resident to a secure facility. During an interview on 06/25/25 at 2:24 p.m., CNA B said she was across the street from the facility on break and saw CR# 1 outside of the facility gate by himself near the carwash. CNA B said CR #1 resisted returning to the facility. CNA B said she called the Weekend Supervisor and RN C for assistance in bringing CR # 1 back to the facility. CNA B said if she had not been at the store across the street on break, no one would have known that CR #1 had left the premises. During an interview on 06/25/25 at 3:05p.m., RN C said she was CR#'s1 nurse on the day of the incident, and it was her first day working with CR # 1 on 6/21/25. RN C said she received a report from the previous nurse that CR #1 was a fall risk, chair-bound, and confused. RN C said CR#1 was sitting in his wheelchair by the nursing station, facing the front door of the facility, when she went down the 100 hall to check on another resident. RN C said the Weekend Supervisor called and told her that CR #1 was outside the facility premises, by the car wash. RN C said she went out to the car wash with the weekend supervisor and assisted CR #1 back to the facility. RN C said she did head to assessment, and CR #1 had no injuries. RN C said CR #1 could not be outside by himself because he was cognitively impaired, and he could have gotten kidnapped or gone into the road. During an interview on 06/25/25 at 4:07 p.m., R N said CR# 1 approached the front door and made sounds, but she did not understand him. R N said she assumed CR #1 wanted to go outside, and she opened the door for him and let him out unattended. She said she did not know if CR #1 could go out by himself and did not ask other staff members. She said he might have exited the parking lot gate when a car entered the facility. R N said she was not aware of the wandering/elopement binder at the reception desk until after the elopement when the administrator brought the wandering and elopement binder to the reception desk. R N said she was under the assumption that residents sign out when they want to leave the facility premises, not when they want to sit outside the front door of the facility. That was why she let CR #1 out the door without him signing out. R N said she no longer work for the facility and her last day was on 06/21/25. During an interview on 06/25/25 at 4:47 p.m., the Administrator said R N told her she let CR #1 out the front door without checking the elopement binder or asking the nurse to make sure CR #1 could go outside by himself. The Administrator stated that R N said she let CR #1 out of the facility through the front door around 9:15 a.m. but was unsure of the exact time. The Administrator said the DON called her and notified her about CR#1 elopement and she came to the facility about 9:45 a.m. When the surveyor asked the Administrator what could have happened to CR #1 when he went outside the facility premises, the Administrator responded that CR #1 could have seen his loved ones while at the care wash. During an interview on 06/25/25 at 4:50 p.m., The DON said CR #1's BIMS score was 2 out of 15 (which indicated severe cognitive impairment). She said he should not have gone outside to sit by himself because he was cognitively impaired. The DON said residents who leave the building must sign out, but it would not have been appropriate for CR #1 to sign out because he had an impaired memory. The DON said R N should have asked a nurse or checked the wandering and elopement binder at the receptionist's desk before letting CR# I out of the building. The DON said anything could have happened to CR #1 when he was by the car wash. During an interview on 06/25/25 at 6:10 p.m., CR #1's RP said the facility called and notified her that CR #1 had left the facility premises, and the staff assisted him back to the facility. CR #1's RP stated that CR #1 was anxious and confused due to his new environment, and the facility should not have allowed him outside the door. Record review of the facility incident and accident dated 08/15/22 read in part incident is defined as an occurrence or situation that was not consistent with the routine care of a resident . Record review of the facility elopement and wandering resident read in part . elopement occurs when a resident leaves the premises or a safe area without authorization .#4. Monitoring and managing residents at risk for elopement or unsafe wandering .4a. resident will be assessed for risk for elopement or unsafe wandering upon admission and throughout their stay by interdisciplinary care team .4c. interventions to increase staff awareness of the resident's risk, modify the resident's behavior 4d. adequate supervision will be provided to help prevent accidents or elopements. Record review of the corrective actions' facility implemented facility beginning on 06/21/25. The facility had AdHoc QAPI Meeting was held on 06/21/25 and it was attendees were the Medical Direction, The Administrator, and DON. The summary and plan: indicated CR #1 observed on the side work outside the facility gate. Staff member who went on break a t a store across the street from the facility approached CR #1 and attempted to redirect him back to the facility. One of the CNAs called ADON who then sent additional staff to assist with redirecting CR #1 back inside the facility. Plan: The facility has an elopement book with resident pictures and resident consent forms for resident who are able to sign out the facility. All new residents will receive BIMS assessment and elopement/wandering assessment. All current facility staff have been in serviced on wandering resident and elopement. All new staff will be in serviced upon hire regarding wandering and elopement. Performance Improvement Plan: Issue: CR#1 left the facility premises and was outside the gate of the facility, by facility staff and brought back without incidence. The following was completed on 06/21/25: CR #1 was returned to the facility with 15 minutes by staff. Head count. No concerns identified Medical Director notified MD and RP notified Head to toe evaluation assessment completed for CR #1 CR #1 transferred to a facility with secured unit Immediate interventions on 06/21/25 and 06/22/25 Wandering evaluations completed for all facility residents to identify other residents at risk for elopement Elopement/wandering binder reviewed and updated as indicated Resident current BIMS score reviewed to confirm residents able to leave the facility unsupervised. Book reviewed and updated as indicated Exit doors checked for securement and function of alarms Exit gate checked for proper function Elopement drills completed all shifts Reeducation on 06/21/25: : (In service on elopement) The Administrator and/ or designee reeducated facility staff on the facility's Elopement and Wandering procedures, as well as Abuse and Neglect. Reeducation included identification of current residents who are elopement/ wandering risk and methods of identifying new elopement/ wandering risk, as well as identifying residents who can sign themselves out and leave the facility unsupervised. Pre and posttest were completed by staff to validate their understanding of the processes. Systemic Changes: 06/22/25, Education on Elopement and Wandering, to include pre/ posttest on first day of hire/ rehire for facility staff. Monitoring Outcomes: Effective 06/22/25, the Administrator and/ or designee will validate staff's understanding of elopement procedures by quizzing staff and completing questionnaires for random staff from all disciplines, all shifts including receptionist weekly for four weeks, then monthly for two months. The Administrator and/ or designee will conduct elopement drills on all shifts monthly for three months. Record review of the facility in-service dated 06/21/25 revealed staff were in serviced on resident leaving facility/elopement and wandering. Residents have the right to sign themselves out of the facility on pass for up to 72 hours at a time. Residents must sign out using the sign out book. There is a sign out book and an elopement book located at the receptionist desk and the nurse's station. In the elopement book there are pictures of residents who are a wandering risk and if they are going towards a door nursing staff must be notified immediately to redirect the resident. The Administrator and DON must be notified as well for any elopement risks. There are also consent forms located in the elopement book for all residents who are able to sign themselves out. If the resident does NOT have a signed consent form located in the book, you must make sure the resident stays within eyesight during the entire exit attempt and notify any facility staff currently working to assist also the DON and Administrator must be notified. Failure to follow the company protocol will result in disciplinary action, up to and including termination. record review of the facility elopement [NAME] revealed the facility completed wandering evaluation on CR #1 and all the resident in the facility after the elopement on 06/21/25. Record review of the facility incident binder revealed the facility completed BIMS for CR #1 and all the resident in the facility on 06/21/25. During an interview on 06/27/25 between 10:25 a.m. and 10:45 a.m., Resident #51 stated that the facility staff did not allow him to go out the front door by himself, but he could go through the back door, which required a code. Resident #51 said the staff would let him out because it was fenced in. Residents #25, #72, #77, #80, and #298 said they could sign out and go out through the front door and sit on the porch or leave the facility, but they have to sign out and sign back in when they entered the facility. During interview on 06/ 25/25 between 2:02 p.m. through 5:56 p.m. LVN R, R N, R G, RN C, CNA L, LVN U, CNA S, CNA B and on 06/26/25 between 9:58 a.m., and 4:30 p.m., LVN N, LVNK, LVN M, CNA K, CNA I, CNA J, CNA P, ADON, Office Manager, and HR were able to state they had a service on wandering and elopement. They said the facility had two binders: one for residents who could sign out and the other for those who could not sign out by themselves (the wandering/elopement binder). They said all residents must sign out before leaving from the front door. They said if a staff member was unsure whether a resident could leave through the front door, then the staff member must review the binders and ask the nurse before letting any resident out the front door. They said they had to lay eyes on their residents during rounds and monitor any residents who wander. They said if the staff could not find any resident, they had to report to the nurse, and the nurse would call Code Pink and notify management. The staff would start by searching all parts of the building and outside the building. The administrator would be the contact person for the facility. During an interview on 06/25/25 at 5:10 p.m., the Administrator said the DON notified her, and when she came to the facility, they (the medical director and DON) had QAPI. At the same time, RN C assessed CR #1 and placed him on 1:1 care until he was transferred to another facility around 4:30 p.m. on 06/21/25. The Administrator stated that the staff received in-person training on wandering and elopement, and electronic training was sent to all staff. No staff member was allowed to work unless they had completed the in-person training on wandering and elopement. The Administrator stated that the in-service was based on the facility's policy regarding accidents, supervision, and wandering/elopement. The Administrator stated that they had updated the two binders: one for elopement/wandering, which included pictures of the resident, and the other binder for residents who could sign out, containing the necessary consent forms. She said the binders are kept at the nursing station and the receptionist's desk. She also said R N(receptionist) no longer works for the facility. During an interview on 06/25/26 at 5:30 p.m., the DON said the weekend supervisor notified that CR #1 had left the facility premises, and she notified the administrator. The DON said she came to the facility on [DATE] and had a QAPI meeting, and then she started head count for all the residents in the facility. She said CR #1 was assessed and placed on 1:1 until he was transferred to a secured facility. The DON stated that the IDT team assisted with reviewing all resident BIMS and elopement risk assessments and updated the elopement binder and sign-out binder accordingly. The DON said she placed One set of binders at the nursing station while the other at the receptionist's desk. The DON stated that she notified CR #1's RP, CR #1's physician and risk management. Observation on 07/27/ at 2:30 p.m., revealed the alarm on the door would go off, the receptionist had the remote control for the door. Observation on 07/27 at 2:45 p.m., revealed regular wheelchair would not trigger the electronic gate to open.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities which involved 3 of 5 residents (Residents #4, #63 and #89) and 3 of 5 staff (RN C, MA A, and LVN O) reviewed for medication administration.1. RN C crushed and administered enteric coated Aspirin 81 mg (a formulation of aspirin, that should not be crushed, that has a special coating to prevent it from dissolving in the stomach) to Resident #4 on 6/25/25.2. MA A administered Sennosides instead of Sennosides with Docusate according to physician orders and failed to administer the prescribed amount of Clearlax (Miralax/Polyethylene Glycol 3350) to Resident #63 on 6/25/25. 3. LVN O failed to set Resident #89's IV Zosyn (a combination of two antibiotics that treat bacterial infections) to the correct flow rate according to the pharmacy label on 6/25/25.These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects and decline in health. Findings include: 1. Record review of Resident #4's face sheet, dated 6/27/25, revealed an [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnosis included heart failure, hypertension (high blood pressure), chest pain, and chronic obstructive pulmonary disease.Record review of Resident #4's quarterly MDS assessment, dated 5/30/25, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #4's care plan dated 3/4/25 revealed she had a history of congestive heart failure. Interventions were to administer cardiac medications as ordered. Monitor, document, and report effectiveness, adverse reactions, and side effects. Aspirin.Record review of Resident #4's Physician orders for June 2025 revealed an order for Aspirin chewable 81 mg give 1 tablet via g-tube one time a day for reduce risk of heart attack, stroke, order date 5/1/25.In an observation on 6/25/25 at 8:39 a.m. revealed RN C prepared Resident #4's medication for administration via g-tube. She prepared 7 medications which included enteric coated Aspirin 81 mg. RN C crushed the enteric coated aspirin along with the other medications and administered it to Resident #4 via g-tube.In an interview on 6/25/25 at 9:36 a.m., RN C said enteric coated formulations could not be crushed because the medication would not work the way it was supposed to. She said she normally reviewed the resident name, medication dose and name but missed where the Aspirin bottle read enteric coated. She said there was no risk to the resident. In an interview and observation on 6/26/25 at 2:20 p.m. the DON said staff could not crush enteric coated formulations because the coating could cause clogging (of the g-tube). She said staff were made aware of which medications not to crush by the list located in the medication book. Observation of the do not crush list revealed enteric coated Aspirin was listed on it.2. Record review of Resident #63's face sheet, dated 6/27/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included constipation, nontraumatic intracerebral hemorrhage (a type of stroke characterized by bleeding within the brain tissue), and hemiplegia (a complete paralysis of one side of the body) and hemiparesis (weakness on one side) following cerebral infarction (stroke) affecting right dominant side.Record review of Resident #63's quarterly MDS assessment, dated 3/21/25, revealed a BIMS score of 6 out of 15, which indicated severe cognitive impairment. She needed assistance from staff with ADL care.Record review of Resident #63's Physician orders for June 2025 revealed orders for: Sennosides - Docusate 8.6 mg - 50 mg give 1 tablet by mouth two times a day related to constipation, order date 1/7/25;Miralax Oral Powder 17 gm/scoop (Polyethylene Glycol 3350) give 1 scoop by mouth one time a day related to constipation, order date 1/7/25.In an observation on 6/25/25 at 9:41 a.m. revealed MA A prepared Resident #63's medication for administration. He prepared Senna 8.6 mg (without Docusate), Clearlax 3350 7.5 mL, and 7 additional medications. While preparing the Clearlax 3350, MA A did not use the provided 17-gram measuring cup but poured the powder into a medicine cup which equaled approximately 7.5 mL. He mixed the powder with water and administered all prepared medications to Resident #63.In an interview on 6/25/25 at 10:08 a.m. MA A said Senna 8.6 mg (without Docusate) was the only Senna on his medication cart. He said the only difference between the medication administered and the medication ordered was the 50 mg and said the medications were the same. MA A said Resident #63's Clearlax order indicated to administer 1 capful. Observation of the Clearlax (Polyethylene Glycol 3350) bottle read, 1(7) g. cap filled to line. He said he administered approximately 5 mL of Clearlax powder to Resident #63 which was not a capful. He said he administered that amount because that was all he had available. He said he normally used the provided measuring cap to measure but did not because the amount of remaining powder was so low. In an interview on 6/26/25 at 2:22 p.m. the DON said Senna Plus (with Docusate) was more effective than Senna (without Docusate) because there was more active ingredient to help with the bowel. She said Senna and Senna Plus were not the same medication and the difference was the Docusate (stool softener). She said nursing staff should use the provided purple top to measure Clearlax to give the correct dose for effectiveness. She said medication aides should communicate with their nurses if they do not understand. She said the facility had a policy in place to follow the 6 rights of medication which included the right resident, time, dose, form, route, and medication.3. Record review of Resident #89's face sheet, dated 6/27/25, revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #89 had diagnoses which included osteomyelitis (a serious bone infection that can occur due to bacteria or fungi), partial traumatic amputation of right foot (some soft-tissue connection remains), type 2 diabetes, dementia, and moderate protein-calorie malnutrition.Record review of Resident #89's 5-day scheduled MDS assessment, dated 6/15/25, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. She required some assistance from staff with ADL care. The MDS revealed she had midline IV access and received IV antibiotics.Record review of Resident #89's Order Audit Report for June 2025 revealed an order for Piperacillin Sod - Tazobactam solution (Zosyn) 3-0.375 gm use 3.375 gram intravenously three times a day for acute osteomyelitis, order date 6/20/25. Order Supply Summary. Medication/Supply and Directions: Zosyn 3.375 gm/50 mL galaxy infuse contents of one bag intravenously over 30 minutes at a rate of 100 mL/hr three times daily.In an observation and interview on 6/25/25 at 4:03 p.m., LVN O flushed Resident #89's PICC lumens and hung the Zosyn 3.375 gm/50 mL bag at a rate of 125 mL/hr. Observation of the Zosyn pharmacy label read, Infuse contents of one bag intravenously over 30 minutes at a rate of 100 mL/hr three times daily. LVN O said she normally set rates at 125 mL/hr when the order indicated for the IV to run over 30 minutes. She said the pharmacy label indicated the rate should be at 100 mL, but she set the rate at 125 mL. LVN O entered Resident #89's and adjusted the rate. She said she normally checked the resident's name, medication, time, strength, and verified the IV bag alongside the order. She said if the rate was set higher, the medication would be administered a little quicker.In an interview on 6/26/25 at 2:35 p.m. the DON said the flow rate was located on the IV bag and on the order in the computer system. She said the IV should be set at the rate provided for efficacy. She said there could be side effects if not given according to the specified rate.In an interview on 6/27/25 at 11:10 a.m. the Administrator said she expected nursing staff to follow the MD order when passing medications for accuracy.Record review of the facility's undated Medications Not To Be Crushed revealed Aspirin EC was listed on it.Record review of the facility's Medication Administration policy dated 10/24/22 read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 14. Administer medication as ordered in accordance with manufacturer specifications. c. Crush medications as ordered. Do not crush medications with do not crush instructions. Do Not Crush Medications: Enteric coated.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #81) out of eight residents reviewed for ADLs. The facility failed to provide personal hygiene to Resident #81 which resulted in patches and dry flaky skin from below the knee to her feet . These deficient practices could place residents at risk of skin breakdown, and reduced feelings of self-worth. Findings included: Record review of Resident #81's face sheet dated 05/24/25 revealed a [AGE] year-old female was admitted on [DATE]. Resident #81 had diagnoses which included: fracture of the neck of left femur (a broken hip), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (a disease of inadequate control of blood levels of glucose). Record review of Resident 81's quarterly MDS assessment, dated 05/27/25, revealed the BIMS score was 03 which indicated severely impaired cognition. Further review of the MDS revealed the resident needed extensive assistance with one on staff assist with ADL care. Record review of Resident #81's care plan initiated 02/25/25 and revision on 06/03/25 revealed the resident had an ADL self-care performance deficit related to CVA with hemiparesis. Intervention: bathing/shower: The resident was totally dependent on one staff to provide bath/shower and as necessary. Personal hygiene/oral care: The resident was totally dependent on one staff for personal hygiene and oral care. Record review of Resident #81's shower record on the POC from 05/29/25 through 06/21/25 revealed the resident had not missed any shower and bed bath. During an interview on 06/24/25 at 10:22 a.m., Resident #81 was sitting up in bed, and the head of the bed was at 45 degrees. Resident #81 said her skin from her lower legs to her feet was dry and itchy. During an observation on 06/24/25 at 10:30 a.m., revealed Resident #81's skin from below her knee to her feet was dry, patchy, and flaky when CNA B removed the resident's socks. During an observation and interview on 06/24/25 at 10:37 a.m., CNA B said Resident #81's skin was dry and flaky. CNA B said Resident #81's shower days were Tuesday, Thursday, and Saturday. CNA B said the aides are responsible for showering the resident and applying lotion to the resident's skin after showering and as needed. CNA B said if the aides did not apply lotion to Resident #81's skin, it could cause the resident's skin to be dry, which could cause skin breakdown. CNA B said the nurse monitors the aides throughout the shift. CNA B said she had an in-service on showing residents, and it included applying lotion to the resident's skin. During an interview on 06/25/25 at 10:30 a.m., LVN U said the aides were responsible for giving Resident #81 a shower and the aide should apply lotion after shower and as needed whenever the aide provided care for Resident #81. LVN U stated if the staff did not apply lotion or cream to Resident #81's skin, the resident's skin would often be dry and flaky, and it would break open. LVN U stated that the nurses monitored the aides throughout the shift, and the nurse manager monitored the nurses during their rounds. During an interview on 06/25/25 at 10:35 a.m., the ADON T stated that the aides are responsible for showering Resident #81 and applying lotion or cream to the resident's skin after showering and as needed to prevent the skin from becoming dry. The ADON T said if the aide did not apply lotion on Resident #81's skin, it could cause her skin to break down. The ADON T said the aides should have done a skills check-off before starting work on the floor, and nurses monitored the aides throughout the shift, while nurse managers monitored the nurses during rounding. During an interview on 07/26/25 at 7:27 a.m., the DON said the aides should apply lotion on Resident #81's skin after shower and as needed. The DON said the aides or nurses should apply lotion on Resident 81 #'s skin during care or whenever Resident #81's skin was dry. The DON said the nurses monitor the aides throughout the shift. She stated the ADONs monitor the nurses during random rounds. The DON said she had not done any in-service on skin integrity, but she may have done one in-service on ADL care. The DON stated that Resident #81's skin could be susceptible to some skin impairment if staff did not apply lotion or cream to the resident's skin. The DON said her expectation during training was the importance of keeping the skin moisturized to avoid skin tears and skin breakdown. She stated the nurse monitored the aides throughout the shift, and the nurse managers monitored the nurses. During an interview on 06/27/25 at 11:13 a.m., the Administrator said her expectation for the staff was to apply cream or lotion on the resident skin on shower days and as needed. She said the aides are supposed to apply moisturizer on residents on shower days and as needed. The Administrator said the aides had skills check on ADL but was unsure if there was a section on applying lotion. The Administrator said the nurse monitors the aides throughout the shift, and the nurse managers monitor the nurse during rounding. Record review of the undated facility policy on skin integrity management system read in part . CNA's will document skin observation each . Record review of the facility policy on ADL dated 5/26/23 read in part . policy explanation and compliance guidelines . #3 . a resident who is unable to carry out activities of daily will receive the necessary services to maintain .grooming .

Based on observation, interviews, and record review the facility failed to have physician orders for the resident's immediate care at time of admission for 1 of 5 residents (Resident #1) reviewed for physician admission orders. The facility failed to provide physician orders for Resident #1 when admitted to the facility with a need for knee immobilizer on 02/18/25. This failure could place the residents at risk of not receiving necessary physician ordered care that could result in worsening conditions or decline in health. Findings included: Record review of Resident #1's face sheet dated 05/24/25 revealed a [AGE] year-old female was admitted on [DATE]. Resident #1 had diagnoses which included: fracture of lower end of left femur (forms the top of left knee joint), hypertension (when the pressure in the blood vessels is too high), and multiple sclerosis (long lasting (chronic) disease of the central nervous system, and paraplegia (inability to move the lower parts of the body). Record review of Resident #1's admission MDS assessment, dated 02/22/25, revealed the BIMS score was 09, which indicated moderately impaired cognition. Further review of the MDS revealed the resident was dependent on staff with all ADL care. Record review of Resident #1's care plan initiated 02/25/25 and revision on 03/27/25 revealed the resident had a non- pressure traumatic wounds to right lower extremities and needs to wear immobilizer to right leg. Intervention: treat as ordered. Record review of Resident #1's June 2025 physician order report for Resident #1 did not reveal the resident had an order for right knee immobilizer. Record review of Resident #1's hospital discharge information dated 02/18/25 read in part . #3 bilateral distal femur fracture. Intervention right knee immobilizer in place . Record review of Resident #1's progress note dated 02/18/25 read in part resident had bilateral femoral fracture and she had right knee immobilizer in place .: Record review of Resident #1's history and physical dated 2/19/25 read in part right knee immobilizer was placed . Record of Resident #1's physician's progress notes dated 04/23/25 read in part . her right distal femoral fracture may open as well, as she has not had her immobilizer in place to the right knee. According to the nursing staff, the immobilizer has been lost. When she first came to the facility the resident had the immobilizer and the DON has been informed . Record review of Resident #1's progress note dated 05/20/25 read in part .IDT met, and it was noted that the resident was unable to obtain a suprapubic catheter after being sent to interventional radiology and urology with no success of receiving the suprapubic catheter. Due to the complication of the resident's anatomy and extensive wounds a new order was obtained for Specialty Hospital for further treatment of wound and an attempt to obtain the best treatment plan. Resident is her own RP and agree with plan of care . During an interview on 05/24/25 at 10:41 a.m., LVN E said Resident #1 had a right knee immobilizer upon admission, and she also replaced the immobilizer after she did the wound care treatment on the right leg. LVN E said Resident #1 had the right knee immobilizer even after the wound on the knee was healed, and when she did her last treatment in March, she did not know when the staff lost the immobilizer. LVN E said she did not see any order for an immobilizer for Resident #1. LVN E said the admitting nurse should have called the physician and clarified the order for the immobilizer and entered it on the PCC, and then it would be transferred to the care plan and TAR. LVN E said Resident #1's fracture could worsen and not heal properly. She stated that the nurse managers monitored the nurses and reviewed the admission packet to ensure all the orders and instructions were transcribed and verified with the physician. LVN E said she was provided in service today (05/24/25) on a clarification order for an immobilizer on admission. During an interview on 05/24/25 at 11:02 a.m., LVN J said Resident #1 had not been in the facility for up to 100 days. LVN J said she did not remember if Resident #1 had an immobilizer on her right leg. She said if Resident #1 did not have an order for an immobilizer, the nurse would not know to apply the immobilizer, and the fracture could worsen. LVN J said the nurse managers should have reviewed the admission paperwork and ensured all orders and recommendations were verified with the physician and entered into the PCC. LVN J said she was provided in service today (05/24/25) on a clarification order for an immobilizer on admission. During an interview on 05/24/25 at 11:18 a.m., the DON said she was unaware Resident #1 had a right knee immobilizer when Resident #1 was admitted to the facility, and she had not seen any immobilizer on the resident's right knee. The DON said to give her time to research the immobilizer because she was not working when Resident #1 was admitted . The DON said the IDT team made the decision to send the resident to the hospital for surgical placement of the Foley catheter because the staff could not insert the foley. The DON Resident #1 was sent to an outside radiologist and urologist and they were not able to insert the foley catheter. The DON said the IDT made the decision to send her to the hospital for aggressive wound care and surgical insertion of foley catheter. During an interview on 05/24/25 at 11:36 a.m., Resident #1's Physician said the resident was discharged from the hospital to the facility with an immobilizer on her right knee, and the staff should have followed up with the order from the hospital. The Physician said she could not remember if the nurse had clarified the immobilizer order with her or the NP. The Physician said Resident #1 should have worn the immobilizer because she had a right femoral fracture. During an interview on 05/24/25 at 2:05 p.m., CNA B said she was not sure if Resident #1 had an immobilizer because she could not remember seeing the immobilizer on the resident. CNA B said if Resident #1 had a fracture and she did not wear the immobilizer, the fracture may not heal well. CNA B said the nurses were responsible for applying the immobilizer to the resident. CNA B said she had in service on resident immobilizer (05/24/25). She said the DON told her to make sure the resident had the immobilizer on and, if it was not in place, to tell the nurse. During an interview on 05/24/25 at 2:15 p.m., CNA H said she thought she saw an immobilizer on Resident #1's leg but was unsure because Resident #1 was moved to another hall. CNA H said the nurse was responsible for applying the immobilizer. CNA H said she had in-service today and was told to tell the nurse that if a resident with an immobilizer were off, the aide would have to notify the nurse. During an interview on 5/24/25 at 2:32 p.m., the Wound Care nurse said she started doing Resident #1's wound treatment on March 5, 2025, until Resident #1 was discharged . The Wound Care did not see any immobilizer on Resident #1 right knee. The Wound Care Nurse said she did not know Resident #1 should have worn an immobilizer on her right knee, and there was no order for the immobilizer. The Wound Care nurse said Resident #1's fracture could worsen if not stabilized. She stated that the admitting nurse and the nurse manager should have ensured that Resident #1's discharge orders and instructions from the hospital were verified and transcribed. She said if the resident did not have an order, then the nurse would not know to apply the immobilizer. During an interview on 05/24/25 at 7:29 p.m., the DON said she was unaware Resident #1 was supposed to wear an immobilizer. The DON said none of the staff told her Resident #1 had an immobilizer on admission, and there was no order. The DON said the clinical should be reviewed and communicated to the doctor upon admission. She stated the admitting nurses should have clarified the discharge medication order and any other equipment, such as an immobilizer, with the physician when Resident #1 was admitted to the facility, and she had the immobilizer on. The DON said the immobilizer was put in place to prevent the fracture from moving and help the healing process. She said without the immobilizer the fracture could heal deformed. The DON said the nurse management team followed up the next day to ensure all the medications and equipment Resident #1 needed for resident care were verified and ordered. During an interview on 05/24/25 at 7:50 p.m., the ADON said the admitting nurse should have reviewed Resident #1 admission paperwork, and the nurse managers would review the paperwork the same day if the resident were admitted early in the day. Then, ADON said that if the resident were admitted later, ADON would review the admission paperwork the next day. She stated another ADON was supposed to review the discharge records, but they worked as a team because they went to the conference hall and reviewed the admission paperwork. She said she could not remember if she reviewed the paperwork with the team. The ADON said she was unaware Resident #1 had an immobilizer when the resident was admitted . She said if the resident should have an immobilizer and she did not, then it could cause more harm to the fracture. She stated that the ADON and DON monitored the nurses and reviewed the admitting paperwork. She said the manager team greets the new residents and introduces themselves, but they do not do skin assessment, and if the immobilizer was under the cover, they would not see it. During an observation and interview on 05/25/25 at 1:24 p.m., Resident #1 was lying on her back on the hospital bed, and she did not have an immobilizer on her right knee. Resident #1 said she was admitted to the facility with an immobilizer, and after a while, the staff stopped applying the immobilizer. Resident #1 denied pain and said the fracture happened when she was dropped at her previous facility. During an interview on 05/26/25 at 1:45 p.m., the Charge nurse at the hospital said Resident #1 was seen by an orthopedic surgeon yesterday(05/25/25) but did not write any order for immobilizer or any other treatment at this time During an interview on 06/17/25 at 9:46 a.m., the Administrator said she was not aware Resident #1 had an immobilizer, or she was supposed to wear one. The Administrator said she was unsure what could happen to the fracture if Resident #1 did not wear the immobilizer because she did not even know what the immobilizer would do. Record review of the facility QAPI meeting dated 05/24/25 revealed issue/plan Resident #1's facility failed to review admission clinicals and in return did not obtain right knee immobilizer order. The Administrator, DON, The Medical Director attended QAPI meeting plan was: in-services: ANE, review of new admission/readmissions process to include reviewing Hospital clinicals for: immobilizer/splints/devices and physician orders. When a resident admits with an immobilizer/splint/devices in place nurse is to obtain physician order for immobilizer/splint/devices. Record review of the facility in service revealed the staff were in serviced on 05/24/25 on admissions with immobilizer read in part . which included: admitting nurse received clarification orders for immobilizer: how long should the immobilizer be in place . where should the immobilizer be placed .skin assessment should also be assessed prior to donning and doffing the immobilizer .add to care plan as well as Kardex . Record review of the facility undated policy on daily clinical meeting process read in part . review new admission . in PCC review for completed admission documentation, correct order transcription includes . required admission . are completed and scheduled appropriately .

Based on observations, interviews, and record reviews the facility failed to ensure residents were free from verbal abuse for 2 of 9 residents (Resident #2 and Resident #3) reviewed for abuse. - The facility failed to prevent verbal abuse by DON K. On 11/20/24 DON K told Resident #2 she would send him to jail if he did not shut up. - The facility failed to prevent verbal abuse by DON K. On 1/30/25 DON K got in Resident #3's face and yelled at her to shut up. These failures could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #2's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), epilepsy (seizures), mild intellectual disabilities, cognitive communication deficit, depression, and unspecified psychosis (psychotic symptoms are present, but not a specific disorder). Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 5 out of 15 which indicated severely impaired cognition. The MDS revealed CR #2 was taking an antidepressant, and a hypnotic. Record review of Resident #2's care plan dated 12/11/24, revealed a Focus: [Resident #2] had verbal outburst towards staff (Started: 7/23/24, Edited: 11/20/24). The goal was to not have any outbursts in 90 days. The interventions were to redirect Resident #2 and take the resident to a quiet environment. Focus: Resident received antianxiety medication r/t restlessness and agitation (Started: 5/3/24, Edited: 10/24/24). The goal was to improve or maintain Resident #2's functional status. The interventions included monitoring Resident #2's mood and response to medications, assess his behavioral/mood symptoms to see if they present a danger to self or others and intervene. Focus: Resident was PASARR positive for ID and receiving psych services for behavior (Start: 3/3/24, Edited: 10/24/24). The goal was to follow the PASARR recommendations. The interventions included following the PASARR recommendations, conduct quarterly meetings and follow any additional services the local authority recommends. Focus: Resident was at increased risk for memory difficulties, personality changes, anxiety, and relationship difficulties d/t depression. The goal was to exhibit indicators of depression/anxiety or sad mood less than once a month. Interventions included administering medications, assist the resident with an activities program that was meaningful, and encourage exercise. Focus: The resident enjoyed talking to staff (Start: 2/5/24, Edited: 10/24/24). The goal was to remain engaged in independent and facility activity. Interventions included encouraging Resident #2 to spend time out of his room at public locations. In an observation and interview with Resident #2 on 5/21/25 at 11:09am, Resident #2 was laying on his back in bed. He did not remember the incident with the DON when asked about it. In an interview with CNA H on 5/21/25 at 12:12pm, she said DON K was verbally abusive to Resident #2 frequently. She said DON K did say she was going to call the police and have Resident #2 sent to jail. In an interview with LVN E on 5/21/25 at 12:14pm, he said on 11/20/24 DON K was yelling at Resident #2 and telling him she could call the police and have him arrested. LVN E said Resident #2 was alert, but he did not remember things. He said Resident #2 yelled out frequently, but you have to know how to take care of him, and he knew how to calm him down. LVN E said DON K was rude to all the residents and all staff. In an interview with the ADON on 5/21/25 at 1:39pm, she said she heard DON K said those things (she was going to have him arrested) to the Resident #2, but she did not actually hear it herself. The ADON did agree that DON K was rude to the residents. In an interview with LVN M on 5/23/25 at 11:09am, she said she heard Resident #2 tell DON K one time that he was going to tell his family member about the way DON K was treating him, and DON K told him, Tell your family member, they can't whoop me. 2. Record review of the provider investigation report submitted to the state by Administrator R dated 2/5/25 revealed in part: .Investigation Summary: On 1/30/25, [LVN M] stated that she had witnessed what she considered to be verbal/mental abuse of a resident by [DON K]. She stated that [Resident #3] was at the nurse's station, and she was yelling and cursing, which she does periodically. [LVN M] stated that [DON K] came out of her office, walked over to [Resident #3] and told her she would call the police if she did not calm down, and that she needs to go to her room, [Resident #3] told [DON K] to get out of my mother fucking face. [DON K] stated to the resident I am in your face, I am in your face in a harsh, belittling manner that was confrontational. In interviewing other staff at/or around the nurse's station at that time, [ADON and LVN O] also stated they heard [DON K] speak harshly, using belittling tone when speaking with [Resident #3] . Record review of Resident #3's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE], with the most recent admission being 2/20/25. Her diagnoses included schizoaffective disorder (both psychosis and bipolar/depression), severe dementia with agitation (restlessness, distress, and potentially aggressive behavior), anxiety, schizophrenia (chronic brain disorder that affects thinking, feeling, and behavior), cognitive communication deficit. Record review of Resident #3's Annual MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Further review of the MDS confirmed she had diagnoses of non-Alzheimer's dementia, anxiety, schizophrenia, and schizoaffective disorder bipolar type. She was taking antidepressants. Record review of Resident #3's care plan dated 1/15/25 revealed a Focus: Resident has behaviors when she starts her menstrual cycle (Initiated: 1/28/25). The goal was that she would be free from behaviors through the review date. Interventions included that staff would redirect the resident and she would be respectful towards staff and others. Focus: Staff reported allegation of verbal abuse (Initiated: 1/31/25). The goal was to be free from verbal abuse. Interventions included monitoring behaviors, following up with psychosocial prn, head to toe assessment, and reporting verbal abuse to HHSC. Focus: Resident enjoys sitting in the hallway people watching (Initiated: 3/6/25). Goal was to attend activities 3 times a week. Interventions included reminding the resident to attend activities and escorting her, and if she exhibits behaviors to redirect her. Focus: Resident has a communication problem r/t alcohol induced dementia (Initiated: 1/28/25). The goal was to be able to make basic needs known. Interventions included monitor/document frustration level and wait 30 seconds before providing resident with word. Allow time to respond, ask yes/no questions, use simple/brief/consistent words/cues. Record review of Resident #3's progress note dated 1/29/25 at 5:35 pm and written by LVN O revealed Resident #3 had behavioral issues with outbursts, was agitated, and screaming at staff and other residents. The MD was notified who gave an order for Ativan (medication for anxiety) 2mg PO Q6hr PRN and a dose was given. Record review of Resident #3's progress note dated 1/30/25 at 8:37 am and written by LVN M revealed the MD ordered a UA for Resident #3. Record review of Resident #3's Lab Results reported 1/30/25 at 9:22pm revealed she had a UTI that was positive for E. Coli (type of bacteria that causes urinary infection). Record review of Resident #3's progress note dated 1/31/25 at 6:22 am and written by LVN E revealed Resident #3 was ordered an antibiotic for a UTI. In an interview with the ADON on 5/20/25 at 1:15pm she said on 1/30/25 Resident #3 was at the nurse's station and was very upset and yelling when DON K went out to talk to her. The ADON said she was in her office, and she heard DON K say, I'm in your face, I'm in your face. In an interview with CNA F on 5/20/25 at 1:51pm he said on 1/30/25 Resident #3 was at the nurse's station yelling and upset and DON K came out of her office and got in the resident's face and told her to Shut up and stop yelling at her nurse's station. CNA F said DON K was rude to all the residents. In an observation and interview on 5/21/25 at 11:14am Resident #3 was sitting in her wheelchair in the dining room. She did not remember the incident when asked about it. In a telephone interview with LVN M on 5/23/25 at 11:09am she said on 1/30/25 she was in her office when she heard commotion at the nurse's station, so she went out to see what was going on. She said Resident #3 was being belligerent and was saying she was missing her purse. LVN M said she did that sometimes because she had alcohol induced dementia. LVN M saw DON K get in Resident #3's face and tell her, You will not act this way. LVN M said then Resident #3 said, Get out of my motherfucking face and then the DON said, I'm in your face, I'm in your face very confrontational. LVN M said the resident looked shocked that DON K was saying this and in her face. LVN M said DON K was disrespectful to the residents and staff all the time. Record review of DON K's Employee Counseling Report from 2/4/25 filled out by Administrator R read in part: .The decision to terminate employment is based on multiple documented complaints and formal statements regarding unprofessional conduct, including reports of verbal abuse, retaliatory behavior, and intimidation, which have contributed to a hostile work environment. Additionally, there were allegations of verbal abuse toward a patient .the consistency and severity of multiple complaints from different individuals, each detailing similar unprofessional behavior in separate incidents, have led the company to conclude that continued employment is not in alignment with our standards and expectations. In an interview with DON K on 5/21/25 at 1:40pm, she denied any verbal abuse to any residents. She said she told Resident #3 Yes, I'm in your face because I have to talk to you. DON K said she did not raise her voice or use any kind of rude tone and then she went with Resident #3 to her room to calm her down. DON K said with Resident #2, he was having an altercation with another resident across the hall from him and he was holding a butter knife. She said she told him he could go to jail if he threatened someone with a knife. Record review of the incidents and accidents log for that month did not reveal any resident altercations that DON K was speaking of. In an interview with Administrator C on 5/22/25 at 1:26pm she said her expectations were that her staff were to maintain professionalism, dignity, and courtesy whenever they took care of the residents. She said there should be no reason their voice should be loud, or they should yell unless they were speaking to a hearing-impaired resident. Administrator C said she did not tolerate scaring residents to get them to do something and the staff would be suspended, reported, and ultimately terminated if she found that happened. Administrator C said if she found out a staff member was abusing a resident they would be suspended, reported, the police would be called, facility guidelines would be followed, and the employee would be terminated if it were true. She said abuse could cause emotional and behavioral concerns with the resident. In an interview with the VP of Operations on 5/22/25 at 1:30pm he said he investigated the incident that was filed against DON K and Resident #3. He said once he and the previous Administrator started interviewing staff about what happened, all the staff started saying how they felt scared, retaliated against, and verbally abused by DON K. He said the findings they found were congruent with the allegations of the investigation, so they terminated DON K. Record review of the facility's policy and procedure on Abuse, Neglect and Exploitation (Implemented: 8/15/22 with no revisions) read in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegations; and Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and Establish coordination with the QAPI program .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property .Existing staff will receive annual education through planned in-services and as needed .The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation .The facility will have written procedures that include: . Assuring that reporters are free from retaliation or reprisal; Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. Resident #1, who ambulated via motorized wheelchair, sustained minimally displaced fractures of the 2nd through 4th metatarsal necks (breaks in the long bones in the foot, specifically the part connecting the bone to the foot's arch) on 03/21/2025 when CNA A failed to turn off the wheelchair while providing care and bumped into the joystick (the mechanism that moves the wheelchair) which caused the wheelchair to propel forward and slam Resident #1's feet into a wall in the shower room. This failure placed residents who ambulate via motorized wheelchair at risk of injury, pain, and anxiety of possible recurrence. Findings include: Record review of Resident #1's face sheet dated 05/21/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), hemiplegia of the right dominant side (when the left side of the brain has been damaged, resulting in paralysis of the right side of the body), hemiplegia of the left non-dominant side (injury, or damage to the right side of the brain, resulting in paralysis of the left side of the body), contracture of muscles - multiple sites (a permanent shortening of a muscle and surrounding tissues leading to limited range of motion and joint stiffness), contracture of the left hand, bipolar disorder (a mental health condition that causes extreme mood swings), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #1's quarterly MDS dated [DATE] revealed she had a BIMS score of 14 (cognitively intact); Resident #1 ambulated via motorized wheelchair; Resident #1 was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers; Resident #1 was frequently incontinent of bladder and always incontinent of bowel; and Resident #1 was prescribed scheduled and PRN pain medication. Record review of Resident #1's care plan revised on 05/07/2025 revealed the following care areas: * Acute fractures of the 2nd through 4th metatarsals of the left foot. Goal included: Resident to remain injury free. Interventions included: Resident will operate her wheelchair correctly. Therapy will inspect the wheelchair. * [Resident #1] has an ADL self-care performance and mobility deficit related to intrinsic and extrinsic factors. Goal included: The resident will maintain current level of function. Interventions included: Bed Mobility - The resident requires assistance from 1-2 staff to turn and reposition in bed. Dressing - The resident is totally dependent in 1-2 staff for dressing. Personal Hygiene/Oral Hygiene - The resident is totally dependent on 1 staff for personal and oral hygiene. * The resident has limited physical mobility related to MS. Goal included: The resident will demonstrate the appropriate use of motorized wheelchair to increase mobility. Interventions included: Locomotion: The resident is able to maneuver/drive her motorized wheelchair. Record review of Resident #1's nursing progress notes for March 2025 revealed: * On 03/21/2025, at 11:27 a.m., RN B wrote, Per Resident and CNA, resident was being repositioned by CNA into her electric wheelchair and CNA bumped into resident's wheelchair causing the wheelchair to move and run into wall. MD notified and order given to have an x-ray done to the left foot. Pain medication given. RP and management notified. * On 03/22/2025, at 7:06 a.m., RN G wrote, Received report from night nurse that resident x-ray of the left foot 3 views was positive for fracture (acute fracture of the 2nd through 4th metatarsals). Order received by night nurse for new order to apply boot and consult podiatrist . * On 03/22/2025, at 1:28 p.m., RN G wrote, Follow-up to fracture of the 2nd through 4th metatarsal, no skin discoloration or swelling noted. Complaint of pain continues, PRN pain medication given. Resident is lying in bed, no distress noted, boot applied to left foot, resident tolerated well. Record review of Resident #1's Radiology Report dated 03/22/2025 revealed, . Significant Findings, Left Foot 3 views . There are minimally displaced fractures of the 2nd through 4th metatarsal necks . Soft tissue swelling is noted . Record review of the facility's document titled, One on One Inservice dated 03/24/2025, at 1:00 p.m. revealed CNA A was educated by an unknown instructor (the signature was illegible) regarding motorized wheelchair safety. The document read in part, Subject: Safety. Return demonstration outcome: Staff able to demonstrate and verbalize how to leave the wheelchair off when a resident is placed in an electric wheelchair until the resident is situated and CNA has completed the ADL with the resident. The document was signed by CNA A and the instructor. Observation and interview with Resident #1 on 05/21/2025, at 12:05 p.m. revealed she was alert and oriented. She was in her room sitting in her motorized wheelchair. Resident #1 sat in her wheelchair with her legs and feet elevated evenly with her hips. Resident #1 stated she always sat in her wheelchair and ambulated with her legs and feet elevated. She said in March 2025, CNA A placed her in her wheelchair in the large part of the shower room (The shower room was separated into three rooms. There were two smaller rooms with showers and there was a larger room where staff could get the residents dry and dressed, which led to the hallway). She said her motorized wheelchair had a joystick on the right side. She said CNA A leaned over her while standing on the right side, and something in her pocket bumped the joystick and caused the wheelchair to move forward and hit her feet against the wall. She said CNA A was possibly repositioning her or reaching for something, but she could not recall for sure. She said she went to a podiatrist (a medical professional devoted to the treatment of disorders of the foot and ankle), and they put a soft cast on her foot. She said she just recently got the cast off. She said she had the wheelchair for five years and the staff were supposed to turn it off when they provided care. She said she was not sure if the staff ever turned it off or not before, but they do turn if off now (after the incident). In a telephone interview with Resident #1's physician on 05/21/2025, at 2:13 p.m., he stated he was familiar with Resident #1 and recalled when staff notified him about the incident when she broke her toes. He said the facility staff called him for x-ray orders. He said staff told him an aide reached over Resident #1 and accidentally hit the go button on her wheelchair. He said the x-ray of her left foot showed fractures of the 2nd through 4th toes. He said they immobilized Resident #1's toes by taping them together and wrapping them. He said the wrap was not a cast, but it allowed the toes to set while aligned in place. He said he was not aware of the proper etiquette for the motorized wheelchair, so he could not say if the staff were supposed to turn the device off while providing care or not. He said the negative outcome of the incident was that Resident #1 fractured her toes. In a telephone interview with RN B on 05/21/2025, at 2:31 p.m., she stated on 03/21/2025, she observed Resident #1 and CNA A walking towards her after Resident #1's shower. She said Resident #1 and CNA A told her after the shower, CNA A leaned over Resident #1 to reposition her and CNA A bumped the joystick, causing it to go forward and hit the wall. She said she called the doctor and asked for something for Resident #1's pain. She said she did not know if the incident was caused by an error by the CNA or a glitch in the chair. She said she asked Resident #1 to show her how the chair worked (she did not give a date or period of time this happened) and Resident #1 told her to touch the joystick to see how it moved. RN B said when she touched the joystick, the wheelchair moved abruptly. She said the negative outcome of this incident was that Resident #1 was so worked up (emotional) about it and she may feel anxious about the incident happening again whenever she is placed in the wheelchair. In an interview with CNA A on 05/21/2025, at 3:05 p.m., she stated she often cared for Resident #1 and placed her in the wheelchair daily. She said the staff were possibly trained related to Resident #1's wheelchair when she initially received the wheelchair, but she (CNA A) was not trained when she started working at the facility in December 2024. She said she previously left the motorized wheelchair on when she cared for Resident #1, but now she turned it off. She said on 03/21/2025, around 10:00 a.m. - 10:30 a.m., after her shower, she placed Resident #1 into her wheelchair with assistance via mechanical lift. She said Resident #1 was already dressed and ready to leave the shower room. She said as she walked away from Resident #1, towards the door, she bumped the joystick, and it got stuck under Resident #1's arm. She said the wheelchair moved forward and her feet ran into the wall. She said Resident #1 said, [CNA A], my feet! CNA A said she turned around and moved Resident #1 away from the wall. She said now, there is a longer joystick on Resident #1's wheelchair. She stated the negative outcome of the incident was that Resident #1 hurt her foot. She said after the incident, she was educated on proper use of the motorized wheelchair. Record review of the facility's policy, titled Incidents and Accidents dated 08/15/2022 revealed, . Definitions: 'Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An 'incident' is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization . Policy Explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care .

