Every finding on record at Legend Oaks Healthcare and Rehabilitation Center -

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #54) reviewed for accidents. CNA A was turning Resident #54 and he fell while performing ADL care to Resident #54 on 7/23/26 resulting in the resident rolling over, falling and sustaining an orbital fracture (one or more of the bones surrounding the eye were broken) and stitches on his forehead. The non-compliance was identified as Past non-compliance. the non-compliance began on 07/23/26 and ended on 07/24/26. The facility corrected the non-compliance before the survey began. This failure could place residents at risk of improper bed positioning, falls with injury, and cause the residents to have lower quality of care. Findings include: Record review of Resident #54's face sheet dated 8/13/26 revealed an [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnosis included type 2 diabetes mellitus with diabetic neuropathy (high blood sugar), hyperlipidemia (high cholesterol), severe protein-calorie malnutrition, peripheral vascular disease (reduced blood flow to the limbs), muscle weakness, repeated falls, muscle wasting and atrophy (the loss of muscle mass and strength), dementia (loss of intellectual functioning), polyneuropathy (degeneration of the peripheral nerves), chronic kidney disease (damaged kidneys), malaise (feel of discomfort/illness), anxiety disorder, difficulty walking, depressive disorder, hypertension (high blood pressure), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs), venous insufficiency (failure of the veins to adequately circulate the blood), dorsalgia(back pain), and cognitive communication deficit. Record review of Resident #54's Quarterly MDS (Minimum Data Set) dated 6/24/26 revealed a BIMS summary score of 9 that indicated moderate cognitive impairment, suggesting some difficulties with memory and thinking that may require additional support. Resident #54 ambulated by wheelchair, and he was dependent where the helper does all of the effort for toileting hygiene, shower/bathe self, personal hygiene, chair/bed-to-chair transfer. Resident #54 required substantial/maximal assistance where the helper does more than half the effort for roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Record review of Resident #54's Care Plan printed on 8/12/26 revealed a cognitive deficit related to dementia, impaired thought processes. Resident #54 was found to have an ADL self-care performance deficit related to weakness, immobility, incontinence, unsteadiness and the intervention was to converse with resident while providing care, explain all procedures/tasks before starting, may use mobility bars to aide in easy turning & repositioning while in bed (started on 6/11/26).bed mobility (roll left and right, sit to lying, lying to sitting on side of bed): requires staff participation to reposition & turn in bed. Resident #54 has had an actual fall with no injury related to immobility, unsteady gait, incontinence on 5/25/25, 10/22/25, 10/23/25, 12/31/25, 5/23/26 and with injury on 7/23/26 revealed interventions: resident encouraged to call for assistance, offered back to bed and meals/activities, staff educated to position resident in center of bed during incontinent care (dated 1/6/26), 12/31/25 staff educated to position resident in center of bed during incontinent care.and 7/23/26 floor mat x2. Record review of Resident #54's Change in Condition Evaluation dated 7/23/2026 revealed the change in condition for fall. Record review of Resident #54's Local Hospital CT Scan Report record dated 7/23/26 revealed a CT Head without contrast, Clinical: Trauma, Comment: There is a frontal scalp laceration. There is a possible acute nondisplaced right orbital roof fracture (break to the bones surrounding the eye). Patient instructions: Received with this packet on 7/23/26 at 2:54 pm: Face laceration: stitches or tape, Facial fracture. Facial fracture: You have a broken bone, or fracture, in your face. This may be a small crack in the bone. Or it may be a major break, with the bone moved out of place. Record Review of the Resident #54's medical record revealed that the resident was evaluated following a traumatic event. A CT of the head/brain without contrast was obtained on 07/23/26. The CT report documented a possible acute nondisplaced right orbital roof fracture. The possible orbital fracture was identified as an acute finding requiring clinical evaluation and follow-up as indicated. Record review of Resident #54's Progress notes dated 7/23/26 at 1:24 am by LVN A revealed CNA (CNA A) reported that while turning the resident during incontinent care, the resident rolled out of the bed onto the floor. Assessment revealed a forehead laceration; pressure was applied immediately. Vital signs were stables, and the resident remained alert and oriented x2 (a patient is awake, responsive, and aware of their identity and current location, but may not be aware of the time or situation). Resident sent to local hospital for further evaluation. Record review of fall assessment dated [DATE] by LVN A revealed: Resident description: Resident unable to give description.Immediate action taken description: Resident assessed immediately. Direct pressure applied to forehead laceration to control bleeding. Neuros checked and vital signs obtained. ADON notified. RP called with no answer, voicemail left requesting a return call. Injuries observed at time of incident: Injury type Bruise- right knee (front), laceration- top of scalp, skin tear- left antecubital, skin tear-face. Level of Consciousness: Alert. Mental Status: oriented to person, oriented to situation. In an observation and interview on 8/11/26 at 8:39 am with Resident #54 he stated he was tired and sleepy. Observation revealed Resident #54 had stitches on his forehead and when asked about the stitches he said everything happened. Observation revealed a fall mat on the left side of the bed and in front of his bed. Resident #54 stated he fell 3 days ago (8/8/26) in the day time (unknown time). He stated that he did not go to the hospital and that he stayed at the facility. In an interview on 8/13/26 at 8:31 am with Resident #54, he stated he was doing ok. He stated that no one was helping him when he fell and that he just fell out the bed by himself. He stated that he was weak and trying to get up out of bed and he fell. Resident #54 stated that when he fell and got stiches, he fell by himself. Resident #54 stated he fell and got stiches about 3 days ago. He stated he got weak and fell. Resident appeared to be confused. In an attempted interview on 8/13/26 at 10:08 am with CNA A, a message was left requesting a return call. In an interview on 8/13/26 at 10:12 am with CNA B, she stated that Resident #54's fall happened at night and she worked the following morning (7/24/26). She stated she did not know what happened, but she did receive report regarding the fall. CNA B stated Resident #54 got confused sometime and got out of his chair because he thought he could sit in another chair. CNA B stated Resident #54 was very stiff and hard to move. She stated Resident #54 was a one person assist, and was an easy transfer, but you have to know how to work with a patient who was stiff and contracted. In an interview and record review on 8/13/26 at 10:17 am with the DON, she stated Resident #54 had a fall during patient care on 7/23/26. She stated that upon investigation, all she got from CNA A was that a fall occurred. Record review of CNA A's statement revealed that it said, as she was turning Resident #54 he fell. The DON stated that Resident #54 did not really move, so he needed to be centered in the bed and then turned. The DON stated that CNA A should have asked for assistance. The DON stated that CNA A did a lot of things wrong, such as bed placement and Resident #54 was not a 2-person assist. The DON stated that the facility had CNA A to write a statement, they did education directly with CNA A and all the staff, they asked for safe surveys where the Social worker went to talk to some of the residents. The DON stated they did not report the incident because the fall was witnessed, but they did have the conversation about reporting with the Administrator. The DON stated the facility did education on all CNA's and the nurses continued with neuro checks for Resident #54. The DON stated Resident #54 had a fall with an orbital fracture. In an interview on 8/13/26 at 10:21 am with ADON A, she stated that she was informed about Resident #54's fall and that it was during incontinence care on the night shift with CNA A. ADON A stated CNA A turned Resident #54 while changing his adult brief and he fell out of bed. ADON A stated, Immediate intervention was that Resident #54 was sent to the hospital and upon Resident#54's return, the fall precautions that were put in place was fall mats. ADON A stated that prior to Resident #54 returning to the facility, she notified the DON, Administrator and the family was notified. ADON A stated staff education was also provided with CNA A for proper placement in bed. ADON A stated the hospital did a CT scan and Resident #54 returned to the facility on 7/24/26 with a dressing and sutures on his head. She stated Physician A saw Resident #54 on the morning of 7/24/26. She stated that CNA A was a new employee that started in June 2026 and she was changing Resident #54's entire bed because it was soiled. In an interview on 8/13/26 at 11:09 am with Physician A she stated Resident #54 was assessed by her once a month. She stated she was told that Resident #54 got rolled over out of the bed and fell and the next day she found out that it was a caregiver. Physician A stated CNA A was doing her job and she rolled Resident #54 too much and he acquired a fall. She stated Resident #54 was sent to the hospital and got x-rays there and was found to have an orbital fracture. Resident #54 was sent by 911 to the local hospital. In an interview on 8/13/26 at 1:37 pm with the Administrator he stated that he was out of the facility that day, but he was told that there was a witnessed fall during care. He stated Resident #54 had a fracture or a potential fracture was what the hospital record said. The Administrator stated when they have a fall with injures they would treat the patient, get them off the ground and the nurse assess them for pain and if there was an injury of unknown origin they report and if it was an injury of known origin they don't report. The Administrator stated if the incident was intentionally done then it would be abuse then they would report it. He stated if it was an incident where someone rolled out of bed and that was why they got hurt they did not report it because there was no sign of abuse. The Administrator stated that to his understanding the staff was doing proper positioning and Resident #54 rolled himself out of the bed. The Administrator stated Resident #54 did not know what the proper positioning was, and the resident said the staff did not do anything wrong. The Administrator stated that he was confused about when he was supposed to report and when he was not. The Administrator stated that they were having a QAPI meeting today and the incident with Resident #54 will be discussed. He stated that they have QAPI meetings to discuss incidents that occurred the previous month. Record review of In-servicesRecord review of Skills checklist Positioning the Resident dated 7/23/26 revealed CNA A was hired on 6/24/26 and completed positioning the resident and all the steps involved for safe transfer on 7/23/26. Record review of Counseling/Disciplinary notice dated 7/23/26 revealed CNA A received a counseling note that stated, Team member did not align resident in the center of the bed which in turn caused him to fall from the bed during peri care and bed change. Corrective action: If this is repeated, you will be subject to appropriate disciplinary action, up to and including discharge. Record review of In-Service Training Report, Proper alignment during peri care while in bed revealed, 1. Resident to be aligned properly when doing care in bed. They should be placed in the center of bed. 2. Ask co-workers for help when you fell a second hand is needed; also make nursing management aware so we can update the care plan and Kardex. Record review of In-Service Training Report dated 7/23/26 on Resident Rights reveled, Residents have the right to Dignity & respect, freedom of choice & autonomy, privacy & communication, Grievance & Protection. Record review of In-Service Training Report dated 7/24/26 on Abuse & Neglect revealed, Abuse can be sexual, physical, financial and emotional. Report abuse immediately or when suspected. Record review of the policy on Quality of Care revised on 04.2025 revealed, It is the policy of this facility to provide an environment that remains as free of accidents hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The non-compliance was identified as Past non-compliance. the non-compliance began on 07/23/26 and ended on 07/24/26. The facility corrected the non-compliance before the survey began.

Based on observation, interview, and record review, the facility failed to ensure rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 5 residents (Resident#85 ) reviewed for call lights. Resident #85's call light was observed to not have a red button inside the call light device to call for assistance on 8/11/2026. This failure could place residents at risk for delays in care and services, increased falls, and excessive waiting times, pain, and a decreased quality of life. Findings includes: Record Review of the face sheet for Resident #85 dated 8/13/2026 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses of hemiplegia/hemiparesis following unspecified cerebrovascular disease affecting right dominant side (mild to moderate weakness), dysphagia following unspecified cerebrovascular disease (difficulty swallowing) , unspecified severed protein-calorie malnutrition, type-two diabetes mellitus with unspecified complication, other malaise, hyperlipidemia- unspecified (high cholesterol), long term use of oral hypoglycemic (blood sugar level is low) drugs, other anxiety disorder, constipation, dementia, insomnia, cerebral infraction, depressive disorder, essential hypertension (high blood pressure) , benign prostatic hyperplasia (the enlargement of an organ), and disorder of prostate. Record Review of Resident #85's Quarterly MDS assessment dated [DATE] revealed a BIMS score 12 out of 15. In section GG Resident #85 was triggered with requiring setup and clean-up assistance with eating and partial/moderate assistance personal hygiene. Record Review of Resident #85's undated care plan revealed the following:'Focus: I am at risk for falls right CVA, generalized weakness, and incontinence.Goal: I will not sustain serious injury through the next review date.Interventions: Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in low position as resident will allow. Keep needed items, water etc., in reach. 'Focus: I have Self-Care Performance deficit related to CVA, dysphagia (difficulty or pain when swallowing foods, liquids, or even saliva), diabetes incontinence, weakness, and unsteady gait.Goal: I will safely perform my ADL's through the review date.Interventions: Converse with Resident while providing care. Explain all procedures/tasks before starting. In an observation and interview on 8/11/2026 at 10:15 a.m. Resident #85 said his call light does not work. He stated he did not know how long his call light was not working. The call light was on the bed frame not within reach and the red button to push for assistance had been removed.In an interview on 8/13/2026 at 10:24 a.m. with LVN A, she stated she has been working at the facility for about a year and a half. She stated she has been working on hall 400 for the last two days. She stated the Resident's call lights should always be within reach and functioning. She stated the nursing staff will complete their rounds to ensure each Resident call light was within reach and functioning. She stated it was important for the safety of the Resident for their call light to be within reach and functioning. She stated the risk to the Resident if the call light was not within reach and functioning was the Resident may be in distress and not be able to get a response in a timely manner. In an interview on 8/13/2026 at 10:35 a.m. with ADON B she stated she has been at the facility for three weeks. She stated the Resident's call light should be within reach and functioning. She stated the facility ensures the Resident's call lights are within reach and functioning every two hours when staff does their rounds. She stated it was all staffs responsibility for ensuring they were within reach and functioning. She stated it was important for the Resident to have their call lights within reach and functioning in case they may need something. She stated the risk to the Resident if their call light was not within reach and functioning was they may have a fall. In an interview on 8/13/2026 at 11:06 a.m. with the DON, she stated she has been at the facility since July 20, 2026. She stated the Resident's call light should be within reach and functioning. She stated the facility does Angel rounds and the maintenance does go around to check each Resident call lights regularly. She stated the risk to the Resident if their call light was not within reach and functioning was they can be injured, bleeding, or choking. She stated it was important for a Resident to have their call light within reach and functioning because they were getting the assistance they need. In an interview on 8/13/2026 at 11:09 a.m. with the Maintenance Director, he stated he has been at the facility since December 2025. He stated the call lights should be within reach and functioning. He stated he did not know Resident #85 call light was not working. He stated he checks on the call light monthly and staff will let him know in between. He stated the risk to the Resident if the call light was not within reach and functioning was potentially waiting longer to get a staff attention. He stated it was his responsibility to ensure they were functioning. In an interview on 8/13/2026 at 11:12 a.m. with the Administrator, he stated he has been at the facility for a little over two years. He stated the Resident's call light should be within reach and functioning. He stated the facility ensures the Resident's call lights are working by having angel rounds regularly. He stated it was the department head's reasonability to ensure that each Resident call light was within reach and functioning. He stated the risk to the resident was a delay in care. Record Review of the policy Call Light System Failure, Response, and Outage Management, undated, revealed: The facility shall maintain a functioning resident call system that enables residents to summon staff assistance from resident rooms, bathrooms, and bathing areas. Resident call lights shall be answered promptly, and resident requests shall be addressed timely in accordance with resident needs, physician orders, care plans, and accepted standards of practice. Residents shall not be left without a means to summon assistance. 8. Before leaving the room, staff shall: place the call light or alternative communication device within the resident's reach.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours for 1 of 2 residents (Resident #54) reviewed. The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for Resident #54's fall with orbital fracture when CNA A failed to properly position the resident while performing ADL care. This failure could cause a diminished quality of life for residents, lower quality of care and morale in the facility. Findings include: Record review of Resident #54's face sheet dated 8/13/26 revealed an [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnosis included type 2 diabetes mellitus with diabetic neuropathy (high blood sugar), hyperlipidemia (high cholesterol), severe protein-calorie malnutrition, peripheral vascular disease (reduced blood flow to the limbs), muscle weakness, repeated falls, muscle wasting and atrophy (the loss of muscle mass and strength), dementia (loss of intellectual functioning), polyneuropathy (degeneration of the peripheral nerves), chronic kidney disease (damaged kidneys), malaise (feel of discomfort/illness), anxiety disorder, difficulty walking, depressive disorder, hypertension (high blood pressure), congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs), venous insufficiency (failure of the veins to adequately circulate the blood), dorsalgia(back pain), and cognitive communication deficit. Record review of Resident #54's Quarterly MDS (Minimum Data Set) dated 6/24/26 revealed a BIMS summary score of 9 that indicated moderate cognitive impairment, suggesting some difficulties with memory and thinking that may require additional support. Resident #54 ambulated by wheelchair, and he was dependent where the helper does all of the effort for toileting hygiene, shower/bathe self, personal hygiene, chair/bed-to-chair transfer. Resident #54 required substantial/maximal assistance where the helper does more than half the effort for roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Record review of Resident #54's Care Plan printed on 8/12/26 revealed a cognitive deficit related to dementia, impaired thought processes. Resident #54 was found to have an ADL self-care performance deficit related to weakness, immobility, incontinence, unsteadiness and the intervention was to converse with resident while providing care, explain all procedures/tasks before starting, may use mobility bars to aide in easy turning & repositioning while in bed (started on 6/11/26).bed mobility (roll left and right, sit to lying, lying to sitting on side of bed): requires staff participation to reposition & turn in bed. Resident #54 has had an actual fall with no injury related to immobility, unsteady gait, incontinence on 5/25/25, 10/22/25, 10/23/25, 12/31/25, 5/23/26 and with injury on 7/23/26 revealed interventions: resident encouraged to call for assistance, offered back to bed and meals/activities, staff educated to position resident in center of bed during incontinent care (dated 1/6/26), 12/31/25 staff educated to position resident in center of bed during incontinent care.and 7/23/26 floor mat x2. Record review of Resident #54's Change in Condition Evaluation dated 7/23/2026 revealed the change in condition for fall. Record review of Resident #54's Local Hospital CT Scan Report record dated 7/23/26 revealed a CT Head without contrast, Clinical: Trauma, Comment: There is a frontal scalp laceration. There is a possible acute nondisplaced right orbital roof fracture (break to the bones surrounding the eye). Patient instructions: Received with this packet on 7/23/26 at 2:54 pm: Face laceration: stitches or tape, Facial fracture. Facial fracture: You have a broken bone, or fracture, in your face. This may be a small crack in the bone. Or it may be a major break, with the bone moved out of place. Record review of Resident #54's Progress notes dated 7/23/26 at 1:24 am by LVN A revealed CNA (CNA A) reported that while turning the resident during incontinent care, the resident rolled out of the bed onto the floor. Assessment revealed a forehead laceration; pressure was applied immediately. Vital signs were stables, and the resident remained alert and oriented x2 (a patient is awake, responsive, and aware of their identity and current location, but may not be aware of the time or situation). Resident sent to local hospital for further evaluation. Record review of fall assessment dated [DATE] by LVN A revealed: Resident description: Resident unable to give description.Immediate action taken description: Resident assessed immediately. Direct pressure applied to forehead laceration to control bleeding. Neuros checked and vital signs obtained. ADON notified. RP called with no answer, voicemail left requesting a return call. Injuries observed at time of incident: Injury type Bruise- right knee (front), laceration- top of scalp, skin tear- left antecubital, skin tear-face. Level of Consciousness: Alert. Mental Status: oriented to person, oriented to situation. In an observation and interview on 8/11/26 at 8:39 am with Resident #54 he stated he was tired and sleepy. Observation revealed Resident #54 had stitches on his forehead and when asked about the stitches he said everything happened. Observation revealed a fall mat on the left side of the bed and in front of his bed. Resident #54 stated he fell 3 days ago (8/8/26) in the day time (unknown time). He stated that he did not go to the hospital and that he stayed at the facility. In an interview on 8/13/26 at 8:31 am with Resident #54, he stated he was doing ok. He stated that no one was helping him when he fell and that he just fell out the bed by himself. He stated that he was weak and trying to get up out of bed and he fell. Resident #54 stated that when he fell and got stiches, he fell by himself. Resident #54 stated he fell and got stiches about 3 days ago. He stated he got weak and fell. Resident appeared to be confused. In an attempted interview on 8/13/26 at 10:08 am with CNA A, a message was left requesting a return call. In an interview on 8/13/26 at 10:12 am with CNA B, she stated that Resident #54's fall happened at night and she worked the following morning (7/24/26). She stated she did not know what happened, but she did receive report regarding the fall. CNA B stated Resident #54 got confused sometime and got out of his chair because he thought he could sit in another chair. CNA B stated Resident #54 was very stiff and hard to move. She stated Resident #54 was a one person assist, and was an easy transfer, but you have to know how to work with a patient who was stiff and contracted. In an interview and record review on 8/13/26 at 10:17 am with the DON, she stated Resident #54 had a fall during patient care on 7/23/26. She stated that upon investigation, all she got from CNA A was that a fall occurred. Record review of CNA A's statement revealed that it said, as she was turning Resident #54 he fell. The DON stated that Resident #54 did not really move, so he needed to be centered in the bed and then turned. The DON stated that CNA A should have asked for assistance. The DON stated that CNA A did a lot of things wrong, such as bed placement and Resident #54 was not a 2-person assist. The DON stated that the facility had CNA A to write a statement, they did education directly with CNA A and all the staff, they asked for safe surveys where the Social worker went to talk to some of the residents. The DON stated they did not report the incident because the fall was witnessed, but they did have the conversation about reporting with the Administrator. The DON stated the facility did education on all CNA's and the nurses continued with neuro checks for Resident #54. The DON stated Resident #54 had a fall with an orbital fracture. In an interview on 8/13/26 at 10:21 am with ADON A, she stated that she was informed about Resident #54's fall and that it was during incontinence care on the night shift with CNA A. ADON A stated CNA A turned Resident #54 while changing his adult brief and he fell out of bed. ADON A stated, Immediate intervention was that Resident #54 was sent to the hospital and upon Resident#54's return, the fall precautions that were put in place was fall mats. ADON A stated that prior to Resident #54 returning to the facility, she notified the DON, Administrator and the family was notified. ADON A stated staff education was also provided with CNA A for proper placement in bed. ADON A stated the hospital did a CT scan and Resident #54 returned to the facility on 7/24/26 with a dressing and sutures on his head. She stated Physician A saw Resident #54 on the morning of 7/24/26. She stated that CNA A was a new employee that started in June 2026 and she was changing Resident #54's entire bed because it was soiled. In an interview on 8/13/26 at 11:09 am with Physician A she stated Resident #54 was assessed by her once a month. She stated she was told that Resident #54 got rolled over out of the bed and fell and the next day she found out that it was a caregiver. Physician A stated CNA A was doing her job and she rolled Resident #54 too much and he acquired a fall. She stated Resident #54 was sent to the hospital and got x-rays there and was found to have an orbital fracture. Resident #54 was sent by 911 to the local hospital. In an interview on 8/13/26 at 1:37 pm with the Administrator he stated that he was out of the facility that day, but he was told that there was a witnessed fall during care. He stated Resident #54 had a fracture or a potential fracture was what the hospital record said. The Administrator stated when they have a fall with injures they would treat the patient, get them off the ground and the nurse assess them for pain and if there was an injury of unknown origin they report and if it was an injury of known origin they don't report. The Administrator stated if the incident was intentionally done then it would be abuse then they would report it. He stated if it was an incident where someone rolled out of bed and that was why they got hurt they did not report it because there was no sign of abuse. The Administrator stated that to his understanding the staff was doing proper positioning and Resident #54 rolled himself out of the bed. The Administrator stated Resident #54 did not know what the proper positioning was, and the resident said the staff did not do anything wrong. The Administrator stated that he was confused about when he was supposed to report and when he was not. The Administrator stated that they were having a QAPI meeting today and the incident with Resident #54 will be discussed. He stated that they have QAPI meetings to discuss incidents that occurred the previous month. Record review of the policy, Freedom from Abuse, Neglect, Exploitation, revision/review date 12.2023, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment.Definitions: neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of Long-Term Care Regulation Provider Letter, PL 2024-14 (Replaces PL 2019-17), Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), date issued August 29, 2024 revealed, A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect.Do Report: abuse (with or without serious bodily injury), an incident that results in serious bodily injury and that involves any of the following: neglect .CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of fifteen rooms (Resident #57's room) as evidenced by: Resident #57 had four (4) pills in a plastic cup on top of the bedside table at 7:13 AM. This failure could place residents at risk for harm and place the facility at risk for a possible drug diversion.The findings include: In an observation on 08/12/2026 at 7:13 AM of Resident #57's room revealed, on the bedside table was a cup with four pills (one oblong yellow, one oblong white, one round white, and one round red) unattended. In an interview on 08/12/2026 at 7:14 AM, Resident #57 stated the pills were okay to be there because she needs to take them with her meal. In an observation and interview on 08/12/2026 at 7:15 AM, ADON A saw the 4 pills in a cup on the bedside table. ADON A picked up the cup and stated medications were not to be left unattended on resident bedside table. ADON A stated reasons for not allowing medication at bedside unattended by nursing staff were that residents could choke when swallowing, another resident can take medications that were not ordered for them and have an adverse reaction. In an interview on 08/12/2026 at 7:20 AM with MA A she stated she left the medications in Resident #57's room. MA A stated she knew she should not leave medications at the bedside unattended. MA A stated she should monitor resident when taking pills as they could choke or have an allergic reaction and other residents could possibly take the wrong medication and have adverse reaction. MA A stated that when a resident refuses medicine, she should take medications back to the medication cart, document refusal and dispose of them. In an interview on 08/12/2026 at 7:24 AM with the DON she stated medication should never be left unattended at bedside. The DON stated residents could choke; a confused resident could take medication that was not for them and have an adverse reaction or an overdose. The DON per policy and procedure. medications are not to be left at bedside unattended. The DON said her expectation was never to have any medications left at bedside unattended by nursing staff. Record review of the Policy and Procedure Section: Medication Administration, Subject: Administration of Drugs, Policy Number: NCMA1, Procedures: #8. Note: Medications are never to be left unattended at the bedside. Policy and Procedure not dated.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure the opened package of grits were dated. The facility failed to ensure the opened package of spaghetti noodles were dated. These failures could cause food borne illnesses, and resident eating expired food. Findings included: Observation and interview on 8/11/26 at 7:50 am with the Dietary Manager, she stated the facility had been preparing for the State to come and that everything should be labeled and dated. Observation in the dry goods room revealed: A package of grits was opened and was not dated. Observation revealed the dietary manager dated the grits immediately. Further observation, interview and record review revealed a package of dry spaghetti noodles was opened and not dated. The Dietary Manager stated that the spaghetti was opened yesterday. Record review of facility policy, Dietary Services, Food Storage, revised 08/2007, revealed It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster. The facility failed to properly dispose of garbage and refuse on and around the dumpster on 8/12/2026. This failure could cause residents to smell odors, have pests, and to experience shame. Findings included: In an observation and interview on 8/12/26 at 9:46 am with the Dietary Manager revealed the garbage dumpster had 2 bags of torn trash bags hanging on the outside of the garbage lid. The dietary Manager stated when the garbage truck came to pick up the trash today (8/12/26), the bags must have hooked on to the lid. Observation revealed trash on the ground all around the garbage dumpster. The trash observed consisted in part of paper items, adult briefs, food, bread, cups, 2 additional small bags, chucks on the ground and a live cat. She said maintenance should be cleaning the property. Additional observations revealed 7 pallets or crates leaning on the fence of the facility. In an interview on 8/12/26 at 3:10 pm with the Administrator he stated the community was dumping things in the dumpster and that they have cleaned it up like 5 times already. He stated that maybe they should build a fence around it. In an interview on 8/13/26 at 9:05 am with the Maintenance Director, he stated it was his job to make sure the grounds were clean by the garbage dumpster. He stated the facility did heavy cleaning once a month, but when the staff see a trash bag on the ground, they need to put it in the garbage dumpster. He stated that he told the staff to pick up the trash bags and shut the garbage dumpster lid when they see it. The Maintenance Director stated the facility cleaned the trash up once a month at no particular time. He stated that he cleaned up all the trash this morning. He stated that the last time the trash had been cleaned was at the beginning of July 2026. He stated that they had a company to pick up the pallets that were on the fence. He stated there were a couple of odd shaped pallets that the company just did not take, so he had to break them down so they could take them. The Maintenance Director stated there was a guy that came to the facility to get the pallets for them. He stated the last time the pallets were taken was probably at the end of June 2026. In an interview on 8/13/26 at 1:37 pm with the Administrator he stated that they try to clean the garbage outside as needed and it usually ends up being once a month when they clean everything and tidy up. He stated they will have a junk person to come and pick up the pallets, but they usually did not want to come unless there were 10 to 15 of them. The Administrator stated they usually try to stack the pallets and keep them organized like paper one on top of the other, and not on the fence. He stated there was a gentleman who brought food to feed the cat that was at the garbage dumpster. The Administrator stated it sounded like there must have been some bags that opened and were not picked up by the garbage truck. Record review of facility policy, Garbage and Refuse Disposal, Department Services/Environmental Services, undated revealed, The facility will maintain procedures for the proper collection, transport, storage, and disposal of garbage and refuse in a manner that promotes sanitation, minimizes odors, prevents pest attraction and harborage, and supports a safe food service environment in accordance with applicable federal, state, and local regulations.Exterior garbage storage areas shall be maintained and monitored to reduce conditions that may attract or harbor insects, rodents, or other pests.The Plant director or designee will conduct routine observations of garbage handlingand storage practices.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of diseases and infections for 1 of 1 resident (Resident #8) reviewed for infection control. The facility failed to ensure LVN A and CNA B used proper infection control procedures when providing wound care and perineal care for Resident #8 on the morning of 08/13/2026. This failure could place residents at risk for wound infection, and cross-contamination. Findings included: Record review of Resident #8's face sheet not dated, revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnoses included Sepsis (a life-threatening response to an infection), Herpes Viral Infection (is an infection caused by herpes simplex viruses (HSV), which can lead to lifelong viral presence and recurring blisters or sores on the skin or mucous membranes), Hydronephrosis (is the swelling of one or both kidneys caused by urine buildup due to blockage or impaired drainage, leading to dilation of the renal pelvis and possible kidney damage), Urinary device (are tools designed to assist with urination, manage incontinence, or allow convenient urination in various situations). Record review of Resident #8's MDS dated [DATE] revealed the resident has an unstageable pressure ulcer/injury (is localized damage to the skin and/or underlying soft tissue-usually over a bony prominence-caused by intense or prolonged pressure, or pressure combined with shear) covered with slough (containing non-viable, dead tissue that appears as a soft, yellowish, white, or tan layer, which can impede healing and increase infection risk), over bony prominence. Resident #8 has an indwelling catheter (including nephrostomy tube (is a thin catheter inserted through the back into the kidney to drain urine when normal urinary flow is blocked)), is always incontinent of bowel, and is dependent for toileting care. Record review of Resident #8's Care plan dated 07/30/2026; Focus: Resident has stage 4 pressure ulcer at sacrum and skin tear at right posterior thigh. He is at risk for pressure ulcerdevelopment related to impaired mobility, bowel incontinence, thin and fragile skin secondary to aging, and needs assistance with bed mobility. Goal: Resident has stage 4 pressure ulcer atsacrum and skin tear at right posterior thigh. He is at risk for pressure ulcer development related to impaired mobility, bowel incontinence, thin and fragile skin secondary to aging, and needs assistance with bed mobility. Interventions: Administer treatments as ordered and monitor for effectiveness. Focus: Foley catheter due to urinary retention/pressure ulcer at sacrum (unstageable to stage 4) and left nephrostomy tube (on 6/5/2026) due to left hydronephrosis. Goal: Foley catheter will remain free from catheter related trauma and will show no signs or symptoms of urinary infection through review date. Interventions: Monitor/record/report to MD for no signs or symptoms: UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior. In an observation 08/13/2026 at 7:20 AM with CNA B with Resident #8. Observation revealed the perineal care was performed with one set of gloves without sanitizing hands between dirty and clean. CNA B cleansed front perineal area, assisted with repositioning resident to side lying position, touching his outer hip and outer thigh area without sanitizing or changing gloves. CNA B then cleaned anal area and both buttocks, pulled dirty pad and diaper from under the resident, obtained new pad and diaper from bedside table, rolled it and placed it under the resident without sanitizing or changing her gloves. CNA B changed her gloves before the resident was repositioned to his back, she then closed diaper, pulled down gown, and pulled up the blankets. In an interview on 08/13/2026 at 7:28 AM with CNA B, she stated she should have sanitized her hands and changed her gloves during and after perineal care before she touched Resident# 8's skin, clothing or bedding. CNA B reported she was nervous during care of resident #8 and has been trained regarding infection control during orientation and in computer in-services quarterly. In an interview on 08/13/2026 at 7:30 AM with the DON, the DON stated the staff should sanitize and change gloves between dirty and clean procedures during perineal care. The DON's expectation going forward was hands will be sanitized and new gloves utilized before touching the resident, clothing and bedding. In an observation 08/13/2026 at 7:35 AM Wound care preparation for Resident#8. The DON and Surveyor observed WCN sanitize her hands, opened treatment cart drawer, withdrew non-sterile gauze from inside the treatment cart without gloves. The WCN then placed contaminated gauze in a plastic cup and sprayed wound cleanser on the gauze. The Wound care preparation was stopped by the DON and WCN was asked to start preparation again with gloves due to contaminating non-sterile gauze with bare hands. In an interview on 08/13/2026 at 8:15 AM with the DON regarding observation of WCN, the DON stated that it was not the proper way to retrieve non-sterile gauze, the WCN was not following standard of care. The WCN should have put on gloves after sanitizing hands to retrieve non-sterile gauze. The DON's expectation was that all wound care supplies should be protected and handled with gloves prior to placing them on the bedside table for use with resident. In an interview on 08/13/2026 at 8:45 AM with the WCN has been employed for one month with the facility, she stated she did not know what the policy regarding sanitizing hands and gathering non-sterile gauze with or without gloves. She stated if hands were not 100% clean the resident receiving wound care had a potential for infection and possible sepsis. The WCN stated she did not know the standard of care for wound care nursing practice and does not have a wound care certification. Record review of the Policy/Procedure for Nursing Clinical, Section: Routine Procedures, Subject: Perineal Care, Policy Number NCRP 47, Procedures #6. Use gloves properly. Revised 05/2007. Record review of the Skin and Wound Care management, Wound Care Level III, page 48, Nursing Services Policy and Procedure Manual for Long-Term Care (C)2001 MED-PASS, Inc. Dated October 2010, #9. Wear exam gloves for holding gauze. Record review of the Policy/Procedure, ROP Section: 483.80 Infection Control, Title: Hand Hygiene, #2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with resident, d. Before performing any non-surgical invasive procedures; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin;j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; m. After removing gloves;

