Every finding on record at Lawrence Street Health Care Center

Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #1) reviewed for parenteral fluids.The facility failed to flush Resident #1's PICC line every shift, obtain orders for the PICC line, and change the dressing every 7 days, from 5/27/26 to 6/16/26.These failures could place residents at risk for infection, blood clot formation, and pain.Findings include:Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included staphylococcal arthritis of the right knee (bacterial infection of right knee), MRSA (antibiotic resistant bacteria), right knee pain, muscle weakness, and lack of coordination.Record review of Resident #1's admission MDS assessment, dated 6/2/26, revealed a BIMS score of 11 out of 15, which indicated moderately impaired cognition. The resident was partial/moderate assistance (helper does less than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with ADLs. The assessment revealed she was on antibiotics.Record review of Resident #1's Admit Screener from 5/28/26 by LVN A, revealed she had a right arm PICC (deep line that ends near the heart for medications/fluids) line and was receiving antibiotics for septic arthritis (infection of the joint). At that time, it was documented the PICC line dressing was intact. LVN A documented he reviewed and verified medications with the physician.Record review of Resident #1's Care Plan, dated 5/28/26, revealed a Focus: Resident had a central line (deep line that ends near the heart for medications/fluids) located in her LUA and was receiving IV medication. Interventions included changing the IV site dressing per physician order and as needed if integrity of dressing was compromised (wet, loose, or soiled), and to use a transparent dressing to ensure visualization of the IV site.Record review of Resident #1's Daily Note from 5/29/26 by LVN H, revealed the resident was receiving IV medications and the IV dressing was intact.Record review of Resident #1's Physician Orders, as of 6/16/26 from MD A, revealed no PICC line orders. There were no orders for the PICC line, for flushes, or for dressing changes. There was an order for Cefazolin Sodium Injection (antibiotic) 2GM, Use 2gm IV Q8hr for septic arthritis of right knee for 40 days that was ordered on 5/28/26.In an interview and observation on 6/16/26 at 9:49 AM, revealed Resident #1 had a PICC line to her LUA with no date on the dressing. Resident #1 said she was getting antibiotics for an infection in her knee.In an interview on 6/16/26 at 3:03 PM, LVN P said he was the nurse taking care of Resident #1. He said a resident with a PICC line should have orders to flush the line and orders to change the dressing every 7 days and PRN. He said if there was not an order, it would not get done. He checked Resident #1's orders and did not see any orders for her PICC line. He said he was going to call the physician right away to get orders. LVN P said as far as he knew, the dressing had been changed since the resident was admitted on [DATE], but he could not say for sure since there were no orders. He said the orders were put in during admission and was unsure how they were missed.In an interview on 6/16/26 at 3:14 PM, the DON said the admitting nurse was the one who entered the orders for the PICC lines. She said the PICC line dressing should be changed every 7 days and should be flushed once a shift. She said if the dressing was not changed it could cause an infection and if the line was not flushed a clot could form. The DON said she noticed this morning (6/16/26) there was no date on the dressing and told the nurse to change the dressing, but she did not know if it had been changed before that.Record review of the facility's, undated, policy and procedure on PICC/Midline [line not as deep and ends in upper arm]/CVAD Dressing Change read in part: It is the policy of this facility to change peripherally inserted central catheter (PICC).dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.Record review of the facility's, undated, policy and procedure on Consulting Physician/Practitioner Orders read in part: The attending physician shall authenticate orders for the care and treatment of assigned residents. Consulting physician/practitioner orders are those orders provided to the facility by a physician/ practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's.Nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order.Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (CR #1) reviewed for accidents and supervision.The facility failed to ensure CR #1 did not elope from the facility on 11/19/24, after being let out by staff to the patio area to smoke unsupervised. CR #1 was found by the previous Social Worker approximately 30 minutes later by a gas station.The non-compliance was identified as PNC. The IJ began on 11/19/24 and ended on 11/19/24. The facility had corrected the non-compliance before the survey. This failure could place residents at risk of elopement or injury.Findings include:Record review of CR #1's face sheet, dated 10/1/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and discharged to a board and care/assisted living/group home on 1/1/25. His diagnosis included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, peripheral vascular disease (a circulatory disorder that results from narrowed blood vessels, leading to reduced blood flow, primarily affecting the legs and feet), muscle weakness, and unspecified lack of coordination. Record review of CR #1's annual MDS assessment, dated 10/14/24, revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. He had no wandering behavior during the assessment period. He used a wheelchair and required set up or clean up assistance with some ADL care. He used a wander/elopement alarm daily.Record review of CR #1's Care Plan, closed on 1/23/25, indicated he was an independent smoker. CR #1 was noncompliant with the smoking policy. 11/22/24 - resident will have supervised smoking related to wander guard (date initiated 11/24/22, revised on 1/23/25). CR #1 had confusional episodes related to dementia (initiated 12/6/23 and revised on 1/23/25). Interventions were to monitor for/address environmental factors, recent changes in environment, environmental noise and commotion. CR #1 had impaired cognitive function or impaired thought processes related to diagnosis of dementia/fluctuating BIMS (date initiated 11/24/22 and revised on 1/23/25). Interventions were to ask yes/no questions in order to determine the resident's needs, cue, reorient and supervise as needed (date initiated 11/24/22 and revised on 1/23/25). CR #1 was at risk for elopement risk/wanderer related to impaired safety awareness, history of elopement. The resident had wander guard to the right lower leg (date initiated 4/11/24, revised on 1/23/25). Interventions were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Wander alert: active wander guard alarm in place on right lower leg, visually check placement of wandering alert device during routine care (date initiated 11/19/24, revised on 1/23/25).Record review of CR #1's Physician Orders revealed orders for: Wander device: check functionality of wander alert device per manufacturer instruction every shift to alert of exit seeking attempts, order date 4/11/24; Wander Device: wander device alarm applied exp 5/10/25, order date 7/1/24.Record review of CR #1's MAR for November 2024 indicated from 11/1/24 - 11/19/24 staff documented yes for Wander Device: Check functionality of wander alert device every shift. A yes was documented from 11/1/24 - 11/17/24 (a.m.) and 11/18/24 - 11/19/24 for wander device: visually check placement of wandering alert device every shift. There was one NA documented on 11/17/24 on the night shift for wander device: visually check placement of wandering alert device every shift. (there was no definition for NA provided on the MAR)Record review of CR #1's Smoking Safety Review, dated 11/4/24, revealed a score of 6, which indicated he was not at risk for smoking-related incidents.Record review of CR #1's Elopement Risk Screener, dated 11/13/24, indicated he was low risk for potential elopement. Interventions included an electronic wander device and homelike environment.Record review of CR #1's IDT note, dated 11/13/24, written by the DON read in part, .Resident has wander guard.Record review of CR #1's Care Conference, dated 11/15/24, revealed a meeting was held on 11/15/24 at 1:00 p.m. regarding CR #1. An RN, Social Worker, Nursing Administration, Family, and Administration attended. The conference indicated CR #1 was found smoking paraphernalia in his room. He was reeducated on the smoking policy. His BIMS was a 9, which indicated moderate cognitive impairment.Record review of CR #1's Psychological Services Progress Note, dated 11/19/24 at 9:04 a.m., indicated CR #1 had a mild cognitive decline. His Mental Status Examination indicated he was oriented to person, place, and time. His speech organization was appropriate, and his judgement was within normal limits.Record review of CR #1's Behavior Note, dated 11/19/24 at 3:45 p.m., and written by previous Social Worker, read in part, .Resident was reported to have eloped from smoking area at back of facility, on foot and left WC behind, around roughly 1500 (3:00 p.m.) to management. Resident was located about 1530 (3:30 p.m.), behind nearby gas station on foot by SW. Resident immediately recognized SW and asked for help back to facility. When SW asked resident about leaving facility, resident reported he left his WC in smoking area because he did not want to push it and left to go get smokes and a beer bc he could not find any staff to go for him. Reresident (sic) was transported back to facility and then assessed by team and has been moved to memory care unit.Record review of CR #1's progress note, dated 11/19/24 at 4:10 p.m., written by the DON, read in part, .Resident returned from being off premises and is in no distress. He is alert and oriented to x 3. Resident's mood and affect are appropriate, and he is calm. He has no visible injuries or signs of trauma. Vital signs are stable. Staff will continue monitoring per care plan and ensure ongoing communication with resident about safety protocols.Record review of CR #1's BIMS, dated 11/19/24 at 4:20 p.m., revealed a BIMS score of 15 out of 15 which indicated intact cognition.Record review of CR #1's Outpatient Psychiatry Progress Note, dated 11/25/24, read in part, .Staff report resident leaving facility unplanned exit recent during the smoke break going to store. Resident was brought back assessed no injuries, educated such behaviors are unacceptable due to safety concerns without staff or family member on pass. GDR not attempted contraindicated at this time due these exit seeking behaviors apparently have been going on for some time, will monitor resident closely wander guard in place. mental status examination:. pleasantly confused.alert to person, situation.short term memory: moderately impaired. concentration and judgment: fair. Gait & Station: Unsteady, wheelchair mobility. Fund of knowledge: impaired.In an interview on 10/1/25 at 1:07 p.m. the SLP said on the day of the incident with CR #1 (11/19/24), she put the code in to unlock the door. She let approximately 5 residents out of the building to smoke and returned to her work. She said she questioned where CR #1 was when the other residents came back in the building. She said she saw CR #1's empty wheelchair but did not see him. She said she went outside to look for him and the fence gate was completely open. She said she ran back inside and told staff and started to search for CR #1. She said the previous SW found him at a gas station. The SLP said when she started working at the facility the Rehab Director instructed her if residents requested to go outside to smoke, they were allowed to and no one ever supervised them. She said it was not her responsibility to supervise the residents while smoking and no one said she had to sit outside with them. She said her orientation did not include any information on smoke break times and there was no list of residents who smoked. She said special supervision was provided to residents with wander guards. She said she was not familiar with CR #1 and did not know he had a wander guard. She said the alarm did not sound when the residents went outside to smoke. She said she was unsure if CR #1 was in the group of residents she let out or if he was let out by another CNA who put in the code and walked away. She said the alarm was supposed to sound and she would have been alerted to the wander guard. She said she did not check the perimeter gates before letting the residents out and said the gate lock was broken. She said she never saw CR #1 try to leave the facility before and was unaware of any plans for CR #1 to leave the facility. She said there was no risk to CR #1 smoking unsupervised with a wander guard because he did it multiple times before. She said after the incident occurred the facility provided an in-service on wandering, wander guards, resident rights, and smoke times. She said she was told CR #1 had a wander guard during the in-service. She said the facility implemented newly assigned smoking times where CNAs must supervise the residents. She said the next couple of days after the incident the facility checked to ensure all wander guards worked properly. In an interview on 10/1/25 at 1:54 p.m. the DON said CR #1 eloped from the back of the facility where the smokers were. She said he was in his wheelchair most of the time, the staff did not see him, he had gotten up out of his wheelchair and was walking. She said in a short amount of time he went down the road to the store to buy cigarettes. She said the staff drove around to look for him and saw him at the store then brought him back to the facility. She said CR #1 was forgetful and had cognitive issues but could understand and showed he was safe. She said he was appropriate to smoke alone. She said CR #1 was aware of what he was doing and the facility staff explained to him he could not do that (leave the facility). She said before the incident occurred, they never saw him do anything like that and were not expecting him to leave the building. She said CR #1 was safe and showed he was more cognitive than they thought. She said a long time ago he had a wander guard when he came but was not exit seeking. She said he never left the building but would wander. She said CR #1's family member informed them in the past, he left his personal home overnight and the family could not find him. She said he had a wander guard because he was monitored. She said residents with wander guards had orders in place to check functioning and expiration dates. She said staff should check the alarms with the wander guard to ensure they worked. She said there was a book that listed residents at risk of elopement. She said residents with wander guards never went outside by themselves and there was always someone outside with the residents. She said someone needed to supervise a resident with a wander guard who smoked and would not want residents with a wander guard to go off on their own. She said the smoking protocol was the same prior to and after the incident. She said residents would go outside to smoke at posted times and a staff member would stay and monitor. She said she was unsure if a staff member stood near the door the day CR #1 eloped. She said there was never a time when residents smoked unsupervised for safety reasons. She said staff were trained on the smoking protocol. In an interview on 10/1/25 at 2:16 p.m., the DON said at one point CR #1 was on the memory care unit and then transitioned to the long-term care side. She said he had no previous incidents or risk and had not exit-seeked in a while. She said she could not remember if the wander guard alarms were working the day he eloped. She said he did not sign himself out of the facility to go to the store but probably could have but not if he had a wander guard on. She said technically there was a reason for the wander guard because at some point he was exit seeking. She said there were changes made after the incident. The facility took the incident to QAPI. She said in-services were conducted with staff on elopement alarms, wander guard monitoring, and smoking policy. She said the facility updated the wander guard book and in-serviced staff on its location. She said they conducted a mock elopement that went well. In a telephone interview on 10/1/25 at 2:26 p.m., the previous Administrator said when she was the Administrator residents were assessed to see if they could smoke independently. She said residents who smoked independently were let out and let back in by staff but could smoke unsupervised. She said if a resident smoked and had a wander guard they would not have passed the smoking assessment to smoke independently to her knowledge. In a telephone interview on 10/1/25 at 2:32 p.m., the Rehab Director said residents with wander guards were supervised outside and did not go out alone. She said the alarm would sound.In an interview on 10/1/25 at 2:56 p.m. the Director of Maintenance said all the facility doors were equipped with alarms. He said the alarms were working at the time of the incident and were checked once per week. He said the back gate was not part of the wander guard system. He said after the incident with CR #1 the facility installed an alarm on the back gate for awareness. He said after the incident the facility replaced the old short fence with a taller fence. He said the facility also ensured no residents went outside without supervision.In an interview on 10/1/25 at 3:24 p.m., the Administrator said he started working for the facility in October of 2024 and was only there for one month when the incident happened with CR #1. He said CR #1 was out smoking with the residents when therapy staff realized his wheelchair was there, but he was not. He said staff searched for him but did not see him on the premises. He said approximately 30 minutes later CR #1 was spotted coming back from the convenience store. He said CR #1 could not understand why facility staff was so concerned because he just went to get beer and cigarettes. He said CR #1 could hold a conversation and had a wander guard. He said there was no policy in place during the incident that he was aware of that required supervision for residents with wander guards but said he did not want them to get into dangerous areas. He said he was unsure of what training staff had on wander guards prior to the incident and was unsure of any issues with the alarms prior to CR #1's incident. He said the incident was taken to QAPI and there was a policy change. He said when he reviewed the previous smoking policy, he did not recall seeing anything about staff staying outside with the residents but now everyone must be supervised. He said staff were educated that residents who had a wander guard in place needed to be supervised while outside. He said staff were made aware of which residents wore wander guards by the binder at the nursing station and the physical wander guard. He said an alarm was placed on the back gate and the height was increased. He said there would never be a time a resident would be outside by themselves. In a telephone interview on 10/2/25 at 11:44 a.m. CR #1's MD said CR #1 had mild cognitive dysfunction. He said CR #1 wandered off and purchased some items (from the store). He said the resident was quite functional but there was some cognitive decline. He said no one was allowed to just wander off from the facility and it was not routine practice to leave the facility. He said CR #1 might have had a wander guard at that point. He said a wander guard in place meant there was some element of concern and would have to review the chart to see why CR #1 needed the wander guard. He said residents needed to be monitored while smoking and an employee had to be outside with them.In a telephone interview on 10/2/25 at 3:33 p.m., the previous SW said when she found out CR #1 was missing, she went to the local corner store because he had asked her previously to get him something from the store. She said she found CR #1 behind the gas station leaning against a pole trying to catch his breath. She said the gas station was located near the main road. She said CR #1 was with it and knew what he had done but should not have been walking that far. She said he was mentally well enough to go to the store and back. She said he had a wander guard because of how he was at home, so he was an elopement risk. She said that was the first time in 2 years he left the building and never threatened to leave before. She said he previously resided on the memory care unit for being sexually inappropriate and exit seeking but said she was not sure. She said when he transitioned to the general population they placed a wander guard on him. She said she was unsure if the need for the wander guard was ever re-evaluated.In a continued telephone interview on 10/2/25 at 3:46 p.m., the previous SW said the residents who smoked were supposed to be supervised by nursing staff. She said the speech therapist was not responsible for watching them. She said around the time of the incident the back gate was messed up, the alarm would not sound, and it was easy for CR #1 to get out. She said the rehab door alarm would mess up but eventually the company came out to rewire everything. She said the wander guard would also not go off at times. She said after the incident it was strictly enforced that someone had to supervise the residents while smoking. She said residents with wander guards should also be supervised.In an interview on 10/2/25 at 4:45 p.m., the DON said she could not remember if CR #1 was reassessed to see if the wander guard was still needed prior to the elopement. In an interview on 10/2/25 at 5:16 p.m. the Administrator said if CR #1 had a wander guard in place he was at high risk for elopement and supervision was needed.In an interview and record review on 10/2/25 at 5:31 p.m. the MDS nurse said on the day of the incident CR #1 had a BIMS score of 15 (cognitively intact). She said the facility could not just take someone off the wander guard but had to monitor. She said the facility was educating CR #1 on the facility processes such as signing out and signing in the facility. She said only cognitively intact residents could sign in and out of the building. She said if the resident had moderate cognitive impairment a staff member could take them to the store. Record review of CR #1's BIMS revealed his cognition was assessed as moderately impaired in the three months prior to his elopement: 7/4/24 (BIMS score 12 out of 15), 9/3/24 (BIMS score 10 out of 15) and 10/14/24 (BIMS score 9 out of 15).Record review of the facility's Smoking Policy and Procedure policy, dated 12/19/17 and signed by CR #1 on 8/5/24, read in part, .Policies: . 2. All smokers will be assessed upon admission and as their cognitive and/or physical status mandates. 3. Residents who have been assessed will only use tobacco products with supervision at the appointed smoking times. Procedure: . 2. A staff member will accompany and supervise all residents during designated smoking times, as staffing levels permit.Record review of the facility's, undated, Resident Alarms policy read in part, .The use of alarms does not eliminate the need for adequate supervision of the resident. Types of alarms include. e. Wander/elopement alarms - includes devices such as bracelets. that alert the staff when the resident nears or exits an area or building.6. Monitoring and modification a. supervision shall be provided to the resident in accordance with the resident's plan of care. b. when alarms are utilized, additional monitoring shall be provided, including but not limited to: i. verifying alarms are used in accordance with the resident's care plan. ii. Verifying alarms are working properly. c. ongoing assessment of the resident shall occur to identify changes in patterns, routines, or medical symptoms of the resident. Interventions shall be modified, as needed, to address any changes. D. Considerations for discontinuation of alarms include, but are not limited to: i. the medical symptoms or risks warranting the use of the alarms are no longer present. Ii. The risks associated with the use of the alarm outweigh the benefit. Iii. Evidence of adverse consequences associated with the use of the alarms. Iv. Resident/family goals and preferences change. It was determined this failure placed CR #1 in an IJ situation from 11/19/24 to 11/19/24. The Administrator was notified and provided with the IJ template on 10/2/25 at 5:12 p.m. The facility took the following action to correct the non-compliance beginning on 11/19/24. Record review of the provider investigation report, signed 11/27/24, read in part, . -The Resident's physician and responsible party were notified of the incident. At approximately 4:00 p.m. the DON performed a full body assessment and noted no injuries or significant changes in condition. SW conducted BIMS 15 (cognitively intact) PHQ -9 score of 0 (no signs of depression). -IDT discussed the incident and determined that updating the smoking protocol was necessary. The Administrator changed smoking times to include a time when sessions would end. The Administrator assigned staff members to be present during each smoking session. The designated smoking times and assigned staff were posted at the nurse's station. -The team reviewed care plans for each resident who smoked. The DON implemented a binder containing a photograph of residents requiring special supervision while smoking. The binder will be kept at the nurse's station. The team determined to place red star stickers on smoking bins to further identify residents requiring special supervision while smoking.-The community initiated training of staff in new processes.-The Administrator suspended smoking sessions until substantial training had been completed .-The Administrator placed (SLP) on suspension until further notice.-The Administrator was informed by Maintenance Director that city fire codes prohibit the gate located in the smoking are from being locked. The Maintenance Director and Administrator inspected the Resident Monitoring Systems and did not find any concerns . -The Community continued to monitor the safety and wellbeing of (CR #1)-No additional incidents were reported.-Nurse Managers continued to review resident care plans and smoking assessment protocols. The community continued to conduct staff training. The community monitored compliance with newly implemented smoking supervision protocols due to reinstatement of smoking sessions.-.The Administrator met with (CR #1) to discuss the community's smoking and discharge and out on pass protocols. (CR #1) stated that he was coming back and that he just ran to the store.-.The incident was reported to Texas Health and Human Services.-The Medical Director visited (CR #1) and mentioned that the resident's cognition is intact.-The DON conducted Elopement Drill. The drill was conducted without concern.-The Regional Maintenance Director inspected the gate located in the smoking area. He gave reports of plans to replace the gate with more height and add an alarm system. No additional concerns reported.Investigation Summary: The community has conducted a root cause analysis related to the incident. The community has amended the smoking protocol to enhance the identification of residents requiring supervision. The community has updated its smoking schedule and established a supervision rotation to promote compliance. The community has educated staff on elopement prevention and the role the updated smoking protocol will play in prevention. The community conducted an elopement drill that had a positive outcome. The community continues to assess (CR #1's) cognitive and functional levels and consult with healthcare providers and responsible parties to continue to promote the least restrictive environment in accordance with the Resident's care needs. The community has educated (CR #1) and other residents on the purpose of Out on Pass, Transfer and Discharge protocols. The community will continue to monitor the effectiveness of the interventions during its quality assurance meetings.Record review of the facility's Smoking Policy - Residents, Elopements, responding and prevention in-service dated 11/19/24 revealed there were approximately 56 staff signatures. The inservice contained protocol on the smoking policy and managing wandering and elopements. Record review of the facility's Resident Smoking Times effective 11/19/24, revealed times and staff who would supervise residents were listed.Record review of the Logbook Report - Resident Monitoring Systems: Check operation of door monitors and patient wandering system, dated 11/19/24, revealed the alarms were checked monthly by the Maintenance Director.Record review of the facility's Wander guards - policy and procedures in-service, dated 11/20/24, revealed there were approximately 52 signatures. The in-service read in part, .residents with wander guards in place should never leave the building without supervision. WG shall be monitored by all staff and should be reported to mgt if malfunctioning or in case of removal by resident or if it is not secure. The list of residents with WG is located at nurses station in a blue binder. These devices are used to monitor residents who are at risk of wandering or elopement. Failure to comply with this policy could result in serious safety risks for the resident. It is the responsibility of all staff members to prioritize the safety of residents at all times.Record review of the Elopment Drill Documentation Form revealed it was conducted on 11/22/24. The document read, . The drill was very organized and effecient (sic). All residents were accounted for. 13 staff participated in the drill.Record review of the facility's 1:1 Training Smoker Safety Resident Elopement Precaution, dated 12/2/24, read in part, .(SLP) received training on updated elopement prevention and smoking protocol. (SLP) understands that resident with wander guard should always be supervised while in the smoking area or outside the community. (SLP) understands that changes or exceptions to the protocols must come in writing from the Administrator or member of the corporate team. The in-service was signed by SLP.Record review of the Elopement Risk binder located at the nursing station which contained 3 residents and their clinical information in it.In an observation and interview on 10/1/25 at 11:35 am revealed CNA S was outside supervising residents during their smoke break. CNA S said she ensured the residents remained safe while outside smoking.In an observation on 10/1/25 at 11:38 a.m. of the back gate revealed a tall brown fence with a magnetic lock. In an interview on 10/1/25 at 11:43 a.m. RN A said if residents were outside on the back patio there was always a staff member present.In an interview on 10/2/25 at 1:01 p.m., CNA J said she was trained on wander guard procedures. She said the alarm would sound if any resident with a wander guard approached the door. She said there was a list of residents who had wander guards at the nursing station. She said if the alarm was not working, she would immediately report it to the Maintenance Director. She said if there was an elopement she would start a head count, determine who was missing and check for the resident around the building. She said if an alarm sounded, she would stop what she was doing and ensure the patients were safe.In an observation on 10/2/25 at 4:45 p.m., with the Maintenance Director and DON revealed the door alarms for halls A, B, and E were functioning and the doors were locked. The alarm would beep if the door bar was pushed. All doors had codes that were required to unlock the door. The code panel was deactivated if a wander guard was in the vicinity. In an interview on 10/2/25 at 4:58 p.m., LVN D said she was trained on elopement protocol, wander guards, and smoking protocols. She said there was a book behind the desk with names and pictures of the wanders with guards. She said the procedure was to search the building and its parameters. She said it was important to be alert and aware of the alarm. She said orders were in place to check wander guards for functioning every shift. She said the new smoking protocol included specified times and staff designated to take residents out. She said the back door was secured at all times and residents were not allowed outside to smoke until specified times and only while supervised.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal Laws, drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 19 residents (Resident #4) reviewed for drug labeling and storage.The facility failed to ensure Resident #4's medication was not stored on the resident's nightstand. This failure could place residents at risk of adverse reactions and drug diversions. Findings included:Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a recent re-admit on, 02/01/2025. Resident #4 had diagnoses which included dry eye syndrome, restlessness and agitation, sleep disorder, muscle weakness, asthma, chronic congestive heart failure (a heart is unable to pump enough blood to meet the body's needs), type 2 diabetes, and dementia.Record review of Resident #4's Quarterly MDS, dated on 09/10/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 of 15, which indicated no impairment. Record review of Resident #4 Medication Administration Record dated for 09/2025 revealed the resident was prescribed the following medications in the morning, Tylenol Oral Tablet 4 mg , amlodipine Besylate Oral Tablet 10 MG, Apixaban Oral Tablet 5 mg, Asboric Acid Oral Tablet, Aspirin Oral Capsule 81 mg, Brumetanide Oral Tablet 2 mg, Cyanoccobalamin Oral Tablet 500 mg, DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 mg, Empagliflozin Oral Tablet 25 MG, Gerrous Sulfate Oral Tablet, Folic Acid Oral Tablet, Isosorbide Mononitrate Oral Tablet 20 mg, Losartan Potassium, Oral Tablet 50 mg, Potassium Chloride ER Oral Tablet Extended Release, Toprol XLOral Tablet Extended Release 24 hour 25 mg, Azelastine HCI Nasal Solution 0.1%, and cyclosporine Opthalmic Solution.Observation on 09/30/2025 at 10:58 AM of Resident #4's nightstand revealed a plastic cup with approximately 10 pills, 1 nasal spray, and one eye drop, which were unattended. In an interview with Resident #4 on 09/30/2025 at 11:00 AM, revealed Resident #4 the medications on the nightstand belonged to him. Resident #4 stated the medication tech left them on the nightstand for him to take once he returned to his room and stated it was CMA M who left them on the nightstand. Resident #4 stated CMA M didn't normally leave the medications on his nightstand and the medications were possibly unattended for 10-15 minutes.In an interview with the DON on 09/30/2025 at 11:06 AM, revealed leaving medications unattended could put the resident at risk by mistakenly taking medications that were not prescribed to them, or another resident passing by could access and take the medications. The expectation for the nurse or medication aide was to stand near the resident and be with the resident the entire time to watch the resident take the medication. Once the resident took the medication, the nurse or medication aide must document. Resident #4 was not eligible for self-administered medication.In an interview with CMA M on 09/30/2025 at 11:09 AM, revealed CMA M stated this morning (09/30/2025) she had the medications ready outside of the room, but housekeeping was cleaning the room. CMA M stated she did not pre-pop medications and when she saw the resident going towards his room, she went into the room and sat Resident #4's medication on the nightstand. CMA M stated she knew better to leave medications unattended, but she knew the resident was going to the room so she left them on the nightstand for him to take once he entered the room. CMA M stated the risk for Resident #4's medication being unattended and not monitored is someone else taking the medication, or a possible choking hazard. The expectation for medication pass was to wash hands, take vitals, administer medication, watch the resident take the medication, wash hands, and document.In an interview with ADMN on 09/30/2025 at 2:16pm, the policy for medications is to always be kept safe and always secured. AMDN stated to his knowledge, residents need to be accessed to know if they can be self-administered. The risk of leaving medications in the room is the resident not taking the medication. Record review of the facility's, undated, policy titled, Medication Storage revealed, General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage . This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 08-20-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and dumpster door was open. In an interview on 08-20-24 at 8:45 am, with the Food Service Manager, he stated the dumpster door when not in use should have doors closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. He stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors are kept closed when not in use. Record review of facility's Policies and Procedures on disposal of garbage and refuse dated 2024 read in part 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors or covers. Containers and dumpster shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart for B Hall/D Hall) of three medication carts reviewed for storage of medications. The Nurse Cart for B Hall/D Hall contained medications without resident identifiers. The Nurse Cart for B Hall/D Hall contained a narcotic medication blister pill card with a punctured protective seal. The failures could place all residents at risk of not receiving the therapeutic benefit of medications, infection, adverse reactions to medications and drug diversion. Findings included: Record review of Resident #2's face sheet dated 08/20/2024 reflected a [AGE] year-old female, admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included dementia, bipolar disorder, diabetes with diabetic neuropathy (nerve damage that can occur with diabetes), depression and chronic pain. Record review of Resident #2's physician's orders as of 08/20/2024 reflected an order for Cannabidiol Oral Solution, 15 drops at bedtime for anxiety/sleep, date started 04/05/2024. Observation on 08/21/2024 at 6:30 AM, revealed in the top drawer of the Nurse medication cart for B Hall/D Hall contained a bottle of Refresh Tears without a resident identifier, and a bottle of CBD (Cannabidiol) oil (a hemp supplement) without a resident identifier. The CBD oil bottle was in the compartment with eye drops. Further review of the top drawer revealed one insulin pen, Lispro (a fast-acting insulin that lowers blood sugar in people with diabetes) without a resident identifier and a second insulin pen, Aspart (a fast-acting insulin that lowers blood sugar in people with diabetes). Both insulin pens contained fluid. Interview on 08/21/2024 at 6:30AM, LVN B stated she was the charge nurse and worked the 7:00PM to 7:00AM shift. LVN B stated she did not use or open the cart on her shift and did not know why the insulin pens, refresh eye drops, and CBD oil were not labeled. LVN B stated the only resident she was aware who used the CBD oil was Resident #2. LVN B stated the Refresh Tears eye drops and the CBD oil should have been in the original boxes with pharmacy labels and resident names. LVN B stated the risk of medications without resident identifiers was that a resident could be given the incorrect medication and cross contamination from being used on another resident. LVN B stated it was the facility's policy to have resident identifiers on all medications. Observation and interview on 08/21/2024 at 9:00AM, the Nurse medication cart for B Hall/D Hall, revealed a narcotic lock box that contained a Hydrocodone-APAP 10-325mg blister pill card with pin holes on the back of one of the pill compartments (Compartment #5). RN C stated that yes there were 2 pin holes on the back of the blister pill card and that a contaminant could get into where the tablet was. RN C further stated that when ingested a resident may get sick and if the holes got larger the pill could fall out, someone could pick it up, eat it and get sick. RN C stated if there was a tear on the protective seal, she would not tape it but knew instead to waste the pill and that she did not know what to do if there were pin holes. RN C then stated that she would waste it with another nurse to be safe. In an interview on 08/21/2024 at 2:00 PM, the DON stated insulin pens should always have the resident name on the pen and on the bag including the date opened along with pharmacy labels. The DON stated the nurse in charge of the medication cart would be responsible for ensuring all medications were labeled and that ultimately all the nurses were responsible to ensure proper labeling of medications. The DON stated possibly the bags for the insulin pens were lost and that the nurses would not intentionally remove the labels. The DON stated that it was unfortunate that it happened and would expect the nurses to discard the pens when found. The DON stated the nurses just did not write the resident name on the bottle of Refresh Tears and the CBD oil did not come from a pharmacy, the original box may have been lost. The DON stated it would be ideal to have the box for the CBD oil or have the resident's name written on the bottle. The DON stated it would be important because not everyone would be familiar with Resident #2, especially agency staff and that it was facility policy to have all medications with resident identifiers. The DON stated it was the nurses assigned to the carts responsibility to maintain accuracy of the medications in the carts. The DON stated it ultimately fell on the DON and ADON to make sure the nurses were doing their duties. The DON stated she expected the nurses to check the carts at the beginning and end of shift during counting. The DON stated she expected the nurse coming on shift to also ensure everything was in order with the medication carts. The DON stated she expected the nurse leaving and the nurse coming on shift to make sure the cart had been checked for any errors. The DON stated she taught the nurses to check the protective seals were intact on the blister pill cards and ensure it did not look tampered with. The DON continued by stating that if the seal were broken, the pill could fall out, get lost, could be tampered with and may not be the correct pill as a result a resident could be harmed and possible harm to nurse licenses as well. Record review of the facility policy for Medication Storage, dated 2023 reflected in part: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .and sufficient to ensure proper sanitation .security .1a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts .2b. Scheduled II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area . Record review of the facility policy for Injection Safety - Drug Diversion, dated 2023 reflected in part: .Definitions: Drug Diversion refers to the theft or other deviations that removes a prescription drug from its intended path form the manufacturer to the patient .2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications .3. Staff with access to controlled medications are trained on the facility's policy for the administration and accountability of controlled substances .5. Ongoing supervision and auditing are conducted in accordance with facility policy to verify that staff are following policies as written .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 received the correct dose of Vitamin D3 (a dietary supplement to help maintain bone health and for vitamin deficiency) as written by the physician. LVN A failed to confirm the correct dose of Vitamin D3 prior to administration. This failure could place residents at risk of not receiving the intended therapeutic benefits of the medications. Findings included: Record review of Resident 1#'s face sheet dated 08/21/2024, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Wernicke's Encephalopathy (brain and memory disorder), cocaine dependence, schizoaffective disorder, anxiety disorder, vitamin deficiency, hypertension and vitamin D deficiency. Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 3 out of 15, indicating severe cognitive impairment. He required supervision or set up for ADL's. He was always continent of bowel and bladder. Record review of Resident #1's undated care plan reflected a nutritional risk related to advanced age and interventions to include administer medications as ordered. Further review reflected the diagnosis of vitamin D deficiency was not addressed. Record review of Resident #1's physician's orders as of 08/21/2024 reflected an order for Vitamin D3 125mcg 1 capsule daily by mouth related to vitamin deficiency. Record review of Resident #1's MAR for August 2024 reflected that LVN A documented administering Vitamin D3 125 mcg capsule on 8/21/2024. In an observation and interview during medication pass on 08/21/2024 at 8:15AM in the memory care unit, revealed LVN A prepared medications for Resident #1. LVN A prepared the following medications: Gabapentin 300mg one capsule, Bupropion HCL SR 150mg one tablet, Prezcobix 800mg/150mg one tablet, Loratadine 10mg one tablet, Folic acid 1mg tablet, multi-vitamin one tablet, thiamine vitamin B-1 100mg one tablet, Emtricitabine 200mg one tablet and Vitamin D3 25mcg 2 tablets. LVN A administered the medications to Resident #1. In an interview and observation on 08/21/2024 at 11:35AM, LVN A stated she started working at the facility around 06/26/2024 and was a full-time employee. Observation of the medication cart in the memory care unit revealed a bottle of Vitamin D3 25mcg. Further observation of the medication cart revealed there was no Vitamin D3 125mcg. LVN A stated she gave Resident #1 two tablets of Vitamin D3 25cmg and stated that the order was for 2 tablets. LVN A stated she missed reading the correct dose on the bottle. LVN A stated Resident #1 was receiving Vitamin D3 for a vitamin deficiency and the risk of not getting the correct dose was Vitamin D deficiency. LVN A stated when she prepared medication for administration to residents, she checked for the right medication, right dose, right amount and right patient/resident. LVN A stated it was important to give the correct medications as written by the physician so the resident would receive the adequate amount. LVN A stated she believed she did the medication competency checklist during orientation and that it was conducted by the DON and ADON. LVN A stated going forward she would be able to write a self-report in the eHR system for medication errors. LVN A stated she would notify the family and the MD of the med error. In an interview on 08/21/2024 at 2:00PM, the DON stated she expected the nursing staff to check the physician orders and make sure orders were still valid, current and nothing had changed. She stated she expected the nurses to check for the right resident, right dose, right medications, right time, no allergies, no contraindications and to check consents if needed prior to administering medications. The DON stated the nurse called the NP when she missed giving the correct dose and that the order could have been put in the system incorrectly, that it was probably supposed to read Vitamin D3 25mcg and not 125mcg as the facility did not have bottles of the 125mcg. The DON stated it was the responsibility of the person transcribing the order to have made sure what was entered was correct and of course when giving the medication, the nurse should have confirmed the dose. The DON stated Resident #1 was receiving Vitamin D3 as a supplement as he had several different diagnoses that would cause low Vitamin D levels also, he was not a big eater and needed to get more nutrients. The DON stated the risk of not receiving the correct dose of Vitamin D3 could be side effects of an overt dose especially if his labs are being regulated or there could have been a contraindication. Record review of the facility policy for Medication Administration, copyright 2024 reflected in part: .Medications are administered by licensed nurses .as ordered by the physician .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dose, c. Right route, e. Right time, f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source .with MAR to verify resident name, medication name, form, dose, route and time .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/preparation discarded after 96 Hours (4 days) per facility policy 2. The facility failed to keep food off the floor. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen on 08/20/24 at 8:15 AM revealed the following. 1. 5 chicken sandwiches in the walk in cooler had use by date 8/19/24. 2. A Plastic container of deli sliced ham in the walk-in cooler had no label/ no date 3. A plastic container - of shredded lettuce dated 8/12/24 and no use by date. 4. A quart of potato salad dated 8/9/24 , and a use by date of 8/15/24 5. 1case of produce - in the walk- in cooler was stored on the floor 6. 1case of chicken in- the walk- in freezer was stored on the floor 7. 1case of French fries- in walk- in freezer was stored on the floor 8. 2cases of breakfast sausage- in walk- in freezer were stored on the floor In an interview with the Dietary Food Service Manager on 08/20/24 at 8:30 AM, he stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. He stated the cases of food should be off the floor due to cross contamination. He stated he or designee , shall be responsible for checking the refrigerator daily for food items that are expiring, and shall be discarded prior to expiration date. Record review of facility's policies and procedures for Food Safety dated 2004 reflected in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 96 hours unless otherwise indicated. Record review of facility's policies and procedures for Food Safety Requirements dated 2004 reflected in part b. foods/beverages be stored in a clean, dry area off the floor to prevent cross contamination.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for quality of care. -The facility failed to complete an appropriate assessment for Resident #1 after she fell out of her wheelchair and a small bump to the back of the head was sustained. -The facility failed to send Resident #1 to the hospital after she fell out of her wheelchair, hit her head and developed a small bump on the back of her head. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of Resident #1's face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks); Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - and behavioral abilities to such an extent that it interferes with a person's daily life and activities); Type 2 Diabetes with Diabetic Chronic Kidney Disease (damaged blood vessels and other cells in the kidneys caused by diabetes); Restless Leg Syndrome (a condition that causes a very strong urge to move the legs); and Hypertension (or high blood pressure, is when the force of blood pushing against your artery walls is consistently too high). Record review of Resident #1's MDS assessment dated [DATE], revealed no interview for mental status was conducted, which indicated the resident was rarely or never understood, and rarely or never made decisions regarding daily life. Resident #1 required limited assistance with bed mobility, transfer, eating, and extensive assistance with toileting. The resident required one-person physical assist with bed mobility, transfer, eating and toileting. Further review of the MDS did not reveal whether the resident used a wheelchair. Record review of Resident #1's care plan revealed she had an Actual Communication Problem related to being Hard of Hearing. Interventions included a communication board for the resident to use to communicate; ensure availability and functioning of adaptive communication equipment. Other interventions included allowing the resident adequate time to respond; repeat as necessary; do not rush; request clarification from the resident to ensure understanding; face when speaking; make eye contact; turn off TV/radio to reduce environmental noise; ask yes/no questions if appropriate; use simple, brief, consistent words/cues; use alternative communication tools as needed. The resident was at risk for falls related to poor safety awareness and weakness. The resident had impaired cognitive function and impaired thought processes related to Alzheimer's Disease and Dementia. Interventions included observations for any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Interventions included fall mat to the floor when in bed, and a medication review. The resident had a 'Do Not Resuscitate' code status, per her hospice provider. Interventions included not starting CPR if the resident was found with no pulse, respirations, or blood pressure. Record review of Resident #1's orders, dated [DATE], revealed no orders for neuro checks or fall risk interventions on [DATE]. Further review of orders revealed the resident was admitted to hospice for routine care on [DATE]. Interventions included pain monitoring using the pain numeric scale (,d+[DATE]) or PAINAD (pain assessment in advanced dementia). Record review of the facility 24-hour report, dated [DATE], revealed the following: Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro's started NP, RP and DON notified. Record Review of Resident #1's Progress Notes, revealed no mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the progress note revealed, at 3:30 PM on [DATE], LVN A wrote Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro's started NP, RP and DON notified. Record review of the resident's Change in Condition, dated [DATE] did not reveal Resident #1's vital signs at the time the resident was assessed on [DATE]. Further review of the Change in Condition revealed, at 5:01 PM on [DATE], LVN A documented the following vital signs for Resident #1 At the time of this evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure ,d+[DATE] - [DATE] at 9:13 AM Pulse: 70 - [DATE] at 9:18 AM RR: 16.0 - ,d+[DATE] at 8:38 AM Temp: 98.3 - [DATE] at 8:40 AM Pulse Oximetry: O2 99.0% - [DATE] at 8:46 AM Further review of the Change in Condition revealed, no responses to questions regarding the resident's pain was documented. Also, no responses to questions behavioral, respiratory, cardiovascular, abdominal, skin, and neurological status evaluations were documented. Record Review of Neuro Checks revealed, vital signs and neuro checks were to be completed every 15 minutes for one hour; every 30 minutes for one hour; every hour for four hours; then, every four hours for 24 hours. [DATE] at 3:30 PM, RN a noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-87; Respiration-18; Temperature-97.7. [DATE] at 3:45 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-88; Respiration-18; Temperature-97.7. [DATE] at 4:00 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-86; Respiration-18; Temperature-97.7; Initials. [DATE] at 4:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-86; Respiration-18; Temperature-97.7. [DATE] at 4:45 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-84; Respiration-18; Temperature-97.7. [DATE] at 5:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-86; Respiration-18; Temperature-97.7. [DATE] at 6:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-88; Respiration-18; Temperature-97.6. [DATE] at 7:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-90; Respiration-18; Temperature-97.6. [DATE] at 8:15 PM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-87; Respiration-18; Temperature-97.7. [DATE] at 9:15 PM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-84; Respiration-18; Temperature-97.7. [DATE] at 1:15 AM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-78; Respiration-18; Temperature-97.7. [DATE] at 5:15 AM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-74; Respiration-18; Temperature-97.3. [DATE] at 9:15 AM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-78; Respiration-18; Temperature-97.6. [DATE] at 1:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-76; Respiration-18; Temperature-97.6. [DATE] at 5:15 PM, RN A noted the resident fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-78; Respiration-18; Temperature-97.6. [DATE] at 9:15 PM Fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-78; Respiration-18; Temperature-98; Initials-RN B [DATE] at 1:15 AM Fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-73; Respiration-18; Temperature-97.9; Initials-RN B [DATE] at 5:15 AM Fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-,d+[DATE]; Pulse-87; Respiration-18; Temperature-97.9; Initials-RN B Record review of Hospice Nursing Clinical Note, dated [DATE], revealed the following: The resident was noted to have a hearing impairment, confusion, and disorientation. Summary: LVN B stated pt fell yesterday while trying to get out of w/c and has small bump on back of head. Facility doing neuro checks on pt. All WNL for pt. Assessment complete, vitals stable, blood pressure on the lower side of normal LVN B will recheck and continue to monitor . Record review of an undated text message from RN A , revealed the following: On [DATE], RN was called in to dining room by nurse aide. Upon arrival it was clear the resident, [Resident #1] was sprawled out on the floor next to her wheelchair lying face up. RN assessed resident head to toe before moving her. Because RN knows resident well, was able to quickly realize she was neurologically at her baseline from before this incident. She was able to track with both eyes, follow commands, move all extremities with no signs of pain. Skin assessment revealed no bleeding, skin warm dry and intact. Only a small bump of about 0.75 inch on back of head close to base of skull .It was reported to nurse by several bystanders that resident hit head after falling out of the wheelchair .RNs clinical decision she was safe to try sitting up. Then after explained what was going to happen next, RN and aide assisted her back into her chair .RN then wheeled resident back to nurse's station where vitals were checked by nurse in charge of her care and neuros protocol started . In an anonymous interview on [DATE] at 9:50 AM [DATE], they said they were present in the dining area of the facility when Resident #1 fell and hit her head. They said they could not remember the exact date or time, but the incident happened a few weeks ago, and a group was at the facility having church service in the dining area. They said the resident was not able to respond or actively participate in the activities taking place. They said the resident was sitting in a wheelchair near a table when the resident flipped backwards in her wheelchair. They said the resident's head hit the floor and it made a very loud sound. They said at the time the resident flipped backwards in the wheelchair, there were no facility staff present in the dining area. They said there were several people part of the group providing the service to residents, and several residents present, but they could only remember the resident who was right next to them at the time of the incident. They said the one resident right next to them at the time and everyone else in the dining area was shocked. They said someone ran and got facility staff to come help the resident. They said three women; one young and two older, all three were Hispanic or White, immediately, came into the dining area, picked the resident up off the floor, and put her back in her wheelchair. They said they told the staff they should not have moved the resident and that they needed to call 911. They said the resident next to them said something to the staff and was concerned about the staff picking the resident up off the floor immediately too. They said the women responded and said they were the professionals and knew what they were doing. They said once the three staff got the resident up, and into her wheelchair, one checked her pulse, and then took the resident out of the dining area. They said the facility did not call 911. They said they remained at the facility about 30 minutes after the resident's fall and never saw an ambulance show up. They said they were concerned because the resident should not have been moved right after hitting her head on the floor. In an interview with Resident #2 on [DATE] at 10:08 AM, she said she attended the church services in the dining area on Sundays. She said she saw Resident #1 fall in the dining area a few weeks back. She said she could not remember exactly when this took place. She said she did not see what was happening with the resident before she fell . She said she saw the resident go backwards out of her wheelchair onto the floor. She said the resident's head made such a loud noise when she hit the floor, she got worried. She said it was a lot of people in the dining area and everybody was concerned because the noise was so loud from the resident hitting her head. She said three staff came in and quickly got the resident up off the floor and back into her wheelchair. She said the staff did not do anything to the resident before they got her off the floor. She said they immediately picked her up. She said she did not know if a nurse checked the resident out after they got her back into her wheelchair. She said she was sure a nurse did not do anything to check on the resident before they moved her. She said it was a lot of people in the dining area when the resident fell and saw what happened, but she did not think there were any staff present when the resident fell . In an interview with Med Aide A on [DATE] at 12:55 PM, she said herself, CNA A, and a nurse were the staff that went into the dining area to help after Resident #1 fell out of her wheelchair. She said she could not remember exactly which nurse it was, but she thought it was RN A. She said the resident was lying on the ground on her back and the resident pointed to her side. She said the resident was not saying anything. She said the resident was not bleeding and did not have any visible injuries. She said she saw the nurse touching different parts of the resident's body. She said the nurse was probably checking for pain. She said then, the three of them (Med Aide A, CNA A and the nurse) grabbed the resident by her pants to pick her up off the ground and placed her back in her wheelchair. She said she thought the nurse might have checked the resident's vitals after they got the resident back into her wheelchair, but she was not sure. She said after they got the resident back into her wheelchair, she went back to the B hall because she had to finish administering meds. She said she did not have to write a statement or complete an incident report because she did not witness anything, and just went there to help get the resident up off the floor. She said staff were not to move a resident until a nurse said it was okay. She said the nurse decided it was okay to pick the resident up and put her back in her wheelchair. In an interview with CNA A on [DATE] at 1:09 PM, she said she was working on the day ([DATE]) Resident #1 fell out of her wheelchair. She said when she made it to the dining area the resident was lying on the ground, on her side. She said she did not observe any bleeding, nor was the resident crying. She said the resident was not speaking at all. She said the resident was mostly nonverbal and only spoke when she felt like it, so it was normal for her not to say anything. She said the resident had a knot on the back of her head, so she went to get an ice pack and a pillow for the resident. She said she knew the resident had a knot on the back of her head because the nurse said the resident did. She said the nurse was RN A. She said when she came back with the ice and the pillow, the nurse said it was okay to get the resident off the floor. She said she did not see RN A take vitals or assess the resident. She said she believed RN A at least assessed the resident because RN A gave the okay to get the resident up. She said CNA A, Med Aide A and RN A got the resident off the floor using her clothes. She said no staff was allowed to move a resident after a fall, unless a nurse said it was safe. She said RN A or the resident's assigned nurse could have taken the resident's vitals after they got the resident back into her wheelchair. In an interview with LVN A on [DATE] at 1:29 PM, she said she was in the middle of doing blood sugar checks on resident's when she found out Resident #1 fell . She said the resident was in the dining room. She said sometimes on Sundays, they were in the dining area for hours having church service. She said the resident had Dementia and Alzheimer's, and her attention span was not that long. She said the only thing she could think of as the cause for the resident's fall, was the resident got tired and wanted to go back to her room. She said the Weekend Supervisor and RN A were the nursing staff that went to the dining room after the resident fell . She said she thought one of the aides came and told her Resident #1 fell , but she was not sure. She said when she went into the dining area, she saw the resident sitting in her wheelchair and talking. She said she saw a nurse have the resident squeeze the nurse's finger, follow their finger with her eyes, and touch the resident's body to check for pain. She said she could not remember which nurse it was but felt like it was the Weekend Supervisor. She said she did not see a nurse check Resident #1's vitals. She said Resident #1 also had a small bump in the back of her head, but never complained of pain. She said she immediately began doing neuro checks on the resident, since she was her assigned nurse. She said neuro checks were performed for 24 hours. She said she was the one to place the call to the nurse practitioner, and the nurse practitioner said to continue to monitor the resident for any changes. She said she did not remember who she spoke to when she contacted the nurse practitioner. She said there were no significant changes in the resident's vitals or complaints of pain. She said the night shift staff was notified about the resident's incident, continued neuro checks and monitoring for changes. She said when a resident fell and had a head injury, she would do an assessment, call the nurse practitioner, begin neuro checks, and monitor the resident for changes in condition. She said she would ask the resident about pain, feel their head, see if there was any active bleeding. She said she would check their blood pressure, pulse, and look for rapid breathing. She said she would talk to the resident, see if they were able to follow her finger. She said Resident #1 was unable to tell you date/time but would tell if she was in any pain. In an interview with RN C on [DATE] at 1:50 PM, she said she worked at the facility for three years. She said if she was alerted a resident fell and hit their head, she would get help and then call 911. She said if the resident had any signs of a hematoma, they would be sent to the hospital. She said she would call emergency services, call the resident's family, NP, MD, administrator, and DON. She said she would also document a change in condition, incident report and fall assessment in the resident's electronic health record. In an interview with RN B on [DATE] at 1:53 PM, she said if she was notified a resident fell , hit their head, and had a small bump on back of their head, she would send the resident out to the hospital immediately via emergency services. She said it did not matter if the resident was on hospice. She said she would send the resident to the hospital and let hospice know after the fact. In an interview with the DON on [DATE] at 2:06 PM, she said she worked at the facility for three years. She said if a resident fell , hit their head, and sustained an injury, it was her expectation of the nurses not to move the resident. She said it was her expectation for the nurses to contact emergency services to transport the resident to the hospital, identify if the resident was on blood thinners, and send them out. She said the nurses were to also notify the resident's NP, family, and hospice, if necessary. She said the nurses would do neuro checks on the resident for three days; go through recent lab work; have a care plan meeting to see what was going on; and make changes to interventions. She said the nurse would fill out an incident report, change of condition, and other post fall documentation in the resident's electronic health record. She said all the documentation should be completed in a timely manner. She said if there was a change of condition observed after the fall, the resident would be sent to the hospital. She said even if the resident had a head injury after a fall, they would call hospice to notify, but the resident still needed to be sent to the hospital. She said the hall charge nurse would enter the incident information in a risk management report, complete a fall risk assessment, and a post fall assessment. She said the nurse was supposed to document what happened; how it happened; pain assessment; injuries; witnesses; any other notes and a signature section at the end. She said the nurse was also responsible for documenting who they spoke to, whether it was the NP, the physician in charge or, the on call after hours physician. She said they also documented notification to the RP, hospice, nurse manager, who they spoke to and whatever orders or information given to them at the time of the notification. She said there was no time it would be okay for a staff to move a resident with a head injury. She said even the fall was unwitnessed, if there was an obvious injury they needed to be kept as still as possible until emergency services arrived. She said if a resident fell and hit their head and the sound from them hitting their head was loud enough to be heard, and the resident had a small bump, that would still be considered a head injury. She said the resident needed to be sent to the hospital. She said a resident who fell , hit their head, and had a head injury not receiving emergency medical services were at risk of a bleed, contusion, concussion, hematoma under the skin, or something that would require a CT scan right away to catch. In an interview on [DATE] at 2:42 PM with the Nurse Practitioner, she said she thought she was contacted by the facility on [DATE] regarding Resident #1 falling. She said if the facility had told her the resident had a head injury, or a small bump on her head, she would have sent the resident out for a CT scan. She said she could not recall who contacted her regarding the resident's fall. She said she was reviewing her notes at that time and could not find any information on the resident's fall on [DATE]. She said if she did not have notes of the fall, no notification was made to her. She said she visited the facility every other day and remembered hearing about the resident's fall from the resident's nurse. She said she just reviewed everything entered in the resident's electronic health record, with the facility, regarding the fall incident on [DATE]. She said if she had been contacted, she would have ordered for the resident to be sent to the hospital for a CT scan. She said the resident was at risk for internal head bleeding and confusion by not receiving emergency medical services on [DATE]. She said it would have been important to send a resident whose baseline mental status was confused out to the hospital for evaluation because they would not be able to tell if there was anything going on internally. In an interview with the Weekend Supervisor on [DATE] at 3:14 PM, she said she worked at the facility for a little over a year. She said it was her expectation for nurses to provide immediate care to a resident who fell and hit their head. She said the nurses were supposed to check vitals, ensure the resident was not in any distress, and call the doctor to tell them what transpired. She said when the nurse got orders from a physician, the nurse should document in the electronic health record, then make notifications to the family and the DON. She said the nurse needed to do an assessment and find out if the resident was on any blood thinners. She said the nurse should check the resident's vital signs, level of consciousness, blood pressure, pulse, respirations, and pupils during an assessment. She said the nurse should assess the resident for pain and ask them if they were in pain. She said the nurse should do a skin assessment and check for range of motion. She said to check for range of motion, the nurse should ask the resident to move their arms and legs, see if they can stand, and bend over. She said if the resident was lying on the floor, the nurse needed to check for range of motion while the resident was still on the floor. She said if the resident had not broken any bones, the nurse and other staff could get them up off the floor, and into a chair or wheelchair. She said the nurse could also get the resident back in their bed, perform another assessment, begin neuro checks at that point, then contact the doctor. She said if the resident had a head injury it was standard for the facility to call the resident's doctor. She said if the doctor had a standing order for residents with a head injury to be sent out to the hospital, then they would send the resident out. She said she did not know what the facility's policy was on resident's who fell and sustained a head injury. She said she had not looked at the policy. She said she was working on [DATE] at the time Resident #1 fell . She said she was doing patient care when she came out of a resident's room, and a family member told her a resident had fallen. She said the nurse and the resident were not in the dining area by the time she found out about the incident. She said everything was already over and handled. She said the nurse should have contacted the NP to get further instruction after Resident #1 fell . She said she believed that it was only family members and residents in the dining hall at the time of the resident's fall. She said residents could not provide statements due to their inability to accurately recall or perceive things. She said there were no statements gathered from anyone who witnessed the incident. She said she did not remember speaking to any other staff to find out what happened and what was done for the resident. She said she only spoke to LVN A about what she had done with Resident #1. She said LVN A told her the resident had been assessed. She said she did not ask LVN A who assessed the resident. She said if LVN A did not assess Resident #1 then RN A likely assessed her. She said if RN A assessed the resident, she would have given LVN A the vital signs and other observations from her assessment. She said if RN A assessed the resident, LVN A would have been the nurse responsible for documenting RN A's assessment, what happened, and the care provided to the resident, according to RN A, in Resident #1's electronic health record. She said she did not know the resident had a small bump on the back of her head after she fell . She said the nurse should have contacted the NP and the DON and notified them about the bump on the back of Resident #1's head. She said LVN A was responsible for completing tasks related to the resident's fall because she was the primary nurse for the resident. She said the DON would have been responsible for reviewing the documentation from the incident. She said she could not recollect whether she notified the DON via text message or phone call about the resident's fall. She said when an incident occurred over the weekend, they were supposed to call the on-call phone to make notification to the on-call person. She said she did not call the on-call phone and did not know whether LVN A called the on-call phone to notify on call management about the resident's fall. She said if Resident #1 fell , hit her head, developed a small bump on the back of the head, and was not sent to the hospital for evaluation, the resident was risk of a subdural hematoma or an internal bleed. In an interview with LVN A on [DATE] at 10:53 AM, she said she was not the nurse who performed an assessment on Resident #1 right after the resident fell . She said she thought the Weekend Supervisor performed the assessment, but it was RN A who performed the assessment. She said RN A told her she was going to put all her information from her assessment of the resident in her electronic health record. She said she asked RN A if she assessed the resident and RN A told her yes. She said she sent a message to the NP regarding the resident falling. She said she had proof she sent a text message to the NP but could not remember when she sent the text message. She said she told the NP the resident fell and hit her head, but she was okay. She said the NP gave orders to continue to monitor the resident. She said she did not tell the NP the resident had a small bump on the back of her head because she did not initially have the bump when she notified the doctor. She said she did not know how long it was between the time she notified the NP of the fall and the time the resident developed the small bump on the back of the resident's head. She said when a physician gave an order for monitoring, it was for staff to monitor for changes in the resident's condition. She said she followed the NP's directives to monitor the resident. She said she said immediately began neuro checks and continued to monitor the resident. She said she did not think about notifying the NP the resident developed a small bump on the back of her head, after falling. She said she did not think the resident was at any sort of risk because she said man who witnessed the resident's fall told her the resident may have hit her shoulder or another body part on the way down to the floor. She said that may have softened the blow if the resident did hit her head. She said she did not think the resident was put at any risk because the resident did not suffer from a bad fall. She said she probably should have notified the NP the resident had a small bump on her head. She said she could not recall whether she contacted to hospice to notify them of the incident. In an interview with RN A on [DATE] at 11:19 AM, she said she worked at the facility for three years. She said she was clinically able to assess a resident from head to toe. She said if she was assessing a resident after a fall, she would do a neurological assessment. She said a neurological assessment consisted of checking for seizures, fo