Based on observations, interviews, and record review, the facility failed to report an alleged violation of abuse to HHSC for 1 of 10 resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to report an allegation of abuse to HHSC after Resident #1's family member expressed concerns when CNA C allegedly handled the resident roughly during resident care. This failure placed residents at risk of continued abuse, neglect, or exploitation. Findings include: Record review of Resident #1's face sheet dated 06/07/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia without behavioral disturbances (a group of thinking and social symptoms that interferes with daily functioning), psychotic disturbance (a mental disorder characterized by a disconnection from reality), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), chronic kidney disease (a type of long-term kidney disease in which either there is a gradual loss of kidney function that occurs over a period of months to years, or abnormal kidney stricture), diabetes (a group of diseases that result in too much sugar in the blood), essential hypertension (a type of high blood pressure that develops gradually over time without an identifiable cause), cognitive communication deficit (a communication difficulty caused by cognitive impairment), muscle wasting and atrophy (the loss of muscle tissue or mass which causes a decrease in strength and make it difficult to perform daily tasks), hypotension of hemodialysis (low blood pressure which is a side effect of hemodialysis treatments), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment);. Resident #1 did not experience hallucinations or delusions and she did not exhibit behaviors or reject care;. Resident #1 required limited assistance from at least one staff for bed mobility and toilet use; and Resident #1 required limited assistance from at least two staff for transfers. Record review of Resident #1's care plan revised 06/06/2024 revealed the following care areas: * Resident #1 is on hemodialysis related to end stage renal disease on Mondays, Wednesdays, and Fridays at 9:15 a.m. Goals included: Resident #1 will have no signs and symptoms of complications from dialysis. Approach included: 1 Liter fluid restriction. Administer medications as ordered. * Resident #1 has a communication problem related to a hearing deficit and impaired ability to make herself understood or understand others through verbal and non-verbal expression. Goals included: Resident #1 will be able to make basic needs by verbalizing on a daily basis. Approach included: Anticipate and meet needs. Encourage resident to continue stating thoughts even if the resident is having difficulty. Ensure/provide a safe environment. Validate resident's message by repeating aloud. * Resident #1 is incontinent of bowel and bladder related to intrinsic and extrinsic factors. Goals included: Resident #1 will have minimal to no complications secondary to bowel and bladder incontinence. Approach included: Apply barrier cream after each episode of incontinent care. Encourage physical activity within limits of physical ability, endurance, and activity tolerance. Check resident every two hours and as needed for incontinence. * Resident #1 has an ADL self-care performance and mobility deficit. Goals included: Resident #1 will have ADL's and mobility needs met. Approach included: Encourage resident to use the bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Monitor refusals of care. Resident #1 requires minimal to moderate assistance by 1-2 staff to turn and reposition in bed frequently and as necessary. Resident #1 requires minimal to moderate assistance by 1-2 staff for transfers. * Resident #1 has a history of CHF and was at increased risk for pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), pulmonary embolus (a condition in which one or more arteries in the lungs become blocked by a blood clot), anemia ( condition in which the blood does not have enough healthy red blood cells and hemoglobin), renal failure (when the kidneys lose the ability to remove waste and balance fluids), CAD (a heart condition that occurs when the coronary arteries have difficulty supplying the heart with enough blood, oxygen, and nutrients), fluid overload (when the liquid portion of the blood is too high), death, edema (when fluid builds up in the body's tissues), increased SOB, decreased appetite, and fluctuating cognition related to unstable oxygen saturation levels, unintended weight gain, impaired skin integrity, and increased edema. Goals included: Resident #1 will have clear lunch sounds, heart rate and rhythm within normal limits. Approach included: Administer cardiac medications as ordered. Check breath sounds. Monitor, document, and report labored breathing and the use of accessory muscles while breathing. Monitor vital signs as ordered. Notify doctor of significant abnormalities. Record review of Resident #1's progress notes for June 2024 revealed the following: On 06/06/2024 at 3:53 p.m., LVN D wrote, . Head to Toe Assessment completed. Resident presents well kept, clothes clean and dry, brief recently changed. Skin warm/dry to the touch. Resident with clear lung fields, heart tones regular, even with S1S2 (heart sounds) heard. Bowel sounds heard x 4 quadrants. G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) in place . Resident ROM continues unchanged or decrease. Resident without signs or symptoms of pain. Resident has no voiced complaints of pain. Resident noted with multiple, documented black heads to entire upper hemisphere; large, raised pink in color raised irregular shaped skin tag (a harmless skin growth) to thoracic spine area of back in between shoulder blade. Round area, brown in color, round in shape noted to left knee. Light colored skin variation noted to left lateral thigh concurrent with definition of birth markings. No other skin issues noted at this time. Record review of a typed statement signed and dated by the Administrator on 06/06/2024 revealed, To Whom It May Concern, At or about 12:30 p.m. [it was] reported to me that Resident #1's family member alleged her aide had been rough with Resident #1. Specifically, removing Resident #1's oxygen cannula, and pulling on and snatching off Resident #1's clothing. During discussion, [I] learned the resident aide has had some performance concerns with attendance and assigned duties, not being rough. Also, the Charge Nurse (LVN B) conveyed that the aide refused to follow instruction in getting resident up and ready for Resident #1's visit. Informed that upon the family member's arrival, she was upset that Resident #1 was not up and ready for her visit. The Charge Nurse faulted his aide for not following his instruction. The aide was located on break and confronted by the Charge nurse and family member for not getting the resident up and ready. Resident #1's family member actively participated in resident ADL care and getting her up and dressed, working with the aide. During that process, the family member became upset with how the aide was dressing Resident #1, dismissing the aide from patient care, stating she was being too rough. According to aide, the family member removed the oxygen cannula from the resident's nose and around the resident's body. Considering aide performance history and failure to follow supervisor instruction will suspend pending outcome of investigation. Observation and interview with Resident #1 on 06/07/2024 at 12:54 p.m. revealed she had just been just dropped off by a transportation company following her dialysis treatment. She was sitting in her wheelchair in the hallway near her room. Resident #1 was being administered oxygen via nasal cannula and an oxygen tank behind her wheelchair. Resident #1 was alert and stated her name. She stated she felt safe in the facility and denied any abuse. Resident #1 talked about topics unrelated to the conversation and appeared to be somewhat confused. In an interview with the Administrator and the DON on 06/07/2024 at 10:15 a.m., the DON stated on the previous day, 06/06/2024, they received a concern from Resident #1's family member saying that CNA C was rough while she dressed her. The DON stated the family member was present and assisted CNA C during the incident. The DON stated CNA C was currently suspended pending the investigation. The Administrator stated he was the facility's abuse coordinator, and he would be responsible for reporting incidents to HHSC. The Administrator stated he did not report the incident to HHSC because it was not an abuse allegation. The DON stated the family member did not use the word abuse when she reported the incident. The DON said the family member said CNA C was rough when she pulled off Resident #1's oxygen and clothing, but their investigation indicated it was the family member who pulled off Resident #1's oxygen because it was wrapped around her leg. The DON stated they were still investigating the incident because the family member had a history of exacerbating situations and not being truthful about encounters. The DON said the family member was used to Resident #1 being up out of bed by 11:00 a.m., but on 06/06/2024, Resident #1 was not up by that time. The DON said Resident #1 had an in-house appointment for a barium swallow test and when the family member arrived prior to the appointment, Resident #1 was not up and ready. The DON said the family member went to LVN B who said CNA C failed to follow his instructions to get Resident #1 up and ready for the appointment. The DON said the family member went to their HR department to get the CNA's name to make a complaint. The DON said that was when she took over the investigation. The DON said she sent CNA C home and then reported the allegation to the abuse coordinator who is also the Administrator. The DON said when the family said Resident #1 was treated roughly, she felt it could possibly have been an abuse complaint. The DON said she interviewed Resident #1, who said nobody harmed her and she felt safe. The DON said she interviewed CNA C and LVN B and she had them write statements regarding the incident in case there was a substantiated abuse allegation. The DON said the protocol was to suspend the alleged perpetrator during an investigation. The Administrator said he did not speak to Resident #1's family member and to him, the situation sounded like the family member was not happy about how Resident #1 was being dressed. The Administrator said, She said the aide was too rough, but what did she mean? The Administrator said the family member should have stopped the aide from doing whatever she was doing and removed Resident #1 from the situation if she thought the aide was being abusive. The Administrator stated that his question was, what was the definition of abuse. The DON stated a head-to-toe assessment was conducted and Resident #1 was negative for any injuries. In a telephone interview with Resident #1's family member on 06/06/2024 at 11:15 a.m., she stated she tried to talk to the Administrator on 06/06/2024, but he did not listen. She said she tried to talk to the DON, but she kept cutting her off while she explained. The family member said the aide snatched Resident #1's legs and was impatient with her. She said the aide told Resident #1 that she needed to cooperate because she had to go pass lunch trays. The family member said Resident #1 was asleep and the aide was trying to change her clothes while she was still sleeping. She said Resident #1 was confused because she was asleep. She said she told the aide she should not do Resident #1 like that because she (the family member) was standing right there. She said she told the aide not to snatch Resident #1 like that. She said when the aide took a cold wipe and snatched Resident #1's legs open to try and clean the feces off of her, Resident #1 said the wipe was cold. She said she took another wipe, ran warm water over it, and told the aide to use the warm wipe, but the aide said she did not have to do anything she told her to do. She said the aide told Resident #1 she had to hurry because she had to go pass lunch trays. She said she told the aide there was a better way to clean Resident #1, but the aide just looked at her. She said she told the aide she could go ahead and pass her trays. She stated she felt Resident #1 was abused but she did not use that word when she expressed her concerns to the DON. She said she was present when the DON asked Resident #1 if she had been abused, but since Resident #1 had dementia, she could not recall incidents minutes after they happen. She told the DON she did not want the aide to help Resident #1 anymore. In a telephone interview with CNA C on 06/10/2024 at 2:42 p.m., she stated on 06/06/2024, when she arrived for her shift around 6:00 a.m., LVN B told her to dress Resident #1 ASAP because she had an appointment. She said when she went to provide incontinent care and dress Resident #1, her family member was there and said to change her adult brief, but not her clothes because she had to do something with her for 14 minutes. She said the family member told her to leave Resident #1 sitting on the bed for 15 minutes. She said when she returned to Resident #1's room after 15 minutes, neither Resident #1 nor the family member were in the room. She said she returned to the room after another 20 minutes, but nobody was in there. She said she passed breakfast trays and went on her break at 11:30 a.m. She said LVN B came and said he told her to change Resident #1 earlier that morning and now her family member was shouting. She said she tried to explain, but LVN B did not give her a chance. She said Resident #1's family member met her down the hall. She said she told the family member she got distracted with other tasks and she was sorry. She said they went to Resident #1's room but she would not turn herself in the bed to allow CNA C to change her adult brief and clean her private parts. She said she stood there 10 minutes asking Resident #1 to turn so she could change her. She said she asked the family member for help, but she just stood there looking at her. She said after standing there for 20-30 minutes, lunch trays were waiting in the hallway. She said she asked the family member for help with changing Resident #1 before lunch got cold. She said the family member got upset and asked why she was talking to her so rudely. She said the family member said she did not have patience with the resident. She said the family member said she was being rough and rude with Resident #1, but she did not know what she was doing that was rough because she was not touching her yet. She said she usually used the bed pad underneath the residents to turn them when they did not want to turn themselves, so she grabbed the bed pad and that was when the family member started shouting. She said the family member noticed Resident #1's oxygen tubing was tangled, so she took it off. CNA C said she tried to take Resident #1's cloths off while the family member had the nasal cannula off. She said she got Resident #1 changed and dressed but eventually, the family member told her to leave and go pass her trays. She said Resident #1 never screamed or made any noise during the process. She said the DON asked her to write a statement and instructed her to go home. Record review of the facility's policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022 revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation. Reporting Allegations to the Administrator and Authorities. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for survey/licensing the facility . 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury . 6. Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents .

Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of ten residents reviewed for quality of care. 1. The facility failed to ensure Resident #1, who had a history of SOB, was sent to her dialysis treatment with oxygen equipment on 06/05/2024 and resulted in an episode of desaturation (low blood oxygen levels) and SOB. 2. The facility failed to ensure Resident #1 was sent to her dialysis treatment with a mechanical lift pad, as ordered by her physician, on 06/05/2024 and 06/12/2024 and resulted in a delay in receiving her dialysis treatment. These failures placed residents at risk of experiencing exacerbations of symptoms, worsening of condition, and delayed medical services/treatment. Findings include: Record review of Resident #1's face sheet dated 06/07/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia without behavioral disturbances (a group of thinking and social symptoms that interferes with daily functioning), psychotic disturbance (a mental disorder characterized by a disconnection from reality), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), chronic kidney disease (a type of long-term kidney disease in which either there is a gradual loss of kidney function that occurs over a period of months to years, or abnormal kidney stricture), diabetes (a group of diseases that result in too much sugar in the blood), essential hypertension (a type of high blood pressure that develops gradually over time without an identifiable cause), cognitive communication deficit (a communication difficulty caused by cognitive impairment), muscle wasting and atrophy (the loss of muscle tissue or mass which causes a decrease in strength and make it difficult to perform daily tasks), hypotension of hemodialysis (low blood pressure which is a side effect of hemodialysis treatments), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment); Resident #1 did not experience hallucinations or delusions and she did not exhibit behaviors or reject care; Resident #1 required limited assistance from at least one staff for bed mobility and toilet use; and Resident #1 required limited assistance from at least two staff for transfers. Record review of Resident #1's care plan revised 06/06/2024 revealed the following care areas: * Resident #1 is on hemodialysis related to end stage renal disease on Mondays, Wednesdays, and Fridays at 9:15 a.m. Goals included: Resident #1 will have no signs and symptoms of complications from dialysis. Approach included: 1 Liter fluid restriction. Administer medications as ordered. * Resident #1 has an ADL self-care performance and mobility deficit. Goals included: Resident #1 will have ADL's and mobility needs met. Approach included: Encourage resident to use the bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Monitor refusals of care. Resident #1 requires minimal to moderate assistance by 1-2 staff to turn and reposition in bed frequently and as necessary. Resident #1 requires minimal to moderate assistance by 1-2 staff for transfers. * Resident #1 has a history of CHF and was at increased risk for pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), pulmonary embolus (a condition in which one or more arteries in the lungs become blocked by a blood clot), anemia ( condition in which the blood does not have enough healthy red blood cells and hemoglobin), renal failure (when the kidneys lose the ability to remove waste and balance fluids), CAD (a heart condition that occurs when the coronary arteries have difficulty supplying the heart with enough blood, oxygen, and nutrients), fluid overload (when the liquid portion of the blood is too high), death, edema (when fluid builds up in the body's tissues), increased SOB, decreased appetite, and fluctuating cognition related to unstable oxygen saturation levels, unintended weight gain, impaired skin integrity, and increased edema. Goals included: Resident #1 will have clear lunch sounds, heart rate and rhythm within normal limits. Approach included: Administer cardiac medications as ordered. Check breath sounds. Monitor, document, and report labored breathing and the use of accessory muscles while breathing. Monitor vital signs as ordered. Notify doctor of significant abnormalities. Record review of Resident #1's progress notes for June 2024 revealed: * On 06/05/2024 at 9:11 a.m., LVN A wrote, Resident left facility and went to dialysis in stable condition. No signs and symptoms of acute distress noted. Dialysis communication sent with resident and driver voiced that he saw it. Record review of Resident #1's undated General Order form revealed: * Received Date: 05/03/2024. Start Date: 05/03/2024. DC Date: 05/20/2024. Order Description: Continuous oxygen: Oxygen at 2 liters/minute via nasal cannula to relive hypoxia (absence of enough oxygen in the tissues to sustain bodily functions) related to diagnosis of SOB . DC Note: Order changed to PRN . Record review of Resident #1's Physician's Orders for June 2024 revealed the following orders: * PRN Oxygen: Oxygen at 2 liters/minute via nasal cannula to relieve hypoxia related to diagnosis of SOB. Special Instructions: Check O2 saturation as needed. Start Date 05/20/2024. End Date: Open Ended. * Resident is to use/have [mechanical] Lift pad in wheelchair on Dialysis days. Special Instructions: Place [mechanical] Lift pad on resident on dialysis days Monday, Wednesday, Friday. Start Date: 04/09/2024. End Date: Open Ended. * Transport to Dialysis Center on Monday, Wednesday, Friday at 9:15 a.m. Start Date: 06/06/2024. End Date: Open Ended. Record review of Resident #1's MAR for June 2024 revealed: * Order: Dialysis Pre-Vitals. Frequency: Once a day on Monday, Wednesday, Friday. Start/End Date: 04/08/2024 - Open Ended. Monday, 06/05/2024 - O2 Saturation Before: 93% In an interview with LVN B on 06/07/2024 at 11:45 a.m., he stated Resident #1 had recently declined cognitively and physically. He said Resident #1 had orders for PRN oxygen. He said when Resident #1 returned from dialysis treatments, she was always very weak, so they put her on oxygen and laid her down. He said Resident #1 normally got out of breath and fatigued, so he always sent her to dialysis with oxygen in case she needed it there. He said they had to check Resident #1 before she left for dialysis to make sure her oxygen was good. He said he worked Monday (06/03/2024) morning (6:00 a.m. - 2:00 p.m.) and cared for Resident #1 before she left for dialysis, but he was off on Wednesday, 06/05/2024 and picked up a shift on a different hall from Resident #1 on that day. He said he heard there was a complaint from Resident #1's dialysis center on 06/05/2024 that she did not go to dialysis with oxygen. Observation and interview with Resident #1 on 06/07/2024 at 12:54 p.m. revealed she had just been just dropped off by a transportation company following her dialysis treatment. She was sitting in her wheelchair in the hallway near her room. Resident #1 was being administered oxygen via nasal cannula and an oxygen tank behind her wheelchair. Resident #1 was alert and stated her name. She stated she felt safe in the facility and denied any abuse. Resident #1 talked about topics unrelated to the conversation and appeared to be somewhat confused. In an interview with CNA F on 06/07/2024 at 1:30 p.m., she stated Resident #1 recently started dialysis treatments and could stand with staff assistance. She said now that Resident #1 was on dialysis, she was weaker than she was before and needed more help. She stated Resident #1 recently started going to dialysis with an oxygen tank. She said she cared for Resident #1 that morning (06/07/2024) and she had the oxygen with her before she went to dialysis. She said Resident #1 usually had oxygen on when she was in bed. In a telephone interview with an RN from Resident #1's dialysis center on 06/11/2024 at 3:15 p.m., she stated she was responsible for Resident #1's care at the center on Wednesday, 06/05/2024. She said when Resident #1 arrived, she was gasping for air and struggling to breath. She stated while Resident #1 was still in the lobby of the center, her oxygen saturation was 92% and she looked down and sleepy, like she was not well. She said Resident #1's head kept dropping but she was still able to respond slower than usual. She said Resident #1 usually came to the center with oxygen from the nursing facility, but she did not have it that day. She said that was the only time she worked with Resident #1 when she did not have the oxygen, but she was told by other staff at the center that it had happened before. She could not provide specific days that Resident #1 did not arrive with oxygen from the nursing facility. She said they got Resident #1 over to their clinic and placed her on 2 liters of oxygen. She said Resident #1's oxygen saturation went up to 98% and her condition improved with better responses, and she looked better. She said she called the facility to let them know what happened and that they forgot to send Resident #1 with oxygen and a mechanical lift pad. She said Resident #1's family member brought an oxygen tank and a mechanical lift pad so Resident #1 could get her treatment. She said after Resident #1 received oxygen, she was able to complete her treatment with no other issues. She said the facility had to send the mechanical lift pad because that was how the center got Resident #1 out of her wheelchair and into the treatment chair. She said the center had a mechanical lift machine, but they did not have pads. She said without the pads, someone would have to lift Resident #1 out of her wheelchair. In a telephone interview with Resident #1's family member on 06/12/2024 at 11:12 a.m., she stated she received a call from Resident #1's dialysis center earlier that morning (06/12/2024) saying the facility forgot to send Resident #1 with a mechanical lift pad again. She said the center needed the pad to lift Resident #1 out of her wheelchair and into the treatment chair. She stated the facility forgot to send the pad several times, but she could not provide specific dates other than 06/05/2024. She said on 06/05/2024, the facility forgot to send oxygen and the mechanical lift pad to the dialysis center. She said she went to the nursing facility on 06/05/2024 to pick up oxygen and the pad. She said when she arrived at the facility, the person at the front desk said all of the staff were in a meeting, so she went and found an oxygen tank and a mechanical lift pad. She said she arrived at the dialysis center a little after 10:00 a.m. and was told several male staff at the center had to pick Resident #1 up out of her wheelchair and placed her into the treatment chair. She said the center staff said it was dangerous for them to pick Resident #1 up that way and they were not supposed to touch patients like that. She said on that day, 06/12/2024, she was on her way to the nursing facility when the dialysis center called her back and said someone from the nursing facility had already dropped off a mechanical lift pad. In an interview with LVN A on 06/14/2024 at 10:00 a.m., she stated she cared for Resident #1 several days the previous week, including Wednesday, 06/05/2024. She said normally, on Resident #1's dialysis days, she is first to get ready. She said she usually checked Resident #1's vital signs, did her finger stick (blood sugar check), gave her medications, and completed her feeding (via g-tube - a tube inserted through the belly that brings nutrition directly to the stomach). She said now, they always send Resident #1 to the dialysis center with an oxygen tank and mechanical lift pad. She said Resident #1 always got her showers before dialysis and the mechanical lift pad was placed underneath her after the shower. She stated Resident #1 did not require mechanical lift transfers at the facility, but they used it at the dialysis center. She stated she did not know this information the previous week on 06/05/2024 when she sent Resident #1 to the center without oxygen or mechanical lift pad. She said Resident #1 was able to stand and pivot for staff at the facility and it was never made known to her that she was supposed to send Resident #1 to dialysis with a mechanical lift pad. She said she only found out when the dialysis center called to say she did not have the oxygen or the pad. She said Resident #1 was not on oxygen until she got pneumonia and was put on continuous oxygen. She said Resident #1 did not want to wear the oxygen and her oxygen levels improved after the pneumonia resolved, so her order was changed to PRN. She said after that, Resident #1 only used the oxygen when she had SOB, which was not often. She said on the morning od 06/05/2024, Resident #1's oxygen saturation was 93% on room air. She said normal oxygen level was above 90%, so Resident #1 did not need the oxygen that morning. She said Resident #1 did not have labored breathing or any other symptoms of SOB. She said on 06/05/2024, the center called the DON who told her to call the dialysis center to check on Resident #1. She said when she called the center, the nurse said Resident #1 was fine but had labored breathing when she arrived. She said the nurse told her Resident #1's oxygen saturation was 94%. She said after that, they are to always send oxygen and the mechanical lift pad to the center. She said she called the transportation center and asked them to always make sure Resident #1 had the oxygen tank when they picked her up. She said on 06/05/2024, Resident #1's family member called and said she was coming to pick up the tank and pad, so she gathered everything and took them to the front so the family member could grab them when she arrived. She said the dialysis center nurse said Resident #1's oxygen level was at 94%, but she had SOB. She said she did not call Resident #1's NP because she did not desaturate. She said she would have notified the NP if Resident #1 desaturated. In an interview with CNA C on 06/14/2024 at 10:33 a.m., she stated she knew to send Resident #1 to the dialysis center with a mechanical lift pad. She said Resident #1 did not normally use a mechanical lift at the facility, so she did not know why she needed it at the dialysis center. She said when she was hired, she was trained to always send Resident #1 with a pad on dialysis days. She said on 06/05/2024, Resident #1 was difficult and gave her trouble during her shower, so she had to get assistance from the nurse. She said she forgot to place the mechanical lift pad underneath Resident #1 after her shower. In an interview with the DON on 06/14/2024 at 10:50 a.m., she stated she previously thought they were sending Resident #1 with a mechanical lift pad as a courtesy to the dialysis center, and she was not aware it was an order. In a telephone interview with Resident #1's NP on 06/14/2024 at 11:07 a.m., she stated Resident #1 previously had aspiration pneumonia and was transferred to the hospital. She said currently, Resident #1 was on oxygen PRN and did not usually need it when she went to dialysis. She said Resident #1 kept taking the oxygen off, so they decided to check her pulse oximetry (a test used to measure the oxygen level of the blood). She said Resident #1's pulse oximetry was fine after the pneumonia resolved, so her order was changed to PRN. The NP said she was not notified that Resident #1 experienced SOB or a decrease in oxygen saturation at dialysis. She said she was not made aware that Resident #1 needed oxygen during dialysis treatments. She said usually, if Resident #1's oxygen saturation was under 93% on room air, she would need oxygen. She said knowing that Resident #1 needed oxygen at dialysis would have definitely made her change the oxygen order. She said the facility should definitely send Resident #1 to dialysis with oxygen. She said if Resident #1's oxygen level was dropping, the facility needed to send the tank with her. In a follow-up interview with the DON on 06/14/2024 at 11:40 a.m., she stated Resident #1's NP just called to give an order to send oxygen with Resident #1 on dialysis days. She said to her, LVN A should have contacted Resident #1's NP to notify her of the incident on 06/05/2024. She stated LVN A should have documented the incident in Resident #1's progress notes. She stated CNA C and the aide who failed to send the mechanical lift pad on 06/12/2024 were both originally from the night shift and were not totally familiar with Resident #1. Record review of the facility's policy titled, Accommodation of Needs revised March 2021 revealed, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. Policy Interpretation and Implementation: 1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis . Record review of the facility's policy titled, Change in a Resident's Condition or Status revised February 2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; . i. specific instruction to notify the physician of changes in the resident's condition . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Based on observations, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 10 residents (Resident #1) reviewed for changes of condition. The facility failed to notify Resident #1's physician when she experienced a change of condition, including SOB and desaturation (low blood oxygen levels) on 06/05/2024. This failure placed residents at risk experiencing a delay in medical treatment and worsening of condition/symptoms. Findings include: Record review of Resident #1's face sheet dated 06/07/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia without behavioral disturbances (a group of thinking and social symptoms that interferes with daily functioning), psychotic disturbance (a mental disorder characterized by a disconnection from reality), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), chronic kidney disease (a type of long-term kidney disease in which either there is a gradual loss of kidney function that occurs over a period of months to years, or abnormal kidney stricture), diabetes (a group of diseases that result in too much sugar in the blood), essential hypertension (a type of high blood pressure that develops gradually over time without an identifiable cause), cognitive communication deficit (a communication difficulty caused by cognitive impairment), muscle wasting and atrophy (the loss of muscle tissue or mass which causes a decrease in strength and make it difficult to perform daily tasks), hypotension of hemodialysis (low blood pressure which is a side effect of hemodialysis treatments), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment); Resident #1 did not experience hallucinations or delusions and she did not exhibit behaviors or reject care; Resident #1 required limited assistance from at least one staff for bed mobility and toilet use; and Resident #1 required limited assistance from at least two staff for transfers. Record review of Resident #1's care plan revised 06/06/2024 revealed the following care areas: * Resident #1 is on hemodialysis related to end stage renal disease on Mondays, Wednesdays, and Fridays at 9:15 a.m. Goals included: Resident #1 will have no signs and symptoms of complications from dialysis. Approach included: 1 Liter fluid restriction. Administer medications as ordered. * Resident #1 has an ADL self-care performance and mobility deficit. Goals included: Resident #1 will have ADL's and mobility needs met. Approach included: Encourage resident to use the bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. Monitor refusals of care. Resident #1 requires minimal to moderate assistance by 1-2 staff to turn and reposition in bed frequently and as necessary. Resident #1 requires minimal to moderate assistance by 1-2 staff for transfers. * Resident #1 has a history of CHF and was at increased risk for pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), pulmonary embolus (a condition in which one or more arteries in the lungs become blocked by a blood clot), anemia ( condition in which the blood does not have enough healthy red blood cells and hemoglobin), renal failure (when the kidneys lose the ability to remove waste and balance fluids), CAD (a heart condition that occurs when the coronary arteries have difficulty supplying the heart with enough blood, oxygen, and nutrients), fluid overload (when the liquid portion of the blood is too high), death, edema (when fluid builds up in the body's tissues), increased SOB, decreased appetite, and fluctuating cognition related to unstable oxygen saturation levels, unintended weight gain, impaired skin integrity, and increased edema. Goals included: Resident #1 will have clear lunch sounds, heart rate and rhythm within normal limits. Approach included: Administer cardiac medications as ordered. Check breath sounds. Monitor, document, and report labored breathing and the use of accessory muscles while breathing. Monitor vital signs as ordered. Notify doctor of significant abnormalities. Record review of Resident #1's progress notes for June 2024 revealed: * On 06/05/2024 at 2:44 a.m., LVN E wrote, Resident having difficulty sleeping, and is monitored every 2 hours during this shift . Resident on oxygen 3 liters at this time and reports comfortable in bed. Will continue to monitor. * On 06/05/2024 at 9:11 a.m., LVN A wrote, Resident left facility and went to dialysis in stable condition. No signs and symptoms of acute distress noted. Dialysis communication sent with resident and driver voiced that he saw it. Record review of Resident #1's undated General Order form revealed: * Received Date: 05/03/2024. Start Date: 05/03/2024. DC Date: 05/20/2024. Order Description: Continuous oxygen: Oxygen at 2 liters/minute via nasal cannula to relive hypoxia related to diagnosis of SOB . DC Note: Order changed to PRN . Record review of Resident #1's Physician's Orders for June 2024 revealed the following orders: * PRN Oxygen: Oxygen at 2 liters/minute via nasal cannula to relieve hypoxia related to diagnosis of SOB. Special Instructions: Check O2 saturation as needed. Start Date 05/20/2024. End Date: Open Ended. * Transport to Dialysis Center on Monday, Wednesday, Friday at 9:15 a.m. Start Date: 06/06/2024. End Date: Open Ended. Record review of Resident #1's MAR for June 2024 revealed: * Order: Dialysis Pre-Vitals. Frequency: Once a day on Monday, Wednesday, Friday. Start/End Date: 04/08/2024 - Open Ended. Monday, 06/05/2024 - O2 Saturation Before: 93% Record review of Resident #1's Physician Order Report for May 2024 and June 2024 revealed: * Start Date: 06/14/2024. End date: Open Ended. Description: Portable oxygen tank to be sent with resident on every dialysis day (Monday, Wednesday, Friday) once a day on Monday, Wednesday, Friday; 8:00 a.m. Observation and interview with Resident #1 on 06/07/2024 at 12:54 p.m. revealed she had just been just dropped off by a transportation company following her dialysis treatment. She was sitting in her wheelchair in the hallway near her room. Resident #1 was being administered oxygen via nasal cannula and an oxygen tank behind her wheelchair. Resident #1 was alert and stated her name. She stated she felt safe in the facility and denied any abuse. Resident #1 talked about topics unrelated to the conversation and appeared to be somewhat confused. In an interview with LVN B on 06/07/2024 at 11:45 a.m., he stated Resident #1 had recently declined cognitively and physically. He said Resident #1 had orders for PRN oxygen. He said when Resident #1 returned from dialysis treatments, she was always very weak, so they put her on oxygen and laid her down. He said Resident #1 normally got out of breath and fatigued, so he always sent her to dialysis with oxygen in case she needed it there. He said they had to check Resident #1 before she left for dialysis to make sure her oxygen was good. He said he worked Monday (06/03/2024) morning (6:00 a.m. - 2:00 p.m.) and cared for Resident #1 before she left for dialysis, but he was off on Wednesday, 06/05/2024 and picked up a shift on a different hall from Resident #1 on that day. He said he heard there was a complaint from Resident #1's dialysis center on 06/05/2024 that she did not go to dialysis with oxygen. In an interview with CNA F on 06/07/2024 at 1:30 p.m., she stated Resident #1 recently started dialysis treatments and could stand with staff assistance. She said now that Resident #1 was on dialysis, she was weaker than she was before and needed more help. She stated Resident #1 recently started going to dialysis with an oxygen tank. She said Resident #1 usually had oxygen on when she was in bed. In a telephone interview with an RN from Resident #1's dialysis center on 06/11/2024 at 3:15 p.m., she stated she was responsible for Resident #1's care at the center on Wednesday, 06/05/2024. She said when Resident #1 arrived, she was grasping for air and struggling to breath. She stated while Resident #1 was still in the lobby of the center, her oxygen saturation was 92% and she looked down and sleepy, like she was not well. She said Resident #1's head kept dropping but she was still able to respond slower than usual. She said Resident #1 usually came to the center with oxygen from the nursing facility, but she did not have it that day. She said that was the only time she worked with Resident #1 when she did not have the oxygen, but she was told by other staff at the center that it had happened before. She could not provide specific days that Resident #1 did not arrive with oxygen from the nursing facility. She said they got Resident #1 over to their clinic and placed her on 2 liters of oxygen. She said Resident #1's oxygen saturation went up to 98% and her condition improved with better responses, and she looked better. She said she called the facility to let them know what happened and that they forgot to send Resident #1 with oxygen. She said Resident #1's family member brought an oxygen tank so Resident #1 could get her treatment. She said after Resident #1 received oxygen, she was able to complete her treatment with no other issues. In an interview with LVN A on 06/14/2024 at 10:00 a.m., she stated she cared for Resident #1 several days the previous week, including Wednesday, 06/05/2024. She said normally, on Resident #1's dialysis days, she is first to get ready. She said she usually checked Resident #1's vital signs, did her finger stick (blood sugar check), gave her medications, and completed her feeding (via g-tube - a tube inserted through the belly that brings nutrition directly to the stomach). She said now, they always send Resident #1 to the dialysis center with an oxygen tank. She stated she did not know this information the previous week on 06/05/2024 when she sent Resident #1 to the center without oxygen. She said she only found out when the dialysis center called to say she did not have the oxygen. She said Resident #1 was not on oxygen until she got pneumonia and was put on continuous oxygen. She said Resident #1 did not want to wear the oxygen and her oxygen levels improved after the pneumonia resolved, so her order was changed to PRN. She said after that, Resident #1 only used the oxygen when she had SOB, which was not often. She said on the morning od 06/05/2024, Resident #1's oxygen saturation was 93% on room air. She said normal oxygen level was above 90%, so Resident #1 did not need the oxygen that morning. She said Resident #1 did not have labored breathing or any other symptoms of SOB. She said on 06/05/2024, the center called the DON who told her to call the dialysis center to check on Resident #1. She said when she called the center, the nurse said Resident #1 was fine but had labored breathing when she arrived. She said the nurse told her Resident #1's oxygen saturation was 94%. She said after that, they are to always send oxygen to the center. She said she called the transportation center and asked them to always make sure Resident #1 had the oxygen tank when they picked her up. She said on 06/05/2024, Resident #1's family member called and said she was coming to pick up the tank so she gathered everything and took them to the front so the family member could grab them when she arrived. She said the dialysis center nurse said Resident #1's oxygen level was at 94%, but she had SOB. She said she did not call Resident #1's NP because she did not desaturate. She said she would have notified the NP if Resident #1 desaturated. In a telephone interview with Resident #1's NP on 06/14/2024 at 11:07 a.m., she stated Resident #1 previously had aspiration pneumonia and was transferred to the hospital. She said currently, Resident #1 was on oxygen PRN and did not usually need it when she went to dialysis. She said Resident #1 kept taking the oxygen off, so they decided to check her pulse oximetry (a test used to measure the oxygen level of the blood). She said Resident #1's pulse oximetry was fine after the pneumonia resolved, so her order was changed to PRN. The NP said she was not notified that Resident #1 experienced SOB or a decrease in oxygen saturation at dialysis. She said she was not made aware that Resident #1 needed oxygen during dialysis treatments. She said usually, if Resident #1's oxygen saturation was under 93% on room air, she would need oxygen. She said knowing that Resident #1 needed oxygen at dialysis would have definitely made her change the oxygen order. She said the facility should definitely send Resident #1 to dialysis with oxygen. She said if Resident #1's oxygen level was dropping, the facility needed to send the tank with her. In a follow-up interview with the DON on 06/14/2024 at 11:40 a.m., she stated Resident #1's NP just called to give an order to send oxygen with Resident #1 on dialysis days. She said to her, LVN A should have contacted Resident #1's NP to notify her of the incident on 06/05/2024. She stated LVN A should have documented the incident in Resident #1's progress notes. Record review of the facility's policy titled, Change in a Resident's Condition or Status revised February 2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; . i. specific instruction to notify the physician of changes in the resident's condition . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions for level II resident review upon a significant change in status assessment for one of nineteen residents (Resident #33) reviewed for PASARR evaluations. The facility failed to refer Resident #33 to the appropriate, State-designated authority when she was diagnosed with MI. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings included: Record review of Resident #33' face sheet dated 5/22/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included multiple sclerosis (a chronic autoimmune disorder affecting movement, ensation, and bodily functions), hemiplegia (one sided-paralysis) and hemiparesis (one-sided muscle weakness) affecting both sides, a contracture (permanent shortening of muscle, tendon, skin, or other tissue that causes deformity or distortion of a joint) of her left elbow, pinguecula (small, yellow, benign growth that develops in the white of the eye) of both eyes, contractures (permanent shortening of muscle, tendon, skin, or other tissue that causes deformity or distortion of a joint) of multiple muscles, myopia (near-sightedness), polyneuropathy (damage to multiple peripheral nerves), bipolar disorder (mental illness characterized by extreme mood swings), dementia (group of symptoms that affects memory, thinking and interferes with daily life), convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), and anxiety disorder (group of mental illnesses that cause constant fear and worry). Record review of Resident #33' quarterly MDS dated [DATE] with an ARD of 3/20/2024 revealed a BIMS score of 15 indicating no cognitive impairment. The MDS documented she had no potential indicators of psychosis, behaviors affecting other residents, rejection of care, or wandering behaviors. Per the MDS, Resident #33 had an impairment of both upper and lower extremities, and she required a wheelchair for mobility. The MDS revealed she required assistance, or was totally dependent on staff, for all ADL's. The MDS revealed she had been administered antipsychotic, antianxiety, and antidepressant medications in the seven days prior to the assessment. Record review of Resident #33' undated care plan revealed a focus on the adverse reactions to her anxiety and antianxiety medication use with interventions including medication administration and monitoring for effectiveness and adverse reactions. The care plan included a focus on her antipsychotic drug use with interventions including medication administration, monitoring for effectiveness and adverse reactions, and quarterly GDR if appropriate. The care plan included a focus on the fall prevention plan that Resident #33 was a part of, with interventions including providing a positive approach to help prevent falls. The care plan revealed a focus on her increased risk of falls with interventions including education related to falls and fall prevention, labs to determine a possible underlying cause, MRR, pharmacy consultant MRR, PT evaluation and treatment as required, and ensuring she had a safe environment. The care plan documented a focus on her dementia with interventions including use of yes/no questions, cuing and reorienting when needed, providing a consistent routine, and task segmentation. The care plan revealed a focus on her bipolar disorder with interventions including medication administration, monitoring and reporting any depressive or manic episodes or mood swings, and a psychiatric health referral. Record review of Resident #33' physician's order's report dated 5/22/2024 revealed orders to monitor for adverse reactions to her antianxiety, antipsychotic, and hypnotic/sedative/tranquilizer medications dated 10/3/2023. The report documented an order for a fall prevention program dated 4/9/2024. The report included an order for psychiatric care services to evaluate and treat Resident #33 dated 10/3/2023. The report documented Resident #33 had prescriptions including Acetaminophen-Codeine 300-30mg tablet one tablet every six hours as needed, Clonazepam 0.5mg tablet one tablet twice daily, Quetiapine 100mg tablet one tablet once daily in the morning, and Quetiapine 200mg tablet one tablet once daily at bedtime, Trazadone 100mg tablet two tablets twice daily at bedtime, and Trazadone 50mg tablet one tablet once daily at bedtime (total of 250mg trazadone at bedtime daily). Observation and interview on 5/21/2024 at 9:22 AM with Resident #33, she said she had lived at the facility for seven years. Resident #33 said the staff provided for all of her needs. Interview on 5/22/2024 at 3:59 PM with the DON, she said the purpose of the PASRR was to obtain outside services for eligible residents. The DON said the MDS nurse was responsible for the PASRR process. Interview on 9/23/2024 at 10:01 AM with the MDS nurse and the Traveling MDS Nurse, the MDS Nurse said she had been employed since February 4, 2024. The MDS Nurse said her primary duties included ensuring MDS assessments were completed and ensuring a resident's PASRR Level 1 (PL1) was completed appropriately and accurately. The Traveling MDS Nurse said the facility was in the process of reviewing all residents with any MI diagnoses were properly identified and had proper PL1's completed. The Traveling MDS Nurse said the facility had residents whose PL1's were not correctly completed and/or coded. The Travelling MDS Nurse said the facility had identified Resident #33 as requiring a new PL1 and a Form 1012 to identify she was not eligible for PASRR services because of her primary dementia diagnosis. The Travelling MDS Nurse said the Form 1012 was a state form which identified residents with MI who had a primary diagnosis of dementia and not eligible for MDS services. The MDS Nurse said Resident #33 Form 1012 required a physician's signature to validate the primary dementia diagnosis. The MDS Nurse said Resident #33 required a new PL1 and Form 1012 because the one on file was inaccurate. The MDS nurse said there had been no adverse results because Resident #33 would not have been eligible for PASRR services and she was receiving psychiatric care services at the facility. The MDS Nurse said the facility used the RAI requirements for PASRR.