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 4 residents ( Resident #1) reviewed for medication storage. - RN A failed to ensure Resident #1's Vancomycin IV was labeled when she administered the medication on 11/12/25. This failure could place residents at risk of incorrect medication administration and adverse reactions to medications. Findings included: Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1]exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25. Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM. An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that included the residents name, medication information and directions for use. She said failure to have a label could result in individuals not knowing what the medication was or how it should be administered. In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing. Record review of the facility policy titled Infusion Therapy Product Labels revised 11/13/2018 revealed, Policy: Infusion therapy products are labeled in accordance with facility requirements and applicable state and federal laws. The label includes sufficient additional information as required to assure safe and efficient administration to residents. Procedures: a. Infusion therapy products are labeled by the provider with: 1) Resident name; 2) Physician name; 3) Pharmacy name, address, and telephone number 4) Contents of solution, including: a) Name of diluent (e.g., NS); b) Name and amounts of each additive; 5) Date dispensed 6) Directions for administration ; 7) Prescription number; 8) Storage instructions; 9) Expiration date and time; 10) Initials of dispensing pharmacist.

Based on observation, interview and record review the facility failed to ensure nurses were able to demonstrate competency in skills to provide nursing and related services for 1 of 1 resident (Resident #1) by 1 of 4 nurses (RN A) reviewed for competent staff. - The facility failed to ensure RN A was competent to administer medications via IV prior to administering medications to Resident #1 on 11/12/25 This failure could place residents at complications from IV medications and adverse reactions. Findings included: Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1] exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25. Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM. An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. Observation revealed a dial a flow pump. Resident #1 appeared to be in no immediate distress, her skin was not red, she took normal breaths and had no shortness of breath. In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that includes the residents name, medication information and directions for use. She went to get a new label and when she returned she informed the surveyor the pharmacy label ordered the vancomycin be administered at 750 mg at 150 ml/hr. every 12 hours and she started the infusion at approximately 11:30 AM. RN A said if Vancomycin was administered rapidly a resident could suffer from burning from the IV, she was not aware of any Vancomycin specific infusion reactions. In an observation and interview that started at 11/12/25 at 11:59 AM, the DON said Vancomycin must be administered at the ordered rate because rapid infusion of Vancomycin can result in red man syndrome which could result in flushing (redness), hypotension and cardiac arrest. In an interview on 11/12/25 at 12:05 PM, ADON A said to her knowledge RN A intentionally changed the medication flow rate to 250 ml/hr. because it was going to slow. ADON A said RN A said she was told by ADON B not to administer the medication until the pump arrived but RN A did not want a delay in Resident #1 receiving her antibiotic due to the absence of an IV pump. In an interview on 11/12/25 at 12:20 PM, the Medical Director said residents who received Vancomycin intravenously could suffer from Red Man Syndrome which is a Vancomycin infusion reaction that can result in tinnitus (ringing/buzzing or hissing in the ear caused by no external source), changes in vitals like hypotension, tachycardia, chest pain, shortness in breath caused by angioedema (swelling in the skin affecting the face, lips, tongue and throat). In an interview on 11/12/25 at 12:28 PM, the DON said when IV medication was administered nursing staff reviewed the order, retrieved supplies, notified the resident of the medication being administered, performed hand hygiene, donned the appropriate PPE, flushed the line and connected the IV medication following proper infection prevention techniques. The DON said the flow rate was determined by the orders on the bag and failure to administer IVs as ordered could result in adverse drug reactions. She said a significant med error was when an error made could be critical, and caused a significant change in a residents condition. The DON said when a resident experienced a significant medication error, the medication should be stopped immediately, the resident must be immediately assessed and the provider notified. In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing. In an interview on 11/12/25 at 01:11 PM, RN A said she started working in the facility in 10/2025. She said before medication was administered via IV, staff verified the order, retrieved the medication from the med room, assessed the resident, flushed the line, connected the IV, and then set the flow rate per the instructions on the IV label. RN A said the facility had two methods of administering IVs, an IV pump which came from the pharmacy or Dial-a-flow tubing which had a dial on the tubing to set the administration rate. She said nursing staff are expected to double check the flow rate prior to starting the infusion and then monitored the resident for at least 15 minutes after the infusion started to ensure the resident did not suffer from an adverse drug reaction. RN A said, a significant med error was this one (Resident #1's vancomycin administration outside of pharmacy orders) and she had not received any training on significant medication errors prior to starting her position on the flow. She said when a resident suffered from a significant medication error they stopped the medication immediately, assessed the resident, reported the error to the DON/NP, and awaited instructions. She said she was not educated about the specific infusion reactions that could occur with Vancomycin infusion rates and after the surveyor notified her of the wrong rate Resident #1 received her Vancomycin, she immediately changed the flow rate to 150 ml/hr. but she did not assess the resident. RN A said she did not follow the appropriate procedures for a significant medication error because she did not stop the infusion, Resident #1 was not assessed, but instead the rate was lowered and the resident was moved to the dining room with no observations completed. She said she was not trained and did not know what assessments had to be completed for vancomycin infusion reactions, she had not received training on how to use dial-a-flow tubing and she had not receiving any training on IV medication administration. RN A said no one had completed a skills assessment of her administration of IV medications and prior to working at the facility she was a nurse that worked from home. She said Resident #1 was her first experience with the dial-a-flow tubing. In an interview on 11/12/25 at 01:36 PM, the DON said seasoned nurses received 3 days of training before they were allowed on the floor and then trained continuous while employed as needed. She said all nurses should have competency assessments completed prior to working independently on the floor. The DON said the facility did not have a system in place to double check IV administration as it relied on the competency of the nurse administering the medication. She said the nurse must follow the rights of medication administration and double check the administration rate of IV medications because a second nurse does not check behind them. The DON said nurses that are not IV certified, like LVNs, received IV training before performing this tasks, but all RNs are IV certified. She said the facility had a skills fair IV training annually in February or March but there was no specific training about using the dial-a-flow tubing. The DON said she did not have any records to indicate RN A received any specific training on the use of dial-a-flow tubing or IV medication administration. She said RN A had no training on Vancomycin infusions or Vancomycin infusion reactions because that competency was expected with each nurses professional license. In an interview on 11/12/25 at 02:16 PM, RN A said she knew Resident #1's Vancomycin was ordered at 150 ml/hr. and she intentionally administered the medication against physician's orders at 250 ml/hr. She said she did not notify members of nursing management when she changed the administration rate. RN A said when she checked the medication room there was no medication pump she could use and she was not aware residents could suffer from an infusion reaction but now she was aware. RN A said ADON B instructed her not to administer the medication and to wait for the pharmacy to deliver the IV pump but since Resident #1 was so combative she wanted to ensure Resident #1 received the antibiotic because nothing else had worked for her infection. She said she was not aware that Vancomycin administered rapidly could result in an infusion reaction. In an interview on 11/12/25 at 02:40 PM, ADON B said between 9:00 and 10:00 AM RN A asked her if IV vancomycin had to be administered using a medication pump. She said yes and when RN A checked the facility there was no pump available so she instructed RN A to not administer the medication and wait for pharmacy to deliver the pump. ADON B said Vancomycin had to be administered by a pump due to its toxicity/narrow therapeutic window because the pump ensured the resident received the right dose for safety reasons. Record review of RN A's Medication Administration- Skills Checklist signed 09/23/25 revealed, Medication Administration- Skills checklist requirement Met was checked. There was no competency for IV medication administration or dial-a-flow tubing competencies documented on the checklist. Record review of the facility policy titled Administration of Drugs and Fluids, Intravenous revised 05/2021 revealed, POLICY:It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES:1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident - Resident is identified prior to medication administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Record review of the facility policy titled Nursing Staff Competency revised 04/2025 revealed, Policy: It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. Procedure: 2. Within 30 days of the date of hire, the nursing staff member shall complete the orientation competency assessment for the appropriate job category to meet the needs of the facility's resident population in accordance with the facility assessment. a. Competency in skills and techniques to care for residents' needs may include but are not limited to: Medication management

Based on observation, interview, and record review the facility failed to administer Parenteral fluids 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 #1) residents reviewed for parenteral fluids. - RN A failed to administer Resident #1's IV antibiotic Vancomycin, a medication with known infusion rate reactions, as ordered when she administered the medication at 250 ml/hr. instead of 150 ml/hr. as ordered on by the pharmacy on 11/12/25. This failure could place residents at vancomycin infusion reactions which could result in hypotension (low blood pressure), tachycardia (fast heartrate) and cardiac arrest (when the heart suddenly stops beating). Findings includeRecord review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection).Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited.Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1][ exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag.Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25.Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM.Record review of Resident #1's Change in Condition assessment dated [DATE] revealed, staff monitored for adverse reactions due to Vancomycin and Resident #1 did not have any changes/remained stable. Her vitals were within range, she had normal body temperature (97.7), blood pressure (118/62), Respirations (17), pulse (72) and her oxygen rate was at 97 %. The nurse received orders for an immediate test of Resident #1's Vancomycin Levels and a BMP.Record review of Resident #1's Progress Notes dated 11/12/25 at 12:35 PM signed by ADON A revealed, Resident assessed for [adverse reactions] to Vancomycin IV. Medical Director in building and updated on Vancomycin administration issue. MDinformed no adverse reaction noted during assessment. New orders received from medical director after viewing resident for STAT Trough (immediate laboratory values) ordered to ensure resident is in therapeutic range with medication. BMP to be drawn tomorrow and redraw for Vanco trough 11/14. Vancomycin to be held until result is received for STAT trough and observed resident q 1hr x 24 hours. NP called and updated on the above.Record review of Resident #1's Lab results dated 11/13/25 revealed, the vancomycin levels came out as low and there were no significant change to her BMP.An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. Resident #1 appeared to be in no immediate distress, her skin was not red, she took normal breaths and had no shortness of breath.In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that includes the residents name, medication information and directions for use. She went to get a new label and when she returned she informed the surveyor the pharmacy label instructed the vancomycin be administered at 750 mg at 150 ml/hr. every 12 hours and she started the infusion at approximately 11:30 AM. RN A said if Vancomycin was administered rapidly a resident could suffer from burning from the IV, she was not aware of any Vancomycin specific infusion reactions.In an observation and interview that started at 11/12/25 at 11:59 AM, the DON said Vancomycin must be administered at the ordered rate because rapid infusion of Vancomycin can result in red man syndrome which could result in flushing (redness), hypotension and cardiac arrest. The surveyor notified the DON of Resident #1's Vancomycin being administered at 250 ml/hr. instead of 150 ml/hr. The DON immediately located Resident #1 in the dining room (the IV was set at 150 ml/hr. when the resident was found in the dining room), returned her to her bedroom and began assessing the resident. The IV was stopped at 12:07 PM, then the DON checked Resident's upper torso for redness and hives to which there was none and Resident #1 began to question what the DON was doing and resist the assessment. Resident #1 appeared to be in no immediate distress, her breathing was normal, she had no redness.In an interview on 11/12/25 at 12:20 PM, the Medical Director said residents that received Vancomycin rapidly could suffer from Red Man Syndrome which is a Vancomycin infusion reaction that can result in tinnitus (ringing/buzzing or hissing in the ear caused by no external source), changes in vitals like hypotension, tachycardia, chest pain, shortness in breath caused by angioedema (swelling in the skin affecting the face, lips, tongue and throat). He said if a resident received Vancomycin at a rate higher than ordered, he expected the IV to be stopped immediately, the resident assessed and the provider notified immediately for orders. He said Vancomycin administered at an incorrect rate was considered a significant medication error but Resident #1 was assessed and suffered no harm. The resident was stable, and labs were ordered to check her Vancomycin level.In an interview on 11/12/25 at 12:28 PM, the DON said Resident #1 was assessed and she had no SOB, Discomfort, irritation at IV site, no pain and her vitals were within normal limits. She said when IV medication was administered nursing staff reviewed the order, retrieved supplies, notified the resident of the medication being administered, performed hand hygiene, donned the appropriate PPE, flushed the line and connected the IV medication following proper infection prevention techniques. The DON said the flow rate was determined by the orders on the bag and failure to administer IVs as ordered could result in adverse drug reactions. She said a significant med error was when an error made could be critical, and caused a significant change in a residents condition. The DON said when a resident experienced a significant medication error, the medication should be stopped immediately, the resident must be immediately assessed and the provider notified.In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. In an interview on 11/12/25 at 02:16 PM, RN A said she knew Resident #1's Vancomycin was ordered at 150 ml/hr. and she intentionally administered the medication against physician's orders at 250 ml/hr. She said she did not notify members of nursing management when she changed the administration rate. RN A said when she checked the medication room there was no medication pump she could use and since Resident #1 was so combative she wanted to ensure Resident #1 received the antibiotic because nothing else had worked. RN A said she was not aware residents could suffer from an infusion reaction but now she was aware.In an interview on 11/12/25 at 02:40 PM, ADON B said between 9:00 and 10:00 AM RN A asked her if IV vancomycin had to be administered using a medication pump. She said yes and when RN A checked the facility there was no pump available so she instructed RN A to not administer the medication and wait for pharmacy to deliver the pump. ADON B said Vancomycin had to be administered by a pump due to its toxicity/narrow therapeutic window because the pump ensured the resident received the right dose for safety reasons.In an interview on 11/12/25 at 02:53 PM, the NP said when she prescribed vancomycin the pharmacy calculated the rate of administration and nursing staff were expected to administer the medication per the pharmacy orders. She said when Vancomycin was administered rapidly, residents could suffer from VIR (vancomycin infusion reactions) which caused rash, hypotension and tachycardia. She said RN A's failure to administer Vancomycin as ordered was a safety concern because her role as a nurse was to follow orders as written.In an interview on 11/12/25 at 03:30 PM, the Pharmacist said the administration rate of Resident #1's Vancomycin was determined by the manufacturers recommendation to be administered over 1 hour and she was ordered to receive the 750 mg dose in the 150 ml solution at 150 ml/hr. He said if Vancomycin was administered too fast a resident could suffer from a pretty bad reaction and they could experience hypotension, tachycardia and cardiac arrest. The pharmacist said nursing staff are expected to follow the pharmacy ordered rate and it was labeled pretty clearly. He said even though RN A did not administer the medication as ordered it was a low risk for an adverse reaction.Record review of the facility policy titled Administration of Drugs and Fluids, Intravenous revised 05/2021 revealed, POLICY:It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES: 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident - Resident is identified prior to medication administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility.

Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 resident (Resident #1) reviewed for accuracy of assessments. - The facility failed to ensure Resident #1's Quarterly MDS dated [DATE] and Discharge MDS dated [DATE] accurately reflected the residents behavior of verbally aggressive behaviors to others and resistance to care. This failures could place residents at risk of inaccurate assessments, which could compromise their plan of care . Findings include Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's Discharge MDS dated [DATE] revealed, an unplanned discharge for a short term general hospital stay with return anticipated. Resident #1 had fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, Focus created on 09/16/24 and revised on 09/29/25: [Resident #1] exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. In an interview on 11/12/25 at 09:51 AM, the Administrator said Resident #1 attempted to elope from the building in April of 2025. She was observed going out the side door at the end of her hall and was immediately brought back into the building by ADON A. He said the resident was confused and propelled herself around the facility. In an observation and interview with ADON A on 11/12/25 at 09:58 AM, ADON B pushed open all exit doors at the end of the 100, 200, 300 and 400 Halls and an alarm was audible. She said Resident #1 liked to challenge the door, was confused, attempted to elope from the building, was generally combative and resistant to care. ADON B said in April of 2025, she observed Resident #1 as she exited the door as the alarm went off and she immediately brought the resident back in. In an interview on 11/12/25 at 10:55 AM, the DON said in April 2025 Resident #1 was visualized going out the door at the end of the hall by ADON A but the staff could not get to her before she went out the door. She send ADON A was alerted to Resident #1 going out the door by an audible alarm, and then immediately returned the resident inside the facility. The DON said Resident #1 was in a wheelchair and she propelled herself around the building, was combative and resistant to care. She said the MDS represented the resident and the care they should receive. The DON said an inaccurate MDS could potentially impact how the resident is cared for. In an interview on 11/12/25 at 11:30 AM, the MDS Nurse said she was new and did not complete Resident #1's assessments. She said the MDS is completed with information from the IDT as well as interviews and observations with family and the resident. She said from what she heard, Resident #1 had behaviors of resisting care but her MDS was codded as no behaviors. The DON said Resident #1 had behaviors since she admitted to the facility in 2024. She said the resident was not friendly, had behaviors most of the time, would grab staff, had verbal behavioral symptoms, roamed in her wheelchair, wandered around and rejected care 4-6 times a week. After the DON reviewed Resident #1's MDS from 10/03/25 and 10/28/25 she said they were inaccurate because they did not acknowledge Resident #1's physical, verbal and other behavioral symptoms. An observation on 11/12/25 at 11:54 AM revealed, Resident #1 sitting in her wheelchair in the doorway of her room receiving Vancomycin 750 mg/ml in 750 ml IV at 250 ml/hr. Her left foot was wrapped in a white dressing and her right arm had IV tubing protruding from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. Observation revealed a dial a flow pump. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. In an interview on 11/12/25 at 11:58 AM, RN A said Resident #1 was confused and was not interviewable. She said the resident was combative and resistant to care, she would not let anyone touch her or provide care. Record review of the facility policy titled Resident Assessment and Associated Processes revised 04/2025 revealed, It is the policy of this facility that resident will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: Identification and demographic information; Customary routine; Cognitive patterns; Communication, Vision; Mood and behavior patterns; Psychological well-being. 5. Assessment information will be used to develop, review, and revise the resident's comprehensive care plan. 7. Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained.

Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 4 residents (Residents #1) reviewed for significant medication errors. - RN A failed to administer Resident #1's IV antibiotic Vancomycin, a medication with known infusion rate reactions, as ordered when she intentionally administered the medication at 250 ml/hr. instead of 150 ml/hr. as ordered by the pharmacy. This failure could place residents at vancomycin infusion reactions which could result in hypotension (low blood pressure), tachycardia (fast heartrate) and cardiac arrest (when the heart suddenly stops beating). Findings included Record review of Resident #1's Face Sheet dated 11/12/25 revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD (group of lung diseases that block airflow cause difficulty breathing), muscle weakness, depression, difficulty walking, right great toe amputation, lower left leg open wound and peritoneal abscess (pus within the abdomen due to an infection). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, fluctuating behaviors of: inattention, disorganized thinking and altered level of consciousness. Behavioral symptoms of: physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing), Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, , or verbal/vocal symptoms like screaming, disruptive sounds) were marked as Behavior not exhibited. Rejection or care and wandering were marked as: Behavior not exhibited. Record review of Resident #1's undated Care Plan revealed, focus: COPD (Chronic Obstructive Pulmonary Disease) r/t SOB, use of medications. Focus: Is on IV Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) r/t leukocytosis (elevated white blood cell count indicating infection). Goal: Will not have any complications related to IV Therapy through the review date. Focus created on 09/16/24 and revised on 09/29/25: [Resident #1] exhibits Behaviors r/t Elopement risk/wanderer, disoriented to place, wanders aimlessly, refuses ADL care/showers frequently. Yells out at other residents. Removes her wound bandages, removes her colostomy bag. Record review of Resident #1's Oder Summary Report dated 11/12/25 revealed, Vancomycin HCl Intravenous Solution Reconstituted 750 MG (Vancomycin HCl) Use 750 mg intravenously every 12 hours for abnormal lab for 10 Days; start date 11/11/25. Record review of Resident #1's November 2025 MAR revealed, the first dose of Vancomycin Resident #1 received was administered by RN A on 11/12/25 at 11:21 AM. Record review of Resident #1's Change in Condition assessment dated [DATE] revealed, staff monitored for adverse reactions due to Vancomycin and Resident #1 did not have any changes/remained stable. Her vitals were within range, she had normal body temperature (97.7), blood pressure (118/62), Respiratiosn (17), pulse (72) and her oxygen rate was at 97 %. The nurse received orders for an immediate test of Resident #1's Vancomycin Levels and a BMP. Record review of Resident #1's Progress Notes dated 11/12/25 at 12:35 PM signed by ADON A revealed, Resident assessed for [adverse reactions] to Vancomycin IV. Medical Director in building and updated on Vancomycin administration issue. MDinformed no adverse reaction noted during assessment. New orders received from medical director after viewing resident for STAT Trough (immediate laboratory values) ordered to ensure resident is in therapeutic range with medication. BMP to be drawn tomorrow and redraw for Vanco trough 11/14. Vancomycin to be held until result is received for STAT trough and observed resident q 1hr x 24 hours. NP called and updated on the above. Record review of Resident #1's Lab results dated 11/13/25 revealed, the vancomycin levels came out as low and there were no significant change to her BMP. An observation on 11/12/25 at 11:52 AM revealed, Resident #1 in her wheelchair in the doorway of her room as she received Vancomycin 750 mg/150 ml at 250 ml/hr. (calculated administration duration of 36 minutes). Her left foot was wrapped in a white dressing and her right arm had IV tubing that protruded from under a white gauze dressing. The IV bag had no labeling outside of the manufacturer labeling, there was no pharmacy label that contained the resident's name, dose and instruction for use, administration flow rate, name of prescriber, or date the medication was ordered. The resident was not interviewable, she was confused, tugged on her IV tubing and was combative with staff who passed by. Observation revealed a dial a flow pump. Resident #1 appeared to be in no immediate distress, her skin was not red, she took normal breaths and had no shortness of breath. In an interview on 11/12/25 at 11:54 AM, RN A said the label for Resident #1's Vancomycin must have fallen off after she hung the medication and all medications must have a pharmacy label that includes the residents name, medication information and directions for use. She went to get a new label and when she returned she informed the surveyor the pharmacy label ordered the vancomycin be administered at 750 mg at 150 ml/hr. every 12 hours and she started the infusion at approximately 11:30 AM. RN A said if Vancomycin was administered rapidly a resident could suffer from burning from the IV, she was not aware of any Vancomycin specific infusion reactions. In an observation and interview that started at 11/12/25 at 11:59 AM, the DON said Vancomycin must be administered at the ordered rate because rapid infusion of Vancomycin can result in red man syndrome which could result in flushing (redness), hypotension and cardiac arrest. The surveyor notified the DON of Resident #1's Vancomycin being administered at 250 ml/hr. instead of 150 ml/hr. The DON immediately located Resident #1 in the dining room (the IV was set at 150 ml/hr. when the resident was found in the dining room), returned her to her bedroom and began assessing the resident. The IV was stopped at 12:07 PM, then the DON checked Resident's upper torso for redness and hives to which there was none and Resident #1 began to question what the DON was doing and resist the assessment. Resident #1 appeared to be in no immediate distress, her breathing was normal, she had no redness. In an interview on 11/12/25 at 12:20 PM, the Medical Director said residents that received Vancomycin rapidly could suffer from Red Man Syndrome which is a Vancomycin infusion reaction that can result in tinnitus (ringing/buzzing or hissing in the ear caused by no external source), changes in vitals like hypotension, tachycardia, chest pain, shortness in breath caused by angioedema (swelling in the skin affecting the face, lips, tongue and throat). He said if a resident received Vancomycin at a rate higher than ordered, he expected the IV to be stopped immediately, the resident assessed and the provider notified immediately for orders. He said Vancomycin administered at an incorrect rate was considered a significant medication error but Resident #1 was assessed and suffered no harm. The resident was stable, and labs were ordered to check her Vancomycin level. In an interview on 11/12/25 at 12:28 PM, the DON said Resident #1 was assessed and she had no SOB, Discomfort, irritation at IV site, no pain and her vitals were within normal limits. She said when IV medication was administered nursing staff reviewed the order, retrieved supplies, notified the resident of the medication being administered, performed hand hygiene, donned the appropriate PPE, flushed the line and connected the IV medication following proper infection prevention techniques. The DON said the flow rate was determined by the orders on the bag and failure to administer IVs as ordered could result in adverse drug reactions. She said a significant med error was when an error made could be critical, and caused a significant change in a residents condition. The DON said when a resident experienced a significant medication error, the medication should be stopped immediately, the resident must be immediately assessed and the provider notified. In an observation and interview in the medication room on 11/12/25 at 12:43 PM, the DON said all IV medications should have a pharmacy label that included the pharmacy's information, resident's name, medication information and directions for use. A bag of Resident #1's IV Vancomycin was observed in the fridge with each IV bag wrapped in a foil manufacturer bag and an attached pharmacy label with pharmacy information, resident information, provider information, drug information and directions for use. The label read Vancomycin 750 ml: Infuse intravenously 150 ml (750 mg) over 60 minutes every 12 hours for 10 days. The DON said failure to label medication could result in staff being unaware of the instructions for use including the dosing. In an interview on 11/12/25 at 01:11 PM, RN A said she started working in the facility in 10/2025. She said before medication was administered via IV, staff are verified the order, retrieved the medication from the med room, assessed the resident, flushed the line, connected the IV, and then set the flow rate per the instructions on the IV label. RN A said the facility had two methods of administering IVs, an IV pump which came from the pharmacy or Dial-a-flow tubing which had a dial on the tubing to set the administration rate. She said nursing staff were expected to double check the flow rate prior to starting the infusion and then monitor the resident for at least 15 minutes after the infusion started to ensure the resident did not suffer from an adverse drug reaction. RN A said, a significant med error was this one (Resident #1's vancomycin administration outside of pharmacy orders) and she had not received any training on significant medication errors prior to starting her position on the flow. She said when a resident suffered from a significant medication error they must stop the medication immediately, assess the resident, report the error to the DON/NP, and await instructions. She said she was not educated about the specific infusion reactions that could occur with Vancomycin infusion rates and after the surveyor notified her of the wrong rate Resident #1 received she immediately changed the flow rate to 150 ml/hr. but she did not assess the resident. RN A said she did not follow the appropriate procedures for a significant medication error because she did not stop the infusion, Resident #1 was not assessed, but instead the rate was lowered and the resident was moved to the dinning room with no observations completed. She said she was not trained and did not know what assessments had to be completed for vancomycin infusion reactions, she had not received training on how to use dial-a-flow tubing and she had not received any training on IV medication administration. RN A said no one had completed a skills assessment of her administration of IV medications and prior to working at the facility she was a nurse that worked from home. She said Resident #1 was her first experience with the dial-a-flow tubing. In an interview on 11/12/25 at 02:16 PM, RN A said she knew Resident #1's Vancomycin was ordered at 150 ml/hr. and she intentionally administered the medication against physician's orders at 250 ml/hr. She said she did not notify members of nursing management when she changed the administration rate. RN A said when she checked the medication room there was no medication pump she could use and since Resident #1 was so combative she wanted to ensure Resident #1 received the antibiotic because nothing else had worked. RN A said she was not aware resident's could suffer from an infusion reaction but now she was aware. In an interview on 11/12/25 at 02:40 PM, ADON B said between 9:00 and 10:00 AM RN A asked her if IV vancomycin had to be administered using a medication pump. She said yes and when RN A checked the facility there was no pump available so she instructed RN A to not administer the medication and wait for pharmacy to deliver the pump. ADON B said Vancomycin had to be administered by a pump due to its toxicity/narrow therapeutic window because the pump ensured the resident received the right dose for safety reasons. In an interview on 11/12/25 at 02:53 PM, the NP said when she prescribed vancomycin the pharmacy calculated the rate of administration and nursing staff were expected to administer the medication per the pharmacy orders. She said when Vancomycin was administered rapidly, residents could suffer from VIR (vancomycin infusion reactions) which caused rash, hypotension and tachycardia. She said RN A's failure to administer Vancomycin as ordered was a safety concern because her role as a nurse was to follow orders as written. In an interview on 11/12/25 at 03:30 PM, the Pharmacist said the administration rate of Resident #1's Vancomycin was determined by the manufacturers recommendation to be administered over 1 hour and she was ordered to receive the 750 mg dose in the 150 ml solution at 150 ml/hr. He said if Vancomycin was administered too fast a resident could suffer from a pretty bad reaction and they could experience hypotension, tachycardia and cardiac arrest. The pharmacist said nursing staff are expected to follow the pharmacy ordered rate and it was labeled pretty clearly. He said even though RN A did not administer the medication as ordered it was a low risk for an adverse reaction. Record review of the facility policy Identifying and Managing Medication Errors and Adverse Consequences revised 04/2007 revealed, Policy Statement: The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. Policy Interpretation and Implementation: 1. The staff and practitioner shall strive to minimize adverse consequences by: 1. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 2. Defining appropriate indications for use. 2. The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's Attending Physician immediately. 3. In the event of a clinically significant adverse medication consequence, nursing staff shall implement and follow any related Physician orders, and shall monitor closely and document the resident's condition and response to any corrective interventions for at least the next 24 hours or as otherwise directed. 4. Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. 5. The Medical Director, Director of Nursing Services, and Consultant Pharmacist shall review medication errors and adverse medication consequences as part of the facility's Quality Assurance process. Record review of the facility policy titled Administration of Drugs and Fluids, Intravenous revised 05/2021 revealed, POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES: 1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. 2. Medications must be administered in accordance with the written orders of the attending physician. 8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. The seven rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident - Resident is identified prior to medication administration; 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed. Record review of the manufacturer's Highlights of Prescribing Information revised 05/2021 revealed, Infusion Reactions: Hypotension, including shock and cardiac arrest, wheezing, dyspnea (shortness of breath), urticaria (hives), muscular and chest pain and red man syndrome which manifests as pruritus (itching) and erythema (redness) that involves the face, neck and upper torso may occur with rapid intravenous administration. To reduce the risk of infusion reactions, administer Vancomycin Injection over a period of 60 minutes or greater and also prior to intravenous anesthetic agent. ADVERSE REACTIONS: The common adverse reactions are anaphylaxis, red man syndrome, acute kidney injury, hearing loss, neutropenia (low type of white blood cell). Record review of the facility policy Administering Medications revised 05/18/2023 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. 20. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - On 11/12/25 the facility failed to ensure the Direct Care Daily Staffing Numbers were updated. The postings read 11/11/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the pony wall on the left side of the front entrance. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. RNs, LVNs and some CNAs worked 12 hour shifts from 6:00 AM to 6:00 PM or 6:00 PM to 6:00 AM. Nursing Managers and the DON worked from 9:00 AM to 5:00 PM, CNAs: 10:00 PM to 6:00 AM, CMAs 6:00 AM - 2:00 PM and 2:00 PM to 10:00 PM. An observation on 11/12/25 at 08:51 AM revealed, the facility Direct Care Daily Staffing Numbers displayed on the wall by the DON's office. The posting read Date: 11-Nov-2025' and included the facility name, census, the scheduled hours, and staffing totals for direct care staff. RNs, LVNs and some CNAs worked 12 hour shifts from 6:00 AM to 6:00 PM or 6:00 PM to 6:00 AM. Nursing Managers and the DON worked from 9:00 AM to 5:00 PM, CNAs: 10:00 PM to 6:00 AM, CMAs 6:00 AM - 2:00 PM and 2:00 PM to 10:00 PM. An observation on 11/12/25 at 09:08 AM revealed, the Staffing Coordinator as she removed the old direct care posting from the wall by the DONs office. In an interview on 11/12/25 at 10:38 AM, the Administrator said the Staffing Coordinator was responsible for the direct care posting. He said the posting should be posted somewhere visible within 2 hours of the first shift. He said the facility had 12 hour shifts for nurse and CNAs from 6- 6 and the posting should be up by 8:00 AM and before each shift. The Administrator said failure to update the posting timely could cause family members confusion of who was giving care that day. In an interview on 11/12/25 at 11:16 AM, the Staffing Coordinator said she made the schedules for the nursing department, found staffing, worked as a CNA/MA as needed and she was responsible for the daily direct care posting. She said the direct care posting had to be posted within 2 hours of the shifts, the facility shifts were 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM and must include the facility name, date, census, staffing types scheduled and the total number of scheduled staff. She said failure to update the posting timely could result in residents and visitors to the building not knowing the facility census or the staffing available for the day. The Staffing Coordinator said her shifts typically ran from 08:15 AM to 05:15 PM and she was expected to update the posting within 2 hours of the beginning of her shift. She said she had not received any training about the regulations regarding the timing of the posting. The Staffing Coordinator said when she arrived on 11/12/25 she was helping residents on the floor which caused her update of the posting to be delayed.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of 8 residents (Resident #18) reviewed for storage of medications. The facility failed to ensure Resident #18's Fluticasone inhaler medication used for shortness of breath, was secured, and not left at the bedside. This deficient practice could place residents at risk for loss of biologicals and place residents at risk of access to hazards. Findings included: Record review of Resident #18's undated admission face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She was initially admitted on [DATE]. Resident #18's diagnoses included: acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), pneumonia, heart failure, and morbid obesity. Record review of Resident #18's hospital Discharge summary dated [DATE] revealed a past medical history of chronic obstructive pulmonary disease (COPD): a lung condition caused by damage to the airway. Record review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18's Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 13 out of 15 which indicated intact cognition. Further review revealed she received respiratory treatments: oxygen and non-invasive mechanical ventilator. Record review of Resident #18's active physician's orders as of 06/05/25 revealed an order for Flovent Diskus Inhalation aerosol powder breath activated 250 MCG/ACT (Fluticasone Propionate (inhalation), I puff inhale orally as needed for SOB, rinse mouth and spit out after use, start date 5/04/25. Further review revealed no physician's order for self-administration of Flovent or any other medications . Continued review of Resident #18's chart revealed there was no self-administration assessment. Record review of Resident #18's June 2025 MAR printed on 6/6/25 revealed therevealed the last time Resident #18 received Fluticasone Propionate (inhalation) was on 6/1/25 at 7:05 PM by LVN-F. In an observation on 06/04/25 at 10:22 AM, the medication with Resident #18's name on the pharmacy label for Flovent Diskus Inhalation aerosol powder breath activated 250 MCG/ACT for Resident #18 was on top of the nightstand behind the mechanical ventilator. Resident #18 had humidified oxygen via nasal cannula and oxygen concentrator set at 2L/m. The resident was on her back with the head of bed raised, alert and oriented with no signs of distress. Resident #18 denied knowing anything about the box of medication on the nightstand. In an interview and observation on 06/04/25 at 10:50 AM, MA-R stated medications should not be left in a resident's room and did not know why Resident #18's inhaler medication was left in the room. MA-R stated that medication was given by the nurses and not the medication aides. MA-R stated the only individuals who could administer medications were the nurses and medication aides. Residents could not self-administer unless they had a doctor order. MA-R stated the risk was that residents who wandered may pick up and ingest the medication that was not for them. MA-R removed the medication from the room. In an interview on 06/04/25 at 1:35 PM, LVN-D stated medications should not be left in resident rooms unless there is a doctor order for the resident to self-administer. LVN-D stated the risk to the resident would be overmedication and misuse of the medications. LVN-D stated she was not assigned to care for Resident #18 and did not know why the medication was left at the bedside. In an interview on 06/04/25 at 1:45 PM, LVN-E stated medications should not be left in resident rooms unless there is an order for self-administration. LVN-E stated she was assigned to Resident #18, checked her chart, and stated that Resident #18 did not have an MD order for self-administration of meds. LVN-E stated she did not know why it was left in the room and that she did not give the inhaler on her shift. LVN-E stated the risk would be the medication could be given to the wrong resident, anyone such as another resident could come into the room take it and can overdose, it can be a choking hazard or can be taken incorrectly. LVN-E stated it would be an infection control issue and the facility does have residents who wander. In an interview on 06/04/25 at 11:37 AM, the DON stated, unless the resident has MD orders to keep medications in the room, they should not be left at the bedside. When asked who was responsible, the DON stated typically the nurses do not leave medications in the room. The DON stated the risk could be if another resident picks up the medication, ingests it they may have a reaction. The DON stated there were residents who wander in the building. The DON stated a resident could overuse their medication and not follow the MD orders if it was left in their room. The DON stated going forward she would conduct in-services for the nurses to understand medications should not be left at the bedside without first obtaining a doctor order, assessing, and educating the resident. The DON stated if a resident has orders to self-administer medications, the medication should be stored appropriately. Record review of the facility policy for Storage of Medications, revised on April 2007, revealed in part: The facility shall store all drugs and biologicals in a safe, secure and orderly manner 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .7. Compartments .containing drugs and biologicals shall be locked when not in use .

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #18) reviewed for comprehensive assessments. The facility failed to ensure that Resident #18's care plan documented interventions for the resident's diagnoses of acute respiratory failure with hypoxia, chronic obstructive respiratory disease, and sleep apnea to include continuous oxygen therapy and the use of BiPAP (bilevel positive airway pressure, a form of noninvasive ventilation) at bedtime. This deficient practice could place residents at risk of not receiving proper care and services. Findings included: Record review of Resident #18's undated admission face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She was initially admitted on [DATE]. Resident #18's diagnoses included: acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), pneumonia, and morbid obesity. Record review of Resident #18's history and physical dated 3/10/25 revealed diagnoses to include obstructive sleep apnea (OSA). Record review of Resident #18's hospital Discharge summary dated [DATE] revealed a past medical history of chronic obstructive pulmonary disease (COPD): a lung condition caused by damage to the airway. Record review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18's Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 13 out of 15 which indicated intact cognition. Further review revealed she received respiratory treatments: oxygen and non-invasive mechanical ventilator. Record review of Resident #18's active physician's orders as of 06/05/25 revealed the following orders: an order for vent settings for the non-invasive ventilator (NIV) with oxygen at 2 liters/min every evening at bedtime for COPD and keep on. Remove at 8:00 AM start date was 04/03/25. An order for Oxygen at 2L/min continuous per nasal cannula, every shift r/t acute respiratory failure with hypoxia, start date 6/04/25. An order for Albuterol inhalation solution, 3ml inhale orally every 6 hours for SOB, start date 04/01/25. An order for Flovent inhalation, 1 puff inhale orally as needed for SOB, rinse mouth and spit out after use, start date 05/04/25. Record review of Resident #18's MAR for May 2025 revealed the resident had been receiving oxygen at 2L/m continuous per nasal cannula every shift, order date was 03/31/25. The resident had been receiving the NIV physician's order every night, order date was 03/31/25. Record review of Resident #18's undated care plan revealed: Focus - At risk for falls r/t Respiratory Failure, anemia, depression, CAD, HTN, CHF, pain, date initiated and created was 03/10/25. Interventions - call light in reach; ensure appropriate footwear; maintain a clear pathway. Focus - has acute/chronic pain r/t Respiratory failure, A-Fib, CHF, CAD, GERD, Cellulitis (a bacterial skin infection), date initiated and created was 03/10/25. Interventions included - administer analgesic medications as per orders. Monitor/record/report to nurse any s/sx of non-verbal pain: changes in breathing. Further review revealed the resident's diagnoses of COPD and sleep apnea were not addressed. Interventions for use of oxygen therapy and the need for the BiPAP were not addressed. Observation and interview on 06/03/25 at 11:00 AM, revealed Resident #18 had humidified oxygen on at 2L/min via nasal cannula. Resident #18 stated she used the BiPAP machine for 7 hours each night, like she would do when she was at home and that she used it because her coughing had been an issue. In an interview on 06/06/25 at 10:27 AM, LVN-G stated she was responsible for care plans for all LTC and skilled care residents since the second MDS nurse recently left the facility 2 months ago. LVN-G stated the purpose of the care plan was to have knowledge on how to care for each individual resident. LVN-G stated the IDT put all their input about the resident's care together and then she would apply the information into the care plan properly. LVN-G stated she oversaw the development of the care plan and would be the only one who would make updates. LVN-G stated Resident #18's respiratory diagnoses, obstructive sleep apnea (OSA), use of oxygen and use of the NIV ventilator should be in the care plan because it was part of continuity of care for the resident. LVN-G stated she did not know about it until she saw the orders for respiratory therapy on 6/4/25, and that it did fall through the cracks. LVN-G stated Resident #18's care plan should have been updated upon admission and she did not know she needed to audit her former partner's work. LVN-G stated she planned to audit every resident so nothing like this happened to other residents. LVN-G stated if it was not in the care plan that meant the team was not reviewing it during IDT meetings but the information was in the TARS so there would not be any harm to the resident as her respiratory status was being monitored. When asked who used or looked at the care plan, LVN-G stated she would hope the whole nursing department and the family would. LVN-G stated for new residents she put everything about the resident and their needs into the care plan and would not wait to put it into the MDS so nurses could know how to care for the residents properly and safely. In an interview on 06/06/25 at 11:05 AM, the DON stated the care plan allows the IDT to know how to meet the needs of the resident. The DON stated the first care plan is initiated by the DON or ADON and the MDS nurse will update from there. The DON stated the respiratory needs of Resident #18 should be in the care plan because it is part of her care and informs the IDT and staff of what they need to do for the resident. The DON stated if not in the care plan, it should not affect the resident because there were other ways to identify the care that Resident #18 needed. Record review of the facility's policy and procedure for Comprehensive Person-Centered Care Planning, revised on August 2017, read in part: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment 2. The baseline care plan will include minimum healthcare information necessary to properly care for a resident .

