Every finding on record at Lampasas Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #1) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS assessment dated [DATE] was updated to reflect all of Resident #1's current functional abilities. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.Findings included: Record review of Resident #1's faces sheet dated 06/17/26 reflected an [AGE] year old male initially admitted to the facility on [DATE] with a readmission of 04/15/26 and had diagnosis that included unspecified severe protein calorie malnutrition (condition that occurs when the body does not receive enough protein and calories to maintain proper health), hypertensive urgency (severely elevated blood pressure), type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels) with hyperglycemia (high blood sugar levels) , and age related physical debility. Record review of Resident #1's admission MDS assessment dated [DATE] reflected that the following areas were not completed and marked with a dash (-).Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene).Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed.Tub/shower transfer: The ability to get in and out of a tub/shower.Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.The MDS assessment reflected all sections were completed and signed for by CRS A. Record review of Resident #1's comprehensive care plan initiated 4/24/26 and last revised 06/17/26 reflected a focus of The resident has an ADL Self Care Performance Deficit with interventions that included: Bathing: requires staff x1 for assistanceDate Initiated: 04/24/2026 Bed Mobility: supervision as neededDate Initiated: 04/24/2026 Discuss with resident/family/POA care any concerns related to loss ofindependence, decline in function.Date Initiated: 04/24/2026 Eating: supervision as neededDate Initiated: 04/24/2026The care plan did not reflect other areas of functional abilities such as personal hygiene, shower transfers, or dressing assistance required. During an interview on 06/17/26 at 03:50 PM with CRS A, she stated she assists with the completion of MDS assessments in the facility. She stated she gathers information from a number of sources to include nursing, therapy, the resident or family member in order to complete the MDS assessment. She stated a dash (-) is used when they don't have the information and its used per the RAI. She stated that she was unable to complete Resident #1's MDS assessment because she did not have the baseline care plan completed by nursing staff. She stated she is aware of the different methods of obtaining the information for the assessment and that a resident or RP interview is also sufficient when trying to determine certain functional abilities, she stated the interviews were not attempted. CRS A stated the MDS assessment is used to help with the comprehensive care plan and if its not completed it had the potential to result in an incomplete care plan and the care provided to residents could not be accurate. During an interview on 06/17/26 at 04:15 PM with the DON she stated that it was her expectation that MDS assessments were accurate and complete. She stated she was not entirely sure on what the protocol was on submitting an MDS assessment or the timeframes for submitting. She stated that for section GG of the MDS assessment functional abilities that information can be used based on prior level of functioning if they had been a resident and are coming back from a hospitalization if they have the history, can interview the resident or RP to obtain the information, or that hospital records can also be used to determine abilities while they were admitted at the hospital. The DON stated that the MDS assessment will go on to help build the plan of care. She stated she was not sure what was followed for the MDS assessments if it was the RAI or if there was an internal policy, but stated state regulations should be followed. The DON stated the MDS assessment guides care; she said if it was not complete they would not have the most updated care which could potentially affect a residents progress and ability to maintain or progress in their level of function. During an interview on 06/17/26 at 04:44 PM with the ADM she stated with MDS assessments there should be no errors on the document, and it should be completed within the 7 days required. She went on to say, there is no room for errors when you have all the information provided to you. She stated the IDT (interdisciplinary team) helped provide all the necessary information to the staff completing the MDS assessment. She stated that apart from the IDT information provided, information needed for the MDS assessment could be obtained through clinical documents from the hospital, updated documents, the face sheet, hospice, she stated a resident or RP interview can also be done to get that information. The ADM stated the facility follows both the RAI manual and the facility policy. She stated based on the policy it refers staff back to the RAI. The ADM stated the MDS affects the way staff care for residents and if it were done wrong, they would be caring for them the wrong way. She stated the DON is ultimately responsible for ensuring the MDS assessments are completed timely and accurately. Review of the facility Resident Assessment- Nursing Policy and Procedure Manual 2003 reflected:A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI).The assessment will include at least the following: physical and mental functional status.RAI assessments must be conducted within 14 days after the date of admission.The results of the assessment are used to develop, review, and revise the residents comprehensive plan of care.Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Record review of the CMS Final MDS 3.0 RAI Manual version 1.20.1 October 2025 reflected:admission: The 5-Day PPS assessment (A0310B = 01) is the first Medicare-required assessment to be completed when the resident is admitted for a SNF Part A stay. Additionally, an OBRA admission assessment (A0310A = 1) is required for a new resident and, under some circumstances, a returning resident and must be completed by the end of day 14. Please refer to Section 2.6 of this Manual for additional information about the OBRA admission assessment. o For the 5-Day PPS assessment, code the resident's functional status based on a clinical assessment of the resident's performance that occurs soon after the resident's admission. This functional assessment must be completed within the first three days (3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start of Most Recent Medicare Stay, and the following two days, ending at 11:59 PM on day 3. The admission function scores are to reflect the resident's admission baseline status and are to be based on an assessment. The scores should reflect the resident's status prior to any benefit from interventions. The assessment should occur prior to the resident benefitting from treatment interventions in order to determine the resident's true admission baseline status. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. o For an OBRA admission assessment, code the resident's usual performance during first 3 days of their stay starting with the date in A1600, Entry Date.Assessment of the GG self-care and mobility items is based on the resident's ability to complete the activity with or without assistance and/or a device. This is true regardless of whether or not the activity is being/will be routinely performed (e.g., walking might be assessed for a resident who did/does/will use a wheelchair as their primary mode of mobility, stair activities might be assessed for a resident not routinely accessing stairs).OBRA/Interim: The Interim Payment Assessment (IPA) (A0310B = 08) is an optional assessment that may be completed by providers in order to report a change in the resident's PDPM (payment driven payment model) classification. OBRA assessments (A0310A = 01 - 06) are required for residents in Medicare-certified, Medicaid-certified, or dually certified nursing homes and are outlined in Chapter 2 of this Manual. For Section GG on the IPA Interim Payment Assessment (IPA) or an OBRA assessment, providers will use the same 6-point scale and activity not attempted codes to assess the resident's usual functional performance during the 3-day assessment period.Coding Instructions:When coding the resident's usual performance, use the six-point scale, or use one of the four activity was not attempted codes to specify the reason why an activity was not attempted.A dash (-) indicates No information. CMS expects dash use to be a rare occurrence.

Based on interview and record review, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (Resident #1) of six residents reviewed for baseline care plans, in that: Resident #1 did not have a baseline care plan developed in 48 hours of his admission on [DATE]. This failure had the potential to cause residents to not be provided needed care to prevent injuries, feelings of helplessness and a diminished quality of life. Findings Include: Record review of Resident #1's faces sheet dated 06/17/26 reflected an [AGE] year old male initially admitted to the facility on [DATE] with a readmission of 04/15/26 and had diagnosis that included unspecified severe protein calorie malnutrition (condition that occurs when the body does not receive enough protein and calories to maintain proper health), hypertensive urgency (severely elevated blood pressure), type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels) with hyperglycemia (high blood sugar levels) , and age related physical debility. Record review of Resident #1's comprehensive care plan reflected it was initiated 4/24/26 and last revised 06/17/26. Record review of Resident #1's medical record reflected there was no available baseline care plan completed within 48 hours of Resident #1's most recent admission on [DATE]. During an interview on 06/17/26 at 03:50 PM with CRS A, she stated she assists with the completion of MDS assessments in the facility. She stated she gathers information from a number of sources to include nursing, therapy, the resident or family member in order to complete the MDS assessment. She stated a dash (-) is used when they don't have the information and its used per the RAI. She stated that she was unable to complete Resident #1's MDS assessment because she did not have the baseline care plan completed by nursing staff. During an interview on 06/17/26 at 04:15 PM with the DON she stated that from what she could see the baseline care plan for Resident #1 was not completed and she could not locate the assessment which had been required within 48 hours of admission. The DON stated the purpose of the baseline care plan is to make sure everyone is on the same page regarding the care. She stated that a negative outcome of not having a baseline care plan available within 48 hours of admission was the staff would not know what needs to be done to care for the resident. During an interview on 06/17/26 at 04:44 PM with the ADM she stated it was her expectation and policy that baseline care plans were to be completed within 48 hours of a resident admission, and she stated it was the DONs responsibility to ensure they were completed. She stated the purpose of the baseline care plan is to ensure they are treating the resident per their diagnosis. She stated a negative outcome of not having it completed in the timeframe required would be it had the potential to lead to an injury or result in the resident ending back in the hospital since nurses wouldn't know how to treat them. Review of the facility undated Base Line Care Plans policy reflected:Completion and implementation of the baseline care plan within 48 hours of a residents admission is intended to promote continuity of care and communication among nursing home staff, increases resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The baseline care plan will-Be developed within 48 hours of a residents admission.Include the minimum healthcare information necessary to properly care for a resident including but not limited to- initial goals based on admission ordersphysician ordersdietary orderstherapy servicessocial servicesPASARR recommendations if applicable

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 (Resident #1) of 4 residents reviewed for accidents and hazards.The facility failed on 04/13/2026 to ensure Resident #1 received 2 person assist when transferred, by use of mechanical lift, when CNA A was observed on AEM operating the mechanical lift alone. This failure could place residents at risk for falls, or skin tears.Findings include: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including: non-traumatic brain dysfunction (brain injuries caused by internal factors rather than external physical trauma, leading to cognitive, physical, and emotional challenges), malnutrition (imbalance between the nutrients the body needs and the nutrients received), anxiety (temporary excessive worry or unease), depression (serious mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional and physical problems), stiffness of unspecified joint, adhesive capsulitis of shoulder (frozen shoulder, pain and stiffness in the should joint), senile degeneration of the brain. Resident #1's functional limitation in range of motion indicated she had impairment on both sides of her upper and lower extremities and utilized a wheelchair. Resident #1 was dependent on staff for eating, toileting, toilet transfer, bed-to-chair transfer, sit to lying, lying to sitting on side of bed. Resident #1's BIMS score was not conducted due to rarely/never being understood. Resident #1's staff assessment for mental status revealed short- and long-term memory problems and severely impaired cognitive skills for tasks of daily living. Review of Resident #1's comprehensive care plan dated 11/06/2025 reflected Resident #1's RP requested electronic monitoring. Interventions included: Educate resident/responsible party of their responsibility associated with electronic monitoring including reporting abuse/neglect within 14 days of viewing surveillance or being informed of abuse/neglect by a person(s) viewing video surveillance of what they believe to be abuse or neglect. Providing a copy of surveillance to facility administration as requested. A focus of impaired communication & risk for distress r/t nonverbal status dated 04/08/2026. A focus of being at risk for falls with interventions that included: mechanical lift with staff x2 to assist with transfers, staff x2 to assist with transfers dated 10/31/2025. Review of AEM dated 04/13/2026 at 7:12 PM, revealed a female staff member (CNA A) operating a mechanical lift by herself, transferring Resident #1 from the bed to the wheelchair, with no additional staff present throughout the transfer.In an observation/attempted interview on 04/15/2026 at 10:30am, Resident #1 was observed sitting upright in a geri chair in the dining room. She had a right-hand contracture, and had eye movements, but would not respond to verbal cues or questions. She appeared well groomed, appropriately dressed, and there was no foul odor near her.In an interview on 04/15/2026 at 2:27pm with Resident #1's RP, they stated that they thought 2 people were supposed to transfer the resident with a mechanical lift. They were afraid that with 1 person, Resident #1 could be dropped. In an interview on 04/15/2026 at 3:14pm with CNA A, she stated she had been working at the facility for 2 months. She stated that she received training from this facility before she started working on the floor. She stated that the training addressed how to properly use a mechanical lift, which included always using 2 operators. She stated that on 4/13/26 the family of Resident #1 had called the nurse's station and made a big deal about getting Resident #1 out of bed, and the other CNA was not on shift yet, and the nurse was busy, so, to honor the family's wishes, CNA A performed the transfer. She stated that she knew she was supposed to have someone helping, but the family of Resident #1 called the facility all the time, would talk to staff through the AEM, threatened to call police, and it made her nervous to do anything. She stated that 2 people were needed to operate the lift because she could drop that person, and using the lift by herself was not safe. She was last in-serviced on 04/14/2026 and the week prior on mechanical lifts. She stated she also got a verbal warning for the improper mechanical lift. In an interview on 04/15/2026 at 1:55pm with the ADON and DON they stated that the family of Resident #1 would talk through the AEM to staff during care, which made staff nervous that they would be talked to disrespectfully while they were providing care. The ADON stated that the family was verbally abusive, the facility would address concerns with the family, but they would bring new issues up regularly. The DON stated that she conducted an in-service on 4/8/2026, and she ensured all shifts received in-services. The DON stated that it took 2 people to use a mechanical lift to ensure safety and prevent falls. In an interview on 04/15/2026 at 3:56pm with the MDSC she stated that she was working as the charge nurse on 04/13/2026 and she saw Resident #1 in the dining room in her geri chair, and it made her wonder how the resident got in the dining room, because she knew CNA A was the only other staff present on Resident #1's hall. She was administering insulin's at the time and was unsure why CNA A did not ask her for help. She stated that there was a sign on the mechanical lift that told staff to use 2 people, and the sign had been there for a while. She stated that she did not write up CNA A, but she gave her a verbal counseling and told her not to make any transfers with a mechanical lift by herself. She stated that a negative outcome could be that a resident could receive a skin tear. Review of an in-service dated 04/08/2026 reflected a title of Gentle Resident Care & Proper Repositioning with material stating, safe handling (IMPORTANT) -Ask for help when needed-use 2-person assist. CNA A's signature was visible on the sign-in sheet.Review of an in-service dated 04/14/2026 and conducted by the ADON reflected a title of Safe Transfers Practices with material stating, All staff must follow the resident's current physician-ordered transfer method as outlined in the care plan. Under no circumstances may a transfer method be downgraded or altered without proper authorization from the interdisciplinary care team and a physician's order.1. Adherence to Transfer Ordersa. Residents with orders for mechanical lift (e.g., Hoyer lift) or sit-to-stand devices must always be transferred using the specified equipment.b. Staff are strictly prohibited from substituting manual transfers or less supportive methods for convenience or time-saving purposes.3. Family Requestsa. Family members and visitors do not have the authority to change or override transfer orders.CNA A's signature was visible on the sign-in sheet.

Based on interviews and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them for 1 of 5 (R#1) residents reviewed for medication administration. MA A failed to accurately administer R#1's p.m. medications on 02/11/26. R#1 was observed with 4 medications on her face. This failure could place residents at risk of not accurately receiving their medications, which could result in a change in condition. Record review of R#1's admission record, dated 02/13/26, reflected she was admitted to the facility on [DATE] and discharged from the facility on 02/11/26. She had medical diagnoses including displaced bimalleolar fracture of right lower leg (a serious, unstable injury involving fractures of both the medial malleolus (inner ankle) and lateral malleolus (outer ankle/fibula), lack of coordination, need for assistance with personal care, muscle wasting and atrophy, unsteadiness on feet, epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), dementia (a decline in mental ability severe enough to interfere with daily life, hypertension (high blood pressure), chronic congestive heart failure and chronic kidney disease. Record review of R#1's quarterly MDS, dated [DATE], reflected she had a 15/15 BIMS, which indicated she was cognitively intact. She also took antidepressant, anticoagulant, opioid, and anticonvulsant medications. She had no s/s of swallowing disorders. Record review of R#1's care plan, revised 12/17/25, reflected she had impaired cognitive function and thought processes, impaired cardiovascular status, and impaired neurological status. She also experienced adverse medication effects and drug related complications and required monitoring for side effects.Record review of R#1's order summary report, dated 02/13/26, reflected, Give 5mg Apixaban oral tablet by mouth two times a day for preventative ordered and started on 12/13/ 25 Give one 500mg Levetiracetam oral tablet two times a day for seizures ordered and started 12/13/25 Give one 500mg Methocarbamol oral tablet by mouth every 6 hours for muscle spasms ordered and started 12/13/25 Give one 25mg Metoprolol Tartrate oral tablet my mouth two times a day for elevated blood pressure ordered and started 12/13/25 Give one 50mg Sertraline HCI oral tablet by mouth one time a day for depression ordered and started 12/13/25Record review of R#1's MAR/TAR for February 2026 reflected MA A documented he orally administered Sertraline MCI 50mg, Apixaban 5mg, Levetiracetam 500mg and Metoprolol Tartrate 25mg on 02/11/26 in the p.m . to R#1. MA A also documented that he orally administered Methocarbamol 500mg to R#1 on 02/11/26 at 5:00 p.m. Record review of R#1's progress notes dated 02/11/26 at 6:51 p.m., written by LVN B reflected, This lvn was notified during shift change 1815 (6:15 p.m.) that resident was not responding, this lvn assessed resident, res had drool and her pm medication was on her face, res would start to answer questions but unable to finish complete thought, this lvn called 911 at 1820 (6:20 p.m.), EMS arrived at 1830 (6:30 p.m.), transporting to hospital for eval and treatment, left facility at 1845 (6:45 p.m.). This lvn notified NP, administrator, DON and daughter. During an observation of R#1's room on 02/13/26 at 10:31 a.m., R#1 was not in her room. During an interview with the BOM on 02/13/26 at 10:32 a.m., she stated R#1 was sent to the hospital on the night of 02/11/26 due to respiratory issues. During an interview with LVN C on 02/13/26 at 2:30 p.m., she stated MAs and nurses administered residents' medications according to physician's orders. She stated MAs and nurses were required to observe residents orally take their medications. She stated there was no one who oversaw and ensured MAs and nurses observed residents orally take their medications. She stated it was important to observe residents orally take their medications and, To make sure residents swallowed the medications or was having trouble swallowing medications or medication was left behind. To make sure to document medication was administered correctly. Residents could be at risk of not receiving their medication, which could hinder their treatment. During an interview with LVN B on 02/13/26 at 2:44 p.m., she stated MAs and nurses administered residents' medications according to physician's orders. She stated MAs and nurses were required to observe, oversee and ensure residents orally take their medications successfully. She stated she observed four medications on R#1's face on 02/11/26 and notified the DON, who identified and provided the medications to EMS when they arrived to take R#1. She stated she did not know what medications she observed and that the DON identified were on R#1's face because she did not administer the medications to R#1, but she believed one of the medications was Metoprolol. She stated MA A administered medications to R#1. She stated it was important to observe residents orally take their medications and, Because it could be a choking hazard and because they might not get the medication. She stated she did not receive any in-services after R#1 was sent to the hospital on [DATE]. During an interview with MA A on 02/13/26 at 3:05 p.m., he stated MAs and nurses administered residents' medications according to physician's orders, facility's policy and procedures, and federal regulations. He stated MAs and nurses were required to observe residents orally take their medications. He stated he verified residents orally took their medications by talking to residents after administering their medications. He stated he observed R#1 take her medications by talking to her after administering the medications to her on 02/11/26 in the p.m. He stated it was important to observe residents orally take their medications, and, To make sure residents are not spitting them out and they are following doctor's orders. Residents could be at risk of getting sick or sicker depending on what the medications are for, and they could choke. He stated the ADM in training in-serviced him on s/s of sedation and resident rights after R#1 was sent to the hospital on [DATE]. He stated he was not in-serviced on medication administration after R#1 was sent to the hospital on [DATE]. During an interview with the Regional Nurse on 02/13/26 at 3:31 p.m., she stated the DON was out of the facility. She stated MAs and nurses administered residents' medications according to physician's orders. She stated MAs and nurses were required to observe residents take their medications and ensure they took successfully took them. She stated she did not know what medications the DON identified R#1 had on her face and provided to EMS on 02/11/26. She stated she did not know if staff started receiving in-services on medication administration before 02/13/26. She stated it was important to observe residents orally take their medications and, Well you want residents to get their medication and meet their levels. Residents could be at risk of not being stable depending on their condition. It's important to make sure residents took their medication. Residents could be at risk depending on residents condition and the medication the resident was required to take.During an interview with the ADM on 02/13/26 at 3:41 p.m. she stated MAs and nurses administered residents medications according to physician's orders. She stated MAs and nurses must observe residents successfully take their medications. She stated she knew it was important to observe residents successfully take their medications and said, You must make sure residents took their medications because it is based on their physician's order. She stated she did not in-service staff on medication administration after staff sent R#1 to the hospital on [DATE] and said, Because I did not think that was the problem. She stated she observed R#1 was drooling and had four pieces of medication on her face. She stated she did not know what medications she observed on R#1's face on 02/11/26 before EMS arrived and took R#1 to the hospital, but she believed one of the medications was a blue pill. She stated R#1 was alert and oriented.During an interview with the ADON on 02/13/26 at 3:51 p.m., she stated MAs and nurses administered and observed residents take their medications successfully. She stated it was important to monitor residents orally take their medications and, To verify it was taken and what was actually take. Residents could be at risk of a missed dose.Review of the facility's medication administration and general guidelines policy, 2025, reflected, Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or otherpersonnel authorized by state laws and regulations to administer medications.2. Medications are administered in accordance with written orders of the attending physician.Checklist for completing proper steps in the administration of medications:.Observes the resident take the medications.

Based on interview, observation and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for PASARR Level I screenings.The facility failed to ensure the PASARR Level 1 screening did not indicate a diagnosis of mental illness, Resident #1 had a diagnosis of bipolar disorder with an onset date of 09/17/2007.This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.Findings included:Record review of Resident #1's face sheet, dated 01/22/2026, reflected he was a [AGE] year-old male, admitted to the facility on [DATE] with an initial admit date of 07/23/2007. Pertinent diagnoses included: bipolar disorder, unspecified (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), schizoaffective disorder, bipolar type (a mental health condition with symptoms of schizophrenia and a mood disorder), bipolar disorder, current episode manic without psychotic features, unspecified (a complex mood disorder characterized by episodes of mania, which can significantly impact an individual's functionality and quality of life), major depressive disorder, single episode, episode (an individual experiencing only one major depressive episode in their lifetime, with no history of previous depressive episodes)Record review of Resident #1's quarterly MDS assessment, dated 12/12/2025, reflected he had a BIMS score of 02, which indicated resident's cognition was severely impaired. The MDS assessment reflected Resident #1 was dependent on staff for toileting and bathing and required substantial/maximal assistance with personal hygiene.Record review of Resident #1's PASARR Level 1 Screening, dated 10/08/2019, reflected that Section C Mental Illness was marked as N/A, which indicated Resident #1 did not have a mental illness.Record review of Resident #1's care plan dated 03/07/25 reflected Resident #1 had a mood problem r/t to diagnosis of depression and schizoaffective disorder bipolar type.Goal: Resident will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date.Interventions included Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. Observe for signs and symptoms of risk for harm to self; suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapy, sense of hopelessness, impaired judgement or safety awareness.In an interview and observation on 01/20/2026 at 11:28 AM, Resident #1 shook his head yes when asked if staff treated him good and took good care of him. He attempted to say something but could not determine what he stated. He shook his head no he had no concerns with staff or living at the facility.In an interview on 01/22/2026 at 2:30 p.m. DON stated the MDS nurse was responsible for ensuring the accuracy of PASRRs. She stated the facility process for identifying residents with a possible MD, ID, or a related condition prior to admission goes through the Business office manager, MDS Coordinator, Nurses, Administrator according to the workflow when they get the referrals. The facility identifies residents with newly evident or possible serious MD, ID, or a related condition after admission based on assessments and bringing providers that can assist with them. DON stated she is not sure why he did not receive a PASSR II, but he has received all service he qualified for.In an interview on 01/22/2026 at 2:48 p.m., LVN A stated the facility process for identifying residents with a possible MD, ID, or a related condition prior to admission. They will look at the hospital clinical paperwork that is available. If they have the diagnosis, they will fill out the form 1012 to change and give it to the doctor letting them know there is a diagnosis. LVN A stated their electronic system SIMP notify the local authority, and they have 72 hours to come out and do the assessment to determine if, they are positive. She denied Resident #1 had a newly evident or possible MD, ID, or a related condition after admission because he dd not have an acute episode, but if he had, they would have referred him to in-house psych. If the residents go out because they cannot manage in house, they will send them to inpatient psych. LVN A denied a referral would not have been put in if he qualified. LVN A stated she has just been there for a couple of weeks, and she is trying to train the new MDS Coordinator and make sure everything is in order. Record review of the facility's policy, PASRR Nursing Facility Specialized Services Policy and Procedure revised 03/06/19 reflected: Policy: It is the policy of facilities to ensure NFSS Forms are submitted timely and accurately .