Based on interview and record review the facility failed to indicate accurately in the assessment, the resident's cognitive status for one of nineteen residents (Resident #69) reviewed for assessment accuracy. - The facility failed to accurately document in the assessment of Resident #69's impairments of both lower extremities. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings include: Record review of Resident #69's face sheet dated 5/22/2024 revealed a [AGE] year-old man admitted on [DATE]. The face sheet documented his diagnoses included cerebral infarction (stroke, blood supply to part of the brain is blocked or reduced), malnutrition (condition that results from lack of sufficient nutrients in the body), adjustment disorder ( short term condition arising due to difficulty in managing the stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning), heart failure (progressive heart disease that affects pumping action of the heart muscles), aphasia (comprehension and communication disorder resulting from damage or injury to the specific area in the brain), hemiplegia (one sided-paralysis) and hemiparesis (one-sided muscle weakness), dysphagia (condition with difficulty in swallowing food or liquid), amputation (removal of a limb, completely or partially) of both legs below the knees, dysarthria (difficulty in speech due to weakness of speech muscles) and anarthria (severe form of dysarthria), gastronomy (surgical procedure for inserting a tube through the abdomen wall into the stomach) status, functional quadriplegia (pattern of paralysis from the neck down), polyneuropathy (damage to multiple peripheral nerves), contracture )permanent shortening of muscle, tendon, skin, or other tissue that causes deformity or distortion of a joint) of the left elbow and right hand, tachycardia (heart rhythm disorder with heartbeats faster than usual, greater than 100 beats per minute), and schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #69's quarterly MDS dated [DATE] with an ARD of 5/4/2024 revealed no BIMS was conducted as he was rarely or never understood. The MDS documented he had both long and short-term memory problems, and he was unable to recall the current season, the location of his room, staff names and/or faces, or that he was in a nursing home. Per the MDS, Resident #69 was severely impaired in his ability to make decisions regarding tasks of daily life. The MDS revealed he had an impairment of one upper extremity and one lower extremity, and he did not use any mobility devices. The MDS documented he was totally dependent on staff for all ADL's except eating. Record review of Resident #69's care plan dated 4/1/2024 revealed a focus on his risk of muscle atrophy and muscle spasticity with interventions including passive and/or active range of motion with AM and PM care daily. The care plan documented a focus on his pain and risk of falls related to his amputations. Observation on 5/21/2024 at 9:09 AM revealed Resident #69 was non-responsive to any questions. Resident #69 was lying with the head of the bed elevated. Resident #69 was receiving nutrition via a G-Tube at 55ml/hr. Resident #69 had visible contractions of both hands. Resident #69 was wearing a brace on left hand. Resident #69 had amputations of both legs below the knees. Interview on 5/22/2024 at 3:59 PM with the DON, she said the purpose of the MDS was to accurately assess the residents, inform the care plan, and accurately document any concerns or needs a resident may have. The DON said she was unsure if a resident who was receiving restorative therapy services would have those services documented on the MDS. The DON said a resident who had an amputation of both legs below the knees should have that information accurately documented on the MDS. The DON said Resident #69 had an amputation of both legs below the knees. The DON said the MDS assisted in creation of the care plan for the residents, and if not accurate could lead to inaccurate care plans. Interview on 5/23/2024 at 10:01 AM with the MDS Nurse, she said she had been employed since 2/4/2024. The MDS nurse said she was responsible for completing the MDS assessment for residents correctly. The MDS Nurse said Resident #69's MDS should have clearly documented he had an amputation of both legs, and it did not. The MDS nurse said the Resident #69's MDS noted he had an impairment of one leg only. The MDS nurse said she did not complete Resident #69's quarterly MDS dated [DATE] correctly. The MDS nurse said the incident was an oversight on her part. The MDS nurse said because the MDS was completed incorrectly, Resident #69 would not suffer any consequences as he could not walk. The MDS Nurse said she would be correcting Resident #69's MDS. Record review of the facility's Resident Assessment Policy dated October 2023 revealed a policy statement which read A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MDS) is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. The policy documented that all information in the MDS assessment would reflect resident observations and interviews. Per the policy, the MDS assessments would be used to create the residents' comprehensive care plans.

47722 Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 2 of 18 residents (Resident #67 and Resident #301) reviewed for pharmacy services. -The facility failed to order Resident #67's medication correctly and he was not getting it for 2 days. -MA A applied Resident #301's Lidocaine patch to the right knee instead of the left thigh according to Physician orders and did not remove the previous Lidocaine patch prior to applying the new one. -The Lidocaine patch was on Resident #301 longer than the recommended timeframe as specified by the Manufacturer instructions and MD. This failure could place residents at risk of inadequate therapeutic outcomes and worsened health conditions. Findings included: 1.Record review of Resident #67's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE], with an original date of 5/18/20. He had diagnoses of non-ST elevation myocardial infarction (heart attack), dermatitis (swelling and irritation of the skin), cognitive communication deficit (difficulty with communication that is affected by disruption of cognition), dysphagia (trouble swallowing), hypertrophic disorder of the skin (increased production of dense, tough, hard, scar-like tissue), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), right hand contracture (fingers curl or pull in toward the palm), cerebral infarction (stroke), aphasia (trouble speaking), and hemiplegia/hemiparesis (paralysis and weakness) following stroke on right side. Record review of Resident #67's Annual MDS assessment dated [DATE] revealed a BIMS score that was unable to be determined due to his medical condition. His cognitive skills for daily decision making were moderately impaired. He had impairment on one side of both his upper and lower extremities and used an electric wheelchair. According to the MDS the resident required substantial/max assistance with toileting hygiene, shower/baths, and lower body dressing. Record review of Resident #67's undated care plan revealed a Focus: Resident was at increased risk for tissue death, sores, and poor wound healing secondary to peripheral vascular disease (bad circulation to arms and legs). (Initiated: 5/24/22, Revised: 5/24/22). Goal: Resident would remain free of complications related to PVD through review date (Initiated: 5/24/22, Revised: 5/22/23, Target: 12/19/23). Interventions: Monitored extremities for signs and symptoms of injury, infection, and ulcers. Record review of Resident #67's progress notes revealed a note from LVN D on 5/21/24 at 12:57pm that read, NP [NP B] visited with resident on this shift. New orders received for hydrocortisone cream 0.5% topically to right thigh BID x 7 days. RP [family member] and the ADON notified. Resident presently in electrical wheelchair rolling around. Record review of Resident #67's Physician Orders revealed an order from MD A on 5/21/24 at 12:57pm that read, Hydrocortisone cream OTC 0.5% topical. Apply topically to right thigh BID x 7 days for rash/scratches. Record review of Resident #67's May 2024 MA MAR revealed on 5/21/24 at 4:00pm, MA B documented the hydrocortisone cream was not administered because it was on the Nurse MAR. On 5/22/24 at 7:00am, MA B documented the hydrocortisone cream was not administered because it was on the Nurse MAR. Record review of Resident #67's May 2024 Nurse MAR on 5/22/24, revealed the hydrocortisone cream was not ordered on it. In an observation and interview with Resident #67 on 5/21/24 at 9:49am, the resident was sitting in an electric chair. The resident had aphasia and was unable to speak well but could answer to yes and no questions and could point and use hand gestures. The resident was able to communicate that he had a rash to his right thigh. In an interview with MA B on 5/22/24 at 12:03pm, she said MAs do not give creams and only nurses are able to administer them. She said she marked on the MA MAR not given and that it was on the NMAR, since the nurses had to give it. She said the medication should have been on the Nurse MAR and after she put that she did not administer it, she went and told the nurse so he could add it to his MAR. She said sometimes the doctor would put the order in wrong and put it on the MA MAR not knowing they were unable to give it. She said if it was left that way, the resident would not get their medication. In an interview with LVN N on 5/22/24 at 12:05pm, he said he did not see the order for the hydrocortisone cream on Resident #67's Nurse MAR. He said he had not given the resident any cream that day (5/22/24) and did not know about it. He said the MA was supposed to tell him if there was an order on their MAR that needed to be moved over, so he could switch it over, but no one had told him anything. He said if the order did not get moved over to the Nurse MAR the resident would go without his medicine. He said the person who put the order in was a nurse on the 10pm-2pm shift and she must have made a mistake. In an interview with the DON on 5/22/24 at 4:15pm, she said hydrocortisone cream was given by nurses only. She said if the medication was listed on the MA MAR, she expected the MA to tell the Charge Nurse so they could remove the order from the MA MAR, put it on the Nurse MAR, and correct the order. She said if the medication was on the MA MAR and the med aide did not say anything and kept documenting not given, the resident would not receive their medication. She also said the nurse who entered the order should have known to put it on the Nurse MAR and not the MA MAR. In an interview with Resident #67 on 5/23/24 at 9:07am, he said he received his first dose of the cream to his thigh that morning (5/23/24). 2.Record review of Resident #301's face sheet dated 5/23/24 revealed a [AGE] year-old female readmitted on [DATE]. Her diagnoses included dementia, contracture of the right knee, hemiplegia (paralysis of one side of the body), and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke), and pain. Record review of Resident #301's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #301's care plan dated 4/16/24 revealed she had acute and chronic pain related to multiple disease process, cerebral infarction, contractures, hemiplegia, and hemiparesis and past injuries. The approach was to administer analgesia medication as ordered . Lidocaine patch. Record review of Resident #301's Physician Orders revealed an order for Lidocaine patch 4%, apply to left thigh once a day at 9:00 a.m . special instructions: remove per schedule. Order date 9/29/23. In an observation and interview on 5/22/24 at 9:15 a.m. revealed MA A applied Resident #301's Lidocaine Patch to her right knee. MA A returned to the medication cart and this State Surveyor reviewed the medication orders with MA A. This State Surveyor asked MA A where the patch was applied. MA A returned to Resident #301's room and removed a Lidocaine patch dated 5/21/24 from her left thigh. MA A said he made a mistake and placed it on her knee. He removed the Lidocaine patch from her right knee and applied it to her left thigh. In an observation on 5/22/24 at 9:25 a.m., the Lidocaine 4% box read, .Do not use more than one patch on your body at a time. Use one patch for up to 12 hours . In an interview on 5/22/24 at 9:26 a.m. MA A said he did not check to see if there was an old patch on Resident #301 prior to applying a new one but should have. He said Resident #301 could not wear two Lidocaine patches at the same time because it was like administering the medication twice. He said the evening shift normally removed the patch. He said the Lidocaine patch box said it could be worn up to 12 hours and if a patch was worn longer than 12 hours it may not work. He said he normally reviewed the MAR to ensure he applied the patch to the right place. He said he should have made sure it was placed on the correct leg and the thigh. In an interview on 5/22/24 at 3:58 p.m. the DON said nursing staff should look for and remove an old patch before applying a new one to avoid giving more medication than they were supposed to. She said staff should follow the physician order and check the strength and placement before applying the patch. She said she was unsure of any adverse reactions if placed in the wrong location. She said Lidocaine patches could stay on for 24 hours and it was based on the physician order. She said the patch was to be removed daily. Record review of Resident #301's progress note dated 5/22/24 at 5:58 p.m. written by LVN M read, called physician to get recommendation for removal of lidocaine patch. The physician recommended the patch is to be applied on for 12 hours to resident left thigh and removed for twelve hours . In an interview on 5/23/24 at 9:28 a.m. the DON said MD B clarified Resident #301's Lidocaine patch order to leave the patch on for 12 hours and remove for 12 hours. Record review of the facility's Administering Medications policy dated December 2001 read in part, .Medications shall be administered in a safe and timely manner, and as prescribed . 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication . Record review of the facility's policy and procedure on Administering Medications (Revised April 2019) read in part: Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .Topical medications used in treatments are recorded on the resident's treatment record (TAR) . Record review of the facility's policy and procedure on Medication and Treatment Orders (Revised July 2016) read in part: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order .Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date, and the time of the order .

Based on observations, interviews and record reviews, the facility failed to ensure the resident environment remained free of accidents hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents hazards. The facility failed to ensure that Resident #1, who was a two-person transfer using the mechanical lift . was transferred using the mechanical lift instead of a one-person manual lift. Resident #1 sustained a tibial plateau fracture to the right knee (a break at the top of the shinbone involving the cartilage surface of the knee joint). An Immediate Jeopardy (IJ) was identified on 03/18/2024 at 2:30PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/18/2024 at 2:30PM. While the immediacy was removed on 03/21/2024 at 6:18PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure resulted in Resident #1 sustaining a fracture to the leg and could place other residents at risk of pain, injuries, and hospitalization . Findings included: Record review of Resident #1's electronic face sheet dated 03/16/2024 revealed a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a disease in which the immune system attacks the protective layers of the nerve fibers and causes inflammation and lesion making it difficult for the brain to send signals to the rest of the body); paralysis affecting the right and left side of the body; contractures to the left elbow; muscle contractures to multiple sites; disorders of bone density and structure; vitamin D deficiency; bipolar disorder (mental illness characterized by extreme mood swings); Hypertension (elevated blood pressure); anxiety disorder, dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities) and seizure disorders. Record review of Resident #1's undated admission packet revealed she was originally admitted to the facility on [DATE]. Record review of Resident #1 annual MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. Resident #1 had functional limitation in range of motion and had impairment to the upper and lower extremities. She used a wheelchair for mobility. Resident #1 was dependent on helpers when transferring to and from a bed to a chair. Resident #1 provided none of the effort to complete transfer activity. Record review of Resident #1's undated care plan revealed: Focus - Resident #1 had ADL self-care performance and mobility deficit r/t dementia, multiple sclerosis, limited mobility, limited range of motion. Date initiated was 04/03/2017. Interventions included - resident unable to ambulate with or without assistance, resident requires total assistance by 2 staff for transfers with mechanical lift. Date initiated was 04/13/2017 and revised on 07/26/2022. Focus - Resident #1 was at increased risk for stress fractures, pain, falls, impaired mobility secondary to diagnosis of osteoarthritis (inflammation of one or more joints). Date initiated was 05/02/2022. Record review of Resident #1's undated active physician orders revealed an order for mechanical lift for transfers with 2 staff, every shift with the start date of 01/10/2024. Record review of Resident #1's Hospital Discharge Summary with the encounter start date of 03/14/2024 read in part: .Chief Compplaint, Patient presens with Trample/strike injury, complained of right knee pain during transfer at facility from wheelchair to bed, patient's right knee got twisted . Further review revealed a CT scan (computer processing to create cross-sectional images of the bones) result of an acute tibial fracture to the right knee. Further review revealed the resident also complained of pain to the left lower extremity. An x-ray of the left lower leg showed mild soft tissue swelling around the ankle. Resident #1 was admitted to the hospital on 03/14/2024 then released to the facility on [DATE] with a right knee immobilizer. Record review of Resident #1's progress note dated 03/13/2024 at 10:39 PM, written by LVN A, revealed the resident sustained pain to the right leg and swelling to the knee when she was transferred from the wheelchair to the bed. Her pain level was 7 out of 10 and was administered routine pain medication and Tylenol was ordered at 6:30 PM. Later, her right knee was swelling. The resident complained of pain when the knee was touched. RP and MD were notified. Record review of Resident #1's progress note dated 03/15/2024 at 4:19 PM, written by LVN B revealed the resident returned from the hospital, x-rays were done at the hospital and the resident had a fracture to the right leg below the knee, closed splint in place. Record review of the facility's investigation report revealed CNA B transferred Resident #1 due to not being able to locate the mechanical lift. Further review revealed per LVN A, no one reported any issues with locating the mechanical lifts. Observation and Interview on 03/16/2024 at 11:20 AM, Resident #1 was lying in bed on her back and awake. She had a soft leg splint to the right leg that extended from above the knee to the ankle. Resident #1 stated that on Wednesday 3/13/24 at around 4:15 PM, she was transferred from the motorized wheelchair to the bed by CNA A and CNA B. She stated she was told by the CNAs that they could not find the mechanical lift. Resident #1 stated CNA B kept saying, I can transfer her from the chair, I got this, and CNA A kept saying that it was not the right way to transfer her, but CNA B was saying I got this. Resident #1 stated her feet were still on the footrests of the wheelchair and CNA B transferred her by grabbing and lifting under both arms. Resident #1 said she wore shoes on her feet. Resident #1 stated then her right knee would not move, that was when CNA A moved her right leg off the footrest. Resident #1 stated if her feet were on the floor she could have turned. Resident #1 stated she was supposed to be transferred using only the mechanical lift. She stated she felt pain immediately after she was transferred. She stated CNA A told LVN A about her pain and LVN A gave her pain medication. Resident #1 stated she was sent to the hospital and the doctor told her she had a fracture below the right knee and that she did not need surgery, just a splint. Resident #1 stated she was very angry that this happened. She stated she already had anxieties especially after they dropped her once from the mechanical lift in 2021 and she had to go to the hospital. Resident #1 stated she knows there were more mechanical lifts, but some lifts were not good, they did not turn or go all the way down. Resident #1 currently stated her pain level was 7 out of 10 and that the pain meds she had been receiving had not taken away the pain completely. She stated she may not have the use of her legs, but she could definitely still feel pain. Observation on 03/16/2024 at 1:45 PM revealed there was a mechanical lift being used on a resident on the 200 Hall. Observation and interview on 03/16/2024 at 4:25 PM, the Maintenance Assistant demonstrated that two other mechanical lifts were functioning. The Maintenance Assistant said one was found in the shower room on 500 Hall and the second mechanical was on the 100 Hall. Interview on 03/16/2024 at 4:08 PM, the Maintenance Assistant stated there were 3 working mechanical lifts and 2 that were not working. He stated that on 03/13/2024, he found 5 batteries and only one was not charging. He stated the repair service company was scheduled to come to the facility on [DATE]. Interview on 03/16/2024 at 6:00 PM, the Administrator stated she was in the process of conducting the accident investigation involving Resident #1 and that there were 3 mechanical lifts working and available the day of the incident (3/13/2024). In a telephone interview on 3/17/2024 at 9:42AM, CNA A stated she started her shift at 2:00 PM on 3/13/2024 and Resident #1 was already in her wheelchair. CNA A stated at around 4:30PM Resident #1 wanted to get back into bed as she had been up all day and her brief was wet. So CNA A searched for the mechanical lift. CNA A stated she always used the mechanical lift to transfer Resident #1. CNA A stated she found one, but it did not have a battery, so she decided to transfer another way but needed help. She stated CNA B told Resident #1 that they could not find the mechanical lift and that she would transfer her. CNA A stated Resident #1 said OK but to watch her legs because they were fragile. CNA A said her plan was to back the wheelchair up to the head of the bed and two people would lift/slide the resident onto the bed by using the mechanical lift sling and pad that the resident was sitting on and this was the safe way to transfer. CNA A said she told CNA B about the plan, so she moved to the other side of the bed waiting to grab the sling and pad. CNA A said CNA B said no, she could transfer the resident herself. CNA A stated she tried to help but CNA B kept saying she got this. CNA A stated she saw that the resident's feet were still on the footrest and that was a mistake, her feet should have been on the ground. CNA A said CNA B was fast and grabbed Resident #1 under both arms and as she was moved, Resident #1 started hollering and said ow, ow! Resident #1's legs were caught between the bed and wheelchair. CNA A stated she lifted both legs and pushed the wheelchair out of the way. CNA A said after CNA B put the resident into the bed, she left the room. CNA A stated, as she was changing Resident #1's brief, the resident was mad and told her that CNA A did offer to help CNA B. CNA A stated she notified the nurse who then gave the resident some Tylenol. CNA A stated she checked on Resident #1 later and noticed her right knee was swollen and she notified the nurse. CNA A stated that during her last round for the evening she decided to search again for the mechanical lift and with the help of another staff, she found one in a bathroom that was locked and needed a code to get in. CNA A stated since she started training at the beginning of March 2024, she was told there was only one mechanical lift. CNA A stated she recalled during orientation receiving papers to read and that information about the mechanical lift was included but did not recall if she had one-on-one training. CNA A stated that where she worked before, if the mechanical lift was unavailable, she would transfer using the pads to slide the resident onto the bed. On 03/17/24 at 11:48AM, an attempt was made to contact CNA B via telephone for an interview. Unable to leave a message. In a telephone interview on 3/17/2024 at 11:05AM, LVN A stated that on 03/13/2024 at 6:00 PM, the caregiver notified him that Resident #1 had complaints of pain to her right leg and he went to the resident's room to assess her. LVN A stated the CNA (he did not recall the name of CNA) told him the resident was transferred to the bed and that they carried her because they could not find the mechanical lift. LVN A stated the CNA told him there were 2 CNAs (he did not know the names of the two CNAs) and she wanted to transfer the resident together, but the other CNA did not want to and transferred the resident by herself instead. LVN A stated he asked both the CNAs why they did not tell him, and they did not reply. LVN A stated he gave Resident #1 Tylenol for pain and at 6:30 PM she denied any pain. LVN A stated at 8:00 PM he gave the resident the scheduled Tramadol and resident denied pain. LVN A stated then the CNA notified him that the resident's leg was swollen. LVN A stated the right knee was swollen, and she screamed when he touched the knee. LVN A stated he placed a call out to the MD, notified the family, and the DON. LVN A stated the DON asked what happened and he stated the aides did a manual transfer. LVN A stated Resident #1 was supposed to be transferred using the mechanical lift because she had MS, was immobile, was total dependent care and was only able to talk and eat. LVN A stated he had only known of one mechanical lift that was on 200 Hall because this was what he saw all the time and aides from other halls would come to 200 Hall and take it when needed LVN A stated the CNAs should have reported to him that they could not find the mechanical lift and that if they had, he would have said not to transfer her that he would find another plan to get the resident to bed safely such as call for more staff to help. Interview on 03/18/2024 at 12:18 PM, CNA C stated there had been issues with the mechanical lifts for about 2 weeks and it started before 03/13/2024. CNA C stated the batteries would die, the feet on the mechanical lifts did not work but she understood they were being repaired. CNA C stated it would take her 45 minutes to find a mechanical lift because everyone needed them. Interview on 03/18/2024 at 12:30PM, Resident #1 stated she had never been transferred manually before this incident since she got the motorized wheelchair 4 years ago. Resident #1 stated she had not been evaluated by Therapy for transfers in the past 4 years. Interview on 3/18/24 at 12:45 PM, the DOR stated that Resident #1 had always been a mechanical lift transfer since she was first admitted due to her medical conditions. The DOR stated the resident would often make her own rehab appointments for offsite therapy and that the only evaluations the facility had for Resident #1 was for splints to the elbows. The DOR stated the facility changed from using PCC (healthcare software provider) to Matrix and it was unknown where, if any, therapy evaluations for transfers would be located for Resident #1. Interview on 3/18/24 at 1:00PM, the Administrator stated she could not recall exactly but thought it was about 2 weeks ago when she was made aware there were issues with the mechanical lifts and did not recall who told her about the issues. The Administrator stated it was during a meeting when it was discussed that new mechanical lifts may need to be purchased The and that there were 2 quotes for new mechanical lifts but needed a 3rd quote. The Administrator stated she was also waiting for Corporate to make the decisions on whether to purchase or make repairs. Interview on 3/18/24 at 1:30PM, the Central Supply Coordinator stated she got 2 quotes for mechanical lifts on 2/8/2024 and was asked by Administrator to get a third which she received the quote on 3/18/2024. Interview on 03/20/2024 at 9:30 AM, the DON stated she was notified that Resident #1 had pain to her leg after being transferred. The DON stated CNA B told her that she was asked to assist with the transfer and that both CNA B and CNA A did the transfer. The DON stated that CNA B was not aware of Resident #1's leg pain. The DON stated CNA A told her she could not locate the mechanica lift and that CNA B decided to transfer Resident #1 herself after CNA A told her she was a 2-person transfer. The DON stated the CNAs should have used the mechanical lift per the resident's care plan and that CNA A should have notified the nurse if she could not find the mechanical lift. The DON stated the risk to the resident if not transferred properly was injury, fall and injury to the employee. The DON stated action was taken to suspend CNA A, CNA B and LVN A pending the investigation. Interview on 3/21/2024 at 2:00 PM, the Administrator stated she was getting another quote because the third quote for mechanical lifts came in high and this was part of the delay in decisions regarding the mechanical lifts when the monthly inspections came up. She stated she was not notified of any issues with the mechanical lifts then the incident with Resident #1 happened. The Administrator stated the incident involving Resident #1 had less to do with the mechanical lifts but more to do with the CNA who did the manual transfer. The Administrator stated she would terminate CNA B. Record review of the facility's mechanical lift service invoice dated 2/21/24 revealed there were 5 of 5 mechanical lifts that were inspected. Two of the 5 mechanical lifts required repairs. Record review of the facility's policy and procedure for Safe Lifting and Movement of Residents, revised on July 2017, read in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation, 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible .8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged . Record review of the facility policy and procedure for Activities of Daily Living, Supporting, revised March 2018, read in part: .Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. mobility (transfer and ambulation, including walking) . On 03/18/2204 at 2:30 PM, an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested ant the time. The following Plan of Removal submitted by the facility was accepted on 3/19/2024 at 6:00 PM. Immediate interventions: Plan of Removal: All direct care nursing staff will be in-serviced on the following- o DON and designees In-serviced direct care clinical staff on Mechanical Lift Transfers (Who requires ML, how many staff assistance is needed, how to use the ML, Resident Profiles to determine residents needs POC), Mechanical Lift Location/Passcodes for shower rooms where/battery stations are located (where to locate and store ML when not in use, where the charging stations are located, the passcodes to shower rooms where charger stations are located). Completion Date: 3/19/2024 o DON and designees audited employee roster to ensure 100% of direct care clinical staff are in serviced regarding Hoyer Transfers, Hoyer Location, Passcodes for shower rooms where battery stations are located. Completion Date: 3/19/2024 o DON and designees in-serviced regarding Abuse/Neglect/Exploitation/Reporting to the Abuse Coordinator (What is abuse, who to report to, reporting immediately), Resident Rights (Review of resident rights), Maintenance Binder to log areas of concerns prompting follow-up (Where binder is located, how to complete log for all issues). Completion Date: 3/19/2024 o DON and designees audited employee roster to ensure 100% of staff are in-serviced regarding Abuse/Neglect/Exploitation and the Reporting of to the Abuse Coordinator, Resident Rights, Maintenance Binder to log areas of concerns prompting follow-up. 3/19/2024 o DON and Designee completed competencies for all direct care clinical staff through Skills Check-Off for Mechanical Lifts. Completion Date: 3/19/2024 o DON and Designee audited employee roster to ensure 100% of direct care clinical staff complete Skills Check-Off for Mechanical Lifts. Completion Date: 3/19/2024 o Administrator/Designee conducted an assessment of working Mechanical Lifts (3 Mechanical Lifts) and total number of residents requiring Mechanical Lift (48 residents) to determine sufficient amount of equipment. Completion Date: 3/19/2024 o Administrator/designee audited and serviced all Mechanical lifts to ensure sufficient number of Mechanical Lifts (3 working Mechanical Lifts) are available. Completion Date: 3/19/2024. o Through observations nurses validated CNAs are utilizing Mechanical Lifts for all residents requiring Mechanical Lifts for transfers. Completion 3/19/2024. o Acknowledgement sheets signed by all direct care staff acknowledging their understanding of the importance of and expectations of how to identify and utilize resident's requiring mechanical lifts, how to use the mechanical lifts, where the mechanical lifts are located, how to charge a mechanical lift, what the codes are for each Shower room, and how and where to report concerns surrounding Mechanical Lifts maintenance issues. Completion Date: 3/19/2024 Demonstration of and acknowledgement that all direct care nursing staff are aware of the above- o DON/ DON Designee will contact all direct care nursing staff to obtain signature and return demonstration on site or via Facetime with demonstration and acknowledgment, however, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by DON/DON Designee to serve as a return demonstration of understanding that- o they are aware of how to identify and utilize resident's requiring mecq.anical lifts, how to use the mechanical lifts, where the mechanical lifts are located, how to charge a mechanical lift, what the codes are for each Shower room, and how and where to report concerns surrounding Mechanical Lifts maintenance issues. Completion Date: 3/19/2024 o DON/ DON Designee will remove all direct care staff from schedules and will not be allowed to provide direct resident care until all training has been completed. Items discussed were: IJ (Immediate Jeopardy) was cited on 3/18/2024 as evidenced by facility's failure to: F689 Free of Accident Hazard/Supervision The facility failed to use the mechanical lift device as determined necessary by physician orders during a transfer from Resident #1's wheelchair to the bed resulting in the resident sustaining a fracture to the right tibia below the knee requiring hospitalization . Training for all direct care nursing staff will include: o In-serviced all direct care clinical staff on Hoyer Transfers, Hoyer Location, Passcodes for shower rooms where battery stations are located and Maintenance Logs. o All direct care clinical staff are in-serviced regarding Hoyer Transfers, Hoyer Location, Passcodes for shower rooms where battery stations are located. o All direct care clinical staff complete Skills Check-Off for Mechanical Lifts. o DON/designee will randomly observe direct care nursing staff demonstrate how to locate and utilize the Mechanical Lift. o All direct care nursing staff were contacted in person or by phone and verbally in-serviced. o All direct care nursing staff in-services will be completed by 2pm 03/19/2024. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. Monitoring of the POR included the following: On 03/20/2024 at 8:45 AM to 3:00 PM and on 03/21/2024 at 11:30 AM to 5:30 PM, observations were made, records were reviewed, and direct care nursing staff were interviewed. During an observation on 03/21/2024 at 1:00 PM, there was a mechanical lift at the end of 300 Hall, a second at the end of 500 Hall and a third at the end of 100 Hall. Battery charging stations were located at all shower rooms in the 100 Hall, 300 Hall, 400 Hall and 500 Hall. There was no battery charging station at the 200 Hall shower room. Observed the codes to the shower rooms were on the doors to the shower rooms. During an observation on 03/21/2024 at 1:30 PM in the 100 Hall, CNA D and CNA E were using a mechanical lift to transfer a resident from the wheelchair to the bed without any issues. During an observation on 03/21/2024 at 5:15 PM, the Maintenance Logbook was located at the nurse station. Direct care nursing staff who worked days, evenings and night shift were interviewed. A total of 15 nursing staff were interviewed: 1 RN, 4 LVNs and 10 CNAs. Nurses and CNAs were able to verbalize their understanding on the use of Mechanical lifts and that 2 staff members were required to operate the lift when transferring. Nursing staff were able to explain where to find the Resident Profiles to determine residents needs on the plan of care. Nursing staff stated they knew there were at least 3 mechanical lifts were functioning and available and that they were stored in the back of each hall. Nursing staff stated they knew the battery charging stations were currently in hall shower rooms. Nursing staff stated they knew the codes to the shower rooms were written on the doors and that the other charging boxes were being repaired. The Nursing staff were able to verbalize their understanding of what to do if the mechanical lifts needed repair and to log the work order promptly into the Maintenance Logbook which was located at the nursing station. The Nursing staff were able to state the inservices for mechanical lift transfers, abuse and neglect, resident rights, abuse reporting procedures were conducted over the last few days and that the mechanical lift inservice was conducted by the DOR and Nurses. The nursing staff were able to state the inservices consisted of verbal, written, and demonstrations with return demonstrations for mechanical lift transfers and manual transfers. On 03/21/2024 at 4:00 PM the DOR stated in person demonstrations and return demonstrations on the use of mechanical lifts and manual transfers were conducted with staff on site. The DOR started the nurse would be able to observe the halls and see when the CNAs were bringing the mechanical lifts into resident rooms. On 03/21/2024 at 4:15 PM the DON stated staff who worked PRN or worked infrequently were inserviced via facetime and videos and were sent inservices and quizzes. The DON stated upon their return to work they would conduct the one-on-one trainings. The staff would double sign by their names when completed. The DON stated if staff were on leave or were absent during the inservices that they would have to do the skills check list before they would be put on the schedule. The DON stated there were currently 4 staff members out on leave. On 03/21/2024 at 4:25 PM The Administrator stated 24 of the 48 residents rarely got out of bed or preferred to remain in bed. The Administrator stated when the Mechanical Lift Assessment Analysis was conducted, the use of mechanical lifts was observed and timed and that was how she knew it would take 15 minutes to transfer a resident. The Administrator stated with the calculation it was determined that 3 mechanical lifts would be enough. On 03/21/2024 at 5:15 PM, LVN C stated he ensures CNAs on his hall were up to date on the residents transfer type needs by communicating with them frequently and throughout the shift. Record review of the undated Mechanical Lift Assessment Analysis revealed it would take 15 minutes to transfer a resident and with 48 residents and 3 mechanical lifts, it would take 4 hours' time to transfer all residents who required the use of a mechanical lift. In an 8-hour shift there would be ample time with 3 mechanical lifts. Record review of the inservice records for Mechanical Lift use, location, passcodes, Resident profiles, Maintenance logbook, Abuse/Neglect/Exploitation, Reporting to the Abuse Coordinator, Resident Rights and skills competency check lists for mechanical lifts were completed by 03/19/2024 and were signed by the staff. Record review of a service invoice dated 3/21/2024 reflected one of the mechanical lifts was removed with plans to be replaced, two other lifts had parts replaced and one mechanical lift had parts that were on order. The 5th and last mechanical lift did not indicate any repairs were needed per the invoice. Record review of the facility's Employee Counseling Report for CNA B dated 03/20/2024 and completed by the Administrator, read in part: .incident description: Improper transfer: Employee did not transfer resident's per resident's care plan . Record review of the sign in sheet, signed by department heads reflected an IDT meeting was held for the IJ F689 on date 03/19/2024. The Administrator was informed the immediate Jeopardy was removed on 03/21/2024 at 6:18 PM. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated with serious injury due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure the nursing staff were licensed for 1 of 10 staff (LVN A) reviewed for competencies. The facility failed to ensure LVN A's license was valid in order to practice as a licensed vocational nurse. This failure could place residents at the facility at risk of not receiving care and services from staff who are properly trained. The findings included: Record review of the current employee roster, provided by the facility via email on [DATE], revealed LVN A, as an LVN, was hired on the date [DATE]. Record review of the employee file for LVN A, revealed that LVN A had an LVN license that expired on [DATE]. Record review of the website on [DATE] https://txbn.boardsofnursing.org/licenselookup revealed that LVN A was listed on the board of nursing as having delinquent license status and an expired license as of [DATE]. In an interview on [DATE] at 6:20 PM, the Administrator stated when the incident on [DATE] occurred, that was when the facility did the audit of licenses and discovered LVN A's expired license. The Administrator stated, at the time of the audit, LVN A told her that he was having issues renewing online. In an interview on [DATE] at 11:05 AM, LVN A stated he had been working full time at the facility for 6 months during the 2:00PM to 10:00PM shift. LVN A stated he was aware his LVN license expired on [DATE] and usually renewed it online. LVN A stated the Texas Board of Nursing changed the online system and when he renewed through the portal, he did not receive an email to proceed. LVN A stated he called the Board of Nursing several times and did not reach anyone. LVN A stated he had to leave the country d/t an emergency from [DATE] to [DATE]. LVN A stated at the beginning of [DATE], he called the Board of Nursing and got someone on the phone and was told his account was blocked and required resetting. LVN A stated he notified the HR Manager last week (week of [DATE]) and he was given the rest of the week to complete the CEUs. LVN A stated he was currently working on the 20 hours of continuing education before proceeding to upload the credits to renew his license. LVN A stated he was working as an LVN at the facility after his license expired. LVN A stated he did administer medications and performed all other LVN tasks. LVN A stated he was not aware he could not work until the DON told him that he could not work with an expired license. During a telephone interview on [DATE] at 4:45 PM, the Texas Board of Nursing stated they had some issues with nurses renewing licenses online d/t operating with incompatible browsers or devices, not typing information correctly or high volumes of submissions. The Texas Board of Nursing stated when that happens the nurses would call for assistance and it would get resolved. The Texas Board of Nursing stated nurses were not required to submit CEUs to renew unless they were being audited or the license was in a delinquent status. The telephone call took a total of 4 minutes including the one-minute wait in the cue. In an interview on [DATE] at 10:49 AM, the DON stated HR would run reports on Licenses and would then send these reports to her. She denied receiving any reports regarding LVN A's license. The DON stated a valid license would indicate that the nurse was trained to practice as a LVN. In an interview on [DATE] at 12:35 PM, the HR Manager stated she started working at the facility on [DATE]. The HR Manager stated Licenses were checked on a monthly schedule and she did the audit last week because she knew some of the CNA licenses were coming up on renewal. The HR Manager stated she was made aware of LVN A's expired license on [DATE] when LVN A's license was audited. The HR Manager stated she did not know when the last time the licenses were audited because she did not start until [DATE]. The HR Manager stated she was aware LVN A was out of the country and that it was not necessary for him to have been at the facility to renew his license. The HR Manager stated that it was important to have a valid nurse license to make sure the staff remained in compliance to provide nursing care to the residents. In an interview on [DATE] at 4:48 PM, the Administrator stated she did not know when licenses were audited prior to the HR Manager. The Administrator stated the Corporate HR staff worked for a month as interim and may know when they were audited last. The Administrator stated it was the responsibility of the staff to ensure their licenses were renewed on time. The Administrator stated the nurses needed a valid license to practice and to be able to provide care to the residents within the nursing scope of practice. The Administrator stated LVN A would be referred to the board of nursing. On [DATE] at 3:10 PM, a call was made to the Corporate HR staff. A message was left to return the Surveyor's call and the Surveyor's state cell number was included. There was no returned call by the time of exit. Record review of the facility's policy for Licensure, certification, and Registration of Personnel, revised in [DATE] read in part: .Employees who require license, certification, or registration to perform their duties must present such verification with their application for employment 3. A copy of recertifications (e.g., annual, b-annual, etc., as applicable) must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certificate, and /or registration. A copy of the recertification must be filed in the employee's personnel record Record review of the facility's policy for Credentialing of Nursing Service Personnel, revised in [DATE], read in part: .Policy Interpretation and Implementation .6. Should the investigation reveal the applicant does not hold a valid license or certification, appropriate state licensing boards and authorities will be notified of the applicant's attempt to practice without a license/certification . Record review of the facility's policy for Licensure or Certification, revised on [DATE] read in part: .You are responsible for providing active, clear, and current license or certification as a condition of employment for certain positions, including but not limited to Licensed Administrator, RN, LPN, CNA Renewal requirements are the employee's responsibility. Failure to provide and maintained an active license in required positions will result in being removed from the schedule and disciplinary action up to and including termination of employment