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. The facility failed to ensure foods were sealed properly in the pantry and freezer. The failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation 06/03/2025 8:29 AM of the kitchen for initial observation revealed the following: 8:30 AM the dry storage area contained: 1 plastic bag of dry spiral noodles not sealed , exposed to air. 8:34 AM the freezer contained: 1 cardboard box of frozen hamburger patties not sealed , exposed to air. 1 cardboard box of frozen breakfast patties not sealed , exposed to air. 1 cardboard box of frozen biscuits not sealed , exposed to air. IInterview with Dietary Manager on 6/3/25 8:40 AM, she stated all food should be closed when stored in the dry food area, or the refrigerator or freezer to maintain freshness, prevent frostbite and contamination. The Dietary Manager stated the residents could get food poisoning or sick if the food was contaminated and the food would not taste good if it was frostbitten. The Dietary Manager stated it was the kitchen staff responsibility to seal and label food items and she did not know who failed to seal and label to the food items. Record Review of the policy on Refrigerators and Freezers copyright 2001 MED-PASS, Inc. (revised December 2014) revealed: Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan or the residents' goals and preference for 2 of 2 residents (Resident #18 and #2) reviewed for respiratory care. -The facility failed to maintain oxygen therapy equipment in a clean and sanitary manner. Resident #18's and Resident #2's mask used with the BiPAP (bilevel positive airway pressure, a form of noninvasive ventilation) was open to air and not stored in a plastic bag. This failure could place residents at risk of infection or a decline in health. Findings included: 1. Record review of Resident #18's undated admission face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She was initially admitted on [DATE]. Resident #18's diagnoses included: acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), pneumonia, heart failure, cellulitis of the right lower limb (a bacterial skin infection) and morbid obesity. Record review of Resident #18's history and physical dated 3/10/25 revealed diagnoses to include obstructive sleep apnea. Record review of Resident #18's hospital Discharge summary dated [DATE] revealed a past medical history of chronic obstructive pulmonary disease (COPD): a lung condition caused by damage to the airway. Record review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18's Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 13 out of 15 which indicated intact cognition. Further review revealed she received respiratory treatments: oxygen and non-invasive mechanical ventilator. Record review of Resident #18's active physician's orders as of 06/05/25 revealed an order for vent settings for the non-invasive ventilator (NIV) with oxygen at 2 liters/min every evening at bedtime for COPD and keep on. Remove at 8:00 AM and start date was 04/03/25. Record review of Resident #18's June 2025 MAR/TAR, revealed on 6/4/25 at 8:00 AM revealed LVN-E removed the NIV mask from Resident #18. Record review of Resident #18's undated care plan revealed oxygen therapy and the need for the BiPAP was not addressed. 2. Record review of Resident #2's undated admission face sheet revealed an [AGE] year-old admitted to the facility on [DATE]. Her diagnoses included hemiplegia (one sided paralysis) and hemiparesis (paralysis to one side of body) following a stroke; diabetes; morbid obesity and obstructive sleep apnea. Record review of Resident #2's admission MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. Further review revealed she received respiratory treatments: oxygen and non-invasive mechanical ventilator. Record review of Resident #2's active physician's orders as of 06/05/25 revealed vent settings for the non-invasive positive pressure ventilator with oxygen at 2 liters/min every day at bedtime for NIV (non-invasive ventilation) off at 8:00AM, start date was 06/04/25. Record review of Resident #2's undated care plan revealed: Focus - Resident #2 received oxygen therapy r/t ineffective gas exchange, OSA, asthma; often refuses her BiPAP at night despite health teaching. Date created on 3/27/25 and revised on 5/07/25. Goal - Will have no s/sx of poor oxygen absorption through the review date. Interventions included - assist with applying the NIV at nighttime per MD orders. Oxygen settings via nasal prongs at 2L/m continuously. In an observation on 06/04/25 at 10:22 AM, revealed Resident #18's mask for the BiPAP NIV was not stored in a bag. The mask was on top of the nightstand and the plastic bag was under the mask. In an interview on 06/04/25 at 10:50 AM, MA-R stated Resident #18's mask for the BiPAP should be in a plastic bag when not in use to keep dirt and dust off and keep from cross-contamination. MA-R stated she did not know why it was not stored properly and who would have left it out. In an interview on 6/4/25 at 1:35 PM, LVN-D was not assigned to Resident #18 and stated the BiPAP mask should be stored in a plastic bag when not in use d/t contaminants could get in the mask leading to resident inhaling contaminants and potential infection. LVN-D states she did not know why it was not in a plastic bag. In an interview on 6/04/25 at 1:45 PM, LVN-E stated she was assigned to Resident #18 and stated the BiPAP mask should be stored in a bag when not in use d/t infection control and a wandering resident could pick it up and put it on their face and mouth. LVN-E stated, the facility did have residents who wander. LVN-E stated she did not know why the mask was not stored properly. In an observation and interview on 6/5/25 at 10:35 AM, revealed Resident #2 was resting on the bed and alert. Resident #2 was not in distress her respirations were even, her skin color was normal and nothing abnormal was observed. The mask for the NIV was draped over the ventilator which was on top of the nightstand. The mask was not stored in a bag. The empty plastic bag was on the wall hook next to the ventilator. Resident #2 did not answer when asked if she knew why she used the NIV. In an interview on 6/5/25 at 11:37 AM, the DON stated she expected BiPAP masks to be inside a plastic bag when not in use for infection control purposes. The DON stated when left out open to air, dust and other contaminants could get on it and could enhance allergies or cause shortness of breath. The DON stated Resident #18 uses the BiPAP because she has COPD and was not sure but maybe Resident #18 may have been the one to remove the mask and place it on the nightstand. The DON stated she visited the resident almost every morning when doing rounds and had seen the mask stored properly. The DON stated she did not know why the mask for Resident #2 was not stored properly. In an interview on 6/6/25 at 7:59 AM, Resident #18 stated she had seen on many occasions that staff would place the mask into a plastic bag after it was taken off her. Record review of the facility's ongoing in-service training report dated 2/13/25 for Infection Control; Oxygen Supplies, conducted by the DON indicated the topic included: every nurse must ensure masks/nasal cannulas must be kept in bags when not in use. Further review revealed that LVN-D signed the in-service and LVN-E's signature was not on the training report. Record review of the facility's policy and procedure for Infection Control, revised on October 2022, revealed in part: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals Goals .decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care .Ensure compliance with state and federal regulations related to infection control . Record review of the facility policy and procedure for Oxygen Equipment, Licensed Nurse Procedures revised on May 2007, revealed in part: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner .Procedures .E. When mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly .

Based on interviews and record reviews, 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 one (Resident #84) of four residents reviewed for pharmacy services. The facility failed to ensure all of Resident #62's medications were administered as ordered by the physician resulting the incorrect medication of Multivitamin. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions. Findings included: Record review of Resident #62's face sheet dated 06/05/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #62's diagnoses included Osteoporosis (a condition that weakens bones and increases the risk of fractures), difficulty in walking, muscle weakness, diabetes, hypertension, and dementia. Record review of Resident #62's quarterly MDS dated [DATE] indicated she had short term and long-term memory problems. She had severely impaired cognitive skills for daily decision making. Record review of Resident #62's active orders as of 07/24/24 included a physician's order for Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) give 1 tablet via mouth daily. Date started was 07/24/24. Record review of Resident #62's undated care plan included: Focus - Resident #62 was at risk for a nutritional deficit related to diagnosis of anorexia, and diabetes. Interventions - Monitor/record/report to MD PRN signs and symptoms of malnutrition. In an observation on 06/04/25 at 7:55 AM, revealed MA-Q prepared medications for Resident #62. MA-Q sanitized her hands and placed the following medications into a medication cups: Multivitamin, one tablet; Loratadine 10 mg one tablet; Famotidine 10 mg 2 tablets; and Amlodipine 5 mg 2 tablets. ; MA-Q washed her hands at the sink, put on clean gloves and administered the medications to Resident #62. Record review of Resident #62's May 2025 MAR/TAR revealed MA-Q documented administration of a Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals), 1 tablet on 06/04/25 in the morning. In an interview on 06/05/2025 at 12:45 PM with MA-Q, requested that she show me the medication she had given to Resident #62 on 06/04/2025. , MA-Q showed the surveyor both bottles and pointed to the multivitamin with minerals. MA-Q stated she gave the multivitamin with minerals yesterday not the multivitamin. MA-Q stated I am positive I did give the correct medication. In an interview on 06/05/2025 at 12:45 PM with MA-R she stated, giving the right medicine to the resident wasis important because giving the wrong medication could cause a bad reaction or the resident may not receive the beneficial effect of the correct medication. She stated the five rights appropriately. MA-R stated there was a difference between a multivitamin and a multivitamin with minerals because a multivitamin with minerals hads minerals. She stated a recent in-service was this morning regarding medication administration. In an interview on 06/05/2025 at 2:25 PM with LVN S, she stated it is important resident gets correct medication because resident could potentially have side effects and adverse reactions, the wrong medicine could cause more serious illness. LVN S stated the correct medication will ease the symptoms, cure and be beneficial with the disease process. LVN S was able to verbalize the five rights for medication administration. LVN S stated there is a difference between a multivitamin and a multivitamin with minerals, and the minerals in the multivitamin with minerals will assist with nutrition and healing. LVN S stated a recent in-service was this morning regarding medication administration. In an interview on 06/05/2025 at 2:30 PM with the Director of Nursing (DON), she stated the correct medication is very important so it can have a positive effect on the resident. The DON stated if the resident receives the wrong medication, it could have an adverse effect. The DON stated the difference between a multivitamin and a multivitamin with minerals was, the multivitamin with minerals is given to supplement resident for wound healing and nutrition. The DON stated in-services are given daily regarding medication administration. The DON stated she, the Assistant Director of Nurses (ADON) or pharmacist are responsible to ensure med aides and nurses administer medication correctly. Record review of facility's Policy for Administering Medications through an Enteral Tube Level III Preparation revealed Purpose: The purpose of this procedure is to provide guidelines for the safe administration. Preparation 1. Verify that there is a physician's medication order. 2. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: Follow the medication administration guidelines. Steps in the procedure: 6. Check the label and confirm the medication name and dose with the EMAR (electronic medical administration record). 7. Check the expiration date on the medication. Properly dispose of expired medications. 8. Prepare the correct dose of medication.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #18 ) reviewed for infection control practices. -The facility failed to ensure CNA-A and CNA-B followed proper infection control and hand hygiene practices during incontinent care for Resident #18. CNA-A failed to change both gloves and perform hand hygiene after cleaning the resident and prior to touching clean items. CNA-A and CNA-B failed to perform hand hygiene prior to leaving Resident #18's room after incontinent care. This failureThis failure could place residents at risk of infection or a decline in health. Findings included: 1. Record review of Resident #18's undated admission face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. She was initially admitted on [DATE]. Resident #18's diagnoses included: acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), pneumonia, heart failure, cellulitis of the right lower limb (a bacterial skin infection) and morbid obesity. Record review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18's Brief Interview for Mental Status (BIMS) (a score used to assess cognitive function) was 13 out of 15 which indicated intact cognition. Resident #18 was always incontinent of urine and frequently incontinent of bowel. Resident #18 was dependent on staff assistance for toileting hygiene and required substantial assistance with showers or bathing self. Record review of Resident #18's undated care plan revealed: Focus - ADL (basic self-care tasks) self-care performance deficit r/t anemia, depression, atrial fibrillation (irregular heartbeat), coronary artery disease (a type of heart disease affecting the major blood vessels to the heart), hypertension (elevated blood pressures), congestive heart failure (a condition where the heart is unable to pump enough blood to meet the body's needs), cellulitis. Date initiated and created was 03/10/2025. Goal - will maintain the highest level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Interventions included - encourage to participate to the fullest extent possible with each interaction; resident will receive the required assistance with transferring. Date initiated and created was 03/10/25. Observation on 06/04/25 at 10:00 AM, during incontinent care, revealed Resident #18 was alert and oriented, lying in bed with the head of bed raised. CNA-A and CNA-B washed their hands at the sink, put on clean gowns and clean gloves. CNA-A and CNA-B lowered the head of the bed and adjusted the bedding. CNA-B assisted by unfastening Resident #18's adult brief. CNA-A used cleansing wipes to clean inside the groin area and vaginal area. CNA-A used one clean wipe per each stroke. CNA-A, using both gloved hands, lifted Resident #18's left leg over the right leg to aid in turning the resident to her right side. CNA-B assisted with turning. CNA-A used one clean wipe per stroke to cleans the peri-anal area from front to back and to cleanse the buttocks. The brief had urine and CNA-A rolled it up and disposed it into the trash bag. CNA-A did not remove used gloves, perform hand hygiene or put on clean gloves. CNA-A then touched the clean brief and positioned it under the resident. CNA-A placed barrier cream onto her right gloved hand and applied cream to Resident #18's peri-anal area and buttocks. Resident #18 turned onto her back and CNA-A applied barrier cream using her right gloved hand to Resident #18's groin area. CNA-A removed the glove on the right hand, disposed it into the trash, did not remove the glove on the left hand and did not perform hand hygiene. CNA-A then put on a clean glove to the right hand only. CNA-A fastened Resident #18's brief with assistance from CNA-B. CNA-A and CNA-B touched the bedding and covered the resident. CNA-A and CNA-B removed their gloves and gown, placed them into the trash bag and secured the trash bag. CNA-A placed the trash bag into the bin in the hallway just outside Resident #18's doorway. CNA-A and CNA-B did not perform hand hygiene prior to leaving Resident #18's room. CNA-A walked to the nearest hand sanitizer dispenser in the hallway and performed hand hygiene and then walked into another resident's room across the hall, where two nurses were assisting a resident back into bed. CNA-B walked down the hallway and out of sight, no hand hygiene was observed while in the immediate area. In an interview on 6/4/25 at 1:00 PM, CNA-A stated after the dirty steps are completed during incontinent care, she would put all the soiled and dirty items into a bag, then put the clean brief on the resident, she would then put the trash bag into the dirty barrel outside the door. CNA-A stated that she did change the glove on the right hand prior to continuing with the clean procedure and used her left gloved hand because it was still clean. CNA-A stated she could touch the clean brief and bed linen at this point. CNA-A then walked away to attend to a resident. In an interview on 6/4/25 at 1:05 PM, CNA-C was not assigned to Resident #18. CNA-C stated when she performs incontinent care, she would change gloves each time they are soiled or used and would perform hand sanitization with each glove change. CNA-C stated it was important for infection control and would not use dirty/used gloves to touch clean briefs. CNA-C stated she would wash hands before stepping out of the room because it was facility policy. CNA-C stated used gloves were dirty and even if soilage is not visible there could be bowel movement on the gloves and it could transfer to clean items. CNA-C stated it was important to keep things clean and hygienic. CNA-C stated the risk would be to other residents if the resident she was just caring for had C-diff in the stool, then it could be transferred to others, infecting them. In an interview on 6/4/25 at 2:00 PM, CNA-B stated she put on gown and gloves when doing incontinent care for Resident #18 because the resident was in EBP d/t sores on the legs. CNA-B stated dirty gloves are still dirty even though they were not visibly dirty. CNA-B stated the risk was cross contamination, if she had dirty gloves and touched the remote control/bed control for example the resident could get an infection if they touch the controls, put their hands in their mouth and they could get sick. When ask why she did not perform hand hygiene prior to leaving Resident #18's room when she was assisting with incontinent care, she stated she was in a rush to get to her next resident and stated she went straight to the sink and washed her hands. In an interview on 6/5/25 at 11:37 AM, the DON stated during incontinent care she expected that the CNAs did not break infection control process, work the dirty area, remove dirty gloves, perform hand hygiene, and put on clean gloves. The DON stated the purpose was to prevent spread of infection and they should not touch clean items with dirty gloves. The DON stated she expected staff to hand sanitize/hand wash prior to leaving a resident room. The DON stated with the use of barrier cream she would expect the staff to remove gloves, hand sanitize, put on clean gloves, and then apply the cream to the resident's skin. The DON stated there was no excuse for CNAs not to follow protocol, as they know better and have had in-service on infection control. Record review of the facility's In-Service Training Report dated 4/16/25, for Incontinent/Perineal Care, conducted by the Staffing Coordinator and IP nurse, indicated CNA-A and CNA-B signed the training report. Record review of the facility's policy and procedure for Hand Hygiene, revised in October 2022 revealed in part: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection .All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors Procedure: 2. Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations: .b. Before and after direct contact with residents .h. Before moving from a contaminated body site to a clean body site during resident care .m. after removing gloves .r. After removing and disposing of personal protective equipment Record review of the facility policy and procedure for Perineal Care, revised on May 2007, revealed in part: It is the policy of this facility to: 1. Cleanse perineum .3. Prevent irritation or infection .Procedures: .5. Wash hands properly .6. Use gloves properly Record review of the facility's policy and procedure for Infection Control, revised on October 2022, revealed in part: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals Goals .decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care .Ensure compliance with state and federal regulations related to infection control .