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 6 residents reviewed for changes of condition. The facility failed to notify Resident #1's physician when she experienced a change of condition, including developing a small bump on the back of the head after she fell out of her wheelchair and hit her head on [DATE]. This failure placed residents at risk experiencing a delay in medical treatment and worsening of condition/symptoms. Record review of Resident #1 ' s face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks); Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - and behavioral abilities to such an extent that it interferes with a person ' s daily life and activities); Type 2 Diabetes with Diabetic Chronic Kidney Disease (damaged blood vessels and other cells in the kidneys caused by diabetes); Restless Leg Syndrome (a condition that causes a very strong urge to move the legs); and Hypertension (or high blood pressure, is when the force of blood pushing against your artery walls is consistently too high). Record review of Resident #1 ' s MDS assessment dated [DATE], revealed no interview for mental status was conducted, which indicated the resident was rarely or never understood, and rarely or never made decisions regarding daily life. Resident #1 required limited assistance with bed mobility, transfer, eating, and extensive assistance with toileting. The resident required one-person physical assist with bed mobility, transfer, eating and toileting. Further review of the MDS did not reveal whether the resident used a wheelchair. Record review of Resident #1's care plan revealed she had an Actual Communication Problem related to being Hard of Hearing. Interventions included a communication board for the resident to use to communicate; ensure availability and functioning of adaptive communication equipment. Other interventions included allowing the resident adequate time to respond; repeat as necessary; do not rush; request clarification from the resident to ensure understanding; face when speaking; make eye contact; turn off TV/radio to reduce environmental noise; ask yes/no questions if appropriate; use simple, brief, consistent words/cues; use alternative communication tools as needed. The resident was at risk for falls related to poor safety awareness and weakness. The resident had impaired cognitive function and impaired thought processes related to Alzheimer's Disease and Dementia. Interventions included observations for any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Interventions included fall mat to the floor when in bed, and a medication review. The resident had a 'Do Not Resuscitate' code status, per her hospice provider. Interventions included not starting CPR if the resident was found with no pulse, respirations, or blood pressure. Record review of the facility 24-hour report, dated [DATE], did not reveal mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the 24-hours report revealed the following: Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro ' s started NP, RP and DON notified. Record Review of Resident #1 ' s Progress Notes, did not reveal mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the progress note revealed, at 3:30 PM on [DATE], did not reveal mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the progress notes revealed, LVN A wrote Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro ' s started NP, RP and DON notified. In an interview with the DON on [DATE] at 2:06 PM, she said if a resident fell , hit their head, and sustained an injury, the nurses were to notify the resident's NP, family, and hospice, if necessary. She said the nurse was also responsible for documenting who they spoke to, whether it was the NP, the physician in charge or, the on call after hours physician. She said they also documented notification to the RP, hospice, nurse manager, who they spoke to and whatever orders or information given to them at the time of the notification. In an interview with the Nurse Practitioner on [DATE] at 2:42 PM, she said she thought she was contacted by the facility on [DATE] regarding Resident #1 falling. She said if the facility had told her the resident had a head injury, or a small bump on her head, she would have sent the resident out for a CT scan. She said she could not recall who contacted her regarding the resident's fall. She said she was currently reviewing her notes at that time and could not find any information on the resident's fall on [DATE]. She said if she did not have notes of the fall, no notification was made to her. She said she visited the facility every other day and remembered hearing about the resident's fall from the resident ' s nurse. She said she just reviewed everything entered in the resident's electronic health record, with the facility, regarding the fall incident on [DATE]. She said if she had been contacted, she would have ordered for the resident to be sent to the hospital for a CT scan. She said the resident was at risk for internal head bleeding and confusion by not receiving emergency medical services on [DATE]. She said it would have been important to send a resident whose baseline mental status was confused out to the hospital for evaluation because they would not be able to tell if there was anything going on internally. In an interview with the Weekend Supervisor on [DATE] at 3:14 PM, she said the nurse should have contacted the NP to get further instruction after Resident #1 fell . She said she did not know the resident had a small bump on the back of her head after she fell . She said the nurse should have contacted the NP and the DON and notified them about the bump on the back of Resident #1's head. She said LVN A was responsible for completing tasks related to the resident ' s fall because she was the primary nurse for the resident. She said the DON would have been responsible for reviewing the documentation from the incident. She said she could not recollect whether she notified the DON via text message or phone call about the resident's fall. She said when an incident occurred over the weekend, they were supposed to call the on-call phone to make notification to the on-call person. She said she did not call the on-call phone and did not know whether LVN A called the on-call phone to notify on call management about the resident's fall. She said if Resident #1 fell , hit her head, developed a small bump on the back of the head, and was not sent to the hospital for evaluation, the resident was risk of a subdural hematoma or an internal bleed. In an interview with LVN A on [DATE] at 10:53 AM, she said she sent a message to the NP regarding the resident falling. She said she had proof she sent a text message to the NP but could not remember when she sent the text message. She said she told the NP the resident fell and hit her head, but she was okay. She said the NP gave orders to continue to monitor the resident. She said she did not tell the NP the resident had a small bump on the back of her head because she did not initially have the bump when she notified the doctor. She said she did not know how long it was between the time she notified the NP of the fall and the time the resident developed the small bump on the back of the resident's head. She said when a physician gave an order for monitoring, it was for staff to monitor for changes in the resident's condition. She said she followed the NP ' s directives to monitor the resident. She said she said immediately began neuro checks and continued to monitor the resident. She said she did not think about notifying the NP the resident developed a small bump on the back of her head, after falling. She said she did not think the resident was at any sort of risk because she said a man who witnessed the resident ' s fall told her the resident may have hit her shoulder or another body part on the way down to the floor. She said that may have softened the blow if the resident did hit her head. She said she did not think the resident was put at any risk because the resident did not suffer from a bad fall. She said she probably should have notified the NP the resident had a small bump on her head. She said she could not recall whether she contacted to hospice to notify them of the incident. In an interview with the DON on [DATE] at 11:58 AM, she said they went through the resident's chart the next day, as a whole team. She said at that time, nothing stuck out to her about the nurse's documentation or concern because she saw the nurse noted she made notification. She said from what she read, they notified the NP and there were no new orders. She said she did not ask any of the nurses if the NP was notified about the bump on the back of the resident's head. She said she was notified by either LVN A or the Weekend Supervisor of the resident's fall on [DATE]. She said LVN A should have also communicated to the doctor the resident had a bump on the back of her head when LVN A notified the NP of the incident. She said the only thing that was concerning to her was LVN A did not tell Resident #1's NP the resident hit her head or had a small bump on the back of her head. She said the resident could have been at risk for not receiving appropriate care due to the physician not being notified the resident had a bump on the back of her head. Interview with the Administrator at 1:04 PM on [DATE], she said the assigned nurse was supposed to notify the DON, NP, family and then hospice. She said it was the responsibility of the nurse providing care to the resident to continue the care and communicate on behalf of the facility because they were the ones with the rapport with the family and doctor for that resident. She said as far as documentation, she reviewed the change of condition form and made sure all the pertinent information was there. She reviewed the incident/accident report to see what happened, if the nurse did an assessment, who the nurse notified, and reviewed the summary of the incident. She said the nurse was also to document any other assessments completed, whether neuro checks had been done, new orders received, and any changes of condition identified in the resident. She said she did not feel the resident was at risk or that the outcome would have been changed in any way because she had a bump on her head. She said the staff typically did not document anything when they communicated with physicians, unless a new order was given, or if they were asked to monitor the resident. She said the NP just said ' okay ' in response to being notified about the resident's fall. She said she had spoken to the NP since the incident and the NP said she would not have sent the resident out to the hospital. She said while the situation was handled appropriately, there was always room for improvement. She said the only thing she felt could have been improved on was more detail in documentation because documentation was key. She said she spoke the doctor about the situation and the doctor said he would not have sent the resident out, even if he had been notified the resident fell and had a small bump on her head. Record review of the undated policy, titled, Fall Prevention Program revealed the following: .9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident ' s care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Record review of the policy, revised February 2021, titled, Change in a Resident ' s Condition or Status revealed the following: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a(an): a. accident or incident involving the resident .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status . Record review of the undated policy, titled, Notification of Changes revealed the following: The facility must inform the resident .consult with the resident ' s physician and/or notify the resident ' s family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents a. Resulting in injury. B. Potential to require physician intervention . Record review of the undated policy, titled, Head Injury revealed the following: It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy Explanation and Compliance Guidelines: 1. Assess resident following a known, suspected, or verbalized head injury. The assessment tool shall include, at a minimum: a. Vital Signs. b. General condition and appearance. c. Neurological evaluation for changes in: i. physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech or slow to answer questions d. Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell or bleeding. e. Any injuries to head, neck, eyes, or face, including lacerations, abrasions, or bruising. f. Pain Assessment . 3. Notify physician and follow orders for care. a. Provide information from physical assessment. b. Describe how injury occurred and how situation has been managed so far. c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. d. Any recent lab or diagnostic test results. 4. Perform neuro checks as indicated or as specified by the physician . 6. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 7. Notify family and document all assessment, actions, and notifications. Record review of the policy, revised [DATE], titled, Falls-Clinical Protocol revealed the following: 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc . 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. those that occur while upright and attempting to ambulate; and c. other circumstances such a sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Monitoring and Follow-Up 1. The staff, with the physician ' s guidance, will follow up on any fall with associated injury until the resident is table and delayed complications such as fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling . Record review of the undated policy, titled, Incident and Accidents revealed the following: It is the policy of this facility to utilize the Risk Management Module in the electronic health records to report, investigate, and revie wany accidents or incident that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refer to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . Policy Explanation The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care .Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines .5. The following incidents/accidents require an incident/accident report but are not limited to: .Equipment malfunction; Falls; Observed accidents/incidents . 6. In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so . 8. The supervisor or other designee will be notified of the incident/accident . 9. The nurse will contact the resident ' s practitioner to inform them of the incident/accident, report any injuries or other finding, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). 10. In the event of .or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner . 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. 15. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for two of two medication carts (B Hall medication cart and medication cart in the secure unit) reviewed for storage of medications. 1. The facility failed to ensure B Hall medication cart and the medication cart in the secure unit did not contain torn protective seals on the back of narcotic medication blister pill cards. 2. The facility failed to ensure the B Hall medication cart did not have loose pills. 3. The facility failed to ensure eye drops were labeled and medications had the expiration dates in the B Hall medication cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings include: 1. Observation on 07/12/2023 at 9:35 AM of B Hall medication cart revealed the locked narcotic storage compartment contained 10 tablets of Lorazepam 0.5 mg in a blister card. Blister compartment number 10 had a torn seal that was taped closed on the back of the blister card. The narcotic count for the Lorazepam was accurate. There were loose pills found at the bottom of the second drawer: one small round pink pill with number 1081 and one small round white pill with numbers 502. A packet of AZO Urinary Pain relief tablets in a blister type package contained 20 brown tablets were found in the top drawer. The package did not have an expiration date. The original package was not in the cart. There were 2 bottles of artificial tears lubricant eye drops in the top drawer. The bottles and the box for the eye drops did not have resident identifiers or an opened date. Both bottles contained fluid. In an interview on 07/12/2023 at 9:35 AM, RN A stated the Lorazepam was taped probably because the back of the package had a tear. RN A stated the tablet should be discarded d/t the risk of infection and the tablet could have been replaced with a different tablet that was not Lorazepam. RN A stated she would notify the DON and the tablet would be destroyed per facility policy. RN A stated the nurses were responsible for maintaining the medication carts and she cleaned the cart regularly. RN A stated the loose pills could fall out and someone could take it and it could cause harm to them. RN A stated the AZO Urinary Pain relief tablets should have expiration dates like all the other medications in the cart. RN A stated both bottles of artificial tears had been opened because the seals were gone and some of the liquid had been used. RN A stated she had not used the bottles and did not know how they got in the cart or which resident they would have been used for. RN A stated she would notify the DON and put the bottles and the packet of urinary pain relief tablets in the medication destruction box. RN A stated the risk of using these bottles of artificial tears on a resident would be eye infection because the same bottle of eye drops should not be used on different residents. 2. Observation on 07/12/2023 at 4:00 PM of the medication cart in the secure unit revealed the locked narcotic storage compartment contained 31 tablets of Lorazepam 0.5 mg in one blister card. Blister number 18 had a tear on the back of the package. A second Lorazepam 0.5 mg blister card contained 9 tablets. Blister number 8 had a tear on the back of the package. The narcotic count for the Lorazepam was accurate. In an interview on 07/12/2023 at 4:00 PM, LVN A stated the risk of having the Lorazepam with a tear in the packaging was the pill could fall out, a resident might pick it up, eat it and they may get harmed. LVN A stated the risk could also be loss of medication supply for the resident it was intended for. LVN A stated she would go to the DON for advice on what to do with the tablets. In an interview on 07/12/2023 at 4:00 PM, the DON stated the Lorazepam with the torn seal should be discarded. In an interview on 07/12/2023 at 6:50 PM, the DON stated the nurses were supposed to maintain the cart daily as needed. The DON stated if a medication should drop, they were supposed to destroy it and the risks would be someone could steal the Lorazepam tablet or someone could accidentally pick it up and ingest it. The DON stated his expectation was the nurses double checked the narcotic medication count against the count sheet for accuracy, loose pills and pills in torn controlled substance blister cards should be destroyed. The DON stated the nurses were responsible for discarding medications per facility policy and the DON or the ADON were responsible for conducting nursing staff in-services covering medications and controlled substances. The DON stated he was unsure when the last in-service took place. Record review of the facility policy for Controlled Substances, revised April 2019, read in part: Policy Statement: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation .8. Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift . Record review of the facility policy for Storage of Medications, revised November 2020, read in part: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Record review of the facility policy for Medication Storage in the Facility, revised August 2014, read in part: B. Drug dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1)The nurse shall place a 'date opened' sticker on the medication and enter the date opened and the new date of expiration .