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 1 resident (Resident #4) reviewed for basic life support, including CPR. -The facility failed to retrieve the automatic external defibrillator (AED) and initiate the basic life support sequence of events (chest compressions, airway, breathing) per the facility's Emergency Procedure- Cardiopulmonary Resuscitation Policy (CPR) for Resident #4. On [DATE] at 2:00 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:12 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place all residents who requested a full code status at risk of not receiving necessary life-saving measures, declining health, and death. Findings include: Record review of Resident#4's face sheet dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE] and readmitted from the hospital on [DATE]. The face sheet listed relevant diagnoses which included: Acute and Chronic Respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Hemiplegia (paralysis on one side of the body) following stroke (damage to brain from interruption of blood supply), Presence of a Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), Atrial Fibrillation (condition in which the heart's upper chambers beat chaotically and irregularly), and Hypertension (elevated blood pressure). Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of4, indicating severe cognitive impairment. Record review of Acknowledgement of Advance Care Planning dated [DATE] revealed Resident [#4] was full code status. Record review of Care Plan (undated) revealed: . [Resident #4] was full code [[DATE]] . Approach: Ensure order entered under advanced directive; Discuss code status and options with resident and family members at routine intervals as needed; Monitor for changes in condition and status and promptly report to MD . Emergency transport to hospital as indicated; Have crash cart ready; If resident found without a pulse, have someone call 911, send other nursing staff to assist with code, send crash cart to location of code, and notify the MD and the DON or designee of code being performed. Record review of vitals [last documented]: [DATE] [7:11 am] Pulse: 81 [DATE] [7:11 am] BP: ,d+[DATE] mmHg [DATE] [9:03 am] Respiration: 18 per minute [DATE] [9:03 am] Oxygen Saturation: 92% Record review of progress note dated [DATE] [9:10am] by LVN K revealed that Resident #4 was nonresponsive with oxygen saturation of 82%. The resident did not respond to sternal rub. Portable oxygen tank was brought into the room and patient placed on non-rebreather mask at 15 liters. 911 notified. The MD notified and the RP contacted. Floor nurse [LVN K] remained with resident until 911 arrived. Eyes fluttered. Record review of progress note dated [DATE] [9:18 am] by LVN K revealed 911 here. Patient unable to arouse. CPR initiated by 911 staff. Floor nurse notified (family member) of what's going on. Patient FULL CODE. Record review of EMS Unit Incident Details revealed the call to 911 was received on [DATE] at 9:11 am. EMS arrived to the facility at 9:30am and arrived to the patient [Resident #4] at 9:32 am. EMS left the facility at 9:56 am and arrived at the hospital at 10:08am. The Clinical Info Narrative section revealed: [Resident #4} was found by nurse lying in bed unresponsive and contacted for EMS assistance. [EMS] arrived to find pt unresponsive with absent pulses and absent respirations and no bystander CPR. Pt was moved to the floor and AED protocol administered, I-gel (a medical devices that facilitate oxygenation and ventilation without endotracheal intubation) was established and CPR administered . Pt [Resident #4] was transported to hospital and transferred to ER nurse and pronounced dead. The Special Circumstances revealed date and time of cardiac arrest: [DATE] at 9:06 am. Arrest witnessed by: Other Healthcare Provider. AED use Prior to EMS arrival: Yes, without defibrillation. First monitored Arrest Rhythm of Patient: Unknown AED Shockable Rhythm, Date and Time Last Known Well: [DATE] at 9:03am. Any return of spontaneous circulation: No, Who Initiated CPR: HFD First Responder . Who first applied the AED: HFD First Responder (Eng/Lad). [Resident #4 Pronounced Dead in ED ]. Record review of Hospital ED report revealed CPR in progress upon arrival [[DATE] at 10:08am]. Patient sent from nursing facility, found by nursing staff unresponsive without oxygen. No bystander CPR. EMS unit began CPR at 9:08am. 7 shocks 3 epi (drug used to reverse cardiac arrest) given by EMS. Time of death called at 10:21 am. Record review of Resident #4's certificate of death dated [DATE] revealed immediate cause of death was complications from chronic respiratory failure. Interview on [DATE] at 8:22 am with LVN K, she said she came to check on the resident around 9am on [DATE]. He had been having breathing difficulty that morning, and she said she and an aide were doing 15-minute rounds [no documentation]. She said around 9:00 am, Resident #4 just started to look unwell, and she called 911. She said oxygen levels decreased to 82%. She said resident's doctor and RP was notified. She said Resident #4 was still responsive with a pulse at this time, so she did not initiate CPR. She said EMS arrived in approximately ,d+[DATE] minutes. LVN K said she was unsure exactly of when Resident #4's vitals started to decline, but it happened between the time she called 911 and when they arrived. She said that Resident #4 was a large man and she and an aide were in the process of getting him to the floor when EMS arrived. She said that EMS immediately took over upon arrival and started CPR . Observed on [DATE] at 1:05 pm, the facility crash cart and AED machine located near the nursing station, adjacent to the dining room. Observed no back board on the crash cart, however, the DON found it between the wall and a different cart parked adjacent to the crash cart [not immediately visible]. Interview on [DATE] at 1:12 pm with LVN K, she said she called EMS because he just did not look good, however, Resident #4 did have a pulse which was why CPR was not initiated at that moment. She said she does not know when he ceased to have a pulse. She said she and CNA H were preparing to lower Resident #4 to the floor in case they had to do CPR. She said by the time they had gotten him down; EMS came in and took over. They immediately started CPR. She said CPR could not be done in the bed because it was not a firm surface . Interview on [DATE] at 1:23 pm with CNA H, she said that on [DATE] she witnessed LVN K frequently checking on Resident #4 through the morning. She said around 9am, LVN K called the ambulance for Resident #4 because he was not looking too good. CNA H said the paramedics arrived quickly. She said Resident #4 was a big man, and it took her and LVN K about 10 minutes to lower the bed and get the resident down to the floor in preparation to begin CPR. She said by the time he was down, the paramedics had already arrived and they took over. CNA H said that she could not say anything about Resident #4's vitals at the time because she did not recall. She said the resident had an air mattress which was why CPR could not be done in the bed. She said she was not familiar with a backboard and did not know the facility had one . Interview on [DATE] at 12:13pm with the DON, she said when a resident codes, whoever was with the resident should call for help and stay with the resident. If the resident was a full code, the resident should be placed on a hard, flat surface while someone else brings the crash cart and AED. Once on, the AED would give instructions and staff would continue CPR until there was a pulse, or 911 arrived, or if the doctor called it and says to stop. She said if the resident was in bed they should be placed on a hard, flat surface. The policy did not specify surface type. She said if the resident were of large stature and in bed, then the resident should have been placed on a backboard. She said failure to implement basic life saving measures could possibly cause harm or death. Interview on [DATE] at 1:03pm with MD Z, he said he was unaware that Resident #4 was having difficulty with his oxygen levels the morning of [DATE]. He said the only call that he remembered from nursing staff was to tell him that they had to call 911 for Resident #4. He said CPR was appropriate if the resident was unresponsive and had no pulse. He was not aware of who implemented CPR for Resident #4. He said he could not say whether or not CPR would have made a difference for Resident #4, but failure to provide CPR in a timely manner could increase likelihood of death. MD Z said the resident has had similar episodes before, a week prior in fact, for which he was sent out to the hospital and returned to the facility. He said that he cannot say what happened differently that lead to Resident #4's death because it could have been that his heart gave out. Interview on [DATE] at 1:40 pm with the Administrator, she said that she started at the facility on [DATE] and had no prior knowledge of the circumstances surrounding the death of Resident #4. She said her expectation would be for nursing staff to, at minimum, document by exception meaning that anything that was outside of a resident's normal should be documented and physician notified. She said if a resident was found unresponsive and without a pulse, a code should be called, and basic life saving measures implemented if the resident was full code. The Administrator said that she spoke to LVN K who told her that she did not start CPR because Resident #4 had a pulse, but there was no documentation, nor could the nurse say when the resident transitioned. She said failure to initiate CPR in a timely manner could be detrimental to the resident. Record review of Emergency Procedure- Cardiopulmonary Resuscitation (2018) revealed: . 6. If the individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR immediately unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or . b. there are obvious signs of irreversible death (e.g., rigor mortis) Record review of Automatic External Defibrillator, Use and Care of Policy (2015) revealed: . 3. The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AE) is part of the CPR/BLS training .4. In general, sudden cardiac arrest should be suspected if: a. the victim's symptoms appeared very suddenly; b. he or she is unresponsive; c. his or her breathing has stopped . 5. If an individual is found unconscious and SCA is suspected, begin the AED protocol . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:00 pm. The Administrator, the DON, the Assisting Administrator, and the CNC were notified. The Administrator was provided with the IJ template via email on [DATE] at 2:17 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:55 pm: The Texas Department of Health and Human Services entered Windsor Houston on [DATE], for a follow up on a Complaint Survey on a P1 that initiated on [DATE]. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F678 as stated below- In-which resident #4 was transferred from facility to ER via EMS where he expired. Immediate Interventions: Plan of Removal: F678 All direct care nursing staff and those with CPR certifications will be in-serviced on the following- The expectation for all direct care nursing staff is to identify and utilize the crash cart, backboard, AED, how to perform CPR and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare . In serviced all floor nurses, administrative nurses, CNAs, CMAs, PTs, OTs, and STs on ensuring the resident is on a hard surface if and when CPR is initiated. If the resident is on an air mattress, the air mattress is to be deflated with backboard in place beneath the resident unless the resident is able to be safely be transferred to the floor. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse. Specifically, to locate the code status binder, which is accessible by all direct care nursing staff and indirect care staff in the facility. All direct care nursing staff will demonstrate and acknowledge how to access code status in Matrix. The employee will log into MatrixCare, select resident, d then search resident by name, resident facesheet, resident identifiers and banners, and resident code status. To validate DNR status, the employee will select resident documents, advance directives tab, and look for the advance directive. The DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The training regarding identification and utilization of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare will be an ongoing continuous training to be conducted quarterly with first training completed [DATE]. Training will also be included in new hire process for all direct care nursing staff and staff with CPR certification which will include a skills competency. The DON/ADON or Designees during morning start-up will ensure that the backboard is with the crash cart and during the weekends and holidays a designee will ensure that the backboard is with the crash cart. (Backboard is now attached to the crash cart). ,d+[DATE] hall nurses will do walking rounds, each shift (6am-2pm, 2pm-10pm, 10pm-6am), to ensure the backboard is in place prior to shift hand-off and will witness on change of shift log that backboard is in place. Nursing to notify the DON for all change of conditions along with MD/RPs. The facility DON/ADON/Designee notified all direct care nursing staff of facility's policies regarding AED, CPR, emergency nursing response, notifications, reporting, and abuse and neglect. The training confirmations will be stored with their employee file in the Human Resources department. On [DATE], the Director of Nursing initiated an addendum to the original in-service initiated on [DATE] to include visual aids and questions to assist staff with identification of the location of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive without a pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. This is to include all direct care nursing staff and those with CPR certifications to cover the topics of: Importance of/and expectation that all licensed nursing staff and those with CPR certifications will demonstrate and acknowledge that they are aware of where to locate the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The DON/DON Designee will contact all direct care nursing staff and those with CPR certificate to obtain signature on site or via Facetime with return demonstration and acknowledgment signed off on prior to start of next shift. However, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by the DON/DON Designee to serve as a understanding of what the expectations are for all floor nurses, administrative nurses, CNAs, CMAs, PTs, OTs, and STs to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. F678-Effective [DATE] the DON/ADON/designee will randomly observe direct care nursing staff demonstrate how to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. All direct care nursing staff and those with CPR certifications were contacted in person or by phone and verbally in-serviced. All direct care nursing staff and those with CPR certifications in-services will be completed by 10:30AM [DATE]. All direct care nursing staff and those with CPR certifications will be made aware and provided with a copy of the facility's policies regarding AED, CPR, emergency nursing response, notifications, and reporting, and abuse and neglect. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. This will be reviewed monthly in QAPI until compliance is met. Monitoring: Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Record review of in-service trainings provided to direct care staff (licensed nurses) and other facility staff in contact with residents as part of the Plan of Removal. The following policies and protocols were reviewed: CPR on soft surfaces; Emergency Cart Checklist; AED, CPR, SBAR, Documentation, Notifying the MD, the RP, the DON, and the Admin; Stop & Watch, Abuse, Neglect, Exploitation, and Residents' Rights, Matrixcare Information, Mock Demonstration of Code Blue (CPR); Vital Signs return demonstration; CPR, Crash cart/Backboard. Interviewed 10 nurses across the three shifts who were able to verbally demonstrate knowledge gained from in-services. Interviewed 7 CNAs, 2 housekeepers, and 1 therapist who were able to verbally demonstrate knowledge gained from in-services. The Administrator, assisting Administrator, DON, and CNC were informed the Immediate Jeopardy was removed on [DATE] at 6:17 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record reviews, the facility failed to consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #4) of 5 residents reviewed for resident rights. -The facility failed to notify and document notification of physician when LVN K rounded on Resident #4 and found oxygen saturation to be 85%. On [DATE] at 2:00 p.m an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:17 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk for receiving inadequate or untimely care. Findings include: Record review of Resident#4's face sheet dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE] and readmitted from the hospital on [DATE]. The face sheet listed relevant diagnoses which included: Acute and Chronic Respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Hemiplegia (paralysis on one side of the body) following stroke (damage to brain from interruption of blood supply), Presence of a Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), Atrial Fibrillation (condition in which the heart's upper chambers beat chaotically and irregularly), and Hypertension (elevated blood pressure). Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of 4, indicating severe cognitive impairment. Record review of Acknowledgement of Advance Care Planning dated [DATE] revealed Resident [#4] was full code status. Record review of Care Plan (undated) read in part .[Resident #4] was full code [[DATE]] . Approach: Monitor for changes in condition and status and promptly report to the MD . [Resident #4] was on oxygen therapy related to shortness of breath, dyspnea, and heart failure ,,, Goal: [Resident #4] will have no signs and symptoms of poor oxygen absorption through the review period . Approach: Monitor, document, and report signs and symptoms of respiratory distress such as; (r)espirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapse of part or all of lung), hemoptysis (coughing up blood), cough, accessory muscle usage, and skin color . Record review of vitals [last documented]: [DATE] [7:11 am] Pulse: 81 [DATE] [7:11 am] BP: ,d+[DATE] mmHg [DATE] [9:03 am] Respiration: 18 per minute [DATE] [9:03 am] Oxygen Saturation: 92% Record review of progress note dated [DATE] [6:20 am] revealed: Upon nursing rounds patient noted with abnormal breathing. Checked sats at this time and noted to be 85%. NC in place, no kinks observed, O2 water bottle, and NC replaced. Patient repositioned, HOB elevated. Floor nurse at bedside monitoring O2 level. Level up to 92% with O2 at this time. Patient breathing pattern stabilized. Call light in reach, bed in low position. CNA staff informed by floor nurse to monitor/check on patient regularly. Will continue to monitor. Interview on [DATE] at 12:13pm with the DON , she said a change in condition is a change from resident's normal or baseline. She said nurses are expected to report changes in condition to the primary provider (doctor) in case the doctor would need to make changes to an order or has another recommendation. She said failure to notify can cause a delay or inadequate treatment . Interview on [DATE] at 1:03pm with MD Z, he said he was unaware that Resident #4 was having difficulty with his oxygen levels the morning of [DATE]. He said the only call that he remembered from nursing staff was to tell him that they had to call 911 for Resident #4 . Interview with LVN K on [DATE] at 1:12 pm, she said she never had a set % oxygen saturation level to which she was instructed to call the doctor if it reached that level. She said the morning of [DATE], she was in and out of the room every 15 minutes checking on the resident after his morning episode of low oxygen. She said she could not recall whether or not she called the doctor to notify him of resident's low oxygen experienced that morning [[DATE] at 6:20am Oxygen sat 85%]. She said she called EMS around 9:00 am because he just didn't look good, and she contacted the resident's doctor, and RP at that time. She said the doctor should be notified of change in conditions so they know what it is happening and can adjust treatment or make a recommendation. She said in this instance, she was closely monitoring the resident and the resident seemed to be doing okay . Interview on [DATE] at 1:40 pm with the Administrator, she said that she started at the facility on [DATE] and had no prior knowledge of the circumstances surrounding the death of Resident #4. She said her expectation would be for nursing staff to, at minimum, document by exception meaning that anything that is outside of a resident's normal should be documented and the physician notified. She said the failure to notify physician of change in condition can result in the resident not getting the appropriate care and possible decline. Record review of Change in Resident's Condition or Status Policy (2021) revealed: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition . i. specific instruction to notify the physician of changes in the resident's condition . 2. A significant change of condition is a major decline or improvement in the resident's status that: . q. will not normally resolve itself without intervention by staff . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR communication Form. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:00 pm The Administrator, the DON, the Assisting Administrator, and the CNC were notified. The administrator was provided with the IJ template via email on [DATE] at 2:17 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:55 pm: The Texas Department of Health and Human Services entered Windsor Houston on [DATE], for a follow up on a Complaint Survey on a P1 that initiated on [DATE]. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F580 as stated below: In-which resident #4 was transferred from facility to ER via EMS where he expired. Plan of Removal: F580 All direct care nursing staff will be in-serviced on the following- The expectation for all direct care nursing staff is to identify and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator. The facility DON/ADON/Designee notified all direct care nursing staff of facility's policies regarding notifications, change of condition, reporting, and abuse and neglect. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify a change of condition, how to complete an SBAR, and how to initiate the proper notifications. Specifically, where to locate the resident's medical history, to ensure they are capturing and can identify a change of condition to then have the proper documentation, and notifications in place. To access the employee will log into MatrixCare, select resident, then search resident by name, then select resident progress notes, residents face sheet for medical diagnosis, residents care plan, residents' orders, resident's vitals, and resident's observations/events, and residents' orders, to ensure the nursing staff member is familiar with the resident's baseline and level of care. The DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding documentation, notifications, change in condition, and abuse and neglect. The training regarding identification of change of conditions and proper notifications will be an ongoing continuous training to be conducted quarterly with the first training completed [DATE]. Training will also be included in the new hire process for all direct care nursing staff which will include a skills competency. The DON/ADON during morning start-up will ensure that all change of conditions are captured with an SBAR along with the proper notifications. The training confirmations will be stored with their employee file in the Human Resources department. This is to include all direct care nursing staff and those with CPR certifications to cover the topics of: Importance of/and expectation that all licensed nursing staff will identify, and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator promptly. The DON/ DON Designee will contact all direct care nursing staff to obtain signatures on site or via Facetime with acknowledgment, however, if unable to obtain face to face a verbal acknowledgement will be obtained along with 2 signatures by the DON/DON Designee to serve as an understanding of what the expectation is for all direct care nursing staff to identify and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator promptly. On [DATE], the facility Administrator and the Director of Nursing notified Medical Director via phone. Items discussed were: IJ (Immediate Jeopardy) was cited on [DATE] as evidenced by facility's failure to: F580- Effective [DATE] the DON/ ADON/ designee will randomly observe direct care nursing staff demonstrate how to identify change of condition and when to do the proper notifications to the MD, the RP, the DON, and the Administrator. The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to identify a change of condition and when to do the proper notifications to the MD, the RP, the DON, and the Administrator. All direct care nursing staff were contacted in person or by phone and verbally in-serviced. All direct care nursing staff in-services will be completed by 10:30AM on [DATE]. All direct care nursing staff will be made aware and provided with a copy of the facility's policies regarding change of condition, notifications, reporting, and abuse and neglect. The DON/ADON/designee completed a 100% audit of all Change of Conditions since [DATE] to ensure that the MD/RP was notified and documentation was in the resident's medical records . Monitoring: Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Record review of in-service trainings provided to direct care staff (licensed nurses) and other facility staff in contact with residents as part of the Plan of Removal. The following policies and protocols were reviewed: CPR on soft surfaces; Emergency Cart Checklist; AED, CPR, SBAR, Documentation, Notifying the MD, the RP, the DON, and the Admin; Stop & Watch, Abuse, Neglect, Exploitation, and Residents' Rights, Matrixcare Information, Mock Demonstration of Code Blue (CPR); Vital Signs return demonstration; CPR, Crash cart/Backboard. Interviewed 10 nurses across the three shifts who were able to verbally demonstrate knowledge gained from in-services. Interviewed 7 CNAs, 2 housekeepers, and 1 therapist who were able to verbally demonstrate knowledge gained from in-services. The Administrator, assisting Administrator, DON, and CNC were informed the Immediate Jeopardy was removed on [DATE] at 6:17 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate threat and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 2 out of 12 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. -The facility failed to ensure Resident #1 and Resident #2 had a code status that was care planned. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. Findings included: Resident #1 Record review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE], with diagnoses of respiratory failure (not having enough oxygen), cognitive communication deficit (trouble communicating), muscle wasting and atrophy, shortness of breath, high blood pressure, and chronic obstructive pulmonary disease (chronic lung disease that makes it hard to breathe). Her face sheet said Full Code. Record review of Resident #1's Admission MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated moderate impairment of cognition. She required substantial/max assistance with toileting, showers/baths, upper/lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder and used a walker for mobility. Record review of Resident #1's undated care plan with a revision date of [DATE], did not have a code status care planned. Record review of Resident #1's Physician Orders revealed an order for Code Status: Full Code, ordered on [DATE] at 8:20 pm by MD A. Record review of the facility's Code Book kept on the crash cart on [DATE] at 1:55 pm, revealed Resident #1's code status was correct in the book. Resident #2 Record review of Resident #2's undated face sheet revealed he was an [AGE] year old male admitted on [DATE] with diagnoses of congestive heart failure (heart is unable to pump fluid out of lungs), type 2 diabetes (body does not produce insulin or is resistant to it), dementia, high blood pressure, myocardial infarction (heart attack), atherosclerotic heart disease (plaque in the arteries of the heart), and lack of coordination. The face sheet said Full Code. Record review of Resident #2's Admission MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. The resident was substantial/mas assist with toileting, showers/baths, lower body dressing, and putting on/taking off footwear. He was always incontinent of bowel and bladder and used a wheelchair. Record review of Resident #2's undated care plan with a revision date of [DATE], did not have a code status care planned. Record review of Resident #2's Physician Orders revealed an order for Code Status: Full Code, ordered on [DATE] at 1:07 am by MD B. Record review of the facility's Code Book kept on the crash cart on [DATE] at 1:55 pm, revealed Resident #2's code status was correct in the book. Interview with the ADON on [DATE] at 3:35 pm, she said one of the most important things to have on a care plan was the resident's code status because staff needed to know what the resident wanted if something happened to them. She said if the care plan did not have the code status the facility could perform the wrong code and get in trouble if it was not what the resident wished for. She said they had a code book on the crash cart that staff usually looked at though in an emergency. She said she was the one in charge of updating the code book from the physician orders in the chart. Interview with LVN A on [DATE] at 3:53 pm, she said the code status was the most important thing to have on a care plan. She said it could affect the resident because if they were a Do Not Resuscitate (DNR) and staff performed CPR the facility would be in trouble. She said the nurses were the ones who updated the care plans with the code status when the resident was admitted to the facility. Interview with the DON on [DATE] at 4:15 pm, she said the nurses were the ones who updated the code status on the care plans when the resident arrived at the facility. She said the MDS Nurse also updated some of the care plans, but mainly the nurse updated the code status. She was not sure why the code statuses were not updated. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised [DATE]) read in part: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment .and no more than 21 days after admission .The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 2 out of 12 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. -The facility failed to ensure Resident #1 and Resident #2 had a code status that was care planned. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. Findings included: Resident #1 Record review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE], with diagnoses of respiratory failure (not having enough oxygen), cognitive communication deficit (trouble communicating), muscle wasting and atrophy, shortness of breath, high blood pressure, and chronic obstructive pulmonary disease (chronic lung disease that makes it hard to breathe). Her face sheet said Full Code. Record review of Resident #1's admission MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated moderate impairment of cognition. She required substantial/max assistance with toileting, showers/baths, upper/lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder and used a walker for mobility. Record review of Resident #1's undated care plan with a revision date of [DATE], did not have a code status care planned. Record review of Resident #1's Physician Orders revealed an order for Code Status: Full Code, ordered on [DATE] at 8:20 pm by MD A. Record review of the facility's Code Book kept on the crash cart on [DATE] at 1:55 pm, revealed Resident #1's code status was correct in the book. Resident #2 Record review of Resident #2's undated face sheet revealed he was an [AGE] year old male admitted on [DATE] with diagnoses of congestive heart failure (heart is unable to pump fluid out of lungs), type 2 diabetes (body does not produce insulin or is resistant to it), dementia, high blood pressure, myocardial infarction (heart attack), atherosclerotic heart disease (plaque in the arteries of the heart), and lack of coordination. The face sheet said Full Code. Record review of Resident #2's admission MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. The resident was substantial/mas assist with toileting, showers/baths, lower body dressing, and putting on/taking off footwear. He was always incontinent of bowel and bladder and used a wheelchair. Record review of Resident #2's undated care plan with a revision date of [DATE], did not have a code status care planned. Record review of Resident #2's Physician Orders revealed an order for Code Status: Full Code, ordered on [DATE] at 1:07 am by MD B. Record review of the facility's Code Book kept on the crash cart on [DATE] at 1:55 pm, revealed Resident #2's code status was correct in the book. Interview with the ADON on [DATE] at 3:35 pm, she said one of the most important things to have on a care plan was the resident's code status because staff needed to know what the resident wanted if something happened to them. She said if the care plan did not have the code status the facility could perform the wrong code and get in trouble if it was not what the resident wished for. She said they had a code book on the crash cart that staff usually looked at though in an emergency. She said she was the one in charge of updating the code book from the physician orders in the chart. Interview with LVN A on [DATE] at 3:53 pm, she said the code status was the most important thing to have on a care plan. She said it could affect the resident because if they were a Do Not Resuscitate (DNR) and staff performed CPR the facility would be in trouble. She said the nurses were the ones who updated the care plans with the code status when the resident was admitted to the facility. Interview with the DON on [DATE] at 4:15 pm, she said the nurses were the ones who updated the code status on the care plans when the resident arrived at the facility. She said the MDS Nurse also updated some of the care plans, but mainly the nurse updated the code status. She was not sure why the code statuses were not updated. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised [DATE]) read in part: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment .and no more than 21 days after admission .The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . .

Based on observation, interview and record review the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and received the necessary treatment and services, to promote healing, prevent infection for 3 of 5 residents (Resident #93, #64, and #34) reviewed for pressure ulcer. -The facility failed to ensure that Resident #93 received adequate pain management medications, and failed to halt a treatment for [REDACTED]. -The facility failed to implement effective interventions to prevent the deterioration of Resident #93's coccyx pressure ulcer/injuries to a Stage IV ulcer that needed multiple debridement and the resident developed osteo[DIAGNOSES REDACTED] (infection in the bone). -The facility staff failed to assess and report Resident #64's Deep Tissue Injury (DTI) to the right heel and a wound to the mid back right side below the shoulder blade to the residents' doctor for treatment -The facility staff failed to follow Resident #64's physician order [REDACTED]. -The facility staff failed to observe, assess, and report Resident #34's DTI to the right heel to the doctor for treatment. These failures resulted in an immediate jeopardy on 10/1/20. While the IJ was lowered on 10/5/20 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures could affect all residents with pressure wounds/ulcers and placed them at risk of pressure sores. Findings included: Resident #93 Record review of the admission sheet for Resident #93 revealed she was a [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #93's comprehensive MDS assessment dated [DATE] revealed a BIMS of 7 out of 15 indicating severely impaired cognition. She required extensive assistance from staff for dressing, toilet use, personal hygiene, and was incontinent of bowel and bladder. Section M (skin conditions) revealed that the resident had 1 stage III pressure ulcer. Record review of Resident #93's Care Plan dated 8/24/2018 and revised on 8/28/2020 read in part . Focus: Resident #93 has stage 3 ulcer of coccyx r/t immobility and noncompliance . Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date . Interventions/Tasks: follow facility policies/protocols for the prevention/treatment of [REDACTED]. Document alternative methods. Teach resident/family the importance of changing positions for preventing of pressure ulcers. Encourage small frequent position changes . Record review of Resident #93's Care Plan dated 9/2/2020 read in part . Focus: The resident has stage 3 pressure ulcer of coccyx r/t decline in mobility, [MEDICAL CONDITION], incontinent status, and non-complaint with adl care . Goal: the resident stage 3 pressure ulcer to coccyx will continue to show improvement in healing with continuing decreases in length and width through next review . Interventions/Tasks: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of [REDACTED]. to MD . Record review of Resident #93's Care Plan dated 9/15/2020 read in part . Focus: The resident has infection of stage 3 coccyx wound r/t resident refusal adl and wound treatment . Goal: The resident will be free from complication related to infection through the review date . Interventions/Tasks: Administer antibiotic as per MD orders. Monitor and document pain and signs and symptoms of pain medicate for pain prior to wound care treatment . Observation on 9/30/20 at 9:25 a.m. revealed the Wound Care Nurse performing wound care on Resident #93 assisted by CNA Z. Prior to start of the treatment, Resident #93 denied having pain. Observation of the residents back revealed there was no dressing. Observation at that time, revealed a stage 4 pressure ulcer to the sacral/coccyx area approximately 10 cm in diameter. The Wound Care Nurse cleaned the center of the wound and the resident cried out in pain. The Wound Care Nurse cleaned the perimeter of the wound and the resident yelled. The Wound Care Nurse did not ask the resident if she was in pain and continued with the treatment. When the Wound Care Nurse dried the area with a dry 4 x 4-inch gauze, the resident cried out in pain . The nurse said, I am almost done. The nurse then removed her soiled gloves and went to wash her hands and donned new gloves. The Wound Care Nurse said the resident had received her routine medication and PRN Tylenol for her break through pain. The Wound Care Nurse continued the wound care treatment. The resident was seen flinching when the Wound Care Nurse applied the Santyl, [MEDICATION NAME] and the Calcium Alginate to the wound. The resident yelled out in pain when the dry dressing was applied. When the resident was asked if she was in pain she said yes. The Wound Care Nurse said, I will call her doctor to get something stronger to manage her pain. Record review of Resident #93's Nursing - Braden scale for predicting pressure sore risk dated 8/14/20 read in part . Category: AT RISK Score: 15. 1. SENSORY PERCEPTION - No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 2. MOISTURE - Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift. 3. ACTIVITY - Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 4. MOBILITY - Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 5. NUTRITION - Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs. 6. FRICTION & SHEAR - Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 7. SCORING- AT RISK 15-18 . (Braden scale the higher the score, the greater the risk). Record review of Resident #93's ADMISSION/WEEKLY SKIN INTEGRITY ASSESSMENT (WH) dated 8/14/20 written by the Wound Care Nurse read in part . A. SKIN CONCERNS IDENTIFIED #1 - OLD OPEN AREA. Coccyx stage III length 1.2, width 1.2, depth 0.9 . Record review of Resident #93's Laboratory results collected 9/21/20 and approved 9/24/20 read in part . Test final site: coccyx bone. Culture Result: ISOLATE: Moderate Growth of proteus mirabilis isolated . (infective organism in the wound) Record review of Resident #93's Dietary Notes dated 9/29/2020 read in part . Wt loss 9.4% x 3 mo (16.2#), 11.6% x 6 mo (20.6#). Poor intake continues. Staff says sometimes Res drinks sodas before meals. Poor intake of <25% q meal, per task report. HX: Says she only eating mashed potatoes off plate some days. H/o snacks in room and family used to bring in outside food. H/o being a picky eater. Stage III to Coccyx. Inadequate PO intake AEB poor intake report, low [MEDICATION NAME] of 2.5, and wt loss. Increased nutrient needs r/t skin breakdown AEB Stage III to Coccyx. Rec SF Med Pass 120cc TID. Rec liquid protein 30cc QD x 30 days. Rec 220 mg Zinc QD x 14 days. Rec restart Vit C BID x 30 days . Record review of Resident #93's Wound Care Progress Note dated 8/10/20 read in part: .Location: coccyx. Date Acquired: 12/3/2018. Acquired at the Facility: Yes. Wound condition: Chronic. Wound status: Not Healed. Wound Measurements: Length: (cm) 1.2, Width: (cm) 1.2, depth: (cm) 0.8. Wound progress: Deteriorating. Stage: Stage 3 pressure injury. Debridement performed for Assessment: Wound #1 coccyx. Debridement: surgical. Level: Skin/Subcutaneous Tissue/Muscle/Fascia/Bone. Post Debridement Measurement: Length: (cm) 1.2, Width: (cm) 1.2, depth: (cm) 0.9 . Record review of Resident #93's Wound Care Progress Note dated 9/21/20 read in part . Location: Wound is located on coccyx. Duration: 7/3/20. Plan of care discussed with facility staff - will submit bone fragments from wound to the facility's lab for culture and MLD pathology for evaluation of osteo[DIAGNOSES REDACTED] (infection in the bone). Wound Measurements: Length: (cm) 8, Width: (cm) 11, depth: (cm) 2.8. Wound progress: Deteriorating. Stage: Stage 4 pressure injury. Debridement performed for Assessment: Wound #1 coccyx. Debridement: surgical. Level: Skin/Subcutaneous Tissue/Muscle/Fascia/Bone . Post Debridement Measurement: Length: (cm) 8, Width: (cm) 11, depth: (cm) 2.8 . Record review of Resident #93's Wound Care Progress Note dated 9/28/20 read in part: . Location: Wound is located on coccyx. Date Acquired: 12/3/2018. Acquired at the Facility: Yes. Wound condition: Chronic. Wound status: Not Healed. Wound Measurement: Length: (cm) 7.5, Width: (cm) 10, depth: (cm) 2.5. Wound progress: No change. Stage: Stage 4 pressure injury. Review of systems: Nutrition: poor appetite. Labs: pathology of sacral bone on 9/21/20=acute osteo[DIAGNOSES REDACTED], culture of sacral bone 9/21/20=proteus mirabilis. Plan of care discussed with facility staff- on [MEDICATION NAME] and meropenern until 11/6/20 for sacral osteo[DIAGNOSES REDACTED]. Debridement performed for Assessment: Wound #1 coccyx. Debridement: surgical. Level: Skin/Subcutaneous Tissue/Muscle/Fascia/Bone. Post Debridement Measurement: Length: (cm) 7.5, Width: (cm) 10, depth: (cm) 2.5 . Record review of Resident #93's physician's orders [REDACTED]. Record review of Resident #93's Nurse Note dated 10/1/2020 12:53 p.m. written by ADON A read in part . At approximately 1120 I was called by the Wound Care Nurse to assess patient. When arrived patient was lethargy. Bp 142/92 HR 154 resp 22 Sat 82%. Patient was immediately placed on a nonrebreather to improve saturation and reduced workload of the heart. 911 was immediately called physician notified. Since patient was DNR a call was placed to RP. Writer was instructed to transfer patient to the hospital. Patient was transported to local hospital for further evaluation . Interview on 9/30/20 at 9:00 a.m. with the Wound Care Nurse, she said Resident #93 had a stage 3 facility acquired pressure ulcer that had opened up. She said the wound was now a stage 4 with osteo[DIAGNOSES REDACTED] (infection in the bone). She said Wound Care Doctor came to the facility on ce a week and had to debride the wound a couple of times. Interview on 9/30/30 at 9:40 a.m. with the Wound Care Nurse, she said she saw there was no dressing on the wound on the residents back and it was open to air. She said CNA D was her assistant who helped prep the resident prior to wound care and she might have removed it while she was cleaning the resident. Interview on 9/30/20 at 9:54 a.m. with CNA D and the Wound Care Nurse, CNA D said she recently started as a Wound Care Nurse assistant. She said she assisted by prepping the resident prior to wound care and provided incontinent care if needed. CNA D said when she removed Resident #93's brief there was no dressing on the wound. The resident was clean and dry. Interview on 9/30/20 at 10:10 a.m. with CNA KK, she said she and CNA DD provided incontinent care earlier this morning to Resident #93. She said she did not recall seeing a dressing on the resident. CNA DD said she recalled seeing a dressing. CNA DD said when they checked on the resident two hours later, the resident was dry and they did not remove the brief but repositioned the resident. CNA DD said the resident would complain of pain while the CNAs provided incontinent care or repositioned her. She said Resident #93 was alert and verbal when you asked her where the pain was located, and she would say her buttock hurts. CNA DD said she notified the resident's nurse. Interview on 9/30/20 at 10:16 a.m. with LVN L, she said Wound Care Nurse was responsible to provide wound care but nurses could do PRN dressing changes. She said nobody notified her this morning that Resident #93's wound dressing was missing. Interview on 9/30/30 at 3:43 p.m. with the DON, he said the wound care assistant also said there was no dressing on the residents back when she prepped the resident for wound care. The DON said the wound should have been covered with a dressing as it was a risk for infections. He said the CNAs were aware that they needed to notify the nurse if a dressing was missing or soiled. In a telephone interview on 10/01/20 at 12:18 p.m. with the Wound Care Doctor, he said he came to the facility every week. He said Resident #93 had pressure related wound. He had debrided the wound, and it deteriorated to a stage 4 with confirmed osteo[DIAGNOSES REDACTED] (infection in the bone). He said she was a little bit resistant to care. He said she would disagree with some of the things that they would try to do such as turning to dress the wound, but was not sure why. He said Resident #93 thought that they were doing something that would not help. He said Resident #93 had a low pain tolerance, maybe because of anxiety or pain, and she would claim that she had pain. She had prn medication and they would give it to her before the wound care. He said he would have to take a look at anxiety medication if she had any ordered. He said when he debrided her, if in pain, he would give her more medication. He said she verbalized disagreement. He said his comments concerning the rope alginate vs dressing - he said rope would fill in the wound better, help with healing, and it would conform to the wound more. He said he had not heard that his orders were not carried out by the facility. He said he had been following the Wound Care Nurse, and he noticed that the wounds were getting worse at the facility. Interview on 10/01/20 at 3:12 p.m. with the DON, he said wound care meetings were held weekly to discuss wounds and weights. He said each person involved in the meeting would do an IDT note which were documented on the patients' nurses notes. He said he does not necessarily go with the Wound Care Doctor on his weekly rounds. He said wounds were discussed in the IDT meeting for Resident #93, it was a combination of things like hospice and nutrition. The resident was refusing care and to eat. She refused just because she did not want it. He said they had speech look at her, but there were no issues. She is alert and oriented. He said if there was no dressing on the wound the CNAs should call the Nurse on the floor or the Wound Care Nurse. So, the nurse can assess. He said there should be a focused skin assessment. There should be a note with an assessment. He said there were a few causes of residents wound deterioration or increase in number of pressure ulcers in the facility such as not turning and repositioning, not getting up, and because of COVID there were a lot of changes. He said, we kind of expected the wounds to increase. The residents were more of social eaters and that activity decreased. There were a lot of factors. He said they tried to increase the repositioning. Supplements were increased and as far as interventions, it would depend on the patient. He said for Resident #93, she was refusing care, the interventions were in place, but she was not accepting them. He said when resident refuses every intervention they would include psych services. He said he was not sure if Resident #93's was receiving psych services. He said Resident #93's wounds were unavoidable. He said for about 4 to 6 weeks she was not eating. A record review by the DON of Resident #93's weights showed stable weights. He said Resident #93 would refuse all treatment, to swallowing pills, dressing changes, and assessments. When asked if Tylenol 500 mg was sufficient to manage stage 4 pressure ulcer with osteo[DIAGNOSES REDACTED] (infection in the bone). The DON said pain was subjective and that depended on the person. He said Resident #93 was not complaining of pain prior to the wound care observation by the surveyor. He said Resident #93 was able to push her call light. He said she has never told him that she had complaints of pain before. He said she has been declining and the last time he saw her was the beginning of last week. He said she did not verbalize anything to him. He said he talked to her last Wednesday before she was started on an antibiotic for osteo[DIAGNOSES REDACTED] (infection in the bone). He said he gets a weekly measurement of the wounds. He said they look at the wound reports as a team to discuss measurements and interventions. Interview on 10/1/20 at 3:40 p.m. with the Administrator, she said she participated in the wound monitoring. She said we know that with everything that happened this year with the COVID Pandemic. We see our patients stay in bed and they don't leave their beds. We identified pressure wounds in our QAPI. We tried to increase supplements. Therapy was helping to get them more mobile. We know that they did not have the motivations to get out like they used to. We go over the Casper report to see where we were at in relation to other facilities. The IDT group has met, and we tried to look at the cause, repositioning and what could be causing the wounds. Therapy was a big intervention we put in place. Repositioning was also a constant topic we discussed with the staff. Also, working with the dietician to look at diets. She said the last time she talked to Wound Care Doctor she told him to let her know of any concerns. She said the Medical Director was made aware of concerns and asked if family could help. She said her expectation from staff was to notify the Wound Care Doctor in a timely manner, as soon as of any new wounds were identified. Interview on 10/2/20 at 12:15 p.m. with the Admissions Coordinator, he said he called the hospital to inquire about Resident 93's medical update. He said Resident #93 had an admitting [DIAGNOSES REDACTED]. Resident #64 Record review of Resident #64's face sheet dated 10/1/20 revealed she was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #64's quarterly MDS dated [DATE] revealed a BIMS score of 3 of 15, indicating severely impaired cognition. She needed extensive assistance of 1-2 staff for bed mobility, transfers, eating, personal hygiene, was incontinent of bowel, and had an indwelling catheter. Her skin condition was documented as at risk for developing pressure ulcers and she had one stage 3 and one stage 4 pressure ulcer. The interventions included a pressure reducing device for bed, nutrition, and/or hydration. Record review of Resident #64's care plan read in part . ADL self-care deficit, revised 7/31/20 . Interventions: The resident requires 1 staff to turn and reposition in bed often every shift and as necessary . The resident requires 1 staff for toileting. She is often incontinent, and staff must ensure peri area is clean and dry . Stage 4 left buttocks pressure ulcer and stage 3 pressure of sacral, revised 9/9/20 . Interventions: administer treatments as ordered and monitor for effectiveness. Follow facility policies/ protocols for the prevention/ treatment of [REDACTED]. Administer treatments as ordered and monitor for effectiveness. Assess/ record/ monitor wound healing. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD . At risk for skin breakdown, revised 5/5/20 . Interventions: Keep skin clean and dry. Monitor/ document location, size and treatment of [REDACTED]. to MD. Use caution during transfers and bed mobility . Interview on 9/30/20 at 11:56 a.m. with the Wound Care Nurse, she said Resident #64 initially developed a facility acquired wound on 7/13/20 to the sacral area. She said Resident #64 was discharged to the hospital on [DATE] and returned on 9/7/20 with 2 additional wounds. She said the resident's large sacral wound was now healed in the middle and identified as two wounds - a stage 4 wound to her left buttocks and a stage 3 to her sacral area. The Wound Care Nurse said those were the only 2 identified wounds on Resident #64 now. Record review of Resident #64's Wound Care Physician note dated 9/28/20 read in part . Culture of sacral wound was completed on 8/23/20 and positive for E.coli. Stage 4 pressure injury to the left buttocks measured 3.6 x 4 x 1 cm. Left buttocks wound order to cleanse wound with normal saline, apply Santyl, apply alginate - use rope, cover wound with dry absorptive dressing, and change dressing daily. Stage 3 pressure injury to the sacral measuring 2.6 x 2.3 x0.2 cm. Stage 3 sacral wound order to cleanse wound with normal saline, apply alginate, cover wound with dry absorptive dressing, and change daily. Record review of Resident #64's Treatment Administration Record dated September, 2020 read in part . Left buttock wound stage 4 - cleanse with wound cleanser/ normal saline pat dry, apply santyl with alginate and cover with adhesive patch daily and prn . start date 9/9/20 . cleanse sacral stage 3 with wound cleanser/ normal saline pat dry, apply Santyl with alginate and cover with adhesive patch daily and prn . start date 9/9/20 . Pressure reducing mattress . start date 9/7/20 . Observation and Interview on 9/30/20 at 12:13 p.m. with the Wound Care Nurse as she did a head to toe assessment on Resident #64. During the assessment the Wound Care Nurse identified a new area on the right heel that was darker in color and non-blanchable. She said it looked like a deep tissue injury. She saw the resident had a dressing on her right middle back area below the shoulder blade without date/time/initials. The Wound Care Nurse removed the dressing and revealed a blood tinged open area approximately 1 x 1 cm. She said she did the Resident #64's treatment to her left buttocks and sacrum yesterday and did not see any further skin concerns. She said she was not aware of the open area to the resident's back or the dark area to heel. She removed the dressing to the resident's left buttocks/sacral area that revealed a left buttock tunneling stage 4 wound and a sacral area stage 3 wound. Approximately two inches below the resident's left buttocks wound, there was two small open abrasions. The Wound Care Nurse identified the 2 new areas and said it was probably related to the adhesive dressing. The Wound Care Nurse performed wound care to the resident's left buttocks and sacral area. She applied Santyl onto a tongue depressor and applied the ointment into the resident's left buttocks wound. Then she used a new tongue depressor and applied Santyl to her sacral wound and the 2 areas below the left buttocks. She opened an alginate pad and placed it on top of the left buttocks and an alginate pad over the sacral wound then covered it with an adhesive dressing. Interview on 9/30/20 following Resident #64's skin assessment and wound care by the Wound Care Nurse. She said she notified the physician about the new skin concern to the resident's right back and right heel. She said the physician gave new orders for Collagen to the back and heel wounds and cover with adhesive dressing. She said she had not reviewed the wound care physician notes from 9/28/20 and was not aware of any order to use rope to the buttocks wound for Resident #64's buttocks wound. She said it was her job to do a skin assessment on Resident #64. The Wound Care Nurse said Resident #64 had a skin assessment weekly, but she said she did not do a skin assessment last week. Interview on 10/1/20 at 2:30 p.m. with ADON A, she said if a CNA identified a new skin concern on a resident they would notify the nurse. She said the nurse would report to the DON and Wound Care Nurse and document it in an incident report. She said the Wound Care Nurse was responsible for doing weekly skin assessments. Interview on 9/30/20 at 1:55 p.m. with the DON, he said the Wound Care Nurse him of Resident #64's wounds to her right back and right heel earlier that day. He said he was not aware of any new changes to Resident #64's skin on her buttocks area. The DON said if a resident had a new wound or change in condition related to skin he expected the floor nurse or CNA to report the concern to him and the Wound Care Nurse Nurse immediately. He said it was the facility policy if a dressing was applied that it also needed to be dated and initialed by the staff who applied the dressing. He said he was not sure who placed the dressing to Resident #64's back. He said, I am trying to identify who changed the dressing with the no date or initials. He said he had not laid eyes on the new wounds. The DON said he expected the Wound Care Nurse to review the Wound Care Physician orders [REDACTED]. Further interview with the DON, he said a weekly skin report form reviewing the resident's skin condition including stage of wound, facility or community acquired, site, previous week dimensions, and current week dimensions. He said the facility administration staff met weekly and discussed the weekly skin report. He said the information was given to him from the wound care physician notes and the treatment care nurse notes. He said he does not necessarily go with the Wound Care Doctor on his weekly rounds. Interview on 10/1/20 at 2:55 p.m. with RN A, the floor nurse for Resident #64. She said she did not know about a dressing to Resident #64's back. She said the Wound Care Nurse had not mentioned a new wound on the resident. Interview on 10/1/20 at 3:09 p.m. with the Wound Care Nurse, she said she had not talked to the doctor about Resident #64's 2 small abrasions below the left buttocks wound. She said she used the same treatment as the left buttocks and sacral area and covered it with an adhesive dressing. Weekly skin assessments for Resident #64 revealed: -9/8/20 new open stage 3 sacrum ulcer 4.2 x 1.8 x 0.3 cm and old stage 4 left buttock pressure ulcer 5 x 4.5 x 3.5 cm. - 9/17/20 stage 3 sacral ulcer 2.8 x 2.5 x0.2 cm with alginate as treatment and stage 4 left buttock measures 3.5 x 4.2 x 1.3 cm with Santyl/ alginate as treatment. -9/24/20 Stage 3 pressure ulcer 2.6 x 2.3 x 0.2cm and stage 4 left buttocks 3.6 x 4.4 x 1.2 cm. Record review of Resident #64's IDT Progress Note dated 9/18/20 at 2:25 p.m. read in part . IDT met and reviewed right stage 4 pressure ulcer to left buttock . treatment Santyl, [MEDICATION NAME] and alginate with adhesive patch covering daily and prn. Wound noted with moderate drainage with slough 1-25% and granulation tissue at 51-70%. Stage 3 pressure ulcer to sacral . treatment alginate and adhesive patch as treatment daily and prn .There are facility protocol in place to promote wound healing and prevent further breakdown of skin which includes pressure reducing mattress, nutrition supplement, weekly wound rounds with wound physician, daily wound care treatment, turning and repositioning per facility protocol . Record review of Resident #64's clinical file revealed no documentation, notes, or orders about the open area to the right mid back below the shoulder blade and right heel color change for the resident. Resident #34 Record review of Resident #34's face sheet dated 10//1/20 revealed she was a [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #34's comprehensive MDS assessment dated [DATE] revealed a BIMS of 6 of 15 indicating severely impaired cognition. She required extensive assistance or total dependence from staff for dressing, toilet use, personal hygiene, and was incontinent of bowel and bladder. Section M revealed that the resident was at risk for developing pressure ulcers/injuries, and had no ulcers at the time of this assessment. Record review of Resident #34's care plan read in part . ADL self-care deficit, revised 2/28/19 . Interventions: The resident requires 1-2 staff to turn and reposition in bed frequently and as necessary . Resident #34 has contractures of the left arm. Provide skin care every shift and as needed to keep clean and prevent skin breakdown. The resident requires extensive to total assistance by 1-2 staff with personal hygiene and oral care . Potential for pressure ulcer development related to dehydration, immobility secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION], revised 3/11/20 . Interventions: Follow facility policies/ protocols for the prevention/ treatment of [REDACTED]. Weekly treatment documentation to include measurements of each area of skin breakdown . Observation and Interview with ADON B and ADON D on 9/30/20 at 3:07 p.m., as they performed a skin assessment on Resident #34. They identified a new change in color to the resident's right heel that appeared to be a DTI. Resident #34 denied pain when the nurse touched the area around the right heel. The resident's right heel had a reddened area covering most of her heel. The nurses documented the skin condition on an admission/readmission skin audit. ADON B said she would notify the Wound Care Nurse and the DON regarding Resident #34's right heel. ADON B also said she would document the skin change in the resident's record. Record review of Resident #34's progress note written by the Wound Care Nurse dated 8/3/20 at 10:37 a.m. indicated right heel wound healed and treatment had been discontinued. Record review of the admission/weekly skin integrity review dated 9/18/20 at 10:21 a.m. by the Wound Care Nurse revealed Resident #34's skin was intact. Record review revealed no further skin assessments or documentation related to a change in skin condition for Resident #34 before the observation with the ADONs. Record review of facility's Preventing of Pressure Ulcers/Injuries policy (Revised January 2020) read in part: . Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resid (TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #93) of 5 residents reviewed for pain management. -The facility staff failed stop a wound care treatment and provide Resident #93 with pain reduction care when the resident cried and yelled out from the pain she experienced during the wound care treatment. This failure placed all residents who received pain medications at risk for unmanaged pain during treatments. Findings included: Resident #93 Record review of the admission sheet for Resident #93 revealed she was [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #93 [DIAGNOSES REDACTED]. Record Review of Resident #93's comprehensive MDS assessment dated [DATE] revealed a BIMS of 7 of 15 indicating severely impaired cognition. She required extensive assistance from staff for dressing, toilet use, personal hygiene, and was incontinent of bowel and bladder. Section M revealed that the resident had 1 stage III pressure ulcer. Section J revealed the resident had a scheduled pain medication regimen. The MDS revealed Resident #93 did not receive PRN pain medication or was offered pain medication and declined it. The resident did not receive non-medication intervention for pain. The question Should pain assessment interview be conducted? was coded yes. Record review of Resident #93's care plan dated 2/6/2017 and revised on 2/12/2017, no more current care plan for pain available for review, read in part . Focus: Resident #93 experience occasional pain r/t [MEDICAL CONDITION], contracture to right elbow arthritis to knee, and chest pain. Goal: Resident #93 will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions/Tasks: administer Ben Gay for right knee pain as indicated. Administer prn [MEDICATION NAME] for chest pain as indicated. Administer routine [MEDICATION NAME] as ordered by physician for dx [MEDICAL CONDITION]. Monitor/document side effects and effectiveness Q-SHIFT. Administer Tylenol extra strength for pain as indicated. Monitor for increased risk for falls. Monitor/document/report PRN adverse reactions to [MEDICATION NAME] therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, [MEDICAL CONDITION] . Record review of the care plan sated 8/24/2018 and revised on 9/15/2020 read in part . Focus: Resident #93 has stage 3 ulcer of coccyx r/t immobility and noncompliance. Goal: blank Interventions/Tasks: Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort . Record review of Resident #93's physician's orders [REDACTED].Tylenol extra strength tablet 500 mg ([MEDICATION NAME]) give 2 tablets by mouth two times a day related to PAIN, UNSPECIFIED (R52) [MEDICATION NAME] WARNING: DO NOT EXCEED 3 GM (3,000MG) OF [MEDICATION NAME] TOTAL FROM ALL SOURCES IN 24HR PERIOD . with the discontinued date of 9/30/2020. Record review of Resident #93's physician's orders [REDACTED]. to monitor for pain: assess resident for s/s of pain. If symptoms are present, refer to interventions and/or medicate appropriately. Interventions: 1) Environmental adjustment 2) Repositioning 3) Hot/cold packs 4) Massage 5) Music therapy 6) Toileting 7) Food/snacks one time a day for Pain monitoring related to pressure ulcer for sacral region, stage 3 . Record review of Resident #93's physician's orders [REDACTED].Tylenol extra strength tablet 500 mg ([MEDICATION NAME]) give 2 tablets by mouth every 8 hours as needed for related to PAIN, UNSPECIFIED (R52) ACETAMIOPHEN WARNING: DO NOT EXCEED 3GM (3,000MG) OF [MEDICATION NAME] TOTAL FROM ALL SOURCES IN 24HR PERIOD .) with the discontinued date of 9/30/2020. Observation and Interview on 9/28/20 at 2:30 p.m. with Resident #93, the resident was on her right side facing the door when this surveyor entered room. The resident said, my butt hurts and was encouraged to use the call-light button to get help. The resident held on to the call light cord clipped to her blanket but did not press the button. This surveyor pressed the call-light for the resident and after a couple of minutes, LVN N came in the room to answer the light. LVN N turned off the light and asked the resident if she needed anything to which the resident responded, my butt hurts. LVN N said, I will let the medication aide know. The LVN told this surveyor that she just started her shift and was in the middle of making her rounds. Record review of Resident #93's MAR for the month of September 2020 revealed the resident received PRN Tylenol tablet 500 mg ([MEDICATION NAME]) 2 tablets on 9/28/20 at 2:40 p.m Record review of Resident #93's Nurses Notes for September 2020 revealed there was no documentation that the resident was receiving medication or non-pharmacological intervention for pain prior to wound care daily or that the physician was contacted to address pain management for the resident. Record review of Resident #93's physician's orders [REDACTED]. Record review of Resident #93's MAR for the month of September 2020 revealed the resident received PRN Tylenol tablet 500 mg ([MEDICATION NAME]) 2 tablets on 9/30/20 at 8:30 a.m. Interview on 9/30/20 at 9:00 a.m. with Treatment Nurse, she said she wanted to do wound care on Resident #93, but the resident said she was in pain. She said she asked her nurse to give her some PRN pain medication. Observation on 9/30/20 at 9:25 a.m. revealed the Treatment Nurse performing wound care on Resident #93 assisted by CNA D. Prior to start of the treatment, Resident #93 denied having pain. Resident #93 was assisted onto her right side revealing there was no dressing on the resident's back. Observation revealed a stage 4 pressure ulcer to the sacral/coccyx area approximately 10 cm in diameter. The Treatment nurse cleaned the center of the wound and the resident cried out in pain. The Treatment nurse cleaned the perimeter of the wound and the resident yelled again. The Treatment nurse did not ask the resident if she was in pain and continued with the treatment. When the Treatment nurse dried the area with a dry 4 x 4-inch gauze, the resident cried out in pain. The nurse said, I am almost done. The nurse then removed her soiled gloves and went to go wash her hands and donned new gloves. The Treatment nurse said the resident had received her routine medication and PRN Tylenol for her break-thru pain. The Treatment nurse continued the wound care treatment. The resident was seen flinching when the Treatment nurse applied the Santyl, [MEDICATION NAME] and the Calcium Alginate to the wound. The resident yelled out in pain when the dry dressing was applied. This surveyor asked the resident if she was in pain and the resident said, yes. The Treatment nurse said, I will call her doctor to get something stronger to manage her pain. Interview on 9/30/30 at 9:40 a.m. with the Treatment Nurse, she said she started full time as a wound care nurse three months ago. She said Resident #93 was given her scheduled and break-thru Tylenol pain medication prior to starting the wound care. The Treatment Nurse said when the resident yelled during the wound care procedure, she was verbalizing that she was in pain. The resident also moved her body away each time she touched the wound. The Treatment Nurse said the resident usually moved her body away to let her know when she was in pain with her body language. She said, Today was the first time she yelled in pain. The Treatment Nurse said she should have stopped the treatment but since the wound was already infected she did not want to leave it open, and continued with the treatment. She said she would call the resident's doctor today to get an order for [REDACTED]. Interview on 9/30/20 at 10:14 a.m. with MA F, she said she administered routine [MEDICATION NAME] and Tylenol for pain to Resident #93 this morning. She said a Medication Aide could only administer OTC and routine meds. She said nurses were responsible for administering the PRN meds. Interview on 9/30/20 at 10:16 a.m. with LVN L, she said Resident #93 was able to verbalize pain. She said the resident only had an order for [REDACTED].#93 her PRN Tylenol 500 mg this morning. Continued Interview on 9/30/20 at 10:18 a.m. with LVN L and the Treatment Nurse, the Treatment Nurse said she was going to call Resident #93's doctor, but the NP was at the facility and ordered [MEDICATION NAME] 50 mg to be administered now, routine q8hrs and PRN. Record review Resident #93's Nurses Notes dated 9/30/2020 10:21:56 written by the Treatment Nurse read in part: .Tylenol 500 mg bid and Tylenol 500 mg q 8hrs prn d/c secondary to new orders for [MEDICATION NAME] 50 mg . Record review Resident #93's nurses notes dated 9/30/2020 10:52 written by the DON read in part . RESIDENT #93 COMPLAINED OF PAIN DURING WOUND CARE. NURSE PRACTITIONER ASSESSED RESIDENT #93 AND GAVE N.O. TO D/C TYLENOL ORDERS AND START [MEDICATION NAME] 50 MG Q DAY 1 HOUR PRIOR TO WOUND CARE AND EVERY 8 HOURS PRN. RP WAS NOTIFIED AND MS. FOSTER WAS ASSESSED FOR PAIN . Record review of Resident #93's Medication Administration Record [REDACTED] Interview on 9/30/30 at 3:43 p.m. with the DON, he said Resident #93 was able to verbalize pain. He said the Treatment Nurse should have stopped, medicated or repositioned the resident, covered the wound with a dressing, and continued the treatment when the pain was managed. He said the resident's NP was in the facility today and ordered [MEDICATION NAME] both routine and PRN. The DON said the [MEDICATION NAME] order was sent to the pharmacy, since it was ordered today it had not arrived, but the nurses were able to get the medication from the e-kit. Record review of the Alzheimer's Association Best Practices in Nursing Care to Older Adults issue titled Assessing Pain in Older Adults with Dementia accessed on 9/30/20 read in part: . STRENGTHS AND LIMITATIONS: Pain is a subjective experience and there are no definitive, universal tests for pain. For patients with dementia, it is particularly important to know the patient and to consult with family and usual caregivers. BARRIERS to PAIN MANAGEMENT in OLDER ADULTS with DEMENTIA: There are many barriers to effective pain management in this population. Some common myths are: pain is a normal part of aging; if a person doesn't verbalize that they have pain, they must not be experiencing it; and that strong [MEDICATION NAME] (e.g., opioids) must be avoided. SUMMARY: An effective approach to pain management in older adults with dementia is to assume that they do have pain if they have conditions and/or medical procedures that are typically associated with pain. Take a proactive approach in pain assessment and management. The use of a standardized pain assessment tool is important in measuring pain. It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and communicate to other health care providers, the patient, and the family . Record review of facility's Pain Assessment and Management policy dated (January 2020) read in part: .purpose: The purposes of this procedure are to help the staff identity pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain. b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; h. Modifying approaches as necessary. 5. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Strategies to pain management: Recognizing pain: a. Non-verbal signs of pain: Behavioral signs of pain, Physiological signs of pain. Defining Goals and Appropriate Interventions-Implementing Pain Management Strategies: a. Non-pharmacological interventions, b. Environmental, c. Physical Exercise, d. Cognitive or Behavioral, e. Pharmacological interventions. Documentation: 2. Document the resident's reported level of pain. Upon completion of pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Reporting: Report the following information to the physician or practitioner; 1. Significant changes in the level of the resident's pain. 3. Prolonged, unrelieved pain despite care plan interventions .