Based on observations, the facility failed to prepare food in accordance with professional standards for food safety in the facility only kitchen reviewed for kitchen sanitation.DC A failed to sanitize her hands in between tasks while preparing puree and taking temperatures. This failure could have placed residents at risk of foodborne illness.Findings included: Observation on 01/20/26, at 11:54 a.m., DC A failed to wash her hands after each transition to a new task, while preparing puree and taking the temperatures of food items placed in the hot tray. During an interview on 01/21/26 at 11:12 a.m., DS A stated she expects all staff in the kitchen to wear hair nets throughout their entire time in the kitchen. She said that all staff in the kitchen should always be practicing hand hygiene by properly washing their hands or changing gloves after each task or if touching an object such Example (the refrigerator, garbage can), DS A reported that staff should wash or replace gloves after each task pertaining to food. DS A reported that not practicing appropriate hand hygiene could result in foodborne illness as well as cross contamination. DS A stated that she could not remember if the kitchen staff had a recent Inservice in hand hygiene/maintain sanitary conditions while preparing food. During an interview on 01/22/26 at 02:19 p.m., DC B stated that he was the only employee who was currently working in the kitchen. DC B revealed that he is also one of the maintenance workers. He reported that when he is takes a temperature for food or preparing food, he always washed his hands or changes his gloves. He reported that he also ensures that he cleans the thermometer off after each use with a new alcohol swab. DC B also reported that he makes sure that he keeps his hair net on and beard covered. He reported that not washing your hands in between each task, could make the resident sick from bacteria. DC B reported that the facility makes them take in-services all the time but could not recall his last in-service on hand hygiene or infection control. During an interview on 01/22/26 at 8:09 a.m., DC A stated that when she is preparing food, she washes her hands and changes her gloves each time she starts something different in the kitchen. DC A reported that not washing your hands while dealing with food and changing task is nasty. She said that it could cause cross-contamination and salmonella. DC A stated that she always washes her hands before starting a new task and denied not practicing proper hand hygiene in 01/20/26. DC A reported that she, not has seen any other staff working with her in the kitchen and not practicing safe hand hygiene. She also reported that the kitchen is often short staff and often works in the kitchen alone. Review of the Policy Infection Control Plan: Overview (dated 03/2024) indicated: Infection Control The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. INTENT The intent of this policy is to ensure that the facility develops, implements, and maintains an Infection Prevention and Control Program to prevent, recognize, and control, to the extent possible, the spread of infection within the facility. DEFINITIONS Definitions are provided to clarify terminology or terms related to infection control practices in nursing homes refers. Hand hygiene is a general term that applies to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR) Hand washing refers to washing hands with plain (i.e., nonantimicrobial) soap and water. 1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty. When hands are visibly soiled (hand washing with soap and water); Before and after direct Before and after eating or handling food (hand washing with soap and water); Before and after assisting a resident with meals. After personal use of the toilet (hand washing with soap and water). caused by norovirus, salmonella, shigella, and C. difficulty (hand washing with soap and water). After blowing or wiping nose. After completing duty. Facility Antimicrobial Stewardship Mission Statement Our facility embraces the importance of an infection prevention.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #12) observed for infection prevention.The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided care for Resident #12.This deficient practice could place residents at risk for infection.Findings included: Record review of Resident #12's face sheet dated 04/23/2024 revealed he was a [AGE] year-old man, with an initial admission date of 04/23/2024 with diagnoses which included: Heart Failure, unspecified, (heart failure but medical records lack detail about the specific type), Obstructive and Reflux Uropathy (blockages or backward flow in the urinary system, where urine can't exit properly, backing up into the Kidneys and potentially causing damage), and Benign Prostatic Hyperplasia ( a common, non-cancerous enlargement of the prostate gland). Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating normal, intact cognition. Further review revealed Resident #12 had an external catheter. Record review of Resident #12's Active Orders dated 01/16/2026 revealed orders which included: - Urinary Catheter (18f) with gravity drainage - Enhanced Barrier Precautions listed under Special Instructions in the Orders tab. Record review of Resident #12's Care Plan dated last reviewed 01/01/2026 revealed a Problem which included The resident has Indwelling Catheter, initiated 01/01/2026 and revised 01/19/2026. This problem area included the following interventions: - Catheter: The resident has (18f). Position catheter bag and tubing below the level of the bladder and in a privacy bag; initiated 01/01/2026 - Change the catheter monthly and prn.; Initiated 01/01/2026 - Check tubing for kinds and maintain the drainage bag off the floor., Initiated 01/01/2026 - Check tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra; Initiated 01/01/2026 - Monitor and document intake and output as per facility policy; Initiated 01/01/2026 - Monitor for s/sx of discomfort on urination and frequency; Initiated 01/01/2026 - Monitor/document for pain/discomfort due to catheter.; Initiated 01/01/2026 - Monitor/record/report to MD for s/sx UTI: pain burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.; Initiated 01/01/2026. Observation on 01/21/2026 at 10:38 AM, revealed there was a sign indicating Enhanced Barrier Precautions on the door to Resident #12's room. There was a supply of PPE available outside the door/room. Further observation revealed CNA A put on gloves but did not put on or wear a gown while performing catheter care for Resident #12. During an interview with CNA A on 01/21/2026 at 10:50 AM., when asked to describe the meaning of EBP, CNA A stated, I forgot to wear a gown. CNA A stated EBP is required when performing direct care to a resident that has conditions such as wounds or any opening to the body. During an interview with the DON on 01/22/2026 at 3:00 PM, the DON stated use of EBPs is expected when a resident has an open wound or medical equipment (i.e., urinary catheter). She stated a negative outcome of failure to abide by EBPs would be the spread of infection. Record review of facility policy titled Enhanced Barrier Precautions effective 4/1/2024 revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply, Wound and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 3 residents reviewed for comprehensive care plans.The facility failed to include Resident #10's tramadol pain medication in her care plan dated 11/20/25.This failure could lead to residents not receiving needed care and/or receiving improper care/treatment.Findings Included:Record review of Resident #10's admission revealed an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with diagnoses that included, but were not limited to, heart failure, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A record review of Resident #10's MDS, completed on 12/22/25, revealed a BIMS score of 99 A BIMS score of 99 indicates that the exam could not be completed. Resident #10 is coded as receiving PRN pain medications.Record review of Resident #10's care plan with last revision date of 11/10/25 revealed no mention of pain medication or having pain-related issues. Record review of Resident #10 order summary dated 10/26/25 revealed the following order with an order start date of 12/01/25:Tramadol HCl Oral Tablet 50 MG (give 1 tablet by mouth every 6 hours as needed for pain). During an interview on 1/08/2026, at 11:12 AM with Resident #10. Resident #10 could not recall which medications she received at the facility and had difficulty answering the questions.During an interview on 01/08/ 2026 at 2:28 PM, The LPN stated she does not handle care plans. The LPN stated the resident's pain should have been documented in the care plan. The LPN stated if Resident #10's care plan was not updated; Resident #10 could receive incorrect treatment. During an interview on 01/08/2026 at 2:42 PM, LVN A stated RNs are responsible for the initial care plan. LVN A stated if Resident #10 was in pain, it should be in the care plan. LVN A stated if the care plan was incorrect, Resident #10 would not have up-to-date information about their care. The LVN stated this could result in Resident #10 receiving the wrong treatment. LVN A stated if any information in the care plan is incorrect, she will contact the provider. LVN A stated she does not update the care plan. During an interview on 01/ 08/2026 at 3:30 PM, The DON stated they currently do not have an MDS coordinator and that a corporate nurse was assisting until one was hired. DON stated LVN B was the last to assist with the MDS duties. DON stated that Resident #10 should have been care-planned for pain. DON stated if the care plan was not up to date, then Resident #10 could not get the right treatment and become sedated or injured. During an interview on 01/08/2026 at 2:42 PM, LVN B stated that she was assisting the facility with its care plans until 12/23/2025. LVN B. stated that PRN pain medication was not typically included in the care plan. LVN B stated that Resident #10 should have had pain listed in her care plan. LVN B stated she was not the one who updates care plans. LVN B stated that nurses are responsible for updating residents' care plans. LVN B stated that if care plans are not updated, residents may receive insufficient care. During an interview on 01/ 08/2026 at 4:11 PM, CNA stated she does not enter anything into the care plan, but if there are changes, she will notify a nurse. CNA stated it was important for the care plan to be up to date because if it was not, residents may not receive appropriate care. CNA stated that a resident could get injured if the care plan was not updated. During an interview on 01/ 08/2026 at 4:20 PM, the ADM stated that all nurses can update residents' care plans and should do so when there was a change. ADM stated that Resident #10 should have been care-planned for pain. ADM stated that because Resident #10 was prescribed Tramadol, Resident #10 should have been care-planned for pain. ADM stated that if care plans are not up to date, a resident could receive incorrect care or be injured. Record review of facility policy titled Comprehensive Care-Planning that was not dated revealed the following: The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical,mental, and psychosocial well-being.Each resident will have a person-centered comprehensive care plan developed and implemented to meet hisother preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two of two residents reviewed for quality of care.The facility failed to provide Resident #1 with post-surgery pain medication for more than 48 hours after admission, provide enteral feeding and hydration for more than 19 hours after admission, and provide colostomy/ileostomy (an opening in the abdomen for feces to leave the body) care to avoid fecal leakage, skin breakdown, and hospitalization.The facility failed to provide Resident #2 with the proper care and assessment to identify an injury of unknown origin that resulted in a large bruise across her chest and breasts.An IJ was identified on 11/18/2025. The IJ template was provided to the facility on [DATE]. While the IJ was removed on 11/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of four because documentation practices do not reflect the proper care and treatment to prevent harm to residents.These failures could place residents at risk of starvation, uncontrolled pain, an unidentified significant injury, and up to and including death. The findings included: A record review of Resident #1's face sheet dated 11/18/2025 reflected at [AGE] year-old female admitted to the facility on [DATE] at 4:40 PM and transferred on 11/1/2025 at approximately 12;00 PM to acute care hospital on for a rash on her stomach Her diagnoses included Surgical Aftercare Following Surgery on the Digestive System (an opening in the abdomen for feces to leave the body) , Sepsis (serious microorganisms in the blood, can cause death), Type 2 Diabetes (the body's inability to produce insulin), Chronic Obstructive Pulmonary Disease (damage to the lungs), Ulcerative Colitis (chronic bowel disease), Acute Kidney Failure (kidney's cannot filter waste), Nonrheumatic Aortic Stenosis (narrowing of the aortic valve), and Cerebral Infarction (stroke). A record review of Resident #1's MDS dated [DATE] reflected no BIMS was available, as the resident resided was in the facility less than 72 hours. A record review of Resident #1's admission care plan dated 10/31/2025 reflected the following: Focus Area: The resident requires tube feeding. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than (X) cc aspirate. The resident is dependent on tube feeding and water flushes. Focus Area: Resident has a diet order other than Regular and is at risk for unplanned weight loss or pain. Interventions: Determine food preferences and provide dietary limitations. Encourage meal completion and document amount consumed. Focus Area: The resident has a potential for uncontrolled pain. Interventions: Anticipate the residents' need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability, and impact on cognition. A record review of Resident #1's admission Nurse Note dated 10/29/2025 at 5:36 PM reflected the following: A. Does the resident require her medications to be crushed? Answer: Yes G. Gastrointestinal 4. Bowel Control. Answer: Ostomy I. Mobility/Safety 7. Eating/Drinking - How much assistance does the resident require? Answer: NPO J. Oral / Nutrition - How does resident receive nutrition/hydration? Answer: Enteral Feeding K. Pain - Have you had pain or hurting any time in the last 5 days? Answer: Yes How much of the time have you experienced pain or hurt over the last 5 days? Answer Frequently Please rate your worst pain over the last 5 days, 0-10 scale. Answer: 6 A record review of Resident #1's admission paperwork from the transferring SNF was attempted on 11/19/2025 at 1:45 PM and again on 11/20/2025 at 10:30 AM. The RCN said all admission documents were in PCC. A record review of Resident #1's referral document from the transferring SNF dated 10/29/2025 at 9:17 AM reflected the following: Continuous Infusions: PRN Meds: oxycodone; no specific dosage or instructions were documented. Recommendations: 1.TF formula changed to Nepro 10/17 due to elevated potassium. Continue Nepro at45 ml/hour for 24 hours to provide 1752 kcals, 80 gm protein and 720 ml free water (Calculations based on 22 hours for anticipated interruptions.)2. Free water flushes per physician. 3.Continue/adjust insulin regimen as medically appropriate per physician. Goal blood sugars 140-180 mg/dL on nutrition support. 4.Adjust Imodium per physician. Goal ileostomy output <800-1000 ml/day.5.Once medically appropriate, may consider resuming standard diabetic enteral formula. Recommend 1440 ml Glucerna 1.2 daily (60 ml/hour uninterrupted goal rate) to provide 1728 kcals, 86 gm protein and 1159 ml free water. A record review of Resident #1's Narcotic Count Log reflected Oxycodone/APAP 5-325 MG, give two tablets by mouth every four hours as needed. The Narcotic Count Log and the two coinciding medication blister packs were discovered by the RNC on 11/18/2025 in the DON's office. LVN - A signed out 1 tablet on 10/30/2025 at 11:45 PM. Remaining count was 59. LVN - B signed out 1 tablet on 10/31/2025 at 8:00 AM. Remaining count was 58. LVN - B signed out 2 tablets on 10/31/2025 at 12:00 PM. Remaining count was 56. LVN - B signed out 2 tablets on 10/31/2025 at 5:00 PM. Remaining count was illegible. ADON - signed out 2 tablets on 11/1/2025 at illegible time. Remaining count was 51. ADON - signed out 2 tablets on 11/1/2025 at 6:03 AM. Remaining count was 49. LVN - C signed out 2 tablets on 11/1/2025 at 11:30 AM. Remaining count was 47. There was a discrepancy with the remaining count. There were 12 tablets signed out and the remaining count was 47 of the initial 60 on the blister pack. A record review of Resident #1's orders reflected an order dated 10/31/2025 for Oxycodone Oral Tablet 5-325 MG (Oxycodone w/Acetaminophen) Give two tablets via G-Tube every 4 hours as needed for pain. An additional order dated 10/31/2025 for Tramadol HCI Oral Tablet 50 mg, give 1 tablet every 6 hours as needed for pain. A record review of Resident #1's medication administration record reflected Oxycodone 2 tablets via G-Tube every 4 hours for pain was administered on 10/31/2025 at 5:10 PM by LVN-B. There was no documentation that Tramadol was administered to Resident #1. Medical records for Resident #1 were requested from the acute care hospital on from the SNF for Resident #1 was requested on 11/19/2025 at 8:32 AM and from the SNF on 11/19/2025 at 2:11 PM. The records were not received. A telephone call was placed to the SNF on 11/19/2025 at 8:54 AM and on 11/20/2025 at 2:17 PM.During an interview on 11/18/2025 at 8:36 AM, Resident #1's RP stated Resident #1 passed away on 11/16/2025 while at the hospital. He said she never recovered from her stay at the facility. He said, I visited her the day after she was admitted to the facility and her colostomy bag had been leaking all night and it was not changed. The area looked infected. They did not feed her until 10/30/2025 and did not give her any pain medication until 10/31/2025. During an interview on 11/18/2025 at 8:54 AM, the NP stated she received a call from the facility on 10/30/2025 at 12:24 PM requesting an order for Oxycodone for Resident #1. The original orders were for Tylenol. She said, I was unaware Resident #1 did not receive pain medication until 10/31/2025 at 5:00 PM.During an interview on 11/18/2025 at 1:28 PM with the ADON, she stated, I am unsure why Resident #1 went more than 24 hours post admission without receiving pain medication. She said pain meds for Resident #1 were administered as ordered. During an interview and observation on 11/18/2025 at 2:02 PM, the RCN said, Resident #1 got medication by mouth. While reviewing PCC on her computer she stated, No one documented, so I cannot follow it [the sequence of events].During an interview on 11/19/2025 at 1:45 PM, the RCN stated the admitting nurse was responsible for reconciling the medication orders. She said ADON and DON were responsible for auditing the narcotics log for discrepancies. A record review of the physicians' orders for Resident #1, reflected the following order dated 10/30/2025 for a Clear Liquid Diet, clear liquid texture, honey consistency. An order dated 10/20/2025 for Enteral Feeding every shift related to Gastroesophageal Reflux Disease. Head of bed up at least 30 degrees during administration of enteral formula or water.A record review of the medication administration record for Resident #1, reflected the following, on 10/30/2025 at 12:00 PM, Resident #1 received enteral feeding via bolus administered by LVN-C. During an interview on 11/18/2025 at 1:28 PM with the ADON, she stated, There was no excuse why she did not receive nutrition until the day after admission. She said, they made sure the formula was at the facility, and they spoke with the NP about a continuous feeding pump.[SP35] [SR36] During an interview and observation on 11/18/2025 at 2:02 PM, the RCN stated while reviewing PCC on her computer she stated, No one documented, so I cannot follow it Where is the order to hold the enteral feeding? Where is the order to resume enteral feeding? She said, the documentation reflected the order for enteral feeding had a stop date of 10/31/2025 at 12:00 AM, the residents' last feeding was on 10/31/2025 at 8:00 PM and she discharged on 11/1/2025 at 12:00 PM. During an interview on 11/20/2025 at 7:58 AM, LVN-A stated she looked for the paper orders/admission packet for Resident #1 because the admitting nurse was supposed to double-check the orders for accuracy. She said she was told they were locked in the DONs office, and she never saw them She said, I put in a note to hold Bolus feedings. Per record review of Resident #1's orders, there was no order to hold bolus feeding.A Record Review of Resident #1's Progress Notes and a note by LVN-C reflected, Resident #1 was transferred to a hospital on [DATE] at 12:20 PM related to the residents' new colostomy that is hard to keep in place and has leaked out causing red rash around the entire stoma. There was no additional documentation related to the stoma and ill-fitting ostomy bag.During an interview with the NP on 11/18/2025 at 8:45 AM, she stated she was unaware of issues with Resident #1's stoma and the bag leaking.Record Review of Resident #2's Face Sheet dated 11/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE] and transferred to anotherfacility on 11/5/2025. Her diagnoses included Unspecified Dementia with Anxiety (memory issue with fear and inability to remain calm, Difficulty Walking(unsteady on feet, risk of falls), History of Falling (has fallen in the past), Muscle Wasting and Atrophy (shrinking of the muscle mass).A record review of Resident #1's MDS dated [DATE] reflected a BIMS score of one (1), which indicated severely impaired cognition.During an interview on 11/18/2025 at 8:51 AM, Resident #1's RP stated, I was notified on 10/31/2025 that she had bruising across her chest, the size of two adulthands. She also had a bruise on her right elbow, and they thought there might be a fracture on her right arm. She was transferred to the emergency room on11/1/2025 for an x-ray, and it was not fractured. She returned to the facility the same day and sustained further bruising under her arm and on her breasts. She saidshe thought it was significant that no one at the facility noticed or reported this to anyone. She said she never observed the staff using a mechanical lift and she wasnot concerned about this. A record review on 11/18/2025 at 10:00 AM of photos provided by Resident #1's RP, reflected visible bruises across the residents' entire chest. The bruises were invarious stages of healing. There was yellow/green bruising across her breasts and moving up halfway to her chin. The yellow bruise was approximately 12 incheswide and approximately 8 inches in height. On each breast, was a dark blue/purple bruise approximately 2 inches by 3 inches. The RP said she took the photos on11/1/2025 when she arrived at the facility. record review on 11/20/2025 at 5:33 PM of a photo provided by the hospice case manager reflected the resident wearing a red shirt and the shirt was pulleddown to reveal her chest area. The bruises were visible bruises across the residents' entire chest and extending behind her shirt. The bruises were in various stagesof healing. There was yellow bruising across her breasts and moving upwards approximately 3-4 inches below her chin. On each breast, there were darkblue/purple bruises approximately 2 to 3 inches wide. The hospice case manager said she received the photo from the hospice aide.A record review of Resident #1's Skin assessment dated [DATE] and completed by LVN - C reflected no new skin concerns were identified in this assessment. A record review of Resident #1's CNA Task Profile in PCC for reporting new skin changes to charge nurse, treatment nurse, ADON or DON when identified. Thetask profile for 10-25-2025 at 8:38 AM through 11/1/2025 at 2:11 PM reflected check marks where CNA acknowledged the task. The check markacknowledgement indicates no identified skin issues. A record Review of the Event Nurses' Note completed by RCN on 10/31/2025 at 3:30 PM reflected Resident #2 had a bruise/injury across her entire chest andbilateral breasts. The colors were coded as Blue/Purple and Yellow/Green. When Resident #2 was asked what happened, she said, I don't know. Record Review of the Injury Nurses' Note completed by LVN - C for Resident #2 dated 11/01/2025 at 8:50 AM reflected a blue/purple bruise, and a possiblefracture to left elbow, sent to emergency room for x-ray.During an interview on 11/18/2025 at 7:40 AM, the ADM stated, On 10/28/2025 I saw Resident #2 from my office while she was in the doorway of the lobby andthe dining room. Resident #2 slumped over the arm of her wheelchair. Her hand was almost touching the floor. At that time, the DS hollered for me to call a CNA to readjust her in her wheelchair. I called for the CNA - A to come assist with the resident. She re-adjusted the resident from behind the wheelchair andplaced her arms under the resident's armpits. I was unaware of any bruising until 10/31/2025 when the hospice CNA reported it to us. He said they investigatedthe bruising incident, and staff did not witness anyone abusing Resident #2, did not witness or report any falls, and there were no incidents with the mechanical lift.He interviewed other residents and there were no reports of abuse from staff or other residents, and they reported feeling safe in the facility. He said the onlyexplanation for the bruises is it was possibly related to the incident on10/28/2025. He was aware of the RP concerns and the RP stated she would be contacting thestate to investigate the concern. During an interview on 11/20/2025 at 3:45 PM, CNA - E stated on 10/28/2025 the ADM requested her assistance to help reposition Resident #2, who was slumpedto the left side and hanging over the arm of her wheelchair. She said, I cannot recall who assisted me in repositioning her. Her wheelchair was tilted back, and wedid not have to apply any physical touch. We used the mechanical lift. Her hospice shower days were Monday, Wednesday, and Thursday. I know that she did nothave any bruises on 10/28/2025, the day of that incident. I change her into her clothes every day and I would have noticed the bruises. During an interview on 11/20/2025 at 3:56 PM, the hospice case manager stated, On Friday, 10/31/2025 the hospice CNA sent me photos of the bruises on the resident. It almost looked like a CPR situation, but we know that did not happen. She said it was possible the bruises were not present on Wednesday, whenthe hospice CNA bathed Resident #1. She said Resident #2 may have sustained the bruises by leaning up against something for an extended time, but that she couldnot speculate, with any certainty, how the resident sustained the bruises. During an interview on 11/20/2025 at 4:18 PM, LVN-RB stated when conducting skin assessments, she looked at the residents' legs, arms, and bottom. She said, If the residents' are in the shower and then I could complete a thorough assessment of the entire body. She said, I cannot recall if Resident #2 was lying in bedwhen I did the assessment. I do not recall if there was bruising on her elbow. During an interview on 11/21/2025 at 4:07PM, CNA - B stated, When I put the resident to bed on 10/30/2025, I noticed the bruising and I reported it to LVN - A.The bruising had just started, and it was purple under her arms and green across her chest. She said, Resident #2 requires a mechanical lift. However, I come intowork occasionally and the resident would be in her chair with no mechanical lift sling underneath, the Resident #2. This was determined to be an Immediate Jeopardy (IJ) on 11/20/2025 at 12:07 PM. The ADM, RCN, ROM, and DON were notified. The ADM was provided the IJ template on 11/20/2025 at 12:07 PM. The following Plan of Removal submitted by the facility was accepted on 11/21/2025 at 5:19 PM. F684 Quality of Care1. The facility failed to ensure Resident #1 received pain medication.2. The facility failed to provide Resident #1 with the physician ordered enteral feeding and failed to order free water for hydration.3. The facility failed to provide Resident #1 with the required colostomy/ileostomy care and supplies.All residents with enteral feedings, received pain meds, or have ostomies have the potential to be affected by the deficient practice. Interventions:1. Resident #1 discharged to ER on [DATE] by facility via EMS and no longer resides in the facility as of 11/20/25.2. An audit of all admissions and readmissions in the last 30 days was completed by the Regional Compliance Nurse and DON to ensure all orders were reconciled and implemented. No additional negative findings were noted. Completed on 11/20/25.3. All residents in the facility were assessed for pain by the DON, ADON and Charge Nurses. No new onset or worsening pain was assessed for any residents. Completed 11/20/25.4. An audit of all controlled and non-controlled pain medication was performed by the Regional Compliance Nurse, DON, and ADON for adequate supply on the med carts and the emergency kit. All residents ordered pain medication had an adequate amount of supply on hand. There was inconsistencies with documentation that were addressed in the in-services. Completed 11/20/25.5. New Process: The DON, ADON or MDS Coordinator will review all new referrals prior to admission to determine the need for any prescriptions, supplies, or equipment such as enteral pumps or formula. All prescriptions, equipment and supplies will be ordered prior to admission to facilitate continuity of care. If there are any issues with supplies or equipment, the DON or designee will notify the MD or appropriate departments for alternative options or place the admission on hold until all physician orders can be implemented timely. The DON, ADON or designee will review all admissions and readmissions daily in the morning clinical meeting to ensure all orders have been transcribed and implemented timely. The administrator will be responsible for the monitoring of this process daily. Training on this new process provided by Regional Compliance Nurse and ADO. A post-test was provided by the Regional Compliance Nurse, and ADO to confirm understanding. Completed 11/20/25.New Process: DON/ADON/Designee will review the PCC dashboard and medication administration report daily to ensure that all pain medications are administered timely as ordered or requested by the residents. If medications are not administered timely, the MD will be notified for further guidance. The PCC dashboard monitors timeliness of medication administration. The PCC dashboard shows PRN medications administered to check with the residents and verify documentation.6. The DON, ADON or designee will review all admissions and readmissions daily in the morning clinical meeting to ensure all orders have been transcribed and implemented timely. The administrator will be responsible for the monitoring of this new process. Training on this new process provided by Regional Compliance Nurse and ADO. Completed on 11/20/257. The Administrator, DON, and ADON were in-serviced 1:1 on the following policies / new processes by the Regional Compliance Nurse and Area Director. A post-test was provided by the Regional Compliance Nurse and ADO to confirm understanding. Completed on 11/20/25.a. Abuse and Neglect- to include the failure to initiate MD orders timely such as enteral feedings, pain medication, and ileostomy care can result in a resident not receiving adequate nutrition, experiencing unnecessary pain, not receiving appropriate care, and will be considered neglect.b. Enteral Feeding Policy- to include following MD orders upon admission. Charge Nurses are to notify the MD and DON immediately if orders cannot be implemented or a resident misses a scheduled feeding.c. Notification of Change in Condition: notify the Charge Nurse, MD, and RP of all changes in conditions such as new onset or worsening pain. If pain medication is not available upon admission, the MD will be notified immediately for further guidance.d. Pain management Policy- to assess any new onset or worsening or uncontrolled pain. Timely administration for pain medication upon admission or readmission. This in-service includes recognizing verbal and non-verbal signs of pain such as verbal expressions of pain, crying, groaning, facial expression, grimacing, frowning, protecting body movements, guarding, and clutching.e. admission Policy- to include the review and implementation of orders such as enteral feeding, pain medication and supplies needed specified by the physician. admission referrals should be reviewed prior to admission with the coordination of prescriptions, supplies, and equipment to facilitate continuity of care.f. Medication Administration- 5 Rights of Medication Administration. This includes documenting the administration of all medications in medical record.g. Medication Reconciliation Policy- the charge nurse and nurse management should perform medication reconciliation every time a resident is admitted or readmitted to the facility. If there are any issues with ordering, receiving, or administering medication, the DON, MD, or Pharmacy should be notified immediately.h. New Process: The DON, ADON or MD Coordinator will review all new referrals prior to admission to determine the need for any prescriptions, supplies, or equipment such as enteral pumps, formula or ostomy supplies. All prescriptions, equipment and supplies will be ordered prior to admission to facilitate continuity of care. If there are any issues with supplies or equipment, the DON or designee will notify the MD or appropriate departments for alternative options or place the admission on hold until all physician orders can be implemented timely. The DON, ADON or designee will review all admissions and readmissions daily in the morning clinical meeting to ensure all orders have been transcribed and implemented timely. The administrator will be responsible for the monitoring of this process daily.The Medical Director was notified of the immediate jeopardy citation on 11/20/25 by the DON.An ADHOC QAPI meeting was completed on 11/20/25 to review the immediate jeopardy citations and subsequent plan of removal. In-services:The Regional Compliance Nurse, Administrator, DON, and ADON will provide an in-service for all staff on the following topics below. All staff who were not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. Staff will sign the in-service sheet to verify that they acknowledge and understand the facility directive. All agency staff will be in-serviced prior to assuming scheduled shift. A post-test was provided by DON and ADON to confirm understanding. Completed 11/20/25.a. Abuse and Neglect- to include the failure to initiate MD orders timely such as enteral feedings, pain medication, and ileostomy care can result in a resident not receiving adequate nutrition, experiencing unnecessary pain, not receiving appropriate care, and will be considered neglect.b. Notification of Change in Condition: notify the Charge Nurse, MD, and RP of all changes in conditions such as new onset or worsening pain. If pain medication is not available upon admission, the MD will be notified immediately for further guidance.The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all Med Aides and Charge Nurses on the following topics below. All staff that were not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. Staff will sign the in-service sheet to verify that they acknowledge and understand the facility directive. All agency staff will be in-serviced prior to assuming scheduled shift. A post-test was provided by DON and ADON to confirm understanding. Completed 11/20/25.a. Abuse and Neglect- to include the failure to initiate MD orders timely such as enteral feedings, pain medication, and ileostomy care can result in a resident not receiving adequate nutrition, experiencing unnecessary pain, not receiving appropriate care, and will be considered neglect.b. Enteral Feeding Policy- to include following MD orders upon admission. Charge Nurses are to notify the MD and DON immediately if orders cannot be implemented or a resident misses a scheduled feeding.c. Notification of Change in Condition: notify the Charge Nurse, MD, and RP of all changes in conditions such as new onset or worsening pain. If pain medication is not available upon admission, the MD will be notified immediately for further guidance.d. Pain management Policy- to assess any new onset or worsening or uncontrolled pain. Timely administration for pain medication upon admission or readmission. This in-service includes recognizing verbal and non-verbal signs of pain such as verbal expressions of pain, crying, groaning, facial expression, grimacing, frowning, protecting body movements, guarding, and clutching.e. admission Policy- to include the review and implementation of orders such as enteral feeding, pain medication and supplies needed specified by the physician. admission referrals should be reviewed prior to admission with the coordination of prescriptions, supplies, and equipment to facilitate continuity of care.f. Medication Administration- 5 Rights of Medication Administration. This includes documenting the administration of all medications in medical record. The charge nurses involved in documentation errors were in-serviced 1:1 by the Regional Compliance Nuse on 11/20/25.g. Medication Reconciliation Policy- the charge nurse and nurse management should perform medication reconciliation every time a resident is admitted or readmitted to the facility. If there are any issues with ordering, receiving, or administering medication, the Charge Nurse, DON, MD, or Pharmacy should be notified immediately. Immediate Jeopardy Monitoring: A record review of Resident #1's Face Sheet in PCC dated 11/18/2025, reflected the resident was discharged on 11/1/2025. A record review of audits completed on 11/20/2025 for the six residents admitted and/or readmitted between 10/31/2025 and 11/19/2025. All orders were reconciled and implemented accordingly, and no concerns were identified. The audits were also reviewed by DON, ADON, and RCN. A record review of pain assessments in PCC for 28 sampled residents revealed they were assessed for pain on 11/20/2025 and there were no concerns.A record review of audit checklist for 23 residents whose pain medications were reviewed. A sample of 3 residents reflected pain medications were ordered and administered as prescribed. No concerns were identified. During an interview on 11/21/2025 at 3:30 PM, the ADM stated all new referrals will be reviewed during the morning clinical meeting and tracked on the Hospital Transfer Form. A record review of the Hospital Transfer Form reflected a multi-page spreadsheet that outlined the responsibilities for the ADM and DON. A record review of the in-service Training Roster for Admission/Re-Admissions dated 11/19/2025, instructed by RCN. DON, ADON and ADM signed as attendees. A record review of the Post Test for New Process reflected completion and comprehension for the MDS Nurse 11/21/2025, DON 11/20/2025, ADON 11/20/2025, and ADM 11/20/2025. During an interview on 11/21/2025 at 3:30 PM, the ADM stated he will review the tracker after the ADON and DON have reviewed all the orders, they will track what was being done each day to ensure accuracy.During an interview on 11/21/2025 at 3:30 PM, the ADM stated he received an in-service on 11/20/2025 and he will review the tracker after the DON and ADON have reviewed all orders, and they will track what has been done to ensure accuracy. A record review of the post-tests dated 11/20/2025 for New Process reflected completion and comprehension for the ADM, DON, and ADON. A record review of the Abuse/Neglect in-service date 11/20/2025 reflected the following would be considered neglect: failure to initiate MD orders timely, this includes enteral feedings, pain medications and ileostomy care which could have resulted in the resident not receiving adequate nutrition, experiencing unnecessary pain, and not receiving appropriate care.A record review of the Enteral Feeding in-service dated 11/20/2025 reflected the charge nurses were required to notify the MD and DON immediately if orders were not implemented and a resident missed a scheduled feeding. A record review of the Pain Management in-service dated 11/20/2025 reflected how to assess new onset or worsening pain, and to recognize verbal and non-verbal signs of pain, which included verbal expressions of pain, crying, groaning, facial expression, grimacing, frowning, protecting body movements, and guarding and clutching. It also included timely administration of pain medication upon admission and/or readmission.A record review of the Admissions in-service dated 11/20/2025 reflected a required review and implementation of physician orders such as enteral feeding, pain medication and supplied needed. admission referrals should be reviewed prior to admission with the coordination of prescriptions, supplies, and equipment to facilitate continuity of care.A record review of the Medication Administration in-service dated 11/20/2025 reflected a review of the Five Rights of Medication Administration: Right Patient, Right Dose, Right Route, Right Drug and Right Time. It also included the requirement to document all administered medication in PCC.A record review of the Medication Reconciliation in-service dated 11/20/2025 reflected the requirement for the charge nurses and nurse management to conduct medication reconciliation every time a resident is admitted or readmitted to the facility. Record Review of the ADHOC QAPI Meeting agenda dated 11/20/2025, reflected a review of the immediate jeopardy citations and subsequent plan of removal. During an interview on 11/22/2025 at 1:05 PM, CNA/CMA - G stated she received Abuse and Neglect, Enteral Feeding, Change of Condition, Pain Management, Medication Administration, and Medication Reconciliation training on 11/21/2025. She cited examples of ANE as yelling at a resid[TRUNCATED]