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 11 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's required use of hearing aids as an assistive device for her hearing impairment were documented in her care plan/Kardex. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and not having continuity of care. Findings included: Review of Resident #1's face sheet dated 02/25/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included unspecified macular degeneration (vision impairment resulting in deterioration of the central part of the retina, a thin layer at the back of the eye on the inner side), cognitive communication deficit (communication difficulty caused by cognitive impairment), muscle weakness, and bradycardia (slower than typical heartbeat). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08 indicating moderate cognitive impairment. Hearing, Speech, and Vision reflected, hearing aid or other hearing appliance used was marked yes. Ability to understand others understanding verbal content however able (with hearing aid or device if used) was marked, usually understands- misses some part/intent of message but comprehends most conversation. Review of Resident #1's care plan last revised 02/12/25 reflected a focus for Resident #1 is at risk for communication deficit related to confusion with interventions that included anticipate and meet needs, monitor/document/report to MD any changes in ability to communicate, potential contributing factors to communication problems, potential for improvement, and monitor/record confounding problems: decline in cognitive status .hearing impairment (ear discharge and cerumen (wax) accumulation. The care plan did not contain a focus on Resident #1's hearing deficit and use of hearing aids with interventions. Review of Resident #1's Kardex dated 02/28/25 reflected no assistive devices indicated, no audio/vision focus. Review of Resident #1's nursing progress notes reflected a nursing note dated 07/06/24 Resident family called from home and reported that Resident #1 lost her left side hearing aid and if we cannot find it, she will come on Monday and report to the ADM and make our facility pay for it, left messages with DON related to this. Review of Resident #1's nursing progress noted reflected social services note dated 09/19/24 SW handed off replacement hearing aids to Resident #1's family, who will take them to have them adjusted for Resident #1. SW opened box and showed Resident #1's family the hearing aids, charger, and cord. Resident #1's family confirmed that all was accounted for and took all equipment. Review of facility grievances reflected a grievance dated 08/01/24 for Resident #1 resident's family reported a concern regarding missing hearing aid with documented resolution facility to cover cost of hearing aid replacement. In an interview on 02/25/25 at 02:14 PM with Resident #1's family, she stated that she believed the facility was not assisting Resident #1 with her hearing aids. She stated that there were times the resident would not have them on, and at one point they were lost. She stated at the time the facility took responsibility for it and assisted with getting them replaced, however the resident went without a full set for months. In an interview on 02/27/25 at 11:01 AM with CNA A, she stated that CNAs would assist residents with hearing aids. She stated she would rely on the care plan or Kardex to determine if the resident required a hearing aid, especially if it was a resident she did not normally work with. CNA A stated that care staff were responsible for putting on a resident's hearing aids in the morning and taking them off at night to charge them so they were ready for the next day. CNA A stated that if hearing aids, were not care planned staff who didn't work with the resident regularly would not know to look for them. She stated it could also result in the resident not being able to hear, would be confused, and would just look at you and not know what you are saying. In an interview on 02/27/25 at 11:22 AM with CNA B, she stated she would look on the Kardex to determine if a resident required an assistive device such as a hearing aid. She stated the CNAs kept up with hearing aids regularly if they knew the resident required them. She stated if a resident was not provided her hearing aids you cannot communicate with them, they will be confused and can take things the wrong way. CNA B stated that if you didn't pay attention to assistive devices required it could cause emotional harm or be neglectful. In an interview on 02/28/25 at 09:38 AM with the SW, she stated that a staff member lost Resident #1's hearing aid which was why the facility reimbursed Resident #1 by getting her a new set. The SW stated that she did not recall the name of the staff member because it was too long ago. The SW stated that if resident's needs with assistive devices were not being met it would have a negative impact on them as they would not be able to hear. In an interview on 02/28/25 at 10:11 AM with CMA C, she stated if there was anything she needed to know, about a resident's assistive devices or if they required, any she would check the Kardex/care plan. CMA C stated she recalled a while back that Resident #1 lost her hearing aids and said that any issues with hearing aids were to be reported to the nurse. She stated if there were no assistive devices documented in the resident's care plan or Kardex, it could result in the resident not getting assistance with her devices or the devices being lost by not being monitored. In an interview and observation on 02/28/25 at 10:53 AM with the DON, she stated that it was her expectation that assistive devices such as hearing aids were documented in the resident's care plan which would then trigger onto the Kardex. She stated the care plan should give care staff the direction of care a resident required. The DON stated that if staff do not observe assistive devices documented or any other issues, it should be reported to a charge nurse. She stated she did not believe there would be any negative outcomes because any issues should be reported, and she believed the charge nurse could take care of any problems through communication. The DON was observed at this time reviewing Resident #1's care plan and verbally confirmed the hearing aids were not documented and should be. In an interview on 02/28/25 at 11:37 AM with the ADM, he stated he thinks that assistive devices are supposed to be care planned as part of the resident assessment. The ADM stated it was his expectation that care plans were accurate and timely and help the resident. The ADM stated if the care plan did not indicate a residents required assistive devices it increased the likelihood that care could be missed and that it was just one more chance to miss getting a resident their hearing aids. Review of the facility Care of Hearing Aid policy last revised 10/2010 reflected: The purpose of caring for a hearing aid is to maintain the residents hearing at the highest attainable level. Review the resident's care plan to assess for any special needs of the resident. Review of the facility Comprehensive Person-Centered Care Planning policy last revised 12/2023 reflected: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. - The facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan. - The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation , interview and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 5 residents reviewed for care plans. 1.The facility failed to develop and implement a Care Plan for Resident #1's fall out of bed on 12/13/2023 and as a result, Resident #1 suffered a second fall out of bed on 4/1/2024. Resident #1 was hospitalized with a fractured hip from 12/13/2023 to 12/28/2023. Resident #1 was hospitalized from 4/1/2024 to 4/11/2024 due to second fall on 4/1/2024. An IJ was identified on 4/18/2024. The IJ template was provided to the facility on [DATE] at 5:23pm. The immediate jeopardy was determined to have been removed on 4/20/2024 due to the facilities implemented actions that corrected the non-compliance. This failure could place residents at risk for not receiving care required to meet their individualized needs and place them at risk for harm. Findings: Record review of Resident #1's Face Sheet dated 4/18/2024 revealed a [AGE] year old female who was admitted on [DATE] with diagnoses of encounter for closed fracture with routine healing (Hip fracture), Type 2 Diabetes Mellitus (High blood sugar) with Unspecified Complications(Insulin), Unspecified Fall, Subsequent Encounter (Receiving routine care), Muscle Wasting and Atrophy (Weakened Muscled), Unspecified Site, Muscle Weakness, Pain, Unspecified, Encounter for Other Orthopedic Aftercare (Care and treatment with a bone specialist), Acquired Absence of Right Leg Below the Knee (Amputation), Paranoid Personality Disorder (Distrust and suspicion), Vascular Dementia (Brain damage caused by strokes), Unspecified Severity, With Agitation, Schizoaffective Disorder (Mood disorder), Bipolar Type. Record Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating the resident was cognitively intact. Section E revealed, no potential indicators of psychosis (Hallucinations) . Section GG revealed Resident #1 was dependent on toileting hygiene, showering/bathing, and lower body dressing. Section GG also revealed Resident #1 was, Substantial/maximal assistance with roll to the left and right. Section H revealed resident was, always incontinent of urine and bowel. Section I revealed Resident #1 had, Medically Complex Conditions, Hip Fracture, Cerebrovascular Accident (Stroke), and Non-Alzheimer's Dementia (Memory loss). Record Review of Resident #1's Care Plan dated 8/6/2023 read in part . Will safely perform her ADLs through the review date .date initiated 8/6/2023 .Bed Mobility: Requires staff participation to reposition and turn in bed date initiated 8/10/2023. Resident #1 at risk for falls related to right below the knee amputation, incontinence, limited mobility, confusion, late effects of CVA (Stroke) date initiated 8/6/2023 .Revision 12/14/2023 .Will not sustain serious injury through the review date .date initiated 8/6/2023 bed in lowest position .date initiated 8/6/2023. Record Review of Resident #1's orders dated 4/18/2024 revealed there were no orders for fall preventions or interventions for fall prevention Record Review of Resident #1's Change in Condition dated 12/13/2023 at 3:19pm read in part .situation Falls .Back, injuries, complaints abrupt onset of severe pain secondary to fall or injury or pain with new abnormal neurological signs .site .left trochanter hip (Bony prominence) laboratory tests/diagnostic procedures x-ray .Resident #1 states she fell with CNA during bed bath. Record Review of Resident #1's X-Ray dated 12/13/2023 Read in part, Impression .A fracture of the left femur (Hip) neck. The age of the fractur is indeterminate. Record review of Nursing note dated 12/14/2023 9:13am read in part .Resident #1 to be sent out to ER (emergency room ). Record Review of Resident #1's hospital notes dated 2/14/2024 read in part . female with a past medical history of CVA(Cerebrovascular disease) .claims the CNA was with her while cleaning her and she did not have a good grip of the rail before moving and she rolled out of bed and fell impacting her left leg and complained of severe left leg pain 1. Acute left femoral fracture consult orthopedics .Cardiology has cleared the patient for surgery with moderate risk patient is status post segmental resection arthroplasty of left femoral neck Consult social services for possible APS (Adult Protective Services) evaluation since patient claims that the CNA was impatient with her during her bed sponge which was responsible for her fall the patient was oriented to place person and time during history taking. Record Review of Hospital #3 Physical Therapy initial evaluation and discharge read in part .non weight bearing left lower extremity .Hoyer lift to chair .Resident #11 with chronic decreased motor control overall .coordination impaired right and left .BED MOBILITY: Rolling: Total Assistance (<25%), Needs 2. Record Review of hospital discharge summary dated 1/1/2024 revealed in part .Discharge diagnoses: Closed fracture of left hip .Procedure: Left Hip [NAME] Resection (Remove head and neck of thigh bone) CT Pelvis(Cat Scan)s .Impression: Complex left proximal femoral age indeterminate sub capital fracture and acute appearing distal neck fracture(Fractured hip). Record Review of Change of Condition notes dated 4/1/2024 3:30pm read in part . condition change: Falls (Resident #1 fell ). Record review of Nursing notes dated 4/1/2024 at 4:11pm read in part . aide in room giving Resident #1 bed bath. Pt leg slide off bed and patient rolled and fell on to the floor. Resident #1 hit left side of head and complaint of pain to her head and ribs did not specify which side .transportation called, and hospital notified. Record review of Resident #1's H &P (History and Physical) dated 4/2/2024 read in part .Chief Complaint: Fall at the nursing home followed by chest pain. Record Review of hospital record dated 4/3/2024 7:58am read in part . wanted to find another facility for Resident #1. SW left voice message and text messages requesting for return call back 4/11/2024 Resident #1' had confusion and found to have MDR Klebsiella (Bacteria in urine) .Infectious Disease consulted, and Resident #1 has completed course of intravenous Meropenem (Antibiotic) in house . wanted to transition to a different long term care facility but unable to. Will return to facility. Record review of Resident #1's hospital records dated 4/1/2024 to 4/11/2024 revealed Resident #1 had no substantial injuries after her second fall. Length of hospital stay was due to a urinary tract infection and family trying to find another facility for resident to go to once discharged . Interview on 4/17/204 at 1:00pm the DON said the first time Resident #1 fell off the bed they ordered an x-ray and once they had the results, they sent her to the hospital. She said the CNA D had her turned on her side and with the below the knee amputation, she fell off the bed. She said the in-service was only with the CNA D. She said the second time Resident #1 fell off the bed it was with CNA C, she was giving her a bed bath and had her on her side. She said while she was bathing Resident #1, CNA C she stepped away to get a fresh basin of water and when she was in the restroom getting the water Resident #1 cried out and said she was slipping and fell off the bed. She said CNA C had already started the bed bath. She said they only in-serviced the CNAs individually as they were isolated incidents. Interview on 4/17/24 at 1:03pm CNA C said she had worked at facility since July 2023, she said she had washed Resident #1's front side and had asked her to roll over on her side. She said she noticed the water was dirty, so she was going to walk in the bathroom and change the water out, she said Resident #1 was holding on the rail with her good hand and she was on her side. She said Resident #1 had said she was slipping when she was changing the water out of the basin and when she came back from the bathroom she was already on the floor. She said Resident #1 did not tell me she was going to fall, or I would not have left her. She said Resident #1 was not feeling good that day and wanted a bed bath instead of a shower. She said afterward the ADON called her in the office and instructed her on the correct procedures in a bed bath and not to leave Resident #1 by herself anymore. She said the ADON made her sign a sheet and in-service sheet. She said as far as a bed bath, they discussed with management they don't give Resident #1 bed baths by themselves anymore. She said Resident #1's bed baths should have been with two people. She said anytime she did anything with her from then on, she did it with two people. She said management told them to use two people now. When asked if she knew if Resident #1 had a history of falls with bed baths, she said yes, she did but she said Resident #1 did not feel good and wanted a bed bath. She said she was going to do a shower and had everything set up for that. She said she had been in-serviced prior to that maybe 2 or 3 months ago. She said everybody was in-service with the first fall but with the second fall she was in-service by herself. She said with the first in-service it was a general how to give a resident a bed bath. She said there was no discussion to make Resident #1 a 2-person assist after the first fall; it was only after the second fall. When asked why it was important to have everybody on the same page, she said it was for safety reasons to prevent the falls from happening. She said if it had been made clear before the bed bath Resident #1 was a 2-person assist, it would have been preventable. Interview on 4/17/2024 at 1:58pm the DON said the care plan should have been updated timely after Resident #1's second fall. Interview on 4/17/2024 at 2:24pm CNA D said when Resident #1 fell off the bed on 12/13/2023 she was giving her a bed bath. She said she only determined the level of assistance needed when she was performing a task on her own and realized she could not do it safely without help. She said she would then have called for help from time to time. She said there was nothing on a Kardex or care plan that she could refer to find out how much assistance she needed to care for a resident, she said a nurse would let them know if a resident needed assistance with feeding. Interview on 4/17/2024 at 2:16pm Resident #1 said the first time she fell she was oily, and the bed was oily. She said she was turned close to the edge of the bed, and she lost her balance and fell out of the bed. She said she could not hold her grip on the bed rails because she was weak. She said she got pushed too close to the edge of the bed, she could not hold her grip and she fell off the bed. She said she did not want the CNAs again because they caused her to fall off the bed. She said she should have had 2 CNAs help her not one. She said when she fell the first time, she broke her hip and they had to repair it at the hospital. She said the second time she fell out of the bed a different CNA was giving her a bed bath. She said the CNA left and went to throw out the bath water and she left her turned on her side. She said she should have never been left on her side like that. She said she could not reposition herself. She said when she fell the second time she landed on her hip. She said she needed a bigger bed mattress as she was too big for the bed and when they turned her, she was at the edge of the bed. She said she had to go to the hospital, but her leg still was not healed from the first fall. Interview in 4/18/2024 at 9:08am ADON A said she had worked at the facility for a year and a half. She said she did most of the in-services. She said Resident #1 should have been deemed a 2 person assist after the first fall because it's an intervention. No other interventions were put in place. The staff can access the Kardex (Care Plan for CNA) and it was in their POC (Point of Care) documentation, and they get report, the nurse was supposed to provide the information to them. I'm not sure when it's in the POC if it populates in the Kardex. I believe Resident #1 should be 2 persons assist. She said the Kardex pulls from the Care Plan. The Kardex was the documentation system for the CNAs and the Care plan too. Staff should have known by Kardex and nursing staff how to provide care for the residents. She said the Kardex pulls from the Care Plan. The Kardex was the documentation system for the CNAs and the Care plan too. Interview on 4/19/24 at 10:22am the DON said the interventions from the IDT (Interdisciplinary Team) meeting they had after Resident #1's first fall were not all put into place for the resident and while receiving bed bath resident rolled off the bed a second time. She said Resident #1 was sent to the hospital and once she returned from hospital there were supposed to be interventions for fall mats placed/wider bed/2 person assist with care, education done with CNA and all staff, falling star identifier. She said Resident #1's second fall happened on 4/1/2024 and the resident was gone for a while, there was a delay and so when Resident #1 was readmitted the interventions didn't all get put in place for the resident. The fall mats, the education for the staff, the falling star identifier, the wider bed and the 2 person staff assist with care and updating the care plan were not put in to place. She said they got missed got missed because Resident #1 was delayed returning to the facility after the second fall. She said Resident #1's family had been looking to send her to another facility. Record review of Resident #1's Care plan dated 8/6/2023 revealed no updated interventions in place to prevent falls. Record review of facilities policy titled: Fall Management System, 12/2023 read in part . It is the policy of the facility to provide an environment that remains free of accident hazards as possible. It is also the policy of the facility of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs . 6. The residents care plan will be updated. Record review of facilities policy titled, Care Plans-Comprehensive 2001 read in part .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident Incorporate risk factors associated with identified problems .assessments of residents are ongoing and care plans are revised as information about the resident and the residents condition change .the care planning/interdisciplinary team is responsible for the review and updating of care plans .when there has been a significant change in the residents condition . An IJ was identified on 4/18/2024 and the facility administrator was notified at 5:23pm. The IJ template was provided to the facility on [DATE] at 5:23pm. On 4/20/2024 at 2:16pm the following Plan of Removal was accepted. Facility Plan for Compliance ADHOC meeting sign in sheet in book with Medical Director in attendance. Meeting held on 4/18/2024. Executive Director, DON, Clinical Cluster Leader, Clinical Resources in attendance. Incidents by Resident including Resident #1in IJ Book (Book containing plan of removal for Immediate Jeopardy). Root Cause Analysis for Resident #1 in IJ book. Updated Care Plan for Resident #1 in IJ Book. Interventions in place since arrival : Resident #1 Requires Assistance of 2 staff members to reposition, may use mobility bars to aide in Easy Turning and repositioning, Resident #1 requires assistance of 2 staff members if receiving a bed bath with mobility bars in place, Resident requires assistance of 2 staff by Hoyer lift with transfers, in IJ book. Fall Risk Evaluations in the POR for all residents were completed. Monitoring for Plan of Removal: In an interview on 4/20/2024 at 9:00am DON said all Care Plans were reviewed and updated as necessary for the residents identified in the Fall Risk Assessments. All persons responsible for care plan updates immediately were herself, the ADONs, Social Work and Wound Care. Review of in Service Training for Resident #1 dated 4/18/2024 reflected resident will have a wide bed, fall mats-bilateral, mobility bars, and two staff members for bed baths/ bed mobility. Review of in-service dated 4/18/2024- Topic Falls .Fall Policy .Fall risk assessment .fall risk management/incident report .Care plans updated .falling star (Emblem place by doors of Residents at risk for falls) .document q (Every)shift x72 hours. Record review on 4/20/2024 at 10:00am of Inservice dated 4/18/24- Topic Bed bath hand hygiene .procedure . ensure safety at all times .follow Kardex .bed height .clean up .call light within reach .do not leave resident lying on side of bed. Record review on 4/20/2024 at 10:00am of Inservice dated - 4/18/24-Topic Mobility, Transfers, Safety, Turning/Repositioning .Do not leave resident unattended while performing care. Record review on 4/20/2024 at 10:00am of Inservice dated 4/18/2024- Topic- Kardex- Clinical, POC, Select Resident. Select Kardex. Record review on 4/20/2024 at 10:00am of Inservice dated 4/18/2024- Topic- Bed Mobility-Levels of assist during bed mobility, independent/setup/limited/eaten/total, mobility bars, 1person/2person assist, always refer to Kardex prior to assisting resident. Record review on 4/20/2024 at 10:00am revealed Falls Post Test taken by all Nurses, CNA's and CMA's. Record review on 4/20/2024 at 10:00am of Observations of bathing, complete bed baths of Clients by staff in IJ book. Record review on 4/20/2024 at 10:00am of Observations of Turning and Repositioning of a Client by staff are in the IJ book. Record review on 4/20/2024 at 10:00amof Incidents (Thigs happening) by Residents .Date 4/18/2024 . 1/1/2024 to 4/18/2024 in IJ book. Record review on 4/20/2024 at 10:00am of Fall Risk Evaluation of Residents dated 4-19-2024 in IJ book. Record review on 4/20/2024 at 10:00am of Resident #1's of Care Plan updates in IJ book. Record review on 4/20/2024 at 10:00am of POR for F689 in IJ book. Record review on 4/20/2024 at 10:00am of POR for F656 in IJ Book. Record review on 4/20/2024 at 10:00am of Quality Team Tracking form .Date 4/18/2024 in IJ Book. Interview on 4/19/2024 at 1:20pm with LVN S she said she had worked at the facility for four months, she said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility this morning. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said she would have found whether the resident was a one or two person assist for ADLs on the Care Plan or the Kardex. She said 2 people were required to assist Resident #1 for bed baths and diaper changes. She said incident reports were immediately after patient assessment. She said they accessed the care plan in Point Click Care (PCC). She said she would have checked the care plan prior to providing care to the resident. Interview on 4/19/2024 at 1:24pm with LVN T she said she had worked at the facility since 2/2023, she said she had been in-serviced on care plans last, fall prevention, bed baths and bed mobility this morning. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said to prevent falls not to leave the resident at the side of the bed. She said she would have found find whether the resident was a one or two person assist for ADLs on the Care Plan or the Kardex. She said 2 people were required to assist Resident #1 for bed baths and diaper changes. She said they accessed the care plan in Point Click Care (PCC). She said she would have checked the care plan prior to performing care on the resident. Interview on 4/19/2024 at 1:48pm pm with CNA F, said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/18/2024. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said she would have found whether the resident was a one or two person assist for ADLs on the Kardex or the Care Plan. She said 2 people were required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex and Care Plan in Point of Care (POC) documentation system and she had checked every day. Interview on 4/19/2024 at 1:52pm pm with CNA G, said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/18/2024. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said she would find whether the resident was a one or two person assist for ADLs on the Kardex. She said 2 people are required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care (POC) documentation system. She said she had always checked the Kardex prior to performing care of the resident. Interview on 4/19/2024 at 2:51pm the MDS nurse said other than MDS documentation she was in care plans every day due to change of condition, family request, personal request there was always a reason to be in care plans. She said when a resident fell or was a fall risk she did care planning immediately so the team could have reviewed to see all interventions were there, appropriate and effective. She said the people involved in performing assessments and evaluations for residents after they experienced a fall with minor and major injuries were therapy and they came right away. She said in twenty-four hours they discussed as a team and brainstormed interventions for residents when they fell . She said the team included the MDS nurse the DON, ADON, Social Worker, Administrator, Activities Director and Dietary. She said therapy was notified right away after a resident fell . She said staff were notified as care plans were added to the Kardex, through clinical meetings, 24-hour report sheets and the charge nurse. She said all residents with a high fall risk in the facility had been identified and their care plans had been reviewed and revised. Interview on 4/19/2024 at 3:19pm the DON said care plans were ongoing for residents who had change of condition or a fall and ideally, they would have updated a care plan as needed. She said multiple people were responsible for updating the care plan such as the 2 MDS nurses, 2 ADON's herself and the wound care nurse. She said Resident #1's care plan got missed and she took ownership of that. She said there was a process issue and that was why they put the revision in place, she said for Resident #1, they did train as they saw fit but each time she was hospitalized they were told by the hospital she would not return but it was not an excuse. She said after a residents fall with minor or major injuries therapy would be notified the next morning in the morning meeting. She said the care plan would have been updated quickly after a resident fall. She said direct care staff were notified of care plan updates after a resident fall by herself or the ADON's as they wemt over the change of conditions with the nurses and what they were doing about it. She said all residents at risk for falls and a fall history had been identified utilizing a fall risk assessment tool and their care plans updated. She said staff were supposed to look at care plans or Kardex at least once per shift to see changes. She said the POC was the charting system, the CNAs used, it had boxes and each one had for expample how much food residents ate, mobility, Foley output, etc. She said CNAs were required to document in each box, the Kardex was on the top right corner in POC and the Kardex was essentially the Care plan. She said the information for the Kardex got pulled from the Care Plan to the Kardex. She said CNAs did not document in the Kardex .they documented in the boxes. Interview on 4/19/2024 at 3:30pm ADON B said they did care planning as needed on residents with high falls risk. She said when they fell or near fall. She said they did care planning with change of condition, quarterly care plans and she was not sure how Resident #1's care plan got missed. She said when residents fell and received minor or major injures the persons involved in assessments and evaluations were the interdisciplinary team, therapy, nursing, and the physician. She said care plans were updated right away after residents fall with minor or major injuries. She said direct care staff were notified in morning meeting and 24-hour reports, she said they did assessments on all residents at high risk for falls and talked to staff, she said they had reviewed and revised the care plans. She said they notified staff and management when the care plan was updated, staff checked the care plan with change of condition and usually every shift, she said they found the care plans in point click care. Interview on 4/19/2024 at 3:40pm RN B said she had worked at the facility for four months. She said they did care planning quarterly and with change of conditions. She said the persons involved in performing assessments and evaluations on residents after falls with minor and major injuries were collaborative. She said it would have been the nurse who was there, the supervisor, physical therapy, occupational therapy, and the interdisciplinary team in the morning. She said therapy was in the building so they would be notified of a resident falling as soon as possible. She said care plan would have been revised in twenty-four hours. She said direct care staff should be notified for updates to the plan of care in morning meeting, her and the DON and ADON would notify staff. She said they did an assessment on residents with high fall risk and their care plans had been reviewed and revised. She said nurses should have looked at care plans with change of condition, as needed, if they had not taken care of the resident before and every day. Interview on 4/19/2024 at 3:50pm with CNA H said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/18/2024. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said she would have found whether the resident was a one or two person assist for ADLs on the POC in the Kardex. She said 2 people were required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care (POC) documentation system. She said she had checked the Kardex every day because anything could have changed. She said she knew when things had changed through the Kardex and nursing staff. Interview on 4/19/2024 at 4:00pm with CNA I said she had worked at the facility for two years and been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/18/2024. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said she would have found whether the resident was a one or two person assist for ADLs on the POC in the Kardex. She said 2 people were required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care (POC) documentation system. She said she would check the Kardex daily and care plan interventions were in the Kardex, she said she would know the Kardex was revised in meetings on the residents and from management. Interview on 4/19/2024 at 4:05pm with CNA J said she had worked at the facility since December 2023. and been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/18/2024. She said she would not leave a resident on the side of the bed to perform another task when doing a bed bath. She said she would find whether the resident was a one or two person assist for ADLs on the POC then click on the resident then click on the Kardex. She said 2 people are required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care (POC) documentation system. She said she would check the Kardex daily at the beginning of every shift and care plan interventions were in the Kardex, she said she would know the Kardex was revised because the nurse would tell her. Interview on 4/19/2024 at 4:34pm with CNA K said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/19/2024. She said she would find whether the resident is a one or two person assist for ADLs in the Kardex. She said 2 people are required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care (POC) documentation system. She said she would check the Kardex daily at the beginning of every shift and care plan interventions were in the Kardex, she said she would know the Kardex was revised because the charge nurse would tell her. Interview on 4/20/2024 at 10:23am with CNA L said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/19/2024. She said she would find whether the resident is a one or two person assist for ADLs in the Kardex. She said 2 people are required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care in right corner. She said to keep the resident from falling she would pull the resident toward her to keep the resident from falling. She said she would check the Kardex daily at the beginning of every shift and care plan interventions were in the Kardex, she said she would know the Kardex was revised because the nurse would tell her. Interview on 4/20/2024 at 10:27am with CNA M said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/20/2024. She said she would find whether the resident is a one or two person assist for ADLs in the Kardex. She said 2 people are required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care. She said she would report a fall to charge nurse immediately. She said she would check the Kardex daily at the beginning of every shift and care plan interventions were in the Kardex, she said she would know the Kardex was revised because the nurse would tell her. Interview on 4/20/2024 at 10:34am with MA#A1 said she had been working at the facility for almost a year. She said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility 4/19/2024. She said she would find whether the resident is a one or two person assist for ADLs in the Kardex. She said 2 people are required to assist Resident #1 for bed baths and diaper changes. She said they accessed the Kardex in Point of Care then go to patient then go to Kardex. She said she would report a fall to charge nurse immediately. She said she would check the Kardex daily at the beginning of every shift and care plan interventions were in the Kardex, she said she would know the Kardex was revised because the staff would tell her or the Kardex. An IJ was identified on 4/18/2024. The IJ template was provided to the facility Administrator on 4/18/2024 at 5:23pm. The Immediate Jeopardy was determined to have been removed on 4/20/2024 due to the facilities implemented actions that corrected the non-compliance.