Based on observation, interview and record review the facility failed to consult with the physician when there was a need to alter the medical treatment of [REDACTED].#s 70, 14, 73, 15, 59, 100, 72, 65 and 30 ) reviewed for physician consultations. Resident #70 ' s physician was not consulted when the resident's pain was not effectively controlled. The physician was not consulted prior to the resident running out of a narcotic pain medication that required a triple script perscription from the physician. The resident ran out of Narco on 3/24/15 and the physician was not notified until 3/28/2015. The Narco was not delivered to the facility until 3/30/2015. The resident experienced pain with the intensity of 7-10 on a scale from 1-10 during this time. The physician was not consulted when Resident #70 was found to have new multiple open areas with excoriation to inner thighs and gluteal fold. Resident #70 had nutritional problems and the physician ordered to give her the medication [MEDICATION NAME] to stimulate her appetite. The facility failed to give her this medication and the physician was not notified. Resident #14, who aspirates thin liquids into the lungs, was not compliant with the thicken liquids ordered by the physician, drank thin liquids and the physician was not consulted. The physicians were not consulted when Resident #s 73, 15, 59, 100, 72, and 65 experienced weight loss for two consecutive months. The Registered Dietitian's recommendations for suplements and increasing tube feedings to increase nutritional intake and prevent further weight loss were not communicated to the physicians. Resident # 30's physician was not promptly consulted when she had a low blood pressure for three days with the physician ordered medications being held. Resident #30's physician ordered STAT labs and was not informed of the abnormal results until a day after the facility was notified of the results. An immediate jeopardy (IJ) was identified on 3/26/2015 . While the IJ was removed on 4/2/2015 the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on consulting physicians of resident conditions. These failures affected nine residents by causing increased duration of pain, further weight loss, risks of aspiration, and delay in treatments and placed 99 residents at risk of not having their physicians consulted when they experience a change in condition and could require their medical care altered so their medical condition was not negatively impacted. Findings include: Resident # 70 Record review of Resident # 70 face sheet revealed a [AGE] year old female readmitted to facility on 6/27/13 with the following diagnose: hypertension, diabetes mellitus, depression, congestive heart failure, muscle weakness, obesity and ends stage kidney disease. Record review of Resident #70 ' s care plan dated 7/13/13 with no update date revealed Resident #70 has impaired comfort related to chronic pain, complaint of pain, [MEDICAL CONDITION]. The care plan goal with target date" ...Resident will have relief from pain when as needed (PRN) medication is used over 90 days with the target date of 5/14/15 ..." Approaches " ...Give PRN pain medication according to physician's order [REDACTED]. Record Review of Resident #70's prescription for [MEDICATION NAME] with APAP ([MEDICATION NAME]) 10/325 mg was dated as being ordered by the physician on 11/12/2014. Record review of Resident # 70 ' s MDS dated [DATE] revealed the resident was moderately impaired for cognition and received as needed pain medication. Record review of Resident #70 ' s MAR dated March 2015 revealed [MEDICATION NAME] ([MEDICATION NAME]) 10/325 mg, one by mouth every 6 hours as needed for pain. Further review of the MAR revealed this medication was administered for complaints of pain on: 3/3, 3/5, 3/7, 3/8, 3/10, 3/11, 3/13, 3/18, 3/19, 3/20 the last dose documented as administered was on 3/24/15. Review of the back of the MAR did not document the time that 3/24/15 dose of [MEDICATION NAME] was administered. Record review of Resident #70 ' s MAR dated March 2015 revealed [MEDICATION NAME] HCL 50 mg, by mouth every 6 hours as needed for pain, reordered by the physician on 2/24/2015. Further review of MAR revealed the medication was administered on the following days: 3/2, 3/3, 3 /4, 3/9, 3/10, 3/13, 3/16, 3/19, 3/20, 3/23, 3/24 3/25, 3/26, 3/27 and 3/28/15. Record review of Resident # 70 ' s nurse ' s notes dated 3/3/15 revealed at 9:22 p.m., "...resident continued to complain of pain to buttocks areas, resident given pain medication twice, resident continued to be monitored for increased pain." Record review of Resident # 70 ' s nurse ' s notes dated 3/4/15 revealed at 10:07 p.m., "...resident was medicated for pain." Observation on 3/10/15 at 12:10 p.m., revealed Resident #70 in bed moaning in pain. The resident verbalized she had generalized pain of 10 on a scale of 0-10. She was medicated for pain following the complaint of pain by staff. Further observation on 3/10/15 at 1:30 pm., revealed Resident # 70 complained of pain being present. Wound care that was scheduled was held due to the resident's pain. Interview on 3/10/15 at 1:35 p.m., LVN # 4 said the resident had not refused wound care due to pain and had not complained of pain during wound care until " today " . Observation and interview on 3/10/15 about 2:10 p.m., during wound care. Resident # 70 said it was ok to perform wound care. Resident # 70 moaned in pain whenever sacral/buttocks wounds were cleaned or touched by LVN # 4 and when she was repositioned. Further observation revealed LVN # 4 did not acknowledge the resident moaning in pain throughout the wound care. Resident # 70 verbalized her buttock was hurting during the wound care. Resident # 70 was noted with large stage II pressure ulcer from left buttock extending to her right buttock and the sacral area. The wound bed did not show any slough or eschar, but had mild drainage. Resident #70 was found to have multiple open areas to inner thigh and excoriations to the perineal areas. She also had an unstageable wound to her left heel. Interview on 3/10/15 following wound care, Resident # 70 ' s family members said that the resident had never been assessed nor medicated for pain before wound care treatment. They said that Resident #70 would moan in pain during treatment and the nurse would not stop and would continue with the treatment. Resident #70 would just continue to moan. Interview on 3/10/15 following the above observation, Resident # 70 ' s family member reported she notified LVN# 4 of multiple open areas she identified on the resident but LVN # 4 did not follow up and did not assess the resident. Interview on 3/10/15 about 3:00 p.m., LVN # 4 said the resident ' s family notified her of the skin excoriations on Resident # 70's inner thighs. She said staff had been applying barrier cream to the excoriated red area but she had not seen the open areas since it was reported to her by the family. Record review of the Individual Narcotic sign out sheet identified as [MEDICATION NAME] for Resident #70 revealed on 3/20/15 at 10:00 A.M. the remaining [MEDICATION NAME] count was one tablet remained. Continued review revealed the last [MEDICATION NAME] was removed and administered on 3/24/15. Interview on 3/29/15 at 1:46 P.M. the DON stated she did not know why the resident ran out of her [MEDICATION NAME] Record review of the facility " Pain Roster " dated 3/1/15 thru 3/31/15 revealed the resident reported the following level of pain based on a 1-10 pain scale with 10 being the worst pain ever experienced on the following dates: 3/20/15 resident ' s pain intensity was 10 3/21/15 resident ' s pain intensity was 10 at 10:57 A.M. and 6:11 P.M. 3/22/15 resident ' s pain intensity was 10 at 12:44 P.M. and 7:08 P.M. 3/26/15 resident ' s pain intensity was 5 at 11:29 P.M. 3/28/15 resident ' s pain intensity was 10 at 9:44 P.M. 3/29/15 resident ' s pain intensity was 10 at 1:19 P.M. Observation on 3/29/15 at 12:36 P.M. revealed Resident #70 in bed awake and alert. Interview on 3/29/15 at 12:36 P.M. during the observation Resident #70 stated her pain intensity level was 7. Resident #70 continued and stated she was out of the [MEDICATION NAME] and was getting [MEDICATION NAME] instead. She stated [MEDICATION NAME] did not work like the [MEDICATION NAME] on her pain. Observations on 3/29/15 at 2:00 P.M. with the DON and at 2:11 P.M. with LVN #3 of the medication cart narcotic box revealed a bubble pack for [MEDICATION NAME]. Continued observation revealed no bubble pack for [MEDICATION NAME] for Resident #70. Interview on 3/29/15 at 2:11 P.M. LVN#3 stated Resident #70 was getting [MEDICATION NAME] 50 mg and [MEDICATION NAME] 10/325 mg every six hours as needed for pain. LVN#3 continued and stated when she realized the [MEDICATION NAME] was out on Saturday (March 28, 2015) she called the pharmacy to request a refill but she was told she needed triplicates. She continued and stated she called the physician to notify him that she needed a triplicate prescription. The doctor questioned why he was not notified during the week. LVN#3 stated she only worked on weekends and she did not know. The physician stated the resident would have to wait until Monday. Record review of Resident#70 ' s physician's order [REDACTED].#3 every four hours as needed for pain. Record review of Resident #70 ' s MAR dated March 2015 revealed Tylenol #3 was discontinued on 3/30/15 and the new order for [MEDICATION NAME] 5/325 mg was the resident was to receive it four times a day was started. Observation on 3/30/15 at 8:15 A.M. revealed Resident #70 was in bed grimacing and holding her left arm. Interview on 3/30/15 at 8:15 A.M. Resident #70 stated they let the [MEDICATION NAME] ran out about a week ago and they were giving the [MEDICATION NAME] and Tylenol which did not work. The resident stated she was having overall chronic body pain and reported her pain intensity on a scale of 1-10 was 9 and a half "at this time ". She continued and stated she did not go to sleep until 4:00 A.M. " this morning " because of the pain. Resident #70 stated " how do you let someone ' s pain medicine run out? " Interview on 3/30/15 at 8:25 A.M. LVN #4 said that the physician ordered another pain medication, Tylenol #3, " yesterday " , but Resident #70 did not want Tylenol #3 because it did not relieve her of pain. She only wanted [MEDICATION NAME] because it was the only pain medication that she had used that helped her with pain. Observation on 3/30/15 at 8:25 A.M. revealed LVN #4 called the physician to reorder [MEDICATION NAME] since Resident #4 had ran out of it. Interview on 3/30/15 at 8:40 A.M. LVN#14 stated when she noticed a resident ' s medicine was about to run out she called the pharmacy for refills and if it cannot be refilled she notifies the physician. She stated she does not notify the DON but will notify the next on coming nurse during report and if she worked the next day she would call the pharmacy and physician again. Interview on 3/30/15 at 9:15 A.M. Resident #70 stated she received [MEDICATION NAME] and Tylenol #3 about 30 minutes earlier and her pain was about the same with no relief. She continued and stated she told her doctor last week she was out of pain medicine. Interview on 3/30/15 at 10:09 A.M. the DON stated she cannot remember any nurse notifying her about Resident #70 ' s [MEDICATION NAME] running out and last night she got an order for [REDACTED]. Interview on 3/30/2015 at 4:45 Resident #70 stated she had just returned from [MEDICAL TREATMENT]. She stated her pain was a 9 on a scale of 1-10 but the nurse just gave her a pain pill. She stated it was not a [MEDICATION NAME] but the nurse stated they had been ordered and should be coming from the pharmacy this evening. She stated the [MEDICATION NAME] was the only drug that was effective for her pain. Further record review of Resident #70 ' s clinical records revealed a physician order [REDACTED]. Record review of Resident #70 ' s MAR dated March 2015 revealed that the staff had initials on the MAR indicating that [MEDICATION NAME] 10 mg was administered to Resident #10 on the following dates: 3/4/, 3/5, 3/7, and 3/8/15. Further record review revealed that the [MEDICATION NAME] was discontinued on 3/9/15. Record review of Resident # 70 ' s " Psychiatric Review /Mental Status Exam " dated 3/9/15 revealed " Primary care physician ordered [MEDICATION NAME] 10 mg every night for appetite but pharmacy has not delivered secondary to no 10 mg pill , will change to [MEDICATION NAME] 15 mg every night so they will send it " . Record review of Resident# 70 ' s progress notes revealed that there was no evidence indicating that Resident # 70 ' s physician was notified of the unavailability of the [MEDICATION NAME] 10 mg ordered 3/3/15. Interview on 3/10/15 at 11:34 a.m., LVN # 4 said the medication was supposed to have been delivered by the pharmacy. She said staff should indicate and document the reason on the back of the MAR when medications were not administered. LVN # 4 said the physician should have been notified that the ordered medication was not available in the ordered dose. Record review of the drug reorder book on 3/30/2015 revealed a binder with dividers for 31 days in it. Behind the divider marked 30 there were several copies of phone orders and tear off slips from medication cards that had been attached to blank pages and faxed to the pharmacy. Interview on 3/30/2015 at 5:00 P.M. the Corporate Educator after being asked for the previous days of the month ' s pharmacy orders, stated the notebook was the corporate system which should have been used at the facility but was not. She stated prior to "today" the nurses had just been shoving the order forms into an accordion binder in the medication room. She stated there was no organization or filing system and there were several folders. She then stated she had started training the nurses to the corporate system. When asked how many nurses she had trained she stated two. When asked to see the in-service form for the two nurses she stated she had not made one out yet. The Corporate Educator was asked to see if she could find the reorder form for Resident #70's [MEDICATION NAME] which ran out on 3/24/2015. She stated she would try to find it. No reorder form was ever provided for review. Record review and interview of the in-service form dated 3/30/2015 concerning the medication reorder system revealed one nurse had signed they had been trained to the corporate medication reorder policy and procedure. Interview on 3/30/2015 at 5:10 P.M. the ADON stated she would order medications when the resident had a seven day supply left. She stated if it was a PRN medication she would use her nursing judgement and assess how many pills a day the resident was taking and then multiply that times 7 to give her a seven day supply. Interview on 3/30/2015 at 5:30 P.M. LVN #20 stated he reordered resident's medications when they had ten pills left. Interview on 3/31/15 at 9:30 A.M. LVN #19 sated she reordered medications on the seventh day before it runs out. She did the ninth day but she would be notified by pharmacy it was too early to refill. Interview on 3/31/15 at 9:36 A.M. LVN #4 stated it depended on the frequency of the medication but she reordered medications 7 days before it runs out. The turnaround time to get the medication depended on if there were any refills left on the medication or if it needed triplicate scripts. Record review of facility ' s policy on treatment of [REDACTED]. Resident #14 Record review of Resident #14 ' s face sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #14 ' s chart revealed a nurse ' s note dated 11/27/2014 which revealed the family had brought the resident food and drink to eat. The note went on to state the resident was not compliant with diet. There was no documentation of physician notification in the chart at this time. Further review revealed no documentation of any physician notification in [DATE], Jan, Feb or March 2015 concerning the resident ' s diet. Record review of Resident #14 ' s MDS dated [DATE] revealed the resident was dependent on staff for activities of daily living but could feed herself with just the assistance of the staff to set up her tray. The MDS also revealed the resident weighed 240 pounds and was on a mechanically altered diet. Record review of Resident #14 ' s consolidated physician's order [REDACTED]. Observation on 3/11/2015 at 12:30 P.M. revealed Resident #14 eating lunch. On her tray revealed a cup of coffee and a glass of water. Both were thin consistency. Review of the lunch tray meal card at this same time revealed the resident was to have Nectar thickened liquids. Observation on 3/11/2015 at 4:00 P.M. revealed Resident #14 in her bed sitting up. The bedside table was over her lap and contained two large glasses of ice water with straws. Both glasses were half full. The resident was alert but due to her [DIAGNOSES REDACTED]. The resident took three to four drinks of water during this observation. The water was of thin consistency. In the room there were no signs or notifications to staff or visitors that the resident was to have thickened liquids. Observation on 3/11/2015 at 5:35 A.M. the supper trays were being passed by the staff. On Resident #14 ' s tray was a glass of nectar thick water and nectar thick juice that were covered with plastic lids and labeled with an N. Interview on 3/11/2015 at 5:40 P.M. the DON was taken to the resident ' s room and asked to explain the system to notify family or visitors concerning fluid consistencies. She stated the resident should have a sign above her bed with a B which alerts staff the resident is to have thickened liquids. She stated the resident should not have the thin water that was located on her bedside table. At this time LVN #5 entered the room and stated that the resident would not drink thickened liquids and had always been non compliant. He stated the family would also offer her thin liquids because she would refuse the nectar thick ones. When asked if the doctor had been informed LVN #5 stated he did not know. Interview on 3/11/2015 at 6:20 P.M. the DON stated Resident #14 ' s physician had been notified and he had ordered a swallowing test to be performed on the resident which she will make sure gets completed. Record review of Resident #14's record concerning the swallowing exam dated 3/20/2015 revealed recommendations of small bites/sips-crush meds-alternate solids/liquids; position upright and supervised feedings with curing . Results of the test also revealed the resident was a silent aspirator on thin liquids. Further review revealed the resident and family were counseled concerning the test results and the resident chose, even after risks explained, to be non compliant and drink thin liquids. The physician was notified on 3/27/2015 of the family and Resident #14's decision and facility forms concerning the refusal of treatment were signed. Resident #73 Record review of Resident # 73 ' s face sheet revealed he was a [AGE] year old male, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 73 ' s Minimum Data Set ((MDS) dated [DATE] revealed her Brief Interview for Memory Status (BIMS) score was 4 which indicated he was severely cognitively impaired. Record review of the same MDS revealed the resident ' s weight was 191 pounds. Record review of Resident #73 ' s MDS dated [DATE] revealed his weight was 172 pounds. The weight loss between 10/17/2014 and 1/09/2015 was not identified on the form. Record review of Resident #73 ' s care plan with a problem onset date of 02/10/15 revealed "...Potential for unintended wt. loss R/T dysphagia inadequate intake of meal AEB coughing while swallowing. Weight loss of 5% in the last 30 days ..." Approach listed "...Notify MD/RP of wt. loss of additional 2# despite interventions ..." Record review of Resident # 73 ' s physician's order [REDACTED]. Resident is NPO ... order dated 03/04/15 revealed ... change feeding to [MEDICATION NAME] 1.5 one can bolus QID. Record review of Resident #73 ' s care plan with a problem onset date of 03/04/15 update revealed "...Resident has feeding tube R/T Dx dysphagia AEB Resident has silent aspiration and alteration in airway clearance. At risk for weight loss ..." Approach listed "...will monitor patients monthly weights ...will notify MD/RP of any weight loss..." Record review of the facility " Weight Change History " form dated 03/12/15 revealed Resident #73 ' s weight history as follows: 10/10/14 191.20 pounds 11/10/14 171.20 pounds 12/09/14 171.80 pounds 01/10/15 173.80 pounds 02/10/15 149.20 pounds 03/03/15 151.20 pounds Record review of the following dietary notes for Resident # 73 revealed: 12/10/14 ...171.8 pounds wt. stabilized this month ... wt. loss 15.5 pounds 8.2% down BW x 3 months ... 01/29/15 ...173.8 pounds wt. stable trending up + 2 months wt. loss of 17.4 pounds 9.1% over 3 months ... 03/05/15 ...March wt. 151.2 pounds wt. stable x 1 month Question 24.8 pound wt. loss for 1 month. Wt. loss 20.6 pounds 11.9% x 3 months 36.1 pounds 19.2% ..On TF [MEDICATION NAME] 1.5 bolus 1 can QID. Flush 150 cc H20 Q4h. Resident NPO ...Recommend change from 1.5 formula QID to a 2.0 formula QID. TF to provide 1900 kcal, 79.8g protein and 664 cc fluid/day ...recommend weekly wts x 4 weeks ... Record review of Resident #73' s physician's order [REDACTED]. Observations of Resident #73 on the following dates and times revealed the resident was unable to communicate. 3/11/15 at 5:45 P.M. 3/12/15 at 8:30 A.M., 8:58 A.M., and 1:47 P.M. Interview on 03/12/15 at 8:30 A.M. ADON-Staffing revealed Resident #73 did not take anything by mouth. She stated even his meds were given by [DEVICE]. She stated his feeding was [MEDICATION NAME] 1.5 bolus QID and she was getting ready to feed him "right now." Interview on 3/12/15 at 12:45 P.M. RD/LD (Registered Dietitian/Licensed Dietitian) stated he recommended a tube feeding increase on 03/05/15 from [MEDICATION NAME] 1.5 bolus 1 can QID to 2.0 formula QID to provide 1900 kcal due to Resident #73 ' s 20.6 pound weight loss between 01/29/15 and 03/15/15. He stated the [MEDICATION NAME] 1.5 was only providing 1420 kcal. He continued and stated he did not know if the physician was notified of the recommendations. He stated he made the recommendations and gave them to the Director of Nursing (DON) who then was to notify the physician. He further stated he recommended weekly weights for Resident #73. Resident #15 Record review of Resident # 15 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #15 ' s Minimum Data Set ((MDS) dated [DATE] revealed on her Brief Interview for Memory Status (BIMS) the resident ' s cognitive pattern was 3 which indicated she was severely impaired for daily decision making (rarely/never made decisions). The MDS revealed the resident was totally dependent on staff for eating. Record review of the same MDS revealed the resident ' s weight was 126 pounds with 51% or more of her total calories received through a tube feeding and her average fluid intake was 501 cc per day from tube feeding. Record review of Resident#15 ' s care plan dated 6/5/14 with no update revealed the problem related to [MEDICAL CONDITION]"... Resident #15 has tube feeding related to impaired swallowing, at risk for weight loss resident was receiving [MEDICATION NAME] 1.2 at 60 ml per hour for 22 hours." Record review of Resident #15 ' s MDS dated [DATE] revealed her weight was 117 pounds. The weight loss was identified and " not on a physician prescribed with loss regimen " ... with 51% or more of her total calories though tube feeding and her average fluid intake was 501 cc per day from the tube feeding. Record review of the facility " Weekly Weight Record " dated November 2014, December 2014 and January 2015 revealed Resident #15 was not on weekly weights. Record review of the facility " Resident Current Weight List " dated 11/15/14 revealed Resident #15 ' s weight was 126.4 pounds, new weight undated was 113.4 pounds and weight dated November 15-16, 2014 was 115.2 pounds. Record review of the facility " Weight Change History " form dated 12/4/14 revealed Resident #15 weight history: 7/11/14- 126.4 pounds 8/10/14- 117.2 pounds Resident in the hospital 10/10/14-126.4 pounds 11/10/14-115.2 pounds Record review of Resident #15 ' s weight history untitled and undated provided by the facility dietician revealed the following weight history: 10/10/14-126.4 pounds 11/10/14-115.2 pounds 12/9/14-115.0 pounds 1/10/15-110.6 pounds 2/10/15- 112.6 pounds Record review of Resident #15 ' s " Initial Dietary Assessment " undated revealed the resident ' s diet was nothing by mouth " NPO " Record review of the following dietary notes for Resident #15 revealed: ... 8/28/14 August 117.2 pounds weight loss 9.2 pounds 7.2 % per month stage III wound ... recommended increase tube feeding [MEDICATION NAME] 1.2 to 65 ml per hour ... ...11/25/14 November at 115.2 pounds ...11.2 pound decrease down 8.8% in 3 months... ...1/15/15 January at 110.6 pounds. Weight loss restarted weight down 15.8 pounds 12.5 % in 3 and 6 months ....recommended [MEDICATION NAME] 1.2 at 65 ml per hour for 22 hours... ...2/12/15 dietary notes revealed February weight pending January at 110.6 pounds ...recommend increase tube feeding to [MEDICATION NAME] 1.2 at 65 cc per hour. Record review of Resident # 15 ' s consolidated physician's order [REDACTED]. Record review of Resident #15' s physician's order [REDACTED]. Observations of Resident #15 on the following dates and times revealed the resident was non-verbal. Her oxygen was per [MEDICAL CONDITION] collar and her tube feeding was running on a pump at 60 ml per hour: 3/10/15 at 10:22 A.M. and 1:10 P.M. 3/11/15 at 10:30 A.M., 11:31 A.M. 12:48 P.M. and 4:00 P.M. 3/12/15 at 8:00 A.M. and 11:00 A.M. Interview on 3/12/15 at 8:35 A.M. RD/LD (Registered Dietitian/Licensed Dietitian) stated he visited the facility four times a month, one time a week. He stated his priority was new and readmitted residents, residents with weight loss and pressure ulcers and then residents with weight gain. The RD/LD stated he recommended a tube feeding increase in August and the resident was on hospice at that time. In September Resident #15 was in the hospital and in February another recommendation to increase her tube feeding to 65 ml per hour was made. He continued and stated he did not know if the physician was notified of the recommendations. He stated he made the recommendation and gave them to the Director of Nursing (DON) who then was to notify the physician. He stated Resident #15 warranted weekly weights when her weight moved from 126 pounds to 115 pounds then 110.6 pounds. He stated he did not know why they were not done. Interview on 3/12/15 at 12:45 P.M. the ADON -skilled stated the DON or Dietician could recommend weekly weights. She stated when the dietician makes a recommendation the quality nurse or the DON notifies the physician. Record review of Resident #15's physician's telephone orders dated 3/12/2015 revealed an order to increase the resident's tube feeding to 65 cc per hour for 22 hours. Observation on 3/25/15 at 3:50 P.M. revealed Resident #15 in the bed receiving O2 [MEDICAL CONDITION] 2 liter per. The feeding tube was dispensing [MEDICATION NAME] 1.2 at 60 cc per hour. Record review of Resident #15's March 2015 MAR revealed the resident was to receive [MEDICATION NAME] 1.2 at 60 cc per hour. The physician's orders [REDACTED]. Interview on 3/25/2015 at 4:05 P.M. the DON stated Resident #15's original dietary recommendation was one of the recommendations that had been overlooked but she had corrected the tube feeding order as of 3/12/2015. After reviewing the order, the March MAR and the resident's tube feeding she stated she remembered talking with the physician, writing the order and giving it to the nurse to transcribe to the MAR. She stated she would make sure it was transcribed now and that the feeding was changed to the correct amount. She also stated she would inservice the nurse on transcribing orders. Continued review revealed no documentation in Resident #15's medical record the physician was notified the resident was and had not received the increase in feeding as ordered on [DATE]. Resident # 59 Record review of Resident # 59 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident#59 ' s care plan dated 3/5/14 with no update revealed the problem " altered nutrition less than body requirements " ... nutrition altered less than body requirements: receives therapeutic diet at risk for non-compliance with diet and weight loss. Record review of Resident #59 ' s MDS dated [DATE] revealed her BIMS score was 2 which indicated her cognition was severely impaired. The MDS revealed the resident required extensive assistance for eating. Record review of the same MDS revealed the resident ' s weight was 111 pounds. Record review of Resident #59 ' s MDS dated [DATE] revealed her weight was 110 pounds. The weight loss was identified and " not on a physician prescribed weight loss regimen Record review of the resident weight change history " form revealed the following: 7/11/4- 116.4 pounds 8/10/14-112.2 pounds 9/10/14- 109.2 pounds 10/10/14- 108.4 pounds 11/10/14-111.0 pounds Continued review did not reveal additional weight change history forms or weekly weights. Record review of the resident ' s dietary progress notes revealed: 6/12/14 June weight 123 pounds ... 7/23/14 July weight 116.4 pounds ...weight loss 6.6 pounds 5.3% in one month ... Resident has a stage II wound ... 8/28/14 weight at 112.2 pounds this month ...weight loss 12.4 pounds 9.9% for 3 months ... 9/18/14 September at 109.2 pound ...weight loss 13.8 pounds 11.2% for 3 months 11.6 pounds loss 9.6% for 6 months. 10/30/14 October weight 108 pounds weight loss 12.8 pounds 10.5% ...on 10/20/15 [MEDICATION NAME] discontinued ... 11/25/14 November weight 111.0 pounds ... 2/26/15 February weight 110.2 pounds weight loss 9