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 8 Resident reviewed for quality of care. The facility failed to ensure MA A notified LVN B on [DATE] when Resident #1's BP reading was 86/54 on [DATE], which is far from baseline. Resident #1 was sent to the ER on [DATE] and was diagnosed with Sepsis (a serious condition that occurs when the body has an extreme reaction to an infection leading to widespread inflammation and potential organ dysfunction.) and Hypotension (or low plod pressure is a condition where blood pressure is lower than 90/60 mm Hg. It can occur as a standalone condition or as a symptom of other health issues). Resident #1 died 2 days later while in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:08 pm and an IJ template was given. While the IJ was removed on [DATE] at 4:37 pm the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for not being provided the care/treatment required to meet their needs. Findings included: Review of Resident # 1's face sheet dated [DATE] reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Acute Respiratory failure (is a serious condition that occurs when the lungs cannot adequately exchange gases, leading to low oxygen level and potentially high carbon dioxide levels.), Hypertension (or high blood pressure is defined as a blood pressure reading of 130/80 mm Hg ), Pneumonia (is an inflammatory condition of the lungs primarily caused by infection from bacteria, viruses, or fungi), Asthma (is a common long-term inflammatory disease of the airways in the lungs. It occurs when allergen or irritants are inhaled, causing the airway to constrict and produce mucus which restricts airflow), Respiratory failure (a condition where you don't have enough oxygen or too much carbon dioxide in your body), COPD (is a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants.). Review of Resident #1's significant change MDS dated [DATE] indicated he had a BIMS score of 8 indicating moderate cognitive impairment. Section I: Active Diagnosis reflected Resident #1 had Hypertension, Pneumonia, Asthma, Respiratory failure. Review of Resident #1's care plan initiated [DATE] reflected Resident #1 had Alteration in Respiratory Status Due to Chronic Obstructive Pulmonary Disease, due to Congestive Heart Failure, Respiratory failure; Alteration in Respiratory Status Due to Pneumonia: Impaired Cardiovascular status related to: Deep Vein Thrombosis, Hypertension, HLD (Hyperlipidemia- High-density lipoprotein), AFib (is an irregular and often very rapid heart rhythm that can lead to blood clot, stroke and heart failure), diuretic therapy. Impaired Cardiovascular status related to deep vein thrombosis, Hypertension HLD, AFib, diuretic therapy with interventions of medications as ordered by physician and observe use and effectiveness, observe and report signs of chest pain, edema, SOB, abnormal pedal pulse, restlessness, and fatigue. Review of Resident #1's physician order reflected: Losartan Potassium Oral Tablet 100 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN -Order Date- [DATE] Review of Resident #1's vitals in her EMR reflected a BP of 86/54 on [DATE] at 10:50 am and 75/41 on [DATE] at 8:12 am. Review of Resident #1's NP progress note, dated [DATE], reflected that orders were given to check vitals BID and if Resident #1 became symptomatic such as lethargy, confusion, nausea/vomiting and bradycardia or if there was any change to Resident #1's BP, to send to the ER. Review of Resident #1's progress notes dated [DATE] at 08:00 am written by RN C reflected: Resident noted be unresponsive this morning. Vital signs 75/41, 94, 22, 97.7 93% on 4l N/C. Message left for NP that resident was being sent out. Message left for [family] at 0736. [Another family] here and notified that resident was being transferred to [local hospital]. DON notified. Review of Resident #1's progress notes dated [DATE] at 12:31 pm written by RN C reflected: Call made to [local hospital] to check on resident. Per ED nurse resident is being admitted to ICU room [xxx] with diagnosis of hypotension and sepsis. Message left with her [family] to update. During an interview on [DATE] at 2:09 pm MA A stated the top number of blood pressure should be over 100 and the bottom number should be over 60. MA A stated she relayed the message to LVN B before she left that Resident #1 was not doing good. She stated she should have checked her BP if she knew she was not doing good. MA A stated she held Resident #1's blood pressure medication on [DATE] due to Resident #1's blood pressure being low, but she did not notify LVN B. MA A stated she worked the 12 hours shift, from 8:00 am to 8:00 pm on [DATE]. During an interview on [DATE] at 2:44 pm the Interim DON stated Blood pressure systolic range is different for each resident because they are on blood pressure medication that can affect blood pressure. The Interim DON stated, if the blood pressure was accurate, she would think the staff would call the NP and get order to send to Resident #1to the ER. The Interim DON stated, if a medication aide took the blood pressure and it was low, the medication aide should be notifying the nurse. The Interim DON stated, I would expect them to tell the nurse what the blood pressure reading were, the facts, the vitals and anything that they saw clinically. You need to keep an eye on the Resident because she doesn't look good is not a good way to notify the nurse. These are my vitals; this is what I saw and observed is what they should be telling the nurses. The Interim DON stated low blood pressure can be a sign of sepsis. The Interim DON stated many things are the signs of sepsis, the MA should have reported that B/P reading to the nurse. During an interview on [DATE] at 3:00 pm the NP stated a blood pressure of 86/54 is low, and she would have liked for the staff to have notified her so that she could have treated Resident #1. The NP stated she would have sent Resident #1 out to the hospital the same day, especially since Resident #1 had history of being septic from UTI/ PNA. The NP stated she was never notified of Resident #1's hypotension. The NP stated the sepsis caused the hypotension because she was not being treated for any infection at the time of her transfer to the ER. I would have sent her out. During an interview on [DATE] at about 3:15 pm, according to the ADON, Interim DON, Interim Administrator, Resident #1 died in the hospital about two days after she was transferred to the hospital due to Kidney failure. During an interview on [DATE] at 3:35 pm LVN B stated she was not notified by MA A of Resident #1's low BP on [DATE]. LVN B stated if she had been notified, she would have re-checked Resident #1's blood pressure manually and notified the NP . Requested Resident #1's hospital records from the facility and hospital, did not get it upon exit. Review of the facility's policy titled Notification of Change in Patient/Resident Health Status dated [DATE] reflected: Purpose -- To ensure all interested parties were informed of the resident's change in health status so that a treatment plan could be developed which is in the best interest of the resident. Process--The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is: (D)A decision to transfer or discharge the resident from the center. Notification will be immediate. Definition: Immediate means as soon as possible no longer than 24 hours. The Administrator and ADON were notified on [DATE] at 5:08 pm that an IJ had been identified and an IJ template was provided. A plan of removal was requested. The following POR was accepted on [DATE] at 01:30 pm Immediate Jeopardy Allegation of Compliance [DATE] To the best of my knowledge and belief, as an agent of (facility), the following allegation of compliance constitutes a written plan demonstrating actions the center took upon awareness of the deficient practice thus removing the Immediate Jeopardy cited on [DATE]. Preparation and execution of this allegation of compliance does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the alleged deficiencies. The allegation of compliance is prepared and/or executed solely because it is required by the provisions of Federal and State Law. F684 - The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is: (D)A decision to transfer or discharge the resident from the center. Notification will be immediate. Immediate Actions for All Residents Potentially Affected: DNS notified the Medical Director of the incident. Completed on [DATE]. Education provided by DNS on duty nursing staff regarding change of condition guidelines and expectation. Completed 6.12.25. Comprehension was validated via a post test. Education provided to on duty nursing staff by the DNS regarding timely notification of change to MD/NP and Responsible Party Nurses completed blood pressure assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. No concerns were identified. Completed 6.12.25. This was completed by inputting resident baselines in our EMR (PCC) that will alert staff. Inservice on this was completed 06-13-25. The ADM removed the CMA and Nurse from patient care until they were educated on a 1:1 basis regarding the change in condition and physician notification guideline. Comprehension was validated via posttest. Completed 6.13.25. The Senior DCO educated the DNS on 6.12.25 regarding the change of condition and physician notification guideline. The DON signed statement of training provided via email from Senior Director of Clinical Operations. Systematic Changes Completed: The DON implemented disciplinary action with staff was aware of significant change but did not report it to the physician. This was completed by 1:1 in-services and progressive discipline. Post test was completed to validate comprehension. Completed 6.13.25. No nursing staff will be allowed to work before being educated on the change of condition and physician notification guideline. This was initiated on 6.12.25. New hires (licensed nurses and CMAs) will be educated on change of condition and physician notification guidelines, as well as facility policy and procedure, accordingly in orientation by human resources/designee. Initiated on 6.12.25., QAPI: On 6.12.25 the DNS implemented a Quality Assurance Performance Improvement (QAPI) plan to include completing a chart (audit ad hoc QAPI signed and acknowledged by DON, Admin and Medical Director) of assessments as follows: Three residents weekly for four weeks Two residents weekly for two weeks Two residents a month for two months The results of the audit will be discussed in daily startup and then in monthly QAPI with follow up as needed. A focused QAPI meeting addressing this event and findings was initiated and completed on [DATE] at 7:00 P.M with the attendance of the Administrator, DNS, and Medical Director. In summary, upon awareness, the center acted swiftly with the corrective actions, team member re-education, and ensured auditing measures were in place to monitor the plan. The center corrected the process and address the identified deficient practice immediately and completed actions. The Surveyor monitored the POR on [DATE] from 1:46 pm to 4:36 pm as followed: During interviews on [DATE] from 1:46 pm to 2:02 pm, CNA F, NA G and NA H stated they were in-serviced by the Interim Administrator and DON on [DATE] on abuse and neglect and reporting change of Resident's condition to the charge nurses. They stated they were trained on checking on residents frequently and if they notice something different in a resident to report exactly what the changes were. They stated they had to complete a questionnaire after the training. During an interview on [DATE] at about 2:22 pm LVN B stated she was in-serviced by the Interim Administrator on [DATE] regarding abuse and neglect and change of condition. LVN B stated she was told to follow facility's policy, notify the NP/MD immediately of any change of condition. LVN B stated she had to complete a questionnaire after the training. LVN B stated the interim Administrator also asked her for a statement regarding Resident #1's incident. LVN B stated she was trained on alerts in PCC for vitals that were out of range. During an interview on [DATE] at about 2:36 pm, LVN E stated she was in-serviced on [DATE] by the DON. LVN E stated she was in-serviced on Abuse and Neglect and Notification to the provider for change in condition of a resident. LVN E stated, if a medication was held or refusal of medication or swelling, notify the NP/MD as quick as you can. LVN E stated intervention should be follow by detail documentation. LVN E stated, if another staff report a Resident's change of condition, the nurse is supposed to assess the resident, take vital signs, do a change of condition form, Notify the NP/MD, give them a description of what you saw, what you assessed and let the NP/MD determine treatment plan. LVN E stated she also had to complete the questionnaires after the training/in-service. During an interview on [DATE] at 2:47 pm RN D stated she was in-serviced by the DON on 06/12/ and [DATE]. RN D stated, Yesterday was about abuse and neglect and change of condition. What to look for, who to notify, what to notify depending on your position. The CNAs and MA notify the nurses, the nurses notify the NP/MD, DON the family. The DON contacted the 2 doctor and got parameter for vital, and it was place in PCC. The DON and ADON put the parameters in PCC. If my CNA or medication aide says a resident doesn't look good, I am going to assess and report findings to the MD/NP, based on the orders send the resident out, notify the DON and the family. During an interview on [DATE] at 2:54 pm the ADON stated she had worked in the facility for about 4 days. The ADON stated she was in-serviced by the DON on 06/12 and [DATE]. The ADON stated in-services were on abuse and neglect and change of condition notification to the NP/MD. The DON stated on [DATE] they completed vitals for all Residents in the facility to get a baseline. The ADON stated on [DATE], the DON contacted the 2 providers and got parameter for vitals for each resident and added clinical alert in PCC for vital signs. The ADON stated it is the responsibility of the DON and the ADON to check every morning for clinical alert on PCC dashboard. The ADON demonstrated the process of checking clinical alerts. During an interview on [DATE] at 3:20 pm the Interim DON stated she was in-serviced by the SR DCO on Change of Condition/Physician Notification. The DON stated after she was trained/in-serviced, she in-serviced nursing staff on abuse and neglect and change of condition, notification to the NP/MD. The Interim DON stated the NAs, CNAs and MAs are expected to report change of condition to the nurses; the nurses are expected to immediately assess the residents and report findings to the NP/MD; the nurses are expected to follow the orders from the NP/MD and notify the resident's family. The Interim DON stated she contacted the NPs for the 2 MDs and got what they wanted for their parameters for vitals in PCC to set an alert for anything outside of that range. The Interim DON stated the nurses were in-serviced on that, they had access to the alert and should check it every shift. The Interim DON stated the DON or designee will check every day/morning. The Interim DON stated she and the ADON completed vitals on all resident s in the facility on [DATE] for a baseline. During an interview on [DATE] at 4:14 pm the Interim Administrator stated, We did 100% assessment of vitals for all the residents. The MD was notified of abnormalities. We also ensured all the residents had a baseline vitals in PCC. We did an Ad Hoc QAPI yesterday [DATE]. We started our in-service on change of condition and notification. No staff can work unless they were in-serviced, everyone that worked and is here have been in-serviced. We did abuse and neglect in-service for all staff including non-medical staff. We did progress discipline on [LVN B] and MA A; it was done 1:1, took statements from the 2 staff. Today we did an in-service on PCC alert for nurses and MAs, those that were here and the rest have to be in-serviced before working. Attempts made to contact MA A on [DATE] at about 4:25 pm but to no avail. Another attempt was made on [DATE] at 08:51 am. Later, during an interview on [DATE] at about 09:02 am, MA A stated she was called to the facility on [DATE] by the Interim Administrator for an in-service. MA A stated she was in-serviced on abuse and neglect and reporting change of condition to the nurses. MA A stated the Interim Administrator told her whenever there was a low blood pressure or something that was not normal to report to the nurses. MA A stated she completed the questionnaire after the training and the Interim Administrator asked her to write a statement. Review of facility's POR documents reflected the following: Education on Change of Condition/Physician Notification dated [DATE] provided by the SR DCO signed by the DON. Review of POR reflected an AD HOC QAPI was held on [DATE] with 3 signatures, The MD, Interim DON and the Interim DON. In-service initiated [DATE] reflected staff were in-serviced by the Interim DON and ADON on the following topics: Notification of change in Patient/Resident Health Status; Abuse, Neglect, Misappropriation, Exploitation. Was signed by 24 staff members. Audit records reflected Resident in the facility blood pressure checked was initiated on [DATE]. Progressive Discipline form dated [DATE] indicated Administrative Leave-Team member has been placed on administrative leave pending investigation and education resulting from a state survey on [DATE] signed by LVN B. In-service dated [DATE] reflected LVN B was in-serviced by the Interim Administrator on the following topics: Notification of change in Patient/Resident Health Status; Abuse, Neglect, Misappropriation, Exploitation. Was signed by LVN B. Progressive Discipline form dated [DATE] indicated Administrative Leave-Team member has been placed on administrative leave pending investigation and education resulting from a state survey on [DATE] signed by MA A. In-service dated [DATE] reflected MA A was in-serviced by the Interim Administrator on the following topics: Notification of change in Patient/Resident Health Status; Abuse, Neglect, Misappropriation, Exploitation. Was signed by MA A. In-service initiated [DATE] reflected the Nurses and MAs were in-serviced by the Interim DON and ADON on the following: PCC Alert on Vitals (When entering vitals in PCC and you receive an alert, you are to follow the instructions in the alert-notification of alert to physician; CMAs should report all alerts to their nurse and the nurse will take the appropriate action if notification to physician is required.) The ADM and ADON were notified on [DATE] at 4:37 pm that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 resident out of 10 residents (Resident #1) reviewed for Activities of Daily Living care. The facility failed to provide nail care to Resident #1 as her nails were long, jagged, and sharp. This deficient practice placed residents at risk of a decline in their hygiene, at risk of skin breakdown, a decreased level of satisfaction with life, and a decreased feeling of self-worth. Findings included: Review of the face sheet for Resident #1, dated 12/06/24, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic venous hypertension with ulcer of lower extremity (a condition that occurs when the valves in the leg veins are damaged, causing blood pressure to remain high in the veins) muscle wasting, and dyspnea (the uncomfortable feeling of not being able to breath well enough) Review of Resident #1's Brief Interview for Mental states, dated 11/07/2024, revealed it did not reflect a score but indicated the resident's cognition was moderately impaired. Review of Section GG functional abilities of Resident #1's quarterly MDS dated [DATE] reflected the resident was dependent on personal hygiene and used a manual wheelchair. Review of the care plan for Resident #1 with a start date of 08/13/2024 and revisited 08/14/24 reflected [Resident #1] is at risk for alterations is [in] skin integrity and pressure injury r/t requires max assist with med mobility. She is often resistant to and or refuses care. Admit with vascular wound right shin. There was no documentation regarding nail care maintenance. Review of the care plan for Resident #1 with a start date of 08/13/2024 reflected Resident #1 had a self-care deficit related to: impaired cognition/dementia and weakness. She was currently on physical and speech therapy. Interventions provide all the effort with the following tasks as this resident is dependent toilet, hygiene, bathing, dress, personal hygiene date initiated 08/13/24. There was no documentation regarding refusal of care for toenail care. Observation and interview on 12/06/2024 at 1:37 pm revealed the toenails on Resident #1's left foot were broken, frayed, uneven in length, and some nails were very sharp. She did not want to talk about her toenails, and she did not want to reveal the toenails on her right foot. Interview on 12/06/2024 at 3:32 pm with the DON revealed nail trimming was to be done during residents' showers by the CNAs unless the resident was diabetic. She stated nail care should be care planned for both weekly and PRN and nailcare was important because unkempt nails could cause skin tears, infections, and resident could scratch themselves. Interview on 12/06/2024 at 3:57 with the Administrator revealed nail care should be care planned because they are part of resident activities of daily living and if a resident refuses nail care, that should be documented. The Administrator revealed they did not have a activities of daily living policy. The Administrator stated that if residents didn't get their nails trimmed, they could sustain skin injuries and possible infection.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: The facility failed to correctly label and date food, dispose of expired items within the expiration dates, and effectively store frozen items in sealed containers. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During the initial tour of the kitchen on [DATE] at 09:00 AM the following was observed: - Reach in freezer 1 contained two bags of frozen breaded chicken patties in a clear zip seal bag, and 1 bag of frozen pineapple slices all with an expiration date of [DATE]. - Reach in freezer 2 contained a clear bag of frozen French fries, the bag was punctured and was observed to have a hole the size of a golf ball which exposed the contents to open air. - 1 clear container of corn flakes was observed with a label that had an open date and use by date of [DATE]. In an interview on [DATE] at 09:15 AM with the DM she stated that she believed that the pineapple bag was mislabeled after the original zip seal bag it was in ripped and was transferred to a new bag. The DM also claimed the frozen chicken patties and container with the cereal were also mislabeled. In an interview on [DATE] at 11:30 AM with the DTN who stated it was her expectation that items in the freezer are labeled with a date the item is received along with the expiration date. She stated packaged items should contain an open date, and a use by date, and items prepared and stored for later (leftovers) should have a prepared date and a use by date. The DTN stated that there should not be any expired food items in the freezers/ refrigerators, and that it was her expectation that all items are sealed properly. She stated a potential negative outcome to having expired items was the potential for it to be served which could have led to illness and that items which are not properly sealed could have led to contamination of the food. An interview on [DATE] at 10:10 AM with the DM who stated that it was her expectation that expired items or items that they are aware of being mislabeled should be thrown away. The DM said food items should have a received/ prepared date along with a use by date. The DM stated that expired items have the potential to make residents sick if they made it to them. She stated that not properly labeling items could result in use of an expired item because nobody would know when it was opened and when it expires. The DM stated all food items should be properly sealed and said a negative outcome to punctured bags in the freezer would cause food items to have frostbite saying, it would affect the food quality and make it taste old. An interview on [DATE] at 4:45 PM with the ADM who stated it was her expectation that items in the refrigerator and freezers are properly labeled and dated to include a received date/ prepared date, and use by date. She stated that no food items should be punctured and expected food items to be properly sealed. The ADM stated that a potential negative outcome of expired items is it could lead to illness if they made it to a resident. She stated food items that are in a punctured bag and not properly sealed would lead to food inconsistency. Review of the facility Food Storage: Cold Foods policy last revised ,d+[DATE] revealed: All Time/ Temperature Control for Safety (TCS) Foods, frozen and refrigerated will be appropriately stored in accordance with guidelines of the FDA Food Code. - All foods will be wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility Receiving policy last revised ,d+[DATE] revealed: Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. - All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. - All food items will be stored in a manner that ensures appropriate and timely utilization based on principles of first in-first out (FIFO) inventory management. Review of the facility Food Storage: Dry Goods policy last revised ,d+[DATE] revealed: All dry goods will be appropriately stored in accordance with the FDA Food Code. - Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the 2022 U.S. Food and Drug Administration Food Code revealed: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; P (2) Is in a container or PACKAGE that does not bear a date or day; P or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in ,d+[DATE].17(A). ,d+[DATE].11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph ,d+[DATE].15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #143) of 5 residents reviewed for resident rights and dignity. The facility failed to promote Resident 143's independence and dignity while assisting her to eat lunch in the dining room. This failure could place residents at risk for a loss of dignity, decreased self- worth, and decreased self-esteem. Finding included: Record review of Resident #143's Face Sheet dated 10/31/24 revealed an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis of unspecified fracture of the right forearm- subsequent encounter for closed fracture with routine healing, age related osteoporosis (disease that weakens bones) with current pathological fracture (bone break caused by an underlying disease that weakens the bones), left humerus subsequent encounter for fracture with routine healing, and fracture of left shoulder girdle- part unspecified- subsequent encounter for fracture with routine healing. Record review revealed no MDS had been completed, resident had been at the facility for 3 days by date of exit; MDS was still in progress. Record review of Resident #143's BIMS assessment dated [DATE] revealed a BIMS score of 15 indicating cognition intact. Record review of Resident #143's Baseline Care Plan dated 10/28/24 revealed barriers to transition included: strength/ endurance, self-care, meal prep/ homemaking, and diet management. Dietary interventions included assistance with eating. Baseline assessment was completed by RN-A. Record review of Resident #143's nursing progress notes revealed a nursing note dated 10/28/24: patient admits from [rehab facility] diagnosis of left humerus fracture, right wrist fracture, patient oriented to room and call bell system, patient agrees to use call bell for assistance. Patient was max assist for transfers. Patient has cast to right wrist and brace to left upper arm. An observation on 10/29/24 at 12:42 PM in the dining room for lunch services, RN-A was observed assisting Resident #143 with eating her meal. RN-A was observed standing to the right of Resident #143's wheelchair, standing over her, and leaning against her wheelchair with her left hand while feeding the resident with her right. After feeding Resident #143 for only a few minutes she was then observed at 12:48 PM leaving Resident #143 and going to assist another resident. RN-A did not return to continue to feed Resident #143. Approximately 10 minutes later, CNA-B was observed sitting next to Resident #143. CNA-B was heard acknowledging to the resident that the food was now cold from sitting there for too long and let her know she would have the kitchen provide her a warm meal. CNA-B was then observed pulling up a chair and returning to assist Resident #143 eat her meal while sitting at eye level with her through the remaining duration of her meal. An interview on 10/29/24 at 12:55 PM with RN-A, she stated that she should have sat next to Resident #143 while she assisted her with her meal. She stated that she did not see a chair available for her to sit in (other chairs were observed at tables that were not completely occupied by residents). RN-A stated that a negative outcome to leaning against a resident's wheelchair while standing over them to feed them was a dignity issue and stated she should be at eye level and be giving undivided attention to the resident. An interview on 10/31/24 at 10:52 AM with Resident #143, she stated her first few days in skilled nursing have been a humbling experience. When asked about the interaction with RN-A during lunch on 10/29/24 she stated that having someone stand over her while feeding her did not make her feel good. She stated both of her arms had fractures and she was not able to use them to feed herself so that she relies on staff completely with her meals. Resident #143 stated that since she arrived at the facility, not receiving timely assistance with her meals has been a common occurrence and that by the time someone does help her eat her meal, it is cold. An interview on 10/31/24 at 4:32 PM with the DON, she stated it was her expectation that when staff assist residents that require feeding assistance, they were expected to sit with the resident and begin feeding them the moment their tray is brought out to them and set down. The DON stated that a negative outcome of not being at eye level while feeding a resident is a dignity issue, they could feel like they are not worthy of companionship while being fed. An interview on 10/31/24 at 4:45 PM with the ADM she stated that it was her expectation that while feeding a resident, care staff should be at eye level and not doing so is a dignity issue. Record review of the facility policy titled Residents Rights and Quality of Life dated 05/01/12 revealed: It is the policy that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside of the facility. A resident has the right to exercise his/her rights as a resident of the facility and a citizen or resident of the U.S. Record review of the Texas Health and Human Services/ Texas Long-Term Care Ombudsman Nursing Facility Residents [NAME] of Rights dated November 2021 revealed: Residents Rights Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States. Dignity and Respect You have a right to be treated with dignity, courtesy, consideration, and respect.