Based on observation, interview and record review the facility failed to provide supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility did not provide adequate supervision for Resident #1 while giving a bed bath on two separate occasions causing her to fall off the bed resulting in prolonged hospital stays. Resident #1 was hospitalized with a fractured hip from 12/13/2023 to 12/28/2023 after she rolled off the side of the bed during a bed bath. Resident #1 was hospitalized from 4/1/2024 to 4/11/2024 after she rolled off the side of the bed during a bed bath. An IJ was identified on 4/18/2024. The IJ template was provided to the facility on [DATE] at 5:23pm. The immediate jeopardy was determined to have been removed on 4/20/2024 due to the facilities implemented actions that corrected the non-compliance. This failure placed residents at risk for accidents and injury. Findings: Record review of Resident #1's Face Sheet dated 4/18/2024 revealed a [AGE] year old female who was admitted on [DATE] with diagnoses of encounter for closed fracture with routine healing (Hip fracture), Type 2 Diabetes Mellitus (High blood sugar) with Unspecified Complications (Insulin), Unspecified Fall, Subsequent Encounter (Receiving routine care), Muscle Wasting and Atrophy (Weak muscles), Unspecified Site, Muscle Weakness, Pain, Unspecified, Encounter for Other Orthopedic Aftercare (Care and treatment with a bone specialist), Acquired Absence of Right Leg Below the Knee (Amputation), Paranoid Personality Disorder (Distrust and suspicion), Vascular Dementia (Brain damage caused by strokes), Unspecified Severity, With Agitation, Schizoaffective Disorder (Mood disorder), Bipolar Type. Record Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating the resident was cognitively intact. Section E revealed no potential indicators of psychosis (Hallucinationa). Section GG revealed Resident #1 was dependent on toileting hygiene, showering/bathing, and lower body dressing. Section GG also revealed Resident #1 was Substantial/maximal assistance with roll to the left and right. Section H revealed resident was always incontinent of urine and bowel. Section I revealed Resident #1 had Medically Complex Conditions, Hip Fracture, Cerebrovascular Accident (Stroke), and Non-Alzheimer's Dementia (Memory loss). Record Review of Resident #1's Care Plan dated 8/6/2023 read in part .Will safely perform her ADLs through the review date .date initiated 8/6/2023 .Bed Mobility: Requires staff participation to reposition and turn in bed date initiated 8/10/2023. Resident #1 was at risk for falls related to right below the knee amputation, incontinence, limited mobility, confusion, late effects of CVA date initiated 8/6/2023 .Revision 12/14/2023 .Will not sustain serious injury through the review date .date initiated 8/6/2023 bed in lowest position .date initiated 8/6/2023. Record Review of Resident #1's orders dated 4/18/2024 revealed there were no orders for fall preventions or interventions for fall prevention Record Review of Resident #1's Change in Condition dated 12/13/2023 at 3:19pm read in part .situation Falls .Back, injuries, complaints abrupt onset of severe pain secondary to fall or injury or pain with new abnormal neurological signs .site .left trochanter hip laboratory tests/diagnostic procedures x-ray .Resident #1 states she fell with CNA during bed bath. Record Review of Resident #1's X-Ray dated 12/13/2023 Read in part .Impression .A fracture of the left femur neck. The age of the fractur is indeterminate. Record review of Nursing note dated 12/14/2023 9:13am read in part .Resident #1 to be sent out to ER . Record Review of hospital notes dated 12/14/2023 read in part . female with a past medical history of CVA(Stroke) .claims the CNA was with her while cleaning her and she did not have a good grip of the rail before moving and she rolled out of bed and fell impacting her left leg and complained of severe left leg pain 1. Acute left femoral fracture consult orthopedics .Cardiology has cleared the patient for surgery with moderate risk patient is status post segmental resection arthroplasty of left femoral neck (Hip replacement) Consult social services for possible APS (Adult protective services) evaluation since patient claims that the CNA was impatient with her during her bed sponge which was responsible for her fall the patient was oriented to place person and time during history taking. Record Review of Hospital #3 Physical Therapy initial evaluation and discharge read in part .non weight bearing left lower extremity .Hoyer lift to chair .Resident #11 with chronic decreased motor control overall .coordination impaired right and left .BED MOBILITY: Rolling: Total Assistance (<25%), Needs 2. Record Review of hospital discharge summary dated 1/1/2024 revealed in part . Discharge diagnoses: Closed fracture of left hip .Procedure: Left Hip [NAME] Resection (Removal of head and neck of thigh bone) CT Pelvis (Cat Scan) .Impression: Complex left proximal femoral age indeterminate sub capital fracture and acute appearing distal neck fracture (Broken hip). Record Review of Change of Condition notes dated 4/1/2024 3:30pm read in part . condition change: Falls. Record review of Nursing notes dated 4/1/2024 at 4:11pm read in part . aide in room giving Resident #1 bed bath. Pt leg slide off bed and patient rolled and fell on to the floor. Resident #1 hit left side of head and complaint of pain to her head and ribs did not specify which side .transportation called, and hospital notified. Record review of hospital record H&P dated 4/2/2024 read in part . Chief Complaint: Fall at the nursing home followed by chest pain. Record Review of hospital record dated 4/3/2024 7:58am read in part . wanted to find another facility for Resident #1. SW left voice message and text messages requesting for return call back 4/11/2024 Resident #1' had confusion and found to have MDR Klebsiella (Bacteria in urine) .Infectious Disease consulted, and Resident #1 has completed course of intravenous Meropenem (Antibiotic) in house . family wanted to transition to a different long term care facility but unable to. Will return to facility. Resident #1 was found to have no substantial injuries on admission to hospital after fall on 4/1/2024, length of hospital stay was due to urinary tract infection and family trying to find another facility for resident to go to once discharged . Observation on 4/17/2024 11:35am Entered Resident #1's room and resident observed sleeping. Interview on 4/17/2024 at 11:35am DON said the Resident #1 fell off the bed while getting a bed bath on 12/13/2024. She said the CNA doing the bed bath was CNA D she said they did in-services on falls, bed baths and did education with CNA D specifically. Interview on 4/17/2024 at 11:51am RN A said she came to the resident's room at the end of her shift and Resident #1 said her leg hurt, she said she asked CNA D hat happened, and she denied she fell . She said another aid told her she fell . She said she fell when she was given a bed bath by CNA D. She said the facility did education on reporting incidents to nurses and falls. She said she did not remember who the other CNA was. Interview on 4/17/2024 at 12:11pm Family Member #2 said Resident #1 had now fallen out of bed the same way twice and was going to transfer her to another facility. Interview on 4/17/204 at 1:00pm the DON said the first time Resident #1 fell off the bed they ordered an x-ray and once they had the results, they sent her to the hospital. She said CNA D had her turned on her side and with the BKA she fell off the bed. She said the in-service was only with the CNA D. She said the second time Resident #1 fell off the bed it was with CNA C, she was giving her a bed bath and had her on her side. She said while she was bathing Resident #1, CAN C she stepped away to get a fresh basin of water and when she was in the restroom getting the water Resident #1 cried out, she was slipping and fell off the bed. She said CAN C had already started the bed bath. She said they only in-serviced the CNAs individually as they were isolated incidents. Interview on 4/17/24 at 1:03pm CNA C said she had worked at facility since July 2023, she said she had washed Resident #1's front side and had asked her to roll over on her side. She said she noticed the water was dirty, so she was going to walk in the bathroom and change the water out, she said Resident #1 was holding on the rail with her good hand and she was on her side. She said Resident #1 had said she was slipping when she was changing the water out of the pail and when she came back from the bathroom she was already on the floor. She said Resident #1 did not tell me she was going to fall, or I would not have left her. She said Resident #1 was not feeling good that day and wanted a bed bath instead of a shower. She said afterward the ADON called her in the office and instructed her on the correct procedures in a bed bath and not to leave Resident #1 by herself anymore. She said the ADON made her sign a sheet and in-service sheet. She said as far as a bed bath, they discussed with management they don't give Resident #1 bed baths by themselves anymore. She said Resident #1's bed baths should have been with two people. She said anytime she did anything with her from then on she did it with 2 people. She said management told them to use 2 people now. When asked if she knew if Resident #1 had a history of falls with bed baths, she said yes, she did but she said Resident #1 did not feel good and wanted a bed bath. She said she was going to do a shower and had everything set up for that. She said she had been in-serviced prior to that maybe 2 or 3 months ago. She said everybody was in-service with the first fall but with the second fall she was in-service by herself. She said with the first in-service it was a general how to give a resident a bed bath. She said there was no discussion to make Resident #1 a 2 person assist after the first fall; it was only after the second fall. When asked why it was important to have everybody on the same page, she said it was for safety reasons to prevent the falls from happening. She said if it had been made clear before the bed bath Resident #1 was a 2 person assist, it would have been preventable. Interview on 4/17/24 at 1:03pm CNA C said she had worked at the facility since July 2023, she said she had washed Resident #1's front and asked her to roll over on her side. She said she noticed the water was dirty, so she was going to walk in the bathroom and change the water out. She said Resident #1 was holding on the bed rail with her good hand, she was on her side, and she was saying she was slipping when she was changing the water out. She said when she came back from the bathroom Resident #1 was already on the floor. She said Resident #1 did not tell her she was going to fall, or she would not have left her. She said Resident #1 was not feeling good that day and wanted a bed bath instead of a shower. She said the ADON called her in and told her about the correct procedures in a bed, not to leave her alone anymore and made her sign an in-service sheet. She said as far as a bed bath they discussed with management, and they do not do Resident #1 by themselves anymore, they should be two people. Anytime she does anything with Resident #1 now she does it with 2 people. She said they told us to use 2 people now. When asked if she knew Resident #1 had a history of falls with bed baths, she said yes, she did but she said Resident #1 did not feel good and wanted a bed bath. She said she was going to do a shower and had everything set up for that. She said she had been in-service prior to that maybe 2 or 3 months ago. Everybody was in-service with the first fall. But with the second fall she was in-service by herself. With the first in-service it was a general how to give a resident a bed bath. There was no discussion to make Resident #1 a 2 person assist after the first fall it was only after the second fall. She said it was important for everyone to be on the same page for safety reasons to prevent the falls from happening. She said if had been made clear before the bed bath she was a 2 person assist, it would have been preventable. Interview on 4/17/2024 at 1:58pm the DON said with the first fall, they did in-services only with CNA D and not the other staff, she said with the second fall she did in-services with [NAME]. She said staff had done their minimum yearly competencies and there was no policy on how frequently they had to do in-services. She said they had the Relias system (Training system) and those were the yearly competencies. She said she thought it had included safety. When asked how often training was given on safety when providing care, she said they had done the monthly infection control. She said Resident #1's bed baths were two persons as of this last fall. She said Resident #1 was not deemed necessary by Physical Therapy after the first fall. She said Physical Therapy did not recommend Resident #1 to be a 2 person assist. She said Resident #1's normal activity level was she rarely ever wanted to come out of her room, she had seen her out of bed less than 10 times, and she was physically able to sit in a chair but did not want to. She said for quite a while she had been sleeping a lot. When asked how soon the care plan should have been updated after Resident #1's second fall, she said the care plan should have been updated timely. She said she did not feel there was a safety issue with Resident #1, and she did not feel feel there was an established pattern with her falling out of bed on 2 separate occasions. She said to the CNA, Resident #1 was a one person assist at the time. She said she did not think she could have prevented the incident aside for calling for help from someone to refill the basin. She said it was not known Resident #1 would lose strength in her arms. Interview on 4/17/2024 at 2:24pm CNA D said when Resident #1 fell off the bed on 12/13/2023 she was giving her a bed bath. She said she was washing her backside, and, in the process, she rolled off the bed. She said it happened so fast and Resident #1 did not provide a warning. She said Resident #1 had grab bars to support herself and she tried to grab Resident #1 to prevent her from falling but she slipped out of her hands. She said Resident #1 at the time was a one person assist for most activities and she did not know her to be a high fall risk. She said she called for help and referred her to the nurse. She said Resident #1 was yelling in pain. She said the ADON gave her one to one training on bed baths, and it was determined she did so correctly. She said she had not had another training since then. She said there was no Kardex (Care Plan for CNAs that tell them how much assistance a resident needs), nothing hanging on the walls to show care plans for residents with regards to assistance levels. She said she only determined the level of assistance needed when she was performing a task on her own and realized she could not do it safely without help. She said she would then have called for help from time to time. She said they all got verbal training or reporting from nurses which determined the level of care needed for each resident. She said there was nothing on a Kardex or care plan that she could refer to find out how much assistance she needed to care for a resident, she said a nurse would let them know if a resident needed assistance with feeding. Interview on 4/17/2024 at 2:16pm Resident #1 said the first time she fell off the bed she was oily, and the bed was oily. She said she was turned close to the edge of the bed, and she lost her balance and fell out of the bed. She said she could not hold her grip on the bed rails because she was weak. She said she got pushed too close to the edge of the bed, she could not hold her grip and she fell off the bed. She said she did not want the CNAs again. She said she should have had 2 CNAs help her not one. She said when she fell the first time, she broke her hip and they had to repair it at the hospital. She said the second time she fell out of the bed a different CNA was giving her a bed bath. She said the CNA left and went to throw out the bath water and she left her turned on her side. She said she should have never been left on her side like that. She said she could not reposition herself. She said when she fell the second time she landed on her hip. She said she needed a bigger bed mattress as she was too big for the bed and when they turned her, she was at the edge of the bed. She said she had to go to the hospital, but her leg still was not healed from the first fall. Interview on 4/17/2024 at 3:00pm CNA E said she had worked at the facility for 3 weeks, she said she had training as a CNA so she would know her responsibility with the resident's bed bath, bathroom, cleaning, wiping changing diapers, transferring to wheelchair and back to bed. She said the facility trained her on what to do and what she can do for the residents. She said when you look at the chart you know how to take care of the people. She said from her training she knew if residents needed one or 2 people assistance. She said she had worked on 300 halls. She said most of the 2-person assistance were located on 200 halls. She said Resident #1 needs 2 people assist. She said the nurse that attends to her asks for assistance. She said Resident #1 needs 2 people to change her and she felt confident in who needed how much care in the building. She said most of the residents she knew by looking, assessing them and could tell how much help they needed. Interview on 4/18/2024 at 8:43am Physical Therapist A said he worked with Resident #1 going on 2 years since April of 2022. He said they did yearly in-services and they in-serviced the staff on transfers and Hoyer lifts. He said he knew Resident #1. He said Resident #1 had a fall and a fracture with the left leg, and they had seen her for therapy before and after that point. He said they worked with her on her mobility status. He said she had always been able to assist with her right arm, she would roll using her right hand up and over and they had to help her so she could hold and stabilize herself. He said he did not know how she fell off the bed the second time and said he knew with therapy she was able to assist with some help to the right. He said he did not know if she was lethargic. He said he did not know Resident #1 fell out of bed twice. He said they were working with her in therapy. He said they were putting with max or total dependent with 1 person. He said she needed verbal cues. He said he would not have left her when getting her bath, he would not have stepped aside, he would have rolled her to her back. He said he would not have left Resident #1 on a sideline position and left unattended. He said they had to be always with Resident #1, do not leave her there. He said given Resident #1's history since her condition has declined to add two people to care and this would be a strong recommendation for bathing. If they had to take their hands off to bathe her, Resident #1 would have been a two person assist and with her history for precautions. He said Resident #1 had become weaker and just from a tolerance position. He said he could bathe Resident #1 but he would be touching her and not stepping away. Interview in 4/18/2024 at 9:08am ADON A said she had worked at the facility for a year and a half. She said she did most of the in-services. She said she did skills check off with CNA D the first time Resident #1 fell off the bed. She said she did a 2 person assist on transferring in-service with all CNAs. She said the second time Resident #1 fell off the bed she did a one-to-one in-service with CNA C on bed positioning, making sure there was a second person assisting, bed leveled for safety. She said nurses, CNAs, CMAs received skills check off in December 2023 on transfers, and they focused on the first fall, that specific incident and what they needed to do moving forward. This was a general training, and they did resident specific training with CNA D and CNA C. She said they covered every 2 hours turning resident, and they got turning training in the skills check off. She said CAN C's training was to make sure someone was there to assist them with turning. She said after Resident #1 fell a second time she did training with CNA C with Resident #1. She said Resident #1 should have been deemed a 2 person assist after the first fall because it's an intervention. She said no other interventions were put in place. The staff could have accessed the Kardex (Care Plan for CNA and it is in their POC documentation, and they get report, the nurse was supposed to provide the information to them. She said she was not sure if its in the POC it populates in the Kardex. She said she believed Resident #1 should have been 2 persons assist. She said the checkoffs went over bed baths, 2 pers assists, everything, so no need to do individual in-services, staff should have known by Kardex and nursing staff how to provide care for the residents. She said the Kardex pulls from the Care Plan. The Kardex was in the documentation system for the CNAS and the Care plan too. Record review on 4/18/2024 at 9:20am revealed the Care Plan had no updates for Resident #1 for CNA assistance with ADLs, fall mats, low bed, or big bed, prior to arrival at the facility. Resident #1 had no fall mats, low bed, big bed prior to arrival at facility. Interview on 4/18/2024 at 9:40am Resident #1 said before her fall, she usually got help from only one person when being changed or when being given a bath. She said she was getting adjusted to the new larger mattress that they had provided her this morning. Record Review of Resident #2's Face Sheet dated 4/18/2024 revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses of .Hemorrhage due to vascular prosthetic devices (Blood loss due to implant), implants and grafts, subsequent encounter, End stage renal disease (Kidney disease), altered mental status (Change in clarity), Hypertensive urgency (High blood pressure), Muscle wasting and atrophy and muscle weakness(Muscle loss and stiffness). Record review of Resident #2s MDS dated [DATE] revealed Resident #2 had a BIMS Score of 12 indicating the resident was moderately cognitively impaired. Section E revealed Resident #2 had no indicators of psychosis. Section GG revealed resident used a walker for mobility and had partial to moderate assistance with bathing and toileting. Resident was substantial assistance with lower body dressing. Interview on 4/18/2024 at 9:40am Resident #2 said she had been Resident #1's roommate for 2-3 months and she looked out for Resident #1 when she needed help. She said she would help press the call light to make them come faster. She stated before Resident #1's fall (4/1/2024), the resident only received help from one person when being changed. She said she did not know whether it was because they were shorthanded and could not get the extra help, but they were typically alone when providing her care. She said she overheard the bed bath happening when Resident #1 fell recently, she heard when Resident #1 yell I'm slipping, I'm slipping and she heard her hit the ground. She said even after that incident, she was still being provided cared by one person for the most part. 4/18/2024 at 9:40am Resident #1 was observed in her room in her bed, left hand contracted, feeding herself with right hand, right below the knee amputation, large bed, Resident #1 able to communicate effectively. Resident #1 said she was adjusting to her new larger bed. 4/18/2024 9:57am LVN R showed the Kardex located in the POC documentation system. She said the Kardex did not show if a person was a one person assist or a 2 person assist. She said the CNAs put in the level of assistance after the care was provided to the resident. She said Resident#1 was a two person assist with turning. She said since she first fell the staff have taken extra precautions and were utilizing two persons with changing briefs. Interview on 4/18/2024 at 10:15am the Administrator he said he had placed resident in a larger bed. Interview on 4/18/2024 at 3:00pm the DON said the staff all knew the resident was a two person assist with bathing after the second fall, she said staff were uncomfortable bathing the Resident #1 without 2-person assistance. 4/19/2024 9:20am Resident #1 observed in her room in bed eating breakfast, Resident #1 said she got a bed bath last night, Resident #1 noted to have bilateral fall mats in the room which she did not have prior to 4/19/2024. Resident #1 noted to have a star next to her name on the doorpost indicating she was a fall risk which she did not have prior to 4/19/2024 and noted to be clean in appearance. Resident #1 said only one CNAs gave her a bed bath last night. She said there were not 2. Interview on 4/19/24 at 10:22am the DON said the interventions from the IDT meeting they had after Resident #1's first fall were not all put into place for the resident and while receiving a bed bath Resident#1 rolled off the bed a second time. She said Resident #1 was sent to the hospital and once she returned from the hospital there were supposed to be interventions for fall mats placed,wider bed, 2 person assist with care, education done with CNA and all staff, and falling star identifier. She said Resident #1's second fall happened on 4/1/2024 and the resident was gone for a while, there was a delay with returning and when Resident #1 was readmitted the interventions did not get put in place for the resident. She said the fall mats, the education for the staff, the falling star identifier, the wider bed and the 2 person staff assist with care and updating the care plan were not put in to place. She said they got missed because Resident #1 was delayed returning to the facility after the second fall. She said Resident #1's family had been looking to send her to another facility. Record review on 4/19/2024 at 11:25am revealed staff in-service dated 1/2/2024 . bed baths, 2 persons assist, level bed for safety, when in doubt ask for help. Surveyor confirmed with CNA C she was not on the in-service 1/2/2024. In-service dated 12/15/2024 for transfer training, bed mobility, Hoyer training. CNA D's signature not on in-service. Record review on 4/17/2024 at 11:14am of Resident #1's Care plan dated 8/6/2024 revealed no updated interventions in place to prevent falls. Record review of facilities policy titled; Fall Management System read in part . It is the policy of the facility to provide an environment that remains free of accident hazards as possible. It is also the policy of the facility of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. An IJ was identified on 4/18/2024 and the facility administrator was notified at 5:23pm. The IJ template was provided to the facility on [DATE] at 5:23pm. On 4/20/2024 at 2:16pm the following Plan of Removal was accepted. On 4/20/2024 at 2:16pm the following Plan of Removal was accepted. Facility Plan for Compliance ADHOC meeting sign in sheet in book with Medical Director in attendance. Meeting held on 4/18/2024. Executive Director, DON, Clinical Cluster Leader, Clinical Resources in attendance. Incidents by Resident including Resident #1in IJ Book (Book containing plan of removal for Immediate Jeopardy). Root Cause Analysis for Resident #1 in IJ book. Updated Care Plan for Resident #1 in IJ Book. Interventions in place since arrival: Resident #1 Requires Assistance of 2 staff members to reposition, may use mobility bars to aide in Easy Turning and repositioning, Resident #1 requires assistance of 2 staff members if receiving a bed bath with mobility bars in place, Resident requires assistance of 2 staff by Hoyer lift with transfers, in IJ book. Fall Risk Evaluations in the POR for all residents were completed. Monitoring for Plan of Removal: In an interview on 4/20/2024 at 9:00am DON said all Care Plans were reviewed and updated as necessary for the residents identified in the Fall Risk Assessments. All persons responsible for care plan updates immediately were herself, the ADONs, Social Work and Wound Care. Record review on 4/20/2024 at 10:00am of in-Service Training for Resident #1 dated 4/18/2024 reflected resident will have a wide bed, fall mats-bilateral, mobility bars, and two staff members for bed baths/ bed mobility. Record review on 4/20/2024 at 10:00am of in-service dated 4/18/2024- Topic Falls . Fall Policy .Fall risk assessment .fall risk management/incident report .Care plans updated .falling star (Emblem placed by doors of Residents at risk for falls) .document q (Every)shift x72 hours. Record review on 4/20/2024 at 10:00am of Inservice dated 4/18/24- Topic Bed bath hand hygiene .procedure . ensure safety at all times .follow Kardex .bed height .clean up .call light within reach .do not leave resident lying on side of bed. Record review on 4/20/2024 at 10:00am of Inservice dated - 4/18/24-Topic Mobility, Transfers, Safety, Turning/Repositioning .Do not leave resident unattended while performing care. Record review on 4/20/2024 at 10:00am of Inservice dated 4/18/2024- Topic- Kardex- Clinical, POC, Select Resident. Select Kardex. Record review on 4/20/2024 at 10:00am of Inservice dated 4/18/2024- Topic- Bed Mobility-Levels of assist during bed mobility, independent/setup/limited/eaten/total, mobility bars, 1person/2person assist, always refer to Kardex prior to assisting resident. Record review on 4/20/2024 at 10:00am revealed Falls Post Test taken by all Nurses, CNA's and CMA's. Record review on 4/20/2024 at 10:00am of Observations of bathing, complete bed baths of Clients by staff in IJ book. Record review on 4/20/2024 at 10:00am of Observations of Turning and Repositioning of a Client by staff are in the IJ book. Record review on 4/20/2024 at 10:00amof Incidents (Thigs happening) by Residents .Date 4/18/2024 . 1/1/2024 to 4/18/2024 in IJ book. Record review on 4/20/2024 at 10:00am of Fall Risk Evaluation of Residents dated 4-19-2024 in IJ book. Record review on 4/20/2024 at 10:00am of Resident #1's of Care Plan updates in IJ book. Record review on 4/20/2024 at 10:00am of POR for F689 in IJ book. Record review on 4/20/2024 at 10:00am of POR for F656 in IJ Book. Record review on 4/20/2024 at 10:00am of Quality Team Tracking form .Date 4/18/2024 in IJ Book. Interview on 4/19/2024 at 1:20pm with LVN S she said she had worked at the facility for four months, she said she had been in-serviced on care plans, fall prevention, bed baths and bed mobility this morning. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said she would have found whether the resident was a one or two person assist for ADLs on the Care Plan or the Kardex. She said 2 people were required to assist Resident #1 for bed baths and diaper changes. She said incident reports were immediately after patient assessment. She said they accessed the care plan in Point Click Care (PCC). She said she would have checked the care plan prior to providing care to the resident. Interview on 4/19/2024 at 1:24pm with LVN T she said she had worked at the facility since 2/2023, she said she had been in-serviced on care plans last, fall prevention, bed baths and bed mobility this morning. She said she would not have left a resident on the side of the bed to perform another task when doing a bed bath. She said to prevent falls not to leave the resident at the side of the bed. She said she would have found find whether the resident was a one o [TRUNCATED]

Based on interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Residents #1) reviewed for quality of care. The facility failed to assess, develop and implement interventions to reduce the risk of falls or injury for Resident #1 after she sustained a fall with major injury ( fracture of the upper arm ) during a one person assist incontinent care. This failure could place residents at risk for not receiving safe appropriate care , more injuries and decline in functioning. The findings include: Record review of Resident # 1's Face Sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS Quarterly Assessment, dated July 9, 2021, revealed Resident #1 has a Brief Interview of Mental Status of 1, which indicated severe cognitive deficit. Resident #1's functional status for toileting was extensive assistance with two+ person physical assist. Resident #1 received occupational therapy from 7/29/20 - 8/19/20 and physical therapy from 11/25/20-12/22/20. Record review of Resident #1 MDS Kardex report, dated 7/9/21, revealed Resident #1 was a two+ person physical assist for toileting. Record review of Resident #1's Comprehensive MDS, dated [DATE] (after the incident on 9/4/21), revealed Resident #1's prior MDS assessment period date was 7/9/21. Resident #1's BIMS was unable to be determined. Resident #1's functional status for toileting was extensive assistance by one-person physical assist. Occupational therapy began 9/7/21. Physical therapy began 9/7/21. Record review of Resident#1's, undated, care plan revealed Resident #1 had an ADL self-care performance deficit due to limited mobility and weakness on right side. Resident #1 required extensive assistance by one staff for toilet use, revised on 9/24/21. Resident #1 required extensive assistance by 2 staff for repositioning and turning in bed. Record review of Resident #1's Incident report, dated 9/4/21 at 8:38 a.m., completed by LVN A revealed CNA was doing her last rounds/changes and she was changing this resident. She turned her on her right side and her left leg went over the bed and CNA was unable to catch her and prevent her from falling. Resident unable to give description. The resident was transferred back into bed via Hoyer left. Resident was not taken to hospital, and no injuries observed post incident. Additional notes dated 9/5/21 was that the x-ray of bilateral hips was negative. X-ray for right shoulder revealed positive for comminuted fracture of the humeral head neck. Record review of Mobile X-Ray report, dated 9/5/21, revealed Resident #1 sustained a comminuted fracture of the humeral head neck. Record review of History and Physical, dated 9/23/21, revealed Resident #1 was seen by her NP for follow up on right humerus fracture, very limited mobility and range of motion. Continue wheelchair mobility, Max assist with ADL's and transfers, PT/OT evaluation and treat. During an interview on 9/29/21 at 11:48 am with CNA A, she said she has provided incontinent care for about 3 months to Resident # 1 and she was two person assist for incontinent care, She said she was not present at the time of her injury. She said the most recent information on Resident # 1 said she was 2 person assist. She used the Kardex to determine Resident #1 was a two person assist She said Resident # 1 was a 2 person assist in toileting and transferring due to her size. She said she provided two-person incontinent care today with her coworker CNA B. She said for Resident #1, she was heavy, she would receive assistance to turn on her side and then provide care. There would be one staff one each side of the bed to prevent falling off of the bed. During an interview on 9/29/21 at 12:55 p.m. with CNA B, she said she has been employed for [AGE] years at this facility. She said she provided incontinent care for Resident # 1. She was a two person assist. The information comes from her kardex. She said Resident # 1 has always been a 2 person assist. She was two person because one of her sides doesn't work. She had a stroke and she is a large resident. She said she would not attempt a one person assist. She said she will make sure she will get another person to assist with care. A staff would be on both sides of the bed to prevent resident from rolling off in a two-person assist. During an interview on 9/29/21 at 1:00 p.m. with CNA C she said she worked with Resident #1 around 3:40 a.m., but she could not recall the date, but she said she was certain on the time because that's the time of the rounds. She said she turned Resident #1 on her right side, and the resident threw her left leg over. She said she tried to stop it from going over the side of the bed. She was standing on the left side of the bed and she turned Resident #1 towards the right. The little railing was up on the bed, it's always up. She said she has been working with Resident # 1 for about a year and 3 months. She has always been a two person assist, but the other worker was busy at the time when Resident #1 needed changed. She said she would normally have used 2 people to change her. She would use the kardex to determine the level of assistance. The Kardex has Resident # 1 as 2 person assist for incontinent care. She said the kardex says extensive care by two people. She said she spoke to the facility the day after it happened, and she was removed from the schedule. The incident happened Saturday (9/4/21), she was scheduled to work Sunday but was removed from schedule and then returned on Tuesday. During an interview on 929/21 at 1:26 p.m. with the MDS Nurse, she said if the kardex had Resident #1 as a 2 person assist then the CNAs followed the Kardex and did two person assist. The kardex came from the care plan. The kardex and the care plan should match. The current care plan identified Resident #1 as an extensive assist 1x staff for toileting assistance, which meant one staff could provide care, but the staff had to hold weight. She said she would do an assessment to determine what should be factual. She could not say why there was a discrepancy between MDS, care plan, and staff testimony on the assistance resident #1 needed. She said she was unable to determine the reason Resident #1 was once 2 person and then changed to 1 person assist in documentation. There was not any justification identified. She said she updated the MDS today (9/29/21) to accurately reflect the injuries to Resident #1. She said Resident #1's level of care was not revisited after the incident. During an interview on 9/29/21 at 2:00 p.m. with the Administrator, he said he did not identify the discrepancy in the MDS, care plan, or any justification why Resident #1's level of care changed. He said it was likely due to a mobility assessment, and Resident #1 status in mobility improved. Record review of facility Nursing Administration policy, dated 5/2007, revealed clinical records contain resident's assessments, and plan of care and services provided. Included in this policy, the Comprehensive Plan of Care, the nurse develops the plan of care in conjunction with resident and appropriate others. The care plan helps the resident attain and maintain the highest level of health, well-being, and quality of life, and is revised as necessary. The plan is current and shows evidence of revision as goals and objectives are achieved or changed.