Based on observation, record review and interview the facility failed to provide services by a qualified person in accordance with the written plan of care/physician's orders [REDACTED].#72, #62, #65, #97, and #15)whose care plans and physician's orders [REDACTED]. Resident #72's was not provided the Nepro supplement and blood pressure medications as ordered by the physician. The resident experienced weight loss for two consecutive months without the supplements recommended by the Registered Dietitian. The resident's blood pressure medicine ordered four times a day was administered three times per day. Resident #62 was not provided tube feedings as ordered by her physician. The resident, who had contractures and was compromised, was not provided the tube feeding as ordered by the physician. Resident #65 was not provided health shakes with meals as ordered by the physician. The resident experienced weight loss without the supplement being given. Resident #97 was not provided hand rolls and treatments to the insides of her hands as ordered by the physician and documented in the care plan. The resident had orders to have hand rolls in place to prevent injury and contractures which was not provided by staff Resident #15's heels were not floated while in bed as documented in the resident's care plan. The resident had pressure sores on her heels that were not provided the treatment ordered by the physician. Resident #15's tube feeding was not provided as ordered by the physician. The resident experienced weight loss and when the doctor increased her tube feeding on 3/12/2015 the facility staff did not implement the increase until 3/25/2015. An immediate jeopardy (IJ) was identified on 3/26/2015. While the IJ was removed on 4/2/2015 the facility remained out of compliance at a scope of patterned and a severity level of actual harm because all staff had not been trained on the following of physician's orders [REDACTED]. These failures affected six residents with increased weight loss, pressure sores and contractures and placed 102 residents at risk of not receiving the care ordered by their physician's or as planned in their care plans which could cause a decline in their health. Findings include: Resident #72 Record review of Resident #72 ' s face sheet revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #72 ' s MDS dated [DATE] revealed the resident was cognitively impaired. The MDS revealed the resident required the assistance of staff for all ADLs. Record review of Resident #72 ' s care plan dated 10-22-2014 revealed a problem of the resident was at risk for weight loss with approaches of serving the diet as ordered by the physician and to have dietary consults as needed. Another problem identified was the resident had a [DIAGNOSES REDACTED]. Record review of Resident #72 ' s weight history revealed the following: 1-10-15 wt. 150.60 pounds 2-10-15 wt. 142.60 pounds 3-10-15 wt. 139.00 pounds Record review of Resident #72 ' s dietary notes dated 2-23-15 revealed the dietitian had documented the resident had an eight pound weight loss and recommended the resident receive one can of Nepro every day for 30 days. Record review of Resident #72 ' s physician's order [REDACTED]. Record review of Resident #72 ' s dietary notes dated 3-24-15 revealed the dietitian documented the resident had an additional weight loss of 3.6 pounds. The dietitian at this time recommended the resident was to be provided one can of Nepro two times a day for 30 days. Review of Resident #72 ' s physician's order [REDACTED]. Record review of Resident #72 ' s MAR dated March 2015 revealed no transcription of the Nepro order and no documentation of the resident receiving the Nepro. Observation and interview on 3-26-2015 at 8:30 A.M. revealed the resident eating breakfast in the dining room. The resident stated his meal was very good and he ate 90 percent of the meal. There was no Nepro served with the meal. Interview on 3-26-2015 at 8:30 A.M. LVN #10 stated Resident #72 received the Nepro on [MEDICAL TREATMENT] days. She stated it was packed by the dietary department. Interview on 3-26-2015 at 8:40 A.M. the Food Service Supervisor stated the dietary department supplied a sack lunch for the residents when they went to [MEDICAL TREATMENT]. She stated the sack lunch consisted of a sandwich, graham crackers and fruit along with a juice. She stated the dietary department does not dispense the Nepro drinks. She stated that would be supplied by the nurses. Interview on 3-26-2015 at 10:30 A.M. the DON stated she had spoken to the nursing staff and figured out the system at the facility was that all residents who had [MEDICAL TREATMENT] was given a can of Nepro on their [MEDICAL TREATMENT] days that was provided by the nurses out of the nourishment room. She stated that Resident #72 went to [MEDICAL TREATMENT] three times a week. She stated she would get the order transcribed to the MAR and in-service the nurses so Resident #72 would receive the Nepro twice a day as ordered. Record review of Resident #72 ' s physician ' s telephone orders revealed an order dated 3-24-2015 for the blood pressure medication [MEDICATION NAME] 10 mg to be administered every 8 hours. The same order also revealed another blood pressure medication [MEDICATION NAME] 50 mg to be administered every 6 hours PRN (as needed) if the resident ' s systolic blood pressure was above 160. Record review of Resident #72 ' s MAR dated March 2015 revealed the medication [MEDICATION NAME] 10 mg had been transcribed to be given every 6 hours and the [MEDICATION NAME] 50 mg to be administered every 8 hours PRN. The medication [MEDICATION NAME] 10 mg had been documented as administered at 8 AM, 2 PM, 8 PM and 2 AM on 3-25-2015. The medication [MEDICATION NAME] 50 mg had not been administered. Interview on 3-26-15 at 8:45 AM the DON stated she was the one who had written the order. She stated she remembered the physician giving the order as it was transcribed not as she had written it on the order and that she had written the order wrong. She stated the doctor wanted the resident to receive the [MEDICATION NAME] every 6 hours and the [MEDICATION NAME] every 8 hours PRN. She stated she would verify and make the corrections. Interview on 3-26-2015 at 11:45 AM LVN #10 stated she had administered Resident #72 ' s medications to him on 3-25-15. She stated, as she showed the medication card of the [MEDICATION NAME], that the label on the medication read to give every 8 hours but the MAR had directions to give every 6 hours. She stated she administered the medications as it was written on the MAR. She showed the sticker on the package that directed staff there was a direction change and to check the resident ' s order. She stated that sticker was just applied to the card and was not there the previous day. She stated she had been trained that when the medication label did not match the MAR she was to check the physician's order [REDACTED]. She stated she did not do what she had been trained to do. Resident #62 Record review of Resident #62 ' s face sheet revealed the resident was admitted to the facility on [DATE]. The resident was [AGE] years old. Her [DIAGNOSES REDACTED]. Observation on 3/10/2015 at 1:24 P.M. revealed the resident in bed with O2 being administered at 2 liters per minute. The resident had a tube feeding being administered per a [DEVICE] and feeding pump of Glucerna 60 cc/hr. The tube feeding was dated 3/10/2015. Record review of Resident #62 ' s MDS dated [DATE] revealed the resident had impairments to both upper and lower extremities. It also revealed the resident was totally dependent on staff for bed mobility and all activities of daily living. The MDS revealed the resident weighed 150 pounds and received her nourishment per a [DEVICE]. Record review of Resident #62 ' s care plan dated 2/14/2015 revealed the resident ate nothing by mouth and obtained all nutrition intake via an external tube. Approaches listed to administer the tube feedings and flushes per physician's order [REDACTED]. Record review of Resident #62 ' s physician's order [REDACTED]. Turn feeding off at 10 A.M. and on at 12:00 P.M. Observation on 3/11/2015 at 9:33 A.M. the resident was positioned on her back with the tube feeding off. The tube feeding bottle had 700 cc Glucerna 1.2 in the bottle dated 3/12/2015 and was marked to be dispensed at 60 cc per hour. After the provision of incontinent care CNA #17 went into the hall to get RN #6 to turn the resident ' s feeding tube back on. Interview on 3/11/2015 at 9:35 A.M. RN #6 stated she was still in orientation and it was her second day. She stated the resident ' s tube feedings were to be at 60 cc per hour and the pump was set for this so she just had to turn the pump back on after the aides elevated her head and were through providing the incontinent care. When asked how she knew the feeding was to be 60 cc per hour she stated it was marked on the bottle. Observation and interview on 3/12/2015 at 1:10 P.M. revealed the resident lying on her back with her knees in the air. Head of bed was elevated 45 degrees. The resident had a tube feeding being administered of Glucerna 1.2 being administered at 60 cc per hour. LVN #4 entered the room and when asked what the resident ' s tube feeding was she stated it was being dispensed at 60 cc per hour for 22 hours and that she had just turned it back on at noon. When asked she stated she would confirm the physician's order [REDACTED]. hour and that she would go adjust the rate. She stated the night nurse always marked the bottles and would set the feeding pump. She stated she would leave a note for the night nurse to make sure the feeding was set at 70 cc per hour. Interview on 3/11/2015 at 4:00 P.M. the DON stated the tube feedings were set up by the night nurse. She stated she would check with the nurse to see why she had set up the resident ' s feedings for 60 cc per hour instead of the doctor ordered 70 cc per hour and in-service her to make sure she doubled checked orders. Resident #65 Record review of Resident #65's face sheet revealed he was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #65's care plan dated 9/8/2014 with no updates noted, revealed no care plan concerning the resident's nutritional status except that the resident was "sad" concerning his having a [DEVICE]. The care plan revealed the resident would be monitored and referred to counseling and a psychiatric evaluation. No approaches were listed for staff to provide. Record review of Resident #65's weight change history revealed the resident weighed 177.70 pounds on 1/10/2015 and 162.80 pounds on 2/10/2015. A 14.6 pound weight loss. Record review of Resident #65's Communication between the Dietitian and the Attending Physician form dated 2/26/2015 revealed the RD/LD recommended a health shake by mouth three times a day with meals for thirty days and weekly weights for four weeks. Record review revealed the recommendations were not communicated to the physician until 3/24/2015 when a physician's orders [REDACTED]. Record review on 3/26/2015 of the nurse's notes revealed the resident had been transferred to the hospital earlier that morning due to vomiting. Record review on 3/26/2015 of Resident #65's dietary card printed by the Food Service Supervisor did not have the health shakes added to the diet order. Interview on 3/26/2015 at 10:30 a.m. the DON stated the health shake order would be carried out by the dietary department due to it being served with meals. She stated the nurses had a form to communicate with the dietary department and would write the orders in the book of the forms and give a copy to dietary. When requested to see the communication form the DON was unable to locate where dietary had been notified to provide the health shakes. Resident #97 Record review of Resident # 97 ' s face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #97 ' s MDS dated [DATE] revealed her cognitive status was severely impaired. The same MDS revealed the resident was totally dependent on staff for all mobility and activities of daily living. The MDS documented the resident had impairments to both upper extremities. Observation at 3:30 P.M. on 3-11-2015 revealed the resident alert and able to track with her eyes. The resident was non-verbal and lying in bed. Both of the resident ' s hands were elevated on a pillow lying on her chest. Her upper arms and hands were contracted. Both hands were in fists with the fingers overlapping each other in an unnatural way. The resident was unable to open her hands upon request. There were no hand rolls in her hands. Record review of Resident #97 ' s care plan originally dated 6/4/2013 (no updates listed on care plan) revealed a problem of contractures to upper and lower extremities. Approaches listed keep hands clean and dry, Use hand rolls and pillows as needed. Record review of Resident #97 ' s physician's order [REDACTED]. Interview with Resident #97 ' s family member on 3/11/2015 at 6:00 P.M. he stated that just last night (3/10/2015) he had told the charge nurse (LVN #8 identified by name) about the resident ' s left hand. He stated when he comes, daily, there is never anything in her hands and he would always try to open them up a little to stretch her fingers. He said when he opened the resident ' s left hand he noticed there was a wound and a buildup of skin and dead tissue. He said the odor was awful. He tried putting some scented lotion inside it but that did not help. He went on to state LVN #8 told him she would tell the treatment nurse and they would take care of the wound. He said he then left for the evening and when he came back tonight he found the resident in the exact same condition with nothing in her hands and no treatment being done to the wound. Observation on 3/11/2015 at 6:00 P.M. of the inside of the left hand revealed a very foul odor and a large amount of dead skin. The inside of the hand appeared moist with injury to the tissue noted in the palm of the hand. The resident was unable to open the hand independently but did not show expressions of pain when family member extended the deformed fingers to show the inside of the hand to the surveyor. Interview on 3/11/2015 at 6:10 P.M. the DON discussed with the family member the condition of the resident ' s hand after the family member showed it once more. The DON stated she would follow up with the nurses and make sure the physician was contacted. Interview on 3/11/2015 at 6:15 P.M. the DON stated LVN #8 had reported the condition of Resident #97 ' s hand to the Treatment Nurse. The Treatment Nurse stated she had looked at the hand and the Resident was to have a hand roll (carrot) in her hands to prevent this. Resident # 15 Record review of Resident # 15 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #15 ' s MDS dated [DATE] revealed her cognitive pattern was 3 which indicated she was severely impaired for daily decision making (rarely/never made decisions). The MDS revealed the resident was total dependence on staff for personal hygiene. Record review of Resident # 15 ' s care plan dated 6/10/14 revealed the problem "...Resident is weak and with contractures to upper extremities and foot drop to left foot ... approaches ...float heels while in bed ..." Record review of the following dietary notes for Resident #15 revealed: ... 8/28/14 August 117.2 pounds weight loss 9.2 pounds 7.2 % per month stage III wound ... recommended increase tube feeding [MEDICATION NAME] 1.2 to 65 ml per hour ... ...11/25/14 November at 115.2 pounds ...11.2 pound decrease down 8.8% in 3 months... ...1/15/15 January at 110.6 pounds. Weight loss restarted weight down 15.8 pounds 12.5 % in 3 and 6 months ....recommended [MEDICATION NAME] 1.2 at 65 ml per hour for 22 hours... ...2/12/15 dietary notes revealed February weight pending January at 110.6 pounds ...recommend increase tube feeding to [MEDICATION NAME] 1.2 at 65 cc per hour. Observations of Resident #15 on the following dates and times revealed the resident was non-verbal. Her oxygen was per [MEDICAL CONDITION] collar and tube feeding was running on a pump at 60 ml per hour: The resident had heel protectors on bilateral lower extremities with heels on the mattress: 3/10/15 at 10:22 A.M. and 1:10 P.M. 3/11/15 at 10:30 A.M. and 4:00 P.M. Interview on 3/12/15 at 12:45 P.M. ADON skilled stated Resident #15 had an air mattress and heel protectors but if her heels were flat on the bed they were not floated. Record review of Resident #15's physician's telephone orders dated 3/12/2015 revealed an order to increase the resident's tube feeding to 65 cc per hour for 22 hours. Observation on 3/25/15 at 3:50 P.M. revealed Resident #15 in the bed receiving O2 [MEDICAL CONDITION] 2 liter per. The feeding tube was dispensing [MEDICATION NAME] 1.2 at 60 cc per hour. Record review of Resident #15's March 2015 MAR revealed the resident was to receive [MEDICATION NAME] 1.2 at 60 cc per hour. The physician's orders [REDACTED]. Interview on 3/25/2015 at 4:05 P.M. the DON stated Resident #15's original dietary recommendation was one of the recommendations that had been overlooked but she had corrected the tube feeding order as of 3/12/2015. After reviewing the order, the March MAR and the resident's tube feeding she stated she remembered talking with the physician, writing the order and giving it to the nurse to transcribe to the MAR. She stated she would make sure it was transcribed now and that the feeding was changed to the correct amount. She also stated she would inservice the nurse on transcribing orders. Record review of the Comprehensive Care Plan policy for the facility dated 7/13 revealed the services provided or arranged by the facility must meet professional standards of quality and be provided by qualified persons in accordance with each resident's written plan of care. A policy was requested concerning [DEVICE]s but on the policy concerning nasogastric tubes was provided. Record review of the facility's policy concerning receiving/recording physician orders [REDACTED].r.n. (as needed). There should also be orders in place that specify the amount of water used for flushing. An immediate jeopardy (IJ) was identified on 3/26/2015 . A plan to lower the immediate jeopardy was submitted and accepted on 3/29/2015 . The plans included: Immediate interventions implemented to include all residents residing in facility that could be affected by an effective system not being in place and monitored to track residents who could be at risk for weight loss. 1. 100% audit of current census was conducted by Corporate Consultant Nurse to ensure weight variances were addressed, malnutrition assessments were completed for all residents to identify any at risk residents without a current weight loss INITIATED: 3/27/2015 COMPLETED: 3/29/2015 Care plans updated to include interventions to prevent weight loss. Dietician reviewed all residents with a significant weight loss. INITIATED: 3/26/2015 COMPLETED: 3/29/2015 100% audit of tube feeding orders to verify ordered formula was being given as per physician orders. INITIATED: 3/27/2015 COMPLETED: 3/27/2015 Corporate Dietitian audited 100% of dietary orders and supplement orders to verify Dietary Managers diet roster matches physician orders. Any discrepancies were corrected. INITIATED: 3/27/2015 COMPLETED: 3/28/2015 Corporate Dietitian conducted a 100% supplement order and delivery during meal service to verify supplements supplied by the kitchen were delivered as ordered. INITIATED: 3/27/2015 COMPLETED: 3/28/2015 100% audit of all new orders from March 1, 2015 current were checked for accuracy of transcription. INITIATED: 3/29/2015 COMPLETED: 3/30/2015 Interventions Issue #1: 1. Residents at risk and those who had a significant weight loss will be identified by the management nurses to begin on 3/26/15 and complete by 3/27/15. Any resident identified to be at risk were assessed, RD, & MD were notified to determine whether a change in treatment regimen was required. 2. MD/Nurse Practitioner will be contacted by DON or Designee with all dietary recommendations and the DON will monitor MD response/orders and ensure all recommendations have been addressed. If MD does not respond within 24 hours the DON or designee will make a second attempt to notify of recommendation. If no response at this 2nd attempt, the DON or designee will contact the Medical Director for orders following every scheduled dietary visit. All recommendations will be addressed within 24 hours of DON / designee receiving recommendations from dietician. All current recommendations were communicated to the MD/Nurse Practitioner, have been addressed, agreed with dietician recommendations, order written and noted in the medical records, transcribed onto MAR, communication forms given to dietary department for all diet changes, and supplement orders. New orders are being administered as directed. 3. All Licensed staff in-serviced by nurse management on notifying DON when Dietary Recommendations have been received from the MD or Nurse Practitioner after every scheduled dietary visit. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. DON is responsible for tracking of the dietary recommendations and ensuring they are followed up on within the specified time frame. 4. All Licensed Staff were in-serviced by nurse managers regarding administration of treatments and medications. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. In-service included what the nurse must do when the medication is not received from the pharmacy when ordered. The nurse must notify the MD immediately to make aware of med not available in order to adjust treatment regimen. Nurse must notify MD of med allergies [REDACTED]. When a medication has to be held due to abnormal vital signs the MD must be notified immediately. Interventions Issue #2: 1. All Licensed Staff were in-serviced by management nurses regarding transcribing all MD orders per policy and procedure. POLICY: When an order is received from the MD, it must be transcribed to an order sheet, the order must be transcribed exactly as it is ordered to the MAR. The nurse must implement the order as transcribed. All orders must be documented in the clinical records stating the order was received, the RP was notified and order initiated. The new order will be documented on the 24 hour report for continuum of care. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. 2. All Licensed Staff were in-serviced by management nurses regarding transcription and implementation of all tube feeding changes and supplements as per physician orders. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. Interventions Issue #3: 1. Licensed Staff were in-serviced by nurses managers regarding completing dietary communication form for all new diet orders or changes prior to working the floor beginning on 3/26/15 and will be completed by 3/31/15. Monitoring: 1. Nurse Managers will verify a dietary communication form was complete for all new diet orders or diet changes and supplements in daily start up meeting. Process improvement began: 3/27/2015 2. Nurse Managers will review all new orders in daily start up meeting to ensure transcription to medication administration records is accurate and complete. Process improvement began: 3/27/2015 3. Nurse Managers will review 24 hour report in start- up process to identify any resident who has refused medications or have had to hold medications due to doctor ' s order for parameters. The managers will review documentation to verify notification to the physician. Process improvement began: 3/27/2015 4. Nurse Managers will monitor medication transcription of medications are accurate in daily start up process. Process improvement began: 3/27/2015 5. Nurse Managers will verify all dietary orders and recommendations are transcribed and implemented in daily start up meeting. Process improvement began: 3/27/2015 6. DON will monitor supplements to ensure the process for administration is being followed to ensure that all residents requiring supplements are receiving it as ordered at it specified time, right amount to be consumed. (Health shakes , and magic cups are listed on the resident ' s tray cards to be served from Nutrition Department and ordered (with or between meals.) Med pass, can supplements (Nepro, Glucerna, Ensure, etc)as ordered on the MAR, will be administered by nurse during medication pass. The hydration /snack cart contains among other items, labeled Health shakes, magic cup if ordered between meals. Process improvement began: 3/27/2015 Monitoring of the plan: Record review of the facility inservices revealed 17 out of 20 licensed nursing staff were inserviced for notification to physician, verification of orders and allergies [REDACTED].(SBAR) form. Record review of the facility inservices revealed 29 out of 37 unlicensed nursing staff were inserviced for notification to the nurse and completion of the stop and watch form. Interviews on 4/2/15 with 11 out of 12 licensed nursing staff on duty identified the need to call the physician for changes in the resident's condition, weight loss, medication or treatment refusal, no relief from pain medication, abnormal lab values, medication not available, abnormal vital signs, verification of orders and allergies [REDACTED]. Interviews on 4/2/15 with 9 out of 10 unlicensed nursing staff and three therapy staff identified the need to complete the stop and watch form and notify the nurse for any complaint of pain or change in the resident. Record review of Resident #'s 62, 15, 30 and 86's clinical record reveal lab results were called to the physicians. Resident #30's blood pressure was low on 4/1/15 which required her blood pressure medication to be held. The physician was notified. Record review of the resident's with weekly weights revealed completed with no changes. The dietician was in the facility on 4/2/15. Observations on 4/1/15 and 4/2/15 revealed Residents #'s 59, 100 and 72 received and completed the dietary recommended supplements. Observation on 4/2/15 revealed Resident #73 received his ordered tube feeding bolus. Observation on 3/28/15, 3/29/15, 3/30/15, 3/31/15, 4/1/15 and 4/2/15 revealed Resident # 15's tube feeding was infusing at 65ml per hour. The resident heels were floated and the catheter was removed as ordered on [DATE]. An immediate jeopardy (IJ) was identified on 3/26/2015 . While the IJ was removed on 4/2/2015 the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the following of physician's orders [REDACTED]. The facility 672 form revealed the census was 108 residents.

Based on observation, record review and interview the facility failed to provide the necessary pain management and appropriate medication treatments to attain or maintain the highest practicable physical, mental and psychosocial well-being according to the comprehensive assessment for two of 10 residents (Resident #70 and #30) assessed for pain management and quality of care Resident #70 ' s pain was not effectively controlled. The facility failed to assess her pain and medicate her for pain. She ran out of pain medications for 6 days and she experienced severe pain with pain score of 10. During treatment for [REDACTED].#4 failed to assess and medicate her for pain. Resident #70 was grimacing in pain and LVN #4 did not stop and continued with the treatment. Resident #70 was found to have new multiple open areas with excoriation to inner thighs and gluteal fold which were not identified and addressed. Resident #70 had nutritional problems and the physician ordered to give her [MEDICATION NAME] to stimulate her appetite. The facility failed to give her this medication and the physician was not notified. Resident #30 was given antibiotics to which she was allergic. The facility failed to check Resident #30 ' s list of allergies [REDACTED]. This failure affected one resident who suffered with chronic pain and one resident who was at risk of various allergic reactions and placed 39 residents on pain management and 65 residents in the facility at risk of poor care and increased pain which could cause a decline in their medical, physical and mental health. An IJ was identified on 3/26/2015. While the IJ was removed on 4/2/2015 the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on assessing and the management of pain. Findings include: Intake # 7 Resident # 70 Record review of Resident # 70 face sheet revealed a [AGE] year old female admitted to facility on 6/27/13 with the following diagnose: hypertension, diabetes mellitus, depression, congestive heart failure, muscle weakness, obesity and ends stage kidney disease. Record review of Resident #70 ' s care plan dated 7/13/13 with no update date revealed Resident #70 has impaired comfort related to chronic pain, complaint of pain, [MEDICAL CONDITION]. The care plan goal with target date" ...Resident will have relief from pain when as needed (PRN) medication is used over 90 days with the target date of 5/14/15 ..." Approaches " ...Give PRN pain medication according to physician ' s orders ...Notify physician and responsible party if pain medication is not effective in relieving pain ... observe for effectiveness of PRN pain medications ..." Record review of Resident # 70 ' s MDS dated [DATE] revealed the resident was moderately impaired for cognition and received as needed pain medication. Record Review of Resident #70's prescription for [MEDICATION NAME] with APAP ([MEDICATION NAME]) 10/325 mg was dated as being ordered by the physician on 11/12/2014. Record review of Resident #70 ' s MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the back of the MAR indicated [REDACTED]. Record review of Resident #70 ' s MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED]. Record review of Resident # 70 ' s nurse ' s notes dated 3/3/15 revealed at 9:22 p.m., "...resident continued to complain of pain to buttocks areas, resident given pain medication twice, resident continued to be monitored for increased pain." Record review of Resident # 70 ' s nurse ' s notes dated 3/4/15 revealed at 10:07 p.m., "...resident was medicated for pain." Observation on 3/10/15 at 12:10 p.m., revealed Resident #70 in bed moaning in pain. The resident verbalized she had generalized pain of 10 on a scale of 0-10. She was medicated for pain following the complaint of pain by staff. Further observation on 3/10/15 at 1:30 pm., revealed Resident # 70 complained of pain being present. Wound care that was scheduled was held due to the resident's pain. Interview on 3/10/15 at 1:35 p.m., LVN # 4 said the resident had not refused wound care due to pain and had not complained of pain during wound care until " today " . Observation and interview on 3/10/15 about 2:10 p.m., during wound care. Resident # 70 said it was ok to perform wound care. Resident # 70 moaned in pain whenever sacral/buttocks wounds were cleaned or touched by LVN # 4 and when she was repositioned. Further observation revealed LVN # 4 did not acknowledge the resident moaning in pain throughout the wound care. Resident # 70 verbalized her buttock was hurting during the wound care. Resident # 70 was noted with large stage II pressure ulcer from left buttock extending to her right buttock and the sacral area. The wound bed did not show any slough or eschar, but had mild drainage. Resident #70 was found to have multiple open areas to inner thigh and excoriations to the perineal areas. She also had an unstageable wound to her left heel. Interview on 3/10/15 following wound care, Resident # 70 ' s family members said that the resident had never been assessed nor medicated for pain before wound care treatment. They said that Resident #70 would moan in pain during treatment and the nurse would not stop and would continue with the treatment. Resident #70 would just continue to moan. Interview on 3/10/15 following the above observation, Resident # 70 ' s family member reported she notified LVN# 4 of multiple open areas she identified on the resident but LVN # 4 did not follow up and did not assess the resident. Interview on 3/10/15 about 3:00 p.m., LVN # 4 said the resident ' s family notified her of the skin excoriations on Resident # 70's inner thighs. She said staff had been applying barrier cream to the excoriated red area but she had not seen the open areas since it was reported to her by the family. Record review of the Individual Narcotic sign out sheet identified as [MEDICATION NAME] for Resident #70 revealed on 3/20/15 at 10:00 A.M. the remaining [MEDICATION NAME] count was one tablet remained. Continued review revealed the last [MEDICATION NAME] was removed and administered on 3/24/15. Interview on 3/29/15 at 1:46 P.M. the DON stated she did not know why the resident ran out of her [MEDICATION NAME] Record review of the facility " Pain Roster " dated 3/1/15 thru 3/31/15 revealed the resident reported the following level of pain based on a 1-10 pain scale with 10 being the worst pain ever experienced on the following dates: 3/20/15 resident ' s pain intensity was 10 3/21/15 resident ' s pain intensity was 10 at 10:57 A.M. and 6:11 P.M. 3/22/15 resident ' s pain intensity was 10 at 12:44 P.M. and 7:08 P.M. 3/26/15 resident ' s pain intensity was 5 at 11:29 P.M. 3/28/15 resident ' s pain intensity was 10 at 9:44 P.M. 3/29/15 resident ' s pain intensity was 10 at 1:19 P.M. Observation on 3/29/15 at 12:36 P.M. revealed Resident #70 in bed awake and alert. Interview on 3/29/15 at 12:36 P.M. during the observation Resident #70 stated her pain intensity level was 7. Resident #70 continued and stated she was out of the [MEDICATION NAME] and was getting [MEDICATION NAME] instead. She stated [MEDICATION NAME] did not work like the [MEDICATION NAME] on her pain. Observations on 3/29/15 at 2:00 P.M. with the DON and at 2:11 P.M. with LVN #3 of the medication cart narcotic box revealed a bubble pack for [MEDICATION NAME]. Continued observation revealed no bubble pack for [MEDICATION NAME] for Resident #70. Interview on 3/29/15 at 2:11 P.M. LVN#3 stated Resident #70 was getting [MEDICATION NAME] 50 mg and [MEDICATION NAME] 10/325 mg every six hours as needed for pain. LVN#3 continued and stated when she realized the [MEDICATION NAME] was out on Saturday (March 28, 2015) she called the pharmacy to request a refill but she was told she needed triplicates. She continued and stated she called the physician to notify him that she needed a triplicate prescription. The doctor questioned why he was not notified during the week. LVN#3 stated she only worked on weekends and she did not know. The physician stated the resident would have to wait until Monday. Record review of Resident#70 ' s physician ' s order dated 3/29/15, Sunday revealed discontinue [MEDICATION NAME] 10/325 every six hours as needed for pain start Tylenol with [MEDICATION NAME] #3 every four hours as needed for pain. Record review of Resident #70 ' s MAR indicated [REDACTED]. Observation on 3/30/15 at 8:15 A.M. revealed Resident #70 was in bed grimacing and holding her left arm. Interview on 3/30/15 at 8:15 A.M. Resident #70 stated they let the [MEDICATION NAME] ran out about a week ago and they were giving the [MEDICATION NAME] and Tylenol which did not work. The resident stated she was having overall chronic body pain and reported her pain intensity on a scale of 1-10 was 9 and a half "at this time ". She continued and stated she did not go to sleep until 4:00 A.M. " this morning " because of the pain. Resident #70 stated " how do you let someone ' s pain medicine run out? " Interview on 3/30/15 at 8:25 A.M. LVN #4 said that the physician ordered another pain medication, Tylenol #3, " yesterday " , but Resident #70 did not want Tylenol #3 because it did not relieve her of pain. She only wanted [MEDICATION NAME] because it was the only pain medication that she had used that helped her with pain. Observation on 3/30/15 at 8:25 A.M. revealed LVN #4 called the physician to reorder [MEDICATION NAME] since Resident #4 had ran out of it. Interview on 3/30/15 at 8:40 A.M. LVN#14 stated when she noticed a resident ' s medicine was about to run out she called the pharmacy for refills and if it cannot be refilled she notifies the physician. She stated she does not notify the DON but will notify the next on coming nurse during report and if she worked the next day she would call the pharmacy and physician again. Interview on 3/30/15 at 9:15 A.M. Resident #70 stated she received [MEDICATION NAME] and Tylenol #3 about 30 minutes earlier and her pain was about the same with no relief. She continued and stated she told her doctor last week she was out of pain medicine. Interview on 3/30/15 at 10:09 A.M. the DON stated she cannot remember any nurse notifying her about Resident #70 ' s [MEDICATION NAME] running out and last night she got an order for [REDACTED]. Interview on 3/30/2015 at 4:45 Resident #70 stated she had just returned from [MEDICAL TREATMENT]. She stated her pain was a 9 on a scale of 1-10 but the nurse just gave her a pain pill. She stated it was not a [MEDICATION NAME] but the nurse stated they had been ordered and should be coming from the pharmacy this evening. She stated the [MEDICATION NAME] was the only drug that was effective for her pain. Further record review of Resident #70 ' s clinical records revealed a physician order dated 3/3/15 for [MEDICATION NAME] 10 mg 1 tablet every night to stimulate the appetite. Record review of Resident #70 ' s MAR indicated [REDACTED]. Further record review revealed that the [MEDICATION NAME] was discontinued on 3/9/15. Record review of Resident # 70 ' s " Psychiatric Review /Mental Status Exam " dated 3/9/15 revealed " Primary care physician ordered [MEDICATION NAME] 10 mg every night for appetite but pharmacy has not delivered secondary to no 10 mg pill , will change to [MEDICATION NAME] 15 mg every night so they will send it " . Record review of Resident# 70 ' s progress notes revealed that there was no evidence indicating that Resident # 70 ' s physician was notified of the unavailability of the [MEDICATION NAME] 10 mg ordered 3/3/15. Interview on 3/10/15 at 11:34 a.m., LVN # 4 said the medication was supposed to have been delivered by the pharmacy. She said staff should indicate and document the reason on the back of the MAR indicated [REDACTED]. Record review of the drug reorder book on 3/30/2015 revealed a binder with dividers for 31 days in it. Behind the divider marked 30 there were several copies of phone orders and tear off slips from medication cards that had been attached to blank pages and faxed to the pharmacy. Interview on 3/30/2015 at 5:00 P.M. the Corporate Educator after being asked for the previous days of the month ' s pharmacy orders, stated the notebook was the corporate system which should have been used at the facility but was not. She stated prior to "today" the nurses had just been shoving the order forms into an accordion binder in the medication room. She stated there was no organization or filing system and there were several folders. She then stated she had started training the nurses to the corporate system. When asked how many nurses she had trained she stated two. When asked to see the in-service form for the two nurses she stated she had not made one out yet. The Corporate Educator was asked to see if she could find the reorder form for Resident #70's [MEDICATION NAME] which ran out on 3/24/2015. She stated she would try to find it. No reorder form was ever provided for review. Record review and interview of the in-service form dated 3/30/2015 concerning the medication reorder system revealed one nurse had signed they had been trained to the corporate medication reorder policy and procedure. Interview on 3/30/2015 at 5:10 P.M. the ADON stated she would order medications when the resident had a seven day supply left. She stated if it was a PRN medication she would use her nursing judgement and assess how many pills a day the resident was taking and then multiply that times 7 to give her a seven day supply. Interview on 3/30/2015 at 5:30 P.M. LVN #20 stated he reordered resident's medications when they had ten pills left. Interview on 3/31/15 at 9:30 A.M. LVN #19 sated she reordered medications on the seventh day before it runs out. She did the ninth day but she would be notified by pharmacy it was too early to refill. Interview on 3/31/15 at 9:36 A.M. LVN #4 stated it depended on the frequency of the medication but she reordered medications 7 days before it runs out. The turnaround time to get the medication depended on if there were any refills left on the medication or if it needed triplicate scripts. Record review of facility ' s policy on treatment of [REDACTED]. Resident # 30 Record review of Resident #30 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 30' s physician's order dated 3/20/15 revealed STAT Chest X-ray and start (antibiotic) [MEDICATION NAME] 500 mg, by mouth daily for 10 days for upper respiratory tract infection. Order was a telephone/verbal order from physician to staff. Record review of Resident # 30 ' s MAR indicated [REDACTED]. Record review of Resident #30 ' s MAR indicated [REDACTED] [MEDICATION NAME] 500 mg PO daily for 10 days. Medication time was 7 a.m. Further review of the March MAR indicated [REDACTED]. Record review of Resident # 30 ' s nurse notes dated 3/23/15 at 2:39 p.m., revealed " resident on [MEDICATION NAME] for upper respiratory tract infection, pharmacy notified writer that Resident # 30 was allergic to [MEDICATION NAME]. Day 2 on medication. No adverse reactions noted. Called MD four times , still waiting for return call. Temperature was 98.7, will continue to monitor for status changes " . Record review of Resident # 30 ' s nurse ' s notes revealed addendum " late entry for 3/21/15: notified MD of allergy to [MEDICATION NAME], initial dose was given, no adverse effects from [MEDICATION NAME] observed " . Record review of Resident #30 ' s nurse notes dated 3/23/15 at 2:58 p.m., revealed new order to discontinue [MEDICATION NAME], start [MEDICATION NAME] 500 mg PO today than 250 mg PO Tuesday, Wednesday, Thursday and Friday. Observation and interview on 3/26/15 at 9: 52 a.m., Resident # 30 was in bed. She stated she had an upper respiratory infection and was receiving antibiotic treatment for [REDACTED]. Interview on 3/26/15 at 12:15 p.m., the ADON said she called pharmacy to inquire why the [MEDICATION NAME] for Resident # 30 was not yet supplied and was told it was because Resident # 30 was allergic to [MEDICATION NAME]. She then called the physician to notify him and got new order. The ADON said the resident had no known adverse reactions. Interview on 3/26/15 about 12:00 p.m., LVN# 4 said she said she did not see the resident ' s allergies [REDACTED]. LVN# 4 further said she could have looked up the resident ' s allergies [REDACTED]. She expressed it did not occur to her to check Resident # 30 ' s allergies [REDACTED]. Record review of the facility policy titled " Medication Ordering " undated revealed " ... Goal: To ensure all medication, pursuant to a valid physician order, are available in the facility at all times ...Nurses should reorder medications when they were down to five to seven day supply. Nursing must identify the refill is in the facility when they were down to three day supply and place the refill card at the medication cart ...Nurse manager should verify all nurses have been in service on medication order/reorder system. Re-order book should be audited on a daily basis to verify all med orders can be accounted for. Medication carts should be audited on a weekly basis to verify no less than a three day supply of medications was available." Record review of facility ' s policy on pain assessment and management dated 11/14 revealed that continuing assessment of the pain management program should occur daily and should focus on the effectiveness of the program and the comfort level of the resident. Pain should be assessed and documented at regular intervals, as necessary and in accordance with the pain management program . Evaluation of the effectiveness of the [MEDICATION NAME] medications in relieving pain to a level that is acceptable to the resident should occur. A policy was requested concerning the reviewing of resident information for allergies [REDACTED]. An IJ was identified on 3/26/2015. A plan to remove the IJ was submitted and accepted on 3/29/2015. The Plans of removal included: Immediate interventions implemented for the resident with pain: 1. Resident #70 - Resident was immediately assessed for pain by DON and noted her pain to be rated at a (7). Resident was administered [MEDICATION NAME] 50mg 1 PO and Tylenol 325 mg 2 tabs PO at 8:15 pm. At 9:00 pm resident was asleep and no compliant of pain. Resident ' s [MEDICATION NAME] 5/325 mg P O q 6 hours arrived at facility around 11:40 pm and resident received a dose as it was changed to routine administration. Resident will be assessed also before during and after treatment , as well as before leaving facility for [MEDICAL TREATMENT] and returning. Immediate interventions implemented for resident as it relates to medication and treatment not being administered as ordered: 1. Resident #70 - On 3/9/2015 [MEDICATION NAME] 10mg 1 tab PO QHS ordered on [DATE] was discontinued. Corrected order for [MEDICATION NAME] 15mg 1 tab PO qHS submitted to pharmacy for delivery. Medication was received in facility and initiated on 3/10/2015. Immediate interventions implemented to include all residents residing in facility that could be affected by an effective system not being in place and monitored to identify residents at risk for pain, or who are experiencing actual pain. 1. 100% audit of current census was conducted by Nurse Managers to ensure all residents with pain were addressed, by completing a new pain assessment for all residents and any residents noted to be experiencing any pain were given medication if they were prescribed. Any resident without pain medication orders, MD was notified for an order for [REDACTED]. 2. Based on 100% audit of pain assessments all Care plans were updated to include interventions to manage pain and include alternate means of pain relief. INITIATED: 3/31/2015 COMPLETED: 3/31/2015 3. Pain assessment roster was reviewed for 100% of resident to ensure that anyone with documented pain has medications available and given as ordered by the physician. INITIATED: 3/30/2015 COMPLETED 3/31/2015 4. 100% audit of current pain meds on hand by nurse managers, to ensure all residents have at least 5 day supply of current pain medication available. Any residents with less than 5 day supply will have medications reordered. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 5. Residents will be assessed on admission and quarterly for pain management. All nurses were re-educated on doing pain assessments. Residents who have been identified of having pain will have pain per pain monitored per pain roster every shift and as needed. INITIATED: 3/30/2015 COMPLETE 3/31/2015 6. Physician will be notified by the charge nurse of any resident who does not experience relief from pain with current pain regimen within 2 hours of medication administration for further interventions to reduce pain to a level that is tolerable for the resident. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 7. Residents will be assessed by charge nurse for pain each shift, and during and after treatments. Interventions will be implemented per orders, or MD will be notified by charge nurse if current regimen is not effective for new orders. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 8. Charge nurses were in-serviced on the process for reordering medication: The nurse will re-order pain medication when there is a 7 day supply remaining. MD will be contacted for triplicate prescription if required, during business hours prior to 7th day to ensure resident has pain medication available at all times. When the nurse receives the narcotic from the pharmacy delivery, pharmacy reconciliation binder will be updated, medication counted and placed in secured drawer in the medication cart. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 9. Nurse Managers will re-educate and or implement progressive disciplinary actions for any nurse who fails to assess, and manage resident pain or ensure at least a 7 day supply of medication is on hand at all times. Monitoring: 1. Nurse Managers will review pain roster daily in the morning meeting to identify all residents that had documented pain levels to ensure each resident received meds routinely, or prn to manage the pain. Process improvement began: 3/30/2015 2. Nurse Managers will review med carts daily with the start up to ensure the residents have at least a 7 day supply of meds for administration. The meds that are close to 7 day refill are called to the physician for the needed triplicate. Process improvement began; 3/30/2015 3. Nurse Managers will review the pharmacy reconciliation binder daily in start-up to verify pain medications ordered were received. Process improvement began: 3/30/2015 4. Department heads will ask resident daily on their guardian angel rounds if they are experiencing any pain, and if the resident states they are the department head will immediately notify the charge nurse, and complete a " Stop & Watch " to ensure the pain was addressed. The department head will present a copy of the stop & watch to the DON for assurance of follow up. Process improvement began: 3/31/2015 Immediate interventions implemented for residents as it relates to MD notification of resident allergies [REDACTED]. Resident #30 - On 3/23/2015 [MEDICATION NAME] 500mg PO X 10 days was D/C ' d after two doses were given. [MEDICATION NAME] 250 mg PO QD was ordered and initiated on 3/23/2015. Resident was assessed for any allergic reactions to the medication and none noted. Stop date 3/29/2015. Interventions Issue : All Licensed Staff were in-serviced by nurse managers regarding notification of allergies [REDACTED]. Nurses were in serviced on noting allergies [REDACTED]. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. Monitoring: Nurse Manages will monitor that residents do not have an allergy to new medication orders in start-up meeting. Process improvement began: 3/27/2015. Monitoring of the plan to lower the immediate jeopardy: Record review of the facility in-services revealed 17 out of 20 licensed nursing staff were in-service to assess the resident's pain level every shift and to notify the physician for any pain not relieved ,any changes in the resident's condition, weight loss, medication or treatment refusal, abnormal lab values, medication not available, abnormal vital signs. To complete a stop and watch form and the physician notification form: situation, background, assessment , response (SBAR) form. Record review of the facility in-services revealed 29 out of 37 unlicensed nursing staff were in-serviced for notification to the nurse if the resident complained of pain and completion of the stop and watch form. Interviews on 4/2/15 with 11 out of 12 licensed nursing staff on duty identified the need to assess the resident's pain level every shift, before and after administering pain medications and for any changes in the resident's condition, weight loss, medication or treatment refusal, abnormal lab values, medication not available, abnormal vital signs. Interviews on 4/2/15 with 9 out of 10 unlicensed nursing staff and three therapy staff identified the need to complete the stop and watch form and notify the nurse for any complaint of pain or change in the resident. Record review of Resident #30's Medication Administration Record [REDACTED]. Record review of Resident #70's physician order's and Medication Administration Record [REDACTED]. and topically ointment to heel wound. Record review of Resident #70 physician order and Medication Administration Record [REDACTED]. Record review of Resident #70's pain roster, nurse's notes, pain assessment sheet and Medication Administration Record [REDACTED]. Record review and interviews with three residents on pain management revealed their pain was being assessed each shift. The resident's had no complaints concerning the management of their pain. Observations and interviews with Resident #70 on 3/31/15, 4/1/15 and 4/2/15 revealed the resident was getting her medication for pain and the staff was asking her pain level. The resident continued and stated she was feeling much better, her pain was in control and she was sleeping at night. The Administrator was informed on 4/2/2015 the IJ was lowered after verification of the plan implementation had occurred. While the IJ was lowered on 4/2/2015 the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on the procedure on pain assessment, management of pain, reordering of medications and the procedure of checking resident ' s charts for allergies [REDACTED]. Facility CMS form 672 dated 3/24/14 listed 40 resident were on a pain management program and 18 residents had pressure ulcers. The census of the facility was 108.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status , such as body weight, based on the comprehensive assessment and failed to consult the physician and implement the dietitian ' s recommendations on six of 12 residents (Resident #s 73, 15, 59, 100, 72, and 65) reviewed for weight loss and dietitian recommendations not being initiated. The physician was not contacted regarding dietary recommendations nor were the dietitian ' s recommendations implemented when: Resident #73 had a weight loss of forty pounds in five months. Resident #15 had a weight loss of 20 pounds in three months. Resident #59 had a weight loss of 9 pounds for one month. Resident #100 had a weight loss of 9 pounds for one month. Resident #72 had a weight loss of 11 pounds in two months. Resudent #65 had a weight loss of 14 pounds in one month. An immediate jeopardy (IJ) was identified on 3/26/2015. While the IJ was removed on 4/2/2015 , the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the monitoring and management of resident's weight. This failure affected six residents who continued to loose weight because dietary recommendations were not implemented and placed 18 residents at risk of weight loss which could cause a decline in the mental and physical health. Findings include: Resident #73 Record review of Resident # 73 ' s face sheet revealed he was a [AGE] year old male, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident # 73 ' s Minimum Data Set ((MDS) dated [DATE] revealed her Brief Interview for Memory Status (BIMS) score was 4 which indicated he was severely cognitively impaired. Record review of the same MDS revealed the resident ' s weight was 191 pounds. Record review of Resident #73 ' s MDS dated [DATE] revealed his weight was 172 pounds and his height was 71 inches. The weight loss between 10/17/2014 and 1/09/2015 was not identified on the form. Record review of Resident #73 ' s care plan with a problem onset date of 02/10/15 revealed "...Potential for unintended wt. loss R/T dysphagia inadequate intake of meal AEB coughing while swallowing. Weight loss of 5% in the last 30 days ..." Approach listed "...Notify MD/RP of wt. loss of additional 2# despite interventions ..." Record review of Resident # 73 ' s physician ' s orders dated 03/02/15 revealed "... discontinue Nutrien 2.0 cal at 30 ml/hr and change to Nutrien 2.0 cal bolus per GT QID Resident is NPO ... order dated 03/04/15 revealed ... change feeding to [MEDICATION NAME] 1.5 one can bolus QID. Record review of Resident #73 ' s care plan with a problem onset date of 03/04/15 update revealed "...Resident has feeding tube R/T Dx dysphagia AEB Resident has silent aspiration and alteration in airway clearance. At risk for weight loss ..." Approach listed "...will monitor patients monthly weights ...will notify MD/RP of any weight loss..." Record review of the facility " Weight Change History " form dated 03/12/15 revealed Resident #73 ' s weight history as follows: 10/10/14 191.20 pounds 11/10/14 171.20 pounds 12/09/14 171.80 pounds 01/10/15 173.80 pounds 02/10/15 149.20 pounds 03/03/15 151.20 pounds Record review of Resident # 73 ' s weight history untitled and undated provided by the facility's dietician revealed the following weight history: 12/10/14 171.8 pounds 01/29/15 173.8 pounds 03/05/15 151.2 pounds Record review of the following dietary notes for Resident # 73 revealed: 12/10/14 ...171.8 pounds wt. stabilized this month ... wt. loss 15.5 pounds 8.2% down BW x 3 months ... no documentation of IBW(ideal body weight). 01/29/15 ...173.8 pounds wt. stable trending up + 2 months wt. loss of 17.4 pounds 9.1% over 3 months ... 03/05/15 ...March wt. 151.2 pounds wt. stable x 1 month Question 24.8 pound wt. loss for 1 month. Wt. loss 20.6 pounds 11.9% x 3 months 36.1 pounds 19.2% ..On TF [MEDICATION NAME] 1.5 bolus 1 can QID. Flush 150 cc H20 Q4h. Resident NPO ...Recommend change from 1.5 formula QID to a 2.0 formula QID. TF to provide 1900 kcal, 79.8g protein and 664 cc fluid/day ...recommend weekly wts x 4 weeks ... The same note revealed the resident was loosing weight but did not visually look like he was loosing weight but recommendations to DON to increase tube feeding and place on weekly weights. Record review of Resident #73' s physician ' s orders, physician ' s progress notes and nurse ' s notes for March 2015 did not reveal the physician was notified of the recommendations. Observations of Resident #73 on the following dates and times revealed the resident was unable to communicate. 3/11/15 at 5:45 P.M. 3/12/15 at 8:30 A.M., 8:58 A.M., and 1:47 P.M. Interview on 03/12/15 at 8:30 A.M. ADON-Staffing revealed Resident #73 does not take anything by mouth. She stated even his meds were given by [DEVICE]. She stated his feeding was [MEDICATION NAME] 1.5 bolus QID and she was getting ready to feed him right now. Interview on 3/12/15 at 12:45 P.M. RD/LD stated he recommended a tube feeding increase on 03/05/15 from [MEDICATION NAME] 1.5 bolus 1 can QID to 2.0 formula QID to provide 1900 kcal due to Resident #73 ' s 20.6 pound weight loss between 01/29/15 and 03/15/15. He stated the [MEDICATION NAME] 1.5 was only providing 1420 kcal. He continued and stated he did not know if the physician was notified of the recommendations. He stated he made the recommendations and gives them to the Director of Nursing (DON) who then was to notify the physician. He further stated he recommended weekly weights for Resident #73. Resident #15 Record review of Resident # 15 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident # 15 ' s consolidated physician ' s orders dated March 2015 revealed "... [MEDICATION NAME] 1.2 at 60 ml per hour for 22 hours ..." order and start date was 9/10/14. Record review of the same physician's orders did not reveal the resident received intravenous therapy (IV) or oral feedings. Record review of Resident #15 ' s Minimum Data Set ((MDS) dated [DATE] revealed her Brief Interview for Memory Status (BIMS) the resident ' s cognitive pattern was 3 which indicated she was severely impaired for daily decision making (rarely/never made decisions). The MDS revealed the resident was totally dependent on staff for eating. Record review of the same MDS revealed the resident ' s weight was 126 pounds with 51% or more of her total calories received through a tube feeding and her average fluid intake was 501 cc per day from tube feeding. Record review of Resident#15 ' s care plan dated 6/5/14 with no update revealed the problem related to [MEDICAL CONDITION]"... Resident #15 has tube feeding related to impaired swallowing, at risk for weight loss resident was receiving [MEDICATION NAME] 1.2 at 60 ml per hour for 22 hours." Record review of Resident #15 ' s MDS dated [DATE] revealed her weight was 117 pounds. The weight loss was identified and " not on a physician prescribed weight loss regimen " ... with 51% or more of her total calories though tube feeding and her average fluid intake was 501 cc per day from the tube feeding. Record review of the facility " Resident Current Weight List " dated 11/15/14 revealed Resident #15 ' s weight was 126.4 pounds, new weight undated was 113.4 pounds and weight dated November 15-16, 2014 was 115.2 pounds. Record review of Resident #15 ' s weight history untitled and undated provided by the facility dietician revealed the following weight history: 10/10/14-126.4 pounds 11/10/14-115.2 pounds 12/9/14-115.0 pounds 1/10/15-110.6 pounds 2/10/15- 112.6 pounds Record review of Resident #15 ' s " Initial Dietary Assessment " undated revealed the resident ' s diet was nothing by mouth " NPO " Record review of the following dietary notes for Resident #15 revealed at the top of the form (not dated) the resident's ideal body weight was 105 pounds. The dietary notes revealed on the following dates: ... 8/28/14 August 117.2 pounds weight loss 9.2 pounds 7.2 % per month stage III wound ... recommended increase tube feeding [MEDICATION NAME] 1.2 to 65 ml per hour ... ...11/25/14 November at 115.2 pounds ...11.2 pound decrease down 8.8% in 3 months... ...1/15/15 January at 110.6 pounds. Weight loss restarted weight down 15.8 pounds 12.5 % in 3 and 6 months ....recommended [MEDICATION NAME] 1.2 at 65 ml per hour for 22 hours... ...2/12/15 dietary notes revealed February weight pending January at 110.6 pounds ...recommend increase tube feeding to [MEDICATION NAME] 1.2 at 65 cc per hour. Record review of Resident #15' s physician ' s orders, physician ' s progress notes and nurse ' s notes did not reveal the physician was notified of the dietary recommendations for 1/2015 or 2/2015. Observations of Resident #15 on the following dates and times revealed the resident was non-verbal. Her oxygen was per [MEDICAL CONDITION] collar and her tube feeding was running on a pump at 60 ml per hour: 3/10/15 at 10:22 A.M. and 1:10 P.M. 3/11/15 at 10:30 A.M., 11:31 A.M. 12:48 P.M. and 4:00 P.M. 3/12/15 at 8:00 A.M. and 11:00 A.M. Interview on 3/12/15 at 8:35 A.M. RD/LD (Registered Dietitian/Licensed Dietitian) stated he visited the facility four times a month, one time a week. He stated his priority was new and readmitted residents, residents with weight loss and pressure ulcers and then residents with weight gain. The RD/LD stated he recommended a tube feeding increase in August and the resident was on hospice at that time. In September Resident #15 was in the hospital and in February another recommendation to increase her tube feeding to 65 ml per hour was made. He continued and stated he did not know if the physician was notified of the recommendations. He stated he made the recommendation and gave them to the Director of Nursing (DON) who then was to notify the physician. He stated Resident #15 warranted weekly weights when her weight moved from 126 pounds to 115 pound then 110.6 pounds. He stated he did not know if they were ever done but they were not recorded on the weight list he was provided. Interview on 3/12/15 at 12:45 P.M. the ADON -skilled stated the DON or Dietician could recommend weekly weights. She stated when the dietician makes a recommendation the quality nurse or the DON notifies the physician. Record review of Resident #15's physician's telephone order dated 3/12/2015 revealed an order to increase the resident's tube feeding to 65 cc per hour for 22 hours. Record review of Resident #15's March 2015 MAR revealed the resident was to receive [MEDICATION NAME] 1.2 at 60 cc per hour. The physician's order dated 3/12/2015 had not been transcribed to the March MAR. Observation on 3/25/15 at 3:50 P.M. revealed Resident #15 in the bed receiving O2 [MEDICAL CONDITION] 2 liter per. The feeding tube was dispensing [MEDICATION NAME] 1.2 at 60 cc per hour. Interview on 3/25/2015 at 4:05 P.M. the DON stated Resident #15's original dietary recommendation was one of the recommendations that had been overlooked but she had corrected the tube feeding order as of 3/12/2015. After reviewing the order, March MAR and the resident's tube feeding she stated she stated she remembered talking with the physician, writing the order and giving it to the nurse to transcribe to the MAR. She stated she would make sure it was transcribed now and the feeding changed. She also stated she would inservice the nurse on transcribing orders. Resident # 59 Record review of Resident # 59 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident#59 ' s care plan dated 3/5/14 with no update revealed the problem " altered nutrition less than body requirements " ... nutrition altered less than body requirements: receives therapeutic diet at risk for non-compliance with diet and weight loss. Record review of Resident #59 ' s MDS dated [DATE] revealed her BIMS score was 2 which indicated her cognition was severely impaired. The MDS revealed the resident required extensive assistance for eating. Record review of the same MDS revealed the resident ' s weight was 111 pounds. Record review of the resident weight change history " form revealed the following: 7/11/4- 116.4 pounds 8/10/14-112.2 pounds 9/10/14- 109.2 pounds 10/10/14- 108.4 pounds 11/10/14-111.0 pounds Record review of Resident #59 ' s MDS dated [DATE] revealed her weight was 110 pounds. The weight loss was identified and " not on a physician prescribed weight loss regimen Record review of the resident ' s dietary progress notes revealed at the top of the form the Resident #59's IBW (ideal body weight)was 135 pounds. 6/12/14 June weight 123 pounds ... 7/23/14 July weight 116.4 pounds ...weight loss 6.6 pounds 5.3% in one month ... Resident has a stage II wound ... 8/28/14 weight at 112.2 pounds this month ...weight loss 12.4 pounds 9.9% for 3 months ... 9/18/14 September at 109.2 pound ...weight loss 13.8 pounds 11.2% for 3 months 11.6 pounds loss 9.6% for 6 months. 10/30/14 October weight 108 pounds weight loss 12.8 pounds 10.5% ...on 10/20/15 [MEDICATION NAME] discontinued ... 11/25/14 November weight 111.0 pounds ... 2/26/15 February weight 110.2 pounds weight loss 9.6 pounds 8.0% for 1 month. Recommend to start Med Pass 120 cc orally three times a day for 30 days ... Record review of Resident # 59 ' s physician ' s orders, physician ' s progress notes and nurse ' s notes for February and March 2015 did not reveal the physician was notified of the resident ' s weight loss. Observation on the following dates and times revealed the resident sitting in the restorative dining room being assisted to eat: 3/10/15 at 1:15 P.M. 3/11/15 at 8:25 A.M. and 12:25 P.M. 3/12/15 at 8:55 A.M. Interview on 3/12/15 at 8:35 P.M. RD/LD stated it was suggested the resident go on tube feedings but the family declined. He continued the interview and stated in February, 2015 he recommended the resident go on Med Pass 120 ml three times a day for 30 days but he did not know if the physician was aware. It was up to the facility to notify the physician of the dietary recommendations. Record review of Resident # 59 ' s consolidated physician ' s orders dated March 2015 revealed "... Mighty Shakes three times a day with meals ..." order and start dated 7/8/14. Continued review of the physician's orders did not reveal the Med Pass 120 cc three times a day for 30 days. Interview on 3/12/15 at approximately 2:00 P.M. the DON stated she was unable to find documentation the physician was notified of the dieticians ' recommendation but he was notified of the recommendations as of today. Resident #100 Record review of Resident #100 ' s face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of Resident #100 ' s quarterly assessment dated [DATE] revealed the resident was on a therapeutic diet of no concentrated sweets. Record review of Resident #100 ' s care plan dated 2/6/15 revealed a problem of the resident had lost weight recently. The approaches included: dietician to evaluate Resident #100 ' s current nutritional status Record review of Resident #100 ' s dietary progress notes dated 8/7/14 revealed the resident ' s weight was 174.2 pounds. Dietary note on 1/8/15 revealed a weight of 173 pounds. Dietary note on 2/26/15 revealed a weight of 165 pounds which was a weight loss of 9 pounds, 5.1% but previously very stable. Recommend offer med pass (nutritional supplement) 90 cc twice daily for 30 days. Record review of Resident #100 ' s dietary recommendation for the physician dated 2/26/15 was as follows: Problem or concern: Mildly low [MEDICATION NAME] level. Weight loss of 9.0 pounds, 5.1% over past month. Recommendation: Offer med pass 90 cc by mouth twice daily for 30 days. Interview on 3/12/15 at 10:20 A.M. the RD/LD stated when recommendations were made they were given to the DON for follow-up with the physician. Interview on 3/12/15 at 11:30 A.M. the DON stated dietary recommendations were forwarded to her for follow-up and faxing. She stated sometimes the desk nurse will fax the recommendations to the physician but ultimately it was her responsibility to ensure the forms were faxed and returned. She said she could not find the forms previously faxed. She stated the physicians were called and they stated they had not received them. She said physician ' s orders were received today and she was taking responsibility for the recommendations not being done. Interview on 3/12/15 at 2:30 P.M. LVN #19 stated she was surprised that Resident #100 had a weight loss because the resident does eat. She said the resident does not always eat her meals from the facility but her family brings in food and her refrigerator was full of food that staff heats up for her when she is hungry. She also stated no one questioned Resident #100 ' s weight loss and re-weighed her. Resident #72 Record review of Resident #72 ' s face sheet revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #72 ' s care plan dated 10-22-2014 revealed a problem of the resident was at risk for weight loss with approaches of serving the diet as ordered by the physician and to have dietary consults as needed. Record review of Resident #72 ' s weight history revealed the following: 1-10-15 wt. 150.60 2-10-15 wt. 142.60 3-10-15 wt. 139.00 Record review of Resident #72 ' s dietary notes dated 2-23-15 revealed the dietitian had documented the resident had an eight pound weight loss and recommended the resident receive one can of Nepro every day for 30 days. Record review of Resident #72 ' s physician ' s orders and nurse ' s notes revealed no communication to the physician concerning the dietitian ' s recommendation. Record review of Resident #72 ' s MDS dated [DATE] revealed the resident was cognitively impaired. The MDS revealed the resident required the assistance of staff for all ADLs. Record review of Resident #72 ' s dietary notes dated 3-24-15 revealed the dietitian documented the resident had an additional weight loss of 3.6 pounds. The dietitian at this time recommended the resident was to be provided one can of Nepro two times a day for 30 days. Review of Resident #72 ' s physician ' s order dated 3-24-2015 revealed an order for [REDACTED]. Record review of Resident #72 ' s MAR dated March 2015 revealed no transcription of the Nepro order and no documentation of the resident receiving the Nepro. Observation and interview on 3-26-2015 at 8:30 A.M. revealed the resident eating breakfast in the dining room. The resident stated his meal was very good and he ate 90 percent of the meal. There was no Nepro served with the meal. Interview on 3-26-2015 at 8:30 A.M. LVN #10 stated Resident #72 received the Nepro on [MEDICAL TREATMENT] days. She stated it was packed by the dietary department. Interview on 3-26-2015 at 8:40 A.M. the Food Service Supervisor stated the dietary department supplied a sack lunch for the residents when they went to [MEDICAL TREATMENT]. She stated the sack lunch consisted of a sandwich, graham crackers and fruit along with a juice. She stated the dietary department does not dispense the Nepro drinks. She stated that would be supplied by the nurses. Interview on 3-26-2015 at 10:30 A.M. the DON stated she had spoken to the nursing staff and figured out the system at the facility was that all residents who had [MEDICAL TREATMENT] was given a can of Nepro on their [MEDICAL TREATMENT] days that was provided by the nurses out of the nourishment room. She stated that Resident #72 went to [MEDICAL TREATMENT] three times a week. She stated she would get the order transcribed to the MAR and in-service the nurses so Resident #72 would receive the Nepro twice a day as ordered. Resident #65 Record review of Resident #65's face sheet revealed he was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #65's care plan dated 9/8/2014 with no updates noted, revealed no care plan concerning the resident's nutritional status except that the resident was sad concerning his having a [DEVICE]. The care plan revealed the resident would be monitored and referred to counseling and a psychiatric evaluation. No approaches were listed for staff to provide. Record review of Resident #65's weight change history revealed the resident weighed 177.70 pounds on 1/10/2015 and 162.80 pounds on 2/10/2015. A 14.6 pound weight loss. Record review of Resident #65's Communication between the Dietitian and the Attending Physician form dated 2/26/2015 revealed the RD/LD recommended a health shake by mouth three times a day with meals for thirty days and weekly weights for four weeks. Record review revealed the recommendations were not communicated to the physician until 3/24/2015 when a physician's order was written for the health shakes to be served three times a day with meals. Record review on 3/26/2014 of the nurse's notes revealed the resident had been transferred to the hospital earlier that morning due to vomiting. Record review on 3/26/2015 of Resident #65's dietary card printed by the Food Service Supervisor did not have the health shakes added to the diet order. Interview on 3/26/2015 at 10:30 a.m. the DON stated the health shake order would be carried out by the dietary department due to it being served with meals. She stated the nurses had a form to communicate with the dietary department and would write the orders in the book of the forms and give a copy to dietary. When requested to see the communication form the DON was unable to locate where dietary had been notified to provide the health shakes. Record review of the facility policy titled "Nutrition" dated 7/13 revealed ...Based on the comprehensive assessment of the resident, this facility ensures that a resident: 1. Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible and 2. Receives a therapeutic diet when there is a nutritional problem... A policy for notification of the physician for changes in the resident status was received but did not address notification for changes in treatment. A policy for following up on dietitian ' s recommendations with the physician was requested but not provided prior to exit. An immediate jeopardy (IJ) was identified on 3/26/2015. A plan to remove the immediacy was accepted on 3/29/2015. The plan of removal included: Immediate interventions implemented for the following residents as it relates to weight loss and dietician recommendation not being communicated to physician: 1. Resident #15-TF order was verified, correct rate of feeding was administered, RP, and MD were notified of feeding rate error. 2. Resident #59- On 3/24/2015, MD was notified of dietary recommendation, that was written by dietician on 2/26/2015 to start weekly weights X 4 weeks, and offer Medpass 120cc TID X 30 days. Order was initiated on 3/27/2015, weekly wts started, and medpass administered and on MAR. 3. Resident #100- On 3/24/2015 MD was notified of dietary recommendation from dietician on 2/26/2015 to offer med pass 90cc PO BID X 30days. MD agreed with recommendation and order written, and implemented as of 3/24/2015. 4. Resident #73 On 3/12/2015, MD was notified of RD recommendation to D/C [MEDICATION NAME] 1.5 1 can per [DEVICE] QID, and start 2 Cal HN 1 can per [DEVICE] QID bolus. Order was implemented and initiated on 3/12/2015. 5. Resident #72 - On 3/24/2015 MD was notified of dietician recommendation received from dietician on 2/23/2015 to start weekly weights and start Nepro 1 can PO BID X 30days. MD agreed with recommendation and order was obtained and written and implemented and initiated on 3/26/2015. 6. Resident #65 - On 3/24/2015, MD was notified of dietary recommendation received on 2/26/2015 from dietician for weekly weights X4 and health shakes PO TID with meals X 30 days. MD agreed with recommendation, order written, resident went to hospital for unrelated health concerns prior to implementation of new orders. Immediate interventions implemented for residents as it relates to medications and treatments such as tube feedings and supplements being administered as transcribed: 1. Resident #15 - On 3/12/2015 MD was notified of dietary recommendation to increase TF of [MEDICATION NAME] 1.2 to 65cc/hr X 22 hour/ day. Weekly wts X 4. On at 10am off @ 8am. MD agreed, order transcribed on 3/26/2015, order was initiated. Weekly weights were D/C ' d as weights are stable. TF order was verified, correct rate of feeding was administered, RP, and MD were notified of feeding rate error. 2. Resident #72 - On 3/24/2015 MD was notified of dietician recommendation received from dietician on 2/23/2015 to start weekly weights and start Nepro 1 can PO BID X 30days. MD agreed with recommendation and order was obtained and written and implemented and initiated on 3/26/2015. Immediate interventions implemented to include all residents residing in facility that could be affected by an effective system not being in place and monitored to track residents who could be at risk for weight loss. 1. 100% audit of current census was conducted by Corporate Consultant Nurse to ensure weight variances were addressed, malnutrition assessments were completed for all residents to identify any at risk residents without a current weight loss INITIATED: 3/27/2015 COMPLETED: 3/29/2015 Care plans updated to include interventions to prevent weight loss. Dietician reviewed all residents with a significant weight loss. INITIATED: 3/26/2015 COMPLETED: 3/29/2015 100% audit of tube feeding orders to verify ordered formula was being given as per physician orders. INITIATED: 3/27/2015 COMPLETED: 3/27/2015 Corporate Dietitian audited 100% of dietary orders and supplement orders to verify Dietary Managers diet roster matches physician orders. Any discrepancies were corrected. INITIATED: 3/27/2015 COMPLETED: 3/28/2015 Corporate Dietitian conducted a 100% supplement order and delivery during meal service to verify supplements supplied by the kitchen were delivered as ordered. INITIATED: 3/27/2015 COMPLETED: 3/28/2015 Interventions Issue #1: 1. Residents at risk and those who had a significant weight loss will be identified by the management nurses to begin on 3/26/15 and complete by 3/27/15. Any resident identified to be at risk were assessed, RD, & MD were notified to determine whether a change in treatment regimen was required. 2. In-serviced initiated by Corporate QA Nurse Consultant on the system for notification of MD of residents with weight loss and will continue to be conducted by a nurse manager prior to nurse working their shift, began on 3/26/15 and will be completed by 3/31/15. SYSTEM: Weights will be reviewed weekly during the weight meeting. Variances will be assessed and interventions will be put into place. The responsible party, dietician, and physician will be notified and documented on the " weight variance assessment " form. A " registered dietician referral " form will be completed. As well as a " Dietary Acute Care plan. " If the resident triggers for significant weight loss, a " physician certification of unavoidable decline in resident condition " will be completed and signed by the physician. 3. MD/Nurse Practitioner will be contacted by DON or Designee with all dietary recommendations and the DON will monitor MD response/orders and ensure all recommendations have been addressed. If MD does not respond within 24 hours the DON or designee will make a second attempt to notify of recommendation. If no response at this 2nd attempt, the DON or designee will contact the Medical Director for orders following every scheduled dietary visit. All recommendations will be addressed within 24 hours of DON / designee receiving recommendations from dietician. All current recommendations were communicated to the MD/Nurse Practitioner, have been addressed, agreed with dietician recommendations, order written and noted in the medical records, transcribed onto MAR, communication forms given to dietary department for all diet changes, and supplement orders. New orders are being administered as directed. 4. All Licensed staff in-serviced by nurse management on notifying DON when Dietary Recommendations have been received from the MD or Nurse Practitioner after every scheduled dietary visit. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. DON is responsible for tracking of the dietary recommendations and ensuring they are followed up on within the specified time frame. Monitoring: Administrator and DON will utilize the Dietary Recommendation Tracking Form to monitor notification of MD and timely return of Dietary Recommendations. Process improvement began: 3/27/2015 Monitoring Record review of the facility inservices revealed 17 out of 20 licensed nursing staff were inserviced for notification to physician for any changes in the resident's condition, weight loss, medication or treatment refusal, no relief from pain medication, abnormal lab values, medication not available, abnormal vital signs. completion of a stop and watch form and the physician notification for: situation, background, assessment , response (SBAR) form. Record review of the facility inservices revealed 29 out of 37 unlicensed nursing staff were inserviced for notification to the nurse and completion of the stop and watch form. Interviews on 4/2/15 with 11 out of 12 licensed nursing staff on duty identified the need to call the physician for notification for any changes in the resident's condition, weight loss, medication or treatment refusal, no relief from pain medication, abnormal lab values, medication not available, abnormal vital signs. Interviews on 4/2/15 with 9 out of 10 unlicensed nursing staff and three therapy staff identified the need to complete the stop and watch form and notify the nurse for any complaint of pain or change in the resident. Record review of Resident #'s 62, 15, 30 and 86's clinical record reveal lab results were called to the physicians. Resident #30's blood pressure was low on 4/1/15 which required her blood pressure medication to be held. The physician was notified. Record review of Resident #30's medication administration record revealed the resident was listed as having an allergy to [MEDICATION NAME]. Record review of Residents #'s 14, 59, 70, 72, 73 and 100 revealed malnutrition assessment were completed to assess the risk of weight loss and malnutrition. Record review of the resident's with weekly weights revealed completed with no changes.The dietician was in the facility on 4/2/15. Observations on 4/1/15 and 4/2/15 revealed Residents #'s 59, 100 and 72 received and completed the dietary recommended supplements. Interview on 3/28/15, 3/29/15,3/31/15 and 4/1/15 Resident #10