Based on observation, interview, and record review the facility failed to provide services with a reasonable accomodation to 1 of 5 residents (Resident #143) by failing to equip the resident with a device to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. The facility failed to ensure Resident #143 was accommodated with a device to call for staff assistance. This failure could place residents at risk of not being able to get assistance when needed. Findings included: Record review of Resident #143's Face Sheet dated 10/31/24 revealed an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis of unspecified fracture of the right forearm- subsequent encounter for closed fracture with routine healing, age related osteoporosis (disease that weakens bones) with current pathological fracture (bone break caused by an underlying disease that weakens the bones), left humerus subsequent encounter for fracture with routine healing, and fracture of left shoulder girdle- part unspecified- subsequent encounter for fracture with routine healing. Record review revealed no MDS was completed, resident had been at the facility for 3 days by date of exit; MDS was still in progress. Record review of Resident #143's BIMS assessment dated [DATE] revealed a BIMS score of 15 indicating cognition intact. Record review of Resident #143's Baseline Care Plan dated 10/28/24 revealed barriers to transition included: strength/ endurance, balance, transfers, walking, stairs, self-care, toileting, bathing, meal prep/ homemaking, pain management, and diet management. The safety section of the baseline care plan indicated history of falls with initial goal remain free from falls and injury and interventions of use call bell, use gait belt, two-person assist with transfers. Record review of Resident #143's nursing progress notes revealed a nursing note dated 10/28/24: patient admits from [rehab facility] diagnosis of left humerus fracture, right wrist fracture, patient oriented to room and call bell system, patient agrees to use call bell for assistance. Patient is max assist for transfers. Patient has cast to right wrist and brace to left upper arm. An interview and observation on 10/31/24 at 10:52 AM with Resident #143, upon entering the room she was observed in her wheelchair at bedside; two pillows that were used to provide support to each of her fractured arms were observed on the floor, the call light was observed also on the floor to her left approximately 2 feet away, not within reach. Across from the resident, a posted sign was observed on the closet door with the words CALL DON'T FALL. The resident expressed that she had been attempting to get help for a while but has not been able to call due to the limited use of both arms because of her fractures. The call light observed was a specialized call pad that if within reach, gentle pressure applied to the end of the pad would allow the resident to call for assistance. The resident stated she needed her arms readjusted to a comfortable position and she also needed water because she was thirsty. The resident expressed it made her feel vulnerable not being able to call for help or do things for herself. Assistance was requested for Resident #143 and CNA-B entered the room acknowledged the residents' concerns, picked up the pillows off the floor and adjusted them underneath the residents' arms providing her support and ensuring comfort and then bringing a cup of fluids to her mouth for a drink of water; indicating she was completely dependent on staff to meet her needs. The call light was then observed being clipped to her shirt near her arms so that Resident #143 would be able to apply pressure on it if assistance was needed. An interview on 10/31/24 at 11:04 AM with CNA-B, she stated she was not sure how long the call light was on the floor or how long Resident #143 had been needing assistance, but that it could have been quite a bit of time. CNA-B stated that it was the expectation that call lights are within reach of the resident, at all times. She stated that Resident #143 was fully depended on staff to do anything, she needs significant help. CNA-B stated a potential negative outcome of Resident #143 not having the call light in reach would be she could fall if she was trying to reach the call light and her needs would not be met. An interview on 10/31/24 at 04:32 PM with the DON, she stated that it was her expectation that call lights are within reach of the residents and answered in a timely manner. She said a potential negative outcome would be the resident not being able to call for assistance which could result in a fall. An interview on 10/31/24 at 04:45 PM with the ADM, she stated call lights should always be in reach and accessible to the resident and they should be answered in a timely manner. The ADM stated a potential negative outcome would be there was the potential for a negative outcome and did not further specify. The call light policy was requested on 10/31/24 at 1:51 PM, the ADM stated there was not a call light policy and instead offered a Call Light In-Service which was what was used to train care staff on the standards and expectations. The undated Call Light In-Service sheet provided revealed: Requirements for Call Lights in Nursing Homes Failure to implement a call system that adheres to these regulations could result in fines, license revocations, or even closures. Here are some requirements for call light systems in nursing homes that you should look for as a resident or family member. Placement Nurse call systems must be accessible within resident rooms. Generally, a call system is required beside the bed and in bathing or toilet facilities. Common areas should also allow access to nurse call systems. The purpose of a call light system is to enable residents to ask for assistance, so they must be placed in all locations where residents may be present. Accessibility Call lights must also be accessible to all residents, including those with disabilities. If they are placed out of reach on a wall, some patients may be unable to call for help. For patients with limited mobility, a call system must be within reach of their bed and other locations. The nursing home is responsible for setting up each resident's call system to meet their needs. Functionality Call systems in nursing homes must be functional and reliable at all times. This system includes a working call light above the resident's door, a functioning station that is always staffed for incoming calls, and loud volumes that staff can hear. Additionally, there are requirements surrounding the response time to each request for assistance. Usually, nurses must respond to the call within a timely manner of the alert.

Based on interviews 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 timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #25) reviewed for comprehensive care plans. The facility failed to ensure Resident #25's comprehensive care reflected Resident #25 Advance Directive status of DNR (Do Not Resuscitate). This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: A record review of Resident #25's face sheet dated 10/02/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25's diagnosis is Chronic Obstructive Pulmonary Disease (COPD), Unspecified (a common lung disease that causes breathing problems and restricted air flow). A record review of Resident #25's Initial MDS assessment, dated 10/08/2024, reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #25's Initial MDS reflected Resident #25's current primary diagnosis of Chronic Obstructive Pulmonary Disease. A record review of Resident #25's care plan, dated 10/18/2024, did not reflect or address Resident #25's Advanced Directive status as DNR. A record review of Resident #25 physician's orders, dated 10/17/2024, reflected Resident #25 had an order dated 10/17/24 Which reads: Do Not Resuscitate (DNR)-10/7/2024 Gentiva Diagnoses: Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Call for concerns. During an interview with the DON on 10/31/24 at 3:20pm, the DON stated that she was responsible for completing MDS and care plan assessments as the MDS Coordinator had recently resigned. She stated Resident #25's care plan should have reflected the residents' code status. The DON stated if a resident's care plan was inaccurate then the resident may not receive the appropriate care. The DON stated that in addition to the facility policy, the care plan should be compliant with the requirements outlined in the Resident Assessment Instrument (RAI). During an interview with the ADM on 10/31/2024 at 4:45pm, the ADM stated that Resident #25's code status of DNR should have been reflected on the resident care plan. The ADM stated if a resident care plan was inaccurate that could cause the resident not to receive the proper care. A record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 2001, reflected 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. A record review of an excerpt of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1(RAI) dated 10/2024 stated the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interviews and record review the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 10 residents (Resident #1) reviewed for baseline care plans. This failure could place the resident at risk of continuity of care and communication among nursing home staff, reduced resident safety, and reduced safeguards against adverse events that are most likely to occur right after admission. Findings included: Record review of Resident #1's Face sheet dated 04/05/24 reflected, a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of irritant contact dermatitis due to fecal, urinary or dual incontinence (inflammation of the skin associated with exposure to urine or stool), diabetes, depression, chronic obstructive pulmonary disease, depression, bipolar disorder, and chronic thromboembolic pulmonary hypertension (a rare and potentially fatal form of elevated blood pressure in the lungs). Record review reflected there was no MDS completed for Resident #1. Record review of Resident #1's care plan dated 02/14/2024 reflected: Focus dated 02/14/2024: - I have a physical functioning deficit with transfers and require assistance of. Goal dated 02/14/2024: I will maintain my current level of functioning with the intervention Intervention dated 02/14/2024: Transfer/Slide Sheet for moving up in bed Interview on 04/05/2024 with the DON at 5:38 pm revealed there was no base line care plan for Resident #1, and it was the facility policy to have a base line care plan within 24 hours of a resident admitting into the facility. The DON believes it was a computer error because Resident #1 was readmitted to the facility and for some reason the Electronic Medical Record software did not generate a reminder to create a base line care plan for his new facility admission. The DON revealed it was important to have a baseline CP because it was necessary to identify the residents needs and how the staff was to implement resident care. She revealed if you don't have a care plan, the resident could have an identified need that was not meet and could cause the resident harm. An example would be not having a care plan that identified and had interventions for falls. The failure of not having a care plan could result in an injury from a fall. Not having a care plan could affect outcomes and patient satisfaction. The DON revealed it was the responsibility for the MDS coordinator to create a care plan, but all staff were responsible for creating a care plan and all the staff discussed care plans during morning meetings. Interview on 04/05/2024 with the ADM at 5:51 pm revealed he was not aware that there was no baseline care plan for Resident #1, and it would be the MDS nurse who would be the driving force to create a care plan. He revealed a care plan was important because it helps the facility determine the residents' treatment plan. He revealed that without a care plan, things that needed to happen to care for the resident could get missed and the resident might not get the full treatment they needed but he does not think that it could get to that point that not having a care plan could cause injury, but it could potentially get to that point. Interview on 04/05/2024 with the MDS Coordinator at 4:32 pm revealed, when shown Resident #1's care plan in the Electronic Medical Record that there was no baseline care plan created for Resident #1. She revealed a care plan was not created because the nurse did not create an initial evaluation when Resident #1 was admitted into the facility and therefore, no base line care plan was created. Record review of the facility's Comprehensive Care Plan policy dated May 1, 2012, revealed: social services staff and/or designee will participate in the development of a comprehensive care plan for each resident. PRACTICE GUIDELINES 1. The interdisciplinary care plan is implemented to guide health care center staff in the provision of necessary care and services to obtain and maintain at the highest practicable physical, mental, and psychological well-being of the resident and promotion of the resident and family in planning care. 3. Interdisciplinary team develops president focused goals. These goals are: A. stated in behavioral terms B. measurable C. brief D. short term with established timeframes E. related directly to the stated problem, need, or concern

Based on observations, interviews and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 10 residents (Resident #30) reviewed for resident rights; in that: The facility failed to ensure Resident #30's call light was within reach. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #30's admission record, dated 09/12/23, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), muscle wasting and atrophy (wasting [thinning] or loss of muscle), dysphagia (difficulty swallowing), and iron deficiency anemia (too few healthy red blood cells due to too little iron in the body. Record review of Resident #30's quarterly MDS assessment, dated 06/23/23, revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. The resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene and supervision for eating. Record review of Resident #30's care plan, initiated 11/16/21 and revised 02/09/22, revealed Resident #30 was care planned for high risk for falls due to history of falls at home, poor cognition, poor safety awareness as evident by attempts to self-transfer. [Resident #30] is unsteady due to fear of falling with a goal of [Resident #30] will be free of falls through the review date and had an intervention of be sure [Resident #30's] call light is within reach and encourage to use it for assistance as needed. Record review of Resident #30's care plan, initiated 11/16/21 and revised 01/18/23, revealed Resident #30 was care planned for an ADL self-care performance deficit r/t Dementia with a goal of will be able to assist in ADL's for next 90 days and had an intervention of encourage [Resident #30] to use bell to call for assistance. During an observation on 09/11/23 at 10:18 AM revealed Resident #30's call light was observed lying on the floor beside the bed and out of Resident #30's reach. In an interview with Resident #30 on 09/11/23 at 10:24 AM, Resident #30 stated she could use her call button to call for help if needed but did not always have it in reach. She stated staff would give her the call light if she told them to before leaving her room. She stated she would get her roommate to call for help if she could not reach her call light and she needed assist. In an interview on 09/12/23 at 11:25 AM, CNA A stated call lights should have been in reach, for all residents at all times. CNA A stated if a call light was not in reach, a resident could fall or could possibly not ask for help. CNA A stated she made rounds every 1 - 2 hours and when she made rounds, she checked to make sure residents had their call lights in reach and to see if the residents had any needs, and that residents were dry and clean. CNA A stated she was in-serviced on call lights. In an interview on 09/12/23 at 11:29 AM, the DON stated the purpose of residents call lights was for residents to get assistance for anything they needed when they were in their rooms. The DON stated if a call light was not in reach, a resident could have wet their bed or could have fell out of bed trying to reach for a remote or something. She stated residents call lights needed to be in reach. She stated staff should have made rounds every 2 hours and checked to make sure residents call lights were in reach. She stated staff were in-serviced on call light recently. In an interview on 09/12/23 at 11:34 AM, the ADM stated the purpose of a residents call light was so residents could call for help. He stated if a residents call light was out of reach and the resident needed help it could be possible the staff would not have known it. He stated staff should have made sure residents call lights were in reach and they had just recently put clips on the call lights to help them stay in place. The ADM stated the staff were in-serviced on call lights in the recent past. In an interview on 09/12/23 at 1:20 PM with the DON reveled the facility did not have a policy on call lights. Record review of staff in-service dated 05/15/23 and titled Universal Fall Precautions revealed staff were in-serviced on call bell within reach. In-service titled How to engage residents in activities to assist with prevention of falls, dated 07/14/23, revealed staff were in-serviced on if residents prefer to stay in their room, they need to be rounded on more frequently to ensure safety with all call bells in reach

Based on interviews and record reviews the facility failed to maintain an effective pest control program to ensure the facility was free of pests in 1 (Resident #1) of 6 resident rooms reviewed for the presence of pests in that: The facility failed to ensure Resident #1's room remained free from maggots. On 1/10/2023 maggots were found in Resident #1's room and on her blanket. This failure could place residents at risk for vector-borne diseases. The findings included: Record review of Resident #1's face sheet dated 01/11/2023 reflected she was admitted on [DATE]. Her diagnoses include Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.) , Constipation, Age-related osteoporosis ( the bones become brittle and fragile), Pain, Hypothyroidism (the thyroid gland doesn't make enough thyroid hormone), Unspecified dementia with behavioral disturbance, Generalized anxiety disorder, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, ), Hereditary and idiopathic neuropathy ( a kind of nervous system illness with unknown origin), Spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord ). Record review of Resident #1's MDS on 1/11/23 revealed that her BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) could not be assessed due to her cognitive level (severe cognitive impairment). Record review of the skin and wound evaluation on 1/11/23 reflected that Resident #1 had skin and wound evaluation every week and the last evaluation was on 1/10/23. Per this evaluation Resident #1 had the following skin issues. 1.An in house acquired new (less than one week) blister at the spine with measurements of 5.1 cm length x 1.4cm width and depth not applicable. The blister had light serous exudation without any infection or odor. The peri wound temperature was normal. 2.An in house acquired new (less than one week) incontinence associated dermatitis (a common skin irritation) at the Left Ischial Tuberosity (The lower part of human pelvis) with measurements of 1.2 cm length x 0.7cm width and depth not applicable. The dermatitis had no exudation, infection, or odor. The peri wound temperature was normal. 3.An in house acquired one week old skin tear at the left calf (lateral) with measurements of 2.9 cm length x 1.4cm width and depth not applicable. The skin tear had no exudation, infection, or odor. The peri wound temperature was normal. Observation on 1/11/23 at 10:15 a.m., revealed that the Resident #1 had moved back to her previous room (room [ROOM NUMBER]) from room [ROOM NUMBER] on 1/11/23. Resident #1's family member and hospice nurse RN A were present in the room. The attempt to conduct an interview failed as she was not interviewable due to her cognitive capacity. During an interview on 01/11/2023 at 10:20 a.m., Resident #1's family member stated, on 01/10/23 maggots were sighted on the floor of Resident #1's room (room [ROOM NUMBER]) and on her blanket. Resident #1's family member said RN A, the facility MM and the ADM witnessed the presence of maggots in room [ROOM NUMBER]. The family member said Resident#1 was in room [ROOM NUMBER], and she was moved to room [ROOM NUMBER] last week. She said she never had seen any insect activities in room [ROOM NUMBER], room [ROOM NUMBER] or any other areas in the facility before. During the interview on 1/11/23 at 10.30 a.m., RN A stated she was with Resident#1 when the maggots were discovered by resident #1's family member. RN A said she saw a cluster of maggots on the floor and about 4 maggots on the resident's blanket. RN A stated Resident #1 lived in room [ROOM NUMBER] with another resident and moved to room [ROOM NUMBER] last week for administering Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% via a nebulizer. RN A stated Resident # 1 had 3 nonstaged ulcers on her body and on her assessment after the observation of maggots in the room on 1/10/23, there were no maggots present either on the ulcers or any other part of her body. During an interview on 1/11/23 at 10. 45 a.m. the MM stated on 1/10/23 he had observed maggots in room [ROOM NUMBER] and on the blanket of Resident #1. The MM stated Room # 210 was not occupied for more than a month and was used to store furniture. The MM said room [ROOM NUMBER] was thoroughly cleaned and sanitized before transferring Resident #1 to that room. He said after the sighting of maggots the pest control person was informed and he was scheduled on 1/12/23 for pest control treatment. When asked about the source of maggots MM stated he could not figure out the source of the maggots however sprayed with the pest control chemical that was suggested by the pest control person. During an interview on 1/11/23 at 1.45 p.m., the DON stated she did not witness the presence of maggots however heard about the incident. She said Resident #1 was moved to room [ROOM NUMBER] from room [ROOM NUMBER] for administering Albuterol Sulfate via nebulizer. She stated per the facility policy nebulizer treatment would be done in a single occupancy room to reduce the risk of transmittable diseases through the nebulizer. Resident #1 was sharing room [ROOM NUMBER] with another resident and that was the reason for transferring Resident #1 temporarily to Room # 210. She said room [ROOM NUMBER] was unoccupied for more than a month and was used to store furniture. When asked the danger of maggots in a residence room, she stated insects and larvae were vectors of many pathogens and they spread diseases, and also since Resident #1 had ulcers the maggots could lodge on the ulcers and grow. During the interview on 1/11/23 at 2.00 p.m., the ADM stated, on 1/10/23 he saw about 15 to 20 maggots clustered together on the floor and about 3 to 4 maggots on resident 1#'s blanket. He said he did not have any idea how they were present there. The ADM stated room [ROOM NUMBER] was unoccupied for a while and was cleaned and sanitized before transferring Resident #1 to that room. He stated he was not ruling out the possibility of maggots being introduced by the family through food or clothing brought in during their visits. He said the resident moved into that room on 1/6/23 and no sighting of any insect activity until 1/10/23. When asked about how he was going to ensure pest free environment in the facility the ADM stated this was the first time any such incident of insect activity in the facility, and he was going to investigate to find out the source of maggots and in the meantime the pest control person would be arriving on 1/12/23 for a thorough pest control treatment in the entire facility. He said the resident was moved back to room [ROOM NUMBER] and room [ROOM NUMBER] was treated with the pest control chemical suggested by the Pest control person. Record review on 1/11/23 of pest control treatment dated revealed that the facility had an annual contract with APT company for a monthly pest control treatment program. The last treatment was on 12/21/22. Prior to this the facility was treated on 11/16/22 and 10/19/22. Review of the Policy for Pest Control dated 2017 revealed: It is the policy of this center to maintain an effective pest control program. 1.The center maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2.Windows are screened at all times. 3.Only approved FDA and EPA insecticides and rodenticides are permitted in the center, and all such supplies are stored in areas away from food storage areas. 4.Garbage and trash are not permitted to accumulate and are removed from the center daily. 5.Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The Dietary Supervisor failed to ensure all foods were discarded prior to their expiration, use-by, best-by, or discard date. This failure placed residents at risk of foodborne illness. Findings included: During observations of the kitchen on [DATE] from 9:17 a.m.-9:37 a.m., the following were noted: At 9:17 a.m., the walk-in refrigerator contained two plastic bags labeled mech pork with use-by dates of [DATE]. At 9:18 a.m., the walk-in refrigerator contained a plastic bag of opened deli meat labeled pulled [DATE]. At 9:19 a.m., the walk-in refrigerator contained a box of 25 individual sour cream packets labeled [DATE] with a use-by date of [DATE]. At 9:22 a.m., the walk-in refrigerator contained a container of coleslaw dressing with an open date of [DATE]. At 9:23 a.m., the walk-in refrigerator contained a rusted tin container of sesame oil dated [DATE]. At 9:24 a.m., the dry storage area contained a package of hot dog buns with a best-by date of [DATE]. At 9:25 a.m., the dry storage area contained one package of whipped topping mix dated [DATE] with a best-by date of [DATE]. At 9:27 a.m., the dry storage area contained seven packages of cocoa powder dated [DATE]. At 9:28 a.m., the dry storage area contained one package of blueberry Jell-O mix with a best-by date of [DATE]. At 9:29 a.m., the dry storage area contained one package of black cherry gelatin mix with a best-by date of [DATE]. At 9:30 a.m., the dry storage area contained one bottle of opened chocolate syrup dated [DATE]. At 9:31 a.m., the dry storage area contained a box of five assorted syrups with best-by dates of [DATE]. At 9:32 a.m., the dry storage area contained one package of au gratin potatoes with a best-by date of [DATE]. At 9:33 a.m., the dry storage area contained three bags of corn chips with expiration dates of [DATE]. At 9:34 a.m., the dry storage area contained one can of green beans with a best-by date of [DATE]. At 9:35 a.m., the dry storage area contained three boxes of individual hot cocoa bags dated [DATE] with best-by dates of [DATE]. At 9:36 a.m., the dry storage area contained two plastic tubs of puree bread mix dated [DATE]. At 9:37 a.m., the dry storage area contained two bags of potato chips with best-by dates of [DATE]. At 9:37 a.m., the dry storage area contained one box of 11 individual containers of Mrs. Dash seasoning with best-by dates of [DATE]. During an interview on [DATE] at 10:16 a.m., the Dietary Supervisor stated the facility's policy was to discard all leftovers after seven days. The Dietary Supervisor stated the two bags labeled mech soft pork, the deli meat, sesame oil, and sour cream packets should have been thrown away. The Dietary Supervisor stated all condiments were discarded 30 days after opening, and the coleslaw dressing should have been discarded. The Dietary Supervisor stated the hot dog buns should have been discarded prior to the printed best-by date. The Dietary Supervisor stated the facility adhered to manufacturers' expiration, use-by, and best-by dates, and all food items contained in the walk-in refrigerator and dry storage area should have been discarded prior to their printed expiration, use-by, or best-by date. During an interview on [DATE] at 8:40 a.m., the Dietary Supervisor stated she was responsible for training kitchen employees on labeling, dating, and expired food items. The Dietary Supervisor stated herself and all kitchen employees were responsible for monitoring the kitchen to ensure compliance. During an interview on [DATE] at 1:30 p.m., the DON stated she was not the person to talk to regarding what the facility's policies were on food storage and labeling and dating, stating I don't want to quote the kitchen's policies. When asked how those policies were monitored, the DON stated the Dietitian came in once a month, looked at residents, and made recommendations for the kitchen. The DON stated the Dietitian made recommendations to the Dietary Supervisor because the Dietary Supervisor oversaw the kitchen, not the DON. When asked who was responsible for monitoring the kitchen and ensuring compliance of those policies, the DON stated the Dietary Supervisor. When asked what a potential negative outcome could occur in residents if food storage and labeling and dating policies were not followed, the DON stated, you can't serve expired foods-we look at food when it comes out, if it looks awry, we take it back-if a resident complains, we take it back. The DON stated the facility had never had an outbreak of foodborne illness or diarrhea in the ten years since she had worked there. During an interview on [DATE] at 1:45 p.m., the Administrator stated, regarding the kitchen's policy on food storage, that kitchen staff labeled food on the container once it was opened, and expired foods needed to be thrown away. The Administrator stated the Dietary Supervisor was ultimately responsible for monitoring the kitchen, but the kitchen employees did that as well. The Administrator stated the Dietary Supervisor monitored the kitchen by completing rounds and she oversaw training of kitchen employees. The Administrator stated himself, the Dietary Supervisor, and the Dietitian were all responsible for monitoring the kitchen and ensuring compliance of food storage policies. When asked what a potential negative resident outcome might occur if the kitchen's food storage policy was not followed, the Administrator stated it would depend, stating maybe nothing but if residents received something that was expired, it could make them sick. During an interview on [DATE] at 2:21 p.m., the Dietitian stated the facility's policies on food storage included labeling everything as it came in and as it was prepared. The Dietitian stated the facility followed manufacturers' best-by and use-by dates. The Dietitian stated kitchen staff and the Dietary Supervisor monitored the kitchen for adherence to food storage policies. The Dietitian stated the Dietary Supervisor monitored these policies by going through food items and ensuring things were in place. The Dietitian stated she provided kitchen audits to let Dietary Supervisor know if anything was out of place but following up with the dates and keeping up with discarding foods at the appropriate time would be up to kitchen staff since she was not in the facility all the time. The Dietitian stated the Dietary Supervisor oversaw training kitchen employees on food storage, stating they should all have a food license, and the Dietary Supervisor would have their training on food safety. The Dietitian stated if the kitchen's food storage policies were not followed, it could result in foodborne illness, lack of quality, and would affect food safety. A record review of the facility's undated policy titled When to Throw Out Food reflected the following: According to the FDA Food Code, all perishable foods that are opened or prepared should be thrown out after 7 days, maximum. Refer to expiration dates and food safety guidelines to know how to handle specific foods. The facility's policy title When to Throw Out Food also reflected that refrigerated lunch meat should be thrown away three to five days after opening. A record review of the facility's policy dated [DATE] titled Refrigerated Storage reflected the following: All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (when applicable) or discarded. Date all bulk condiment items with 'date opened,' (i.e., pickles, mustard, relish) to assure proper rotation and note 'use by' date according to Food Storage and Shelf-Life form. A record review of the facility's policy dated [DATE] titled Dry Goods Storage: Recommended Maximum Storage Period if Unopened reflected baking materials, syrups, and miscellaneous mixes were to be stored for up to 12 months.