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 8 residents (Resident #7, #8, CR #1) reviewed for accidents and supervision. - CNA-A and CNA-D did not ensure resident #7 was wearing appropriate footwear when ambulating to transfer from chair to bed as called for in the written care plan and physician's orders [REDACTED]. - CNA-E transferred Resident #8 with a two person transfer using a gait belt and the belt was threaded backwards threw the metal buckle. This failure placed Resident #8 at risk of fall and injury. - The facility failed to provide Mechanical lift to transfer CR #1 in accordance with the plan of care. CNA-B and CNA-C transferred CR #1 under her arms and sustained Rt. shoulder dislocation. These failures affected two current and one former residents and placed the other 87 residents dependent on staff for assistance with transfers at risk for injury. The findings included: Resident #7 Record review of Resident #7's MDS assessment, dated 8/7/17, revealed [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS revealed in part; -limited/1 person physically assist for transfer Record review of Resident #7's care plan initiated on 8/8/17 revealed in part; Focus: ADL Self Care Performance Deficit r/t ineffective gas exchange, generalized weakness. Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with modified independence. Interventions: TRANSFERS: Requires limited assistance X2 staff participation with transfers. Focus: At risk for falls r/t generalized weakness initiated 8/9/17 revised 8/9/17 Goals: will demonstrate the appropriate use of assistive device(s) to increase balance and self-correction when ambulating in the SNF, reducing the potential for falls. Interventions: Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c. Observation on 8/16/17 at 4:10 p.m. revealed Resident #7 was sitting in her recliner with oxygen on, full clothed and no shoes or socks. Resident #7 shoes were in front of her feet with the socks one in each shoe. Resident #7 stated that she was waiting to get in bed so that she could have a chest x-ray done. Observation on 8/16/17 at 4:15 p.m. with CNA-A and CNA-D assisting Resident #7 in a 2 person transfer revealed CNA-A applied the gait belt around the abdomen of Resident #7, explained the procedure and gently kicked Resident #7 shoes to the side. CNA-A and CNA-D placed one hand on the gait belt in front and other hand behind the resident, and on their count of three assisted the resident up out of the recliner. During this time Resident #7 feet slid forward and she lost her balance, CNA-D further kicked Resident #7 shoes to the edge of the bed and pivot to place Resident #7 on the bed. Resident #7 gave a sigh and deep breath. Record review of CNA Kardex (computer system, facility CNAs use to identify resident participation and CNA support required for a specific Resident's ADL needs) for Resident #7 revealed under the section Safety: Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c. and under the section Transfers: Requires limited assist X2 staff participation with transfers. Interview with CNA-A on 8/16/17 at 5:00 p.m. revealed she should have made sure the resident had shoes on and the bed was locked. CNA-A stated Resident #7 didn't fall she slipped and lost her balance. Interview with Resident #7 on 8/16/17 at 6:30 p.m. revealed they facility nursing staff always use a gait belt on her, and she always put her shoes on before she stands up, but this time it didn't happen and she lost her balance and almost fell on the floor. Resident #8 Record review of Resident #8's MDS assessment, dated 6/26/17, revealed [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's MDS revealed she was: - Usually understood or understands others and had clear speech - BIMS of 4, severely impaired cognitively for decision making -limited/1 person physically assist for transfers -extensive/1 person physically assist for bed mobility, dressing, toilet use and personal hygiene -supervision and set-up for eating -supervision/1 person physically assist for bathing -frequently incontinent of bladder and frequently incontinent of bowel Resident #8 had two active ADL care plans in the medical record with target dates of 9/28/17. Record review of Resident #8's First current care plan initiated on 5/1/17 and revised on 6/15/17 with target date 9/28/17 revealed in part; Focus: Resident ADL Functions, Bed Mobility extensive with 1 staff member assistance. Transfer: extensive with 1 staff member assistance. Interventions: .Assist with ADLs as needed Assist with transfers as needed, assist with repositioning as appropriate. Interventions of care plan dated 5/1/17 did not include specific needs identified in Resident #8's current MDS for self-performance and support by direct care staff to assist with ADL care needs. (Bed Mobility, Transfer, Dressing, Eating, Toileting, Personal Hygiene, or Bathing) Record Review of Resident #8's Second current Care plan initiated on 8/8/17 and revised on 8/9/17 with target date 9/28/17 revealed in part; Focus: ADL Self Care Performance Deficit r/t cognitive impairment and dementia Interventions: TOILET USE: Requires extensive assist x1 staff participation to use toilet and for incontinent care. TRANSFERS: Requires x1 staff participation with transfers. BED MOBILITY: Requires extensive assistance x1 staff participation to reposition and turn in bed. BATHING: Requires x1 staff participation with bathing. PERSONAL HYGIENE: Requires extensive assist x1 staff participation with personal hygiene. DRESSING: Requires extensive assist x1 staff participation to dress. There was no documentation in Resident #8's Care plan as to how much ADL self-performance is required/need for direct care staff to assist Resident #8 in areas of Transfers, and Bathing. Observation on 8/16/17 at 4:00 p.m. revealed Resident #8 was sitting on the edge of the bed, fully clothes, had her shoes on, CNA-E placed the gait belt around her waist and threaded the belt through the hole portion of the buckle and then threaded it through the tooth end of the metal buckle. CNA-E and CNA-F pulled resident #8 to the standing position, CNA-E used one hand in front and back of resident, CNA-F placed his left hand on the gait belt, right arm under Resident #8 right arm pulling on her arm during transfer to stand. Interview with CNA-E on 8/16/17 at 4:10 p.m. revealed he place the gait belt on backwards, he should have threaded the belt first through the opening that is toothed on the metal buckle and then through the other metal hole portion of the buckle on the gait belt. CNA-E stated the gait belt was not secured properly and could have slipped and hurt resident. Interview with CNA-F on 8/16/17 at 4:10 p.m. revealed I'm not supposed to go up under her arm. To transfer, and surveyor made him nervous watching transfer. CR #1 Intake # 2 Record review of face sheet dated 8/8/17 revealed CR #1 was [AGE] years old, admitted on [DATE], readmission of 6/28/17 with [DIAGNOSES REDACTED]. Record review of CR #1's MDS assessment, dated 7/18/17, revealed she was: -BIMS = 7, severely impaired cognitively for decision making -extensive/2 person physically assist for transfers -extensive/1 person physically assist for dressing, eating, bed mobility and personal hygiene -total dependence/1 person physically assist for toilet use and bathing -frequently incontinent of bowel and bladder Record review of CR #1's electronic care plan for ADL Care revealed in part; Focus: ADL Self Care Performance Deficit r/t Limited mobility. Interventions/Tasks: TRANSFERS: Requires Mechanical lift for transfers X2 staff assist. Record review of CNA Kardex for Resident #7 revealed under the section Transfers: Requires Mechanical lift for transfers X2 staff assist. Record review of facility Provider Investigation Report dated 8/10/17 revealed on 8/4/17 at 2:30 p.m. LVN T reported that CNA-B and CNA-C request for him to assess CR #1, upon assessment CR #1's right shoulder appeared to be dislocated and according to both CNAs they were transferring CR #1 from the shower chair to bed and after CR #1 was placed on the bed they heard her right shoulder pop. Record review of SBAR dated 8/4/17 timed for 4:48 p.m. revealed Situation, other changes in condition: Suspected shoulder dislocation, Specify exact location of pain: Site Right shoulder (front), Description Suspected dislocation. Record review of Nursing Progress note dated 8/4/17 and timed 8:14 p.m. revealed LVN T documented in part .At about 14:30 (2:30pm) CNA-B reported to this nurse that resident R shoulder appears to be dislocated, enter room observed resident in bed R shoulder appears to be dislocated NP in the building, New order to send resident to ER. Record review of physician progress notes [REDACTED].Visit type: New Problem, This NP was called to patient's room, patient was previously in the shower, according to nursing patient was moved by systems in the shower unclear patient was being held under her arms, right shoulder appears to be dislocated painful, shoulder seems to be protruding for, patient has limited range of motion with excruciating pain. Further review of physician progress notes [REDACTED]. Physical Exam Musculoskeletal: Limited range of motion in right shoulder, right shoulder blade appears to be protruding forward, painful to touch. Assessment & Plan right shoulder pain/dislocation- will send patient to the emergency room , for evaluation and treatment. Record review of Hospital A, X-ray, report dated 8/4/17 results revealed findings in part .Transverse fracture through the mid-shaft of the humerus, with 7mm of lateral displacement of the distal component. Non-displaced fracture of the base of the coracoid process of the scapula. Interview with CNA-B on 8/16/17 at 2:15 p.m. revealed on 8/4/17 at about 2:30 p.m. she was needing help to put CR #1 back to be after her shower and that CNA-C helped her. CNA-B stated that CR #1 was able to help a little but both of them put their arm under CR #1 arms and transferred her from the shower chair to the bed and when they did they heard her arm pop. CNA-B stated that she wished she would have used the Hoyer lift to transfer CR #1. CNA-B said she did not look at the Kardex prior to transferring CR #1 but went off memory. CNA-B revealed she was suspended pending investigation and in-serviced 1:1 on looking at Kardex and to have gait belt to transfer properly. Interview with CNA-C on 8/16/17 at 2:30 p.m. revealed on 8/4/17 at about 2:30 p.m. she assisted CNA-B in transferring CR #1 from the shower chair to the bed and did so by placing her arm under CR #1 arm. CNA-C stated when CR #1 was placed on the side of the bed she heard her arm pop. CNA-C said No it was not the proper was to transfer CR #1 under her arms, It could cause injury. CNA-C revealed she was in-serviced on use of the Kardex to ID Resident assistance needed with ADLs and to use gait belt. CNA-C was not aware CR #1 care plan and Kardex included mechanical lift for transfers. Interview on 8/16/17 at 3:20 p.m. with LVN M revealed that she was one of the nurses responsible for updating the care plans but that she also updates the CNA pocket worksheet. LVN M stated that any resident's current care plan should reflect the current MDS. LVN M stated that once the care plan is completed in the computer the information under the Intervention section populates to the Kardex, computer system, facility CNAs use to identify resident participation and CNA support required for a specific Resident's ADL needs and documents care provided. Interview on 8/16/17 at 4:30 p.m. with DON stated she expected the care plan to include how much ADL self-performance and how much physical assistance from direct care staff is required to assist residents in areas of ADL care. DON revealed that she expects MDS nurses to update Care Plans daily as needed and they were to bring their computers to the morning meeting so Care plans could be updated. DON stated CNAs are to follow the Kardex for resident care needs. Record Review of facility Policy and Procedure revises 05/2007 revealed in part . Section: Quality of Care Subject: Transfer of a Resident, Safe Procedures: #2. Know the resident's abilities and limitations. #3. Use good body mechanics at all times. #4. Ensure that the Resident wears proper footwear that fits well and has nonskid soles. Two-person transfers: E. Provide the necessary help for the resident to stand-up. The caregivers should stand on both sides of the resident and hold the gait belt. The facility's CMS 672 form, dated 8/16/17, indicated the facility's census was 89 residents.

Based on observation, interview and record review, the facility failed to prevent neglect of residents for 1 of 8 residents (Resident CR #1) reviewed for neglect. - The facility failed to provide Mechanical lift to transfer CR #1 in accordance with the plan of care. CNA-B and CNA-C transferred CR #1 under her arms and sustained Rt. shoulder dislocation. These failures affected one former resident and placed all 89 residents dependent on staff for assistance with transfers at risk for injury. The findings included: Intake # 2 Record review of face sheet dated 8/8/17 revealed CR #1 was [AGE] years old, admitted on [DATE], readmission of 6/28/17 with [DIAGNOSES REDACTED]. Record review of CR #1's MDS assessment, dated 7/18/17, revealed she was: -BIMS = 7, severely impaired cognitively for decision making -extensive/2 person physically assist for transfers -extensive/1 person physically assist for dressing, eating, bed mobility and personal hygiene -total dependence/1 person physically assist for toilet use and bathing -frequently incontinent of bowel and bladder Record review of CR #1's electronic care plan for ADL Care revealed in part; Focus: ADL Self Care Performance Deficit r/t Limited mobility. Interventions/Tasks: TRANSFERS: Requires Mechanical lift for transfers X2 staff assist. Record review of CNA Kardex for Resident #7 revealed under the section Transfers: Requires Mechanical lift for transfers X2 staff assist. Record review of facility Provider Investigation Report dated 8/10/17 revealed on 8/4/17 at 2:30 p.m. LVN T reported that CNA-B and CNA-C request for him to assess CR #1, upon assessment CR #1's right shoulder appeared to be dislocated and according to both CNAs they were transferring CR #1 from the shower chair to bed and after CR #1 was placed on the bed they heard her right shoulder pop. Record review of SBAR dated 8/4/17 timed for 4:48 p.m. revealed Situation, other changes in condition: Suspected shoulder dislocation, Specify exact location of pain: Site Right shoulder (front), Description Suspected dislocation. Record review of Nursing Progress note dated 8/4/17 and timed 8:14 p.m. revealed LVN T documented in part .At about 14:30 (2:30pm) CNA-B reported to this nurse that resident R shoulder appears to be dislocated, enter room observed resident in bed R shoulder appears to be dislocated NP in the building, New order to send resident to ER. Record review of physician progress notes [REDACTED].Visit type: New Problem, This NP was called to patient's room, patient was previously in the shower, according to nursing patient was moved by systems in the shower unclear patient was being held under her arms, right shoulder appears to be dislocated painful, shoulder seems to be protruding for, patient has limited range of motion with excruciating pain. Further review of physician progress notes [REDACTED]. Physical Exam Musculoskeletal: Limited range of motion in right shoulder, right shoulder blade appears to be protruding forward, painful to touch. Assessment & Plan right shoulder pain/dislocation- will send patient to the emergency room , for evaluation and treatment. Record review of Hospital A, X-ray, report dated 8/4/17 results revealed findings in part .[MEDICATION NAME] fracture through the mid-shaft of the humerus, with 7mm of lateral displacement of the distal component. Non-displaced [MEDICAL CONDITION] of the coracoid process of the scapula. Interview with CNA-B on 8/16/17 at 2:15 p.m. revealed on 8/4/17 at about 2:30 p.m. she was needing help to put CR #1 back to be after her shower and that CNA-C helped her. CNA-B stated that CR #1 was able to help a little but both of them put their arm under CR #1 arms and transferred her from the shower chair to the bed and when they did they heard her arm pop. CNA-B stated that she wished she would have used the Hoyer lift to transfer CR #1. CNA-B said she did not look at the Kardex prior to transferring CR #1 but went off memory. CNA-B revealed she was suspended pending investigation and in-serviced 1:1 on looking at Kardex and to have gait belt to transfer properly. Interview with CNA-C on 8/16/17 at 2:30 p.m. revealed on 8/4/17 at about 2:30 p.m. she assisted CNA-B in transferring CR #1 from the shower chair to the bed and did so by placing her arm under CR #1 arm. CNA-C stated when CR #1 was placed on the side of the bed she heard her arm pop. CNA-C said No it was not the proper was to transfer CR #1 under her arms, It could cause injury. CNA-C revealed she was in-serviced on use of the Kardex to ID Resident assistance needed with ADLs and to use gait belt. CNA-C was not aware CR #1 care plan and Kardex included mechanical lift for transfers. Interview on 8/16/17 at 3:20 p.m. with LVN M revealed that she was one of the nurses responsible for updating the care plans but that she also updates the CNA pocket worksheet. LVN M stated that any resident's current care plan should reflect the current MDS. LVN M stated that once the care plan is completed in the computer the information under the Intervention section populates to the Kardex, computer system, facility CNAs use to identify resident participation and CNA support required for a specific Resident's ADL needs and documents care provided. Interview on 8/16/17 at 4:30 p.m. with DON stated she expected the care plan to include how much ADL self-performance and how much physical assistance from direct care staff is required to assist residents in areas of ADL care. DON revealed that she expects MDS nurses to update Care Plans daily as needed and they were to bring their computers to the morning meeting so Care plans could be updated. DON stated CNAs are to follow the Kardex for resident care needs. Record Review of facility Policy and Procedure revises 05/2007 revealed in part . Section: Quality of Care Subject: Transfer of a Resident, Safe Procedures: #2. Know the resident's abilities and limitations. #3. Use good body mechanics at all times. #4. Ensure that the Resident wears proper footwear that fits well and has nonskid soles. Two-person transfers: E. Provide the necessary help for the resident to stand-up. The caregivers should stand on both sides of the resident and hold the gait belt. The facility's CMS 672 form, dated 8/16/17, indicated the facility's census was 89 residents.

Based on observation, interview and record review the facility failed to ensure the services provided or arranged by the facility, as outlined by physician orders [REDACTED].#7, and CR #1) reviewed for physician's orders [REDACTED]. CNA-A, CNA-D did not ensure resident #7 was wearing appropriate footwear when ambulating to transfer from chair to bed as called for in the written care plan and physician's orders [REDACTED]. The facility failed to provide Mechanical lift to transfer CR #1 in accordance with the plan of care. CNA-B and CNA-C transferred CR #1 under her arms and sustained Rt. shoulder dislocation. These failures affected one current and one former residents and placed the other 87 residents dependent on staff for assistance with transfers at risk for injury. The findings included: Resident #7 Record review of Resident #7's MDS assessment, dated 8/7/17, revealed [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's MDS revealed in part; -limited/1 person physically assist for transfer Record review of Resident #7's care plan initiated on 8/8/17 revealed in part; Focus: ADL Self Care Performance Deficit r/t ineffective gas exchange, generalized weakness. Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with modified independence. Interventions: TRANSFERS: Requires limited assistance X2 staff participation with transfers. Focus: At risk for falls r/t generalized weakness initiated 8/9/17 revised 8/9/17 Goals: will demonstrate the appropriate use of assistive device(s) to increase balance and self-correction when ambulating in the SNF, reducing the potential for falls. Interventions: Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c. Observation on 8/16/17 at 4:10 p.m. revealed Resident #7 was sitting in her recliner with oxygen on, full clothed and no shoes or socks. Resident #7 shoes were in front of her feet with the socks one in each shoe. Resident #7 stated that she was waiting to get in bed so that she could have a chest x-ray done. Observation on 8/16/17 at 4:15 p.m. with CNA-A and CNA-D assisting Resident #7 in a 2 person transfer revealed CNA-A applied the gait belt around the abdomen of Resident #7, explained the procedure and gently kicked Resident #7 shoes to the side. CNA-A and CNA-D placed one hand on the gait belt in front and other hand behind the resident, and on their count of three assisted the resident up out of the recliner. During this time Resident #7 feet slid forward and she lost her balance, CNA-D further kicked Resident #7 shoes to the edge of the bed and pivot to place Resident #7 on the bed. Resident #7 gave a sigh and deep breath. Record review of CNA Kardex (computer system, facility CNAs use to identify resident participation and CNA support required for a specific Resident's ADL needs) for Resident #7 revealed under the section Safety: Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c. and under the section Transfers: Requires limited assist X2 staff participation with transfers. Interview with CNA-A on 8/16/17 at 5:00 p.m. revealed she should have made sure the resident had shoes on and the bed was locked. CNA-A stated Resident #7 didn't fall she slipped and lost her balance. Interview with Resident #7 on 8/16/17 at 6:30 p.m. revealed they facility nursing staff always use a gait belt on her, and she always put her shoes on before she stands up, but this time it didn't happen and she lost her balance and almost fell on the floor. CR #1 Intake # 2 Record review of face sheet dated 8/8/17 revealed CR #1 was [AGE] years old, admitted on [DATE], readmission of 6/28/17 with [DIAGNOSES REDACTED]. Record review of CR #1's MDS assessment, dated 7/18/17, revealed she was: -BIMS = 7, severely impaired cognitively for decision making -extensive/2 person physically assist for transfers -extensive/1 person physically assist for dressing, eating, bed mobility and personal hygiene -total dependence/1 person physically assist for toilet use and bathing -frequently incontinent of bowel and bladder Record review of CR #1's electronic care plan for ADL Care revealed in part; Focus: ADL Self Care Performance Deficit r/t Limited mobility. Interventions/Tasks: TRANSFERS: Requires Mechanical lift for transfers X2 staff assist. Record review of CNA Kardex for Resident #7 revealed under the section Transfers: Requires Mechanical lift for transfers X2 staff assist. Record review of facility Provider Investigation Report dated 8/10/17 revealed on 8/4/17 at 2:30 p.m. LVN T reported that CNA-B and CNA-C request for him to assess CR #1, upon assessment CR #1's right shoulder appeared to be dislocated and according to both CNAs they were transferring CR #1 from the shower chair to bed and after CR #1 was placed on the bed they heard her right shoulder pop. Record review of SBAR dated 8/4/17 timed for 4:48 p.m. revealed Situation, other changes in condition: Suspected shoulder dislocation, Specify exact location of pain: Site Right shoulder (front), Description Suspected dislocation . Record review of Nursing Progress note dated 8/4/17 and timed 8:14 p.m. revealed LVN T documented in part .At about 14:30 (2:30pm) CNA-B reported to this nurse that resident R shoulder appears to be dislocated, enter room observed resident in bed R shoulder appears to be dislocated NP in the building, New order to send resident to ER. Record review of physician progress notes [REDACTED].Visit type: New Problem, This NP was called to patient's room, patient was previously in the shower, according to nursing patient was moved by systems in the shower unclear patient was being held under her arms, right shoulder appears to be dislocated painful, shoulder seems to be protruding for, patient has limited range of motion with excruciating pain. Further review of physician progress notes [REDACTED]. Physical Exam Musculoskeletal: Limited range of motion in right shoulder, right shoulder blade appears to be protruding forward, painful to touch. Assessment & Plan right shoulder pain/dislocation- will send patient to the emergency room , for evaluation and treatment. Record review of Hospital A, X-ray, report dated 8/4/17 results revealed findings in part .[MEDICATION NAME] fracture through the mid-shaft of the humerus, with 7mm of lateral displacement of the distal component. Non-displaced [MEDICAL CONDITION] of the coracoid process of the scapula. Interview with CNA-B on 8/16/17 at 2:15 p.m. revealed on 8/4/17 at about 2:30 p.m. she was needing help to put CR #1 back to be after her shower and that CNA-C helped her. CNA-B stated that CR #1 was able to help a little but both of them put their arm under CR #1 arms and transferred her from the shower chair to the bed and when they did they heard her arm pop. CNA-B stated that she wished she would have used the Hoyer lift to transfer CR #1. CNA-B said she did not look at the Kardex prior to transferring CR #1 but went off memory. CNA-B revealed she was suspended pending investigation and in-serviced 1:1 on looking at Kardex and to have gait belt to transfer properly. Interview with CNA-C on 8/16/17 at 2:30 p.m. revealed on 8/4/17 at about 2:30 p.m. she assisted CNA-B in transferring CR #1 from the shower chair to the bed and did so by placing her arm under CR #1 arm. CNA-C stated when CR #1 was placed on the side of the bed she heard her arm pop. CNA-C said No it was not the proper was to transfer CR #1 under her arms, It could cause injury. CNA-C revealed she was in-serviced on use of the Kardex to ID Resident assistance needed with ADLs and to use gait belt. CNA-C was not aware CR #1 care plan and Kardex included mechanical lift for transfers. Interview on 8/16/17 at 3:20 p.m. with LVN M revealed that she was one of the nurses responsible for updating the care plans but that she also updates the CNA pocket worksheet. LVN M stated that any resident's current care plan should reflect the current MDS. LVN M stated that once the care plan is completed in the computer the information under the Intervention section populates to the Kardex, computer system, facility CNAs use to identify resident participation and CNA support required for a specific Resident's ADL needs and documents care provided. Interview on 8/16/17 at 4:30 p.m. with DON stated she expected the care plan to include how much ADL self-performance and how much physical assistance from direct care staff is required to assist residents in areas of ADL care. DON revealed that she expected MDS nurses to update Care Plans daily as needed and they were to bring their computers to the morning meeting so Care plans could be updated. DON stated CNAs are to follow the Kardex for resident care needs. The facility's CMS 672 form, dated 8/16/17, indicated the facility's census was 89 residents.