Based on observations, record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical wellbeing of nine of 22 residents (Residents # 15, #73, #72, #65, #59, #100, #70, #30, and #14) who were reviewed for having the highest physical and mental wellbeing because of the effective management of the facility. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on identifying weight loss, the implementation of the Registered Dietitian ' s recommendations and the notification of the physicians. The Administrator failed to supervise the DON on training the nursing staff on consulting with the physician when a resident did not receive the treatment, diet or medication as ordered due to the medication not being available, the resident refused, or the medication was held due to the physician ' s ordered parameters and with lab and x-ray results timely. The Administrator failed to supervise the DON on training the nursing staff on the transcription and implementation of physician ' s orders and the checking of resident ' s allergies [REDACTED]. The DON failed to communicate timely the Registered Dietitian ' s recommendations to the physician when residents experienced weight loss to prevent further weight loss. The DON failed to train and monitor the nursing staff on transcribing and following physician ' s orders. The DON failed to train and monitor the nursing staff on consulting with the physician when a resident did not receive treatments, medications, diets or had a change in condition. The DON failed to train and monitor the nursing staff on not administering medications from the emergency drug box prior to verifying allergies [REDACTED]. The DON failed to train and monitor the nursing staff in notifying the physician when residents were non-compliant with their diet and were at risk of aspiration. An immediate jeopardy (IJ) was identified on 3/26/2015 and 3/30/2015. While the IJ was removed on 4/2/2015, the facility remained out of compliance at a scope of wide spread and a severity level of Actual Harm that is not immediate jeopardy because all staff had not been trained on new systems which included consulting with the physician, transcribing and implementing physician ' s orders. This failure affected 9 residents who experienced weight loss and not receiving their medications , treatments and diets as ordered by their physicians which placed them at risk of a decline in mental and physical health and care which could cause increased pain, suffering, or death. Findings include: Record reviews revealed residents # 15, 73, 72, 65, 59 and 100 all experienced weight loss and were seen by the Registered Dietitian. The dietitian made recommendations for increasing tube feedings and adding supplements to the resident ' s diets to increase the caloric intake of the residents in January, February and March of 2015 which were never communicated to the physician nor implemented which contributed to the residents loosing additional weight. Resident #72's physician changed the resident's blood pressure medications that were transcribed and given incorrectly for six doses prior to the order being clarified with the physician. The medication orders transcribed on the medication sheet did not match the prescription or doctor's order but was not questioned by the staff. Resident #70 did not receive the wound treatments to her Stage II decubitus as ordered by the physician nor the appetite enhancing medication to increase caloric intake to assist with wound healing for four days due to the pharmacy not supplying the medications and treatments. Resident #70 ' s physician was not notified the resident was not receiving the medications or the treatments. Resident #70 who had a history of [REDACTED]. Resident #70 had to go without the pain medication she felt was most effective for 6 days when she had pain she rated at 10 on a scale from 1-10. Resident #30, who was on four blood pressure medications had a decrease in systolic blood pressure, 93, for three days and the physician was not consulted. The resident had stat lab work on 3/21/2015 with the results not being communicated to the physician until 3/23/2015. Resident #30 had a stat chest x-ray completed on 3/21/2015 and the results were not communicated to the physician until 3/26/2015. Resident #30 was ordered to receive an antibiotic which the staff administered two doses without checking the allergies [REDACTED]. Record review revealed Resident #14 physicians was not consulted when Resident #14, who was a silent aspirator of thin liquids refused the nectar thick liquids and was drinking thin liquids. The resident had been non-compliant with the diet since 11-2014. Please refer to this CMS form 2567 dated 4/2/2015 F 157, 282, 309 and 325 for the evidence of the deficient practices. Interview on 3/26/2015 at 3:50 P.M. the DON stated she did not know what caused the breakdown of consulting with the physicians. She stated all nurses had been trained on when to consult the physician, how to transcribe physician ' s orders and to follow physician ' s orders concerning diet, treatments and medications. In the same interview the DON stated the QA program at the facility had identified the weight loss of the residents as a problem that needed to be addressed in February 2015. She stated they had started to address the issue by weighing every resident weekly. She stated she was the one who was responsible for the follow up being done with the physicians concerning the dietary recommendations and she had just missed some of them. She stated the dietitian came weekly and left his recommendations with her. She stated on Resident #72 she had been the one who took the order and transcribed it to the MAR. She stated she had been at the facility for 12 hours that day and was exhausted and that was how the error happened. During the interview on 3/26/2015 at 3:50 P.M. the DON stated she had numerous ways that she checked the competency of the nursing staff. She said one way was with skill check off sheets. Another way was to question them and give them different scenarios to assess how they would handle different situations. She said some more training was needed and she would ensure it was completed by each nurse. Interview on 3/26/2015 at 4/20 P.M. the Administrator stated the QA committee had already started acting on the weight loss issue of the residents in the February 2015 meeting. She stated she monitored the effectiveness of the DON through various ways. One way was to observe her with the staff. She stated with herself being an RN also she could relate and understand the directions and trainings the DON provided. She stated the QA committee had also identified that there was a communication problem between the nursing staff from one shift to the next. She stated the DON had been training staff on the use of the twenty four hour reports and the following up on resident conditions. During the same interview she stated the company provided numerous resources for the Administrators and the DONs in the company. She stated the company had a Medical Director and corporate quality nursing staff to assists the facilities along with an educational and compliance department. She stated they would all learn from this survey and would make sure improvements were made. Record review of the facility policy titled "Nutrition" dated 7/13 revealed ...Based on the comprehensive assessment of the resident, this facility ensures that a resident: 1. Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible and 2. Receives a therapeutic diet when there is a nutritional problem... A policy for notification of the physician for changes in the resident status was received but did not address notification for changes in treatment. An immediate jeopardy (IJ) was identified on 3/26/2015. A Plan of Removal (POR) of the IJ were submitted and accepted on 3/29/2015. The POR included: Immediate interventions implemented for the following residents as it relates to weight loss and dietician recommendation not being communicated to physician: 1. Resident #15-TF order was verified, correct rate of feeding was administered, RP, and MD were notified of feeding rate error. 2. Resident #59- On 3/24/2015, MD was notified of dietary recommendation, that was written by dietician on 2/26/2015 to start weekly weights X 4 weeks, and offer Medpass 120cc TID X 30 days. Order was initiated on 3/27/2015, weekly wts started, and medpass administered and on MAR. 3. Resident #100- On 3/24/2015 MD was notified of dietary recommendation from dietician on 2/26/2015 to offer med pass 90cc PO BID X 30days. MD agreed with recommendation and order written, and implemented as of 3/24/2015. 4. Resident #73 On 3/12/2015, MD was notified of RD recommendation to D/C [MEDICATION NAME] 1.5 1 can per [DEVICE] QID, and start 2 Cal HN 1 can per [DEVICE] QID bolus. Order was implemented and initiated on 3/12/2015. 5. Resident #72 - On 3/24/2015 MD was notified of dietician. recommendation received from dietician on 2/23/2015 to start weekly weights and start Nepro 1 can PO BID X 30days. MD agreed with recommendation and order was obtained and written and implemented and initiated on 3/26/2015. 6. Resident #65 - On 3/24/2015, MD was notified of dietary recommendation received on 2/26/2015 from dietician for weekly weights X4 and health shakes PO TID with meals X 30 days. MD agreed with recommendation, order written, resident went to hospital for unrelated health concerns prior to implementation of new orders. Immediate interventions implemented for resident as it relates to resident being non-compliant with diet: 1. Resident #14 - MD notified of resident non- compliance with the diet order for nectar thickened liquids. Resident administered swallow test on 3/20/2015. Based on the resident ' s examination and swallow test, the following strategies were recommended by the professional interpreting the results: Small bites/sips - crush meds- alternate solids/liquids; position upright supervised PO feeding, cueing for strategies. Aspiration level and timing noted on the test results showed resident was silently aspirating on THIN LIQUIDS at the time of the trial. Resident and family educated on risk of consuming thin liquids and being non-compliant with specific orders. MD acknowledged and signed refusal form notification to family and resident on 3/27/2015. Immediate interventions implemented for resident as it relates to medication and treatment not being administered as ordered: 1. Resident #70 - On 3/9/2015 [MEDICATION NAME] 10mg 1 tab PO QHS ordered on [DATE] was discontinued. Corrected order for [MEDICATION NAME] 15mg 1 tab PO qHS submitted to pharmacy for delivery. Medication was received in facility and initiated on 3/10/2015. 2. On 2/24/2015 Resident was readmitted into facility with orders for balsam per/castor oil/ trypsin topical ointment to heel wound Q 12hours was not delivered from pharmacy. MD notified on 2/28/2015. New order received to clean right heel with normal saline and apply sure prep q day LOTA. Immediate interventions implemented for resident as it relates to MD notification when resident have a change in vital signs that may require medications to be adjusted: 1. Resident #30 - On 3/26/15, B/P reading was low X 3 days, and MD was notified. New orders were given to D/C dydralazine 50mg QID a decrease from 50mg to 25mg QID and ECG was ordered. Awaiting results from echocardiogram completed on 3/24/2015. MD advised that he would like to be notified of abnormal vital signs. Immediate interventions implemented for residents as it relates to MD notification of lab order results, including stat labs: 1. Resident #30 -- Stat Chest Xray was ordered 3/20/2015; implemented on 3/21/2015. Chest Xray results obtained from imaging service. MD notified of results of chest Xray on 3/26/2015. No radiographic evidence of acute [MEDICAL CONDITION] disease. MD notified of results from CXR. No new orders noted. Immediate interventions implemented for residents as it relates to MD notification of resident allergies [REDACTED]. 1. Resident #30 - On 3/23/2015 [MEDICATION NAME] 500mg PO X10days was D/C ' d after two doses were given. [MEDICATION NAME] 250mg PO QD was ordered and initiated on 3/23/2015. Resident was assessed for any allergic reactions to the medication and none noted. Stop date 3/29/2015. Immediate interventions implemented for residents as it relates to medications and treatments such as tube feedings and supplements being administered as transcribed: 1. Resident #15 - On 3/12/2015 MD was notified of dietary recommendation to increase TF of [MEDICATION NAME] 1.2 to 65cc/hr X 22 hour/ day. Weekly wts X 4. On at 10am off @ 8am. MD agreed, order transcribed on 3/26/2015, order was initiated. Weekly weights were D/C ' d as weights are stable. TF order was verified, correct rate of feeding was administered, RP, and MD were notified of feeding rate error. 2. Resident #72 - On 3/24/2015 MD was notified of dietician recommendation received from dietician on 2/23/2015 to start weekly weights and start Nepro 1 can PO BID X 30days. MD agreed with recommendation and order was obtained and written and implemented and initiated on 3/26/2015. Immediate interventions implemented to include all residents residing in facility that could be affected by an effective system not being in place and monitored to track residents who could be at risk for 1. 100% audit of current census was conducted by Corporate Consultant Nurse to ensure weight variances were addressed, malnutrition assessments were completed for all residents to identify any at risk residents without a current weight loss. Care plans updated to include interventions to prevent weight loss. Dietician reviewed all residents with a significant weight loss. 100% Lab audit completed by Corporate Nurse to from January 2015 through current to verify lab drawn and physician was notified of results. 100% audit of tube feeding orders to verify ordered formula was being given as per physician orders. Corporate Dietitian audited 100% of dietary orders and supplement orders to verify Dietary Managers diet roster matches physician orders. Any discrepancies were corrected. Corporate Dietitian conducted a 100% supplement order and delivery during meal service to verify supplements supplied by the kitchen were delivered as ordered. Corporate Consultant conducted 100% audit of allergies [REDACTED]. 100% MAR indicated [REDACTED]. Pharmacy Delivery Reconciliation system was implemented to verify all medications from pharmacy have been delivered. 100% audit of all new orders from March 1, 2015 current were checked for accuracy of transcription. Interventions Issue #1: 1. Residents at risk and those who had a significant weight loss will be identified by the management nurses to begin on 3/26/15 and complete by 3/27/15. Any resident identified to be at risk were assessed, RD, & MD were notified to determine whether a change in treatment regimen was required. 2. In-serviced initiated by Corporate QA Nurse Consultant on the system for notification of MD of residents with weight loss and will continue to be conducted by a nurse manager prior to nurse working their shift, began on 3/26/15 and will be completed by 3/31/15. SYSTEM: Weights will be reviewed weekly during the weight meeting. Variances will be assessed and interventions will be put into place. The responsible party, dietician, and physician will be notified and documented on the " weight variance assessment " form. A " registered dietician referral " form will be completed. As well as a " Dietary Acute Care plan. " If the resident triggers for significant weight loss, a " physician certification of unavoidable decline in resident condition " will be completed and signed by the physician. 3. MD/Nurse Practitioner will be contacted by DON or Designee with all dietary recommendations and the DON will monitor MD response/orders and ensure all recommendations have been addressed. If MD does not respond within 24 hours the DON or designee will make a second attempt to notify of recommendation. If no response at this 2nd attempt, the DON or designee will contact the Medical Director for orders following every scheduled dietary visit. All recommendations will be addressed within 24 hours of DON / designee receiving recommendations from dietician. All current recommendations were communicated to the MD/Nurse Practitioner, have been addressed, agreed with dietician recommendations, order written and noted in the medical records, transcribed onto MAR, communication forms given to dietary department for all diet changes, and supplement orders. New orders are being administered as directed. 4. All Licensed staff in-serviced by nurse management on notifying DON when Dietary Recommendations have been received from the MD or Nurse Practitioner after every scheduled dietary visit. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. DON is responsible for tracking of the dietary recommendations and ensuring they are followed up on within the specified time frame. 5. All Licensed Staff were in-serviced by nurse management to notify the MD when the resident refuses to follow a therapeutic diet and record in the clinical record. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. 6. All Direct Care Staff were in-serviced by Nurse Managers to utilize the Stop and Watch Form to communicate when a resident refuses to follow prescribed diet or follow dietary restrictions initiated on 3/27/15 and will be complete on 3/31/15. 7. All Licensed Staff were in-serviced by nurse managers regarding administration of treatments and medications. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. In-service included what the nurse must do when the medication is not received from the pharmacy when ordered. The nurse must notify the MD immediately to make aware of med not available in order to adjust treatment regimen. Nurse must notify MD of med allergies [REDACTED]. When a medication has to be held due to abnormal vital signs the MD must be notified immediately. 8. All Licensed Staff were in-serviced by nurse management regarding notification of MD when resident has medications with parameters that require the medication be held. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. 9. All Licensed Nurses were in-serviced by Nurse Managers to document on the 24 Hour Report when medications have been held and document this in Nurse Note, initiated on 3/27/15 and will be completed by 3/31/15. 10. All Licensed Staff were in-serviced by management nurses regarding notification of MD on all stat lab results and document notification in the nurses notes. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. 11. All Licensed Staff were in-serviced by nurse managers regarding notification of allergies [REDACTED]. Nurses were in serviced on noting allergies [REDACTED]. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. 12. Nurse Managers include: DON, Staffing ADON (SADON), QA Nurse, Assessment Nurse #1, Assessment Nurse #2, and Medicare Coordinator and Treatment Nurse. Interventions Issue #2: 1. All Licensed Staff were in-serviced by management nurses regarding transcribing all MD orders per policy and procedure. POLICY: When an order is received from the MD, it must be transcribed to an order sheet, the order must be transcribed exactly as it is ordered to the MAR. The nurse must implement the order as transcribed. All orders must be documented in the clinical records stating the order was received, the RP was notified and order initiated. The new order will be documented on the 24 hour report for continuum of care. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. 2. All Licensed Staff were in-serviced by management nurses regarding transcription and implementation of all tube feeding changes and supplements as per physician orders. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. Interventions Issue #3: 1. Assessment Nurses were in-serviced by Assessment Nurse Consultant regarding the Malnutrition Assessment upon admission and quarterly to identify residents at risk for weight loss and completion of the dietary referral form for at risk residents on 3/27/15. 2. Assessment Nurses and DON were in-serviced by QA Nurse Consultant regarding the procedure for completion of the Weight Variance Assessment Form for residents with significant weight loss for 5% within 1 month; 7.5% within 3 months; and 10% within 6 months or have an insidious weight loss on 3/27/15. 3. Licensed Staff were in-serviced by nurses managers regarding completing dietary communication form for all new diet orders or changes prior to working the floor beginning on 3/26/15 and will be completed by 3/31/15. 4. Members of the Weight Variance Committee, DON, Food Service Supervisor, Dietician, QA Nurse, Administrator, Restorative Aides and Social Worker were in-serviced by the QA Nurse Consultant to utilize the dietary referral forms and the weight variance assessment forms to monitor at risk and significant weight losses on 3/27/15. Monitoring: 1. The weekly Weight Variance QA meeting following the completion of the weekly / monthly weights will include: review, evaluation, and completion of weight variance assessment form. Process improvement began: 3/27/2015. 2. Administrator and DON will use Assessment Report in Electronic Medical Record program to monitor that Malnutrition Assessments are being completed upon admission and quarterly thereafter in daily start up meeting. Process improvement began: 3/27/2015. 3. Administrator and DON will utilize the Dietary Recommendation Tracking Form to monitor notification of MD and timely return of Dietary Recommendations. Process improvement began: 3/27/2015. 4. Administrator and DON will review the Stop and Watch Forms in daily start up meeting to monitor when residents refuse to comply with therapeutic diet orders. Process improvement began: 3/27/2015. 5. Nurse Managers will verify a dietary communication form was complete for all new diet orders or diet changes and supplements in daily start up meeting. Process improvement began: 3/27/2015. 6. Nurse Managers will review all new orders in daily start up meeting to ensure transcription to medication administration records is accurate and complete. Process improvement began: 3/27/2015. 7. Nurse Managers will review 24 hour report in start- up process to identify any resident who has refused medications or have had to hold medications due to doctor ' s order for parameters. The managers will review documentation to verify notification to the physician. Process improvement began: 3/27/2015. 8. Nurse Managers will review the lab tracking log in the daily start up meeting to verify physicians were notified and documentation notification in the Nurses ' Note. Process improvement began: 3/27/2015. 9. Nurse Manages will monitor that residents do not have an allergy to new medication orders in start-up meeting. Process improvement began: 3/27/2015. 10. Nurse Managers will monitor medication transcription of medications are accurate in daily start up process. Process improvement began: 3/27/2015. 11. Nurse Managers will verify all dietary orders and recommendations are transcribed and implemented in daily start up meeting. Process improvement began: 3/27/2015. 12. QA Nurse Consultant will monitor that Weight Variance Committee members are utilizing the dietary referral forms and weight variance assessment forms to monitor at risk and significant weight loss during scheduled visits. Process improvement began: 3/27/2015. 13. DON will monitor supplements to ensure the process for administration is being followed to ensure that all residents requiring supplements are receiving it as ordered at it specified time, right amount to be consumed. (Health shakes, and magic cups are listed on the resident ' s tray cards to be served from Nutrition Department and ordered (with or between meals.) Med pass, can supplements (Nepro, Glucerna, Ensure, etc) as ordered on the MAR, will be administered by nurse during medication pass. The hydration /snack cart contains among other items, labeled Health shakes, magic cup if ordered between meals. Process improvement began: 3/27/2015. 14. DON/designee will monitor refusal of medications notification to MD daily in the start up with review the 24 hour report, nurse ' s notes, and charge nurse report. Process improvement began: 3/27/2015. The second plan of removal of the immediate jeopardy identified on 3/30/2015 was submitted and accepted on 3/31/2015. The plan included: Immediate interventions implemented for the resident with pain: 1. Resident #70- Resident was immediately assessed for pain by DON and noted her pain to be rated at a (7). Resident was administered [MEDICATION NAME] 50mg 1 PO and Tylenol 325mg 2 tabs PO at 8:15pm. At 9:00pm resident was asleep and no compliant of pain. Resident ' s [MEDICATION NAME] 5/325mg P O q 6 hours arrived at facility around 11:40pm and resident received a dose as it was changed to routine administration. Resident will be assessed also before during and after treatment , as well as before leaving facility for [MEDICAL TREATMENT] and returning. Immediate interventions implemented to include all residents residing in facility that could be affected by an effective system not being in place and monitored to identify residents at risk for pain, or who are experiencing actual pain. 1. 100% audit of current census was conducted by Nurse Managers to ensure all residents with pain were addressed, by completing a new pain assessment for all residents and any residents noted to be experiencing any pain were given medication if they were prescribed. Any resident without pain medication orders, MD was notified for an order for [REDACTED]. 2. Based on 100% audit of pain assessments all Care plans were updated to include interventions to manage pain and include alternate means of pain relief. INITIATED: 3/31/2015 COMPLETED: 3/31/2015 3. Pain assessment roster was reviewed for 100% of resident to ensure that anyone with documented pain has medications available and given as ordered by the physician. INITIATED: 3/30/2015 COMPLETED 3/31/2015 4. 100% audit of current pain meds on hand by nurse managers, to ensure all residents have at least 5 day supply of current pain medication available. Any residents with less than 5 day supply will have medications reordered. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 5. Residents will be assessed on admission and quarterly for pain management. All nurses were re-educated on doing pain assessments. Residents who have been identified of having pain will have pain per pain monitored per pain roster every shift and as needed. INITIATED: 3/30/2015 COMPLETE 3/31/2015 6. Physician will be notified by the charge nurse of any resident who does not experience relief from pain with current pain regimen within 2 hours of medication administration for further interventions to reduce pain to a level that is tolerable for the resident. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 7. Residents will be assess by charge nurse for pain each shift, and during and after treatments. Interventions will be implemented per orders, or MD will be notified by charge nurse if current regimen is not effective for new orders. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 8. Charge nurses were in-serviced on the process for reordering medication: The nurse will re-order pain medication when there is a 7 day supply remaining. MD will be contacted for triplicate prescription if required, during business hours prior to 7th day to ensure resident has pain medication available at all times. When the nurse receives the narcotic from the pharmacy delivery, pharmacy reconciliation binder will be updated, medication counted and placed in secured drawer in the medication cart. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 9. Nurse managers will re-educate and or implement progressive disciplinary actions for any nurse who fails to assess, and manage resident pain or ensure at least a 7 day supply of medication is on hand at all times. Monitoring: 1. Nurse Managers will review pain roster daily in the morning meeting to identify all residents that had documented pain levels to ensure each resident received meds routinely, or prn to manage the pain. Process improvement began: 3/30/2015 2. Nurse managers will review med carts daily with the start up to ensure the residents have at least a 7 day supply of meds for administration. The meds that are close to 7 day refill are called to the physician for the needed triplicate. Process improvement began; 3/30/2015 3. Nurse managers will review the pharmacy reconciliation binder daily in start-up to verify pain medications ordered were received. Process improvement began: 3/30/2015 4. Department heads will ask resident daily on their guardian angel rounds if they are experiencing any pain, and if the resident states they are the department head will immediately notify the charge nurse, and complete a " Stop & Watch " to ensure the pain was addressed. The department head will present a copy of the stop & watch to the DON for assurance of follow up. Process improvement began: 3/31/2015 Monitoring of the plan: Record review of the facility inservices revealed 17 out of 20 licensed nursing staff were inserviced for notification to physician, for any changes in the resident's condition, weight loss, medication or treatment refusal, no relief from pain medication, abnormal lab values, medication not available, abnormal vital signs, verification of orders and allergies [REDACTED]. Record review of the facility inservices revealed 29 out of 37 unlicensed nursing staff were inserviced for notification to the nurse and completion of the stop and watch form. Interviews on 4/2/15 with 11 out of 12 licensed nursing staff on duty identified the need to call the physician for notification for any changes in the resident's condition, weight loss, medication or treatment refusal, no relief from pain medication, abnormal lab values, medication not available, abnormal vital signs, verification of orders and allergies [REDACTED]. Interviews on 4/2/15 with 9 out of 10 unlicensed nursing staff an