Based on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 7 residents (Resident #15) reviewed for medication administration and 1 of 2 medication carts (B Hall medication cart) reviewed for accounting. 1. The facility failed to ensure an accurate recordkeeping of liquid Lorazepam (a controlled substance) from the B Hall medication cart. 2. The facility failed to check Resident #15's blood pressure prior to administering Metoprolol used to treat high blood pressure. 3. The facility failed to ensure Resident #15 received the prescribed nebulizer treatment by leaving the medication at the bedside for the resident to self-administer. The resident did not have an order to self-administer the medication. Findings include: 1. Observation and record review on 07/12/2023 at 9:35 AM revealed the B hall medication cart's locked narcotic compartment contained a bottle of Lorazepam 2mg/1ml which contained between 10ml and 12ml of fluid according to the measurements on the side of the bottle label. The controlled drug receipt/disposition form listed the following entries: -06/05/2023 at 5:30 PM, RN B documented 0.5ml was given and the amount left in the bottle was 16 ml. -06/10/2023 at 5:30 PM, RN A documented 0.5ml was given and the amount left in the bottle was 15.5ml. -07/07/2023 at 10:00 AM, RN A documented 0.5ml was given and the amount left in the bottle was 15ml. -07/07/2023 at 1:00 PM, RN A documented 0.5ml was given and the amount left in the bottle was 14.5ml. -The last entry was on 07/09/2023 at 10:00 AM, RN A documented that 0.5ml was given and the amount left in the bottle was 14ml. In an interview on 07/12/2023 at 9:35 AM, RN A stated the bottle of Lorazepam came from Hospice Services. RN A stated she would notify the DON about the discrepancy between the amount left in the bottle and the balance written on the narcotic sheet. In an interview on 07/13/23 at 9:45 AM, the DON stated the bottle of liquid Lorazepam 2mg/ml contained 11.5ml. The DON stated the nurses needed to track this more closely and that he did not think there would be any problems with controlled medications in liquid form. In an interview on 07/13/23 at 9:50 AM, RN B stated it was his signature on the controlled drug receipt/disposition form for the Lorazepam 2mg/ml from 05/24/23 to 06/05/23. RN B stated the liquid in the bottle was hard to see and he always compares what was in the bottle to what was written on the form. RN B stated on 06/05/23 the count was correct and he did not know why there was a discrepancy on 07/09/23 because he did not sign anything out after 06/05/23. RN B stated the nurses were responsible for documenting accurately. In an interview on 07/13/23 at 10:50 AM, RN A stated it was her signature on the controlled drug receipt/disposition form for the Lorazepam 2mg/ml from 06/10/2023 to 07/09/2023. RN A stated the liquid tended to leak around the syringe and bottle whenever a dose was removed, and this would account for some liquid loss. RN A stated she was responsible for documenting accurately on the sheets. RN A stated when discrepancies were found, then corrections were made. RN A stated moving forward corrections would be made in time and hoped they would get prefilled syringes instead. In an interview on 07/13/23 at 1:30 PM, the DON stated the liquid Lorazepam estimated loss was 6 doses based on each administered dose being 0.5ml and the estimated volume remained was closer to 11ml. The DON stated moving forward it was decided a self-report would be submitted and all staff who had access to the box would be drug tested in case of drug diversion. The DON stated the facility would no longer accept multidose liquid bottles of controlled medications d/t the difficulty to accurately track the remaining volume of liquid. The DON stated the manufacturer label on the bottle read: approximate volume of solution was in the bottle. Record review of the NDC 0054-3532 Lorazepam label information solution, concentrate oral, details, usage, and precautions, ndclist.com, revised February 2017, read in part: .Lorazepam is a federal controlled substance (C-IV) because it can be abused or lead to dependence. Keep Lorazepam in a safe place to prevent misuse and abuse. Selling or giving away Lorazepam may harm others and is against the law . Record review of the facility's policy for Controlled Substances, revised April 2019, read in part: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .10. Upon Administration: a. The nurse administering the medication is responsible for recording . (5) quantity of the medication remaining .12. At the end of each shift: A. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. B. Any discrepancies in the controlled substance count are documented and reported to the director nursing services immediately. C. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the administrator. D. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action is indicated .1. Policies and procedures for monitoring-controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. Record review of the facility's policy for Medication ordering and Receiving from Pharmacy, revised August 2014, read in part: Medication Packaging, medications are provided in packaging to facilitate accurate administration and accountability of the medication. All packaging meets USP (United States Pharmacopeia) standards . 2. Record review of Resident #15's admission record face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included critical illness myopathy (a disease of limb and respiratory muscles observed during treatment in the intensive care unit), obstructive sleep apnea (a sleep related breathing disorder), HTN (elevated blood pressure), hyperlipidemia (elevated fats in the blood), morbid obesity, heart disease, atrial fibrillation (irregular, rapid heart rhythm), lymphedema (tissue swelling), depression, and urinary tract infection (an infection that affects any part of the urinary system). Record review of Resident #15's admission MDS, dated [DATE], revealed she had a BIMS score of 15, which indicated intact cognition. She required extensive assistance with most ADLs. She required oxygen therapy and non-invasive mechanical ventilator (BIPAP-therapy to treat sleep apnea). Record review of Resident #15's physician order summary report, as of 07/11/2023, revealed an order for Budesonide inhalation suspension 0.5/2ml, one application inhale orally two times a day for shortness of breath. The order date was 06/25/2023. Metoprolol succinate ER oral tablet extend release 24 hours 25mg, give one tablet by mouth two times a day for BP. Hold for SBP less than 110 and DBP less than 60 or HR less than 60. The order date was 06/25/2023. Further review of the physician order revealed there was no order for self-administration of medications. Record review of Resident #15's, undated, care plan revealed she had the potential for impaired gas exchange r/t exhibiting SOB/trouble breathing when laid flat. Interventions included: check O2 saturations and provide respiratory treatments as ordered. Further review of the care plan revealed there was no plan addressing the diagnosis of hypertension. During observation and interview of a medication pass on the evening of 07/11/2023 at 8:15 PM, LVN B administered medications to Resident #15 which included Metoprolol ER 25mg oral tablet. LVN B then checked Resident's BP on her right wrist using a wrist BP monitor. LVN B said the BP was 71/30 and it was too low. LVN B checked her oxygen saturation rate on her right hand, and it was 97% and the pulse was 61. LVN B checked Resident #15's BP on her left arm using a manual BP cuff and stethoscope. LVN B wrapped the BP cuff upside down around the resident's left forearm, instead of the upper arm and with the BP tubing pointing towards the shoulder. LVN B placed the bell of the stethoscope at the anterior aspect of the elbow joint. LVN B said the BP reading was 124/72. LVN B poured the liquid Budesonide inhalation suspension 0.5/2ml into the chamber of the nebulizer tubing, reattached the nebulizer face mask then hung the strap of the facemask onto a basket that was on the bedside table and moved the bedside table closer to the resident. LVN B asked the resident if she could reach the equipment. The compressor nebulizer machine was turned off and was on top of the nightstand within the resident's reach. Resident #15 stated she could reach the mask as well as the machine and would start the breathing treatment when she could bend her right arm after the IV was complete. LVN B walked out of the room and said he would check on her later. LVN B stated he forgot to check her BP before administering the Metoprolol. LVN B stated the risk to the resident was the BP could drop. LVN B stated he used a medium BP cuff because there was no larger cuff available. LVN B stated he was ex-military and checking BP on the lower arm was what was done out in the field. LVN B stated he knew checking the BP on the forearm would result in a reading that would be off and not as accurate. LVN B stated checking the BP this way was not facility policy. LVN B stated he should have re-checked using the wrist BP monitor on the resident's left wrist. LVN B had no explanation as to why he didn't do this instead of using the manual cuff. LVN B stated it was not the facility policy to leave the breathing treatment medication at the bedside and then walk away. LVN B did not have an explanation as to why he walked away with the medication at the bedside. LVN B returned to the resident's room and emptied the nebulizer chamber of the liquid Budesonide. LVN B stated he would return after the IV was completely infused, administer the nebulizer treatment, and make sure the resident took the medication correctly before walking out of room. LVN B stated he usually checked the resident's vitals before administering medications, but he was thrown off his routine d/t earlier issues with another resident. In an interview on 07/12/2023 at 6:50 PM, the DON stated the nurse was supposed to check Resident #15's BP before administering the Metoprolol and to use the manual BP cuff correctly by wrapping the cuff around the upper arm with the tubing pointing down the arm. The DON stated the facility did have a large BP cuff available but would check the cart to make sure. The DON stated LVN B was trained on the use of a BP cuff. The DON stated the nurse was not supposed to leave the Budesonide breathing treatment at the bedside and walk away. The DON stated, normally the facility staff went over self-administration of medications with the resident and then got an order from the physician. The DON stated the risks of leaving a breathing treatment for the resident to self-administer would be infection as it would be unsanitary to just leave it, the resident may not receive the full treatment and the nurse was supposed to monitor and ensure the resident was tolerating the treatment well. The DON stated LVN B did not follow policy. The DON stated he expected a self-administration order in place prior to leaving a resident with any medication. The DON stated he would conduct a one-on-one training with LVN B. The DON stated the facility did not have a written policy and procedure for the use of blood pressure cuffs. Record review of Resident #15's, blood pressure summary revealed LVN B rechecked her blood pressure on 07/12/2023 at 12:24 AM. The result was 121/72 lying down taken on the right arm. Record review of LVN B's Competency Checklist, dated 2/26/2023, revealed he did not require further training and the competency was completed on 3/23/2023. The checklist included medications administration and vital signs which included blood pressure. The checklist included performing nebulizer treatments. Record review of the facility's policy for Administering Medications, revised April 2019, read in part: Policy heading - Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame .11. The following information is checked/verified for each resident prior to administering medications .b. Vital signs, .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely Record review of the facility's policy for Administering Medications through a Small Volume (Handheld Nebulizer, revised October 2010, read in part: Purpose - the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure .13. Turn on the nebulizer and check the outflow port for visible mist .17. Remain with the resident for the treatment .18. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness, and nervousness throughout the treatment

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #44) reviewed for care plans. The facility failed to implement Resident #44's care plan by failing to ensure bed rails were installed on the resident's bed frame. This deficient practice could place residents at risk for not receiving appropriate care and services. Findings Include: Record review of Resident #44's face sheet, dated 07/12/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44 had diagnoses which included dementia with other behavioral disturbance (problems with memory, thinking, and behavior), morbid obesity (excess weight), polyneuropathy (damaged nerves), quadriplegia unspecified (pattern of paralysis), and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid). Record review of Resident #44's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 out of 15, which indicated she was cognitively intact. Resident #44 required two-person physical assist with bed mobility and one-person physical assist with transferring, toileting, and bathing. Record review of Resident #44's Care Plan, dated 08/02/2022, read in part .Focus: [Resident #44] utilizes an enabling device (1/4 bed rails) to help with positioning, provide a sense of comfort/security, and/or promote independence poor balance admit to [name of hospice] under the continued care of [physician's name], date initiated: 09/07/2022. Intervention: [Resident #44] will utilize 1/4 bed rails to promote increased independence Record review of Resident #44's orders, dated 04/26/2023, read in part .Bed Rail(s): bilateral one-quarter bed rail(s) installed as enabling device Record review of Resident #44's Informed Consent for Bed Rail Use revealed it was completed, signed, and dated on 04/24/2023 by the resident's family member. Record review of Resident #44's Bed Rail Safety Review, dated 04/24/2023, was completed and signed. Further review revealed recommendation to continue with bed rail(s). Observation and interview on 07/11/2023 at 10:01 a.m. of Resident #44 was completed. Resident was observed lying in bed reading a book. Her bed frame did not have attached bed rails. She said she wanted to know why she could not have bed rails. She said she used to have bed rails but did not know why she no longer had them. She said the bed rails helped her to reposition herself. Observation on 07/12/2023 at 12:30 p.m. revealed Resident #44's bed frame did not have attached bed rails. In an interview on 07/12/2023 at 4:56 p.m., the DON said Resident #44's assessment, consent, and orders for the bed rails were completed. He said the bed rails were also care planned. He said he did not know why the rails had not been installed. He said the resident's bed had switched a lot since she was admitted to the facility. He said the nurse was responsible for ensuring the bed rails were implemented. He said he talked with the nurses and was not able to determine who and when the bed was changed out last. He said the risk posed to the resident from not receiving the bed rails was that it could make it more difficult for them to turn . Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, read in part . .4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. receives the services and/or items included in the plan of care

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessment for 1 of 17 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan was revised to include interventions for falls to help prevent injuries. This failure could place residents at risk of not having their needs addressed and inconsistency of care. Findings include: Record review of Resident #7's face sheet, dated 07/13/2023, revealed a [AGE] year-old male who was admitted into the facility on [DATE]. The resident had diagnoses which included alcohol dependence with alcohol-induced persisting dementia, degenerative disease of nervous system, hypertension, and quadriplegia. Record review of Resident #7's admission MDS, dated [DATE], revealed the resident was assessed to need substantiated to maximal assistance with transfer and the resident was assessed to have had a fall within the last month prior to admission. The resident's BIMS score was 7, which indicated the resident's cognition was severely impaired. Record review of Resident #7's care plan, last revised on 07/13/2023, revealed Resident #7 had actual falls related to poor balance, poor safety awareness and unsteady gait and actual falls occurred on 05/01/2023 due to sliding off the bed, and on 05/05/2023, 05/21/2023, 05/30/2023 and 06/08/2023. The intervention of a fall mat use for resident falls was added after State Surveyor intervention on 07/13/2023. Observation and interview on 07/11/2023 at 10:15AM, revealed Resident #7 was lying in bed with a fall mat to the side of his bed and stated he could get around okay on his own without assistance. In an interview on 07/13/2023 at 3:12PM, CNA T stated Resident #7 did not know how to use his call light and managed multiple times to transfer himself in his chair even with the wheelchair placed out of reach. She stated the resident had a fall mat since he was first admitted , in April 2023 and she believed the resident needed the mat to prevent him from acquiring bruises when he fell after scooting himself out of bed and onto the floor. In an interview on 017/17/2023 at 3:24PM, LVN A stated Resident #7 needed the fall mat because she believed he had a condition similar to restless leg syndrome which caused the resident to often scoot to the edge of his bed and increased his risk of falling. She stated the fall mat was used and should be listed on his care plan as one of his interventions for falls. In an interview on 07/17/2023 at 3:35 PM, the DON stated Resident #7's care plan needed to be updated to ensure all necessary interventions for falls were listed in his care plan to ensure he was not at increased risk for injuries. Record review of the facility's policy on Falls, revised March 2018, stated, . If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions Record review of the facility's policy on Care Plans, revealed, no information regarding revision timing of care plans.

Based on observations, interviews, temperature log review, and facility policy and procedure review, the facility failed to ensure food was served in accordance with professional standards for food service safety. Specifically, the dishwasher did not reach the appropriate temperature to sanitize the dishes. The deficient practice affected 40 of 44 residents of the facility who received meals from the kitchen. Findings included: A review of the policy titled, Sanitization, revised October 2008, revealed, Dishwashing machines must be operated using the following specifications: Low-Temperature dishwasher (chemical sanitation) wash temperature (120 degrees F [Fahrenheit]). A review of the D2 TimeSaver dish machine specification sheet, undated, revealed the minimum water temperature of the dish machine should be 120 degrees F. Observations of the dishwasher in the kitchen on 06/02/2022 between 1:08 PM and 1:28 PM revealed the dishes from the lunch meal were being washed. During the observations, the dishwasher ran five loads of dishes and the thermometer of the dish machine did not read above 110 degrees F and ran as low as 95 degrees F during the first load. As the surveyor was exiting the kitchen, Dietary Aide (DA) A was loading a sixth load of dishes into the machine. During an interview with the Dietary Manager (DM) on 06/02/2022 at 1:33 PM, he stated he was not sure what the appropriate temperature of a low temperature machine should be. He stated the appropriate rinse temperature for low temperature machines should be 110-115 degrees F. He stated the registered dietitian provided guidance for the appropriate temperature of the dish machine. He stated it was important for the dish machine to rinse at the proper temperature to kill the germs and bacteria on the dishes and provide effective cleaning. During an interview with DA A on 06/02/2022 at 2:50 PM, she stated the dishwasher temperature should run at 120 degrees F for effective dish washing. She stated she checked the temperature of the machine after the fifth load of dishes, and it was reading low at 110 degrees F. She stated she informed the DM and continued to do dishes in the dish machine. She stated if the dishwasher was reading at a low temperature, it should not be used, and the dishes should be done by hand. She stated all the lunch dishes were run through the dishwasher and placed on the racks for use at the dinner meal. The dishes were not re-washed. During an interview with the Registered Dietitian (RD) on 06/02/2022 at 1:51 PM, she stated the low temperature dish machine rinse temperature should be 120 degrees F. She stated she checked the temperature weekly when she visited the facility. She stated there had been no issues brought to her attention about the temperature of the dish machine. She stated if an issue was suspected the facility had another thermometer that should be used to check rinse temperature. She stated 110 degrees F was not a safe rinse temperature. A review of the Temperature Log sheet, dated 6/02/2022, for the lunch meal dishes, indicated a dishwasher rinse temperature of 110 degrees F. No other temperatures for May 2022 or June of 2022 were out of range. During a follow-up interview with the DM on 06/02/2022 at 2:00 PM, he stated DA A informed him of the temperature being low but not as low as 110 degrees F. He stated the dish machine should have been stopped and the lunch dishes should have been washed by hand in the three-compartment dish sink. During an interview with the dishwasher Service Representative (SR) on 06/02/2022 at 2:31 PM, he stated the service provided to the dish machine at the facility included temperature monitoring. He stated he was in the facility to check the dish machine every two weeks. He stated there were no issues with the dish machine thermometer or temperature of the dish machine on 05/24/2022. He stated the dish machine usually ran at 125 degrees F. He stated the minimum temperature at which the facility dish machine should be run was 120 degrees F for effective cleaning and sanitization of the dishes. During an interview with the Director of Nursing (DON) on 06/02/2022 at 3:11 PM, he stated he was not familiar with safe dishwashing temperatures for the dishwasher in the kitchen. He stated any issues with the dish machine temperature were reported to the maintenance director and the dish machine service representative. During an interview with the Administrator on 06/03/2022 at 11:31 AM, she stated no residents had been sent out to the hospital with stomach issues in the past 24 hours. She stated if dietary staff members noticed the temperature of the dish machine was low, they were to notify the DM immediately and await further instructions. She stated washing dishes at improper temperatures could lead to improper sanitization. She stated no temperature issues had been brought to her attention in the past. Texas Administrative Code (TAC) §554.354(g)(1)(F), Tag 0820. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 06/03/2022, F812.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (Resident #33) of one resident who was fed by enteral means (a feeding tube) received the appropriate treatment and services to prevent complications of enteral feeding (tube feeding), including but not limited to, aspiration pneumonia. Specifically, the facility failed to ensure Resident #33's bed was not in a flat position when the resident's enteral feeding was actively running. Findings included: A review of the facility policy titled, Enteral Feedings - Safety Precautions, revised November 2018, revealed, Purpose: To ensure the safe administration of enteral nutrition .Preventing aspiration .3. Elevate the head of the bed (HOB) at least 30[degrees] during tube feeding and at least 1 hour after feeding. A review of the Admission Record revealed the facility readmitted Resident #33 on 04/09/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed with the resident. The Staff Assessment for Mental Status indicated the resident was severely cognitively impaired. The resident required one person's physical assistance for bed mobility, eating, and personal hygiene. A review of the June 2022 physician's orders revealed the resident was NPO (nothing by mouth). A review of the June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the undated care plan revealed the resident required a tube feeding related to swallowing disorder, dementia, and cancer. The interventions included to encourage and assist the resident to elevate the head of bed as tolerated. On 05/31/2022 at 12:10 PM, Resident #33 was observed in their room. The resident was connected to their enteral feeding system and the tube feeding was running. The observation revealed the resident's bed laid flat when their tube feeding was running. On 05/31/2022 at 12:20 PM, Registered Nurse (RN) E was observed to enter Resident #33's room. RN E acknowledged the resident's feeding tube was connected and running. Upon observing the resident in bed, RN E immediately got a hold of the bed's remote control and raised the head of the bed. RN E stated the bed was not at her preferred angle. RN E stated she preferred to have the head of the bed raised to an angle of between 30-45 degrees. She acknowledged the resident's head was on a pillow. However, the head of the resident's bed was flat. During an interview on 06/01/2022 at 12:42 PM, Licensed Vocational Nurse (LVN) P stated that she was in the resident's room to assist Certified Nurse Aide (CNA) F with turning the resident. She stated that RN E had turned off the tube feeding machine prior to when the repositioning was carried out with Resident #33. LVN P stated that the bed was adjusted to an angle of approximately 20 degrees during the repositioning. She stated the facility had no tool with which they measured the angle the bed was at. Per LVN P, she had never had a measuring tool to determine the angle of a bed from any facility before. LVN P stated she could not give a definitive angle she left the resident's bed after she completed care with the resident. She stated that she just knew the head of the bed was not flat. During a follow-up interview with RN E on 06/01/2022 at 1:12 PM, she stated she reported the observation on 05/31/2022 to the Assistant Director of Nursing (ADON) and that an in-service was started immediately. On 06/01/2022 at 1:14 PM, Administrator in Training (AIT) B and the Administrator were interviewed. AIT B stated the facility's attention was brought to the surveyor's observation related to Resident #33's bed angulation when the resident was actively feeding through their tube feeding machine. AIT B stated the Administrator instructed him to conduct an in-service with staff on the proper angle required of the head of bed when a resident was actively being fed through enteral means. AIT B stated the head of the bed should be at an angle of 30 to 45 degrees when a resident was actively connected to a running tube feeding machine. On 06/01/2022 at 2:05 PM, during an interview, the Director of Nursing (DON) stated that the tube feeding was administered via dual pump. The DON stated the machine function was such that one side was for feeding and the other was for flushing. Per the DON, the facility was to follow physician orders when providing care to residents on tube feeding. The DON indicated the requirement for tube feeding to include, but not limited to, keeping the head of the bed at an angle of 30-45 degrees when a resident was connected to an actively running tube feeding machine to help prevent aspiration. The DON clarified that if a resident's bed was completely flat, having the resident's head on just the pillow would not suffice for the required angulation. During an interview on 06/03/2022 at 2:09 PM, the facility Medical Director (MD) stated that it was important to have the head of the bed elevated to at least an angle of 30-45 degrees when a resident was actively feeding through enteral means. The MD stated that a few exceptions existed such as when the resident had decubitus and the angulation could affect the exertion of pressure to the area. He stated that regardless of any other underlying condition, the bed should not be completely flat to prevent the resident from aspiration. Texas Administrative Code (TAC) §554.901(6)(E), Tag 1466. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 06/03/2022, F693.

Based on observation, interview, and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #1) of 6 residents reviewed for call light access. The facility failed to ensure Resident #1's call light was in reach. This failure placed residents at risk of not having their needs and preferences met and a decreased quality of life. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's baseline care plan with effective date 12/28/2021 revealed Resident #1 needed assist of 1 for bed mobility; assist of 2 for transfer, walks with assist of 1 for locomotion/ambulation, incontinent/wears briefs for toileting. The baseline care plan also indicated Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included orient to room/call bell, encourage to ask for help, place assistive device within reach Interview and observation on 01/04/22 at 11:02 AM, Resident #1 was observed sitting in her wheelchair right next to her bed. Resident #1 said she needed help with her underwear, she had not been able to get much help, she had been at the facility since Sunday. She also said she did not belong there and she wanted to go home. Resident #1 said she does not use the call light for help. The call light was on the floor behind her bed. Interview with the RN A on 01/04/22 at 11:06 am., she said she was not the charge nurse for Hall C, the charge nurse for Hall C should be RN B, and surveyor was not able to find anybody else present near Hall C. Surveyor asked RN A to help out Resident #1. RN A said the call light was not supposed to be on the floor , the nurses should make sure the call lights are within reach of the resident. She said sometime the resident may drop the call light unintentionally. Interview with RN B on 01/04/22 at 12:02 pm., she said she's the charge nurse for Hall C, she said they are supposed to be checking on every resident hourly, and residents should be able to reach their call lights. The last time she checked Hall C was around 10:00 am to 10:15 am and she did not notice the call light for Resident #1 was on the ground. She will go check on the call light again immediately. Interview with the ADON on 01/04/22 at 1:26 pm, she said staff should make sure the residents have their call light in reach in order for staff to be notified when residents needed something, and the nurses should be doing their rounds every 2 hours to check on the residents. She will address this with the DON and staff on this topic. Review of policy titled Routine Resident Checks which revealed staff shall make routine resident checks to help maintain resident safety and well-being. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.