Based on interview and record review, the facility failed to obtain laboratory services to meet the needs of one resident (Resident #22) of four residents reviewed for quality of care. The facility did not obtain a current A1C (average blood sugar) lab for Resident #22 . This failure placed Resident #22 at risk of uncontrolled diabetes. Findings included: A record review of Resident #22's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes, morbid (severe) obesity, hyperlipidemia (high cholesterol), hypertension (high blood pressure), heart failure, gastroesophageal reflux disease (acid reflux), and chronic obstructive pulmonary disease (lung disease). A record review of Resident #22's MDS assessment completed on 5/05/2022 reflected a BIMS score of 15, a BMI of 56.1, and an active diagnosis of diabetes mellitus. A record review of Resident #22's care plan last revised on 5/18/2022 reflected a potential for hypo/hyperglycemia (low/high blood sugar) related to diagnosis of diabetes mellitus and a nutritional problem related to obesity. A review of Resident #22's care plan goals reflected he would not develop complications related to obesity, including diabetes. A review of care plan interventions reflected Resident #22 was to be administered medications as ordered by MD, assessed for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), assessed for labs as ordered by MD, and assessed for fasting blood sugar as ordered by MD. Resident #22's care plan interventions reflected lab/diagnostic work was to be obtained as ordered, monitored, and results were to be reported to MD and followed up on as indicated. A record review of Resident #22's physician orders reflected a no added salt diet ordered on 5/07/2021 and no orders for insulin or diabetic medication. Resident #22's orders did not reflect a standing order for his A1C (average blood sugar) to be checked regularly. A record review of Resident #22's lab report dated 5/06/2021 reflected his blood sugar level was 112 mg/dL, which was flagged as high. A record review of Resident #22's lab report dated 11/02/2021 reflected his blood sugar level was 181 mg/dL, which was flagged as high. A record review of Resident #22's lab report dated 3/17/2022 reflected his blood sugar level was 164 mg/dL, which was flagged as high. A record review of Resident #22's lab report dated 9/29/2021 reflected a hemoglobin A1C (average blood sugar) lab ordered by Medical Director with a result of 6.7 and a reference range of 4.0-6.0. During an interview on 6/14/2022 at 11:28 a.m., Resident #22 stated he took insulin when he was at home, and he was not sure why he was not receiving it in the nursing facility. During an interview on 6/15/2022 at 1:26 p.m., the LVN stated Resident #22's A1C (average blood sugar) was checked every four months. During an interview on 6/15/2022 at 2:05 p.m., the DON stated Resident #22 had no standing order for A1C (average blood sugar) to be checked, and he had a one-time order for it to be checked on 9/29/2021. During an interview on 6/16/2022 at 10:01 a.m., the Medical Director stated her expectations for monitoring diabetic residents who were not on medication included checking their A1C (average blood sugar) every six months. The Medical Director stated Resident #22 was under her care as of then, and he would go back to seeing his PCP when he was discharged . The Medical Director stated, I know you're looking at Resident #22 and you can pin this one on me. The Medical Director stated Resident #22's A1C (average blood sugar) was probably checked when he was hospitalized in April 2022. The Medical Director stated that after searching in her records to locate Resident #22's last A1C (average blood sugar) check, she found it was last checked on 10/08/2021, and the result was 6.7. When asked if she was concerned that Resident #22's A1C (average blood sugar) had not been checked in over six months, the Medical Director stated, no because his blood glucoses were not out of whack. During an interview on 6/16/2022 at 10:55 a.m., the DON stated the facility did not have a written policy on laboratory services. The DON stated residents were transported in a van to have lab work completed out of house at either the hospital or through [NAME]. The DON stated regarding Resident #22, the Medical Director had then instructed her to create a standing order to check Resident #22's A1C (average blood sugar) every four months. During an interview on 6/16/2022 at 1:30 p.m., the DON stated the facility's policy on obtaining lab work included to obtain labs as ordered. When asked how this process was monitored, the DON stated the ADON and herself worked on it together. The DON stated the Admissions & Marketing Coordinator helped transport residents to the clinic and obtained records. The DON stated the records were then sent to the doctor for review and uploaded into their electronic health records system. When asked who monitored the process of obtaining lab work, the DON stated, the ADON and I, and pharmacy oversees us. When asked what a potential negative resident outcome might include if recommended labs were not obtained, the DON stated if lab work was not obtained as scheduled, there could be erroneous results such as delayed medication dosage. The DON stated when a demented person is taken out, it caused havoc and exasperated their dementia. During an interview on 6/16/2022 at 1:45 p.m., the Administrator stated regarding the facility's policy on obtaining lab work, that the doctor ordered it and the facility took residents down to the lab at the hospital behind them, got the lab work, and notified the physician or whoever their doctor was. The Administrator stated this process was monitored by the DON and ADON, who went over labs on a routine basis and ensured they were completed. The Administrator stated if they were not done, the DON and ADON would make sure it was getting done. When asked who monitored the process of obtaining lab work to ensure compliance, the Administrator stated labs were ordered by the physician and then entered in by the DON. The Administrator stated the doctor had to order the labs and then the nurse would put in the order. When asked what kind of potential negative resident outcome might occur if recommended labs were not obtained, the Administrator stated, maybe nothing, maybe something. The Administrator stated if there were signs and symptoms, that would give you a heads up that something was wrong, that the resident was suffering from diabetes. The Administrator stated if residents were showing signs, that might indicate it was time to do bloodwork. When asked what some signs might include, the Administrator stated he did not know. During an interview on 6/16/2022 at 2:00 p.m., the DON stated Resident #22 did not follow any diet and his wife oftentimes brought him pizzas.

Based on interview and record review the facility failed to implement policies and procedures to ensure that one of six sampled residents with a history of insulin dependent diabetes (Resident # 1) was free of neglect. RN A failed to ensure Resident #1 ' s blood glucose level was checked prior to the administration of rapid acting insulin. On [DATE] around 6:35 a.m., Resident #1 had a Blood Glucose level of 41. Without rechecking the resident ' s blood glucose level, RN A administered rapid acting insulin between 7:15 a.m. and 7:45 a.m. to Resident #1. The resident ' s blood glucose level continued to decrease and resident was discharged to the hospital on [DATE] unconscious and in respiratory distress. The resident died on [DATE] in the hospital. This was determined to be past non-compliance at immediate jeopardy level from [DATE] until [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place six residents receiving insulin for diabetes at risk of injury or death due to [DIAGNOSES REDACTED]. Findings: Review of Resident # 1 ' s Face Sheet dated [DATE] reflected an [AGE] year old female first admitted to the facility on [DATE]. Review of Diagnoses/History page for Resident Carson dated [DATE] reflected [MEDICAL CONDITIONS], insulin dependent diabetes (type 2), depression, anxiety disorder, Parkinson ' s disease, [MEDICAL CONDITION], cardiac arrhythmias, heart failure, intestinal obstruction, [MEDICAL CONDITION] and end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Review of Care Plan for Resident # 1 with a problem onset date of [DATE] and updated on [DATE] reflected that Resident # 1 had labile blood sugars related to Type II diabetes mellitus. The goal was for Resident was for complications to be identified and addressed. One of the approaches was to observe for signs of hypo/[MEDICAL CONDITION]. Review of physician's order [REDACTED].# 1 reflected: Blood glucose checks before meals and bedtime for diabetes [MEDICATION NAME] (fast acting insulin) 100 units/ml [MEDICATION NAME]- Administer 8 units subcutaneously daily at supper for diabetes [MEDICATION NAME] 100 units/ml [MEDICATION NAME]- Administer 6 units subcutaneously daily at breakfast and lunch for diabetes No parameters for blood glucose levels were included for insulin administration on the orders. Review of Properties of Different Types of Insulin dated [DATE] provided by the facility reflected [MEDICATION NAME] starts acting in 15 to 30 minutes, peak acting time is 1 to 2 hours and lasts for 3 to 6 hours. In an interview on [DATE] at 9:52 a.m. Registered Nurse (RN) A said there was nothing out of the ordinary about Resident # 1 at the start of her shift on [DATE]. RN A said she took Resident # 1 ' s blood glucose around 6:35 a.m. and the result showed a reading of 41. RN A said she gave Resident # 1 apple juice and she drank about 3 ounces (oz). She said Resident # 1 refused orange juice but ate a few bites of applesauce. RN A said she contacted the MD B who was on call that morning but had to leave a voice mail. RN A said the aides then got resident # 1 dressed and took her to breakfast. RN A said she went to the dining room between 7:15 a.m. and 7:45 a.m. and was informed by the aide that Resident # 1 had consumed bowl of Cream of Wheat. RN A said she encouraged Resident # 1 to drink the rest of her milk but did not stay to see if she drank the milk. RN A said she knew Resident # 1 and since her blood glucose usually ran high and she had eaten breakfast she gave her the scheduled dose of insulin (6 units of [MEDICATION NAME]) without checking her blood glucose. RN A said in hindsight she should have checked her blood glucose before giving her the scheduled dose of insulin. RN A said after breakfast the aides took Resident # 1 to her room to let her take a nap. RN A said during the next couple of hours she walked by Resident # 1 ' s room at least twice and saw her asleep in bed but also saw her move at least one of her extremities. RN A said at about 11:35 a.m. she went to check Resident # 1 ' s blood glucose and could not wake her up. RN A said she was breathing regularly and her pulse was strong and regular but her blood glucose was too low for the glucometer to read. RN A said she made a sugar paste and rubbed it under Resident # 1 ' s tongue while RN B called the Director of Nursing (DON), the ambulance and doctor. RN A said RN C retrieved the [MEDICATION NAME] pen from the E-Kit and gave the injection in her thigh. RN A said the ambulance arrived and loaded Resident # 1 on the stretcher. RN A said Resident # 1 was still unresponsive. RN A said she knew the facility had written procedures for low blood sugar but she is not sure what the procedure was when this incident occurred. RN A said she did not look up the procedures when the morning blood glucose was 41. RN A said if she had not known the resident she would have checked the blood glucose again before giving the insulin. Review of Blood Glucose checks and Insulin administration for Resident # 1 for [DATE] through [DATE] reflected blood glucose readings were frequently below 70 and insulin was held. (Note: RN A said Resident # 1 always had a high blood glucose) In an interview on [DATE] at 5:00 p.m. DON said a nurse should know not to give insulin to a resident who had a blood glucose of 41 unless a subsequent blood glucose is above 70. She said RN A said she didn ' t take Resident # 1 ' s blood glucose again before giving her the scheduled insulin. DON said it would be standard practice to hold the insulin. DON said on the same day this happened, [DATE] there was a meeting with Medical Doctor (MD) A to make changes to the care in response to a hypoglycemic episode. DON said she also did training to make sure all nurses on staff knew how to recognize and provide proper care for [DIAGNOSES REDACTED]. DON said the son reported to the facility that Resident # 1 died on [DATE]. In an interview on [DATE] at 5:03 p.m. RN B said he was working as a Medication Aide (MA) on [DATE] day shift when he heard RN A shouting at someone to wake up. RN B said he went in the room that was the location of the shouting and saw RN A doing a sternal rub trying to wake up Resident # 1. RN B said after talking to RN A to determine the problem he went to call the ambulance and the doctor. The doctor gave the order to give a [MEDICATION NAME] injection and send Resident # 1 to the hospital. RN B said RN C gave the [MEDICATION NAME] injection to Resident # 1 but she was still unconscious. The ambulance arrived just after that to transport Resident # 1 to the hospital. In an interview on [DATE] at 10:45 am MD B said he would expect a resident with a blood glucose of 41mg be treated for [REDACTED]. MD B said he was unable to answer the phone when the nurse called on early in the morning on [DATE]. She was notifying him of Resident # 1 having [DIAGNOSES REDACTED]. He did not feel it was necessary to call the nurse back and he did not hear anything else until the resident was unconscious. He told the nurse to give [MEDICATION NAME] and send the resident to the emergency room . Review of Nurse ' s Notes from [DATE] for Resident # 1 reflected: 12:51 p.m.- AM glucose registered 41, resident was given orange juice. Insulin (6 units of [MEDICATION NAME] 100mg/ml [MEDICATION NAME]) given when she started eating breakfast. Did not eat all the breakfast and was assisted to drink apple juice and have a snack of applesauce. Noon glucose registered low , sugar paste put under tongue, no swalling and she would not arouse. [MEDICATION NAME] given by RN . EMS called, vital signs (temp) 97.1, pulse oximetry 87%, pulse 55, respirations 20-deep & regular, (blood pressure) ,[DATE]. Family, (MD B) (on call) and DON notified. Review of Prehospital Care Report Summary from ambulance service dated [DATE] for Resident # 1 reflected the ambulance left the facility at 12:08 p.m. with Resident # 1 who was unresponsive and started an IV (intravenous) line and continued the oxygen started in the facility. Blood Glucose read 13 and D50 ([MEDICATION NAME] 50mg was given by IV. Resident started a heart rhythm of v-tach ([MEDICAL CONDITION] meaning the lower chambers of the heart were not pumping properly). CPR (cardiopulmonary resuscitation) was started and Resident # 1 was taken to closest emergency room and arrived at 12:16 p.m. Review of Hospital emergency room Record dated [DATE] for Resident # 1 reflected that CPR was in progress upon arrival at 12:16 p.m. and continued until spontaneous circulation and breathing returned at 12:28 p.m. [DIAGNOSES REDACTED]. Resident # 1 was stabilized and discharged to be transported to larger hospital in closest city. Record review of Facility Investigation initiated [DATE] for hypoglycemic episode and subsequent death of Resident # 1 reflected on [DATE] resident was found unresponsive with a blood sugar that was too low to read. A written statement from RN A from [DATE] reflected her admission that she gave Resident # 1 her insulin despite a blood glucose reading of 41mg that morning because the resident usually has a high blood glucose. Review of Diabetes Management Guideline undated and provided by the facility as procedures in place prior to [DATE] reflected, [DIAGNOSES REDACTED]: can occur when oral or injected medications are given that directly lower blood glucose. Guidelines also reflected, ADA(American Diabetes Association) defines [DIAGNOSES REDACTED] as blood glucose less than or equal to 70mg. Whenever a glucose test indicates [DIAGNOSES REDACTED] treatment should be provided immediately. Guidelines reflected, treatment of [REDACTED]. If resident is unable to swallow or has decreased level of consciousness with declining blood sugars and symptoms: Glucogan IM would be indicated. Review of Facility Provided Abuse/Neglect Prohibition Policy reflected that Neglect means not providing the services and care to prevent harm to the resident/patient. Proper staff training and monitoring are included as components of the policy to prevent abuse and neglect. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from [DATE] - [DATE]. The facility took the following action to correct the non-compliance on [DATE]. 1. Meeting with Medical Director on [DATE], in response to Resident #1 going to the hospital, to update procedures and for [DIAGNOSES REDACTED] and add to hold insulin on all scheduled doses for blood sugar lower than 70 mg/ml. Review of [DIAGNOSES REDACTED] Guidelines dated [DATE] ordered by facility Medical Director, MD A, reflected, If a resident or patient is Conscious and exhibiting sign s of [DIAGNOSES REDACTED] with a blood glucose (BG) of less than 70. Give a snack Peanut butter/crackers with juice and notify MD (medical doctor). Repeat BG in 15 minutes. The guidelines also reflected, If resident or patient is Unconscious with BG less than 70. Administer [MEDICATION NAME]. Notify physician and Call 911. 2. New procedures were added on [DATE] to require staff to contact the doctor and retake the blood glucose level in 15 minutes if the blood glucose is below 70 mg/ml and repeat if still below 70 mg/ml. 3. Training for current and new procedures for [DIAGNOSES REDACTED] for all nurses prior to working with residents initiated on [DATE]. Review of In-services dated [DATE] and [DATE] reflected all nursing staff were provided training on new guidelines, identifying [DIAGNOSES REDACTED] and proper treatment of [REDACTED]. The investigator reviewed medical orders for all residents on insulin, current policies and procedures for diabetic care and in-services provided related to new policies and procedures. It was confirmed that the facility now has procedures in place to address [DIAGNOSES REDACTED]. The DON provided a list that indicated six residents were on insulin.

Based on interview and record review the facility failed to implement written policies and procedures to ensure that one of six sampled residents with a history of insulin dependent diabetes (Resident # 1) was free of neglect. RN A failed to ensure Resident #1 ' s blood glucose level was checked prior to the administration of rapid acting insulin. On [DATE] around 6:35 a.m., Resident #1 had a Blood Glucose level of 41. Without rechecking the resident ' s blood glucose level, RN A administered rapid acting insulin between 7:15 a.m. and 7:45 a.m. to Resident #1. The resident ' s blood glucose level continued to decrease and resident was discharged to the hospital on [DATE] unconscious and in respiratory distress. The resident died on [DATE] in the hospital. This was determined to be past non-compliance at immediate jeopardy level from [DATE] until [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place six residents receiving insulin for diabetes at risk of injury or death due to [DIAGNOSES REDACTED]. Findings: Review of Facility Provided Abuse/Neglect Prohibition Policy reflected that Neglect means not providing the services and care to prevent harm to the resident/patient. Proper staff training and monitoring are included as components of the policy to prevent abuse and neglect. Review of Resident # 1 ' s Face Sheet dated [DATE] reflected an [AGE] year old female first admitted to the facility on [DATE]. Review of Diagnoses/History page for Resident Carson dated [DATE] reflected [MEDICAL CONDITIONS], insulin dependent diabetes (type 2), depression, anxiety disorder, Parkinson ' s disease, [MEDICAL CONDITION], cardiac arrhythmias, heart failure, intestinal obstruction, [MEDICAL CONDITION] and end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Review of Care Plan for Resident # 1 with a problem onset date of [DATE] and updated on [DATE] reflected that Resident # 1 had labile blood sugars related to Type II diabetes mellitus. The goal was for Resident was for complications to be identified and addressed. One of the approaches was to observe for signs of hypo/[MEDICAL CONDITION]. Review of physician's order [REDACTED].# 1 reflected: Blood glucose checks before meals and bedtime for diabetes [MEDICATION NAME] (fast acting insulin) 100 units/ml [MEDICATION NAME]- Administer 8 units subcutaneously daily at supper for diabetes [MEDICATION NAME] 100 units/ml [MEDICATION NAME]- Administer 6 units subcutaneously daily at breakfast and lunch for diabetes No parameters for blood glucose levels were included for insulin administration on the orders. Review of Properties of Different Types of Insulin dated [DATE] provided by the facility reflected [MEDICATION NAME] starts acting in 15 to 30 minutes, peak acting time is 1 to 2 hours and lasts for 3 to 6 hours. In an interview on [DATE] at 9:52 a.m. Registered Nurse (RN) A said there was nothing out of the ordinary about Resident # 1 at the start of her shift on [DATE]. RN A said she took Resident # 1 ' s blood glucose around 6:35 a.m. and the result showed a reading of 41. RN A said she gave Resident # 1 apple juice and she drank about 3 ounces (oz). She said Resident # 1 refused orange juice but ate a few bites of applesauce. RN A said she contacted the MD B who was on call that morning but had to leave a voice mail. RN A said the aides then got resident # 1 dressed and took her to breakfast. RN A said she went to the dining room between 7:15 a.m. and 7:45 a.m. and was informed by the aide that Resident # 1 had consumed bowl of Cream of Wheat. RN A said she encouraged Resident # 1 to drink the rest of her milk but did not stay to see if she drank the milk. RN A said she knew Resident # 1 and since her blood glucose usually ran high and she had eaten breakfast she gave her the scheduled dose of insulin (6 units of [MEDICATION NAME]) without checking her blood glucose. RN A said in hindsight she should have checked her blood glucose before giving her the scheduled dose of insulin. RN A said after breakfast the aides took Resident # 1 to her room to let her take a nap. RN A said during the next couple of hours she walked by Resident # 1 ' s room at least twice and saw her asleep in bed but also saw her move at least one of her extremities. RN A said at about 11:35 a.m. she went to check Resident # 1 ' s blood glucose and could not wake her up. RN A said she was breathing regularly and her pulse was strong and regular but her blood glucose was too low for the glucometer to read. RN A said she made a sugar paste and rubbed it under Resident # 1 ' s tongue while RN B called the Director of Nursing (DON), the ambulance and doctor. RN A said RN C retrieved the [MEDICATION NAME] pen from the E-Kit and gave the injection in her thigh. RN A said the ambulance arrived and loaded Resident # 1 on the stretcher. RN A said Resident # 1 was still unresponsive. RN A said she knew the facility had written procedures for low blood sugar but she is not sure what the procedure was when this incident occurred. RN A said she did not look up the procedures when the morning blood glucose was 41. RN A said if she had not known the resident she would have checked the blood glucose again before giving the insulin. Review of Blood Glucose checks and Insulin administration for Resident # 1 for [DATE] through [DATE] reflected blood glucose readings were frequently below 70 and insulin was held. (Note: RN A said Resident # 1 always had a high blood glucose) In an interview on [DATE] at 5:00 p.m. DON said a nurse should know not to give insulin to a resident who had a blood glucose of 41 unless a subsequent blood glucose is above 70. She said RN A said she didn ' t take Resident # 1 ' s blood glucose again before giving her the scheduled insulin. DON said it would be standard practice to hold the insulin. DON said on the same day this happened, [DATE] there was a meeting with Medical Doctor (MD) A to make changes to the care in response to a hypoglycemic episode. DON said she also did training to make sure all nurses on staff knew how to recognize and provide proper care for [DIAGNOSES REDACTED]. DON said the son reported to the facility that Resident # 1 died on [DATE]. In an interview on [DATE] at 5:03 p.m. RN B said he was working as a Medication Aide (MA) on [DATE] day shift when he heard RN A shouting at someone to wake up. RN B said he went in the room that was the location of the shouting and saw RN A doing a sternal rub trying to wake up Resident # 1. RN B said after talking to RN A to determine the problem he went to call the ambulance and the doctor. The doctor gave the order to give a [MEDICATION NAME] injection and send Resident # 1 to the hospital. RN B said RN C gave the [MEDICATION NAME] injection to Resident # 1 but she was still unconscious. The ambulance arrived just after that to transport Resident # 1 to the hospital. In an interview on [DATE] at 10:45 am MD B said he would expect a resident with a blood glucose of 41mg be treated for [REDACTED]. MD B said he was unable to answer the phone when the nurse called on early in the morning on [DATE]. She was notifying him of Resident # 1 having [DIAGNOSES REDACTED]. He did not feel it was necessary to call the nurse back and he did not hear anything else until the resident was unconscious. He told the nurse to give [MEDICATION NAME] and send the resident to the emergency room . Review of Nurse ' s Notes from [DATE] for Resident # 1 reflected: 12:51 p.m.- AM glucose registered 41, resident was given orange juice. Insulin (6 units of [MEDICATION NAME] 100mg/ml [MEDICATION NAME]) given when she started eating breakfast. Did not eat all the breakfast and was assisted to drink apple juice and have a snack of applesauce. Noon glucose registered low , sugar paste put under tongue, no swalling and she would not arouse. [MEDICATION NAME] given by RN . EMS called, vital signs (temp) 97.1, pulse oximetry 87%, pulse 55, respirations 20-deep & regular, (blood pressure) ,[DATE]. Family, (MD B) (on call) and DON notified. Review of Prehospital Care Report Summary from ambulance service dated [DATE] for Resident # 1 reflected the ambulance left the facility at 12:08 p.m. with Resident # 1 who was unresponsive and started an IV (intravenous) line and continued the oxygen started in the facility. Blood Glucose read 13 and D50 ([MEDICATION NAME] 50mg was given by IV. Resident started a heart rhythm of v-tach ([MEDICAL CONDITION] meaning the lower chambers of the heart were not pumping properly). CPR (cardiopulmonary resuscitation) was started and Resident # 1 was taken to closest emergency room and arrived at 12:16 p.m. Review of Hospital emergency room Record dated [DATE] for Resident # 1 reflected that CPR was in progress upon arrival at 12:16 p.m. and continued until spontaneous circulation and breathing returned at 12:28 p.m. [DIAGNOSES REDACTED]. Resident # 1 was stabilized and discharged to be transported to larger hospital in closest city. Record review of Facility Investigation initiated [DATE] for hypoglycemic episode and subsequent death of Resident # 1 reflected on [DATE] resident was found unresponsive with a blood sugar that was too low to read. A written statement from RN A from [DATE] reflected her admission that she gave Resident # 1 her insulin despite a blood glucose reading of 41mg that morning because the resident usually has a high blood glucose. Review of Diabetes Management Guideline undated and provided by the facility as procedures in place prior to [DATE] reflected, [DIAGNOSES REDACTED]: can occur when oral or injected medications are given that directly lower blood glucose. Guidelines also reflected, ADA(American Diabetes Association) defines [DIAGNOSES REDACTED] as blood glucose less than or equal to 70mg. Whenever a glucose test indicates [DIAGNOSES REDACTED] treatment should be provided immediately. Guidelines reflected, treatment of [REDACTED]. If resident is unable to swallow or has decreased level of consciousness with declining blood sugars and symptoms: Glucogan IM would be indicated. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from [DATE] - [DATE]. The facility took the following action to correct the non-compliance on [DATE]. 1. Meeting with Medical Director on [DATE], in response to Resident #1 going to the hospital, to update procedures and for [DIAGNOSES REDACTED] and add to hold insulin on all scheduled doses for blood sugar lower than 70 mg/ml. Review of [DIAGNOSES REDACTED] Guidelines dated [DATE] ordered by facility Medical Director, MD A, reflected, If a resident or patient is Conscious and exhibiting sign s of [DIAGNOSES REDACTED] with a blood glucose (BG) of less than 70. Give a snack Peanut butter/crackers with juice and notify MD (medical doctor). Repeat BG in 15 minutes. The guidelines also reflected, If resident or patient is Unconscious with BG less than 70. Administer [MEDICATION NAME]. Notify physician and Call 911. 2. New procedures were added on [DATE] to require staff to contact the doctor and retake the blood glucose level in 15 minutes if the blood glucose is below 70 mg/ml and repeat if still below 70 mg/ml. 3. Training for current and new procedures for [DIAGNOSES REDACTED] for all nurses prior to working with residents initiated on [DATE]. Review of In-services dated [DATE] and [DATE] reflected all nursing staff were provided training on new guidelines, identifying [DIAGNOSES REDACTED] and proper treatment of [REDACTED]. The investigator reviewed medical orders for all residents on insulin, current policies and procedures for diabetic care and in-services provided related to new policies and procedures. It was confirmed that the facility now has procedures in place to address [DIAGNOSES REDACTED]. The DON provided a list that indicated six residents were on insulin.