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procuring medications for one of 19 (Residents #70) reviewed for availability of medications. Resident # 70 ' s ordered pain medication (Norco) was not reordered by nursing staff until the resident's supply was completely gone . The resident had pain she rated between 7-10 on a scale from 1-10 with 10 being the worst pain. Resident #70 found the pain medication Norco to be the most effective for the pain. Resident #70 missed six days of her narcotic pain medication Norco. An IJ was identified on 3/26/2015 and 3/30/2015. While the IJ was removed on 4/2/2015 the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on assessing and the management of pain. This deficient practice affected one resident who had six days of escalated pain and placed 39 residents at risk of not receiving ordered medications to treat their conditions which could result in a decline in health or a worsening of their medical condition. Intake # 7 Findings include: Resident # 70 Record review of Resident # 70 ' s face sheet revealed a [AGE] year old female admitted to facility on 6/27/13 and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident # 70 ' s MDS dated [DATE] revealed the resident was cognitively intact with a BIMS of 15.Continued review of the MDS revealed the resident ' s speech clarity was clear with distinct intelligible words. The MDS identified the resident as being on pain medication. Record review of Resident # 70 ' s MDS dated [DATE] revealed the resident was moderately impaired for cognition and received as needed pain medication with a pain intensity of 10 on a scale of 0 to 10 with 10 being the most severe pain. Record review of Resident #70 ' s care plan dated 7/13/13 with no update date revealed Resident #70 had impaired comfort related to chronic pain, complaint of pain, neuropathy. The care plan goal with target date was " ...Resident will have relief from pain when as needed (PRN) medication is used over 90 days with the target date of 5/14/15 ... " Approaches included " ...Give PRN pain medication according to physician ' s orders ...Notify physician and responsible party if pain medication is not effective in relieving pain ... observe for effectiveness of PRN pain medications ... " Record review of Resident #70 ' s MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the back of the MAR indicated [REDACTED]. Record review of Resident #70 ' s MAR indicated [REDACTED]. Further review of MAR indicated [REDACTED]. Record review of Resident#70 ' s MAR indicated [REDACTED]. Continued review revealed it was administered at 8:40 A.M. on 3/30/15. Record review of the Individual Narcotic sign out sheet identified as Norco for Resident #70 revealed on 3/20/15 at 10:00 A.M. the remaining Norco count was one tablet l remained. Continued review revealed the last Norco was removed and administered on 3/24/15. Record review of Resident#70 ' s physician ' s order dated 3/29/15 revealed discontinue Norco 10/325 every six hours as needed for pain start Tylenol with codeine #3 every four hours as needed for pain. Record review of Resident #70 ' s MAR indicated [REDACTED]. Record review of the facility " Pain Roster " dated 3/1/15 thru 3/31/15 revealed the resident reported the following level of pain based on a 1-10 pain scale with 10 being the worst pain ever experienced on the following dates: 3/20/15 resident ' s pain intensity was 10 3/21/15 resident ' s pain intensity was 10 at 10:57 A.M. and 6:11 P.M. 3/22/15 resident ' s pain intensity was 10 at 12:44 P.M. and 7:08 P.M. 3/26/15 resident ' s pain intensity was 5 at 11:29 P.M. 3/28/15 resident ' s pain intensity was 10 at 9:44 P.M. 3/29/15 resident ' s pain intensity was 10 at 1:19 P.M. Observation on 3/29/15 at 12:36 P.M. revealed Resident #70 in bed awake and alert. Interview on 3/29/15 at 12:36 P.M. during the observation Resident #70 stated her pain intensity level was 7. Resident #70 continued and stated she was out of the Norco and was getting Tramadol instead. She stated Tramadol did not work like the Norco on her pain. Interview on 3/29/15 at 1:46 P.M. the DON stated she did not know how the resident ran out of her Norco. Observations on 3/29/15 at 2:00 P.M. with the DON and at 2:11 P.M. with LVN #3 of the medication cart narcotic box revealed a bubble pack for Tramadol. Continued observation revealed no bubble pack for Norco for Resident #70. Interview on 3/29/15 at 2:11 P.M. LVN#3 stated Resident #70 was getting Tramadol 50 mg and Hydrocodone 10/325 mg every six hours as needed for pain. LVN#3 continued and stated when she realized the Norco was out on Saturday (March 28, 2015) she called the pharmacy to request a refill but she was told she needed triplicate prescription from the doctor. She continued and stated she called the physician to notify him that she needed a triplicate prescription. The doctor questioned why he was not notified during the week. LVN#3 stated she only worked on weekends and she did not know. The physician stated the resident would have to wait until Monday. Observation on 3/30/15 at 8:15 A.M. revealed Resident #70 in bed grimacing and holding her left arm. Interview on 3/30/15 at 8:15 A.M. Resident #70 stated they let my Norco run out about a week ago and they were giving my Tramadol and Tylenol which did not work. The resident stated she was having overall chronic body pain and reported her pain intensity on a scale of 1-10 was 9 and a half at this time. She continued and stated she did not go to sleep until 4:00 A.M. this morning. Resident #70 stated " how do you let someone ' s pain medicine run out? " Interview on 3/30/15 at 8:25 A.M. LVN#4 stated yesterday the physician ordered Tylenol #3 but the resident did not want that; she wanted the Norco. Observation on 3/30/15 at 8:25 A.M. revealed LVN#4 placed a call to the physician for the Norco order. LVN #4 stated to the physician the resident was out of Norco. Interview on 3/30/15 at 8:40 A.M. LVN#14 stated when she noticed that a resident ' s medicine was about to run out she called the pharmacy for refills and if it could not be refilled she notified the physician. She stated she did not notify the DON but would notify the next on coming nurse during report and if she works the next day she would call the pharmacy and physician again. Interview on 3/30/15 at 9:15 A.M. Resident #70 stated she received Tramadol and Tylenol #3 about 30 minutes earlier and her pain was about the same with no relief. She continued and stated she told her doctor last week she was out of pain medicine. Interview on 3/30/15 at 10:09 A.M. the DON stated she cannot remember any nurse notifying her about Resident #70 ' s Norco running out and last night she got an order for [REDACTED]. Interview on 3/31/15 at 9:30 A.M. LVN #19 sated she reorders medication on the seventh day before it runs out. She did the ninth day but she would be notified by pharmacy it was too early to refill. Interview on 3/31/15 at 9:36 A.M. LVN#4 stated it depends on the frequency of the medication but she reorders medication 7 days before it runs out . The turnaround time to get the medication depends on if there were any refills left on the medication or if it needed triplicate scripts. Record review of the facility policy titled " Medication Ordering " undated revealed ... Goal: To ensure all medication, pursuant to a valid physician order, are available in the facility at all times ...Nurses should reorder medications when they were down to five to seven day supply. Nursing must identify the refill is in the facility when they were down to three day supply and place the refill card at the medication cart ...Nurse manager should verify all nurses have been in service on medication order/reorder system. Re-order book should be audited on a daily basis to verify all med orders can be accounted for. Medication carts should be audited on a weekly basis to verify no less than a three day supply of medications was available. An IJ was identified on 3/26/2015 . A plan to remove the IJ was submitted and accepted on 3/31/2015. The Plans of removal included: Immediate interventions implemented for the resident with pain: 1. Resident #70 - Resident was immediately assessed for pain by DON and noted her pain to be rated at a (7). Resident was administered Tramadol 50mg 1 PO and Tylenol 325 mg 2 tabs PO at 8:15 pm. At 9:00 pm resident was asleep and no compliant of pain. Resident ' s Norco 5/325 mg P O q 6 hours arrived at facility around 11:40 pm and resident received a dose as it was changed to routine administration. Resident will be assessed also before during and after treatment , as well as before leaving facility for dialysis and returning. Immediate interventions implemented to include all residents residing in facility that could be affected by an effective system not being in place and monitored to identify residents at risk for pain, or who are experiencing actual pain. 1. 100% audit of current census was conducted by Nurse Managers to ensure all residents with pain were addressed, by completing a new pain assessment for all residents and any residents noted to be experiencing any pain were given medication if they were prescribed. Any resident without pain medication orders, MD was notified for an order for [REDACTED]. 2. Based on 100% audit of pain assessments all Care plans were updated to include interventions to manage pain and include alternate means of pain relief. INITIATED: 3/31/2015 COMPLETED: 3/31/2015 3. Pain assessment roster was reviewed for 100% of resident to ensure that anyone with documented pain has medications available and given as ordered by the physician. INITIATED: 3/30/2015 COMPLETED 3/31/2015 4. 100% audit of current pain meds on hand by nurse managers, to ensure all residents have at least 5 day supply of current pain medication available. Any residents with less than 5 day supply will have medications reordered. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 5. Residents will be assessed on admission and quarterly for pain management. All nurses were re-educated on doing pain assessments. Residents who have been identified of having pain will have pain per pain monitored per pain roster every shift and as needed. INITIATED: 3/30/2015 COMPLETE 3/31/2015 6. Physician will be notified by the charge nurse of any resident who does not experience relief from pain with current pain regimen within 2 hours of medication administration for further interventions to reduce pain to a level that is tolerable for the resident. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 7. Residents will be assessed by charge nurse for pain each shift, and during and after treatments. Interventions will be implemented per orders, or MD will be notified by charge nurse if current regimen is not effective for new orders. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 8. Charge nurses were in-serviced on the process for reordering medication: The nurse will re-order pain medication when there is a 7 day supply remaining. MD will be contacted for triplicate prescription if required, during business hours prior to 7th day to ensure resident has pain medication available at all times. When the nurse receives the narcotic from the pharmacy delivery, pharmacy reconciliation binder will be updated, medication counted and placed in secured drawer in the medication cart. INITIATED: 3/30/2015 COMPLETED: 3/31/2015 9. Nurse Managers will re-educate and or implement progressive disciplinary actions for any nurse who fails to assess, and manage resident pain or ensure at least a 7 day supply of medication is on hand at all times. Monitoring: 1. Nurse Managers will review pain roster daily in the morning meeting to identify all residents that had documented pain levels to ensure each resident received meds routinely, or prn to manage the pain. Process improvement began: 3/30/2015 2. Nurse Managers will review med carts daily with the start up to ensure the residents have at least a 7 day supply of meds for administration. The meds that are close to 7 day refill are called to the physician for the needed triplicate. Process improvement began; 3/30/2015 3. Nurse Managers will review the pharmacy reconciliation binder daily in start-up to verify pain medications ordered were received. Process improvement began: 3/30/2015 4. Department heads will ask resident daily on their guardian angel rounds if they are experiencing any pain, and if the resident states they are the department head will immediately notify the charge nurse, and complete a " Stop & Watch " to ensure the pain was addressed. The department head will present a copy of the stop & watch to the DON for assurance of follow up. Process improvement began: 3/31/2015 Immediate interventions implemented for residents as it relates to MD notification of resident allergies [REDACTED]. Resident #30 - On 3/23/2015 Levaquin 500mg PO X 10 days was D/C ' d after two doses were given. Azithromycin 250 mg PO QD was ordered and initiated on 3/23/2015. Resident was assessed for any allergic reactions to the medication and none noted. Stop date 3/29/2015. Interventions Issue : All Licensed Staff were in-serviced by nurse managers regarding notification of allergies [REDACTED]. Nurses were in serviced on noting allergies [REDACTED]. Nurses will not be allowed to work the floor prior to receiving this education beginning on 3/26/15 and will be completed by 3/31/15. Monitoring: Nurse Manages will monitor that residents do not have an allergy to new medication orders in start-up meeting. Process improvement began: 3/27/2015. Monitoring of the plan to lower the immediate jeopardy: Record review of the facility in-services revealed 17 out of 20 licensed nursing staff were in-service to assess the resident's pain level every shift and to notify the physician for any pain not relieved ,any changes in the resident's condition, weight loss, medication or treatment refusal, abnormal lab values, medication not available, abnormal vital signs. To complete a stop and watch form and the physician notification form: situation, background, assessment , response (SBAR) form. Record review of the facility in-services revealed 29 out of 37 unlicensed nursing staff were in-serviced for notification to the nurse if the resident complained of pain and completion of the stop and watch form. Interviews on 4/2/15 with 11 out of 12 licensed nursing staff on duty identified the need to assess the resident's pain level every shift, before and after administering pain medications and for any changes in the resident's condition, weight loss, medication or treatment refusal, abnormal lab values, medication not available, abnormal vital signs. Interviews on 4/2/15 with 9 out of 10 unlicensed nursing staff and three therapy staff identified the need to complete the stop and watch form and notify the nurse for any complaint of pain or change in the resident. Record review of Resident #30's Medication Administration Record [REDACTED]. Record review of Resident #70's physician order's and Medication Administration Record [REDACTED]. and topically ointment to heel wound. Record review of Resident #70 physician order and Medication Administration Record [REDACTED]. Record review of Resident #70's pain roster, nurse's notes, pain assessment sheet and Medication Administration Record [REDACTED]. Record review and interviews with three residents on pain management revealed their pain was being assessed each shift. The resident's had no complaints concerning the management of their pain. Observations and interviews with Resident #70 on 3/31/15, 4/1/15 and 4/2/15 revealed the resident was getting her medication for pain and the staff was asking her pain level. The resident continued and stated she was feeling much better, her pain was in control and she was sleeping at night. The Administrator was informed on 4/2/2015 the IJ was lowered after verification of the plan implementation had occurred. While the IJ was lowered on 4/2/2015 the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on the procedure on pain assessment, management of pain, reordering of medications and the procedure of checking resident ' s charts for allergies [REDACTED]. Facility CMS form 672 dated 3/24/14 listed 40 resident were on a pain management program.

Based on observations, record reviews and interviews the facility failed to have sufficient nursing staff trained to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being as determined by resident assessments and individual plans of care for ten of 22 residents (#70, #14, #73, #15, #59, #100, #72, #65, #30, and #97) reviewed for sufficient care being provided by staff. Facility nursing staff failed to notify the physician when : Resident #70 did not receive treatments and medications as ordered. Resident #14 was non compliant with her diet. Residents #s 73, 15, 59, 100, 72, and 65 experienced weight loss. Resident #30's stat lab and x-ray abnormal results. Facility nursing staff failed to follow physician's orders [REDACTED]. Resident #72's nutritional supplement and blood pressure medications. Resident #62's tube feedings. Resident #65's health shakes with meals. Resident #97's hand rolls and treatments to the insides of her hands. Resident #15's heels were not floated while in bed. Resident #15's tube feeding. Facility nursing staff failed to effectively: Assess and manage the pain of Resident #70. Review Resident #30's allergy history prior to administering new medications. These failures affected ten residents and placed 98 residents at risk of not receiving the medical care and treatments required for them to maintain their highest level of health and function. Findings include: Resident # 70 Record review of Resident # 70's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #70 did not receive the medication [MEDICATION NAME] for five days because it was unavailable from the pharmacy. (see tag F157 for evidence.) Resident #70's pain was not assessed and managed. Resident #70 was not medicated effectively prior to the treatment for [REDACTED]. (See F309 for evidence). Resident #70's pain was not assessed and managed on a daily basses. Assessments would reflect her pain intensity at a 10 on a scale of 1-10 with 10 being the most severe with no documentation of pain medication or alternate pain management being provided to the resident (See F309 and F425 for evidence). Resident #70 had history of chronic pain which required treatments of narcotic pain medication on a daily basis to control. Facility staff did not reorder the narcotic pain medication timely and the resident was not provided the medication she felt most effective for her pain for six days. (see F309 and F425 for evidence) Resident #14 Record review of Resident #14 ' s face sheet revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Resident #14 had a medical condition which resulted in her aspirating thin fluids into her lungs. The physician ordered nectar thickened liquids for the resident. The resident refused the nectar thick liquids and drank thin liquids from November 2014 to March 2015 without the physician being consulted. (See F157, F323, and F365 for evidence). Resident #73 Record review of Resident # 73 ' s face sheet revealed he was a [AGE] year old male, admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #73 had a weight loss of forty pounds in five months and the dietitian's recommendations to change the resident's tube feeding to increase nutritional intake was not communicated to the physician or implemented. (see F157 and F325 for evidence). Resident #15 Record review of Resident # 15 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Resident #15 experienced a weight loss of 20 pounds in three months and the dietitian recommended an increase in her tube feeding on 2/12/2015. This was not communicated to the physician until 3/12/2015. The physician ordered the increase on 3/12/2015 which was not implemented by the facility staff until 3/25/2015. (see F157 and F325 for evidence). Resident #15's care plan instructed staff to float her heels while in bed which was not provided. (See F282 for evidence). Resident # 59 Record review of Resident # 59 ' s face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Resident #59 experienced a weight loss of nine pounds in one month and the dietitian recommended med pass supplement which was not communicated to the physician or implemented. (See F157 and F325 for evidence) Resident #100 Record review of Resident #100 ' s face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Resident #100 experienced a weight loss of nine pounds in one month and the dietitian recommended med pass supplement which was not communicated to the physician or implemented. (See F157 and F325 for evidence). Resident #72 Record review of Resident #72 ' s face sheet revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. Resident #72 experienced a weight loss of 11 pounds and the dietitian recommended Nepro supplement which was not communicated to the physician . (See F157 and F325 for evidence). Resident #72's physician changed his blood pressure medications which were transcribed wrong onto the MAR and were administered by staff not as ordered by the physician. (see tag F282 for evidence). Resident #65 Record review of Resident #65's face sheet revealed he was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #65 experienced a weight loss of 14 pounds and the dietitian recommended health shakes be added to meals which was not communicated to the physician or implemented. (See F157 and F325 for evidence). Resident # 30 Record review of Resident #30 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 had stat lab and x-rays conducted at the facility on 3/20/2015 and the physician was not notified of the results until 3/23/2015. Resident #30's medical history revealed she was allergic to the antibiotic [MEDICATION NAME]. When the physician ordered this medication staff administered two doses to the resident from the emergency kit prior to being notified by the pharmacy of the allergy. (See F157, and F309 for evidence). Resident #97 Record review of Resident # 97 ' s face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Resident #97 had severe contractures to both hands with fists tightly clinched. The resident had excoriated and odorful dead skin inside her hand. She was not provided hand rolls or treatment as ordered by the physician. (See F282 for evidence). Interview on 3/26/2015 at 3:50 P.M. the DON stated she did not know what caused the breakdown of consulting with the physicians. She stated all nurses had been trained on when to consult the physician, how to transcribe physician's order [REDACTED]. In the same interview the DON stated the QA program at the facility had identified the weight loss of the residents as a problem that needed to be addressed in February 2015. She stated they had started to address the issue by weighing every resident weekly. She stated she was the one who was responsible for the follow up being done with the physicians concerning the dietary recommendations and she had just missed some of them. She stated the dietitian came weekly and left his recommendations with her. She stated on Resident #72 she had been the one who took the order and transcribed it to the MAR. She stated she had been at the facility for 12 hours that day and was exhausted and that was how the error happened. During the interview on 3/26/2015 at 3:50 P.M. the DON stated she had numerous ways that she checked the competency of the nursing staff. She said one way was with skill check off sheets. Another way was to question them and give them different scenarios to assess how they would handle different situations. She said some more training was needed and she would ensure it was completed by each nurse. The DON stated the training of the staff was an ongoing process and she did not record a lot of the trainings she did because they were one on one. She stated the facility did have several scheduled inservices which included varieties of topics but she could not remember specifically when the last inservices were concerning some of the concerns which were now being addressed. Record review of inservices revealed that frequent inservices were held at the facility including ones on abuse and neglect. There was no evidence of inservices concerning the taking, transcribing and following of physician's orders [REDACTED]. The facility CMS form 672 revealed a census of 108.

Based on interview and record review, the facility failed to consult with the physician when there was a need to alter the medical treatment of [REDACTED].#1) reviewed for physician consultations occurring when an alteration in the resident's medical care was required . CR#1 ' s physician was not consulted concerning her abnormal blood oxygen level (O2 saturation) during physical therapy. This failure affected one resident and placed 108 current residents at risk of not consulting with their physicians for a condition which had the potential of negatively impacting their medical condition and psychosocial well-being. Intake # 1 Findings include: CR#1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of CR#1 ' s physician's order [REDACTED]. Review of the residents consolidated physician's orders [REDACTED]. Record review of CR #1's Physical therapy (PT) Evaluation and Plan Treatment dated 1/31/15 revealed " Assessment Summary " Impression "...At evaluation after gait 125 feet with drop in oxygen saturation level to 80% required instruction in breathing techniques and 5 minute seated break prior to recovery to 96%. No oxygen noted in room and no orders noted in chart for oxygen. Notified Director of Nursing (DON) of drop in oxygen and DON stated she will follow up for order for as needed oxygen ..." Record review of CR #1's history and physical dated 2/2/15 revealed the resident was alert and oriented to time, place and person. Record review of CR#1 ' s Physical Therapy Treatment Encounter Note dated 2/3/15 revealed " ...ambulated 50 feet the complained of shortness of breath and fatigue ... " Continued review of the therapy note did not reveal the resident had oxygen. Record review of CR#1 ' s Physical Therapy Treatment Encounter Note dated 2/4/15 revealed " ...oxygen during exercise stopped when oxygen fell to 50%. Transferred to room nurse informed and as needed oxygen applied ... " electronically signed by PTA #1. Record review of CR #1's clinical record revealed no physician notification form or nurse ' s notes to indicate the physician was consulted of CR#1' s decreased blood oxygen level during therapy. Record review of CR #1's Medication Administration Record [REDACTED]. Record review of CR #1's physician's orders [REDACTED]. Interview on 2/25/15 at 10:50 A.M. PTA #1 stated she did not remember what nurse she spoke with regarding CR #1's oxygen level and she was fairly sure the resident had oxygen on. PTA#1 stated she would report any changes to the nurse. Interview on 2/25/15 at 2:50 P.M. the DON stated she did not remember this happening and usually if she told someone she was going to take care of something she did, especially something as important as oxygen. Interview after the DON reviewed CR#1 ' s clinical record, she stated there was no order for the resident to be on oxygen and any nurse who was aware of this could have taken care of this. Record review of the facility titled " Oxygen Administration " dated 8/2013 revealed " ...The purpose of this procedure is to provide guidelines for safe oxygen administration ...1. Verify that there is a physician's order [REDACTED]. A policy for notification of the physician for changes in the resident status was requested but not provided prior to exit. The facility reported the census was 108.

Based on observation, interview and record review the facility failed to provide services according to or obtain the physician's order for one of six residents (CR#1) reviewed for physician's orders being followed by all the nursing staff. Resident CR#1 did not receive her antibiotic as ordered after admission. This failure affected one resident and placed 108 residents at risk of medical decline due to not receiving care as ordered by the physician. Intake # 1 Findings included: Resident CR#1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of CR#1 ' s Admission Nursing Assessmentdated January 31, 2015 revealed Time of admission: 1800 (6:00 P.M.). Record review of CR#1 ' s physician ' s orders dated 1/30/15 to 1/31/15 revealed Meropenem (antibiotic) Intravenous (IV) (administered in to a vein) every eight hours. Record review of CR#1 ' s consolidated physician ' s orders dated February 2015 revealed Meropenem IV every eight hours start date 1/30/15. Record review of CR #1's admission Medication Administration Record [REDACTED].M., 4 P.M. and 12 A.M. Continued review of the MAR indicated [REDACTED]. Record review of CR #1's MAR indicated [REDACTED].M. Record review of CR#1 ' s nurse ' s notes dated 2/1/15 11:14 A.M. revealed "...this nurse gave initial dose of IV antibiotic Meropenem ..." Record review of CR#1 ' s history and physical dated 2/2/15 revealed the resident was alert and oriented to time, place and person. Record review of the facility " Complaint/Grievance Report " dated 2/3/15 "... Date of occurrence 1/31/15 revealed Resident CR#1 did not receive antibiotic on time since admission ..." Observation on 2/25/15 at 12:45 P.M. of the facility IV emergency drug box revealed a bottle of Meropenem powder. Interview on 2/25/15 at 12:45 P.M. LVN#1 stated the Meropenem powder would have to be reconstituted and LVNs were not allowed to do that. Interview on 2/25/15 at 2:50 P.M. the DON stated the antibiotic was not given and she thought it was discontinued until the facilty received it. A policy for following physician's orders was requested but not provided prior to exit. The facility reported the census was 108

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procuring medications for two of six Residents # ' s (CR#1 and Resident # 5) reviewed for availability of medications. CR#1 ' s ordered antibiotic was not promptly made available for administration following her admission on 1/30/15. CR#1 missed four routine doses of her ordered medications. Resident #5 missed one dose of an antibiotic eye drop. This deficient practice affected two residents who missed scheduled medications and placed 107 residents at risk of not receiving ordered medications to treat their conditions which could result in decline in health or a worsening of their medical condition. Intake # 1 Findings include: Resident CR#1 Record review of CR #1's face sheet revealed she was admitted to the facility on [DATE]. She was [AGE] years old. Her [DIAGNOSES REDACTED]. Record review of CR#1 ' s admission nursing assessment dated [DATE] revealed Time of admission: 1800 (6:00 P.M.) . Record review of CR#1 ' s physician ' s orders dated 1/30/15 to 1/31/15 revealed Meropenem (antibiotic) Intravenous (IV) (administered in to a vein) every eight hours. Record review of CR#1 ' s consolidated physician ' s orders dated February 2015 revealed Meropenem IV every eight hours start date 1/30/15. Record review of CR#1 ' s admission Medication Administration Record [REDACTED].M., 4 P.M. and 12 A.M. Continued review of the MAR indicated [REDACTED]. Record review of CR#1 nurse ' s notes dated 1/31/15 at 10:07 P.M. revealed "... At 6:30 A.M. this nurse received report from outgoing nurse that resident had just arrived on the night before and her medications were not here ..." continued review revealed the nurse notified the physician the ordered antibiotic was in the same family make up as the resident ' s allergy. Information the physician requested was sent to him "... the physician sent a fax to continue the Meropenem IV as ordered ... this nurse made three attempts to the on call pharmacy to obtain her IV antibiotics ..." Record review of CR#1 ' s nurse ' s notes dated 1/31/15 at 10:10 P.M. revealed "... This nurse again has made three attempts to notify pharmacy about resident ' s IV antibiotics ..." Record review of CR#1 clinical record revealed a fax dated 1/31/15 from CR#1 ' s physician "...CR#1 continue the medications including Meropenem. Discontinue after 10 days." Record review of CR#1 ' s MAR indicated [REDACTED].M. Record review of CR#1 ' s nurse ' s notes dated 2/1/15 at 11:14 A.M. revealed "...this nurse gave initial dose of IV antibiotic Meropenum ..." Record review of CR#1 ' s history and physical dated 2/2/15 revealed the resident was alert and oriented to time, place and person. Record review of the facility Complaint/Grievance Report dated 2/3/15 "... Date of occurrence 1/31/15 revealed Resident CR#1 did not receive antibiotic on time since admission ..." Interview on 2/25/15 at 12:30 P.M. LVN#1 stated sometime there were problems getting medications from the pharmacy. Weekend staff indicated an order was stat so we get it a little quicker. She stated new orders staff will put as stat also we get them faster. Interview on 2/25/15 at 12:34 P.M. LVN#2 stated sometimes she had trouble getting medications from the pharmacy. Interview on 2/25/15 at 12:45 P.M. LVN#1 stated the Meropenem powder would have to be reconstituted and LVNs were not allowed to do that so we would have to wait for pharmacy to deliver it already mixed. Observation on 2/25/15 at 12:45 P.M. of the facility IV emergency drug box revealed a bottle of Meropenem powder. Resident #5 Record review of Resident #5 ' s face sheet revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #5 ' s consolidated physician's orders dated February 2015 revealed Ciprofloxacin eye drop four times a day start date 1/12/15. Record review of Resident #5 ' s MAR indicated [REDACTED].M. Continued review of the back of the same MAR indicated [REDACTED].M. Ciprofloxacin eye drops not given due to being out of stock, pharmacy notified. Observation on 2/25/15 at 9:05 A.M. revealed Resident #5 was awake and alert in bed but kept closing his eyes. The resident did not engage in conversation. Interview on 2/25/15 at approximately 2:50 P.M. the DON stated she did not know why Resident #5 ' s eye drops were missed for that one dose. Record review of the facility policy titled " Pharmaceutical Policies " dated 7/13 revealed "... The pharmaceutical services of this facility are the responsibility and under the direction of the nursing director and the consultant pharmacist ..." The facility reported the census was 108.

Based on observation, interview, and record review the facility failed to provide services according to or obtain the physician's order for three of eight residents reviewed for physician's orders being followed by all three shifts of the nursing staff. (Residents #2, #1 and #3 ). Resident #2 ' s Tylenol #3, a narcotic medication, was administered after receiving a physician's order to discontinue it. Resident #1 ' s [MEDICATION NAME] 0.25 mg, a controled medication, every 12 hours was not administered as ordered by the physician. Resident #3's [MEDICATION NAME] 7.5 mg, a narcotic medication, every 8 hours was not administered as ordered by the physician. This failure affected three residents and placed 104 residents at risk of medical decline do to not receiving care as ordered by the physician. Findings included: Intake # 1 Resident #2 Record review of Resident #2 ' s face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 2/10/2015 at 1:20 P.M. revealed two bubble packs of Tylenol #3 (one bubble pack of 30 and another bubble pack of 5) for Resident #2 on the 200 hallway medication cart. Record review of Resident #2 ' s physician's orders dated 12/27/2014 revealed an order to " discontinue Tylenol #3 " . Record review of Resident #2 ' s Tylenol #3 ' s control drug record revealed she received Tylenol #3 on the following dates: 12/31/14, 1/3/15, 1/7/15, 1/8/15, 1/11/15, 1/12/15, 1/15/15, 1/18/15, 1/26/15, 2/3/15 and 2/9/15. Interview on 2/10/2015 at 1:30 P.M. the DON confirmed Resident #3 ' s Tylenol was discontinued on 12/27/14 and it should have not been administered after that date. The medicationt should have been immediately removed from the cart. She stated she was going to conduct an investigation into this issue. Interview on 2/10/2015 at 2:15 P.M. LVN #1 stated he had worked with Resident #2. He said when she complained of pain he went to Resident #2 ' s control drug record and saw she had Tylenol #3 for pain. He stated he did not look on the MAR (medication administration record) for the order or to document it. He stated he would remove one Tylenol #3 and record the removal on the control drug record only. He stated that was not the correct procedure and he should have checked for an active order on the MAR and also document the administration on the MAR. Resident #1 Record review of Resident #1 ' s face sheet revealed she was an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1 ' s physician's orders dated 11/19/13 revealed an order for [REDACTED]. Record review of Resident #1 ' s [MEDICATION NAME] 0.25 mg ' s control drug record revealed she received 1 [MEDICATION NAME] 0.25 mg on the following dates: 12/31/14, 1/5/15, 1/6/15, 1/7/15, 1/8/15, 1/9/15, 1/12/15, 1/13/15, 1/14/15, 1/16/15, 1/23/15, 1/27/15, 1/28/16, 1/29/15, 1/30/15, 2/2/15 and 2/6/15. Further record review revealed she did not receive any [MEDICATION NAME] on the following dates: 1/19/15, 1/20/15, 1/21/15, 1/22/15, 1/26/15, 2/3/15, 2/4/15 and 2/5/15. Interview on 2/10/2015 at 2:15 P.M. LVN #1 stated he was Resident #1 ' s nurse on 2/3/15, 2/4/15 and 2/5/15. He stated he did not give Resident #1 ' s [MEDICATION NAME] to her because he was reading the order incorrectly and thought it was a PRN (as needed) order. Interview on 2/10/2015 at 2:30 P.M. the DON confirmed Resident #1 was not receiving her [MEDICATION NAME] as ordered. She stated apparently the nurses were not reading the Physician's orders thoroughly or correctly and the residents were not receiving their medications as ordered. Resident #3 Record review of Resident #3 ' s face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s physician's orders dated 11/17/14 revealed an order for [REDACTED]. Record review of Resident #3 ' s [MEDICATION NAME] 7.5 mg ' s control drug record revealed the resident received her [MEDICATION NAME] three times a day except on the following days: 2/1/15 only received at 1:00 A.M 2/6/15 only received at 9:00 A.M. & 5:00 P.M. 2/7/15 only received at 1:00 A.M. & 9:00 P.M. 2/8/15 only received at 1:00 A.M. & 9:00 A.M. Interview on 2/10/2015 at 3:30 P.M. the DON stated there seemed to be several nurses on all three shifts that were not following facility policy and not carrying out orders correctly. She stated there would be an investigation. She would have coaching and consulting and in-services to correct the issue. Record review of the facility ' s policy medication administration dated 8/13 revealed in part the following ... " 5. Verify the " R " ' s (the " right " ) patient, drug, dosage form, dose, route and frequency ...9. Initial each dose given in MAR after each resident ... " . Facility CMS 672 dated 2/10/2015 listed a census of 107 residents.

Based on interview, and record review, the facility failed to provide services according to the physician's orders for one of nine residents (CR#1) reviewed for quality of care. CR# 1 ' s antibiotic medication Ertapenem one gram ordered by the physician to be given daily for seven days on 9/12/13 was not implememnted. CR #1 was admitted to the hospital on [DATE] with altered mental status [MEDICAL CONDITION] (a potentially life threatening complication of an infection). This failure affected one resident and placed 106 residents at risk of not receiving care as ordered by the physician which could cause a medical decline. Findings include: Intake # 8 Record review of CR# 1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Interview on 11/12/14 at 2:27 P.M., CR# 1 ' s family member said the resident ' s family visited CR # 1 on 9/29/14 , and notified other family members that the resident did not look good. The family member said the facility had not contacted any of the family members about the resident ' s continued decline. The family member stated CR# 1 did not recognize him when he visited the facility on 9/30/14 and they had requested the resident be transfered to the hospital. The family member further said that the resident was diagnosed at the hospital with severe dehydration, altered mental status,[MEDICAL CONDITION] and was in a very bad shape. The family member said CR# 1 remained in the intensive care unit for some time. Record review of CR # 1 MAR dated September 2014 revealed [MEDICATION NAME] IV one gram for 10 days was started on 8/25/14 and completed on 9/3/14. Record review of CR# 1 ' s urine analysis lab result dated 9/10/14 revealed many bacteria in the resident's urine. Record review of CR # 1 thr urine speciman collected 9/10/2014 had culture results dated 9/12/14 which was after CR # 1 completed the [MEDICATION NAME] treatment. The urine culture results revealed gram negative bacteria ([MEDICATION NAME] aerogenes) was identified. Further review of the result revealed isolated bacteria was sensitive to the antibiotic Ertapenem. Record review of CR# 1 ' s physician's order dated 9/12/14 revealed a telephone order for the antibiotic medication Ertapenem one gram daily for seven days . Record review of CR # 1 ' MAR dated September 2014 revealed the ordered medication Ertapenem was not transcribed onto the MAR and not documented as administered. Further review of CR # 1 ' s record revealed no evidence indicating the reason the antibiotic Ertapenem was not administered, and no discontinue order was found for the medication . Record review of CR #1's MDS dated [DATE] , revealed the resident cognition was five(severely impaired) . She required extensive assistance with all ADLs except eating which was supervised. Interview on 11/13/14 at 11:30 A.M., LVN #1 said upon the family requests she assessed the resident the morning of 9/30/14 and she noted the resident was not as alert as before. She stated CR #1 was alert to self and person but was usually alert and oriented to person place and time. LVN # 1 said the residents' family member inquired what happened to CR# 1 and requested to have her transferred to the hospital. The resident was sent to the hospital. LVN # 1 said the resident had received medication to help her appetite which did not seem to be effective because she remained eating about the same. LVN # 1 said she noticed the resident was weaker than usual and staff had to assist her with meals. LVN #1 said CR#1 had a urinary tract infection which was treated with [MEDICATION NAME] before her transfer to the hospital. LVN # 1 was not aware of the ordered medication Ertapenem and did not know it was not administered. Interview on 11/14/14 at 8:55 A.M., the DON said she was not aware of the ordered antibiotic medication Ertapenem. She said she would search the resident ' s record to see if the medication was discontinued. The DON after inquiry found no discontinuation order for the Ertapenem, and no evidence the medication was ever supplied by pharmacy. The DON stated normal procedure was the nurse who took the order would transcribe the medication to the MAR and order the medication from the pharmacy. Record review of CR# 1 ' s hospital record dated 9/30/14 revealed she was admitted with an acute change in mental status, metabolic [MEDICAL CONDITION], severe dehydration,[MEDICAL CONDITION] and hypertension. Facility census dated 11/13/14 listed 106 residents in the facility

Based on interview and record review the facility failed to provide necessary care and services to attain the highest practicable mental and physical well-being for one of nine residents (CR# 1) reviewed. Resident CR # 1 had a change in condition and did not receive care as ordered by the physician. CR# 1 ' s urine analysis and culture dated 9/10/14 and 9/12/14 respectively identified a urinary tract infection. CR# 1 ' s was ordered antibiotic medication Ertapenem one gram daily for seven days on 9/12/13 which was not administered. CR # 1 was transferred to the hospital on [DATE], per family request, and was diagnosed with [REDACTED]. This failure affected one resident and placed 106 residents in the facility of risk of not receiving timely medical care and services, which would have a negative impact on their health and wellbeing. Findings include: Intake # 8 CR #1 Interview on 11/12/14 at 2:27 P.M., CR# 1 ' s family member said the resident ' s family visited CR # 1 on 9/29/14 , and notified other family members that the resident did not look good. The family member stated CR# 1 did not recognize them when they visited the facility on 9/30/14. The family member further said the resident was diagnosed at the hospital with severe dehydration, altered mental status,[MEDICAL CONDITION] and was in a very bad shape. The family member said CR# 1 remained in the intensive care unit for some time. Record review of CR# 1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1 ' s care plan dated 6/25/14 , revealed CR #1 was independent with meals and required only tray set up assistance. The goal documented was to maintain independence with meals within the next 90 days. The approaches included: monitor for decline in ability to feed self and report any changes to charge nurse , MD and responsible party. Record review of CR# 1 ' s Basal metabolic panel lab (BMP ) dated 8/26/14 revealed high BUN-31 and creatinine 2.5. Comprehensive metabolic panel (CMP) dated 8/27/14 revealed high BUN-33 (normal range 7-25) and creatinine of 2.6 (normal range 0.6-1.2). Further review revealed the lab findings were reported to CR # 1's physician with no new orders. Elevated BUN and Creatinine levels could indicated kidney damage or [MEDICAL CONDITION]. Further review of CR # 1 ' s records revealed no other labs were drawn after 8/27/14. Record review of CR #1's care plan dated 6/25/2014revealed no mention of signs or symptoms of kidney problems, dehydration or renal problems. The care plan was not updated after lab values. Record review of the Social Worker ' s notes dated 9/3/14 revealed "CR# 1 's (family member) is concerned that she is not eating as well as she should. She does not get out of bed and engage in activities. She sleeps too much. She gets up early in the morning and watches the news. She enjoys company. She had services offered and available as needed. She is mostly bedfast. She has visits from her family. She is DNR. May have some depression issues as well. Social services will continue to monitor " . Interview on 11/14/14 at 10:00 A.M., the DON said the above concerns from CR # 1 ' s family member were not communicated to her or nursing staff. Record review of CR# 1 ' s urine analysis lab result dated 9/10/14 revealed many bacteria in urine, urine culture dated 9/12/14 revealed isolated organism as [MEDICATION NAME] aerogenes. Record review of CR# 1 ' s weight log revealed: 6/10/14- 202.8 lbs. 7/11/14- 200.0 lbs. 8/10/14 -197.2 lbs. 9/10/14 -196.6 lbs. Record review of CR#1 ' physician's orders [REDACTED]. Record review of CR #1's Nurses notes revealed documentation on 9/25/2014 of the resident eating 35 % of her breakfast. Conitinued review revealed on 9/26/2014 the resident had eaten 65 % of her breakfast. No other documentation concerning meal or fluid consumption was noted. Record review of CR # 1's urine culture results dated 9/12/14 revealed the urine was collected 9/10/14 after CR # 1 completed the [MEDICATION NAME] treatment. The urine culture results revealed gram negative bacteria ([MEDICATION NAME] aerogenes) was identified. Further review of the result revealed isolated bacteria was sensitive to the antibiotic Ertapenem. Record review of CR# 1 ' s physician's orders [REDACTED]. Record review of CR # 1 's MAR dated September 2014 revealed the above ordered antibiotic medication Ertapenem was not transcribed onto the MAR and not administered. Further review of CR # 1 ' s record revealed no evidence indicating a reason why the above antibiotic was not administered, and there was no discontinuation order found Record review of CR #1 ' s MDS dated [DATE] , revealed the resident cognition was 5 ( severely impaired) . She required extensive assistance with all ADLs except eating which was supervised. Interview on 11/13/14 at 11:30 A.M., LVN #1 said upon the family requests she assessed the resident the morning of 9/30/14 and she noted the resident was not as alert as before. She stated CR #1 was alert to self and person but was usually alert and oriented to person place and time. LVN # 1 said the residents' family member inquired what happened to CR# 1 and requested to have her transferred to the hospital. The resident was sent to the hospital. LVN # 1 said the resident had received medication to help her appetite which did not seem to be effective because she remained eating about the same. LVN #1 said CR#1 not eating or drinking had been "going on for a while" and the resident was losing weight. CR# 1 was no longer coming out of her room and was weaker than usual. LVN # 1 said she noticed the resident was weaker than usual and staff had to assist her with meals. LVN #1 said CR#1 had a urinary tract infection which was treated with [MEDICATION NAME] before her transfer to the hospital. LVN # 1 expressed she noticed a decline in the resident's overall health but there was not any sign requiring emergency treatment. LVN # 1 was not aware of the ordered medication Ertapenem and did not know it was not administered. Interview on 11/14/14 at 8:45 A.M., the DON said she received a " stop and watch " notice (an alert tool indicating a change in condition of a resident) from an aide on the morning of 9/30/14. The DON said prior to that date she was not aware of a decline of CR# 1. The DON said she went into the resident ' s room on 9/30/14 to check on her and offered her some water and CR #1 took a few sips. The DON said she had nothing to compare with as she did not know CR# 1 ' s normal behavior. She further said the resident ' s physician was contacted and he gave the order to send CR #1 to the hospital. The DON said she was not aware of the ordered antibiotic medication Ertapenem. She said she would search the resident ' s record to see if the medication was discontinued. The DON after inquiry found no discontinuation order for the Ertapenem, and no evidence the medication was ever supplied by pharmacy. The DON stated the normal procedure would be that the nurse who took the order for the medication would transcribe the order to the MAR and then send the requestion to the pharmacy to have the medication filled. Record review of CR# 1 ' s form titled SBAR communication form dated 9/30/14 revealed the reason for the transfer : CR # 1 had altered mental status, unable to respond to commands, responded to name only, contacted MD , advised to transfer to hospital. Record review of CR# 1 ' s hospital record dated 9/30/14 revealed she was admitted with acute change in mental status, metabolic [MEDICAL CONDITION], severe dehydration,[MEDICAL CONDITION] and hypertension. Record review of facility ' s policy on hydration revised 7/2013 revealed " the facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. " Sufficient fluid " means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake) and maintain health. Facility census dated 11/13/14 listed 106 residents.