Based on observation, interview and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 9 residents (Resident #1) reviewed accuracy of assessments, in that: Resident #1's quarterly MDS assessment did not reflect Resident #'s current transfer assistance/need . This deficient practice could affect residents and place them at risk of inadequate care. The findings included: Resident #1 Record review of Resident #1's medical record face sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan dated 10/17/2017 stated she was limited assist x 1 a person for transfers. Further review revealed care plan was not updated since 10/17/2017. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she required limited assistance of one person for transfers. Record review of CNAs ADL documentation look back for Resident #1 used to complete the above MDS revealed the resident's record had only three ADL entries : one was dependent for transfers and two indicated the resident required assistance of staff. In an interview on 04/08/2021 at 12:32 pm, Resident #1's nurse, LVN B, she said that Resident # 1 needed assistance of two people with Hoyer lift for Transfers. She said he needed extensive assistance for his unsteady balance and was at risk for falls. In an interview on 04/08/2021 at 12:56 pm, Resident #1's CNA, CNA C, she said that Resident # 1 needed assistance of two people with Hoyer lift for Transfers. She said he needed extensive assistance for his unsteady balance and was at risk for falls. Observation and interview with Resident # 1 on 04/08/2021 at 1:40pm Resident #1 said she was doing well and she likes been in the facility. She said that one day the battery on a Hoyer was not working but the staff replaced the battery and the Hoyer worked and they transferred her with a Hoyer. She said that the staff always use the Hoyer lift to transfer her. In an interview on 04/08/2021 at 1:50pm MDS coordinator A said that Resident #1 prefers Hoyer lift for all her transfers. She Said that maybe therapy determines who supposed to be transferred on a Hoyer Lift but she not sure. In an interview on 04/08/2021 at 2:21pm DOR said, when the resident declines the staff will notify the therapy department and the therapy will screen the residents and will recommend the mode transfer after discharging from therapy. She Said that Resident #1 was recommended to uses a Hoyer lift for transfers last year. In a further interview on 04/08/2021 at 2:27pm MDS Coordinator A said that she added the mechanical lift care plan on 04/08/2021 at around 10am in the morning and she was running behind from on completing MDS assessments and care plan because of the full book and the winter storm. In an interview on 04/08/2021 at 3:10 pm, MDS Coordinator A said that she got ADL's from CNA documentation. She said the care plan should match the latest MDS assessment. She coded the ADL's transfers on Resident #1 based on the CNA documentation in the look back. She said she know that Resident#1 uses a Hoyer lift, but she coded based on what was documented by CNA because that was the documentation that the OIG will look at and she doesn't want money to be take away when her MDS coding does not match CNA documentation. She Said that moving forward she will review CNA documentation before completing the MDS. In an interview on 04/08/2021 at 3:31 pm, Interim DON said MDS and care plan must reflect the resident status. She said that she will have therapy screen Resident #1 again and train CNAs on proper documentation that will reflect resident's current condition. She said MDS coordinator must assess resident prior to completing the MDS so that she can code the MDS based on the resident status. She said MDS coordinator was under the leadership of the administrator. In an interview on 04/08/2021 at 4:00pm with administrator said that they have noticed that the MDS coordinator was not coding the MDS assessment right and they had initiated some training on ADL's documentation and MDS completion Record review of the facility's undated MDS completion policy read in part . our facility will conduct and submit resident's assessments in accordance with the current federal and state timeframes and guidelines. Record review of the facility's undated care plan policy read in part . The comprehensive, person centered care plan is developed within (7) days of the completion of the required comprehensive assessment (MDS) 13. Assessments of residents are ongoing and care plans are revised as information about residents and the condition change.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 7 residents (Resident #3) reviewed for Activities of Daily Living (ADLs). Resident #3 was not provided a shower for a week. This failure placed resident who require assistance with bathing at risk of diminished quality of life, infection, impaired skin integrity, and loss of dignity and self-worth. Findings included: Record review of Resident #3's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 6 out 15 indicating severe cognitive impairment. Further review of the MDS revealed he needed physical help in part for bathing activity with the assist of one person. Record review of Resident #3's undated care plan revealed he was able to shower himself with supervision and set up from staff. Interview on 4/8/2021 at 12:00 PM, an ex-employee said Resident #3 told her on 4/5/21 he had not received a bath the past two days. The ex- employee said Resident #3 was supposed to get his baths on the evening shift but the CNA's assigned to him were not doing their showers. Interview on 4/8/21 at 1:00 pm, CNA C said there was a shower schedule they followed and residents either got their showers on Monday, Wednesday, Friday or Tuesday, Thursday, Saturday depending whether they were in the A bed or the B bed. CNA C said they would receive shower in the morning (7a - 7p) or the evening (7p - 7a) based on whether they were in an even or odd room. CNA A said there was some times where showers were running behind or missed because it became a busy day where she just was not able to get to it and she would either give the resident who missed their shower one the following day or ask the evening shift if they could give the shower. She denied ever having a situation where she was not able to give showers for several days. CNA C said there was mostly agency staff who worked on the warm hall and said she knew there was some issues with some residents getting their showers in the evening on that hall. CNA C said CNA's should document when they complete showers on shower sheets and mark it in the computer on the POC. She said the shower sheets are turned into the charge nurse and they put them in a box outside the DON's office. CNA C said if a resident refuses a shower, they should document the shower was refused. Interview and observation on 4/8/2021 at 3:30 PM, Resident #3 was located in his room on the warm hall (quarantine hallway) sitting in his wheelchair. Resident #3 said he had not received a shower since he's been on the warm hall which had been since he came back from the hospital (7days). Resident #3 agreed he returned from the hospital on 4/1/21. Resident #3 said he had asked the evening CNA's for his shower and they said they would do it and would never come back to give him the shower. Resident #3 did not know who the CNA's were he had asked and said he did not recognize the staff that worked on the warm hallway. Resident #3 said he wasn't sure which days were his showers days since he was on the warm hall but said he was told the evening shift CNA was the person that was supposed to give him a shower. Resident #3 said he had not complained to anyone about not getting a shower because he did not want to get anyone in trouble. Resident #3 said he would like to get a shower and denied having issues with getting a shower when he was in his usual room off the warm hall. Interview on 4/8/21 at 3:37 PM, the interim DON said the CNA's should be filling out shower sheets and entering them in the POC. The interim DON said she did not know of Resident #3 having concerns of not getting a shower. The interim DON said she would look for Resident #3's shower sheets and provide them to surveyors. Interview and records review on 4/8/21 at 3:45 PM, the interim DON said the last shower sheet they could find for Resident #3 was completed on 3/17/21 (shower sheet reviewed by surveyor). The interim DON said they have mostly agency staff that worked on the quarantine hallway and they had some issues with the staff down there not doing the work and have had to ask that they not return to the building. The interim DON said she could not say whether Resident #3 got his showers or not and said it was possible that he did not because she did not have any evidence to support that he did. The interim DON said she would see to it and that someone go offer him a shower right now. Record review of Resident #3's Bath POC for April 2021 revealed there was no documented bath since he returned to the facility from the hospital on 4/1/21 (7 days). Interview on 4/8/21 at 4:00 PM, the Administrator said Resident #3 was supposed to receive his showers on Tuesday, Thursday, and Saturday on the evening shift. The Administrator said she looked up the CNA's working the evening shift since 4/1/21 and they were all agency staff who were no longer affiliated with the facility and did not have their contact information. The Administrator said the agency staff were trained on the bath schedule and where/how to document. The Administrator did not know why the POC was blank for Resident #3. The Administrator said Resident #3 could be forgetful sometimes where he may have had a shower and would forget until he was reminded that he had one. The Administrator said Resident #3 sometimes complained about things that were not true, but she could not say for sure whether he got his showers or not on the days he claimed they were not given. Record review of the facility's Activities of Daily Living (ADL's) policy (Revised March 2018) revealed in part, .Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . Record review of the facility's Bath, Shower/Tub policy (Revised February 2018) revealed in part, .Documentation 1. The date and time shower/tub were performed. 2. The name and title of the individual(s) who assisted the resident with shower/tub bath. 3. All assessment data obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data .

Based on observation, interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 4 of 4 residents, (Residents # 2, 6, 39, and 45) reviewed for PASRR Level 1 screenings. The facility did not send the correct PASRR Level 1 screening to the local authority for Residents #2, 6, 39, and 45. This failure could affect residents with mental illness and place them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings include: Resident #2 Record review of Resident #2's admission record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's PASRR level 1 screening dated 12/04/2014 revealed Resident #2 was negative for mental illness, intellectual disability, and developmental disability. Record review of Resident #2's physician's orders [REDACTED]. Record review of Resident #2's admission Minimum Data Set ((MDS) dated [DATE] revealed in part: Brief Interview of Mental Status (BIMS) unable to be completed with a score of 99. The staff assessed her cognitive skills for daily decision making at 3 which indicated severely impaired. Resident #2 was totally dependent of two staff assist with bed mobility, transfers and toilet use and totally dependent of one staff assist for dressing, eating and personal hygiene. The resident was always incontinent of bladder and bowel. Her active [DIAGNOSES REDACTED]. Record review of all of Resident #2's care plans revealed no care plan to address [MEDICAL CONDITION]. The next review date for the existing care plans was 5/21/21. Interview on 02/10/2021 at 03:20 PM, MDS LVN A said Resident #2's PASRR was not correct because of her [MEDICAL CONDITION] diagnosis. She was responsible for completing the PASRR level I. She did not say why she had not completed one prior. Interview on 02/09/2021 at 11:45 AM, the Corporate RN said [MEDICAL CONDITIONS] disorder and [MEDICAL CONDITION] should be marked yes on the Level I PASRR, she said Resident #2 should have been and was not. Resident #6 Record review of the face sheet for Resident #6 revealed the initial admitted was 4/10/19 and revised admitted [DATE]. The [DIAGNOSES REDACTED]. Record review of Resident # 6's PASRR I screening on admitted d 2/14/2019 revealed no mental disorder, intellectual disability or developmental disability. Record review of the admission MDS dated [DATE] revealed Resident #6's cognitive skills for daily decision making were impaired, she required extensive assistance from staff for ADLs, and was incontinent of bowel and bladder. Record review of Resident #6 physician order [REDACTED]. Record review for the care plan for Resident #6 revealed she had impaired cognitive function, behavior problem of making false accusations against staff, antipsychotic medications. There was no care plan for PASRR. Record review of Resident #6's quarterly psych assessment dated [DATE] revealed a referral was made to psych services for depression. Observation of Resident #6 on 2/9/21 at 8:45 AM revealed she was sitting in her room in her wheelchair, with breakfast tray on the bedside table. Interview at that time revealed she stated things were ok now but could be better, but she did not specify. Observation of Resident #6 on 2/10/21 at 11:15 AM revealed she was sitting in her wheelchair in her room. When approached by surveyor, she appeared confused and did not want to talk. In an interview on 2/11/21 at 9:40 AM, the MDS LVN A revealed the MDS could only be coded according to how it was coded at the previous facility, and if the prior assessment is coded no for MI, ID, DD, then this facility codes it the same way. She further stated if a resident shows presence of depression, a referral to psych services would be made. Resident #39 Record review of Resident #39's Admission Record revealed the resident was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 39's Quarterly MDS dated [DATE] revealed she had a BIMS of 15 out of 15 indicating no cognitive impairment. The behavior section indicated she had hallucinations. She required total assistance of 2 or more people for transfers, toileting, personal hygiene, and bathing. She required extensive assistance of 2 or more people for dressing. She is frequently inconstant of bowel and bladder. Her active [DIAGNOSES REDACTED]. Record review of Resident #39's PASRR level 1 for the admitted [DATE] screening undated revealed Resident #39 was negative for mental illness, intellectual disability, and developmental disability. Record review of Resident #39's care plans revealed Focus: Resident #39 used anti-anxiety medications ([MEDICATION NAME]) due to Anxiety disorder. Goal: Resident #39 will show decreased number 3 per week episodes of anxiety through review date. Resident #39 will be free from discomfort or adverse reactions related to anti-anxiety therapy through review date. Intervention: Administer Anti-Anxiety medications as order by physician. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of [MEDICATION NAME]. Refer to psychologist/psychiatrist as needed. Focus: Resident #39 uses antidepressant medication ([MEDICATION NAME]) due to depression hallucinations. Goal: Resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Resident will show decreased episodes of signs and symptoms of depression through the review date. Intervention: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. Refer to psychologist as needed. Record review of Resident #39's physician orders [REDACTED]. In an interview with MDS LVN A on 2/11/2021 at 1:30 PM revealed [DIAGNOSES REDACTED]. She said she could not think of any other mental illnesses at the time that would qualify. She gets the results from the PASRR that she receives upon entrance from the place the resident is coming from such as another facility or hospital. She does not change them if they do have a mental illness and it says no. She just does a psych consult for residents with mental illness if they are exhibiting any behaviors. She stated she had not received PASRR training. Resident #45 Record review of Resident #45's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #45's Admission MDS dated [DATE] revealed she had a BIMS score of 11 out of 15 which indicated her cognition was moderately impaired. Resident #45 required extensive assistance of two staff assist with bed mobility and required extensive assistance of one staff assist for transfers, dressing and toilet use. The resident was occasionally incontinent of bladder and bowel. Her active [DIAGNOSES REDACTED]. Record review of all of Resident #45's care plans revealed no care plan to address [MEDICAL CONDITION] disorder, depressive type and [MEDICAL CONDITION] with delusions. The existing care plans had a next review date of 04/18/2021. Record review of Resident #45's physician orders [REDACTED]. Record review of Resident #45's PASRR level 1 screening for the admitted [DATE] revealed Resident #45 was negative for mental illness, intellectual disability, and developmental disability. Interview on 02/09/2021 at 3:20 PM, MDS LVN A said Resident #45's PASRR was coded the way it was when she came in. It was correct because she had a psychologist consult. MDS LVN A said [DIAGNOSES REDACTED]. When the Level I was done at the hospital or transferring we do not correct the level I if it was coded no even if there was a [DIAGNOSES REDACTED]. Interview on 02/09/2021 at 11:45 AM, the Corporate RN said [MEDICAL CONDITIONS] disorder and [MEDICAL CONDITION] should be marked yes on the PASRR Level I. Resident #45 should have been and was not. Interview on 02/11/2021 at 11:56 PM, the Administrator said the [DIAGNOSES REDACTED]. Interview on 02/11/2021 at 12:18 PM, the Administrator said we do not have a PASRR policy we follow the state guidelines.

Based on record review, and interview 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 that meets professional standards of quality of care for 2 of 16 residents reviewed for base line care plans. (Residents #2 and #45) The facility failed to develop a baseline care plan that addressed the PASRR [DIAGNOSES REDACTED].#45. These failures could place new residents at risk of not receiving necessary care and services or having important care needs identified. Findings Include: Record review of Resident #2's admission record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's physician's orders [REDACTED]. Record review of Resident #2's admission Minimum Data Set ((MDS) dated [DATE] revealed in part: Brief Interview of Mental Status (BIMS) unable to be completed with a score of 99. The resident's cognitive skills for daily decision making was 3 which indicated severely impaired. Resident #2 was totally dependent of two staff assist with bed mobility, transfers and toilet use and totally dependent of one staff assist for dressing, eating and personal hygiene. The resident was always incontinent of bladder and bowel. Active [DIAGNOSES REDACTED]. Record review of all of Resident #2's care plans revealed no care plan to address [MEDICAL CONDITION]. The existing care plans next next review date was 05/05/2021. Interview on 02/11/2021 at 11:35 AM, MDS LVN A said Resident #2 was not care planned for [MEDICAL CONDITION]. Interview on 02/11/2021 at 11:45 AM Corporate RN said Resident #2 should have a care plan for [MEDICAL CONDITION]. Record review of Resident #45's admission record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #45's admission MDS dated [DATE] revealed her BIMS score of 11 out of 15 which indicated her cognition was moderately impaired. Resident #45 required extensive assistance of two staff assist with bed mobility and required extensive assistance of one staff assist for transfers, dressing and toilet use. The resident was occasionally incontinent of bladder and bowel. Active [DIAGNOSES REDACTED]. Record review of Resident #45's undated care plans revealed no care plan to address [MEDICAL CONDITION] disorder, depressive type and [MEDICAL CONDITION] with delusions. Record review of Resident #45's physician orders [REDACTED]. Interview on 02/11/2021 at 11:35 AM MDS LVN A said the care plan was the plan of care for the residents. The resident was to be care planned for their diagnoses, behaviors and medications. Resident #45 was not care planned for her Schiaoaffective Disorder or [MEDICAL CONDITION], LVN A said she should be care planned. She did not say why she did not do the care plan for these diagnoses. Interview on 02/11/2021 at 11:45 AM Corporate RN said the care plan was the plan of care if something occurred to the resident. She said [MEDICAL CONDITIONS] disorder and [MEDICAL CONDITION] should be care planned. Interview on 02/11/2021 at 11:56 AM, the Administrator said the care plan was the individualized plan for the resident's care and the residents with these [DIAGNOSES REDACTED]. Record review of the policy titled Care Plans, Comprehensive Person-Centered revised December 2016 revealed in part: Policy Statement: A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. 1. The Interdisciplinary Team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 18 residents (Residents #66, #57 and #230) reviewed for supervision. -The facility failed to ensure CNA H properly performed a two-person Hoyer Lift transfer to Resident #66 which resulted in an injury to the resident's forehead and being sent out to the local emergency room . -The facility failed to ensure that Resident #57 didn't have access to potentially dangerous items that were at the nurse's station on the secure unit. -The facility failed to ensure potentially dangerous items were not kept at the bedside for Resident #230. These failure affected three residents and placed them at risk for accidents and injury. Findings include: Resident #66 Record review of Resident # 66 's medical records revealed he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident # 66's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed his Brief Interview for Mental Status (BIMS) was unable to be scored. His cognitive skills for daily decision making was severely impaired which indicated he never/rarely made decision. He was totally dependent of two plus people for bed mobility, transfer, dressing, toilet use and personal hygiene. Record review of Resident #66's care plan-initiated date 5/25/18 and last reviewed 4/26/19 revealed: Focus Resident #66 has limited physical mobility related to disease process dementia, traumatic, subdural hemorrhage, weakness and two-person Hoyer lift transfers. Record review of Resident #66's nurse's progress note dated 4/19/19 at 4:45 PM read in part Resident being transferred from bed to wheelchair using a Hoyer lift and struck his head against hooks used for Hoyer strap. Resident found in wheelchair bleeding. Resident has a cut in the middle of his forehead. Forehead cleansed with normal saline and steri strips applied, ice applied. Record review of Resident #66's incident accident report dated 4/19/19 read in part Incident Description: After transferring resident from bed to wheelchair via Hoyer. The straps were being unhooked when one strap struck resident in the forehead causing a small laceration measuring 1.3cm. Continued review of the incident and accident form revealed CNA H was the only witness to the incident. Record review of CNA H Disciplinary Warning Notice dated 4/19/19 was signed by CNA H read in part: Warning for Defective work, carelessness, failure to follow company policy, failure to obey safety rules. Disposition Suspension Remarks Failure to follow rules with Hoyer; 2 person assist. Employee was transferring resident per self 1 person only which resulted in injury. Record review of Resident #66's nurse's progress notes dated 4/20/2019 at 12:50 AM Resident continues to profusely bleed from the forehead, unable to stop with pressure dressing and ice pack. Northwest emergency medical services notified of resident needing to go to emergency room for evaluation and treatment. Record review of Resident #66's nurses progress notes dated 4/20/2019 at 3:25 AM revealed resident transported back to the facility and placed in his bed with safety in place at bedside. No problems noted. Responsible party notified that resident is back in the facility. Record review of Resident #66's Weekly Skin Observation Tool dated 4/30/19 at 2:08PM revealed Skin warm and dry. Small scab noted to forehead . Interview on 05/29/19 at 1:09 PM with the DON she stated she did not remember too much about the details of the incident. She did remember CNA H reported that he was transferring Resident #66 from the bed to the wheelchair and as he was removing the straps from the Hoyer lift the hook came back and hit the resident it made an extremely small skin tear. It did not require treatment except for a dry dressing. The resident pulled the dressing off and it started to bleed. During the investigation it was determined CNA H did the transfer alone. Hoyer lift transfers were always to be two person. CNA H was disciplined and sent home Interview on 05/29/19 at 1:18 PM with the Administrator she stated she did not remember what happened. All Hoyer lift transfers were to be two person. It was possible CNA H did the transfer alone. In an observation on 5/30/19 at 10:55AM of Resident #66 being transferred by Hoyer lift from the bed to the wheel chair by CNA B and CNA T the resident was moving his arms freely grabbing and reaching out throughout the procedure. No marks or wounds were observed on the resident. Resident #66 was not interviewable. In an interview on 5/30/19 at 11:20 AM with CNA B and CNA T they stated we have to use two people to do all Hoyer Lift transfers that was how we were trained. For Resident #66 we may need more than two people because of the way he was always moving, reaching and grabbing at things. In an interview on 05/30/19 at 02:19 PM with LVN K he stated a staff member was doing a Hoyer lift transfer to Resident #66 when the strap hit him in the head. The head was very vascular, and it started to bleed. It was a very small abrasion. It was cleaned and dressed. The LVN stated the CNA told him he did the transfer alone. The CNA was the only other one in the room. The disciplinary form and sent the CNA home. In an interview on 5/30/19 at 2:45 PM with CNA H he stated he did the Hoyer Lift transfer to Resident #66 by himself because he could not find his coworker and he believed he could handle it. After unhooking the strap the hook swung around and hit the resident in the forehead caused a small cut. The nurse was notified immediately. In an interview on 5/31/19 at 9:59 AM with the Administrator she stated she did not report the incident because at the time she did not feel it was a significant injury. She was told what happened and saw it was such a tiny injury. The administrator stated she believed from how she read the regulations serious injuries were to be reported. Also, at the time of the transfer she did not feel CNA H was being neglectful he did not intend to cause harm he violated facility policies. Resident #57 Record review of Resident # 57's face sheet revealed an [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE]. He was admitted with the following [DIAGNOSES REDACTED]. Record review of Resident #57's Annual Minimum Data Set ((MDS) dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) of 2 out of 15 indicating severe cognitive impairment. Record review of Resident #57's care plan initiated on 6/18/2018 revealed: Focus Resident #57 has impaired cognitive function and thought process due to Dementia. He is currently taking [MEDICATION NAME] and [MEDICATION NAME] for memory. Interventions Cue resident and supervise as needed. Observation of Resident #57 on 5/30/2019 at 10:20 AM revealed resident reaching over the half wall that separated the hall way and the nurse's station and opened the door that was unlocked from the other side. Then he closed door and continued pacing up and down the hall. The storage closet door was cracked open and had six bottles of mouth wash that read keep out of reach of children. There was also a can of air freshener on the nurse's station counter. Staff were assisting other residents at the back of the unit at this time. There were no staff present to redirect Resident #57. Interview with CNA J on 5/30/2019 at 10:34 AM revealed they monitored the nurse's station at all times and made sure the door was locked at all times. She said with Resident #57 they monitor the area at all times to make sure he doesn't get behind the nurse's station and they redirect him as needed. She said that air freshener, cleaning supplies, or sprays of any kind should not be on the counter. She said the storage closet should always be closed. She said the building was old, so the doors don't close well. Interview with the DON and Administrator on 5/30/2019 at 11:00 AM revealed they have seen the Resident #57 open the door before, but he has never gone into the nurse's station. They said he was monitored and will try and follow staff into the area but has not been back in the area as they usually redirect resident. Resident usually paces back and forth a lot. The storage closet should always be closed. They stated they only keep supplies in the closet. The mouth wash must have come from a confiscation of one of the resident's rooms. Resident #230 Record review of Resident # 230's medical records revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident # 230's Initial Care Admission MDS assessment dated [DATE] revealed his BIMS was 11 out of 15, indicating moderate cognitive impairment. He was admitted for short term rehab with the intent to return to community. He required limited assistance for bed mobility and dressing. He required minimal assistance of one person for transfer, locomotion on unit, eating, toilet use, and personal hygiene. Observation of Resident #230 on 5/29/19 at 11:05 am, in room [ROOM NUMBER]A (D Hall) noted a bag of hazardous items on top of the dresser. The bag contained a bottle of odor spray, foam cleaner, wash gel and packages of cream. Observation and interview with Resident #230 on 5/30/19 at 2:50PM revealed the bag of items was no longer on the dresser. When asked where the items went, the resident commented, The staff came by yesterday and put it up. It was in the top drawer. Record Review of facility admission handbook titled Health Services Management of Texas Operational Policy Handbook, undated on page 10, indicated items NOT allowed in Residents' Rooms: * Aspirin, [MEDICATION NAME], etc * [MEDICATION NAME], Vicks, Deep Heat, Ben-Gay, etc * Vaseline, Olive Oil, Castor Oil, etc * Cough syrup or drops * Rubbing alcohol or any [MEDICATION NAME] * Ex-lax or any laxative. Record review of the facility policy titled Lifting Machine, Using a Mechanical dated 2001 Med-Pass, Inc (Revised (MONTH) (YEAR)) read in part: Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . General Guidelines: 1. At least two (2) nursing assistances are needed to safely move a resident with a mechanical lift .

Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (CR #1) reviewed for supervision. The facility failed to supervise CR#1 while he ate a snack in his room. CR#1 was identified as being high risk for choking and died of asphyxiation after being left unsupervised. This failure affected 1 expired Resident. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility had implemented effective interventions and monitoring in place. The facility remained out of compliance at scope of isolated of actual harm but not immediate jeopardy. Findings Include: Intake 4, & 5 CR#1 Record review of CR#1's Face Sheet revealed he was a [AGE] year old male admitted to the facility [DATE] and readmitted [DATE]. He was Full Code Status with [DIAGNOSES REDACTED]. Record review of CR #1's Physician order [REDACTED]. Record review of CR#1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 11 indicating he was moderately impaired. The MDS also indicated CR#1 needed supervision with one person physical assist for eating, used a wheelchair for mobility, and was on a mechanically altered diet. Review of CR#1's Care Plan, undated, revealed in part: Focus: at risk for aspiration r/t eats too fast Dx Parkinson with Interventions: Encourage CR #1 to eat meals in the dinning room, Encourage CR #1 to slow down while eating; Focus: Resident has impaired cognitive function, impaired thought processes and Impaired decision making r/t Dx Dementia with Intervention: Cue, reorient and supervise as needed; Focus: CR#1 has potential nutritional problem r/t impaired cognition, hx variable po intake. Missing some natural teeth with Interventions: Observe and report any s/sx of dysphagia Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, Provide served diet as ordered Monitor intake and record meals, Pureed NAS Diet with nectar thick liquids, use special spoon ordered by speech therapy assist with smaller bites; Focus: CR#1 has an ADL self-care performance deficit r/t Dementia- impaired cognition with Interventions: Eating: CR#1 is able to feed himself with setup and supervision; Focus: CR #1 has [DIAGNOSES REDACTED]. Record review of CR#1's Modified [MEDICATION NAME] Swallow Study(MBSS) Physician Evaluation and Management Report dated [DATE] revealed in part: - Indication for Evaluation - Life Limiting or Threatening Dysphagia Disorder with feeding difficulties, coughing positive, coughing with PO intake positive, choking positive, risk of aspiration positive, risk of silent aspiration positive. - Chief Complaint - Coughing positive, Choking positive, feeding difficulties, Pneumonia positive, Suspect silent aspiration. - Current Diet Solids: Pureed, Liquids: Nectar Thick - Objective Examination: General: The patient is chronically ill appearing with evidence of chronic distress as indicated by the following: Wheelchair bound, Non-ambulatory, Unable to hold head erect or with difficulty, Special Reclining Chair. Oral-Visual Inspection of Oral Cavity: Mucosal integrity, Poor dentition, Natural teeth, Missing Teeth. - Discussion: Based on the results of the MBSS, [MEDICAL CONDITION] evaluation and the patient general medical condition, their overall dysphagia severity is severe. The following considerations are offered to enhance the management of this patient: Poor mastication with small volume of mechanical soft visualized by patient swallowing pieces whole increasing risk of choking. The patient's response to aspirate/penetration include poor reflexive cough, ineffective cough, inconsistent reflexive cough, inefficient volitional cough. - Conclusion: Patient is at high risk for an aspiration pneumonia due to the following process: Advanced age, Aspiration, Coughing with PO intake ., patient is also at risk for Choking Episode, this patient demonstrates Reduced Stamina and General Myasthenia(Muscle Weakness). - Diet recommendations - PO Diet: Solid: Pureed. Alt bites/sips, Liquids: Thin liquids, no straws. - Strategies - We recommend the following actions regarding the patient's feeding: Small Bites/Sips -No Straws- Multiple Swallows x ,[DATE] - Crush Meds- Monitor PO Intake Rate- Alternate Solids/Liquids Position Upright- Supervised PO Feeding- Cueing for Strategies. Record review of CR#1's CNA undated, electronic Visual/Bedside Kardex Report (information of how to care for assigned residents) revealed in part: Safety: Encourage CR#1 to eat meals in the dining room; Monitors: Observe for and report any s/sx of dysphagia Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat; Eating/Nutrition: Eating; Resident is able to feed himself with setup and supervision, Pureed NAS Diet with nectar thick liquids, use special spoon ordered by speech therapy assist with smaller bites. Record review of CR#1's electronic medical record revealed the following Progress Notes written by LVN K read in part . Progress note dated [DATE] at 9:22 p.m. CNA N summoned Nurse from hallway. Code called. Resident noted to be skin cool and pallor. Respirations 0 and pulse 0. Progress note dated [DATE] at 9:39 p.m. revealed At 9:24 p.m. Crash Cart in place. Staff present doing compressions while writer assembling and applying AED and notifying 911. At 9:26 p.m. AED never advised shock and CPR continued. EMS arrived at 938pm and care turned over to EMS. Record review of CR #1's hospital emergency room records dated [DATE] at 11:39 p.m. revealed, in part . HPI (History of Present Illness) Notes [AGE] year-old male presents to the ER via EMS with active CPR in progress. He was found by the nursing home team 15 minutes prior to EMS arrival. Re-Evaluation/Progress #1 .Patient time of Death 1:01 a.m. Record review of CR #1's hospital emergency room Release of Body Record of Death undated report revealed date of death [DATE] at 1:01 a.m. Death Reportable to ME(Medical Examiner) within 24 hours of Admission, Emergency Department Deaths. Record review of Texas Harris County, Case Study, Medical Examiner basic information received online [DATE] (https://ifs.harriscountytx.gov/Pages/CaseStatus.aspx) revealed CR #1's Manner of Death: Accident, Primary Cause of Death: Asphyxiation due to upper respiratory tract obstruction. Last updated [DATE] at 8:30 a.m. Record review of Facility completed DADS 3613-A Form dated and signed by the Administrator on [DATE] revealed Incident Category Death, Description of the Allegation After completing staff interviews and speaking with the ME, it has been determined that CR#1 was provided a peanut butter and jelly sandwich for his snack, which was suctioned from his airway at the hospital, where he expired. Investigation Summary CR#1 had taken his evening medications without difficulty. The CNA assigned to CR#1 was interviewed the following morning and she stated that she offered him a variety of bedtime snacks and provided him a peanut butter and jelly sandwich which he requested. CNA returned to his room to pass hydration and discovered CR#1 to be unresponsive. CR#1 expired at the hospital. According to the ME who called the following day, peanut butter was suctioned from CR#1's airway. The facility finds the investigation of Death to be confirmed. Interview on [DATE] at 12:00 p.m. with Administrator and DON revealed they both were notified by LVN K on [DATE] after 9:00 p.m. about sending CR#1 to the hospital for being unresponsive. Administrator stated that LVN K had given CR#1 his night time medications and ,[DATE] minutes later he was unresponsive and she remembered that it was not enough time to be a medication error and she asked LVN K what he thought happened. He said he thought the resident may have had a [MEDICAL CONDITION] and he was taken to the hospital Administrator stated that the next morning she was asking questions and investigating and found out he had received a sandwich and earlier that day we got a call from the ME who said the hospital had suctioned peanut butter from CR#1's airway. Administrator stated that CNAs were to check the residents diets before giving a snack and at the snack cart has a daily updated list of residents on mechanically altered diets. She further stated that this system is their most solid system if she had to pick one. Interview with the DON on [DATE] at 12:24 p.m. revealed once they found out from the ME (Medical Examiner) about CR #1 having peanut butter in his airway, they began training and in-servicing with question and answer quizzes for the nursing staff. CNA N was immediately suspended. She said that CNA N never came back to the facility after she was suspended. DON stated that she expected CNAs would know about each resident's requirements for supervision during meals, and that the CNAs should know their residents and the information is in the Kardex care plan. DON stated that, following the incident involving CR#1, staff was in-serviced, a QAPI plan was developed and a Monitoring tool put into place to ensure residents were being provided with the correct texture and consistency meals, hydration and snacks. Interview with CNA C on [DATE] at 3:28 p.m. revealed she was working on [DATE] and was the other CNA on the B-hall where CR#1 resided. CNA C stated that she had delivered a Purred Diet tray to CR #1 that day for supper and that he was able to feed himself so she set-up his meal and left him alone to eat. She stated that she later returned to pick up the tray and the resident had eaten most of his tray and he was in a good mood and talking. She stated that there was no evidence of anything wrong. Interview with LVN K on [DATE] at 4:00 p.m. revealed he was the nurse assigned to CR#1 on [DATE], ,[DATE] shift, when he was sent to the hospital. LVN K stated when he came in and made his rounds he did not notice anything abnormal for CR#1 and CNA N was also assigned to care for the resident. LVN K revealed that around 9:00 p.m. CNA N was passing out HS Snacks and that he told her to also pass water after the snacks, then 10 minutes later she was calling him to come check on CR #1, found him unresponsive, called 911 and he was sent to the hospital. LVN K stated that he did not know at that time that CR#1 had received a HS snack, and he didn't find out until the next day when he returned for his shift and the DON asked and notified him. LVN K stated that if he had known CR #1 was given something to eat he would have made sure some one was with him because he had a history of [REDACTED]. Surveyor attempted to interview CNA N on [DATE] at 12:44 p.m., 1:56 p.m. message left, and 5:00pm not able to leave message mail box full. Record Review of CNA N's employee file revealed she was hired on [DATE]. There was no terminated date entered on her record. An IJ was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] due to facility having appropriate interventions and monitoring in place. The facility remained out of compliance at isolated of actual harm that was not an immediate jeopardy. The facility Administrator was notified on [DATE] at 4:30pm that there was a past non-compliance due to the above failures. Monitoring by surveyor revealed: - Observations on [DATE] at 8am of 2 Residents eating in their rooms revealed they were served breakfast meal appropriate with their ordered diet/ meal ticket. - Record review of the 2 Residents medical record reveled that they did not require supervision. - Observations on [DATE] at 8:45am in the Dining Room revealed residents being assisted and supervised with meals. Observed 5 random residents eating meals as ordered on their meal tickets. Staff observed looking at Dietary roster orders making sure residents had ordered diet and administration staff using the monitoring tool to ensure compliance. - Observations on [DATE] at 11:45am of 3 Residents eating in their rooms revealed they were served Lunch meal appropriate with their mechanically altered diet/ meal ticket. -Record review of the 3 Residents medical record reveled that they did not require supervision. - Observations on [DATE] at 12:30pm the Dining Room revealed Staff comparing Dietary roster orders to ensure residents were offered ordered diet consistency. Observed 4 random residents eating diet as ordered on their meal tickets and being assisted/supervised with their meal. -Record Review of the facility's in-service conducted on [DATE] revealed the subject was Resident Snacks/Meals content summary of training When serving residents snacks, meals etc. you must ensure the food and drinks are in accordance to their diet. The food and liquid must be the correct consistency. Diets can be found in the binders on the coolers, on the meal tickets, Kardex or from the charge nurse. If a resident request something not on their diet, inform their charge nurse. - Record review of in-service dated [DATE] conducted with Nursing staff and Dietary staff revealed Topic/Title: (form facility created on [DATE]) Monitoring Tool to be utilized to monitor compliance of snacks, meals/diets, and hydration pass to ensure consistencies are provided as ordered, Location of information-altered diets/ thickened liquids -Record Review of the facility's Resident Roster dated [DATE] listed 25 Residents that required supervision with meals. - Interview on [DATE] at 1:04pm with the Acting DON who was also the Regional Nurse, revealed that they are doing what they are doing now to ensure this incident does not recur. She said facility Nursing staff was assigned daily task of using the Monitoring Tool completion and if errors are found they are to immediately correct and get the right diet and call Nursing Administration for further instruction and to document the information on the Monitoring tool so that it can be brought to QAPI. Acting DON said residents requring supervison will have to eat in the dining room or if they request to eat in room, a nursing staff member would stay with them until they finished their meal and the same for snacks offered to resident in their rooms if they require supervision a staff member will stay until the snack is finished. - Interviews with 5 nursing staff on [DATE] revealed that they were all in serviced, knew what to do, and aware how to identify the residents who were on mechanically altered diets, those staff interviewed also stated that they had been inserviced on assisting residents with meals and how to identify what type of assistance is needed for the residents they were assigned to. All 5 nursing staff vocalized their understanding of which residents required supervision with meals. Record Review of the facility's binder, meal tickets and Kardex revealed that all resident's diet's were listed on there. Record Review of the facility's policy, Safety and supervision of Residents, revised ,[DATE], revealed, in part: . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Individualized, Resident-Centered Approach to Safety: 2. The Interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 4. implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Provide training, as necessary;