Based on interview and record review the facility failed to ensure that services meet professional standards and quality of care when one of six residents with a history of insulin dependent diabetes (Resident #1) was given insulin without checking blood glucose causing a hypoglycemic event. RN A failed to ensure Resident #1 ' s blood glucose level was checked prior to the administration of rapid acting insulin. On [DATE] around 6:35 a.m., Resident #1 had a Blood Glucose level of 41. Without rechecking the resident ' s blood glucose level, RN A administered rapid acting insulin between 7:15 a.m. and 7:45 a.m. to Resident #1. The resident ' s blood glucose level continued to decrease and resident was discharged to the hospital on [DATE] unconscious and in respiratory distress. The resident died on [DATE] in the hospital. This was determined to be past non-compliance immediate jeopardy from [DATE] until [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place six residents receiving insulin for diabetes at risk of injury or death due to [DIAGNOSES REDACTED]. Findings: Review of the Nurse Practice act from the Texas Board of Nursing reflected The Texas Board of Nursing . standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure . (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses .shall: (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same Review of Resident # 1 ' s Face Sheet dated [DATE] reflected an [AGE] year old female first admitted to the facility on [DATE]. Review of Diagnoses/History page for Resident Carson dated [DATE] reflected [MEDICAL CONDITIONS], insulin dependent diabetes (type 2), depression, anxiety disorder, Parkinson ' s disease, [MEDICAL CONDITION], cardiac arrhythmias, heart failure, intestinal obstruction, [MEDICAL CONDITION] and end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Review of Care Plan for Resident # 1 with a problem onset date of [DATE] and updated on [DATE] reflected that Resident # 1 had labile blood sugars related to Type II diabetes mellitus. The goal was for Resident was for complications to be identified and addressed. One of the approaches was to observe for signs of hypo/[MEDICAL CONDITION]. Review of physician's order [REDACTED].# 1 reflected: Blood glucose checks before meals and bedtime for diabetes [MEDICATION NAME] (fast acting insulin) 100 units/ml [MEDICATION NAME]- Administer 8 units subcutaneously daily at supper for diabetes [MEDICATION NAME] 100 units/ml [MEDICATION NAME]- Administer 6 units subcutaneously daily at breakfast and lunch for diabetes No parameters for blood glucose levels were included for insulin administration on the orders. Review of Properties of Different Types of Insulin dated [DATE] provided by the facility reflected [MEDICATION NAME] starts acting in 15 to 30 minutes, peak acting time is 1 to 2 hours and lasts for 3 to 6 hours. In an interview on [DATE] at 9:52 a.m. Registered Nurse (RN) A said there was nothing out of the ordinary about Resident # 1 at the start of her shift on [DATE]. RN A said she took Resident # 1 ' s blood glucose around 6:35 a.m. and the result showed a reading of 41. RN A said she gave Resident # 1 apple juice and she drank about 3 ounces (oz). She said Resident # 1 refused orange juice but ate a few bites of applesauce. RN A said she contacted the MD B who was on call that morning but had to leave a voice mail. RN A said the aides then got resident # 1 dressed and took her to breakfast. RN A said she went to the dining room between 7:15 a.m. and 7:45 a.m. and was informed by the aide that Resident # 1 had consumed bowl of Cream of Wheat. RN A said she encouraged Resident # 1 to drink the rest of her milk but did not stay to see if she drank the milk. RN A said she knew Resident # 1 and since her blood glucose usually ran high and she had eaten breakfast she gave her the scheduled dose of insulin (6 units of [MEDICATION NAME]) without checking her blood glucose. RN A said in hindsight she should have checked her blood glucose before giving her the scheduled dose of insulin. RN A said after breakfast the aides took Resident # 1 to her room to let her take a nap. RN A said during the next couple of hours she walked by Resident # 1 ' s room at least twice and saw her asleep in bed but also saw her move at least one of her extremities. RN A said at about 11:35 a.m. she went to check Resident # 1 ' s blood glucose and could not wake her up. RN A said she was breathing regularly and her pulse was strong and regular but her blood glucose was too low for the glucometer to read. RN A said she made a sugar paste and rubbed it under Resident # 1 ' s tongue while RN B called the Director of Nursing (DON), the ambulance and doctor. RN A said RN C retrieved the [MEDICATION NAME] pen from the E-Kit and gave the injection in her thigh. RN A said the ambulance arrived and loaded Resident # 1 on the stretcher. RN A said Resident # 1 was still unresponsive. RN A said she knew the facility had written procedures for low blood sugar but she is not sure what the procedure was when this incident occurred. RN A said she did not look up the procedures when the morning blood glucose was 41. RN A said if she had not known the resident she would have checked the blood glucose again before giving the insulin. Review of Blood Glucose checks and Insulin administration for Resident # 1 for [DATE] through [DATE] reflected blood glucose readings were frequently below 70 and insulin was held. (Note: RN A said Resident # 1 always had a high blood glucose) In an interview on [DATE] at 5:00 p.m. DON said a nurse should know not to give insulin to a resident who had a blood glucose of 41 unless a subsequent blood glucose is above 70. She said RN A said she didn ' t take Resident # 1 ' s blood glucose again before giving her the scheduled insulin. DON said it would be standard practice to hold the insulin. DON said on the same day this happened, [DATE] there was a meeting with Medical Doctor (MD) A to make changes to the care in response to a hypoglycemic episode. DON said she also did training to make sure all nurses on staff knew how to recognize and provide proper care for [DIAGNOSES REDACTED]. DON said the son reported to the facility that Resident # 1 died on [DATE]. In an interview on [DATE] at 5:03 p.m. RN B said he was working as a Medication Aide (MA) on [DATE] day shift when he heard RN A shouting at someone to wake up. RN B said he went in the room that was the location of the shouting and saw RN A doing a sternal rub trying to wake up Resident # 1. RN B said after talking to RN A to determine the problem he went to call the ambulance and the doctor. The doctor gave the order to give a [MEDICATION NAME] injection and send Resident # 1 to the hospital. RN B said RN C gave the [MEDICATION NAME] injection to Resident # 1 but she was still unconscious. The ambulance arrived just after that to transport Resident # 1 to the hospital. In an interview on [DATE] at 10:45 am MD B said he would expect a resident with a blood glucose of 41mg be treated for [REDACTED]. MD B said he was unable to answer the phone when the nurse called on early in the morning on [DATE]. She was notifying him of Resident # 1 having [DIAGNOSES REDACTED]. He did not feel it was necessary to call the nurse back and he did not hear anything else until the resident was unconscious. He told the nurse to give [MEDICATION NAME] and send the resident to the emergency room . Review of Nurse ' s Notes from [DATE] for Resident # 1 reflected: 12:51 p.m.- AM glucose registered 41, resident was given orange juice. Insulin (6 units of [MEDICATION NAME] 100mg/ml [MEDICATION NAME]) given when she started eating breakfast. Did not eat all the breakfast and was assisted to drink apple juice and have a snack of applesauce. Noon glucose registered low , sugar paste put under tongue, no swalling and she would not arouse. [MEDICATION NAME] given by RN . EMS called, vital signs (temp) 97.1, pulse oximetry 87%, pulse 55, respirations 20-deep & regular, (blood pressure) ,[DATE]. Family, (MD B) (on call) and DON notified. Review of Prehospital Care Report Summary from ambulance service dated [DATE] for Resident # 1 reflected the ambulance left the facility at 12:08 p.m. with Resident # 1 who was unresponsive and started an IV (intravenous) line and continued the oxygen started in the facility. Blood Glucose read 13 and D50 ([MEDICATION NAME] 50mg was given by IV. Resident started a heart rhythm of v-tach ([MEDICAL CONDITION] meaning the lower chambers of the heart were not pumping properly). CPR (cardiopulmonary resuscitation) was started and Resident # 1 was taken to closest emergency room and arrived at 12:16 p.m. Review of Hospital emergency room Record dated [DATE] for Resident # 1 reflected that CPR was in progress upon arrival at 12:16 p.m. and continued until spontaneous circulation and breathing returned at 12:28 p.m. [DIAGNOSES REDACTED]. Resident # 1 was stabilized and discharged to be transported to larger hospital in closest city. Record review of Facility Investigation initiated [DATE] for hypoglycemic episode and subsequent death of Resident # 1 reflected on [DATE] resident was found unresponsive with a blood sugar that was too low to read. A written statement from RN A from [DATE] reflected her admission that she gave Resident # 1 her insulin despite a blood glucose reading of 41mg that morning because the resident usually has a high blood glucose. Review of Diabetes Management Guideline undated and provided by the facility as procedures in place prior to [DATE] reflected, [DIAGNOSES REDACTED]: can occur when oral or injected medications are given that directly lower blood glucose. Guidelines also reflected, ADA(American Diabetes Association) defines [DIAGNOSES REDACTED] as blood glucose less than or equal to 70mg. Whenever a glucose test indicates [DIAGNOSES REDACTED] treatment should be provided immediately. Guidelines reflected, treatment of [REDACTED]. If resident is unable to swallow or has decreased level of consciousness with declining blood sugars and symptoms: Glucogan IM would be indicated. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from [DATE] - [DATE]. The facility took the following action to correct the non-compliance on [DATE]. 1. Meeting with Medical Director on [DATE], in response to Resident #1 going to the hospital, to update procedures and for [DIAGNOSES REDACTED] and add to hold insulin on all scheduled doses for blood sugar lower than 70 mg/ml. Review of [DIAGNOSES REDACTED] Guidelines dated [DATE] ordered by facility Medical Director, MD A, reflected, If a resident or patient is Conscious and exhibiting sign s of [DIAGNOSES REDACTED] with a blood glucose (BG) of less than 70. Give a snack Peanut butter/crackers with juice and notify MD (medical doctor). Repeat BG in 15 minutes. The guidelines also reflected, If resident or patient is Unconscious with BG less than 70. Administer [MEDICATION NAME]. Notify physician and Call 911. 2. New procedures were added on [DATE] to require staff to contact the doctor and retake the blood glucose level in 15 minutes if the blood glucose is below 70 mg/ml and repeat if still below 70 mg/ml. 3. Training for current and new procedures for [DIAGNOSES REDACTED] for all nurses prior to working with residents initiated on [DATE]. Review of In-services dated [DATE] and [DATE] reflected all nursing staff were provided training on new guidelines, identifying [DIAGNOSES REDACTED] and proper treatment of [REDACTED]. The investigator reviewed medical orders for all residents on insulin, current policies and procedures for diabetic care and in-services provided related to new policies and procedures. It was confirmed that the facility now has procedures in place to address [DIAGNOSES REDACTED]. The DON provided a list that indicated six residents were on insulin.

Based on interview and record review the facility failed to ensure that one of six residents with a history of insulin dependent diabetes (Resident # 1) was free of significant medication errors. RN A failed to ensure Resident #1 ' s blood glucose level was checked prior to the administration of rapid acting insulin. On [DATE] around 6:35 a.m., Resident #1 had a Blood Glucose level of 41. Without rechecking the resident ' s blood glucose level, RN A administered rapid acting insulin between 7:15 a.m. and 7:45 a.m. to Resident #1. The resident ' s blood glucose level continued to decrease and resident was discharged to the hospital on [DATE] unconscious and in respiratory distress. The resident died on [DATE] in the hospital. This was determined to be past non-compliance at immediate jeopardy level from [DATE] until [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place six residents receiving insulin for diabetes at risk of injury or death due to [DIAGNOSES REDACTED]. Findings: Review of Resident # 1 ' s Face Sheet dated [DATE] reflected an [AGE] year old female first admitted to the facility on [DATE]. Review of Diagnoses/History page for Resident Carson dated [DATE] reflected [MEDICAL CONDITIONS], insulin dependent diabetes (type 2), depression, anxiety disorder, Parkinson ' s disease, [MEDICAL CONDITION], cardiac arrhythmias, heart failure, intestinal obstruction, [MEDICAL CONDITION] and end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT]. Review of Care Plan for Resident # 1 with a problem onset date of [DATE] and updated on [DATE] reflected that Resident # 1 had labile blood sugars related to Type II diabetes mellitus. The goal was for Resident was for complications to be identified and addressed. One of the approaches was to observe for signs of hypo/[MEDICAL CONDITION]. Review of physician's order [REDACTED].# 1 reflected: Blood glucose checks before meals and bedtime for diabetes [MEDICATION NAME] (fast acting insulin) 100 units/ml [MEDICATION NAME]- Administer 8 units subcutaneously daily at supper for diabetes [MEDICATION NAME] 100 units/ml [MEDICATION NAME]- Administer 6 units subcutaneously daily at breakfast and lunch for diabetes No parameters for blood glucose levels were included for insulin administration on the orders. Review of Properties of Different Types of Insulin dated [DATE] provided by the facility reflected [MEDICATION NAME] starts acting in 15 to 30 minutes, peak acting time is 1 to 2 hours and lasts for 3 to 6 hours. In an interview on [DATE] at 9:52 a.m. Registered Nurse (RN) A said there was nothing out of the ordinary about Resident # 1 at the start of her shift on [DATE]. RN A said she took Resident # 1 ' s blood glucose around 6:35 a.m. and the result showed a reading of 41. RN A said she gave Resident # 1 apple juice and she drank about 3 ounces (oz). She said Resident # 1 refused orange juice but ate a few bites of applesauce. RN A said she contacted the MD B who was on call that morning but had to leave a voice mail. RN A said the aides then got resident # 1 dressed and took her to breakfast. RN A said she went to the dining room between 7:15 a.m. and 7:45 a.m. and was informed by the aide that Resident # 1 had consumed bowl of Cream of Wheat. RN A said she encouraged Resident # 1 to drink the rest of her milk but did not stay to see if she drank the milk. RN A said she knew Resident # 1 and since her blood glucose usually ran high and she had eaten breakfast she gave her the scheduled dose of insulin (6 units of [MEDICATION NAME]) without checking her blood glucose. RN A said in hindsight she should have checked her blood glucose before giving her the scheduled dose of insulin. RN A said after breakfast the aides took Resident # 1 to her room to let her take a nap. RN A said during the next couple of hours she walked by Resident # 1 ' s room at least twice and saw her asleep in bed but also saw her move at least one of her extremities. RN A said at about 11:35 a.m. she went to check Resident # 1 ' s blood glucose and could not wake her up. RN A said she was breathing regularly and her pulse was strong and regular but her blood glucose was too low for the glucometer to read. RN A said she made a sugar paste and rubbed it under Resident # 1 ' s tongue while RN B called the Director of Nursing (DON), the ambulance and doctor. RN A said RN C retrieved the [MEDICATION NAME] pen from the E-Kit and gave the injection in her thigh. RN A said the ambulance arrived and loaded Resident # 1 on the stretcher. RN A said Resident # 1 was still unresponsive. RN A said she knew the facility had written procedures for low blood sugar but she is not sure what the procedure was when this incident occurred. RN A said she did not look up the procedures when the morning blood glucose was 41. RN A said if she had not known the resident she would have checked the blood glucose again before giving the insulin. Review of Blood Glucose checks and Insulin administration for Resident # 1 for [DATE] through [DATE] reflected blood glucose readings were frequently below 70 and insulin was held. (Note: RN A said Resident # 1 always had a high blood glucose) In an interview on [DATE] at 5:00 p.m. DON said a nurse should know not to give insulin to a resident who had a blood glucose of 41 unless a subsequent blood glucose is above 70. She said RN A said she didn ' t take Resident # 1 ' s blood glucose again before giving her the scheduled insulin. DON said it would be standard practice to hold the insulin. DON said on the same day this happened, [DATE] there was a meeting with Medical Doctor (MD) A to make changes to the care in response to a hypoglycemic episode. DON said she also did training to make sure all nurses on staff knew how to recognize and provide proper care for [DIAGNOSES REDACTED]. DON said the son reported to the facility that Resident # 1 died on [DATE]. In an interview on [DATE] at 5:03 p.m. RN B said he was working as a Medication Aide (MA) on [DATE] day shift when he heard RN A shouting at someone to wake up. RN B said he went in the room that was the location of the shouting and saw RN A doing a sternal rub trying to wake up Resident # 1. RN B said after talking to RN A to determine the problem he went to call the ambulance and the doctor. The doctor gave the order to give a [MEDICATION NAME] injection and send Resident # 1 to the hospital. RN B said RN C gave the [MEDICATION NAME] injection to Resident # 1 but she was still unconscious. The ambulance arrived just after that to transport Resident # 1 to the hospital. In an interview on [DATE] at 10:45 am MD B said he would expect a resident with a blood glucose of 41mg be treated for [REDACTED]. MD B said he was unable to answer the phone when the nurse called on early in the morning on [DATE]. She was notifying him of Resident # 1 having [DIAGNOSES REDACTED]. He did not feel it was necessary to call the nurse back and he did not hear anything else until the resident was unconscious. He told the nurse to give [MEDICATION NAME] and send the resident to the emergency room . Review of Nurse ' s Notes from [DATE] for Resident # 1 reflected: 12:51 p.m.- AM glucose registered 41, resident was given orange juice. Insulin (6 units of [MEDICATION NAME] 100mg/ml [MEDICATION NAME]) given when she started eating breakfast. Did not eat all the breakfast and was assisted to drink apple juice and have a snack of applesauce. Noon glucose registered low , sugar paste put under tongue, no swalling and she would not arouse. [MEDICATION NAME] given by RN . EMS called, vital signs (temp) 97.1, pulse oximetry 87%, pulse 55, respirations 20-deep & regular, (blood pressure) ,[DATE]. Family, (MD B) (on call) and DON notified. Review of Prehospital Care Report Summary from ambulance service dated [DATE] for Resident # 1 reflected the ambulance left the facility at 12:08 p.m. with Resident # 1 who was unresponsive and started an IV (intravenous) line and continued the oxygen started in the facility. Blood Glucose read 13 and D50 ([MEDICATION NAME] 50mg was given by IV. Resident started a heart rhythm of v-tach ([MEDICAL CONDITION] meaning the lower chambers of the heart were not pumping properly). CPR (cardiopulmonary resuscitation) was started and Resident # 1 was taken to closest emergency room and arrived at 12:16 p.m. Review of Hospital emergency room Record dated [DATE] for Resident # 1 reflected that CPR was in progress upon arrival at 12:16 p.m. and continued until spontaneous circulation and breathing returned at 12:28 p.m. [DIAGNOSES REDACTED]. Resident # 1 was stabilized and discharged to be transported to larger hospital in closest city. Record review of Facility Investigation initiated [DATE] for hypoglycemic episode and subsequent death of Resident # 1 reflected on [DATE] resident was found unresponsive with a blood sugar that was too low to read. A written statement from RN A from [DATE] reflected her admission that she gave Resident # 1 her insulin despite a blood glucose reading of 41mg that morning because the resident usually has a high blood glucose. Review of Diabetes Management Guideline undated and provided by the facility as procedures in place prior to [DATE] reflected, [DIAGNOSES REDACTED]: can occur when oral or injected medications are given that directly lower blood glucose. Guidelines also reflected, ADA(American Diabetes Association) defines [DIAGNOSES REDACTED] as blood glucose less than or equal to 70mg. Whenever a glucose test indicates [DIAGNOSES REDACTED] treatment should be provided immediately. Guidelines reflected, treatment of [REDACTED]. If resident is unable to swallow or has decreased level of consciousness with declining blood sugars and symptoms: Glucogan IM would be indicated. It was determined these failures placed Resident #1 in an immediate Jeopardy (IJ) situation from [DATE] - [DATE]. The facility took the following action to correct the non-compliance on [DATE]. 1. Meeting with Medical Director on [DATE], in response to Resident #1 going to the hospital, to update procedures and for [DIAGNOSES REDACTED] and add to hold insulin on all scheduled doses for blood sugar lower than 70 mg/ml. Review of [DIAGNOSES REDACTED] Guidelines dated [DATE] ordered by facility Medical Director, MD A, reflected, If a resident or patient is Conscious and exhibiting sign s of [DIAGNOSES REDACTED] with a blood glucose (BG) of less than 70. Give a snack Peanut butter/crackers with juice and notify MD (medical doctor). Repeat BG in 15 minutes. The guidelines also reflected, If resident or patient is Unconscious with BG less than 70. Administer [MEDICATION NAME]. Notify physician and Call 911. 2. New procedures were added on [DATE] to require staff to contact the doctor and retake the blood glucose level in 15 minutes if the blood glucose is below 70 mg/ml and repeat if still below 70 mg/ml. 3. Training for current and new procedures for [DIAGNOSES REDACTED] for all nurses prior to working with residents initiated on [DATE]. Review of In-services dated [DATE] and [DATE] reflected all nursing staff were provided training on new guidelines, identifying [DIAGNOSES REDACTED] and proper treatment of [REDACTED]. The investigator reviewed medical orders for all residents on insulin, current policies and procedures for diabetic care and in-services provided related to new policies and procedures. It was confirmed that the facility now has procedures in place to address [DIAGNOSES REDACTED]. The DON provided a list that indicated six residents were on insulin.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for 1 of 6 residents reviewed for neglect (Resident #1). The facility failed to provide a physician prescribed steroid medication used to reduce side effects such as dizziness and falling associated with [MEDICAL CONDITION] treatment that Resident #1 was receiving. Resident #1 had three falls with injury from 2/23/12-02/25/12. The medication was ordered to start 02/17/12 and was not administered to the resident until 5:00 PM on 02/24/12 after two of the falls had already occurred. This deficient practice contributed to Resident #1 having three consecutive falls with injuries due to not receiving physician prescribed medication used to reduce the side effects of the [MEDICAL CONDITION] treatment he was receiving. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was not interviewable. On 03/20/12 at 11:45 AM, the Director of Nurses (DON), informed the surveyor that Resident #1 had [MEDICAL CONDITION] that metastasized to the brain and had been receiving [MEDICAL CONDITION] treatment from (02/20/12 -03/05/12) during the time of the referenced falls. Review of Resident #1 ' s Admission Minimum Data Set ((MDS) dated [DATE] reflected the resident had a fall history during the month before admission and 2-6 months before admission. Observation on 03/20/12 at 3:05 PM, revealed Resident #1 sitting in his wheelchair. Resident #1 was alert and oriented to self. The resident had a 3.5 inch long scab on the back of his head where staples had recently held it together. During an interview on 03/20/12 at 3:05 PM, Resident #1 stated that he did not feel dizzy anymore. Resident #1 could not recall the falls he had on 02/23/12-02/25/12. Review of Resident #1 ' s nursing notes dated 02/23/12 at 5:19 AM, reflected " Resident was observed lying on the floor in his room when this nurse was entering room to give roommate medication. Resident did not call out for help. 3 skin tears noted to his right arm; one to tricep area, one to elbow and one right above elbow area. Areas were cleansed with wound cleaner and steri strips were applied. Resident complains of right shoulder pain although range of motion to right arm is within normal limits; able to move all extremities. Resident assisted to bed with total lift x 3 assist. Stated he went to the bathroom and on his way back he fell . Neuros initiated due to unwitness fall. MD notified via fax and DON also notified. Will request AM nurse to notify family. Will continue to monitor. " Review of Resident #1 ' s Incident/Accident Report Investigation Follow- Up dated 02/24/12 reflected " CNA reports resident fell in bathroom in room. CNA reports resident is on the bathroom floor on his knees and blood on the wall. Resident seen on his knees in bathroom hovering over toilet and small amount of blood noted on bathroom wall. Resident assisted to wheelchair x2 assist. [MEDICAL CONDITION] noted to back of head. Not actively bleeding. Unknown if resident lost consciousness. Alert and oriented x2 which is normal for resident. [MEDICAL CONDITION] cleansed but needs staples or sutures. ER notified to have resident transferred to ER. DON notified and MD on call also notified. Daughter notified of residents transfer. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 6:31 AM, reflected " CNA reports that resident on the floor in the bathroom in room and that there ' s blood on the wall in the bathroom. Resident seen on his knees in the bathroom hovering over the toilet and small amount of blood was noted on the wall. Resident assisted to wheelchair x2 assist. [MEDICAL CONDITION] noted to the back of residents head. Unknown if resident lossed consciousness; alert and oriented x2 which is normal for resident. [MEDICAL CONDITION] is not actively bleeding but it is a deep [MEDICAL CONDITION] that requires more care so (ambulance) called to have resident transported to (hospital), (hospital) called to let them know of residents transfer. MD on call notified, DON notified and daughter notified of residents fall and transfer. Resident out to ER at 6:20 AM via (ambulance). Nursing note dated 02/24/12 at 8:09 AM reflected " back from hospital with four staples to laceration. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 3:34 PM, reflected " Received call from (Resident ' s #1 ' s responsible party- his daughter) who inquired whether or not resident was taking steroids, she reported that she had given the prescription to a nurse at facility on Friday (02/17/12). After investigation, it was determined that resident had not received medication, and it had not been ordered from the pharmacy. At approximately 3:05 PM, (Resident #1 ' s daughter) arrived at the facility and this writer informed her of situation. [MEDICATION NAME] 4 mg by mouth three times per day was ordered from pharmacy. Medication order entered into computer. DON notified. " Review of Resident #1 ' s nursing notes dated 02/25/12 at 3:53 PM, reflected " @1240 AM a loud noise was heard coming from resident ' s room and sensor pad alarming. This nurse and CNA to resident ' s room and the resident was seen on his knees on the floor next to his bed. When resident was asked what happened, he stated " I had to pee. " Resident assisted to bed x2 assist which bed was in lowest position and remains in lowest position. Sensor pad was in place and working. Deep purple abrasion noted to residents right forearm and a skin tear also noted to upper right forearm 1.3 cm in length. Stated he scraped his arm on the wheelchair trying to hang on to it to prevent from falling. " Review of Resident #1 ' s Incident Reports from all three falls on 02/23/12, 02/24/12 and 02/25/12 did not show that medications were reviewed status [REDACTED]. Review of the facility ' s Summary of Investigation, dated 02/27/12, signed by the Director of Nurses (DON), reflected " Resident #1 observed by roommate going to bathroom without assistance. Call light was not on. Roommate heard a ruckus in bathroom. Roommate turned on call ligh for himself and when light was answered, nurse aide asked about roommate ' s whereabouts. Roommate responded in the bathroom. Nurse aide knocked and did not get appropriate response so entered the bathroom and observed resident on his knees in hovering over toilet. Nurse aide observed blood to back of his head and called for a nurse. When the nurse arrived she noted blood on bathroom wall. The nurse cleaned and assessed the resident, noted laceration to back of head. Neuro checks initiated, ambulance called, physician notified, daughter notified, Director of Nursing (DON) notified, Administrator notified. Resident returned from emergency room with 4 staples to the back of head. Neuro checks resumed. Resident then went to doctor ' s appointment. Upon return from doctor ' s appointment neuro checks resumed. Care plan changed to include low bed with mat beside bed, bed and wheelchair sensor pads, toilet every 2 hours especially between 4am and 5:30 am. Resident already has a room close to the nurse ' s desk. " During an interview on 03/20/12 at 3:04 PM, Resident #1 ' s daughter stated that after the resident fell on [DATE], the nurse at [MEDICAL CONDITION] center questioned as to whether the resident had not been receiving his steroid ([MEDICATION NAME]) order as ordered. The daughter stated the nurse told her that the steroid was given to help prevent the negative side effects from the [MEDICAL CONDITION] treatment he was receiving. The daughter stated that the nurse explained that if the resident hadn ' t been receiving the steroid as ordered then that would definitely contribute to her father ' s recent falls. Review of Resident #1 ' s Physician order [REDACTED]. " Review of the handwritten physician order [REDACTED]. Review of Resident #1 ' s electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" [MEDICATION NAME] 4 mg tablet- I tablet by mouth three times a day for inflammation; Side Effects: Stomach upset, headache; Start Date: 02/24/12; Discontinue Date: 03/20/12. " The medication was checked as given for the first time on 02/24/12 at 5:00 PM. During an interview on 03/20/12 at 4:15 PM the DON stated the resident had returned for a doctor's appointment on 02/17/12 and provided the new steroid medication order slip. The DON stated that the slip had been placed into the chart, but was not transcribed onto the resident's physician orders [REDACTED]. The DON stated she did not consider the missing medication a factor while doing her investigation of the fall because she didn ' t think the medication was used for balance. The DON stated she did not know what clinical indication the steroid was specifically ordered for. The DON stated that she did complete a medication error report when the daughter informed them that Resident #1 had not been receiving his medication as ordered. Review of Resident #1 ' s Medication Error Report dated 02/24/12 reflected the date of error as 02/17/12 for an order of [MEDICATION NAME] 4 mg, 1 by mouth three times per day. The description of error reflected " Medication order was not processed. " The corrective action taken reflected " Medication started, physician notified. " Measures taken to prevent recurrence included " in-serviced on how to process orders. " During an interview on 03/21/12 at 4:45 PM, Resident #1 ' s [MEDICAL CONDITION] Oncologist stated the prescription for [MEDICATION NAME] (a sterioid) was prescribed for the resident to help reduce the swelling in the brain associated with the [MEDICAL CONDITION] treatment the resident was receiving. The [MEDICAL CONDITION] Oncologist stated the dose of this medication would have helped reduce the side effects from the swelling, such as dizziness and altered mental status. The [MEDICAL CONDITION] Oncologist stated if the resident had received the ordered steroid medication the resident might not have been fallen on 02/23/12, 02/24/12, and 02/25/12. Review of Resident #1 ' s Care Plan dated 02/16/12 and updated 02/23/12, 02/24/12, and 02/25/12 did not reflect any interventions regarding the missing steroid medication. A low bed, chair alarm, bed alarm, mat at bedside and toileting program was added on 02/24/12. Review of information regarding the use of [MEDICATION NAME] with [MEDICAL CONDITION] for [DIAGNOSES REDACTED]s from ?The [MEDICAL CONDITION] Medical Group, Inc 2010, reflected " some patients get a dull headache and/or pressure sensation in the head as the treatment series evolves. This is caused by swelling around the tumor and will typically respond to [MEDICATION NAME] ([MEDICATION NAME]). Your physician and staff will work closely with you during the treatment course to try to optimize the dose of that medication. There is a fine balancing act between minimizing [MEDICATION NAME] side effects versus minimizing pressure in the head caused by swelling around the tumor. You should never change your [MEDICATION NAME] dose without first consulting with your treating physician. Nausea and vomiting are unusual with [MEDICAL CONDITION] to the head unless there is a significant amount of swelling and pressure in the head. This would typically be treated by starting or raising the dose of [MEDICATION NAME]. " Review of the facility ' s policy on Abuse and Neglect dated 07/01/09 reflected " To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases in compliance with applicable state and federal regulations. " The policy also reflected the definition of " neglect " as " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " The Administrator reported a facility census of 36.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 6 residents reviewed for neglect (Resident #1). The facility failed to provide a physician prescribed steroid medication used to reduce side effects such as dizziness and falling associated with [MEDICAL CONDITION] treatment that Resident #1 was receiving. Resident #1 had three falls with injury from 2/23/12-02/25/12. The medication was ordered to start 02/17/12 and was not administered to the resident until 5:00 PM on 02/24/12 after two of the falls had already occurred. This deficient practice contributed to Resident #1 having three consecutive falls with injuries due to not receiving physician prescribed medication used to reduce the side effects of the [MEDICAL CONDITION] treatment he was receiving. Findings include: Review of the facility ' s policy on Abuse and Neglect dated 07/01/09 reflected " To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases in compliance with applicable state and federal regulations. " The policy also reflected the definition of " neglect " as " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was not interviewable. On 03/20/12 at 11:45 AM, the Director of Nurses (DON), informed the surveyor that Resident #1 had [MEDICAL CONDITION] that metastasized to the brain and had been receiving [MEDICAL CONDITION] treatment from (02/20/12 -03/05/12) during the time of the referenced falls. Review of Resident #1 ' s Admission Minimum Data Set ((MDS) dated [DATE] reflected the resident had a fall history during the month before admission and 2-6 months before admission. Observation on 03/20/12 at 3:05 PM, revealed Resident #1 sitting in his wheelchair. Resident #1 was alert and oriented to self. The resident had a 3.5 inch long scab on the back of his head where staples had recently held it together. During an interview on 03/20/12 at 3:05 PM, Resident #1 stated that he did not feel dizzy anymore. Resident #1 could not recall the falls he had on 02/23/12-02/25/12. Review of Resident #1 ' s nursing notes dated 02/23/12 at 5:19 AM, reflected " Resident was observed lying on the floor in his room when this nurse was entering room to give roommate medication. Resident did not call out for help. 3 skin tears noted to his right arm; one to tricep area, one to elbow and one right above elbow area. Areas were cleansed with wound cleaner and steri strips were applied. Resident complains of right shoulder pain although range of motion to right arm is within normal limits; able to move all extremities. Resident assisted to bed with total lift x3 assist. Stated he went to the bathroom and on his way back he fell . Neuros initiated due to unwitness fall. MD notified via fax and DON also notified. Will request AM nurse to notify family. Will continue to monitor. " Review of Resident #1 ' s Incident/Accident Report Investigation Follow- Up dated 02/24/12 reflected " CNA reports resident fell in bathroom in room. CNA reports resident is on the bathroom floor on his knees and blood on the wall. Resident seen on his knees in bathroom hovering over toilet and small amount of blood noted on bathroom wall. Resident assisted to wheelchair x2 assist. [MEDICAL CONDITION] noted to back of head. Not actively bleeding. Unknown if resident lost consciousness. Alert and oriented x2 which is normal for resident. Head lacteration cleansed but needs staples or sutures. ER notified to have resident transferred to ER. DON notified and MD on call also notified. Daughter notified of residents transfer. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 6:31 AM, reflected " CNA reports that resident on the floor in the bathroom in room and that there ' s blood on the wall in the bathroom. Resident seen on his knees in the bathroom hovering over the toilet and small amount of blood was noted on the wall. Resident assisted to wheelchair x2 assist. [MEDICAL CONDITION] noted to the back of residents head. Unknown if resident lossed consciousness; alert and oriented x2 which is normal for resident. [MEDICAL CONDITION] is not actively bleeding but it is a deep [MEDICAL CONDITION] that requires more care so (ambulance) called to have resident transported to (hospital), (hospital) called to let them know of residents transfer. MD on call notified, DON notified and daughter notified of residents fall and transfer. Resident out to ER at 6:20 AM via (ambulance). Nursing note dated 02/24/12 at 8:09 AM reflected " back from hospital with four staples to laceration. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 3:34 PM, reflected " Received call from (Resident ' s #1 ' s responsible party- his daughter) who inquired whether or not resident was taking steroids, she reported that she had given the prescription to a nurse at facility on Friday (02/17/12). After investigation, it was determined that resident had not received medication, and it had not been ordered from the pharmacy. At approximately 3:05 PM, (Resident #1 ' s daughter) arrived at the facility and this writer informed her of situation. [MEDICATION NAME] 4 mg by mouth three times per day was ordered from pharmacy. Medication order entered into computer. DON notified. " Review of Resident #1 ' s nursing notes dated 02/25/12 at 3:53 PM, reflected " @1240 AM a loud noise was heard coming from resident ' s room and sensor pad alarming. This nurse and CNA to resident ' s room and the resident was seen on his knees on the floor next to his bed. When resident was asked what happened, he stated " I had to pee. " Resident assisted to bed x2 assist which bed was in lowest position and remains in lowest position. Sensor pad was in place and working. Deep purple abrasion noted to residents right forearm and a skin tear also noted to upper right forearm 1.3 cm in length. Stated he scraped his arm on the wheelchair trying to hang on to it to prevent from falling. " Review of Resident #1 ' s Incident Reports from all three falls on 02/23/12, 02/24/12 and 02/25/12 did not show that medications were reviewed status [REDACTED]. Review of the facility ' s Summary of Investigation, dated 02/27/12, signed by the Director of Nurses (DON), reflected " Resident #1 observed by roommate going to bathroom without assistance. Call light was not on. Roommate heard a ruckus in bathroom. Roommate turned on call ligh for himself and when light was answered, nurse aide asked about roommate ' s whereabouts. Roommate responded in the bathroom. Nurse aide knocked and did not get appropriate response so entered the bathroom and observed resident on his knees in hovering over toilet. Nurse aide observed blood to back of his head and called for a nurse. When the nurse arrived she noted blood on bathroom wall. The nurse cleaned and assessed the resident, noted laceration to back of head. Neuro checks initiated, ambulance called, physician notified, daughter notified, Director of Nursing (DON) notified, Administrator notified. Resident returned from emergency room with 4 staples to the back of head. Neuro checks resumed. Resident then went to doctor ' s appointment. Upon return from doctor ' s appointment neuro checks resumed. Care plan changed to include low bed with mat beside bed, bed and wheelchair sensor pads, toilet every 2 hours especially between 4am and 5:30 am. Resident already has a room close to the nurse ' s desk. " During an interview on 03/20/12 at 3:04 PM, Resident #1 ' s daughter stated that after the resident fell on [DATE], the nurse at [MEDICAL CONDITION] center questioned as to whether the resident had not been receiving his steroid ([MEDICATION NAME]) order as ordered. The daughter stated the nurse told her that the steroid was given to help prevent the negative side effects from the [MEDICAL CONDITION] treatment he was receiving. The daughter stated that the nurse explained that if the resident hadn ' t been receiving the steroid as ordered then that would definitely contribute to her father ' s recent falls. Review of Resident #1 ' s Physician order [REDACTED]. " Review of the handwritten physician order [REDACTED]. Review of Resident #1 ' s electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" [MEDICATION NAME] 4 mg tablet- I tablet by mouth three times a day for inflammation; Side Effects: Stomach upset, headache; Start Date: 02/24/12; Discontinue Date: 03/20/12. " The medication was checked as given for the first time on 02/24/12 at 5:00 PM. During an interview on 03/20/12 at 4:15 PM the DON stated the resident had returned for a doctor's appointment on 02/17/12 and provided the new steroid medication order slip. The DON stated that the slip had been placed into the chart, but was not transcribed onto the resident's physician orders [REDACTED]. The DON stated she did not consider the missing medication a factor while doing her investigation of the fall because she didn ' t think the medication was used for balance. The DON stated she did not know what clinical indication the steroid was specifically ordered for. The DON stated that she did complete a medication error report when the daughter informed them that Resident #1 had not been receiving his medication as ordered. Review of Resident #1 ' s Medication Error Report dated 02/24/12 reflected the date of error as 02/17/12 for an order of [MEDICATION NAME] 4 mg, 1 by mouth three times per day. The description of error reflected " Medication order was not processed. " The corrective action taken reflected " Medication started, physician notified. " Measures taken to prevent recurrence included " in-serviced on how to process orders. " During an interview on 03/21/12 at 4:45 PM, Resident #1 ' s [MEDICAL CONDITION] Oncologist stated the prescription for [MEDICATION NAME] (a sterioid) was prescribed for the resident to help reduce the swelling in the brain associated with the [MEDICAL CONDITION] treatment the resident was receiving. The [MEDICAL CONDITION] Oncologist stated the dose of this medication would have helped reduce the side effects from the swelling, such as dizziness and altered mental status. The [MEDICAL CONDITION] Oncologist stated if the resident had received the ordered steroid medication the resident might not have been fallen on 02/23/12, 02/24/12, and 02/25/12. Review of Resident #1 ' s Care Plan dated 02/16/12 and updated 02/23/12, 02/24/12, and 02/25/12 did not reflect any interventions regarding the missing steroid medication. A low bed, chair alarm, bed alarm, mat at bedside and toileting program was added on 02/24/12. Review of information regarding the use of [MEDICATION NAME] with [MEDICAL CONDITION] for [DIAGNOSES REDACTED]s from ?The [MEDICAL CONDITION] Medical Group, Inc 2010, reflected " some patients get a dull headache and/or pressure sensation in the head as the treatment series evolves. This is caused by swelling around the tumor and will typically respond to [MEDICATION NAME] ([MEDICATION NAME]). Your physician and staff will work closely with you during the treatment course to try to optimize the dose of that medication. There is a fine balancing act between minimizing [MEDICATION NAME] side effects versus minimizing pressure in the head caused by swelling around the tumor. You should never change your [MEDICATION NAME] dose without first consulting with your treating physician. Nausea and vomiting are unusual with [MEDICAL CONDITION] to the head unless there is a significant amount of swelling and pressure in the head. This would typically be treated by starting or raising the dose of [MEDICATION NAME]. " The Administrator reported a facility census of 36.