Based on observation, interview, and record review the facility failed to ensure 1 of 6 residents (CR#1) reviewed for puree diets received the diet ordered per physician order. The facility failed ensure and provide CR #1 had puree diet for his HS snack. CR #1 was given a peanut butter and jelly sandwich to eat in his room. CR#1 choked and died from asphyxiation. This failure affected 1 expired resident. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility had implemented effective interventions and monitoring in place. The facility remained out of compliance at scope of isolated of actual harm but not immediate jeopardy. Findings Include: Intake 4, & 5 CR#1 Record review of CR#1's Face Sheet revealed he was a [AGE] year old male admitted to the facility [DATE] and readmitted [DATE]. He was Full Code Status with [DIAGNOSES REDACTED]. Record review of CR #1's Physician order [REDACTED]. Record review of CR#1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 11 indicating he was moderately impaired. The MDS also indicated CR#1 needed supervision with one person physical assist for eating, used a wheelchair for mobility, and was on a mechanically altered diet. Review of CR#1's Care Plan, undated, revealed in part: Focus: at risk for aspiration r/t eats too fast Dx Parkinson with Interventions: Encourage CR #1 to eat meals in the dinning room, Encourage CR #1 to slow down while eating; Focus: Resident has impaired cognitive function, impaired thought processes and Impaired decision making r/t Dx Dementia with Intervention: Cue, reorient and supervise as needed; Focus: CR#1 has potential nutritional problem r/t impaired cognition, hx variable po intake. Missing some natural teeth with Interventions: Observe and report any s/sx of dysphagia Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, Provide served diet as ordered Monitor intake and record meals, Pureed NAS Diet with nectar thick liquids, use special spoon ordered by speech therapy assist with smaller bites; Focus: CR#1 has an ADL self-care performance deficit r/t Dementia- impaired cognition with Interventions: Eating: CR#1 is able to feed himself with setup and supervision; Focus: CR #1 has [DIAGNOSES REDACTED]. Record review of CR#1's Modified [MEDICATION NAME] Swallow Study(MBSS) Physician Evaluation and Management Report dated [DATE] revealed in part: - Indication for Evaluation - Life Limiting or Threatening Dysphagia Disorder with feeding difficulties, coughing positive, coughing with PO intake positive, choking positive, risk of aspiration positive, risk of silent aspiration positive. - Chief Complaint - Coughing positive, Choking positive, feeding difficulties, Pneumonia positive, Suspect silent aspiration. - Current Diet Solids: Pureed, Liquids: Nectar Thick - Objective Examination: General: The patient is chronically ill appearing with evidence of chronic distress as indicated by the following: Wheelchair bound, Non-ambulatory, Unable to hold head erect or with difficulty, Special Reclining Chair. Oral-Visual Inspection of Oral Cavity: Mucosal integrity, Poor dentition, Natural teeth, Missing Teeth. - Discussion: Based on the results of the MBSS, [MEDICAL CONDITION] evaluation and the patient general medical condition, their overall dysphagia severity is severe. The following considerations are offered to enhance the management of this patient: Poor mastication with small volume of mechanical soft visualized by patient swallowing pieces whole increasing risk of choking. The patient's response to aspirate/penetration include poor reflexive cough, ineffective cough, inconsistent reflexive cough, inefficient volitional cough. - Conclusion: Patient is at high risk for an aspiration pneumonia due to the following process: Advanced age, Aspiration, Coughing with PO intake ., patient is also at risk for Choking Episode, this patient demonstrates Reduced Stamina and General Myasthenia(Muscle Weakness). - Diet recommendations - PO Diet: Solid: Pureed. Alt bites/sips, Liquids: Thin liquids, no straws. - Strategies - We recommend the following actions regarding the patient's feeding: Small Bites/Sips -No Straws- Multiple Swallows x ,[DATE] - Crush Meds- Monitor PO Intake Rate- Alternate Solids/Liquids Position Upright- Supervised PO Feeding- Cueing for Strategies. Record review of CR#1's CNA undated, electronic Visual/Bedside Kardex Report (information of how to care for assigned residents) revealed in part: Safety: Encourage CR#1 to eat meals in the dining room; Monitors: Observe for and report any s/sx of dysphagia Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat; Eating/Nutrition: Eating; Resident is able to feed himself with setup and supervision, Pureed NAS Diet with nectar thick liquids, use special spoon ordered by speech therapy assist with smaller bites. Record review of CR#1's electronic medical record revealed the following Progress Notes written by LVN K read in part . Progress note dated [DATE] at 9:22 p.m. CNA N summoned Nurse from hallway. Code called. Resident noted to be skin cool and pallor. Respirations 0 and pulse 0. Progress note dated [DATE] at 9:39 p.m. revealed At 9:24 p.m. Crash Cart in place. Staff present doing compressions while writer assembling and applying AED and notifying 911. At 9:26 p.m. AED never advised shock and CPR continued. EMS arrived at 938pm and care turned over to EMS. Record review of CR #1's hospital emergency room records dated [DATE] at 11:39 p.m. revealed, in part . HPI (History of Present Illness) Notes [AGE] year-old male presents to the ER via EMS with active CPR in progress. He was found by the nursing home team 15 minutes prior to EMS arrival. Re-Evaluation/Progress #1 .Patient time of Death 1:01 a.m. Record review of CR #1's hospital emergency room Release of Body Record of Death undated report revealed date of death [DATE] at 1:01 a.m. Death Reportable to ME(Medical Examiner) within 24 hours of Admission, Emergency Department Deaths. Record review of Texas Harris County, Case Study, Medical Examiner basic information received online [DATE] (https://ifs.harriscountytx.gov/Pages/CaseStatus.aspx) revealed CR #1's Manner of Death: Accident, Primary Cause of Death: Asphyxiation due to upper respiratory tract obstruction. Last updated [DATE] at 8:30 a.m. Record review of Facility completed DADS 3613-A Form dated and signed by the Administrator on [DATE] revealed Incident Category Death, Description of the Allegation After completing staff interviews and speaking with the ME, it has been determined that CR#1 was provided a peanut butter and jelly sandwich for his snack, which was suctioned from his airway at the hospital, where he expired. Investigation Summary CR#1 had taken his evening medications without difficulty. The CNA assigned to CR#1 was interviewed the following morning and she stated that she offered him a variety of bedtime snacks and provided him a peanut butter and jelly sandwich which he requested. CNA returned to his room to pass hydration and discovered CR#1 to be unresponsive. CR#1 expired at the hospital. According to the ME who called the following day, peanut butter was suctioned from CR#1's airway. The facility finds the investigation of Death to be confirmed. Interview on [DATE] at 12:00 p.m. with Administrator and DON revealed they both were notified by LVN K on [DATE] after 9:00 p.m. about sending CR#1 to the hospital for being unresponsive. Administrator stated that LVN K had given CR#1 his night time medications and ,[DATE] minutes later he was unresponsive and she remembered that it was not enough time to be a medication error and she asked LVN K what he thought happened. He said he thought the resident may have had a [MEDICAL CONDITION] and he was taken to the hospital Administrator stated that the next morning she was asking questions and investigating and found out he had received a sandwich and earlier that day we got a call from the ME who said the hospital had suctioned peanut butter from CR#1's airway. Administrator stated that CNAs were to check the residents diets before giving a snack and at the snack cart has a daily updated list of residents on mechanically altered diets. She further stated that this system is their most solid system if she had to pick one. Interview with the DON on [DATE] at 12:24 p.m. revealed once they found out from the ME (Medical Examiner) about CR #1 having peanut butter in his airway, they began training and in-servicing with question and answer quizzes for the nursing staff. CNA N was immediately suspended. She said that CNA N never came back to the facility after she was suspended. DON stated that she expected CNAs would know about each resident's requirements for supervision during meals, and that the CNAs should know their residents and the information is in the Kardex care plan. DON stated that, following the incident involving CR#1, staff was in-serviced, a QAPI plan was developed and a Monitoring tool put into place to ensure residents were being provided with the correct texture and consistency meals, hydration and snacks. Interview with CNA C on [DATE] at 3:28 p.m. revealed she was working on [DATE] and was the other CNA on the B-hall where CR#1 resided. CNA C stated that she had delivered a Purred Diet tray to CR #1 that day for supper and that he was able to feed himself so she set-up his meal and left him alone to eat. She stated that she later returned to pick up the tray and the resident had eaten most of his tray and he was in a good mood and talking. She stated that there was no evidence of anything wrong. Interview with LVN K on [DATE] at 4:00 p.m. revealed he was the nurse assigned to CR#1 on [DATE], ,[DATE] shift, when he was sent to the hospital. LVN K stated when he came in and made his rounds he did not notice anything abnormal for CR#1 and CNA N was also assigned to care for the resident. LVN K revealed that around 9:00 p.m. CNA N was passing out HS Snacks and that he told her to also pass water after the snacks, then 10 minutes later she was calling him to come check on CR #1, found him unresponsive, called 911 and he was sent to the hospital. LVN K stated that he did not know at that time that CR#1 had received a HS snack, and he didn't find out until the next day when he returned for his shift and the DON asked and notified him. LVN K stated that if he had known CR #1 was given something to eat he would have made sure some one was with him because he had a history of [REDACTED]. Surveyor attempted to interview CNA N on [DATE] at 12:44 p.m., 1:56 p.m. message left, and 5:00pm not able to leave message mail box full. Record Review of CNA N's employee file revealed she was hired on [DATE]. There was no terminated date entered on her record. An IJ was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] due to facility having appropriate interventions and monitoring in place. The facility remained out of compliance at isolated of actual harm that was not an immediate jeopardy. The facility Administrator was notified on [DATE] at 4:30pm that there was a past non-compliance due to the above failures. Monitoring by surveyor revealed: - Observations on [DATE] at 8am of 2 Residents eating in their rooms revealed they were served breakfast meal appropriate with their ordered diet/ meal ticket. - Record review of the 2 Residents medical record reveled that they did not require supervision. - Observations on [DATE] at 8:45am in the Dining Room revealed residents being assisted and supervised with meals. Observed 5 random residents eating meals as ordered on their meal tickets. Staff observed looking at Dietary roster orders making sure residents had ordered diet and administration staff using the monitoring tool to ensure compliance. - Observations on [DATE] at 11:45am of 3 Residents eating in their rooms revealed they were served Lunch meal appropriate with their mechanically altered diet/ meal ticket. -Record review of the 3 Residents medical record reveled that they did not require supervision. - Observations on [DATE] at 12:30pm the Dining Room revealed Staff comparing Dietary roster orders to ensure residents were offered ordered diet consistency. Observed 4 random residents eating diet as ordered on their meal tickets and being assisted/supervised with their meal. -Record Review of the facility's in-service conducted on [DATE] revealed the subject was Resident Snacks/Meals content summary of training When serving residents snacks, meals etc. you must ensure the food and drinks are in accordance to their diet. The food and liquid must be the correct consistency. Diets can be found in the binders on the coolers, on the meal tickets, Kardex or from the charge nurse. If a resident request something not on their diet, inform their charge nurse. - Record review of in-service dated [DATE] conducted with Nursing staff and Dietary staff revealed Topic/Title: (form facility created on [DATE]) Monitoring Tool to be utilized to monitor compliance of snacks, meals/diets, and hydration pass to ensure consistencies are provided as ordered, Location of information-altered diets/ thickened liquids -Record Review of the facility's Resident Roster dated [DATE] listed 25 Residents that required supervision with meals. - Interview on [DATE] at 1:04pm with the Acting DON who was also the Regional Nurse, revealed that they are doing what they are doing now to ensure this incident does not recur. She said facility Nursing staff was assigned daily task of using the Monitoring Tool completion and if errors are found they are to immediately correct and get the right diet and call Nursing Administration for further instruction and to document the information on the Monitoring tool so that it can be brought to QAPI. Acting DON said residents requring supervison will have to eat in the dining room or if they request to eat in room, a nursing staff member would stay with them until they finished their meal and the same for snacks offered to resident in their rooms if they require supervision a staff member will stay until the snack is finished. - Interviews with 5 nursing staff on [DATE] revealed that they were all in serviced, knew what to do, and aware how to identify the residents who were on mechanically altered diets, those staff interviewed also stated that they had been inserviced on assisting residents with meals and how to identify what type of assistance is needed for the residents they were assigned to. All 5 nursing staff vocalized their understanding of which residents required supervision with meals. Record Review of the facility's binder, meal tickets and Kardex revealed that all resident's diet's were listed on there. Record Review of the facility's policy, Therapeutic Diets, revised ,[DATE], revealed, in part: . 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for [REDACTED]. 9. Snacks will be compatible with the therapeutic diet. 12. If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives.

Based on observation, interviews and record review the facility failed to ensure that pain management was provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one of eight residents (Resident #2) reviewed for pain. -The facility failed to obtain an order for [REDACTED].>This failure affected one resident and placed her at risk for a decline in her mental and emotional well-being. The findings included: Intakes 4, 4, 8 Resident #2 Record review of Resident #2's face sheet revealed that she was a [AGE] year old female who was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Admission MDS (Minimum Data Set) dated 11/21/18 revealed that she was understood and that she understood others. It also revealed in Cognitive Patterns that she had a BIMS score of 15 indicating no cognitive impairment. Review of her Functional Status revealed that she required total assistance/2 persons for transfer, total assistance of 1 person assistance for locomotion and bathing. She required extensive/2 person assistance for bed mobility. She required extensive/1 person assistance for dressing, toilet use, and personal hygiene. In Health Conditions-Pain Management revealed that she had pain presence, occasionally. Her pain rated 8 over the last 5 days, on a scale from 0-10 (Zero-no pain and 10 worst pain). Under Skin Conditions, it revealed that she had an unstageable pressure ulcer that was present upon admission. It also revealed that she had a surgical wound. Under medications it was revealed that she took an opioid 6 days. Record review of Resident #2's Care plans (undated) revealed that Resident #2 was admitted with unstageable pressure ulcer to her left heel and left stump, status [REDACTED]. to ensure the residents comfort. Another focus revealed that Resident #2 was on routine pain management of [MEDICAL CONDITION]/partial amputation of left foot with interventions to include . -The resident's pain is aggravated by treatment to her foot. -administer [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) as per orders and anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Another focus revealed that Resident #2 had an amputation of the metatarsal of her left foot due to poor circulation secondary to [MEDICAL CONDITION], her goal was that her wound would heal and progress without complications. Record review of Resident #2's Incident Report dated 2/1/19 with a revision date of 2/5/19 revealed the Incident Description; -Nursing description: Nurse heard resident yelling and immediately went to resident room . Other staff members present in patients room. -Resident description: Resident explained that another resident was in her room and struck her. The other resident came in her room and drank her coke and ate my candy , when I told her to go to her room, she started hitting me. Injuries observed at time of incident Bruise to left buttock. Record review of Resident #2's progress notes dated 2/1/19, a health status note by LVN A read Resident reported to this nurse, SOS Help me , this [***] is trying to kill me. Resident #2 stated that Resident #4 kept saying Shut up, and pointing her finger close to Resident #2's face, then she started hitting me everywhere. LVN A in same progress note, noted that Resident #2 had bruising to her right hip area and leg. Record review of Resident #2's Pain Level summary revealed: 2/1/19 at 2:16 am pain level of 9 2/2/19 at 10:32am pain level of 6 2/2/19 at 10:50 pm pain level of 6 2/3/19 at 2:23 pm pain level of 7 2/4/19 at 8:41am pain level of 8 -no documentation of [MEDICATION NAME] given 2/5/19 at 5:47 am she had a pain level of 8- (No [MEDICATION NAME] given, Resident #2 was out of [MEDICATION NAME]) 2/5/19 at 3:16 pm she had a pain level of 8- ([MEDICATION NAME] was given from the emergency kit, after surveyor asked about Resident #2's pain medication) 2/5/19 at 3:53 pm after receiving [MEDICATION NAME] 50 mg at 3:16 pm her pain level was 0. Record review of Resident #2's Physicians orders for (MONTH) 2019 revealed an order for [REDACTED].>-[MEDICATION NAME] HCL 50 mg. Give one tablet by mouth every 6 hours as needed for pain. Start date 12/19/18 -[MEDICATION NAME] 300 mg . Give one capsule by mouth two times a day for neuropathic pain. Start date 12/19/18 -[MEDICATION NAME] Tablet 325 mg . Give two tablets by mouth every 4 hours as needed for fever or mild pain . Not to exceed 3 grams of [MEDICATION NAME] in 24 hour period. -Cleanse wound to distal left foot stump with normal saline and gauze, pat dry, apply [MEDICATION NAME] and calcium alginate to wound bed, apply [MEDICATION NAME] to periwound and cover with gauze until healed, start date 1/15/19. -Cleanse left heel with normal saline and gauze, pat dry, apply medi honey to wound , cover with calcium alginate , [MEDICATION NAME] to peri wound and cover with dry dressing every day. Record review of Resident #2's narcotic sheet for (MONTH) 2019 revealed that she had taken her last [MEDICATION NAME] 50 mg on 2/4/19 at 5:30 am, and that she was completely out of [MEDICATION NAME]. Record review of Resident #2's (MAR) Medication Administration Record [REDACTED] -[MEDICATION NAME] 50 mg, 1 tablet by mouth every 6 hours as needed for pain (4-6) with a start date of 12/19/18. It revealed that she had gotten [MEDICATION NAME] 50 mg on; 2/1/19 at 2:16 am for pain level of 9 2/2/19 at 10:32am for pain level of 6 2/2/19 at 10:50 pm for pain level of 6 2/3/19 at 2:23 pm for pain level of 7 2/5/19 at 3:16 pm for pain level of 8 after surveyor intervention. -[MEDICATION NAME] 300 mg , give one capsule by mouth two times a day for [MEDICAL CONDITION] pain and she missed a dose on 2/1/19. -[MEDICATION NAME] Tablet 325 mg. Give two tablets by mouth every 4 hours as needed for fever or mild pain. Not to exceed 3 grams of [MEDICATION NAME] in 24 hour period. 2/4/19 at 8:41 am for pain level of 8. After receiving [MEDICATION NAME] her pain level at 10:11 am and 4:54 pm pain level was documented as 0. 2/5/19 at 5:47 am for pain level of 8. After receiving [MEDICATION NAME] her pain level at 6:30 am was 4 and at 6:33 am it was documented as 2. In an interview and observation on 2/5/19 at 9:10 am with Resident #2, she stated that right now her left foot was throbbing so bad she could hardly stand it. She stated that she had been telling everyone. She stated that they gave her Tylenol, but that was like taking baby aspirin and that it didn't help. She also stated that she was shaken up by being attacked on Friday and that she had pain in her right hip from being hit on the bone. She stated that Resident #4 hit her on Friday (02/1/19) during dinner. She stated that Resident #4 came in her room, drank her Pepsi, and was going to take her balloons and candy. I said no she can't have that and resident came over my bed and hit me all over, she was just swinging. Resident #2 was observed crying during the interview. When surveyor asked her why she was crying, she stated that she was crying because of pain to her left foot and right hip. In an interview on 2/5/19 at 9:40am with LVN B, she stated that the request for [MEDICATION NAME] order was faxed over Monday morning (2/4/19) a refill form was faxed to the Doctor. She stated that when she counted yesterday (02/04/19) morning Resident #2 was completely out of [MEDICATION NAME] 50mg. She stated that she then called the Attending Physician and the office and asked if they got the refill request for Resident #2's [MEDICATION NAME]. She then stated that she faxed the request again. She stated that she also texted the doctor's nurse practitioner and was told that they were handling it. She stated that she left it that way and when she got back this morning Resident #2 still did not have [MEDICATION NAME]. She stated that she was not sure how they ran out of [MEDICATION NAME], and that it happened over the weekend. She stated that usually if the Resident has 4-5 pills left, she would notify the doctor. She said that once she faxed for refill, she would also text it to the physician office and then wait for a response. In an another interview on 2/6/19 at 9:03 am with LVN B, she stated that when she sees 4-5 pills left, she would write the residents name down on pharmacy request and then she will fax it, for narcotics. She further stated that she would let incoming nurse know and also document it on the 24 hour book that oncoming nurse will need to follow up on medication pending. She also stated that she told the 2-10pm nurse that she faxed over refill for [MEDICATION NAME] to Resident #2's Attending Physician and she still had not received it. She asked the oncoming nurse to follow up. In an interview on 2/5/19 at 1:04 pm with the ADON, she stated that pain meds are normally reordered 3 days before they run out. The nurses call the doctor and faxes the doctor. She further stated that she wouldn't want them to run out of pain medications especially now since they are [MEDICATION NAME] Resident #2's heel. She further stated that she faxed and called Resident #2's Attending Physician around 9-9:30 am this morning. In an interview on 2/5/19 at 4:00 pm with the treatment nurse, she stated that the wound care doctor changed the dressing yesterday and he used a numbing agent and Resident #2 was not in pain on heel. In an interview on 2/6/19 at 8:48 am with Resident #2's Attending Physician, he stated that he told the facility in January, when he filled the order for [MEDICATION NAME] on 1/16/19 that he wouldn't fill another order, that she had to be seen by pain management for chronic pain. He also stated that he was not aware that Resident #2 had been attacked. He further stated that if a resident complains of new pain, he would order imaging to make sure there was no new fracture, and would prescribe a new order for pain medication. He further stated that he would see Resident #2 later that day. In an interview on 2/6/19 at 8:17 am with CNA B, she stated that she didn't work on the weekends, but she worked with Resident #2 on Monday (2/4/19) and that she complained of pain. CNA B stated that she elevated Resident #2's foot and then told LVN B. In an interview on 2/6/19 at 8:22 am with Resident #2, she stated that she slept really good last night after receiving her pain medication. She stated that she was not in any pain. When surveyor asked to look at her right hip she stated that they looked last night and there was no bruise to her right hip. She stated that she raised her right leg to protect her left foot during the attack, if Resident #4 had hit her left foot where the wound was. She stated that there was no telling what she would have done to her. She stated that her foot hurts enough already and that she had [MEDICAL CONDITION] and that Resident #4 must have hit the bone. In an interview on 2/6/19 at 8:38 am with CNA C, she stated that on Sunday (2/3/19) Resident #2 complained of pain and needed a pain pill in the afternoon, around lunch time. She stated that she told the nurse and was told that she would get her a pain pill. In an interview on 2/6/19 at 10:06 am with the DON, she stated that pain medications should be refilled when they have 5 days of medication left. She stated that she didn't know about Resident #2 needing her [MEDICATION NAME]. In an interview on 2/6/19 at 1:47 pm with LVN C, she stated that she gave the pain medication to Resident #2 on 2/4/19 at approximately 5:00 am. she stated that she didn't document that she gave [MEDICATION NAME]. She stated that, at 5:00 am I went in to give Resident #2 her morning meds and she asked for pain medicine. She stated that Resident #2 said her pain level was 7-8. She stated that she didn't write it down because she was hit in the jaw and ear that morning and she completely blanked. She further stated that she didn't write it anywhere on the MAR. She stated that she pulled Resident #2's [MEDICATION NAME] Narcotic Card, wrote a fax to her Attending Physician requesting for triplicate for narcotic. She stated that she faxed it and when you fax something you need to follow up. She stated that she told the nurse coming on the next shift that she needed to follow up. In an interview on 2/6/19 at 3:15 pm with the Administrator, she stated that they were having problems getting refills from Resident #2's attending physician. She stated that they now have two orders for [MEDICATION NAME] for Resident #2. One from the Attending Physician and one from the Medical Director. Record Review of the facility's Pain - Clinical Protocol policy, 2001 MED_PASS, Inc (revised 2013) revealed in part . Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes a review of each person's known [DIAGNOSES REDACTED]. 4. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning. Treatment/Management 2. The physician will order appropriate medication interventions to address the individual's pain.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one of 6 residents (CR #1) reviewed for supervision. -The facility failed to supervise CR #1 and failed to intervene when he refused to come inside during 90 + degree heat, he developed heat stroke and had to be admitted to the hospital. This failure affected one former resident and could affect 23 current residents on the secure unit and put them at risk for sun burn, dehydration, heat exhaustion and heat stroke. The findings include: Complaint: 0 Record review of CR #1's face sheet revealed that he was a [AGE] year old male who was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Initial MDS (Minimum Data Set) dated 4/23/18 revealed that he had clear speech, understood and was understood by others. His BIMS (Brief Interview for Mental Status) score was 7 of 15, indicating moderate cognitive impairment. His functional status revealed that he required total/2 person assistance for toileting and extensive/2 person assistance for bed mobility and dressing. He required extensive/1 person assistance for transfer and personal hygiene and limited /1 person assistance for locomotion. His medication status revealed that he got a diuretic. Record review of CR #1's care plan revealed that he had impaired cognitive function and impaired decision making related to [MEDICAL CONDITION]. The goals were that the resident would maintain current level of cognitive function and that he would remain oriented to person, place, situation, and time through the review date. CR #1 was resistive to care, ADL care due to dementia, as evidenced by striking out at staff during incontinent care and assistance with dressing, the goal was for him to experience no negative outcomes related to resistance to care. Interventions read in part .educate resident/family/caregivers of the possible outcomes of not complying with treatment or care, and to involve the family as appropriate. CR #1 was not care planned for potential for dehydration related to diuretic use. Record review of CR #1's consolidated physicians orders dated on or after 5/18/18 revealed that he had an order for [REDACTED]. Record review of CR #1's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed that he received [MEDICATION NAME] (diuretic) 2mg tablet every day until 5/17/18. Record review of CR #1's progress note dated 5/16/18 revealed a note text, written by LVN A who wrote; Resident had been sitting outside on the patio. Responsive to stimuli. Accepting fluids. At approx . 1715 (5:15 PM) Resident brought in via w/c from outside patio area, non - responsive, in respiratory distress making snoring sound. Resident was very warm to touch. v/s 85/52, 24, 105.5 temp. Resident transferred to bed by 2 staff. Head of bed elevated and feet. O2 initiated at 2 L NC, 911 dispatch contacted for emergency transport. DON aware. (Family member) notified. MD notified. 17:35 (5:35 PM), 911 EMS arrived and transported resident to the ER. Record review of the accuweather.com website revealed the outside temperature at the facility on 5/16/18 was 93 degrees Fahrenheit. Record review of CR #1's emergency room documentation on admission on 5/16/18 revealed that his skin was warm, dry and sun burnt. Axillary temperature was 106.1. CR #1 was discharged to the ICU with [DIAGNOSES REDACTED]. A wound consultation on 5/16/18 revealed that CR #1 had a generalized [MEDICATION NAME] papular rash on the anterior aspect of trunk and chest and that he had blisters on all extremities. In an observation of CR #1 in the CCU (Critical Care Unit) on 5/18/18 at 8:11 am, he was intubated and on a ventilator. He was able to open his eyes. His nurse pulled up his gown which revealed that his chest and abdomen were red with multiple small blisters on his skin. His forehead and head were pink, no peeling. He had a large fluid filled blister to his right forearm, below the elbow , the nurse measured it and it was 6 cm x 4.2 cm. In an interview on 5/17/18 at 3:15 pm with LVN A, she stated that she worked the 2-10 shift yesterday, she stated that CR #1 refused to come inside, and that he was outside from 2 pm to 5 pm. She stated that the staff gave him water and juice. She stated that she offered him snacks to get him to come inside and participate in activities. She further stated that they could not force them to come inside. She stated that residents can come and go outside, the alarm goes off , but they can go outside. When asked if there was a policy to check residents who are outside, she stated that she was sure there was. She stated that when CR #1 was brought in she tried to stimulate him, but he did not respond, he was red, not sun burned and his temp was 105.5. In an observation on 5/17/18 at 4:15 pm, the surveyor went to the outside courtyard of the memory care unit, the door opened and the alarm went off. Resident #2 was sitting outside in a chair, in the shade. He had a full mug of ice water. At 4:21 pm when surveyor entered the unit from outside the door did not alarm. In an interview on 5/17/18 at 4:15 pm with Resident #2, he stated that he got water when outside most days. He stated that he was outside till 9 pm last night. He stated that CR #1 was talking early in the day but that he didn't talk anymore after he was burnt. In an interview on 5/17/18 at 4:23 pm, CNA B stated that the alarm goes off when going outside, not when coming in. In a telephone interview on 5/17/18 at 4:35 pm with CR #1's family member, he stated that CR #1 was still in the CCU (Cardiac Care Unit) on a ventilator. He stated that he was called by the facility around 5:00 pm and that CR #1 was found outside and unresponsive. He said that they gave him O2 and they called 911. He stated that he went straight to the ER which took about 15 minutes. He stated that CR #1 was not there yet. He stated that he talked to EMS and they had to intubate him in the parking lot. In an interview on 5/18/18 at 9:02 am with LVN C , she stated that she works the 6-2 shift and worked at the facility for last 4 years. She was working the secure unit this day, however she works all halls of the facility. She stated that residents on the memory care/secure unit can go outside when they want, and that they make sure that they are okay. We check on them every 15 minutes. She further stated that they do not document that they are checking on the residents every 15 minutes. She stated that they encourage the residents who don't want to come in by offering snacks and juice. She stated that they give them water and sit with them until they can convince the resident to come inside. She said sometimes she will tell the CNA and they can get the resident to come in. In an observation and interview on 5/18/18 at 9:15 am, revealed that Resident #2 was sitting outside by the uncovered gazebo with full sun. He had a walker by his chair, with no water. He stated that he used to be a roofer and that he enjoyed the sun. He stated that he would move to the shade if it got too hot. In a telephone interview on 5/18/18 at 9:30 am with CNA C, she stated that she worked for the facility for 1 week. She stated that she did not receive education on Dementia and how to deal with difficult residents in the facility. She stated that she worked the day that CR #1 went to the hospital. She stated that CR #1 was sitting outside and she noticed that he was sweating and breathing bad, and that he was knocked out. She further stated that she brought him to the nurse. She said she then went to get another nurse and the nurses took him into his room. She thinks it was around dinner time when she found him. She stated that she came on at 2:00 pm and he was already outside. She stated that she did not know how long he was outside. She stated that she looked in his room and that he was not there on the start of her shift. She further stated that she didn't know where he was and that she could not remember if he was her patient. She could not remember if she had the front or the back hall. She stated that the assistant activity staff whet out to give the residents kool-aid but didn't know if CR #1 got any. She stated the Assistant Activity girl was new, and that she had only been there 2-3 days. In a telephone interview on 5/18/18 at 9:56 am with CNA C, she stated that he was her resident and that she saw him outside when they were passing punch. She stated that when she got the report at 2:00 pm she didn't see him. When the door alarm went off, she noticed that CR #1 was outside and also noticed the Assistant Activity person passing juice. In an interview on 5/18/18 at 10:18 am with the Assistant Activity Director, she stated that she had started working at the facility on 5/11/18. She stated that on 5/16/18 when she came in at 10:00 am, CR #1 was in the hallway with his stuff. He wanted to go home. She stated that CR #1 went outside after lunch, around one something. She stated that she went to check on him outside around 2:30 pm. She stated that she gave him water and punch and that he was talking at that time, telling her he wanted to go home. She stated that he was wearing a short sleeve shirt and sweat pants. She stated that she saw him again around four something, not sure of the time but that she noticed he was red and did not answer her. She stated she let the CNA and the nurse know. She stated that she saw CNA C pulling CR #1 inside. She said CNA C was pulling his wheelchair in backwards, he was sweating and he was red, dark red , not sure if he was talking. She stated that earlier she told LVN A that he was refusing to come in. She further stated that the DON told her to document everything that she does. In an interview on 5/18/18 at 1:08 pm with the DON, she stated that she was in her office with the Administrator and the Corporate RN, when LVN A came to the door and said CR #1's BP was 85/over something, and his temp was 105 and that 911 was on the way. The DON stated that she did not get up and go look at him and that she could not remember the exact time, but that it was in the evening, it must have been around 6:30 pm or so. She stated that she couldn't tell what happened, but that they had found him outside. She stated that she investigated it today and that she had talked to the Assistant Activity Director to get the whole story . She stated that in the back of her mind, she thought he might have had a heat stroke. If residents refuse to come inside, the CNA should tell the nurse, if the nurse cannot get them to come inside, they should tell me and the family. She stated that she was not informed that he refused to come inside. She stated that she didn't think they reported it and that this was her worst nightmare. She stated that from her understanding, every employee got dementia training. She further stated that they were not supposed to send new staff with no training back there on the secure unit. She stated that the staff development person quit today and that she was putting staff anywhere without regards to training. During shift report they are supposed to do walking rounds and are supposed to see every patient. In an interview on 5/18/18 at 2:50 pm with CNA D, he stated that he worked 2-10 shift and occasionally the day shift. He stated that CR #1 was CNA C's resident. He stated that CR #1 was already outside when he came on at 2 pm. He stated that when he made his rounds outside, he saw CR #1 sitting outside, he was awake and talking to another resident around 2:50 pm, he didn't have water with him. He stated that the next time he saw him was when CNA C was bringing him through the door at 5:15 pm, he was very hot, breathing hard, and eyes closed, he was flushed-red but not burned, he was not sweating. He stated that he did not see blisters at that time. He stated that he put ice packs under his arms, but nowhere else on the body. He stated that if a resident refuses to come in, go away, come back and ask again, if they still refuse, tell the nurse. In an interview on 5/18/18 at 3:20 pm with the Administrator, she stated that she did not report this incident to the state, because she didn't know she had to. She further stated that she didn't start the investigation until yesterday after the state entered the building. In an observation on 5/18/18 at 4:30 pm of the outside courtyard on the memory care unit revealed that the spot where CR #1 was sitting on the day that he developed heat stroke was mostly shaded. The courtyard had a high fence creating little air movement. In an interview on 5/21/18 at 8:25 am with the Administrator, she stated that she filed a report to the state for CR #1 on Friday evening (5/18/18). She stated that she got the ER report late Friday afternoon. When the surveyor asked why they didn't follow up with CR #1's condition the next day, she stated that she could not answer that. In an interview on 5/21/18 at 8:50 am with the DON, she stated that the corporate nurse was in-servicing staff on rounding, heat exhaustion, monitoring and documenting. She said that someone goes out every hour to see if anyone was outside, and records on logs. It was implemented on Friday (5/18/18), log starts from 10 am and goes to 7 pm . She said if residents that refuse to come in after 15 minutes, tell the nurse, the nurse try's, and if resident was still refusing , they were to tell me and call the family. In an observation on 5/21/18 at 9:05 am, Resident # 2 was outside, being escorted inside by the Administrator who was carrying his water. Record review of the facility's recent in-services revealed training covering Resident Safety on 5/17/18 which included in part Heat Stroke , Heat Exhaustion, Heat Cramps, Sunburn, and Heat Rash. another in-service training covered Reporting /Communication Potential Abuse Neglect related to change in condition and Supervision of Secured Unit Resident Outdoors dated 5/18/18. Review of the facility's Hourly Check for Safety/Hydration log started 5/19/18. Review of the facility's Memory Care Unit Policy revealed in part -Specialized Staff Training, staff will be trained in the needs of residents residing on the unit. -The unit will be secured/locked per keypad entry. -Frequent /periodic and as needed visual checks of each resident will take place 24 hours per day. Information provided by the DON on the resident roster revealed that their were 23 residents residing on the secure unit.

Based on observation, interview and record review, the facility failed to ensure that each resident had the right to be free from abuse and neglect for one of six residents (CR #1) reviewed for neglect. -The facility failed to supervise and to intervene when CR #1 refused to come inside during 93 degree heat. This failure affected one former resident and could affect 23 current residents on the memory care unit and put them at risk for sun burn, dehydration, heat exhaustion and heat stroke. Findings include: Complaint: 0 Record review of CR #1's face sheet revealed that he was a [AGE] year old male who was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Initial MDS (Minimum Data Set) dated 4/23/18 revealed that he had clear speech, understood and was understood by others. His BIMS (Brief Interview for Mental Status) score was 7 of 15, indicating moderate cognitive impairment. His functional status revealed that he required total/2 person assistance for toileting and extensive/2 person assistance for bed mobility and dressing. He required extensive/1 person assistance for transfer and personal hygiene and limited /1 person assistance for locomotion. His medication status revealed that he got a diuretic. Record review of CR #1's care plan revealed that he had impaired cognitive function and impaired decision making related to [MEDICAL CONDITION]. The goals were that the resident would maintain current level of cognitive function and that he would remain oriented to person, place, situation, and time through the review date. CR #1 was resistive to care, ADL care due to dementia, as evidenced by striking out at staff during incontinent care and assistance with dressing, the goal was for him to experience no negative outcomes related to resistance to care. Interventions read in part .educate resident/family/caregivers of the possible outcomes of not complying with treatment or care, and to involve the family as appropriate. CR #1 was not care planned for potential for dehydration related to diuretic use. Record review of CR #1's consolidated physicians orders dated on or after 5/18/18 revealed that he had an order for [REDACTED]. Record review of CR #1's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed that he received [MEDICATION NAME] (diuretic) 2mg tablet every day until 5/17/18. Record review of CR #1's progress note dated 5/16/18 revealed a note text, written by LVN A who wrote; Resident had been sitting outside on the patio. Responsive to stimuli. Accepting fluids. At approx . 1715 (5:15 PM) Resident brought in via w/c from outside patio area, non - responsive, in respiratory distress making snoring sound. Resident was very warm to touch. v/s 85/52, 24, 105.5 temp. Resident transferred to bed by 2 staff. Head of bed elevated and feet. O2 initiated at 2 L NC, 911 dispatch contacted for emergency transport. DON aware. (Family member) notified. MD notified. 17:35 (5:35 PM), 911 EMS arrived and transported resident to the ER. Record review of the accuweather.com website revealed the outside temperature at the facility on 5/16/18 was 93 degrees Fahrenheit. Record review of CR #1's emergency room documentation on admission on 5/16/18 revealed that his skin was warm, dry and sun burnt. Axillary temperature was 106.1. CR #1 was discharged to the ICU with [DIAGNOSES REDACTED]. A wound consultation on 5/16/18 revealed that CR #1 had a generalized [MEDICATION NAME] papular rash on the anterior aspect of trunk and chest and that he had blisters on all extremities. In an observation of CR #1 in the CCU (Critical Care Unit) on 5/18/18 at 8:11 am, he was intubated and on a ventilator. He was able to open his eyes. His nurse pulled up his gown which revealed that his chest and abdomen were red with multiple small blisters on his skin. His forehead and head were pink, no peeling. He had a large fluid filled blister to his right forearm, below the elbow , the nurse measured it and it was 6 cm x 4.2 cm. In an interview on 5/17/18 at 3:15 pm with LVN A, she stated that she worked the 2-10 shift yesterday, she stated that CR #1 refused to come inside, and that he was outside from 2 pm to 5 pm. She stated that the staff gave him water and juice. She stated that she offered him snacks to get him to come inside and participate in activities. She further stated that they could not force them to come inside. She stated that residents can come and go outside, the alarm goes off , but they can go outside. When asked if there was a policy to check residents who are outside, she stated that she was sure there was. She stated that when CR #1 was brought in she tried to stimulate him, but he did not respond, he was red, not sun burned and his temp was 105.5. In an observation on 5/17/18 at 4:15 pm, the surveyor went to the outside courtyard of the memory care unit, the door opened and the alarm went off. Resident #2 was sitting outside in a chair, in the shade. He had a full mug of ice water. At 4:21 pm when surveyor entered the unit from outside the door did not alarm. In an interview on 5/17/18 at 4:15 pm with Resident #2, he stated that he got water when outside most days. He stated that he was outside till 9 pm last night. He stated that CR #1 was talking early in the day but that he didn't talk anymore after he was burnt. In an interview on 5/17/18 at 4:23 pm, CNA B stated that the alarm goes off when going outside, not when coming in. In a telephone interview on 5/17/18 at 4:35 pm with CR #1's family member, he stated that CR #1 was still in the CCU (Cardiac Care Unit) on a ventilator. He stated that he was called by the facility around 5:00 pm and that CR #1 was found outside and unresponsive. He said that they gave him O2 and they called 911. He stated that he went straight to the ER which took about 15 minutes. He stated that CR #1 was not there yet. He stated that he talked to EMS and they had to intubate him in the parking lot. In an interview on 5/18/18 at 9:02 am with LVN C , she stated that she works the 6-2 shift and worked at the facility for last 4 years. She was working the secure unit this day, however she works all halls of the facility. She stated that residents on the memory care/secure unit can go outside when they want, and that they make sure that they are okay. We check on them every 15 minutes. She further stated that they do not document that they are checking on the residents every 15 minutes. She stated that they encourage the residents who don't want to come in by offering snacks and juice. She stated that they give them water and sit with them until they can convince the resident to come inside. She said sometimes she will tell the CNA and they can get the resident to come in. In an observation and interview on 5/18/18 at 9:15 am, revealed that Resident #2 was sitting outside by the uncovered gazebo with full sun. He had a walker by his chair, with no water. He stated that he used to be a roofer and that he enjoyed the sun. He stated that he would move to the shade if it got too hot. In a telephone interview on 5/18/18 at 9:30 am with CNA C, she stated that she worked for the facility for 1 week. She stated that she did not receive education on Dementia and how to deal with difficult residents in the facility. She stated that she worked the day that CR #1 went to the hospital. She stated that CR #1 was sitting outside and she noticed that he was sweating and breathing bad, and that he was knocked out. She further stated that she brought him to the nurse. She said she then went to get another nurse and the nurses took him into his room. She thinks it was around dinner time when she found him. She stated that she came on at 2:00 pm and he was already outside. She stated that she did not know how long he was outside. She stated that she looked in his room and that he was not there on the start of her shift. She further stated that she didn't know where he was and that she could not remember if he was her patient. She could not remember if she had the front or the back hall. She stated that the assistant activity staff whet out to give the residents kool-aid but didn't know if CR #1 got any. She stated the Assistant Activity girl was new, and that she had only been there 2-3 days. In a telephone interview on 5/18/18 at 9:56 am with CNA C, she stated that he was her resident and that she saw him outside when they were passing punch. She stated that when she got the report at 2:00 pm she didn't see him. When the door alarm went off, she noticed that CR #1 was outside and also noticed the Assistant Activity person passing juice. In an interview on 5/18/18 at 10:18 am with the Assistant Activity Director, she stated that she had started working at the facility on 5/11/18. She stated that on 5/16/18 when she came in at 10:00 am, CR #1 was in the hallway with his stuff. He wanted to go home. She stated that CR #1 went outside after lunch, around one something. She stated that she went to check on him outside around 2:30 pm. She stated that she gave him water and punch and that he was talking at that time, telling her he wanted to go home. She stated that he was wearing a short sleeve shirt and sweat pants. She stated that she saw him again around four something, not sure of the time but that she noticed he was red and did not answer her. She stated she let the CNA and the nurse know. She stated that she saw CNA C pulling CR #1 inside. She said CNA C was pulling his wheelchair in backwards, he was sweating and he was red, dark red , not sure if he was talking. She stated that earlier she told LVN A that he was refusing to come in. She further stated that the DON told her to document everything that she does. In an interview on 5/18/18 at 1:08 pm with the DON, she stated that she was in her office with the Administrator and the Corporate RN, when LVN A came to the door and said CR #1's BP was 85/over something, and his temp was 105 and that 911 was on the way. The DON stated that she did not get up and go look at him and that she could not remember the exact time, but that it was in the evening, it must have been around 6:30 pm or so. She stated that she couldn't tell what happened, but that they had found him outside. She stated that she investigated it today and that she had talked to the Assistant Activity Director to get the whole story . She stated that in the back of her mind, she thought he might have had a heat stroke. If residents refuse to come inside, the CNA should tell the nurse, if the nurse cannot get them to come inside, they should tell me and the family. She stated that she was not informed that he refused to come inside. She stated that she didn't think they reported it and that this was her worst nightmare. She stated that from her understanding, every employee got dementia training. She further stated that they were not supposed to send new staff with no training back there on the secure unit. She stated that the staff development person quit today and that she was putting staff anywhere without regards to training. During shift report they are supposed to do walking rounds and are supposed to see every patient. In an interview on 5/18/18 at 2:50 pm with CNA D, he stated that he worked 2-10 shift and occasionally the day shift. He stated that CR #1 was CNA C's resident. He stated that CR #1 was already outside when he came on at 2 pm. He stated that when he made his rounds outside, he saw CR #1 sitting outside, he was awake and talking to another resident around 2:50 pm, he didn't have water with him. He stated that the next time he saw him was when CNA C was bringing him through the door at 5:15 pm, he was very hot, breathing hard, and eyes closed, he was flushed-red but not burned, he was not sweating. He stated that he did not see blisters at that time. He stated that he put ice packs under his arms, but nowhere else on the body. He stated that if a resident refuses to come in, go away, come back and ask again, if they still refuse, tell the nurse. In an interview on 5/18/18 at 3:20 pm with the Administrator, she stated that she did not report this incident to the state, because she didn't know she had to. She further stated that she didn't start the investigation until yesterday after the state entered the building. In an observation on 5/18/18 at 4:30 pm of the outside courtyard on the memory care unit revealed that the spot where CR #1 was sitting on the day that he developed heat stroke was mostly shaded. The courtyard had a high fence creating little air movement. In an interview on 5/21/18 at 8:25 am with the Administrator, she stated that she filed a report to the state for CR #1 on Friday evening (5/18/18). She stated that she got the ER report late Friday afternoon. When the surveyor asked why they didn't follow up with CR #1's condition the next day, she stated that she could not answer that. In an interview on 5/21/18 at 8:50 am with the DON, she stated that the corporate nurse was in-servicing staff on rounding, heat exhaustion, monitoring and documenting. She said that someone goes out every hour to see if anyone was outside, and records on logs. It was implemented on Friday (5/18/18), log starts from 10 am and goes to 7 pm . She said if residents that refuse to come in after 15 minutes, tell the nurse, the nurse try's, and if resident was still refusing , they were to tell me and call the family. In an observation on 5/21/18 at 9:05 am, Resident # 2 was outside, being escorted inside by the Administrator who was carrying his water. Record review of the facility's recent in-services revealed training covering Resident Safety on 5/17/18 which included in part Heat Stroke , Heat Exhaustion, Heat Cramps, Sunburn, and Heat Rash. Another in-service training covered Reporting /Communication Potential Abuse Neglect related to change in condition and Supervision of Secured Unit Resident Outdoors dated 5/18/18. Record review of the facility's Hourly Check for Safety/Hydration log started 5/18/18. Record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation of Property, Prevention, Protection, and Response Policy and Procedures revised on 2/1/17 read in part; Policy: Abuse, Neglect, Exploitation and Misappropriation of Property, collectively known and referred to as ANEM and as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardians, friends or any other individuals. Neglect: The failure of the facility , its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure that care is provided as needed by the patient. Information provided by the DON on the resident roster revealed that their were 23 residents residing on the secure unit.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices, for three of 13 residents, (CR #1, Resident #'s 6 and 9) reviewed for quality of care, as evidenced by: The facility failed to follow CR #1's physician's orders and did not administer Potassium supplements as ordered causing CR #1 critical low Potassium levels and shortness of breath. The facility failed to update CR #1's physician about her continuous episodes of loose stools, abnormal vital signs, changes in her skin color, increased in swelling and weakness. CR #1 was sent to the ER per family request and she was admitted to the ICU with [DIAGNOSES REDACTED].#1 died 4 days later. The facility failed to ensure timely administration of antibiotic treatment for [REDACTED].#6. There was a three day delay in starting the treatment. The facility failed to ensure timely administration of antibiotic treatment for [REDACTED].#9. This failure affected one former resident (CR #1) and two current residents (Resident #6, #9) who resided on Hall B and placed an additional 20 current residents on Hall B at risk for serious medical complications, decline in condition and the need for hospitalization or death. Findings Include: Intake # 1 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 was sent to theER on [DATE] per family request. CR #1 died on [DATE]. Record review of CR #1's Admit/Readmit Screener document dated [DATE] revealed that CR #1's skin color was normal upon admission to the facility. Record review of CR #1's admission assessment MDS dated [DATE] revealed a BIMS score of 13, indicating she was cognitive intact. She required extensive assistance with all ADLs. CR # 1 was occasionally incontinent of bowel and bladder. Record review of CR #1's care plan with goals through [DATE] revealed in part; Focus: CR #1 has impaired immunity related [MEDICAL CONDITION]. Record review of CR #1's consolidated Physician's orders for [DATE] revealed orders in part; -[DATE] Potassium chloride 40 mEq/15 ml by mouth every day for cardiac heart failure. -[DATE] [MEDICATION NAME] tablet 40 mg. 1 tablet by mouth two times a day for diuretics. -[DATE] [MEDICATION NAME] tablet 750 mg 1 tablet by mouth one time a day for infection. Record review of CR #1's [DATE] MAR revealed that Potassium chloride 40 mEq/15 ml by mouth every day for cardiac heart failure order was not transcribed to the MAR. CR #1 did not receive Potassium chloride 40 mEq/15 ml as ordered for 4 days. Record review of CR #1's progress/nurses notes revealed in part; [DATE] at 10:26 a.m. by LVN A CR #1 having short of breath, oxygen saturation 85%, nebs and inhalers given and increased to 91%. Vital signs blood pressure ,[DATE], pulse 110, respirations 24. Audible wheezing and productive cough. CR #1 stated she is also having leg cramps. MD (Physician) notified. New orders for STAT CBC, BMP, BNP and 2 view chest x-ray Record review of CR #1's laboratory report revealed in part; -[DATE] Potassium level critically low at 2.2 mmol/L Reference range (3XXX,[DATE].1). Record review of CR #1's progress/nurses notes revealed in part; -[DATE] at 612 p.m. by LVN A CR #1's potassium level 2.2. MD (Physician) with new orders for potassium chloride 40 meq by mouth every 2 hours for 3 doses . Record review of CR #1's consolidated Physician's orders for [DATE] revealed orders in part; -[DATE] Potassium chloride ER Tablet Extended Release 20 mEq. Give 2 tablet by mouth one time only for [DIAGNOSES REDACTED] for 1 day and repeat in 2 hours. -[DATE] Potassium chloride ER Tablet Extended Release 20 mEq. Give 2 tablet by mouth one time only for [DIAGNOSES REDACTED] (low potassium) for 1 day. -[DATE] Potassium chloride solution 20 mEq/15 ml. (10%) Give 30 ml by mouth one time a day. Record review of CR #1's laboratory report revealed in part; -[DATE] Potassium level at 3.9 mmol/L Reference range (3XXX,[DATE].1). Record review of CR #1's daily skilled assessment dated [DATE] at 6:23 a.m. signed by RN A revealed in part; Vital signs at 6:24 a.m. Temperature: 98.1, Pulse 114 regular, blood pressure lying left arm: ,[DATE] . Blood pressure a little low. CR #1 is on [MEDICATION NAME]. Fluids encouraged and blood pressure to be taken in 2 hours ,[DATE] .Bowel/GI: No assessments written. CR #1 thinks she is having diarrhea, one small walnut sized stool only noted .Cardiovascular: 2 + moderate [MEDICAL CONDITION] (swelling) . Record review of CR #1's bowel and bladder elimination ADL chart revealed in part; [DATE] at 5:59 a.m. an incontinent episode of loose/diarrhea. Record review of CR #1's progress/nurses notes revealed in part; - [DATE] at 8:41 a.m. [MEDICATION NAME] 100 mg tablet not given. CR #1 had 2 large liquid brown stools this a.m. Signed by LVN B -[DATE] at 10:15 a.m. Spoke with MD A via telephone, reported resident's complaining of diarrhea times two days. CR #1 has had two large liquid stools with formed particles contained. Stool brown in color with unpleasant odor. Signed by LVN B -[DATE] at 11:03 a.m. Second call placed to MD A office request for medication for loose stool, awaiting return call. Signed by LVN B -Record review CR #1's Physician's order dated [DATE] at 7:28 p.m. and created by LVN B revealed an order for [REDACTED]. -Record review of CR #1's MAR revealed that [MEDICATION NAME] A-D 2 mg by mouth one tablet was administered on [DATE] at 9:26 p.m. Record review of CR #1's bowel and bladder elimination ADL chart revealed in part; -[DATE] at 3:20 a.m. an incontinent episode of loose/diarrhea. Record review of CR #1's progress/nurses notes signed by LVN B revealed in part; -[DATE] at 8:00 a.m. [MEDICATION NAME] 100 mg by mouth not given this a.m. CR #1 recovering from multiple loose stools [DATE]. Record review of CR #1's bowel and bladder elimination ADL chart revealed in part; -[DATE] at 10:22 a.m. an episode of one formed large bowel movement. -[DATE] at 10:59 p.m. an incontinent episode of loose/diarrhea. -[DATE] at 1:59 p.m. an episode of large loose/diarrhea stool. Record review of CR #1's vital signs dated [DATE] at 7:00 a.m. -Blood pressure ,[DATE]. Pulse 120. Record review of CR #1's progress/nurses notes signed by LVN C revealed in part; -[DATE] at 1:35 p.m. CR #1's FM stated she wanted to send CR #1 to hospital. MD (Physician) paged. Awaiting response. -2:46 p.m. ambulance called to pick up CR #1. -2:50 P.M. ambulance arrived to transfer CR #1. -3:00 P.M. Ambulance left for transport. Left message with answering service regarding CR #1 sent to hospital per family member request. Record review of facility's transfer form dated [DATE] revealed in part; CR #1 vital signs: Temperature: 98.1, Pulse: 122, Respirations: 20, Blood pressure: ,[DATE] . No further assessments noted on report. Record review of emergency room documentation dated [DATE] at 3:14 p.m. revealed in part; . CR #1 presents with [MEDICAL CONDITION]. The onset was just prior to arrival. The degree of [MEDICAL CONDITION] is systolic blood pressure: 80 mmHg. Diastolic blood pressure 50 mmHg. Additional history: CR #1 with generalized weakness and fatigue. History of metastatic [MEDICAL CONDITION]. Had immunotherapy about 2 months ago. Having swelling to legs and yellowing of skin. Physical examination: -Skin: jaundice. (is a yellowish or greenish pigmentation of the skin) -Cardiovascular: [MEDICAL CONDITION]; bilateral, pedal, pretibial (the inner of the two bones of the leg, that extend from the knee to the ankle), 4 + pitting. -Medical decision making: [MEDICAL CONDITION], shock, hypovolemia, orthostatic [MEDICAL CONDITION], dehydration, [MEDICAL CONDITIONS]. -Reexamination reevaluation: [DATE] at 5:03 p.m. Will continue intravenous fluids, antibiotics have already been started. -Procedure: Critical care note: Critical conditions addressed for impending deterioration include: airway, respiratory, cardiovascular. -Associated risk factors: [MEDICAL CONDITIONS]. -Impression and Plan: [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. -Plan: Condition: Critical. Admit to Intensive Care Unit time: [DATE] at 5:05 p.m Record review of the History and Physical dated [DATE] at 5:41 p.m. by Hospital Physician revealed in part; CR #1 admitted on [DATE]. Chief complaint: Shortness of breath, weakness, [MEDICAL CONDITION]. [AGE] year old female, was sent from the nursing facility because of low blood pressure, shortness of breath. CR #1 has also been complaining of diarrhea. Significant fatigue and generalized weakness. CR #1 has stage 4 [MEDICAL CONDITION]. CR #1 has been having generalized swelling. Lungs: decreased breath sounds. Scattered bilateral rhonchi. Abdomen is soft, mildly distended. There seem to be underlying ascites. Bilateral upper and lower extremity [MEDICAL CONDITION]. -Impression: dyspnea, [MEDICAL CONDITION], pneumonia,[MEDICAL CONDITION] and leukocytosis, chronic obstructive pulmorary disease, type 2 diabetes, hypertension, anasarca and stage 4 [MEDICAL CONDITION] . Record review of medical-dictionary.thefreedictionary.com/anasarca/ generalized massive [MEDICAL CONDITION]. Record review of www.med-health.net > 1 + [MEDICAL CONDITION]: 2 mm or less: slight pitting, no visible distortion, disappears rapidly. 2 + [MEDICAL CONDITION]: 2 - 4 mm indent: somewhat deeper pit, no readably detectable distortion, disappears in 10 - 25 seconds. 3 + [MEDICAL CONDITION]: 4 - 6 mm: pit is noticeably deep. May last more than a minute. Dependent extremity looks swollen and fuller. 4 + [MEDICAL CONDITION]: 6 - 8 mm: pits is very deep. Last for ,[DATE] minutes. Dependent extremity is grossly distorted . Record review of CR #1's hospital laboratory report in part; -[DATE] White blood cells: 19.3 (high) -Sodium 140 (normal) Radiology report in part; -1. Hepatomegaly. The liver parenchyma is replaced by multiple low density masses suspicious for metastatic disease. -3. Right lower lobe consolidation with trace bilateral pleural fluid. 4.- Findings of anasarca with diffuse soft tissue [MEDICAL CONDITION] of the body wall and small abdominopelvic ascites. In a phone interview on [DATE] at 9:45 a.m. with LVN C, she stated that she was the charge nurse for CR #1 on [DATE] and said that CR #1 looked fine and that a family member came that day and that the family member spoke with another family member over the phone and that the family member requested to send CR #1 to the hospital. LVN C then said that she did not know why the family member decided to send CR #1 and further said probably was because CR #1 was a little yellow, her legs were yellow, one portion of the leg was yellow. When asked if she communicated with the MD that CR #1's skin was yellow, LVN C stated CR #1 was fine, I was taking her to the bathroom and she was not different from before. I did not receive any reports of changes in condition on her. I took her vital signs at around 9 or 10 a.m. and the blood pressure was on the low side but I don't remember that her pulse was 120. When asked if she took CR #1's vital signs when family requested to send CR #1 to the hospital, LVN C stated I don't believe I had time to take her vital signs. I don't really remember. The paramedics took the vital signs and I don't think there was anything abnormal. When asked what assessments she completed on CR #1 on [DATE], LVN C responded One of her legs had a little of [MEDICAL CONDITION] only. CR #1 was fine. I did not feel it was a reason to call the MD because CR #1 was doing fine, she was just a little yellow. CR #1 had no other changes in condition, no diarrhea that I was aware. In an interview on [DATE] at 1:35 p.m with the Interim DON, she stated that it was a transcription error that CR #1's potassium order was not transcribed to the MAR. She further said that orders were supposed to be reviewed the next morning of the admission by the DON and unit managers. She further stated she did not know if CR #1's orders were reviewed because she was not the DON at the time CR #1 was admitted to the facility. Interim DON then said that she did not have information regarding CR #1 and that she just heard about CR #1 when surveyor walked into the facility. In an interview on [DATE] at 1:55 p.m. with LVN A, she said that she was the Interim Unit Manager for about a month. She further said that when CR #1 had the episode of shortness of breath and leg cramping, she called the MD and read the medications to the MD. She further said that she did not check at the MAR and did not know that CR #1 had not being receiving the potassium as ordered. LVN A continued saying that she was not the Unit Manager when CR #1 was in the facility and that she was not aware of any changes in condition. LVN A then said that when a resident had a change in condition such as abnormal laboratory readings or any physical changes, the MD and RP were called and residents were assessed and monitored for 72 hours and that every shift would charted on the residents until the problem resolved. In a phone interview on [DATE] at 2:21 p.m. with CNA E, she stated that she worked a couple of times with CR #1. CNA E stated that on [DATE] (the day that CR #1 was sent to the hospital), she worked with CR #1 and then said On that day when I saw her in the morning I said 'wow' her skin is different, she looked yellow and I even wonder if she was getting jaundice. CR #1 had diarrhea, she was having diarrhea. CR #1 was having hard time standing up. The first time I worked with her, like a week ago, CR #1 was slow, but she went to the bathroom well. CR #1 was not jaundice. Her skin was not yellow. This time, she was jaundice and was having hard time standing up and I had to get the help from the charge nurse (LVN C). The charge nurse was aware CR #1 had diarrhea. Further interview with CNA E, she stated that she did not get any report that CR #1 had any episodes of loose stools before. CNA E continued saying that day when CR #1 went to the hospital, her RP came and said she wanted CR #1 to go to the hospital. In an interview on [DATE] at 4:30 p.m. with MD A and the Interim Administrator, the MD A stated that the NP saw CR #1 when she was in the facility. He then said that CR #1 was admitted to the hospital with [REDACTED]. MD A then said that CR #1 was getting weaker and weaker. He further said that CR #1 was transferred to the ICU due [MEDICAL CONDITION] and [MEDICAL CONDITION] and that CR #1 died 4 days later. MD A then said that he did not remember what information the NP gave him regarding CR #1 but that he did not remember CR #1 having any diarrhea in the facility and that CR #1 did not have problems with diarrhea at the hospital. MD A said that CR #1 had very poor [MEDICAL CONDITION] status due to her diagnoses. In an interview on [DATE] at 8:45 a.m. with the NP and the Interim Administrator, the NP stated that she saw CR #1 twice. The NP said that on [DATE] when she saw CR #1, CR #1 was doing well and that on [DATE] when she saw CR #1, CR #1 was having chest congestion and ordered laboratory work and x-rays due to CR #1's history [MEDICAL CONDITION]. NP then said There were no other significant changes that I was made aware of. I don't recall CR #1 having any jaundice or skin color changes. After [DATE], MD A would had been notified of any changes in CR #1's condition because I had a family emergency. In an interview on [DATE] at 9:50 a.m. with CNA C, she stated that she worked with CR #1 on [DATE] during the 6 to 2:00 p.m. shift, and said that she remembered that CR #1 had 4 to 5 times diarrhea and that her skin was yellowish in color. CNA C said that she made the charge nurse aware. In a phone interview on [DATE] at 10:00 a.m. with CNA D, she stated that on the night before CR #1 went to the hospital on [DATE], during the night shift, CR #1 had watery loose stools twice. She said that the first time it was a large amount and that the second time it was not as large. CNA D stated that any changes in condition she reported to the charge nurse. In a phone interview on [DATE] at 10:23 a.m. with LVN B, she stated that she did not remember any information related to CR #1. Attempted a phone interview on [DATE] at 11:20 a.m. with RN A but she did not answer. In a phone interview on [DATE] at 2:23 p.m. with CR #1's FM, she stated that on [DATE], CR #1's RP went to the facility to visit CR #1. CR #1's FM stated that CR #1's RP called her on the phone hysterically to inform her that CR #1 did not look well. She said that CR #1's RP told her that CR #1 looked very swollen, very weak and that she looked very yellow. She said that CR #1 did not even looked like a human anymore. CR #1's FM continued saying I told CR #1's RP to have them call the MD so that the MD could evaluate CR #1. She then called me and told me that the charge nurse told her that it was a Sunday, that the MD was not available. I then told her to ask the charge nurse to call 911 and then CR #1's RP told me that the charge nurse told her that the facility couldn't just call 911, that they needed to call the MD first. At that moment, I told CR #1's RP, tell them that if they don't call 911, we are going to call 911, but CR #1 needed immediate attention. CR #1's RP then called me and said that the facility had called the ambulance. CR #1's FM further said CR #1's RP told me that the charge nurse had told her that we were acting as if CR #1 was going to die soon. Continued interview with CR #1's FM, she stated that since [DATE] CR #1 called her on the phone and informed her of the episodes of loose stools and that CR #1 was concerned because she was getting weaker. CR #1's FM further said that when EMS arrived, CR #1's RP did not see the facility staff taking CR #1's vital signs and that the paramedics were the ones taking the vital signs and that the paramedics had told CR #1's RP that the blood pressure was ,[DATE] and that CR #1 was complaining of chills. CR #1's FM then said I called the ER MD and he told me that they were going to send CR #1 to the ICU due to septic pneumonia. If CR #1 was having a change in her condition, why nobody called us, why they did not call the MD, were they going to let her die in the facility. Resident #6 Record review of the facility face sheet revealed Resident #6 was a [AGE] year old female. She was admitted to the facility on [DATE] and re-admitted on [DATE] with following [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly assessment dated [DATE] revealed she had severe cognitive impaired with a BIMS score of 03 out of a possible 15. She required extensive assistance for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Resident #6 was always incontinent of bowel and bladder. Record review of Resident #6's care with goals dated through [DATE] revealed in part: -Focus: Resident #6 has an ADL self-care performance deficit related to impaired cognition, weakness and deconditioning. Incontinent of bowel and bladder related to impaired cognition, unaware of need to be toileting. Resident #6 has impaired cognitive function and impaired thought processes related to short term memory loss, long term memory loss, difficulty making decisions, inattention and dozes off at times. -Interventions/Tasks: Resident #6 requires moderate to maximum assistance for toileting and personal hygiene. Clean peri-area with each incontinence episode. Check frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Record review of Resident #6's urinalysis final report dated [DATE] revealed in part; -the presence of: white blood cells, red blood cells, blood, protein and bacterial. Continued review of the report revealed under the results was the following hand written: date [DATE] and [MEDICATION NAME] 100mg orally twice a day for seven days. Record review of Resident #6's urine culture final report dated [DATE] revealed in part; -Results: greater than 100,000 CFU/mL of Escheriachia coli. Record review of Resident #6's consolidated orders dated ,[DATE]/ 2017 revealed orders in part; [DATE] [MEDICATION NAME] (antibiotic) capsule 100 mg. Give 1 capsule by mouth two times a day for urinary tract infection for seven days. Record review of Resident #6's medication administration record (MAR) dated [DATE]-[DATE] revealed orders in part; [DATE] [MEDICATION NAME] (antibiotic) capsule 100 mg. Give 1 capsule by mouth two times a day for urinary tract infection for seven days. Observation on [DATE] at 10:24 a.m. Resident #6 was in a low bed with bilateral floor mats next to the bed. The resident was awake and alert but was confused and could not engage in an interview. In an interview on [DATE] at 3:10pm interim DON stated the [MEDICATION NAME] did not get started until [DATE]. She continued and stated she would need to review the system to see what happened and why the medication was dropped. In an interview on [DATE] at 3:55pm interim DON stated the nurse practitioner (NP) received the abnormal original faxed laboratory result and responded by writing the order for [MEDICATION NAME] on the lab slip but she faxed it to the wrong fax number in the business office which we do not use. In an interview on [DATE] at 8:57am LVN A stated Resident #6's physician only wanted to communicate by fax. The lab was faxed over but the NP faxed the order to a fax number we do not use located in the business office and no one was in the office over the weekend. LVN A continued and stated when she came in on Monday she followed up and the NP told her she was on her way in and would order the medication when she arrived. Resident #9 Record review of the facility face sheet revealed Resident #9 was an [AGE] year old male. He was admitted to the facility on [DATE] and re-admitted on [DATE] with following [DIAGNOSES REDACTED]. Record review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was moderately impaired with a BIMS score of 07 out of a possible 15. He required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Record review of Resident #9's care plan with goals dated [DATE] revealed in part: -Focus: Resident #9 has altered respiratory status/difficulty breathing related to wheezing. -Interventions/Tasks: [MEDICATION NAME] for 10 days Record review of Resident #9's chest radiology report dated [DATE] revealed in part; -Minimal right lower lobe infiltrate. Continued review of the report revealed under the results was the following hand written: date noted [DATE] and RLL infiltrate needs antibiotic and nebs [MEDICATION NAME] 500mg one daily for 10 days. Record review of the nurse's progress notes dated [DATE] revealed chest X-ray showed minimal right lower lobe infiltrate. Result faxed and informed physician by phone. Record review of Resident #9's consolidated orders dated [DATE] revealed orders in part; [DATE] [MEDICATION NAME] Tablet 500mg one by mouth one time a day for upper respiratory infection (URI) for 10 days. Record review of Resident #9's medication administration record (MAR) dated [DATE]-[DATE] revealed orders in part; [DATE] [MEDICATION NAME] 500mg by mouth one time a day for 10 days for URI. In an interview on [DATE] at 12:25pm LVN A stated the order came across the wrong fax number again over a weekend. She stated the office was notified twice about the correct fax number to use. She stated the antibiotic was not started in a timely manner. In an interview on [DATE] at 12:40pm interim DON stated she had implemented a unit manager to work over the weekend to help monitor the charts, labs and orders seven days a week. The staff should do a follow up call to the office after faxing an abnormal result. LVN A found this on Monday and did the follow up call to the office for an order. Record review of the facility policy and procedure with title Acute Condition Changes - Clinical Protocol Revised [DATE] revealed in part; Assessment and Recognition: 1.- During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay. 2.- In addition, the Nurse shall assess and documents/report the following baseline information: a.- vital signs, d.- level of consciousness, g.- onset, duration, severity, h.- recent labs, j.- all active [DIAGNOSES REDACTED]. Monitoring and follow-Up: 1.- The staff will monitor and document the resident's progress and responses to treatment and the Physician will adjust treatment accordingly. 2.- The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Record review of the facility policy and procedure with title Change in a Resident's Condition or Status revised [DATE] revealed in part: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .etc .). 3.- Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: There is a significant change in the resident's physical, mental, or psychosocial status. 6.- The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Record review of the facility's policy and procedure with title Medication and Treatment orders revised [DATE] revealed in part; 1.- Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Facility roster revealed 22 current residents on Hall B.