Based on interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 6 residents reviewed for falls (Resident #1). Resident #1 had three falls with injury from 2/23/12-02/25/12. The facility failed to review the resident's medications to determine if they were contributing to the falls. A physician prescribed steroid medication, used to reduce side effects such as dizziness and falling associated with radiation treatment that Resident #1 was receiving, was not given as ordered from 02/17/12 to 02/24/12. This deficient practice contributed to Resident #1 having three consecutive falls with injuries due to not receiving physician prescribed medication used to reduce the side effects of the radiation treatment he was receiving. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was not interviewable. On 03/20/12 at 11:45 AM, the Director of Nurses (DON), informed the surveyor that Resident #1 had lung cancer that metastasized to the brain and had been receiving radiation treatment from (02/20/12 -03/05/12) during the time of the referenced falls. Review of Resident #1 ' s Admission Minimum Data Set ((MDS) dated [DATE] reflected the resident had a fall history during the month before admission and 2-6 months before admission. Observation on 03/20/12 at 3:05 PM, revealed Resident #1 sitting in his wheelchair. Resident #1 was alert and oriented to self. The resident had a 3.5 inch long scab on the back of his head where staples had recently held it together. During an interview on 03/20/12 at 3:05 PM, Resident #1 stated that he did not feel dizzy anymore. Resident #1 could not recall the falls he had on 02/23/12-02/25/12. Review of Resident #1 ' s nursing notes dated 02/23/12 at 5:19 AM, reflected " Resident was observed lying on the floor in his room when this nurse was entering room to give roommate medication. Resident did not call out for help. 3 skin tears noted to his right arm; one to tricep area, one to elbow and one right above elbow area. Areas were cleansed with wound cleaner and steri strips were applied. Resident complains of right shoulder pain although range of motion to right arm is within normal limits; able to move all extremities. Resident assisted to bed with total lift x3 assist. Stated he went to the bathroom and on his way back he fell . Neuros initiated due to unwitness fall. MD notified via fax and DON also notified. Will request AM nurse to notify family. Will continue to monitor. " Review of Resident #1 ' s Incident/Accident Report Investigation Follow- Up dated 02/24/12 reflected " CNA reports resident fell in bathroom in room. CNA reports resident is on the bathroom floor on his knees and blood on the wall. Resident seen on his knees in bathroom hovering over toilet and small amount of blood noted on bathroom wall. Resident assisted to wheelchair x2 assist. Head laceration noted to back of head. Not actively bleeding. Unknown if resident lost consciousness. Alert and oriented x2 which is normal for resident. Head lacteration cleansed but needs staples or sutures. ER notified to have resident transferred to ER. DON notified and MD on call also notified. Daughter notified of residents transfer. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 6:31 AM, reflected " CNA reports that resident on the floor in the bathroom in room and that there ' s blood on the wall in the bathroom. Resident seen on his knees in the bathroom hovering over the toilet and small amount of blood was noted on the wall. Resident assisted to wheelchair x2 assist. Head laceration noted to the back of residents head. Unknown if resident lossed consciousness; alert and oriented x2 which is normal for resident. Head laceration is not actively bleeding but it is a deep head laceration that requires more care so (ambulance) called to have resident transported to (hospital), (hospital) called to let them know of residents transfer. MD on call notified, DON notified and daughter notified of residents fall and transfer. Resident out to ER at 6:20 AM via (ambulance). Nursing note dated 02/24/12 at 8:09 AM reflected " back from hospital with four staples to laceration. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 3:34 PM, reflected " Received call from (Resident ' s #1 ' s responsible party- his daughter) who inquired whether or not resident was taking steroids, she reported that she had given the prescription to a nurse at facility on Friday (02/17/12). After investigation, it was determined that resident had not received medication, and it had not been ordered from the pharmacy. At approximately 3:05 PM, (Resident #1 ' s daughter) arrived at the facility and this writer informed her of situation. Dexamethasone 4 mg by mouth three times per day was ordered from pharmacy. Medication order entered into computer. DON notified. " Review of Resident #1 ' s nursing notes dated 02/25/12 at 3:53 PM, reflected " @1240 AM a loud noise was heard coming from resident ' s room and sensor pad alarming. This nurse and CNA to resident ' s room and the resident was seen on his knees on the floor next to his bed. When resident was asked what happened, he stated " I had to pee. " Resident assisted to bed x2 assist which bed was in lowest position and remains in lowest position. Sensor pad was in place and working. Deep purple abrasion noted to residents right forearm and a skin tear also noted to upper right forearm 1.3 cm in length. Stated he scraped his arm on the wheelchair trying to hang on to it to prevent from falling. " Review of Resident #1 ' s Incident Reports from all three falls on 02/23/12, 02/24/12 and 02/25/12 did not show that medications were reviewed status [REDACTED]. Review of the facility ' s Summary of Investigation, dated 02/27/12, signed by the Director of Nurses (DON), reflected " Resident #1 observed by roommate going to bathroom without assistance. Call light was not on. Roommate heard a ruckus in bathroom. Roommate turned on call ligh for himself and when light was answered, nurse aide asked about roommate ' s whereabouts. Roommate responded in the bathroom. Nurse aide knocked and did not get appropriate response so entered the bathroom and observed resident on his knees in hovering over toilet. Nurse aide observed blood to back of his head and called for a nurse. When the nurse arrived she noted blood on bathroom wall. The nurse cleaned and assessed the resident, noted laceration to back of head. Neuro checks initiated, ambulance called, physician notified, daughter notified, Director of Nursing (DON) notified, Administrator notified. Resident returned from emergency room with 4 staples to the back of head. Neuro checks resumed. Resident then went to doctor ' s appointment. Upon return from doctor ' s appointment neuro checks resumed. Care plan changed to include low bed with mat beside bed, bed and wheelchair sensor pads, toilet every 2 hours especially between 4am and 5:30 am. Resident already has a room close to the nurse ' s desk. " During an interview on 03/20/12 at 3:04 PM, Resident #1 ' s daughter stated that after the resident fell on [DATE], the nurse at the cancer center questioned as to whether the resident had not been receiving his steroid (dexamethasone) order as ordered. The daughter stated the nurse told her that the steroid was given to help prevent the negative side effects from the radiation treatment he was receiving. The daughter stated that the nurse explained that if the resident hadn ' t been receiving the steroid as ordered then that would definitely contribute to her father ' s recent falls. Review of Resident #1 ' s Physician order [REDACTED]. " Review of the handwritten physician order [REDACTED]. This order was signed by the Radiation Oncologist. Review of Resident #1 ' s electronic Medication Administration Record (eMAR) dated February 2012 reflected the order for " Dexamethasone 4 mg tablet- I tablet by mouth three times a day for inflammation; Side Effects: Stomach upset, headache; Start Date: 02/24/12; Discontinue Date: 03/20/12. " The medication was checked as given for the first time on 02/24/12 at 5:00 PM. During an interview on 03/20/12 at 4:15 PM the DON stated the resident had returned for a doctor's appointment on 02/17/12 and provided the new steroid medication order slip. The DON stated that the slip had been placed into the chart, but was not transcribed onto the resident's physician orders [REDACTED]. The DON stated she did not consider the missing medication a factor while doing her investigation of the fall because she didn ' t think the medication was used for balance. The DON stated she did not know what clinical indication the steroid was specifically ordered for. The DON stated that she did complete a medication error report when the daughter informed them that Resident #1 had not been receiving his medication as ordered. Review of Resident #1 ' s Medication Error Report dated 02/24/12 reflected the date of error as 02/17/12 for an order of Dexamethasone 4 mg, 1 by mouth three times per day. The description of error reflected " Medication order was not processed. " The corrective action taken reflected " Medication started, physician notified. " Measures taken to prevent recurrence included " in-serviced on how to process orders. " During an interview on 03/21/12 at 4:45 PM, Resident #1 ' s Radiation Oncologist stated the prescription for Dexamethasone (a sterioid) was prescribed for the resident to help reduce the swelling in the brain associated with the radiation treatment the resident was receiving. The Radiation Oncologist stated the dose of this medication would have helped reduce the side effects from the swelling, such as dizziness and altered mental status. The Radiation Oncologist stated if the resident had received the ordered steroid medication the resident might not have been fallen on 02/23/12, 02/24/12, and 02/25/12. Review of Resident #1 ' s Care Plan dated 02/16/12 and updated 02/23/12, 02/24/12, and 02/25/12 did not reflect any interventions regarding the missing steroid medication. A low bed, chair alarm, bed alarm, mat at bedside and toileting program was added on 02/24/12. Review of information regarding the use of dexamethasone with radiation for [DIAGNOSES REDACTED]s from ?The Radiation Medical Group, Inc 2010, reflected " some patients get a dull headache and/or pressure sensation in the head as the treatment series evolves. This is caused by swelling around the tumor and will typically respond to Decadron (dexamethasone). Your physician and staff will work closely with you during the treatment course to try to optimize the dose of that medication. There is a fine balancing act between minimizing dexamethasone side effects versus minimizing pressure in the head caused by swelling around the tumor. You should never change your dexamethasone dose without first consulting with your treating physician. Nausea and vomiting are unusual with radiation to the head unless there is a significant amount of swelling and pressure in the head. This would typically be treated by starting or raising the dose of dexamethasone. " Review of the facility ' s policy on Abuse and Neglect dated 07/01/09 reflected " To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases in compliance with applicable state and federal regulations. " The policy also reflected the definition of " neglect " as " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " The Administrator reported a facility census of 36.

Based on interview and record review, the facility failed to ensure 1 of 6 residents were free from any significant medication errors (Resident #1). The facility failed to provide a physician prescribed steroid medication used to reduce side effects such as dizziness and falling associated with [MEDICAL CONDITION] treatment that Resident #1 was receiving. Resident #1 had three falls with injury from 2/23/12-02/25/12. The medication was ordered to start 02/17/12 and was not administered to the resident until one week later at 5:00 PM on 02/24/12. This deficient practice contributed to Resident #1 having three consecutive falls with injuries due to not receiving physician prescribed medication used to reduce the side effects of the [MEDICAL CONDITION] treatment he was receiving. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was not interviewable. On 03/20/12 at 11:45 AM, the Director of Nurses (DON), informed the surveyor that Resident #1 had [MEDICAL CONDITION] that metastasized to the brain and had been receiving [MEDICAL CONDITION] treatment from (02/20/12 -03/05/12) during the time of the referenced falls. Review of Resident #1 ' s Admission Minimum Data Set ((MDS) dated [DATE] reflected the resident had a fall history during the month before admission and 2-6 months before admission. Observation on 03/20/12 at 3:05 PM, revealed Resident #1 sitting in his wheelchair. Resident #1 was alert and oriented to self. The resident had a 3.5 inch long scab on the back of his head where staples had recently held it together. During an interview on 03/20/12 at 3:05 PM, Resident #1 stated that he did not feel dizzy anymore. Resident #1 could not recall the falls he had on 02/23/12-02/25/12. Review of Resident #1 ' s nursing notes dated 02/23/12 at 5:19 AM, reflected " Resident was observed lying on the floor in his room when this nurse was entering room to give roommate medication. Resident did not call out for help. 3 skin tears noted to his right arm; one to tricep area, one to elbow and one right above elbow area. Areas were cleansed with wound cleaner and steri strips were applied. Resident complains of right shoulder pain although range of motion to right arm is within normal limits; able to move all extremities. Resident assisted to bed with total lift x3 assist. Stated he went to the bathroom and on his way back he fell . Neuros initiated due to unwitness fall. MD notified via fax and DON also notified. Will request AM nurse to notify family. Will continue to monitor. " Review of Resident #1 ' s Incident/Accident Report Investigation Follow- Up dated 02/24/12 reflected " CNA reports resident fell in bathroom in room. CNA reports resident is on the bathroom floor on his knees and blood on the wall. Resident seen on his knees in bathroom hovering over toilet and small amount of blood noted on bathroom wall. Resident assisted to wheelchair x2 assist. [MEDICAL CONDITION] noted to back of head. Not actively bleeding. Unknown if resident lost consciousness. Alert and oriented x2 which is normal for resident. Head lacteration cleansed but needs staples or sutures. ER notified to have resident transferred to ER. DON notified and MD on call also notified. Daughter notified of residents transfer. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 6:31 AM, reflected " CNA reports that resident on the floor in the bathroom in room and that there ' s blood on the wall in the bathroom. Resident seen on his knees in the bathroom hovering over the toilet and small amount of blood was noted on the wall. Resident assisted to wheelchair x2 assist. [MEDICAL CONDITION] noted to the back of residents head. Unknown if resident lossed consciousness; alert and oriented x2 which is normal for resident. [MEDICAL CONDITION] is not actively bleeding but it is a deep [MEDICAL CONDITION] that requires more care so (ambulance) called to have resident transported to (hospital), (hospital) called to let them know of residents transfer. MD on call notified, DON notified and daughter notified of residents fall and transfer. Resident out to ER at 6:20 AM via (ambulance). Nursing note dated 02/24/12 at 8:09 AM reflected " back from hospital with four staples to laceration. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 3:34 PM, reflected " Received call from (Resident ' s #1 ' s responsible party- his daughter) who inquired whether or not resident was taking steroids, she reported that she had given the prescription to a nurse at facility on Friday (02/17/12). After investigation, it was determined that resident had not received medication, and it had not been ordered from the pharmacy. At approximately 3:05 PM, (Resident #1 ' s daughter) arrived at the facility and this writer informed her of situation. [MEDICATION NAME] 4 mg by mouth three times per day was ordered from pharmacy. Medication order entered into computer. DON notified. " Review of Resident #1 ' s nursing notes dated 02/25/12 at 3:53 PM, reflected " @1240 AM a loud noise was heard coming from resident ' s room and sensor pad alarming. This nurse and CNA to resident ' s room and the resident was seen on his knees on the floor next to his bed. When resident was asked what happened, he stated " I had to pee. " Resident assisted to bed x2 assist which bed was in lowest position and remains in lowest position. Sensor pad was in place and working. Deep purple abrasion noted to residents right forearm and a skin tear also noted to upper right forearm 1.3 cm in length. Stated he scraped his arm on the wheelchair trying to hang on to it to prevent from falling. " Review of Resident #1 ' s Incident Reports from all three falls on 02/23/12, 02/24/12 and 02/25/12 did not show that medications were reviewed status [REDACTED]. Review of the facility ' s Summary of Investigation, dated 02/27/12, signed by the Director of Nurses (DON), reflected " Resident #1 observed by roommate going to bathroom without assistance. Call light was not on. Roommate heard a ruckus in bathroom. Roommate turned on call ligh for himself and when light was answered, nurse aide asked about roommate ' s whereabouts. Roommate responded in the bathroom. Nurse aide knocked and did not get appropriate response so entered the bathroom and observed resident on his knees in hovering over toilet. Nurse aide observed blood to back of his head and called for a nurse. When the nurse arrived she noted blood on bathroom wall. The nurse cleaned and assessed the resident, noted laceration to back of head. Neuro checks initiated, ambulance called, physician notified, daughter notified, Director of Nursing (DON) notified, Administrator notified. Resident returned from emergency room with 4 staples to the back of head. Neuro checks resumed. Resident then went to doctor ' s appointment. Upon return from doctor ' s appointment neuro checks resumed. Care plan changed to include low bed with mat beside bed, bed and wheelchair sensor pads, toilet every 2 hours especially between 4am and 5:30 am. Resident already has a room close to the nurse ' s desk. " During an interview on 03/20/12 at 3:04 PM, Resident #1 ' s daughter stated that after the resident fell on [DATE], the nurse at [MEDICAL CONDITION] center questioned as to whether the resident had not been receiving his steroid ([MEDICATION NAME]) order as ordered. The daughter stated the nurse told her that the steroid was given to help prevent the negative side effects from the [MEDICAL CONDITION] treatment he was receiving. The daughter stated that the nurse explained that if the resident hadn ' t been receiving the steroid as ordered then that would definitely contribute to her father ' s recent falls. Review of Resident #1 ' s Physician order [REDACTED]. " Review of the handwritten physician order [REDACTED]. Review of Resident #1 ' s electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" [MEDICATION NAME] 4 mg tablet- I tablet by mouth three times a day for inflammation; Side Effects: Stomach upset, headache; Start Date: 02/24/12; Discontinue Date: 03/20/12. " The medication was checked as given for the first time on 02/24/12 at 5:00 PM. During an interview on 03/20/12 at 4:15 PM the DON stated the resident had returned for a doctor's appointment on 02/17/12 and provided the new steroid medication order slip. The DON stated that the slip had been placed into the chart, but was not transcribed onto the resident's physician orders [REDACTED]. The DON stated she did not consider the missing medication a factor while doing her investigation of the fall because she didn ' t think the medication was used for balance. The DON stated she did not know what clinical indication the steroid was specifically ordered for. The DON stated that she did complete a medication error report when the daughter informed them that Resident #1 had not been receiving his medication as ordered. Review of Resident #1 ' s Medication Error Report dated 02/24/12 reflected the date of error as 02/17/12 for an order of [MEDICATION NAME] 4 mg, 1 by mouth three times per day. The description of error reflected " Medication order was not processed. " The corrective action taken reflected " Medication started, physician notified. " Measures taken to prevent recurrence included " in-serviced on how to process orders. " During an interview on 03/21/12 at 4:45 PM, Resident #1 ' s [MEDICAL CONDITION] Oncologist stated the prescription for [MEDICATION NAME] (a sterioid) was prescribed for the resident to help reduce the swelling in the brain associated with the [MEDICAL CONDITION] treatment the resident was receiving. The [MEDICAL CONDITION] Oncologist stated the dose of this medication would have helped reduce the side effects from the swelling, such as dizziness and altered mental status. The [MEDICAL CONDITION] Oncologist stated if the resident had received the ordered steroid medication the resident might not have been fallen on 02/23/12, 02/24/12, and 02/25/12. Review of Resident #1 ' s Care Plan dated 02/16/12 and updated 02/23/12, 02/24/12, and 02/25/12 did not reflect any interventions regarding the missing steroid medication. A low bed, chair alarm, bed alarm, mat at bedside and toileting program was added on 02/24/12. Review of information regarding the use of [MEDICATION NAME] with [MEDICAL CONDITION] for [DIAGNOSES REDACTED]s from ?The [MEDICAL CONDITION] Medical Group, Inc 2010, reflected " some patients get a dull headache and/or pressure sensation in the head as the treatment series evolves. This is caused by swelling around the tumor and will typically respond to [MEDICATION NAME] ([MEDICATION NAME]). Your physician and staff will work closely with you during the treatment course to try to optimize the dose of that medication. There is a fine balancing act between minimizing [MEDICATION NAME] side effects versus minimizing pressure in the head caused by swelling around the tumor. You should never change your [MEDICATION NAME] dose without first consulting with your treating physician. Nausea and vomiting are unusual with [MEDICAL CONDITION] to the head unless there is a significant amount of swelling and pressure in the head. This would typically be treated by starting or raising the dose of [MEDICATION NAME]. " Review of the facility ' s policy on Abuse and Neglect dated 07/01/09 reflected " To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases in compliance with applicable state and federal regulations. " The policy also reflected the definition of " neglect " as " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " The Administrator reported a facility census of 36.