Based on observation, interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice and to promote healing for two of eight residents (Residents #1 and #4) reviewed for pressure ulcers. -The facility failed to accurately assess, evaluate and update the current treatment for [REDACTED]. -Resident #4 developed a pressure sore and the facility failed to identify the wound and provide timely treatment. -The facility failed to provide routine assessments to determine pressure sore risk for Resident #4, whose last Braden Scale for Predicting Pressure Ulcer risk was 5 months ago. These failures affected two residents (Residents #1 and #4) and placed an additional four residents with pressure ulcers at risk for developing new pressure ulcers and a decline in existing pressure ulcers due to the delayed discovery and treatment. Findings included: Intake: # 6/TX 645 Resident #1 Record review of Resident #1 ' s admission face sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] and readmitted on [DATE] and 3/11/15 with [DIAGNOSES REDACTED]. Resident #1 was transferred to a local hospital on [DATE] and underwent surgical debridement for a Stage IV pressure sore. Record review of Resident #1 ' s clinical record revealed a telephone physician ' s order dated 9/5/2016 which read in part; cleanse left gluteal fold open area with normal saline and pat dry. Apply calcium alginate cover with a dry dressing daily and as needed. Record review of Resident #1 ' clinical record revealed a telephone physician ' s order dated 10/12/2016 which read in part Bactrim antibiotic twice daily for seven days for wound infection and wound consult for wound on left upper thigh. Continued review of Resident #1's clinical record did not reveal documentation that a wound care physician consult was done. Record review of Resident #1 ' s electronic quarterly Braden Scale for Predicting Pressure Sore Risk dated and signed 10/13/2016 revealed a score of 15 indicating the resident was at risk for developing pressure wounds. Record review of Resident #1 ' s electronic quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was usually understood and understood others. The resident ' s Brief Interview for Mental Status (BIMS) was scored as nine out of 15 which indicated her cognition was moderately impaired. Continued review of the resident MDS revealed she required extensive assistance from two staff for bed mobility, transfer and toilet use. The resident required extensive assistant from one staff for dressing and personal hygiene. Resident #1 had limitations in range of motion to her bilateral upper and lower extremities. Review of the same MDS did not reveal the presence of current pressure wounds but Resident #1 did have moisture associated skin damage. The MDS document healed stage II pressure wounds. The MDS did reveal the resident was identified as being at risk of developing pressure ulcers. Record review of Resident #1 ' s electronic care plans undated revealed in part the focus area Resident #1 has moisture associated skin damage to her gluteal fold. The care plan revealed the goal Resident #1 will have no complications related to excoriation of the left thigh through 1/10/2017. Continued review of the care plan revealed interventions in part: Monitor and document location, size and treatment of [REDACTED]. Record review of Resident #1 ' s electronic care plans undated revealed in part the focus area Resident #1 has potential for pressure injury development related to history of ulcers, immobility. The care plan revealed the goal Resident #1 will have intact skin, free of redness, blisters or discoloration by 1/10/2017. Continued review of the care plan revealed interventions in part: Administer treatments as ordered and monitor for effectiveness; low air loss mattress. Record review of the physician progress notes [REDACTED]. Record review of Resident #1 ' s Treatment Administration Record (TAR) dated 12/01/2016-12/31/2016 revealed the following treatment order: Cleanse left gluteal fold open area with normal saline, pat dry and apply calcium alginate and cover daily and as needed. Continued review of the resident's TAR revealed it was initialed as completed from 12/01/2016 to 12/31/2016. Record review of Resident #1 ' s weekly skin observation tool dated 12/29/2016 revealed the resident had an area identified as her left thigh (rear) which measured 5Cm x 6.2Cm x 0.3Cm and was not staged. Continued review of the form revealed the following notes in part: resident has an open area to her left upper thigh rear due to moisture associated skin damage, outer peri-wound noted with maceration and wound is beefy red, skin peeling, peri-wound with redness, no odor, and sanguineous drainage. Record review of the facility skin assessment form dated 1/3/17 revealed Resident #1 had excoriation to her left thigh (rear) which measured 4.7Cm x 0.5 Cm x 0.1Cm. Continued review of the form revealed the wound treatment was calcium alginate and the wound was identified on 7/4/2016. Record review of Resident #1 ' s electronic consolidated physician ' s order dated 1/1/2017 -1/31/2017 read in part apply calcium alginate to left gluteal fold topically everyday order dated 12/9/2016. Record review of Resident #1 ' s nursing progress notes dated 1/4/2017 revealed in part Resident #1 sitting in the wheelchair shivering and bluing around her lips and finger tips. Resident was transferred back to bed. Her vital signs were blood glucose accucheck was 197, blood pressure 98/60; heat rate was 100 beats per minute; respiratory rate 24 breaths per minute and axially temperature was 100 degrees. Continued review of the Resident #1 ' s nurses ' progress note revealed there was odor and drainage from her wound. Record review of Resident #1 ' s local hospital record revealed she was admitted at the local hospital on [DATE]. Continued review of the resident ' s hospital record revealed the physician consultation note dated 1/5/2017 read in part: reason for consultation was evaluation of sacral and ischia breakdown. Review of the same hospital physician consultation notes revealed the examination of Resident #1 ' s skin read in part: Examination of the left side of the ischium has a pretty significant size wound bed. The full extent of the opening is approximately about 8 to 9 Cm long by about 3 to 4 Cm wide. The lower part is shallow and has decent granulation. The upper aspect at ischium proper has an opening that penetrates deep. The opening is about 2 to 3 Cm in diameter. It goes down about 3 to 4 Cm deep. There is some slough in there and I can palpate right over the slough to the boney prominence. The bone appears to be smooth, but there is a lot of necrotic tissue and some odor to the wound bed. Drainage is murky and cloudy . Assessment: 1. Left ischial stage IV decubitus ulcer with a lot of necrotic tissue in the base . . I have informed primary care of my findings. I advised him that the wound is deep and will need surgical debridement . Record review of Resident #1 ' s local hospital record revealed surgical documentation dated 1/9/2017 revealed pre-operative Diagnosis: [REDACTED]. In an interview on 1/11/2017 at 9:12am the Administrator stated the facility did not have a wound care physician. She stated there was a corporate physician who can be contacted remotely if needed but he was in another state. Observation on 1/11/2017 at 9:25am of Resident #1 ' s room in the facility revealed her name at the door entrance. Continued review revealed the resident ' s belongings at the bedside. The resident did not have a low air loss mattress in place. In an interview on 1/11/2017 at 10:10am with Treatment Nurse #1 she stated she had been the treatment nurse since March 2016. Treatment Nurse #1 stated she received wound care treatment in-services from the former wound care physician. She continued and stated there was not a wound care physician here at this time. If there was a consult for a wound care physician the social worker would locate one. In an interview on 1/11/2017 at 10:45am, the DON stated Resident #1 ' s chart was reviewed when the resident went to the hospital and it was discovered at that time the physician ' s order for the wound care consultant on 10/12/2016 had never been followed through. As the interview continued, the DON stated when a consult for a wound care physician was ordered the nursing department gets a list from the local hospital and uses one of the physicians on the list. The DON stated she was unable to find a recent physician ' s progress note or wound assessment from the physician since the 11/22/2016 visit. The DON continued and stated she did not know why there was not a more recent order for wound care after the September 2016 order. At this time the DON stated she saw Resident #1 ' s wound on the day the resident went to the hospital and she did not realize how bad it got so rapidly, but the resident had co-morbidities. In an interview on 1/25/2017 at 4:40pm, MD B said wound treatments should be reviewed as needed, depending on the progress of the wound. He said if the wound was not getting better, the wound treatment needed to be reevaluated. In an interview on 1/25/2017 at 4:40pm, MD A said he was familiar with Resident #1. He said in March 2016, Resident #1 fell from her wheelchair while out on pass with her husband and acquired a deep tissue injury to her ischium. He said he was expecting it to break down soon after the injury, and was surprised it took this long to break down. He said wound care physicians look at wounds differently than other physicians because they see a superficial wound and think there may be something more to it. He said calcium alginate may be an appropriate treatment to the superficial wound, but the wound was deep. He said when he first saw the wound in the hospital in January 2017, he said it looked about 2-3 centimeters in diameter, had a tapering core with slough, and about 5% of necrotic tissue. He said the wound went to the bone and there was osteo[DIAGNOSES REDACTED]. Observation on 1/11/2017 at 12:10pm revealed Resident #1 in the local hospital on a low air loss mattress. The resident had Normal Saline intravenous (IV) infusing on a pump with [MEDICATION NAME] IV antibiotics infusing also. Resident #1 opened her eyes for short periods, answered questions but returned back to sleep. She had a deep open wound to her left ischium which had a dry dressing and gauze packing deep inside. There was [MEDICATION NAME] source tube feeding on a pump to her gastroscopy tube. Resident #4 Record review of the facility face sheet indicated Resident #4 was a [AGE] year old male, with an admission date of [DATE] and re-admission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of the Braden Scale-For Predicting Pressure Sore Risk with the last assessment date of 8/02/16, revealed a score of 16 indicating at risk for developing pressure sores. Further record review revealed instructions to complete assessment: -Complete on admission for 4 weeks and then quarterly thereafter. Continued record review revealed no further assessments for predicting pressure sore risk. Record review of the quarterly assessment MDS dated [DATE] indicated Resident #4 had severe cognitive impairment and had a BIMS score of 0 out of a possible score of 15. He required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene and limited assistance for locomotion and eating. He was always incontinent of bowel and had an indwelling catheter. Resident #4 had impairment to both his upper and lower extremities. Resident #4 was at risk of developing pressure ulcers and did not have a pressure ulcer at time of the assessment. Further record review revealed that Resident #4 was not on a turning/repositioning program. Record review of Resident #4's care plan with target date of 3/13/2017 revealed in part; -Focus: Resident #4 has tunneling area to buttocks area. Potential for increase skin impairment or pressure injury. -Interventions: Monitor/document/report as needed any changes in skin status; appearance, color, wound size and stage. Record review of Resident #4's Weekly Skin observation tool dated 1/16/2017 at 8:57 a.m. revealed in part; -Observations: 23) Coccyx: tunneling. 14) abdomen: suprapubic catheter, 52) left toe: discoloration. Notes: Left foot contracted. Observation on 1/25/2017 at 8:55 a.m. Resident #4 was lying in bed on his back with the head of the bed elevated at approx 45 degrees. Further observation at that time during incontinent care revealed that Resident #4 had an open area to his left hip area approx 2.0 x 1.0 c.m., wound base red that was not protected with a dressing. Further record review of Resident #4's Weekly Skin observation tool dated 1/25/2017 at 1:44 p.m. revealed in part; -Observations: -Left hip: Pressure Stage 2. Measurements: 2x1.0 c.m., -Sacrum Pressure Stage 1. Measurements: 2.0 c.m. -right intergluteal cleft Pressure Stage 1. Measurements: [MEDICAL CONDITION] c.m. Notes: Left hip with stage 2 open area 2 c.m. by 1 c.m. no depth. Wound center pink medium color with edges darker pink. Sacrum linear reddened area 2 c.m. in length skin intact. Record review of Resident #4's physician orders dated January 2017 revealed orders in part; -12/09/2016: Wound cleanser, apply to intergluteal cleft topically every day shift for tunnel cleanse area with vashe solution (cleanse solution that removes microorganisms), lightly pack with ¾ silver calcium alginate rope (dressing with antimicrobial properties). Further record review revealed no orders for left hip stage 2 open area. In an interview on 1/25/2017 at 9:06 a.m., CNA A stated Resident #4 had the open area to his left hip since yesterday morning during breakfast time and further said I told the DON and the charge nurse right when I found the open area. CNA A then said that skin conditions were reported verbally to charge nurses and the DON. In an interview on 1/25/2017 at 9:11 a.m. LVN B stated that Resident #4 had only wound care orders for the intergluteal cleft and that Resident #4 did not have any other wounds. In an observation and interview on 1/25/2017 at 9:32 a.m. with LVN B and the DON during skin assessment to Resident #4, the DON stated as she saw Resident #4's open area to his left hip Open area could be from the brief. Is like a popped blister. It doesn't look bad. Further interview at that time, LVN B stated I will call the MD to get orders. Continued interview, the DON stated to CNA A did you just notice it this morning? good job. DON then exited room. In a second interview on 01/25/2016 at 9:36 a.m. with CNA A, she stated I told my DON and charge nurse yesterday as soon as I saw the open area to Resident #4's left hip. It was around breakfast time. We are supposed to report open areas to charge nurse and DON and that's what I did. In an interview on 01/25/2017 at 11:45 a.m. with the DON, she stated that she was acting as the wound care nurse at that moment because there was no wound care nurse at the facility. She stated that she did the wound care to pressure sores and the charge nurses would do the wound care on conditions that were not pressure sores. DON then said that the skin assessments were supposed to be done weekly and that she believed some skin assessments might be a little behind because there was wound care nurse at the facility. DON further said I did not know about Resident #4's new open area, I just learned about it today but I will investigate what happened. Further interview with the DON on 1/25/2017 at 2:00 p.m., she stated that Braden assessments were supposed to be done by the charge nurse upon admission and quarterly afterwards. DON said that during IDT meeting the facility monitored that all Braden assessments are completed and then said I haven't had a chance to review Resident #4's Braden Assessments. Continued interview at that time, the DON stated CNA A stated that she did not remember what time she reported Resident #4's open area yesterday but she said that she reported to the charge nurse. I talked to the charge nurse already and she told me that CNA A reported Resident #4's open area to his left hip at around 2 or 3 p.m. on 1/24/2017 and that she wrote the information on the 24 hour report . When asked, if writing new skin conditions such as pressure sores on the 24 hour report instead of calling the MD to obtain orders was the proper procedure to be followed, the DON stated No, the correct procedure was to assess the wound, call the MD and write information on the progress/nurses notes. https://en.wikipedia.org/wiki/Braden_Scale_for_Predicting_Pressure_The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by(NAME)Braden and(NAME)Bergstrom.(1) <https://en.wikipedia.org/wiki/Braden_Scale_for_Predicting_Pressure_Ulcer_Risk> The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer <https://en.wikipedia.org/wiki/Pressure_ulcer>.(2) <https://en.wikipedia.org/wiki/Braden_Scale_for_Predicting_Pressure_Ulcer_Risk> The Braden Scale has 6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear (see Braden Scale). These categories address the 2 primary etiologic factors of Pressure Ulcer development: intensity and duration of pressure and tissue tolerance for pressure. Sensory perception, mobility, and activity address clinical situations that predispose a patient to intense and prolonged pressure, while moisture, nutrition, and friction/shear address clinical situations that alter tissue tolerance for pressure. WHEN TO DO A RISK ASSESSMENT: * Long-term care- initial assessment on admission, then reassessment weekly for the first 4 weeks, monthly to quarterly after that, and whenever the resident ' s condition changes. Record review of the facility policy and procedure revised September 2013 with title Prevention of Pressure Ulcers revealed in part; .The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to the area and subsequent destruction of tissue . 4.- Pressure ulcers are often made worse by continual heat, moisture such as feces, urine . Preparation: 2.- Review current Braden Scale Reporting: Notification of attending MD if new skin alteration is noted Record review of the facility policy titled Pressure Ulcer Treatment Revision dated September 2013 revealed .Stage IV Pressure Ulcers: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed . Requested to DON on 1/25/2017 at 3:00 p.m. protocol for Skin assessments and Braden Scale assessments and were not provided at time of exit. According to the list provided by the DON, there were 5 residents in the facility with pressure sores.

Based on observation, interview, and record review, the facility failed to ensure services were provided by the facility in accordance with the resident's written plan of care for 1 of 4 residents (Resident #1) reviewed for following physician's orders. -The facility failed to ensure Resident #1 received a physician wound care consult as ordered by the physician. The resident's wound worsened to a Stage IV pressure sore and she underwent surgical debridement. This failure affected 1 resident and could affect 19 current residents residing on D hall who could experience a decline in their health and well-being. Findings included: Intake # 6/TX 645 Record review of Resident #1 ' s admission face sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] and readmitted on [DATE] and 3/11/15 with [DIAGNOSES REDACTED]. Resident #1 was transferred to a local hospital on [DATE] and underwent surgical debridement for a Stage IV pressure sore. Record review of Resident #1 ' s clinical record revealed a telephone physician ' s order dated 9/5/2016 which read in part; cleanse left gluteal fold open area with normal saline and pat dry. Apply calcium alginate cover with a dry dressing daily and as needed. Record review of Resident #1 ' clinical record revealed a telephone physician ' s order dated 10/12/2016 which read in part Bactrim antibiotic twice daily for seven days for wound infection and wound consult for wound on left upper thigh. Continued review of Resident #1's clinical record did not reveal documentation that a wound care physician consult was done. Record review of Resident #1 ' s electronic quarterly Braden Scale for Predicting Pressure Sore Risk dated and signed 10/13/2016 revealed a score of 15 indicating the resident was at risk for developing pressure wounds. Record review of Resident #1 ' s electronic quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was usually understood and understood others. The resident ' s Brief Interview for Mental Status (BIMS) was scored as nine out of 15 which indicated her cognition was moderately impaired. Continued review of the resident MDS revealed she required extensive assistance from two staff for bed mobility, transfer and toilet use. The resident required extensive assistant from one staff for dressing and personal hygiene. Resident #1 had limitations in range of motion to her bilateral upper and lower extremities. Review of the same MDS did not reveal the presence of current pressure wounds but Resident #1 did have moisture associated skin damage. The MDS document healed stage II pressure wounds. The MDS did reveal the resident was identified as being at risk of developing pressure ulcers. Record review of Resident #1 ' s electronic care plans undated revealed in part the focus area Resident #1 has moisture associated skin damage to her gluteal fold. The care plan revealed the goal Resident #1 will have no complications related to excoriation of the left thigh through 1/10/2017. Continued review of the care plan revealed interventions in part: Monitor and document location, size and treatment of [REDACTED]. Record review of Resident #1 ' s electronic care plans undated revealed in part the focus area Resident #1 has potential for pressure injury development related to history of ulcers, immobility. The care plan revealed the goal Resident #1 will have intact skin, free of redness, blisters or discoloration by 1/10/2017. Continued review of the care plan revealed interventions in part: Administer treatments as ordered and monitor for effectiveness; low air loss mattress. Record review of the physician progress notes [REDACTED]. Record review of Resident #1 ' s Treatment Administration Record (TAR) dated 12/01/2016-12/31/2016 revealed the following treatment order: Cleanse left gluteal fold open area with normal saline, pat dry and apply calcium alginate and cover daily and as needed. Continued review of the resident's TAR revealed it was initialed as completed from 12/01/2016 to 12/31/2016. Record review of Resident #1 ' s weekly skin observation tool dated 12/29/2016 revealed the resident had an area identified as her left thigh (rear) which measured 5Cm x 6.2Cm x 0.3Cm and was not staged. Continued review of the form revealed the following notes in part: resident has an open area to her left upper thigh rear due to moisture associated skin damage, outer peri-wound noted with maceration and wound is beefy red, skin peeling, peri-wound with redness, no odor, and sanguineous drainage. Record review of the facility skin assessment form dated 1/3/17 revealed Resident #1 had excoriation to her left thigh (rear) which measured 4.7Cm x 0.5 Cm x 0.1Cm. Continued review of the form revealed the wound treatment was calcium alginate and the wound was identified on 7/4/2016. Record review of Resident #1 ' s electronic consolidated physician ' s order dated 1/1/2017 -1/31/2017 read in part apply calcium alginate to left gluteal fold topically everyday order dated 12/9/2016. Record review of Resident #1 ' s nursing progress notes dated 1/4/2017 revealed in part Resident #1 sitting in the wheelchair shivering and bluing around her lips and finger tips. Resident was transferred back to bed. Her vital signs were blood glucose accucheck was 197, blood pressure 98/60; heat rate was 100 beats per minute; respiratory rate 24 breaths per minute and axially temperature was 100 degrees. Continued review of the Resident #1 ' s nurses ' progress note revealed there was odor and drainage from her wound. Record review of Resident #1 ' s local hospital record revealed she was admitted at the local hospital on [DATE]. Continued review of the resident ' s hospital record revealed the physician consultation note dated 1/5/2017 read in part: reason for consultation was evaluation of sacral and ischia breakdown. Review of the same hospital physician consultation notes revealed the examination of Resident #1 ' s skin read in part: Examination of the left side of the ischium has a pretty significant size wound bed. The full extent of the opening is approximately about 8 to 9 Cm long by about 3 to 4 Cm wide. The lower part is shallow and has decent granulation. The upper aspect at ischium proper has an opening that penetrates deep. The opening is about 2 to 3 Cm in diameter. It goes down about 3 to 4 Cm deep. There is some slough in there and I can palpate right over the slough to the boney prominence. The bone appears to be smooth, but there is a lot of necrotic tissue and some odor to the wound bed. Drainage is murky and cloudy . Assessment: 1. Left ischial stage IV decubitus ulcer with a lot of necrotic tissue in the base . . I have informed primary care of my findings. I advised him that the wound is deep and will need surgical debridement . Record review of Resident #1 ' s local hospital record revealed surgical documentation dated 1/9/2017 revealed pre-operative Diagnosis: [REDACTED]. In an interview on 1/11/2017 at 9:12am the Administrator stated the facility did not have a wound care physician. She stated there was a corporate physician who can be contacted remotely if needed but he was in another state. Observation on 1/11/2017 at 9:25am of Resident #1 ' s room in the facility revealed her name at the door entrance. Continued review revealed the resident ' s belongings at the bedside. The resident did not have a low air loss mattress in place. In an interview on 1/11/2017 at 10:10am with Treatment Nurse #1 she stated she had been the treatment nurse since March 2016. Treatment Nurse #1 stated she received wound care treatment in-services from the former wound care physician. She continued and stated there was not a wound care physician here at this time. If there was a consult for a wound care physician the social worker would locate one. In an interview on 1/11/2017 at 10:45am, the DON stated Resident #1 ' s chart was reviewed when the resident went to the hospital and it was discovered at that time the physician ' s order for the wound care consultant on 10/12/2016 had never been followed through. As the interview continued, the DON stated when a consult for a wound care physician was ordered the nursing department gets a list from the local hospital and uses one of the physicians on the list. The DON stated she was unable to find a recent physician ' s progress note or wound assessment from the physician since the 11/22/2016 visit. The DON continued and stated she did not know why there was not a more recent order for wound care after the September 2016 order. At this time the DON stated she saw Resident #1 ' s wound on the day the resident went to the hospital and she did not realize how bad it got so rapidly, but the resident had co-morbidities. In an interview on 1/25/2017 at 4:40pm, MD B said wound treatments should be reviewed as needed, depending on the progress of the wound. He said if the wound was not getting better, the wound treatment needed to be reevaluated. In an interview on 1/25/2017 at 4:40pm, MD A said he was familiar with Resident #1. He said in March 2016, Resident #1 fell from her wheelchair while out on pass with her husband and acquired a deep tissue injury to her ischium. He said he was expecting it to break down soon after the injury, and was surprised it took this long to break down. He said wound care physicians look at wounds differently than other physicians because they see a superficial wound and think there may be something more to it. He said calcium alginate may be an appropriate treatment to the superficial wound, but the wound was deep. He said when he first saw the wound in the hospital in January 2017, he said it looked about 2-3 centimeters in diameter, had a tapering core with slough, and about 5% of necrotic tissue. He said the wound went to the bone and there was osteo[DIAGNOSES REDACTED]. Observation on 1/11/2017 at 12:10pm revealed Resident #1 in the local hospital on a low air loss mattress. The resident had Normal Saline intravenous (IV) infusing on a pump with [MEDICATION NAME] IV antibiotics infusing also. Resident #1 opened her eyes for short periods, answered questions but returned back to sleep. She had a deep open wound to her left ischium which had a dry dressing and gauze packing deep inside. There was [MEDICATION NAME] source tube feeding on a pump to her gastroscopy tube. Record review of the facility policy titled Verbal Orders Revision dated February 2014 revealed . Verbal orders shall only be given in an emergency or when the Attending Physician is not immediately available to write or sign the order . Continued review of the policy did not reveal protocol for following through on physician ' s orders. Record review of the facility policy titled Prevention of Pressure Ulcers Revision dated September 2013 revealed . 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to the area and subsequent destruction of tissue . Record review of the facility policy titled Pressure Ulcer Treatment Revision dated September 2013 revealed .Stage IV Pressure Ulcers: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed . According to the facilities resident roster revealed 20 residents on D hall

Based on observation, interview and record review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #5) reviewed for incontinent care. -Resident #5 was found with brief heavily saturated with urine and his buttocks covered with excoriation areas and skin breakdown to his left buttocks that were not identified by the staff and the resident complained of pain. This failure affected 1 resident and placed an additional 64 residents who were occasionally or frequently incontinent of bladder at risk for not receiving care and assistance when needed. Findings included: Intake: # 0/TX 913 Record review of the facility face sheet indicated Resident #5 was a [AGE] year old male, with an admission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of the quarterly assessment MDS dated [DATE] indicated Resident #5 was sometimes able to make self understood and was sometimes able to understand others. He required extensive assistance of one person for bed mobility, transfer, dressing, toileting and personal hygiene. He was always incontinent of bowel and bladder. Resident #5 was at risk of developing pressure ulcers and did not have a pressure ulcer at time of the assessment. Record review of Resident #5's Weekly Skin observation tool dated 1/09/2017 at 8:21 a.m. revealed in part; Notes: Skin warm to touch, dry and intact. Further record review revealed no further weekly skin assessments. Record review of Resident #5's care plan with target date of 2/26/2017 revealed in part; -Focus: Resident #5 is incontinent of bowel and bladder. Potential for pressure injury and other increase skin impairment related to incontinence and history of scratching self (left shin). -Goal: Resident #5 will remain free from skin breakdown due to incontinence and brief use. -Interventions: Toilet use: Resident #5 requires maximum assistance by staff for toileting, provide incontinent care as needed. Record review of Resident #5's Progress Note dated 1/10/2017 read in part . [MEDICAL TREATMENT] nurse called said Resident #5 was arriving to [MEDICAL TREATMENT] soiled, wet, need to change him before going to [MEDICAL TREATMENT] . Record review of Resident #5's MD orders for dates 01/01/2017 to 01/31/2017 revealed no wound care orders. Observation on 01/25/2017 at 8:26 a.m. revealed Resident #5 in the dining area eating his breakfast. Observation on 01/25/2017 at 10:03 a.m. revealed that Resident #5 was still in the dining area attending an activity. Observation and interview on 01/25/2017 at 10:06 a.m. during incontinent care for Resident #5 revealed that as CNA A transferred Resident #5 to his bed, his dark colored pants had a wet area on the buttocks area and the chair where he was seated had a puddle of liquid on top of it. Further observation and interview, when pointed at the chair that had the puddle of liquid CNA A stated I will have to change his clothing, he is going to [MEDICAL TREATMENT] today. When asked what time was the last time Resident #5 had incontinent care, CNA A stated I did incontinent care right after breakfast. At that time, CNA A left the room and said was going to get cleaning wipes. In an interview on 01/25/2017 at 10:10 a.m. with Resident #5, when asked if he had incontinent care right after breakfast, Resident #5 nodded his head to the sides and said No. Continued observation on 01/25/2017 at 10:12 a.m. during incontinent care revealed that his brief was wet up to the top of the brief and the inside of the brief was brown in color. Further observation revealed that there was a circular area approx 10 c.m. in diameter of bright red colored blood on the back of the brief on the left side. At that time, CNA A stated Resident #5 is a very heavy wetter. Further observation revealed Resident #5 had a large excoriated and red raised area to both of his buttocks. The left buttocks had scattered small open areas. One of the open areas to his left middle buttock measured 1.0 x .5 c.m. and another open area by the left inner buttock was 1.0 x .2 c.m. (per LVN C measurements). Wound base on all open areas were red. Continued observation revealed that the red raised excoriated areas extended to Resident #5's upper inner, posterior thighs. Further interview at that time, CNA A said that she worked with Resident #5 sometime last week and that Resident #5 already had the current condition to his buttocks areas. CNA A then said his buttocks were like this with the open areas since last week and I reported to a nurse but I don't remember who. CNA A then said I think the blood is coming from the open areas to his left buttocks. Continued interview on 1/25/2017 at 10:20 a.m. with Resident #5, when asked if areas on his buttocks hurt, Resident #5 responded yeah. In an interview on 1/25/2017 at 10:24 a.m. with LVN C, she stated as she looked at Resident #5's buttocks areas he is on [MEDICATION NAME] (anti-itch medication), he scratches the area. At that time, asked Resident #5 if area was itchy and he responded No. LVN C then asked Resident #5 if the buttocks area was in pain and Resident #5 responded yeah. When asked LVN C if Resident #5 had any orders for his buttocks, LVN C responded I need to see if there are any orders and left the room. Further observation and interview on 1/25/2017 at 10:28 a.m. with LVN C while she was assessing Resident #5's buttocks, she stated Resident #5 has no orders for his buttocks. Nobody has reported to me any changes on his skin condition. Staff were supposed to report to charge nurses and write their observations on shower sheets. When asked to describe to surveyor Resident #5's skin condition, LVN C stated numerous little open excoriated reddened areas. It's a raised rash covering both of his buttocks, ¾ of his left buttock and at least half of his right buttock and extends to the top of the back of both of his thighs. LVN C then said I will call the MD. Will go and check with the DON and will ask if she has any shower sheet papers for Resident #5. LVN C then exited room. In an interview on 1/25/2017 at 10:40 a.m. LVN C said that she was not able to locate the DON because she was not in her office and further said I will call the MD now to get orders. Record review of Resident #5's progress/nurses notes revealed in part; - 1/25/2017 at 10:40 a.m. signed by LVN C Called in to Resident #5's room when CNA was changing brief. Blood was noted in brief where left buttock would be. Left buttocks pink, raised area covering ¾ area of the buttocks slightly down the thigh with several open areas from resident scratching. Largest area 1 x 0.5 c.m. which appears to be from scratching. Right buttocks raised pink area ½ of buttock down the thigh more than the left thigh. MD notified. NP called and no answer. Waiting for response . In an interview on 1/25/2017 at 10:47 a.m. with the DON, she stated that she had a stack of skin sheets in her office and was going to try to look any skin sheets for Resident #5. She further said that she believed Resident #5 had something like a reddened area but was not sure and then said let me see if I can find any skin sheets related to his condition . Further interview and observation on 1/25/2017 at 10:57 a.m., she stated while flipping through some papers on her desk I find everybody except for Resident #5 . DON then said that CNA's were supposed to fill in the skin sheets anytime they find a new skin condition. DON continued saying that the skin assessments were supposed to be done weekly and that she believed some skin assessments might be a little behind because there was no wound care nurse at the facility. Continued interview and observation on 1/25/2017 at 11:05 a.m. DON opened Resident #5's brief and when pointed the brownish color of the inside of the brief, the DON stated well, he is a [MEDICAL TREATMENT] patient. He has been drinking in the dining room. In a telephone interview on 1/25/2017 at 11:07am, Clinical coordinator at a [MEDICAL TREATMENT] center, said Resident #5 visited the [MEDICAL TREATMENT] clinic 3 times a week, on Mondays, Wednesdays and Fridays. She said there were a few times Resident #5 arrived to [MEDICAL TREATMENT] soiled through his clothing and had to return to the nursing home to change his clothes and brief. She said on 1/6/2017, Resident #5 returned to the facility to change and almost didn ' t make it back in time for treatment. She said on 1/9/2017, Resident #5 was so wet that the [MEDICAL TREATMENT] staff went to the store and bought briefs. She said there were similar occurrences about 6 times at the end of the year, in November and December. Observation on 1/25/2017 at 11:11 a.m. of Resident #5's skin with the DON revealed that Resident #5's brief had 2 stains of bright red blood on his brief at the direction of his left buttocks. DON then said I see 2 minute open areas to his left buttocks. Resident #5 scratches himself. His skin is just discolored. Is darker in color on his buttocks area but I will not say is reddened. The skin is elevated, but I will have to let the NP to see it. I don't see anything wrong with it. Nobody has reported any skin condition to me, but will need to talk to the MD . DON then asked Resident #5 are you in pain? While DON touched Resident #5's left buttocks area. Resident #5 responded yeah. Record review of Resident #5's progress/nurses notes dated 1/25/2017 at 12:28 p.m. read in part NP called with new orders for [MEDICATION NAME] (skin protectant) lotion to apply twice a day as needed for itching to buttocks and Tylenol ([MEDICATION NAME]) 325 mg, 2 by mouth every 6 hours as needed for pain. Requested to DON on 1/25/2017 at 3:00 p.m. protocol for Skin assessments and Braden Scale assessments and were not provided at time of exit. CMS 672 revealed 65 residents who were occasionally or frequently incontinent of bladder.

Based on interview and record review, the facility failed to evacuate 1 of 7 residents (Resident #1) reviewed for neglect, in an a timely manner as evidenced by: -Resident #1 was not evacuated from her room during a facility fire on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 1 resident and could place 95 other residents at risk of being left unattended in the event of a facility emergency. Complaint # 5 Findings include: Record review of Resident #1's face sheet revealed an admission date of [DATE], she was [AGE] years old. Record review revealed [DIAGNOSES REDACTED]. Record review of Resident #1's admission care plan dated [DATE] revealed resident was able to make her self understood, had clear speech and was able to understand other. Further review revealed resident required 1 person assist for bed mobility, transfer assist, bathing, dressing/grooming and personal hygiene. Observation on [DATE] at 11:00 am of rooms [ROOM NUMBERS] on the E wing of the facility revealed workers were seen renovating and painting the areas that had been affected by the fire that occurred on [DATE]. Interview on [DATE] at 11:30 am, Medical Records Staff stated Resident #1 was completely forgotten in her room, room [ROOM NUMBER], when the other residents were evacuated. Staff A stated the situation, of Resident #1 being left, was not realized until after the fire department had put out the fire. In continued interview at that time, Medical Records Staff stated, it was Monday, [DATE], about 7:00 pm when I was getting ready to head home and I heard the fire alarm. At first I thought it was a drill before I found out it was coming from E hall. We started evacuating all the residents on E hall. The fire department came and asked us to evacuate everybody in the building because by then there were flames. We then evacuated everybody in the building. The fire was contained within a short time. When the fire was put out, we were asked to bring back the residents starting from halls A, B, C and D. Later, the fire department said it was ok to bring back the residents in E hall. We did a head count of every resident and found that one resident living in E hall was missing, Resident #1. We went in and found her in her room. We brought her out and gave her some food. She said she was really scared. I can't explain what happened but she was just forgotten. We are all lucky that the fire was put out quickly. She could have died . The fire affected only two rooms. In an interview on [DATE] at 12:00 noon, LVN C stated I have been here for sixteen months. I usually work 6 to 2 shift but I stayed over on Monday, [DATE], so I was here when the fire incident occurred. I worked on E hall just like today. The fire occurred in room [ROOM NUMBER] of E hall. About 6:30 pm, CNA F alerted me that she smelled smoke. We went from room to room and found the AC was smoking in room E 10. Resident #5 was in the room that day and we took him out immediately. The smoke triggered the fire alarm and the fire department was called. We took everybody out but we forgot Resident #1 who was new resident that had come in on Friday, [DATE] and placed in room [ROOM NUMBER] A. She was the only person in the room that day. We noticed that she was forgotten after the fire had been put out and we did a head count to return the residents to their rooms. We found out she was not there during the head count and we went to her room and found her. She said she was scared but there was nothing she could do. In continued interview at that time, LVN C stated, room [ROOM NUMBER] is adjacent to room [ROOM NUMBER] and there were two residents were in room [ROOM NUMBER] on that day. The fire affected only rooms, rooms [ROOM NUMBERS], and they are being renovated now. Interview with the facility Administrator on [DATE] at 1:04 pm he stated there was a fire incident in the facility on [DATE] about 6:30 pm. He stated as follows, I am the administrator. There was fire incident here on Monday. The fire was out in about 30 minutes. I live 15 minutes away and I was called when the fire occurred. By the time I arrived, they had every resident out;everyone was accounted for. The fire affected rooms [ROOM NUMBERS] of E hall and we are doing some work there now. He stated, we have a written policy for fire hazard; we do fire drill every month. I feel that my staff did a good job that day. In an interview on [DATE] at 1:30 pm, the ADON stated I have been here for two years. I am the ADON. I was off on Monday [DATE] but I was called to come in when the fire incident occurred. I live just seven minutes away. By the time I arrived, the staff had evacuated every resident out of their rooms and out of the building. When the fire was out, we did a head count of the residents. Everyone was accounted for except for one lady, Resident #1. We went to her room and the fire department found her in her room with the door shut. I did not talk to the lady. I have not done so since that day. I think she is still here. Observation on [DATE] at 1:50 pm revealed Resident #1 in her room. Resident was alert and oriented. Further observation revealed Resident #1's room ( room [ROOM NUMBER]) was directly across from rooms [ROOM NUMBERS] on E hallway. In an interview at that time, Resident #1 stated, I have been here since last Friday, [DATE]. I had a stroke and my left arm and the left side of my body was affected. My left arm is not responding and is swollen. I am unable to get up unless I am assisted. I am receiving therapy to see if it will help. In continued interview at that time, Resident #1 stated, I remember the fire on Monday, [DATE]. It was scary; I was yelling, hitting on the call light and banging on that table with this remote control. There was too much noise and they couldn't hear me. The alarm was very loud. I thought I perceived some smoke smell but I was more concerned with the alarm than the smoke. I wished it could stop so they could hear me and come and get me. By the time they came to me everything was over. It was scary, I could have died . Record review of facility Disaster Plan, dated [DATE], read in part: .in case of smoke or fire: 1) move residents to safe place.f. Evacuate all residents from the effected area. Record review of fire department run report, dated [DATE], read in part: .observed evacuation evacuation in progress.notices flames coming from a pipe in the roof.then advised staff to begin evacuation.a full alarm was then requested.Engine -1A requested a second alarm and additional units to assist with the evacuation. During a confidential interview on [DATE] it was stated that they believed there was not a name on the residents door and staff may have thought the room was empty. In an interview on [DATE] at 2:32 pm, CNA E stated she was in the facility on the evening of the fire, [DATE]. CNA E stated when there is a fire, you locate where the fire is and remove the residents from the area. CNA E stated she was not aware that a resident was left until the fire was over; she didn't know how it happened. In an interview on [DATE] at 2:40 pm, CNA F stated she was at the facility on the evening of the fire. She stated no one is assigned to remove specific residents, it is a collective effort by the staff. In an interview with the Administrator on [DATE] at 2:50 pm, he stated the facility had not conducted any training on fire safety since the incident; he stated nothing formal was done except providing the staff with breakfast and lunch for a job well done. He stated he was aware that Resident #1 was left behind in the room and that the door was closed to protect her from smoke. He stated she was not in any danger. He stated he felt like Resident #1 was not on the weekend census due to being a new admit so during the head count it appeared everyone was there. He further stated he had spoken with Resident #1 and she had said she was scared but had no other complaints otherwise. Record review of facility abuse prevention policy, dated [DATE], read in part: .Our residents have the right to be free from .neglect.neglect occurs when center staff fails to monitor and/or supervise the delivery of resident care and a service to assure that care is provided as needed by the resident. The facility administrator was notified on [DATE] at 4:24 pm that an IJ situation had been identified due to the above failure. Interview and observation of Resident #1 was conducted on [DATE] at 2:28 pm in her room. Resident #1 stated she remembered the fire. She stated she had smelled smoke, had been banging on the table but and could hear the alarm going off. She stated staff came for her after it was over, she did not know how long it was but it seemed like a long time. She stated she was scared, but once the staff came and took her to the dining room with the other residents,she felt better. The IJ was removed on [DATE]. In the event of smoke or fire, Lawrence Street will act as follows: I. Move residents in a safe place II. Alert Staff and Fire Department III. Close all doors and windows IV. Notify the Administrator and Director of Nursing V. Use fire extinguisher if fire is controllable VI. Evacuate residents from the affected area at least beyond the nearest smoke doors. VII. All employees will stand by in case evacuation is necessary Employees will adhere to the R.A.C.E. (Rescue, Alarm, Contain, Extinguish) Protocol for fire safety. This will include the following: Rescue - stop what you are doing and remove anyone in immediate danger from the fire Alarm - activate the nearest fire alarm pull stations Contain - close all doors and windows that you can safely reach to contain the fire Extinguish - only attempt to extinguish the fire if it is safe to do so. Retrieve the nearest fire extinguisher and follow P.A.S.S. procedure: P = Pull the pin breaking the plastic seal A = Aim at the base of the fire S = Squeeze the handles together S = Sweep from side to side Evacuate: Ambulatory persons should be instructed to leave under their own power and report to a designated assembly point. Persons that require assistance with mobility should be assisted or taken to the assembly point. Get out as safely and quickly as possible. During an evacuation, staff members conducting the evacuation will check each room to ensure that the residents are properly relocated. Upon verifying that the room is properly evacuated, the door will be shut. An X will be made on the door indicating that the room has been properly evacuated. After evacuating the area, complete a head count to make sure everyone is accounted for. All facility staff will be inserviced on all of the above by [DATE] by the Director of Nursing or Assistant Director of Nursing. The Surveyor confirmed the plan had been implemented sufficiently to remove the IJ by: Record review of the in-service sign-in sheets that revealed staff from all departments and shifts had been inserviced on [DATE] and [DATE] on RACE (Rescue/Alarm/Contain/Extinguish), PASS (Pull/Aim/Squeeze/Sweep), fire evacuation and safe resident removal. Interviews conducted with 4 nursing staff, 1 dietary staff, 1 housekeeping staff and 1 maintenance revealed staff had knowledge of evacuation procedures, knowledge of PASS and RACE and how to conduct resident room checks. The Administrator was informed on [DATE] at 3:10 pm that the IJ was removed; however the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. According to the CMS 672 form, there were 74 residents who required transfer assistance.

Based on interview and record review the facility Administration failed to administer the facility in a manner that enabled it to use its resources effectively maintain the highest practicable well-being for 1 of 7 residents (Resident #1) reviewed for their highest practicable well-being. The Administrator failed to: --identify resident safety issues. --failed to identify training nedds of staff after an emergency incident occured; --failed to evaluate/re-evaluate the faciilty policy on resident evaucation procedures The DON failed to: --assess a resident after not being properly evacuated during a facility evacuation. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 1 resident and could place 95 other residents at risk of safety from fire. Complaint # 5 Findings include: In an interview on [DATE] at 1:00 pm, the Administrator was asked how did he think the incident of the IJ came about. The Administrator stated he did not think it was a legitimate incident. He stated staff had evacuated the residents out of the facility when the fire fighters took over the incident. He stated he was called about 7:10 pm and arrived at 7:30 pm and all of the residents had been evacuated by that time. He stated at that time he didn't think there was anything to correct; that the staff did a great job. He stated since that time, they have re-vamped their evacuation procedures. In an interview on [DATE] at 1:15 pm, the DON said to ensure staff are competent in evacuation skills they are having in-services often and doing practice fire drills monthly. She also stated they do shout out (random/on the spot) in-services and monthly questionnaires. Interview on [DATE] at 11:30 am, Medical Records Staff stated Resident #1 was completely forgotten in her room, room [ROOM NUMBER], when the other residents were evacuated. Medical Records Staff stated the situation, of Resident #1 being left, was not realized until after the fire department had put out the fire. In continued interview at that time, Staff A stated, it was Monday, [DATE], about 7:00 pm when I was getting ready to head home and I heard the fire alarm. At first I thought it was a drill before I found out it was coming from E hall. We started evacuating all the residents in E hall. The fire department came and asked us to evacuate everybody in the building because by then there was flame. We then evacuated everybody in the building. The fire was contained within a short time. When the fire was put out, we were asked to bring back the residents starting from halls A, B, C and D. Later, the fire department said it was ok to bring back the residents in E hall. We did a head count of every resident and found that one resident living in E hall was missing, Resident #1. We went in and found her in her room. We brought her out and gave her some food. She said she was really scared. I can't explain what happened but she was just forgotten. We are all lucky that the fire was put out quickly. She could have died . The fire affected only two rooms. In an interview on [DATE] at 12:00 noon, LVN C stated on Monday, [DATE], I was here when the fire incident occurred. I worked on E hall just like today. The fire occurred in room [ROOM NUMBER] of E hall. About 6:30 pm, CNA F alerted me that she smelled smoke. We went from room to room and found the AC was smoking in room E 10. Resident #5 was in the room that day and we took him out immediately. The smoke triggered the fire alarm and the fire department was called. We took everybody out but we forgot Resident #1 who was new resident that had come in on Friday, [DATE] and placed in room [ROOM NUMBER] A. She was the only person in the room that day. We noticed that she was forgotten after the fire had been put out and we did a head count to return the residents to their rooms. We found out she was not there during the head count and we went to her room and found her. She said she was scared but there was nothing she could do. Interview with the facility Administrator on [DATE] at 1:04 pm he stated there was a fire incident in the facility on [DATE] about 6:30 pm. He stated, There was fire incident here on Monday ([DATE]). The fire was out in about 30 minutes. I live 15 minutes away and I was called when the fire occurred. By the time I arrived, they had every resident out;everyone was accounted for. The fire affected rooms [ROOM NUMBERS] of E hall and we are doing some work there now. He stated, we have a written policy for fire hazard; we do fire drill every month. I feel that my staff did a good job that day. In an interview on [DATE] at 1:30 pm, the ADON stated I am the ADON. I was off on Monday [DATE] but I was called to come in when the fire incident occurred. By the time I arrived, the staff had evacuated every resident out of their rooms and out of the building. When the fire was out, we did a head count of the residents. Everyone was accounted for except for one lady, Resident #1. We went to her room and the fire department found her in her room with the door shut. In an interview on [DATE] at 1:50 pm Resident #1 stated, I have been here since last Friday, [DATE]. I had a stroke and my left arm and the left side of my body was affected. Resident #1 stated, I remember the fire on Monday, [DATE]. It was scary; I was yelling, hitting on the call light and banging on that table with this remote control. There was too much noise and they couldn't hear me. The alarm was very loud. I thought I perceived some smoke smell but I was more concerned with the alarm than the smoke. I wished it could stop so they could hear me and come and get me. By the time they came to me everything was over. It was scary, I could have died . Record review of facility Disaster Plan, dated [DATE], read in part: .in case of smoke or fire: 1) move residents to safe place.f. Evacuate all residents from the effected area. Record review of fire department run report, dated [DATE], read in part: .observed evacuation evacuation in progress.notices flames coming from a pipe in the roof.then advised staff to begin evacuation.a full alarm was then requested.Engine -1A requested a second alarm and additional units to assist with the evacuation. During a confidential interview on [DATE] it was stated that they believed there was not a name on the residents door and staff may have thought the room was empty. In an interview on [DATE], CNA E stated she was in the facility on the evening of the fire, [DATE]. CNA E stated when there is a fire, you locate where the fire is and remove the residents from the area. CNA E stated she was not aware that a resident was left until the fire was over; she didn't know how it happened. In an interview with the Administrator on [DATE] at 2:50 pm, he stated the facility had not conducted any training on fire safety since the incident; he stated nothing formal was done except providing the staff with breakfast and lunch for a job well done. He stated he was aware that Resident #1 was left behind in the room and that the door was closed to protect her from smoke. He stated she was not in any danger. He stated he left like Resident #1 was not on the weekend census due to being a new admit so during the head count it appeared everyone was there (had been accounted for). He further stated he had spoken with Resident #1 and she had said she was scared but had no other complaints otherwise. The facility administrator was notified on [DATE] at 4:24 pm that an IJ situation had been identified due to the above failure. The IJ was removed on [DATE]. In the event of smoke or fire, Lawrence Street will act as follows: I. Move residents in a safe place II. Alert Staff and Fire Department III. Close all doors and windows IV. Notify the Administrator and Director of Nursing V. Use fire extinguisher if fire is controllable VI. Evacuate residents from the affected area at least beyond the nearest smoke doors. VII. All employees will stand by in case evacuation is necessary Employees will adhere to the R.A.C.E. (Rescue, Alarm, Contain, Extinguish) Protocol for fire safety. This will include the following: Rescue - stop what you are doing and remove anyone in immediate danger from the fire Alarm - activate the nearest fire alarm pull stations Contain - close all doors and windows that you can safely reach to contain the fire Extinguish - only attempt to extinguish the fire if it is safe to do so. Retrieve the nearest fire extinguisher and follow P.A.S.S. procedure: P = Pull the pin breaking the plastic seal A = Aim at the base of the fire S = Squeeze the handles together S = Sweep from side to side Evacuate: Ambulatory persons should be instructed to leave under their own power and report to a designated assembly point. Persons that require assistance with mobility should be assisted or taken to the assembly point. Get out as safely and quickly as possible. During an evacuation, staff members conducting the evacuation will check each room to ensure that the residents are properly relocated. Upon verifying that the room is properly evacuated, the door will be shut. An X will be made on the door indicating that the room has been properly evacuated. After evacuating the area, complete a head count to make sure everyone is accounted for. All facility staff will be inserviced on all of the above by [DATE] by the Director of Nursing or Assistant Director of Nursing. The Surveyor confirmed the plan had been implemented sufficiently to remove the IJ by: Record review of the in-service sign-in sheets that revealed staff from all departments and shifts had been inserviced on [DATE] and [DATE] on RACE (Rescue/Alarm/Contain/Extinguish), PASS (Pull/Aim/Squeeze/Sweep), fire evacuation and safe resident removal. Interviews conducted with 4 nursing staff, 1 dietary staff, 1 housekeeping staff and 1 maintenance revealed staff had knowledge of evacuation procedures, knowledge of PASS and RACE and how to conduct resident room checks. The Administrator was informed on [DATE] at 3:10 pm that the IJ was removed; however the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. According to the CMS 672 form, the census was 96.

Based on interview and record review, the facility failed to implement its written policies and procedures that prohibited mistreatment/neglect for 1 of 7 residents (Resident #1) reviewed for neglect, as evidenced by: -Resident #1 was not evacuated from her room during a facility fire on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. This failure affected 1 resident and could place 95 other residents at risk of safety from fire. Complaint # 5 Findings include: Record review of facility abuse prevention policy, dated [DATE], read in part: .Our residents have the right to be free from .neglect.neglect occurs when center staff fails to monitor and/or supervise the delivery of resident care and a service to assure that care is provided as needed by the resident. Record review of Resident #1's face sheet revealed an admission date of [DATE], she was [AGE] years old. Record review revealed [DIAGNOSES REDACTED]. Record review of Resident #1's admission care plan dated [DATE] revealed resident was able to make her self understood, had clear speech and was able to understand other. Further review revealed resident required 1 person assist for bed mobility, transfer assist, bathing, dressing/grooming and personal hygiene. Observation on [DATE] at 11:00 am of rooms [ROOM NUMBERS] on the E wing of the facility revealed workers were seen renovating and painting the areas that had been affected by the fire that occurred on [DATE]. Interview on [DATE] at 11:30 am, Medical Records Staff A Resident #1 was completely forgotten in her room, room [ROOM NUMBER], when the other residents were evacuated. medical Records Staff stated the situation, of Resident #1 being left, was not realized until after the fire department had put out the fire. In continued interview at that time, Medical Records Staff stated, it was Monday, [DATE], about 7:00 pm when I was getting ready to head home and I heard the fire alarm. At first I thought it was a drill before I found out it was coming from E hall. We started evacuating all the residents in E hall. The fire department came and asked us to evacuate everybody in the building because by then there were flames. We then evacuated everybody in the building. The fire was contained within a short time. When the fire was put out, we were asked to bring back the residents starting from halls A, B, C and D. Later, the fire department said it was ok to bring back the residents in E hall. We did a head count of every resident and found that one resident living in E hall was missing, Resident #1. We went in and found her in her room. We brought her out and gave her some food. She said she was really scared. I can't explain what happened but she was just forgotten. We are all lucky that the fire was put out quickly. She could have died . The fire affected only two rooms. In an interview on [DATE] at 12:00 noon, LVN C stated I have been here for sixteen months. I usually work 6 to 2 shift but I stayed over on Monday, [DATE], so I was here when the fire incident occurred. I worked on E hall just like today. The fire occurred in room [ROOM NUMBER] of E hall. About 6:30 pm, CNA F alerted me that she smelled smoke. We went from room to room and found the AC was smoking in room E 10. Resident #5 was in the room that day and we took him out immediately. The smoke triggered the fire alarm and the fire department was called. We took everybody out but we forgot Resident #1 who was new resident that had come in on Friday, [DATE] and placed in room [ROOM NUMBER] A. She was the only person in the room that day. We noticed that she was forgotten after the fire had been put out and we did a head count to return the residents to their rooms. We found out she was not there during the head count and we went to her room and found her. She said she was scared but there was nothing she could do. In continued interview at that time, LVN C stated, room [ROOM NUMBER] is adjacent to room [ROOM NUMBER] and there were two residents were in room [ROOM NUMBER] on that day. The fire affected only rooms, rooms [ROOM NUMBERS], and they are being renovated now. Interview with the facility Administrator on [DATE] at 1:04 pm he stated there was a fire incident in the facility on [DATE] about 6:30 pm. He stated as follows, I am the administrator. There was fire incident here on Monday ([DATE]). The fire was out in about 30 minutes. I live 15 minutes away and I was called when the fire occurred. By the time I arrived, they had every resident out;everyone was accounted for. The fire affected rooms [ROOM NUMBERS] of E hall and we are doing some work there now. He stated, we have a written policy for fire hazard; we do fire drill every month. I feel that my staff did a good job that day. In an interview on [DATE] at 1:30 pm, the ADON stated I have been here for two years. I am the ADON. I was off on Monday [DATE] but I was called to come in when the fire incident occurred. I live just seven minutes away. By the time I arrived, the staff had evacuated every resident out of their rooms and out of the building. When the fire was out, we did a head count of the residents. Everyone was accounted for except for one lady, Resident #1. We went to her room and the fire department found her in her room with the door shut. I did not talk to the lady. I have not done so since that day. I think she is still here. Observation on [DATE] at 1:50 pm revealed Resident #1 in her room. Resident was alert and oriented. Further observation revealed Resident #1's room ( room [ROOM NUMBER]) was directly across from rooms [ROOM NUMBERS] on E hallway. In an interview at that time, Resident #1 stated, I have been here since last Friday, [DATE]. I had a stroke and my left arm and the left side of my body was affected. My left arm is not responding and is swollen. I am unable to get up unless I am assisted. I am receiving therapy to see if it will help. In continued interview at that time, Resident #1 stated, I remember the fire on Monday, [DATE]. It was scary; I was yelling, hitting on the call light and banging on that table with this remote control. There was too much noise and they couldn't hear me. The alarm was very loud. I thought I perceived some smoke smell but I was more concerned with the alarm than the smoke. I wished it could stop so they could hear me and come and get me. By the time they came to me everything was over. It was scary, I could have died . Record review of facility Disaster Plan, dated [DATE], read in part: .in case of smoke or fire: 1) move residents to safe place.f. Evacuate all residents from the effected area. Record review of fire department run report, dated [DATE], read in part: .observed evacuation evacuation in progress.notices flames coming from a pipe in the roof.then advised staff to begin evacuation.a full alarm was then requested.Engine -1A requested a second alarm and additional units to assist with the evacuation. During a confidential interview on [DATE] it was stated that they believed there was not a name on the residents door and staff may have thought the room was empty. In an interview on [DATE] at 2:32 pm, CNA E stated she was in the facility on the evening of the fire, [DATE]. CNA E stated when there is a fire, you locate where the fire is and remove the residents from the area. CNA E stated she was not aware that a resident was left until the fire was over; she didn't know how it happened. In an interview on [DATE] at 2:40 pm, CNA F stated she was at the facility on the evening of the fire. She stated no one is assigned to remove specific residents, it is a collective effort by the staff. In an interview with the Administrator on [DATE] at 2:50 pm, he stated the facility had not conducted any training on fire safety since the incident; he stated nothing formal was done except providing the staff with breakfast and lunch for a job well done. He stated he was aware that Resident #1 was left behind in the room and that the door was closed to protect her from smoke. He stated she was not in any danger. He stated he felt like Resident #1 was not on the weekend census due to being a new admit so during the head count it appeared everyone was there (had been accounted for). He further stated he had spoken with Resident #1 and she had said she was scared but had no other complaints otherwise. The facility administrator was notified on [DATE] at 4:24 pm that an IJ situation had been identified due to the above failure. Interview and observation of Resident #1 was conducted on [DATE] at 2:28 pm in her room. Resident #1 stated she remembered the fire. She stated she had smelled smoke, had been banging on the table but and could hear the alarm going off. She stated staff came for her after it was over, she did not know how long it was but it seemed like a long time. She stated she was scared, but once the staff came and took her to the dining room with the other residents,she felt better. The IJ was removed on [DATE]. In the event of smoke or fire, Lawrence Street will act as follows: I. Move residents in a safe place II. Alert Staff and Fire Department III. Close all doors and windows IV. Notify the Administrator and Director of Nursing V. Use fire extinguisher if fire is controllable VI. Evacuate residents from the affected area at least beyond the nearest smoke doors. VII. All employees will stand by in case evacuation is necessary Employees will adhere to the R.A.C.E. (Rescue, Alarm, Contain, Extinguish) Protocol for fire safety. This will include the following: Rescue - stop what you are doing and remove anyone in immediate danger from the fire Alarm - activate the nearest fire alarm pull stations Contain - close all doors and windows that you can safely reach to contain the fire Extinguish - only attempt to extinguish the fire if it is safe to do so. Retrieve the nearest fire extinguisher and follow P.A.S.S. procedure: P = Pull the pin breaking the plastic seal A = Aim at the base of the fire S = Squeeze the handles together S = Sweep from side to side Evacuate: Ambulatory persons should be instructed to leave under their own power and report to a designated assembly point. Persons that require assistance with mobility should be assisted or taken to the assembly point. Get out as safely and quickly as possible. During an evacuation, staff members conducting the evacuation will check each room to ensure that the residents are properly relocated. Upon verifying that the room is properly evacuated, the door will be shut. An X will be made on the door indicating that the room has been properly evacuated. After evacuating the area, complete a head count to make sure everyone is accounted for. All facility staff will be inserviced on all of the above by [DATE] by the Director of Nursing or Assistant Director of Nursing. The Surveyor confirmed the plan had been implemented sufficiently to remove the IJ by: Record review of the in-service sign-in sheets that revealed staff from all departments and shifts had been inserviced on [DATE] and [DATE] on RACE (Rescue/Alarm/Contain/Extinguish), PASS (Pull/Aim/Squeeze/Sweep), fire evacuation and safe resident removal. Interviews conducted with 4 nursing staff, 1 dietary staff, 1 housekeeping staff and 1 maintenance revealed staff had knowledge of evacuation procedures, knowledge of PASS and RACE and how to conduct resident room checks. The Administrator was informed on [DATE] at 3:10 pm that the IJ was removed; however the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy as the facility needed to continue to monitor its plan for effectiveness. According to the CMS 672 form, the census was 96.