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident to 1 of 6 residents reviewed for medications (Resident #1). The facility failed to provide a physician prescribed steroid medication used to reduce side effects such as dizziness and falling associated with radiation treatment that Resident #1 was receiving. Resident #1 had three falls with injury from 2/23/12-02/25/12. The medication was ordered to start 02/17/12 and was not administered to the resident until one week later at 5:00 PM on 02/24/12. This deficient practice contributed to Resident #1 having three consecutive falls with injuries due to not receiving physician prescribed medication used to reduce the side effects of the radiation treatment he was receiving. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was not interviewable. On 03/20/12 at 11:45 AM, the Director of Nurses (DON), informed the surveyor that Resident #1 had lung cancer that metastasized to the brain and had been receiving radiation treatment from (02/20/12 -03/05/12) during the time of the referenced falls. Review of Resident #1 ' s Admission Minimum Data Set ((MDS) dated [DATE] reflected the resident had a fall history during the month before admission and 2-6 months before admission. Observation on 03/20/12 at 3:05 PM, revealed Resident #1 sitting in his wheelchair. Resident #1 was alert and oriented to self. The resident had a 3.5 inch long scab on the back of his head where staples had recently held it together. During an interview on 03/20/12 at 3:05 PM, Resident #1 stated that he did not feel dizzy anymore. Resident #1 could not recall the falls he had on 02/23/12-02/25/12. Review of Resident #1 ' s nursing notes dated 02/23/12 at 5:19 AM, reflected " Resident was observed lying on the floor in his room when this nurse was entering room to give roommate medication. Resident did not call out for help. 3 skin tears noted to his right arm; one to tricep area, one to elbow and one right above elbow area. Areas were cleansed with wound cleaner and steri strips were applied. Resident complains of right shoulder pain although range of motion to right arm is within normal limits; able to move all extremities. Resident assisted to bed with total lift x3 assist. Stated he went to the bathroom and on his way back he fell . Neuros initiated due to unwitness fall. MD notified via fax and DON also notified. Will request AM nurse to notify family. Will continue to monitor. " Review of Resident #1 ' s Incident/Accident Report Investigation Follow- Up dated 02/24/12 reflected " CNA reports resident fell in bathroom in room. CNA reports resident is on the bathroom floor on his knees and blood on the wall. Resident seen on his knees in bathroom hovering over toilet and small amount of blood noted on bathroom wall. Resident assisted to wheelchair x2 assist. Head laceration noted to back of head. Not actively bleeding. Unknown if resident lost consciousness. Alert and oriented x2 which is normal for resident. Head lacteration cleansed but needs staples or sutures. ER notified to have resident transferred to ER. DON notified and MD on call also notified. Daughter notified of residents transfer. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 6:31 AM, reflected " CNA reports that resident on the floor in the bathroom in room and that there ' s blood on the wall in the bathroom. Resident seen on his knees in the bathroom hovering over the toilet and small amount of blood was noted on the wall. Resident assisted to wheelchair x2 assist. Head laceration noted to the back of residents head. Unknown if resident lossed consciousness; alert and oriented x2 which is normal for resident. Head laceration is not actively bleeding but it is a deep head laceration that requires more care so (ambulance) called to have resident transported to (hospital), (hospital) called to let them know of residents transfer. MD on call notified, DON notified and daughter notified of residents fall and transfer. Resident out to ER at 6:20 AM via (ambulance). Nursing note dated 02/24/12 at 8:09 AM reflected " back from hospital with four staples to laceration. " Review of Resident #1 ' s nursing notes dated 02/24/12 at 3:34 PM, reflected " Received call from (Resident ' s #1 ' s responsible party- his daughter) who inquired whether or not resident was taking steroids, she reported that she had given the prescription to a nurse at facility on Friday (02/17/12). After investigation, it was determined that resident had not received medication, and it had not been ordered from the pharmacy. At approximately 3:05 PM, (Resident #1 ' s daughter) arrived at the facility and this writer informed her of situation. Dexamethasone 4 mg by mouth three times per day was ordered from pharmacy. Medication order entered into computer. DON notified. " Review of Resident #1 ' s nursing notes dated 02/25/12 at 3:53 PM, reflected " @1240 AM a loud noise was heard coming from resident ' s room and sensor pad alarming. This nurse and CNA to resident ' s room and the resident was seen on his knees on the floor next to his bed. When resident was asked what happened, he stated " I had to pee. " Resident assisted to bed x2 assist which bed was in lowest position and remains in lowest position. Sensor pad was in place and working. Deep purple abrasion noted to residents right forearm and a skin tear also noted to upper right forearm 1.3 cm in length. Stated he scraped his arm on the wheelchair trying to hang on to it to prevent from falling. " Review of Resident #1 ' s Incident Reports from all three falls on 02/23/12, 02/24/12 and 02/25/12 did not show that medications were reviewed status [REDACTED]. Review of the facility ' s Summary of Investigation, dated 02/27/12, signed by the Director of Nurses (DON), reflected " Resident #1 observed by roommate going to bathroom without assistance. Call light was not on. Roommate heard a ruckus in bathroom. Roommate turned on call ligh for himself and when light was answered, nurse aide asked about roommate ' s whereabouts. Roommate responded in the bathroom. Nurse aide knocked and did not get appropriate response so entered the bathroom and observed resident on his knees in hovering over toilet. Nurse aide observed blood to back of his head and called for a nurse. When the nurse arrived she noted blood on bathroom wall. The nurse cleaned and assessed the resident, noted laceration to back of head. Neuro checks initiated, ambulance called, physician notified, daughter notified, Director of Nursing (DON) notified, Administrator notified. Resident returned from emergency room with 4 staples to the back of head. Neuro checks resumed. Resident then went to doctor ' s appointment. Upon return from doctor ' s appointment neuro checks resumed. Care plan changed to include low bed with mat beside bed, bed and wheelchair sensor pads, toilet every 2 hours especially between 4am and 5:30 am. Resident already has a room close to the nurse ' s desk. " During an interview on 03/20/12 at 3:04 PM, Resident #1 ' s daughter stated that after the resident fell on [DATE], the nurse at the cancer center questioned as to whether the resident had not been receiving his steroid (dexamethasone) order as ordered. The daughter stated the nurse told her that the steroid was given to help prevent the negative side effects from the radiation treatment he was receiving. The daughter stated that the nurse explained that if the resident hadn ' t been receiving the steroid as ordered then that would definitely contribute to her father ' s recent falls. Review of Resident #1 ' s Physician order [REDACTED]. " Review of the handwritten physician order [REDACTED]. Review of Resident #1 ' s electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" Dexamethasone 4 mg tablet- I tablet by mouth three times a day for inflammation; Side Effects: Stomach upset, headache; Start Date: 02/24/12; Discontinue Date: 03/20/12. " The medication was checked as given for the first time on 02/24/12 at 5:00 PM. During an interview on 03/20/12 at 4:15 PM the DON stated the resident had returned for a doctor's appointment on 02/17/12 and provided the new steroid medication order slip. The DON stated that the slip had been placed into the chart, but was not transcribed onto the resident's physician orders [REDACTED]. The DON stated she did not consider the missing medication a factor while doing her investigation of the fall because she didn ' t think the medication was used for balance. The DON stated she did not know what clinical indication the steroid was specifically ordered for. The DON stated that she did complete a medication error report when the daughter informed them that Resident #1 had not been receiving his medication as ordered. Review of Resident #1 ' s Medication Error Report dated 02/24/12 reflected the date of error as 02/17/12 for an order of Dexamethasone 4 mg, 1 by mouth three times per day. The description of error reflected " Medication order was not processed. " The corrective action taken reflected " Medication started, physician notified. " Measures taken to prevent recurrence included " in-serviced on how to process orders. " During an interview on 03/21/12 at 4:45 PM, Resident #1 ' s Radiation Oncologist stated the prescription for Dexamethasone (a sterioid) was prescribed for the resident to help reduce the swelling in the brain associated with the radiation treatment the resident was receiving. The Radiation Oncologist stated the dose of this medication would have helped reduce the side effects from the swelling, such as dizziness and altered mental status. The Radiation Oncologist stated if the resident had received the ordered steroid medication the resident might not have been fallen on 02/23/12, 02/24/12, and 02/25/12. Review of Resident #1 ' s Care Plan dated 02/16/12 and updated 02/23/12, 02/24/12, and 02/25/12 did not reflect any interventions regarding the missing steroid medication. A low bed, chair alarm, bed alarm, mat at bedside and toileting program was added on 02/24/12. Review of information regarding the use of dexamethasone with radiation for [DIAGNOSES REDACTED]s from ?The Radiation Medical Group, Inc 2010, reflected " some patients get a dull headache and/or pressure sensation in the head as the treatment series evolves. This is caused by swelling around the tumor and will typically respond to Decadron (dexamethasone). Your physician and staff will work closely with you during the treatment course to try to optimize the dose of that medication. There is a fine balancing act between minimizing dexamethasone side effects versus minimizing pressure in the head caused by swelling around the tumor. You should never change your dexamethasone dose without first consulting with your treating physician. Nausea and vomiting are unusual with radiation to the head unless there is a significant amount of swelling and pressure in the head. This would typically be treated by starting or raising the dose of dexamethasone. " Review of the facility ' s policy on Abuse and Neglect dated 07/01/09 reflected " To prevent abuse, neglect or exploitation of residents, to the extent possible and ensure proper investigation and reporting of suspected cases in compliance with applicable state and federal regulations. " The policy also reflected the definition of " neglect " as " failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. " The Administrator reported a facility census of 36.

Based on observation, interview, and record review it was determined the facility failed to immediately consult with 1 resident's physician (Resident #8) of 16 residents reviewed for change of condition, when Resident #8 experienced a change of condition that required physician intervention. The facility failed to consult with Resident #8's physician from 7/2/11 through 7/5/11 when the resident's left knee became discolored, swollen, and warm. On 7/6/11 an x-ray report revealed the resident had suffered a [MEDICAL CONDITION] left leg bone (femur). Resident #8 was admitted to a local hospital for medical treatment. This resulted in an Immediate Jeopardy (IJ) on 7/13/11. While the Immediate Jeopardy was removed on 7/14/11, the facility remained out of compliance at a Scope of a pattern and Severity of Actual Harm that is not IJ due to the facility requiring time to monitor their plan of removal for effectiveness. This deficient practice caused actual harm for Resident #8 who suffered a painful bone fracture, but could have affected all 24 residents who were diagnosed with [REDACTED]. This failure could prevent these residents from receiving necessary medical treatment in a timely manner. Findings include: Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old at the time of this survey. Her [DIAGNOSES REDACTED]. According to her significant change MDS dated [DATE], Resident #8 had severe cognitive impairment. She was unable to speak, and rarely if ever understood or made herself understood. She needed extensive physical help from 2 staff members for bed mobility, and was totally dependent on 2 staff for transfers. Resident #8 was an in-patient at a regional hospital at the time of this survey. Review of Resident #8's Care Plan dated 5/10/11 revealed: -- the problem of activities of daily living. According to this care plan, the resident required total assistance from 2 staff members for bed mobility. The care plan also specified the resident was to be transferred by total lift (mechanical lift). -- the problem of risk for injury and immobility related to need for bed side rails. The approaches included the requirement for staff to reposition the resident every 2 hours. Review of Resident #8's nursing notes revealed: -- on 7/3/11 at 8:00 p.m. LVN 'A' documented the resident was up in a gerichair (a type of recliner with castors) for the evening meal. The nurse documented the resident's left leg appeared to be painful when the resident was repositioned. The nurse did not document any assessment of the resident at that time, nor did the nurse document any consultation with the resident's physician. -- on 7/4/11 at 7:00 p.m. LVN 'A' documented Resident #8 seemed to be in pain when repositioned. The nurse documented the resident's left leg seemed to be the source of the pain, but the nurse did not document any assessment of the resident at that time, and did not document any consultation with the resident's physician. -- on 7/6/11 LVN 'B' wrote a late entry for 7/5/11 at 5:00 p.m. The nurse documented a CNA (CNA 'A') came to him and asked him to look at Resident #8's left knee which, according to the CNA, was discolored and swollen. The nurse documented he assessed the resident's knee, finding it to be swollen, warm to the touch, and yellowish in color. The nurse did not document any consultation at that time with the resident's physician. -- on 7/6/11 at 1:15 a.m. LVN 'D' documented she assessed Resident #8's left knee. The nurse documented the resident's knee was swollen with a yellowish bruising, was warm to touch, and painful. The nurse documented she contacted the physician who ordered an x-ray of the knee. Review of Resident #8's x-ray report dated 7/6/11 at 3:26 a.m. revealed the resident had suffered an acute [MEDICATION NAME] oriented [MEDICAL CONDITION] end of the upper left leg bone. According to the report, the displacement of the fracture was greater than 1 shaft width (the broken ends of the bone were completely separated and out of alignment). Review of Resident #8's hospital history and physical report dated 7/9/11 revealed the resident had a comminuted [MEDICAL CONDITION] femur (the large upper leg bone was fractured into several pieces). In interviews on 7/12/11 at 2:52 p.m. and at 4:40 p.m. LVN 'A' said she had worked in the facility about 1 year. She said on 7/2/11 a CNA reported to her Resident #8 flinched and moaned in pain when her left leg was moved. The LVN said she went to the resident's room and assessed the resident's left leg. The LVN said the inside of the resident's left knee had a yellowish bruise. She said on 7/4/11 the resident's left knee looked no worse. The LVN said she did not contact the resident's physician because she did not think the resident's injury was significant. In a telephone interview on 7/12/11 at 3:10 p.m. CNA 'A' said he didn't recall what day the incident occurred, however at 4:30 p.m. he saw Resident #8's left knee was swollen about twice normal size. He said the knee had 2 bruises that were yellow and blue in color and the knee seem sore. He said reported the injury to LVN 'B' and to the ADON. In an interview on 7/12/11 at 3:32 p.m. CNA 'B' said on 7/4/11 shortly after 6:00 a.m. she saw the hospice aides bring Resident #8 from the shower room. CNA 'B' said one of the hospice aides asked her to look at the resident's left knee. CNA 'B' said the resident's knee was significantly swollen, and the resident flinched when the knee was touched. CNA 'B' said she reported this to LVN 'C', but did not see LVN 'C' assess the resident. In an interview on 7/12/11 at 3:41 p.m. CNA 'C' said she had worked in the facility a couple of months and knew Resident #8. She said on 7/2/11 at about 3:30 p.m. she noticed Resident #8's left knee had a yellowish and purple bruise. Using a tape measure to show the surveyor the size of the bruise, CNA 'C' said the bruise was about 8 inches long by about 4 inches wide. The CNA said the resident's knee was significantly swollen and painful. She said she asked Resident #8 if the knee was painful. CNA 'C' said the resident answered "yes". The CNA said she reported this to LVN 'A' who came to Resident #8's room and looked at the resident's knee. The CNA said the next day, 7/3/11, the resident's left knee seemed more swollen, and the resident seemed to be having pain when repositioned in bed and when transferred from her bed to a chair. The CNA said on 7/4/11 she worked with CNA 'A'. CNA 'C' said CNA 'A' reported the resident's painful, swollen knee to LVN 'B' who assessed the resident's knee. In an interview on 7/15/11 at 5:30 a.m. LVN 'B' said he had worked in the facility about 1 year. He said he did not remember what day it was when around supper time CNA 'A' reported to him Resident #8 had a swollen left knee. LVN 'B' said he assessed the resident's knee. He said the resident's knee was swollen, discolored, and warm. He said the resident did not appear to be in pain at that time. He said he thought the resident might have had some sort of inflammation caused by arthritis, but he did not think at that time the resident had a bone fracture. He said it did not occur to him to call the resident's physician. In an interview on 7/12/11 at 4:05 p.m. LVN 'C' said on 7/4/11 in the early morning a hospice aide came to her and told her Resident #8's left knee was swollen. LVN 'C' said she went to the resident's room and assessed the knee which, she said, was definitely swollen but not bruised at that time. The LVN said at that time she thought she should call the resident's physician, however she did not make the call because she was busy with other things. Observation on 7/12/11 at 9:00 p.m. revealed Resident #8 was resting in bed in the hospital. She appeared to be sleeping at this time. Her left leg was in traction (her left leg was attached to a mechanical device which applied a weight to pull the resident's left leg in order to straighten the fractured bone). In an interview on 7/13/11 at 9:30 a.m. the DON said she had been on vacation at the time Resident #8 had sustained the injury to her left knee. The DON said when she returned from vacation she learned of Resident #8's knee injury. The DON said she conducted an investigation and concluded the injury probably occurred when the resident was repositioned in bed. The DON said the fracture progressively worsened each time the resident was repositioned and transferred via the mechanical lift. The DON reviewed Resident #8's nursing notes and said the nurse on duty should have contacted the resident's physician when the injury was first noticed. In an interview on 7/13/11 at 11:30 a.m. the ADON said she had worked in the facility for about 4 years. She said she had been the ADON about 3 1/2 years. She said on 7/5/11 at about 5:00 p.m. CNA 'A' asked her to assess Resident #8's left knee. The ADON said the resident's knee at that time was not swollen, but there was some yellowish discoloration across and around the inner part of the knee. She said the resident was sometimes able to answer simple questions, so at that time she asked the resident if she was in pain. The ADON said the resident did not answer. In a telephone interview on 7/13/11 at 1:35 p.m. LVN 'D' said during the night of 7/5/11-7/6/11 she assessed Resident #8's left knee. She said the knee was swollen about twice the size of the right knee. She said there was yellowish bruising over the entire knee,. She said the bruised area was about the size of her hand. She said there was a noticeable knot or bulge at the inside of the knee which she immediately suspected was caused by the end of a fractured bone. She said when she lightly touched the affected area, the resident was obviously in pain as evidenced by the resident's facial expressions. The LVN said when she finished her assessment she immediately called the physician who ordered an x-ray. The Administrator was notified that an Immediate Jeopardy (IJ) had been identified on 7/13/11. Plan to Lift Immediate Jeopardy: On 7/14/11 at 4:00 p.m. the facility submitted an acceptable plan to lift immediate jeopardy. According to this plan, the corporation's consulting registered nurse provided an inservice for all available staff on 7/13/11 at 8:00 p.m. Licensed nurses who were not available to attend this inservice would not be allowed to work until they attended a similar inservice which was to be provided by the director of nurses. The inservice included information related to assessment of change of resident condition and immediate consultations with physicians when a change of condition occurs. Verification of the Plan to Lift Immediate Jeopardy: The survey team interviewed licensed nursing staff from each shift and verified those nurses attended the above inservice and were able to explain the information provided in the inservice. While the Immediate Jeopardy was removed on 7/14/11, the facility remained out of compliance at a Scope of a pattern and Severity of Actual Harm that is not IJ due to the facility requiring time to monitor their plan of removal for effectiveness. According to the facility's CMS Form 672 dated 7/12/11 there were 24 residents who had some level of dementia.

Based on observation, interview, and record review it was determined the facility failed to provide 1 resident (Resident #8) of 16 sampled residents the necessary care and services to attain or maintain the highest practicable well-being. The facility failed to assess and provide necessary medical care when Resident #8 sustained a knee fracture on or about 7/2/11. This resulted in an Immediate Jeopardy on 7/13/11. This failure caused actual harm for Resident #8 who suffered a painful bone fracture, but could have affected all 24 residents who were diagnosed with [REDACTED]. This failure could prevent resident from receiving necessary medical treatment in a timely manner. Findings include: Review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. She was [AGE] years old at the time of this survey. Her [DIAGNOSES REDACTED]. According to her significant change MDS dated [DATE], Resident #8 had severe cognitive impairment. She was unable to speak, and rarely if ever understood or made herself understood. She needed extensive physical help from 2 staff members for bed mobility, and was totally dependent on 2 staff for transfers. Resident #8 was an in-patient at a regional hospital at the time of this survey Review of Resident #8's Care Plan dated 5/10/11 revealed: -- the problem of activities of daily living. According to this care plan, the resident required total assistance from 2 staff members for bed mobility. The care plan also specified the resident was to be transferred by total lift (mechanical lift). -- the problem of risk for injury and immobility related to need for bed side rails. The approaches included the requirement for staff to reposition the resident every 2 hours. Review of Resident #8's nursing notes revealed: -- on 7/3/11 at 8:00 p.m. LVN 'A' documented the resident was up in a gerichair (a type of recliner with castors) for the evening meal. The nurse documented the resident's left leg appeared to be painful when the resident was repositioned. The nurse did not document any assessment of the resident at that time. -- on 7/4/11 at 7:00 p.m. LVN 'A' documented Resident #8 seemed to be in pain when repositioned. The nurse documented the resident's left leg seemed to be the source of the pain, but the nurse still did not document any assessment of the resident at that time. -- on 7/6/11 LVN 'B' wrote a late entry for 7/5/11 at 5:00 p.m. The nurse documented a CNA (CNA 'A') came to him and asked him to look at Resident #8's left knee which, according to the CNA, was discolored and swollen. The nurse documented he assessed the resident's knee, finding it to be swollen, warm to the touch, and yellowish in color. The nurse did not document any measurement of the amount of swelling, such as by use of a measuring tape to measure the diameter of the knee. The nurse also failed to document the extent of the bruising. -- on 7/6/11 at 1:15 a.m. LVN 'D' documented she assessed Resident #8's left knee. The nurse documented the resident's knee was swollen with a yellowish bruising, was warm to touch, and painful. The nurse documented she contacted the physician who ordered an x-ray of the knee. Review of Resident #8's x-ray report dated 7/6/11 at 3:26 a.m. revealed the resident had suffered an acute [MEDICATION NAME] oriented [MEDICAL CONDITION] end of the upper left leg bone. According to the report, the displacement of the fracture was greater than 1 shaft width (the broken ends of the bone were completely separated and out of alignment). Review of Resident #8's hospital history and physical report dated 7/9/11 revealed the resident had a comminuted [MEDICAL CONDITION] femur (the large upper leg bone was fractured into several pieces). In interviews on 7/12/11 at 2:52 p.m. and at 4:40 p.m. LVN 'A' said she had worked in the facility about 1 year. She said on 7/2/11 a CNA reported to her Resident #8 flinched and moaned in pain when her left leg was moved. The LVN said she went to the resident's room and assessed the resident's left leg. The LVN said the inside of the resident's left knee had a yellowish bruise. She said on 7/4/11 the resident's left knee looked no worse. The LVN said she did not contact the resident's physician because she did not think the resident's injury was significant. In a telephone interview on 7/12/11 at 3:10 p.m. CNA 'A' said he didn't recall what day the incident occurred, however at 4:30 p.m. he saw Resident #8's left knee was swollen about twice normal size. He said the knee had 2 bruises that were yellow and blue in color and seemed sore. He said reported the injury to LVN 'B' and to the ADON. In an interview on 7/12/11 at 3:32 p.m. CNA 'B' said on 7/4/11 shortly after 6:00 a.m. she saw the hospice aides bring Resident #8 from the shower room. CNA 'B' said one of the hospice aides asked her to look at the resident's left knee. CNA 'B' said the resident's knee was significantly swollen, and the resident flinched when the knee was touched. CNA 'B' said she reported this to LVN 'C', but did not see LVN 'C' assess the resident. In an interview on 7/12/11 at 3:41 p.m. CNA 'C' said she had worked in the facility a couple of months and knew Resident #8. She said on 7/2/11 at about 3:30 p.m. she noticed Resident #8's left knee had a yellowish and purple bruise. Using a tape measure to show the surveyor the size of the bruise, CNA 'C' said the bruise was about 8 inches long by about 4 inches wide. The CNA said the resident's knee was significantly swollen and painful. She said she asked Resident #8 if the knee was painful. CNA 'C' said the resident answered "yes". The CNA said she reported this to LVN 'A' who came to Resident #8's room and looked at the resident's knee. The CNA said the next day, 7/3/11, the resident's left knee seemed more swollen, and the resident seemed to be having pain when repositioned in bed and when transferred from her bed to a chair. The CNA said on 7/4/11 she worked with CNA 'A'. CNA 'C' said CNA 'A' reported the resident's painful, swollen knee to LVN 'B' who assessed the resident's knee. In an interview on 7/15/11 at 5:30 a.m. LVN 'B' said he had worked in the facility about 1 year. He said he did not remember what day it was when around supper time CNA 'A' reported to him Resident #8 had a swollen left knee. LVN 'B' said he assessed the resident's knee. He said the resident's knee was swollen, discolored, and warm. He said the resident did not appear to be in pain at that time. He said he thought the resident might have had some sort of inflammation caused by arthritis, but he did not think at that time the resident had a bone fracture. He said it did not occur to him to call the resident's physician. In an interview on 7/12/11 at 4:05 p.m. LVN 'C' said on 7/4/11 in the early morning a hospice aide came to her and told her Resident #8's left knee was swollen. LVN 'C' said she went to the resident's room and assessed the knee which, she said, was definitely swollen but not bruised at that time. The LVN said at that time she thought she should call the resident's physician, however she did not make the call because she was busy with other things. Observation on 7/12/11 at 9:00 p.m. revealed Resident #8 was resting in bed in the hospital. She appeared to be sleeping at this time. Her left leg was in traction (her left leg was attached to a mechanical device which applied a weight to pull the resident's left leg in order to straighten the fractured bone). In an interview on 7/13/11 at 9:30 a.m. the DON said she had been on vacation at the time Resident #8 had sustained the injury to her left knee. The DON said when she returned from vacation she learned of Resident #8's knee injury. The DON said she conducted an investigation and concluded the injury probably occurred when the resident was repositioned in bed. The DON said the fracture progressively worsened each time the resident was repositioned and transferred via the mechanical lift. The DON reviewed Resident #8's nursing notes and said the nurse on duty should have contacted the resident's physician when the injury was first noticed. In an interview on 7/13/11 at 11:30 a.m. the ADON said she had worked in the facility for about 4 years. She said she had been the ADON about 3 1/2 years. She said on 7/5/11 at about 5:00 p.m. CNA 'A' asked her to assess Resident #8's left knee. The ADON said the resident's knee at that time was not swollen, but there was some yellowish discoloration across and around the inner part of the knee. She said the resident was sometimes able to answer simple questions, so at that time she asked the resident if she was in pain. The ADON said the resident did not answer. In a telephone interview on 7/13/11 at 1:35 p.m. LVN 'D' said during the night of 7/5/11-7/6/11 she assessed Resident #8's left knee. She said the knee was swollen about twice the size of the right knee. She said there was yellowish bruising over the entire knee,. She said the bruised area was about the size of her hand. She said there was a noticeable knot or bulge at the inside of the knee which she immediately suspected was caused by the end of a fractured bone. She said when she lightly touched the affected area, the resident was obviously in pain as evidenced by the resident's facial expressions. The LVN said when she finished her assessment she immediately called the physician who ordered an x-ray. The Administrator was notified on 07/12/2011 that an Immediate Jeopardy had been identified. Plan to Lift Immediate Jeopardy: On 7/14/11 at 4:00 p.m. the facility submitted an acceptable plan to lift immediate jeopardy. According to this plan, the corporation's consulting registered nurse provided an inservice for all available staff on 7/13/11 at 8:00 p.m. Licensed nurses who were not available to attend this inservice would not be allowed to work until they attended a similar inservice which was to be provided by the director of nurses. The inservice included information related to assessment of change of resident condition and timely consultations with physicians. Verification of the Plan to Lift Immediate Jeopardy: The survey team interviewed licensed nursing staff from each shift and verified those nurses attended the above inservice and were able to explain the information provided in the inservice. While the Immediate Jeopardy was removed on 7/14/11, the facility remained out of compliance at a Scope of a pattern and Severity of actual harm that is not IJ due to the facility requiring time to monitor their Plan of Removal for effectiveness. . According to the facility's CMS Form 672 dated 7/12/11 there were 24 residents who had some level of dementia.