Based on interview and record review, the facility failed to provide laboratory services as ordered for 2 of 7 residents (Resident #1 and CR #1) reviewed for laboratory services. - CR #1 had an order to complete a [MEDICATION NAME] lab on 2/9/16. The [MEDICATION NAME] lab was not drawn on 2/9/16 and the resident went to the hospital and was found to have toxicity. - Resident #1 had an order to complete a CMP, CBC, TSH, HGBA 1c, and lipid panel labs on 2/4/2016. The lab was not drawn until 2/11/2016. This failure affected 1 resident and 1 former resident and placed 27 residents at risk of not receiving treatment in a timely manner which could lead to complications and hospitalization . Findings include: Intake # 2 CR #1 Record review of CR #1's medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was discharged to the hospital on [DATE]. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's physician's Order Summary Report dated February 2016 revealed the following order: [MEDICATION NAME] tablet 125 mcg, give 1 tablet by mouth one time a day for heart failure. Hold for heart rate under 60. The order was dated 2/3/16. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's Progress Note dated 2/9/16 revealed that a nurse documented that a CMP, CBC, Lipid, HGBA1c, and TSH were drawn in the morning. Results Pending at this time. Record review of CR #1's Phlebotomy Log revealed that a CMP, CBC, Lipid, HGBA1c, and TSH were requisitioned to be drawn by the Phlebotomist. Record review of Lab Reports printed on 2/9/16 revealed that CR #1 had the above labs drawn. During an interview on 3/22/16 at 12:23 p.m. with the Regional Nurse, she stated that the laboratory was called, and no [MEDICATION NAME] levels were drawn on 2/9/16. She further stated the Phlebotomy log does not have an order for [REDACTED].>During an interview on 3/22/16 at 12:35 p.m. with the administrator, he stated that CR #1's Nurse Practitioner stated the [MEDICATION NAME] level was not a stat order, resident was not sick. He confirmed that the [MEDICATION NAME] level was not drawn at all. Record review of emergency room visit on 2/17/16 for CR #1 resident revealed a [MEDICATION NAME] level of 2.8 ng/ml, normal level (0.5-2.0 ng/ml). Further review revealed that the emergency room physician documented that Resident CR #1 was demonstrating signs of [MEDICATION NAME] toxicity with [MEDICAL CONDITION] and unremitting nausea and vomiting. Resident #1 Record review of Resident #1 ' s medical record revealed he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was [AGE] years of age. Record review of a Resident #1 ' s physician's order [REDACTED]. Record review of Resident #1 ' s Progress Note dated 2/4/2016 revealed that a nurse documented that his labs were drawn that morning. Lab drawn in AM and results pending. Record review of Lab Reports printed on 2/11/2016 revealed that Resident #1 had the above labs collected and completed on 2/11/2016. The physician reviewed the lab results on 2/12/2016. In an interview on 3/22/2016 at 1:55 p.m., ADON A said when a lab was ordered, it was usually collected overnight on the 10 p.m. to 6 a.m. shift. She said a lab collected 7 days after it was ordered was too long. She said she would try to locate Resident #1 ' s labs ordered 2/3/2016. In an interview on 3/22/2016 at 2:03 p.m., ADON A confirmed that Resident #1 ' s labs were not completed until 2/11/2016. In an interview on 3/22/2016 at 2:10 p.m., the DON said she had only been at the facility for 3 days. She said when labs are ordered they are supposed to be completed within 24 hours or if ordered on Friday, completed by Monday. She said a 7 day delay is too long. In an interview on 3/22/2016 at 2:50 p.m., LVN A said she completed the order for Resident #1 ' s labs on 2/3/2016. She said after the order was received, she filled out a requisition form to give to the lab service. She said when she returned to the facility on her next shift, she looked in the progress notes and a nurse note dated 2/4/2016 said that the sample was collected. She said they realized a while later that it was not completed and reordered the labs. Record review of an In-Service Training Report dated 2/25/2016 revealed that nursing staff were educated on lab requisitions, follow-up, and documentation. Night shift to check if labs drawn . Record review of an undated Legend Rounds Observation Tool revealed that staff ensured residents received lab services and a tracking system was in place to ensure labs were completed as ordered. According to the DON, there were 2 residents receiving [MEDICATION NAME] medication. According to the facility census, there were 25 residents on the 400 hall.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain the highest practicable mental and physical well-being in accordance with the comprehensive assessment and plan of care for three of 16 residents (Resident#74, #11 and #80) reviewed for receiving timely medical care after a change in condition. The facility failed to provide prompt treatment to Resident # 74's Stage IV pressure ulcer with exposed sacral bone when it was identified to have become infected, deteriorated and odorous on 7/13/2015. Resident # 74 developed acute ostemylitis, oral antibiotic treatment was not started until 7/18/2015 and Intravenous antibiotics was only started 7/27/15 after wound care specialist recommended IV treatment. The facility failed to provide appropriate wound care and treatment to Resident #74's wound to prevent wound infection and acute ostemylitis to his sacral bone. The facility failed to consult with Resident #74's physician when his heart rate increased. The facility failed to provide assessments and treatments to prevent infection [MEDICAL CONDITION] of the pressure ulcers on Resident #11 ' s buttocks. Resident #11 ran a low grade fever for 15 days, had odor from the wound, and had a critical lab value between 6/12/2015 and 6/27/2015. The resident was finally diagnosed with [REDACTED]. The facility failed to provide appropriate wound care to Resident #11's left knee, left thigh, right ischium, and sacrum pressure ulcer. Resident #80 ' s wound became infected with a bacteria associated with indwelling catheter usage, after multiple occurrences of his indwelling urinary catheter leaking without physician consultation or any interventions. This failure affected three residents who had declines in their health due to delayed or inappropriate treatments and placed ten additional residents with pressure ulcers at increased risk of not having prompt medical interventions provided when a change in condition occurred and a delay in receiving treatment which could negatively impact their health. Findings include: Resident #74 Record review of Resident #74 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. Resident # 74 ' s [DIAGNOSES REDACTED]. Record review of Resident #74's MDS dated [DATE] revealed the resident was dependent with ADLs, and had no documentation for cognition, the resident had one stage III pressure ulcers with a length of 6.0 cm, width x 5.0 cm x 0.3 cm depth. Most severe type of tissue was granulation tissue. Record review of Resident #74 ' s care plan dated 7/28/15 revealed the resident has an infection of the wound; goal was the resident will be free from complication related to infection through the review date. Approach was to administer antibiotic as MD order. Further review of care plan revised 7/28/15 revealed Resident # 74 was on intravenous medication [MEDICATION NAME] related to wound infection through 9/8/15, goal was the resident will not have any other complication related to intravenous therapy ,approach includes-monitor/ document /report to MD as need signs and symptoms of infection at the site: drainage , inflammation, swelling, redness and warmth, signs of infiltration at the site, [MEDICAL CONDITION] at the insertion site , taut or stretching skin , blanching or coolness of the skin slowing or stopping of the infusion, leaking of IV, fluid out of the insertion site etc. Further review of care plan neither addressed [MEDICAL CONDITION] infection nor infection control protocol for staff to observe during care. Record review of Resident #74 ' s initial wound consult evaluation dated 6/15/15 revealed unstageable (Necrotic) wound to sacrum of 3.2 cm length x 2.1 cm width with thick adherent devitalized necrotic tissue of 100%. Debridement was performed. Record review of Resident #74 ' s Wound Care Specialist evaluation dated 6/22/15 revealed a stage IV wound to the sacrum with thick adherent devitalized necrotic tissue of 30%, granulation tissue of 70%, wound improved. Record review of Resident #74 ' s Wound Care Specialist evaluation dated 6/30/15 revealed stage IV wound to sacrum thick adherent devitalized necrotic tissue of 10%; granulation tissue of 90%, wound size was 3 cm x 1.8 cm x 1.8 cm- improved. Record review of Resident #74 ' s Wound Care Specialist evaluation dated 7/6/15 revealed stage IV wound to sacrum, granulation tissue of 100%, wound size same as above and no change. Record review of Resident #74 ' s nurses ' notes dated 7/6/15 at 10;37p.m., revealed a critical lab report received for the stool being positive for [MEDICAL CONDITION]. The physician was notified and a new order for [MEDICATION NAME] liquid 125 mg via [DEVICE] four times daily for 10 days and contact isolation were ordered. Record review of Resident #74 ' s Wound Care Specialist evaluation dated 7/13/15 revealed stage IV wound to sacrum,thick adherent devitalized necrotic tissue of 30%, granulation tissue of 70%. Wound radius had odor-wound deteriorated. Wound size - 3 cm x 2.5 cm x 2.3 cm. Findings indicate deterioration was because of infection. Further review of the additional information section revealed - bone exposed. Patient being treated for [REDACTED]. MD said he would follow up on this. Record review of Resident #74 ' s nurses ' notes dated 7/17/15 at 4:46p.m., revealed culture of the sacral stage IV pressure ulcer revealed moderate Enterbacter Aerogenosa (bacteria usually found in the intestinal tract) , called MD, waiting return call. Call placed to residents responsible party and informed of lab results. gave report to on-coming nurse . Record review of Resident #74 ' s nurses ' notes dated 7/18/15 at 11:58 a.m., revealed called MD to clarify order [MEDICATION NAME] and suggested a midline placement for intravenous antibiotic treatment; MD [MEDICATION NAME] and gave order for midline. Record review of Resident #74 ' s nurses ' notes dated 7/18/15 at 4:07 p.m., revealed infusion nurse from outside company here to insert midline. Midline placement unsuccessful, peripheral placement unsuccessful too, MD notified. [MEDICATION NAME] via G- tube. MD okayed it and gave order for [MEDICATION NAME] 500 mg tablets via [DEVICE] for 14 days. Midline order discontinued. Record review of Resident #74 ' s MAR indicated [REDACTED]. Initial dose administered on 7/18/15 at PM. Record review of Resident #74 ' s Wound Care Specialist evaluation dated 7/20/15 revealed stage IV wound to sacrum, thick adherent devitalized necrotic tissue of 10%, granulation tissue of 90%, Wound size - 3 cm x 2.5 cm x 2.3 cm, with undermining of 2 cm at 10 ' oclock. Further review of the additional information section revealed bone specimen report pending, instructed nurse to call primary care physician when she receives the report and also discussed with DON. Deep swab technique of stage IV pressure wound of the sacrum on 7/14/15 demonstrated Enterbacter Aerogenosa. Record review of Resident #74 ' s bone Biopsy report revealed specimen was collected 7/13/14, received 7/17/15 and report released 7/26/15. [DIAGNOSES REDACTED]. Record review of Resident #74 ' s Wound Care Specialist evaluation dated 7/27/15 revealed stage IV wound to sacrum, thick adherent devitalized necrotic tissue of 10%, granulation tissue of 90%, wound size - 3.5 cm x 2.7 cm x 2.3 cm., no change from 7/20/15, undermining at 2.5 cm at 10 ' oclock. Further review of the additional information section revealed discussed bone specimen report with Primary care physician, recommended intravenous antibiotic for 6 weeks. He agreed with this and said he will give orders to the nurses and follow up. Bone specimen showed acute osteo[DIAGNOSES REDACTED] . Record review of Resident#74 ' s nurse ' s notes dated 7/27/15 at 4:17p.m., revealed resident had new order for PICC (peripheral inserted central catheter) ,start [MEDICATION NAME] 400 mg/ml intravenous twice daily for 6 weeks, start Meropenem 500 mg/ml intravenous every 8 hours for wound /pressure ulcer , check lab-CBC, BMP and phosphorus to be collected in the AM. Record review of Resident#74 ' s MAR indicated [REDACTED] [MEDICATION NAME] 400 mg/ml and Meropenem 500 mg/ml intravenous were started on 7/28/15. Observation of wound care on 7/28/15 at 2:33 p.m., revealed Resident #74 had an unstageable pressure ulcer to the right heel, and stage IV sacrum. Further observation of sacral stage IV revealed dark macerated large wound to sacrum area. The wound had a foul odor, appeared wet and had a heavy drainage. The wound bed had some slough with undermining noted at 12pm, 3pm and 6pm. Further observation on 7/28/15 at 2:33 p.m., of the wound care revealed RN#3 pushed normal saline out from a bullet into the wound. She then attempted cleaning the wound bed by putting one finger into the wound cavity and drying the normal saline inside not paying attention to the undermining. She used one side of the gauze to clean several areas. She did not clean the wound edge and cleaned the surrounding sacral area moving up to down, and side to side in no particular order using one side of the gauze on multiple areas. Interview following wound care on 7/28/15 at 2:33 p.m when RN#3, was asked about the odor from the wound, she said the resident had osteo[DIAGNOSES REDACTED] to his sacral bone and that the wound was not infected. She said the Wound Care Specialist was at the facility yesterday to see the wound. She said the resident was on an antibiotic treatment. She expressed the wound odor was bad before and it was better now. Record review of Resident #74 ' s record revealed an SBAR (screening, background, assessment and report) for a change in condition on 7/29/15 at 2:00 p.m. Resident #74 had a low grade fever of 100.3. MD was in the facility at 5:30 p.m., and wrote order for UA with culture and sensitivity, chest X-ray follow up fever, and blood culture and sensitivity twice. Tylenol 325 mg was given for mild fever 100.3. At 6:30 p.m., temperature decreased to 98.9. Record review of Resident #74 ' s nurses notes dated 7/30/15 revealed at 6:10 a.m., temperature was 99.8. Tylenol 32 5mg two tablets given. Record review of Resident #74 ' s chest X-ray dated 7/29/15 revealed mild [MEDICAL CONDITION] vascular congestion. Interview on 7/30/15 at 10:30 a.m., LVN #2 said Resident #74' s heart rate around 9:00 a.m., was 130. She said the resident ' s physician was not notified of the elevated heart rate because she was busy trying to administer medications to other residents. LVN # 2 agreed the resident ' s heart rate was elevated and was a change in his condition . LVN #2 expressed the resident had a change in condition yesterday and labs were ordered by the physician. Interview on 7/30/15 at 2:30 p.m., LVN # 2 said the residents ' physician was notified of his elevated heart rate around 10:45 am and an order was received to transfer the resident to the hospital. Record review of Resident #74 ' s physician's orders [REDACTED]. Record review of Resident #74 ' s MAR indicated [REDACTED] [MEDICATION NAME] tablet 50 mg, give three tablets via G- tube two times a day for hypertension, hold for SPB less than 90, call if pulse was greater than 105.,medication times were 8am and 4pm. The medication was documented as given every day. Further review of Resident #74 ' s MAR indicated [REDACTED] 7/13/15 -112, 141, 118 and 112. 7/14/15- 120, 124 and 118. 7/15/15- 112. 7/17/15- 109 and 110. 7/18/15- 115. 7/19/15-125. 7/20/15- 137, and 112. 7/21/15- 109, and 109. 7/23/15-118. 7/24/15- 112, -108. 7/25/15- 117, 122, 108 and 120. 7/26/15- 128 and 131. 7/27/15-121, 121 and 121. 7/28/15-121. Record review of Resident # 74 ' s nurse ' s notes revealed there was no documentation indicating the resident ' s physician was consulted of any of the elevated heart rates on any of the dates. Interview on 7/30/15 at 4:30 p.m., RN# 3 said she had been doing wound treatments in the facility for about 3 months. She expressed prior to working at the facility she had 3 month wound care experience somewhere else. RN# 3 said she did not receive wound management training prior to assuming the wound treatment position. She said the Wound Care Specialist contacted and notified the resident ' s primary care physician on the resident's wound progress. She said she did not notify Resident # 74 ' s physician of his wound infection because the Wound Care Specialist discusses those things with the primary care physician and then would tell her to follow up. She stated the Wound Care Specialist came to the facility on e time a week. Resident #11 Record review of Resident #11 ' s face sheet revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #11 ' s admission MDS dated [DATE] revealed no cognitive screen was completed due to the resident ' s inability to respond. Continued review of the resident ' s MDS revealed he was dependent on two facility staff for all care. Record review of Resident #11 ' s initial care plan for pressure ulcers dated 6/16/15 revealed locations of Left Heel, Right Hip, Left Buttocks, Right Buttocks, and Right Heel with interventions which included for staff to notify physician for any signs/symptoms of infection. The same care plan revealed the resident was totally dependent on staff for all bed mobility and ADLs. Record review of Resident #11's June 2015 physician's orders [REDACTED]. Terbinafine HCL tablet 250 mg-give 2 tablets daily for antifungal for 42 days start date 6/12/15. Voriconazole tablet 200 mg-give 2 tablets every 12 hours for antibiotic for 30 days start date 6/12/15. Record review of Resident #11 ' s medical record revealed the following Wound Care Specialists documentation: 6/15/15-Initial evaluation by Wound Care Specialist per physician request. Right buttock wound unstageable with necrosis (dead tissue). Wound size was 6 cm X 4 cm with moderate serous exudate (drainage from the circulatory system containing serum).The wound was debrided. Left buttock stage III pressure ulcer. Wound size 4.8 cm X 4.5 cm X 0.2 cm with moderate serous exudate. 6/22/15-Right buttock wound unstageable due to necrosis. Wound size 6 cm X 4 cm with moderate serous exudate. The wound was debrided. Left buttock stage III. Wound size 4.5 cm X 4.0 cm X 0.2cm with moderate serous exudate. Record review of Resident #11 ' s progress notes revealed the following: 6/12/15-the nurse took the patient ' s temp which was 100.3. The patient ' s family asked the nurse to transfer the patient to the hospital. The nurse called the Nurse Practitioner (NP) and an order was given to administer Tylenol then monitor vital signs after 30 minutes. The nurse also told the NP the family was insisting to transfer patient to the hospital and the NP responded the family would have to sign an Against Medical Advice (AMA) form. The family declined to sign the AMA and told the nurse to continue monitoring the patient. 30 minutes after administration of medications the patient ' s temperature was 98.2. 6/20/15 11:00 A.M.-resident noted with elevated temp of 100.3 and heart rate of 120. NP notified and orders received for labs and chest x-ray. 6/20/15 12:30 P.M.-week-end treatment nurse documented left buttock had small serosanguinous (pale red to pink in color serous drainage) discharge and odor was present. 6/20/15 10:54 P.M.-critical lab hemoglobin 7.0 received. NP notified, no new orders. NP will be here in a.m. to assess resident. 6/23/15 8:59 P.M.-temperature 100.3. Two tabs of [MEDICATION NAME] 325 mg given. 6/26/15 8:49 P.M.-week-end treatment nurse documented cleansed and dressed buttock wound twice, one in a.m. and another at 8:30 p.m. since family requested to change. (family member) verbalized wound is smelling foul. CNA and wound care nurse dressed the wound again. Wound had scant discharge, wound bed with 30% slough, foul smell was noted. Treatment in place and informed the family that resident is on antibiotic twice daily and stop date would be 7/18. Family said that every night when they come the resident had fever. Informed the charge nurse regarding it and the LVN charge nurse took temperature and called the NP for the condition. Charge nurse relayed the NP is coming tomorrow to assess the patient. 6/27/15 10:57 A.M.-Spoke to NP. Fever 100.6. Advised to give two tabs of [MEDICATION NAME] 325mg tablets. 6/28/15-LVN documented at 5:00 P.M. on 6/27/15 the resident had fallen to the floor from a Hoyer stretcher. NP notified and the resident was transferred to the hospital ER 911. Record review of the hospital ER physician note revealed the following: Additional physical exam information large sacral decubitus ulcer with foul smelling discharge. Hemoglobin 6.2 Hematocrit 20.1 Critical values. The resident was admitted as an in-patient to the telemetry unit. Record review of the physician's History and Physical for Resident #11 dated 7/27/15 revealed the following documentation: Last month had a fall and was transferred to the hospital There he was treated for [REDACTED]. Observation of Resident #11 on 7/28/15 at 9:02 A.M. during initial tour revealed the resident was lying in bed resting comfortably. He had an indwelling catheter to gravity drainage and a [DEVICE] for nutrition with a feeding infusing at 60cc. He had non-purposeful movement of the right hand and was observed grabbing at covers. He was groomed, no odors present. His left hand was contracted and there was no hand roll or splint in place. Interview on 7/28/15 at 9:02 A.M. LVN#25, she stated Resident #11 was to have nothing by mouth ( NPO), non-responsive and bedfast. She stated he had an indwelling catheter due to sacral wounds, was on IV antibiotics and had a PICC line. She said he had an abdominal dressing next to his [DEVICE] and she did not know why or what was under it. She also said he was on isolation [MEDICAL CONDITION] to his wounds. She further stated he had returned from the hospital last Friday after a long stay. She stated he was transferred to the hospital on [DATE] due to being dropped during a transfer. Interview on 7/30/15 at 12:30 P.M. RN #3 treatment nurse stated she works Monday through Friday and had not noted any odors to the wounds for Resident #11. She said the week-end RN documented odors but did not leave her a message in her report of any odor. She stated the week-end treatment nurse usually communicated to her by leaving a written report and the Wound Care Specialist saw the resident every Monday. Attempts to contact the week-end treatment nurse for an interview were unsuccessful. Observation on 7/30/14 at 2:35 P.M. of RN #3 and LVN #9 as they performed wound care for Resident #11's left knee, left thigh, right ischium, and sacrum revealed the following: RN #3 used a normal saline bullet to squeeze normal saline on Resident #11's left knee wound and used a gauze dressing to clean inside and outside the wound area wiping several times with the same gauze. She did this twice. RN#3 used a normal saline bullet to squeeze normal saline on the resident's left thigh wound and wiped around the wound four times using the same gauze. RN #3 used a normal saline bullet to squeeze normal saline on the resident's right ischial wound and wiped around the wound several times using the same gauze. She did this twice. LVN #9 performed wound care on the abdominal wounds. There were four separate wounds but RN#3 stated they were measured as one due to the close proximity of each wound however there was closure of skin between each wound. LVN #9 used a normal saline bullet to squeeze normal saline on each wound and cleansed each one with the gauze dressing. She then squeezed normal saline on the proximal abdominal wound and used a gauze to clean the area wiping four times using the same gauze. She then used one gauze moistened with normal saline to clean the two middle wounds several times. RN#3 used a normal saline bullet to squeeze normal saline on the sacral wound and wiped the wound and surrounding area several times using the same gauze. She repeated this twice. Interview immediately after the wound care on 7/30/14 at 2:35 P.M. revealed LVN #9 and RN#3 did not recognize any infection control issues with the way the wound care was performed. Neither nurse identified that using the same gauze over the wound in different areas several times would cross contaminate the area. Resident # 80 Record Review of Admission Record revealed Resident #80 was a [AGE] year old male originally admitted on [DATE] with [MEDICAL CONDITION] with Depressed Mood, [MEDICAL CONDITION], Paralysis Agitans, Pressure Ulcer, Contracture of Joint Multiple Sites, Muscular Wasting, Muscle Weakness, and Dysphagia. Resident #80 was readmitted to the facility on [DATE] with Gastrointestinal Tract Hemorrhage, [MEDICAL CONDITION], and Gastrostomy. Record Review of MDS dated [DATE] revealed Resident #80 was rarely/never understood with severely impaired cognitive skills for daily decision making. Resident #80 was totally dependent on staff for bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene, and bathing. Resident #80 had impaired range of motion to both sides of his upper and lower extremities and was always incontinent of both bowel and bladder. Resident #80 had one Stage IV pressure ulcer and one unstageable pressure ulcer due to eschar. Record Review of MDS dated [DATE] revealed Resident #80 was rarely/never understood with severely impaired cognitive skills for daily decision making, altered level of consciousness, and psychomotor [MEDICAL CONDITION]. Resident #80 remained totally dependent on staff for bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene, and bathing. Resident #80 continued to have impaired range of motion to both sides of his upper and lower extremities and remained always incontinent of bowel. Resident #80 had an indwelling catheter for urination. Resident #80 had one Stage IV pressure ulcer with granulation tissue. Record Review of Resident #80 ' s Care Plan initiated on 2/20/2015, revised on 7/30/2015 revealed Resident #80 was admitted on [DATE] with an unstageable 6 cm x 7 cm x 0.3 cm decubitus ulcer to the sacral area. He was initially admitted as hospice-respite resident from a private home. Resident #80 was discharged to the hospital on [DATE] due to a change of condition. He was discharged with Stage IV sacral 2.7 cm x 2 cm x 0.5 cm pressure ulcer. He was readmitted back to the facility on [DATE] with a Stage IV sacral pressure measuring 4 cm x 3 cm x 0.9cm. His current pre-[MEDICATION NAME] level on 2/25/2015 was 13.8 mg/dl which is below the normal range of 19-38 mg/mg. Stage IV sacrum currently 3.5 cm x 2.6 cm x 0.5cm, left ear pressure from O2 tubing. Care Plan Interventions initiated 2/20/2015 include Notify physician for any signs and symptoms of infection to the site. and Position off wound, if possible. Record Review of Nurses Notes revealed Resident #80 had a leaking catheter that soiled the brief on 6/25/2015, 6/29/2015, 7/5/2015, and 7/19/2015. The catheter size remained an #18 with 30 ml bulb. Record Review of Wound Care Specialist Evaluation dated 7/6/2015 revealed Stage IV sacral wound duration greater than 161 days improving with decreased necrotic tissue and surface area, wound size 2.7 cm x 1.9 cm x 0.4 cm surface area 5.13 cm2. Wound dressing order changed from previous order of Lodosorb and PRN Barrier cream surrounding wound bed. New order cleanse sacral wound with normal saline, pat dry, apply silver absorbing agent and PRN Barrier cream surrounding skin and cover with dry protective dressing every day. Record review of Wound Care Specialist Evaluation dated 7/13/2015 revealed Stage IV sacral wound duration greater than 167 days Deteriorated with generalized decline of patient, recommendation to reposition side to side only, wound size 3.2 cm x 2.3 cm x 0.5 cm surface area 7.36 cm2. Wound dressing order changed to cleanse sacral wound with normal saline, pat dry, apply pack of dakins (wet to dry dressing) and cover with dry protective dressing every day. Record Review of Wound Care Specialist Evaluation dated 7/20/2015 revealed Stage IV sacral wound duration greater than 174 days Deteriorated with generalized decline of patient, wound size 3.5 cm x 2.6 cm x 0.5 cm surface area 9.10 cm2. Wound dressing order changed to cleanse sacral wound with normal saline, pat dry, apply polymem silver and Barrier cream surrounding wound, cover with dry protective dressing every day. Record Review of Wound Care Specialist Evaluation dated 7/27/2015 revealed Stage IV sacral wound duration greater than 180 days Deteriorated with Infection, procedure to surgically excise subcutaneous tissue along with infected tissue, wound size 4.1 cm x 2.8 cm x 0.5 cm surface area 11.48 cm2. Wound dressing order changed to cleanse sacral wound with normal saline, pat dry, apply [MEDICATION NAME] Blue and cover with dry protective dressing every day. Record Review of Resident #80 Medical Record revealed no communication with primary physician of deteriorating wound condition or infection. Observation on 7/28/2015 at 9:30 am revealed Resident #80 dressed in a hospital gown, lying on an air mattress with eyes closed, arms crossed over chest. Interview on 7/28/2015 at 9:31 am with RNA #5 revealed Resident #80 was alert and oriented times one, bedfast, incontinent of bowel, contracted in bilateral upper and lower extremities and had an indwelling catheter, gastrostomy tube, and a wound on his bottom. Record Review of Nurse Note for Resident #80 dated 7/30/2015 revealed Resident #80 had a temperature of 104.4 degrees. Nurse Practitioner was notified and ordered a Stat Chest X-ray, CBC, CMP, increase bolus flushes, one time dose Tylenol 650 mg via gtube, and one time dose [MEDICATION NAME] 1GM injection. Tylenol was administered at 12:30 pm and [MEDICATION NAME] was administered at 1:00 pm. Temperature was 103.7 degrees at 1:45 pm and 102.8 degrees at 3:00 pm. (Family member) requested that Resident #80 be sent to the hospital. Interview with LVN #16 on 7/30/2015 at 4:48 pm revealed Resident #80 is being sent to the hospital because he has an elevated temperature, I was told during shift change and up until now he has not had a fever. When asked if Resident #80 was receiving an antibiotic, LVN #16 stated The Nurse Practitioner ordered a one-time dose of [MEDICATION NAME] IM today just [MEDICATION NAME]. Record Review of Situation Background Assessment Recommendation (SBAR) dated 7/30/2015 and completed by LVN #16 revealed Resident #80 had a Change of Condition to include a fever of 104.4 degrees axillary, other things that have occurred with this change are swelling, shaking, chills and increased respirations . Record Review of Access Clinical Laboratory Wound Culture collected 7/28/2015 and released 7/30/2015 revealed sacral wound contained Heavy Providencia Stuartii organism. Record review of the National Center for Biotechnology Information, Providencia Stuartii is a common cause of antibiotic-resistant bacteriuria in patients with long-term indwelling catheters. Record review of facility policy on skin care did not address the above concerns. A policy concerning resident assessments and change of conditions was requested but not provided prior to exit. The facility's CMS form 672 dated 7/28/15 revealed 13 residents had pressure sores in the facility.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician when there was changes in condition which occurred in three of sixteen residents (Residents #11, #80 and #74) reviewed for notification of physician. Resident #11's physician was not consulted when there was a change in his Stage IV pressure sore concerning an odor. On 6/20/15 the week-end treatment nurse documented the left buttock had small serosanguinous discharge and odor was present. On 6/28/2015 the resident was transferred to the hospital [MEDICAL CONDITION] (a life threatening complication of an infection) was diagnosed Resident #80 ' s physicians was not promptly consulted concerning the continued leakage of urine from the indwelling catheter. On 7/30/2015 the resident's wound culture results were positive for Providencia Stuartill ( antibiotic-resistant bacteriuria related to indwelling catheters). Resident # 74 ' s physician was not consulted of his increased heart rates which affected the administration of the residents antihypertensive medication. These failures affected three residents who were denied prompt interventions for their conditions and a hospitalization stay for one resident and placed 89 residents at risk of not having their physicians promptly consulted when a change in condition occurs which would cause a hospital stay, pain, delay in treatment and a decline in health. Findings include: Resident #11 Record review of Resident #11 ' s face sheet revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #11 ' s admission MDS dated [DATE] revealed no cognitive screen was completed due to the resident ' s inability to respond. Continued review of the resident ' s MDS revealed he was dependent on facility staff for all care and required two persons to assist. The same MDS revealed the resident had two unstageable pressure ulcers due to slough or escar tissue upon admission. The MDS also revealed on admission the resident had a total of 1 stage II pressure sore and 1 stage III pressure sore. The MDS revealed the resident received tube feedings to meet his nutritional needs. Record review of Resident #11 ' s care plan for pressure ulcers dated 6/16/15 revealed an intervention which included: Notify physician for any signs/symptoms of infection. Record review of Resident #11's physician's orders [REDACTED]. Left Knee: Cleanse with normal saline (ns), pat dry, apply hydrogel and cover with dry dressing every day. Sacral area: Cleanse with ns, pat dry, apply silver absorbing agent. Cover with 4x4 and dry dressing every day. Left Buttock: Clean with ns, pat dry, cover with calcium alginate and dry dressing every day and as needed. Right Ischium: Clean with ns, apply santyl, cover with dry dressing every two days. Back upper Right Leg: Clean with ns, apply skin prep. and dress daily. Right Heel : Clean with ns, pat dry, apply skin prep every day. Left Heel: apply skin prep., pat dry and dress daily. Left Medial thigh: clean with ns, pat dry apply hydrogel. Cover with dry protective dressing every day. Abdominal Wound: Clean with ns, pat dry, apply Silver absorbing agent and cover with dry dressing every day. Observation of Resident #11 on 7/28/15 at 9:02 A.M. during initial tour revealed the resident was lying in bed resting comfortably. He had an indwelling catheter to gravity drainage, [DEVICE] for nutrition with a feeding infusing at 60 cc. He had non-purposeful movement of the right hand and was observed grabbing at covers. He was groomed, no odors present. His left hand was contracted and there was no hand roll or splint in place. Interview at the time of the above observation LVN#25 stated Resident #11 was NPO, non-responsive and bedfast. She stated he had an indwelling catheter due to sacral wounds, was on IV antibiotics and had a PICC line. She said he had an abdominal dressing next to his [DEVICE] and she did not know why or what was under it. She also said he was on isolation [MEDICAL CONDITION] to his wounds. She further stated he had returned from the hospital last Friday for a long stay after being sent out on 6/27/15 due to being dropped during a transfer. Record review of Resident #11 ' s medical record revealed the following wound care physician documentation: 6/15/15-Initial evaluation by wound care per physician request. Right buttock wound unstageable with necrosis. Wound size 6 X 4 cm with moderate serous exudate. The wound was debrided. Left buttock stage III pressure ulcer. Wound size 4.8 X 4.5 X 0.2 cm with moderate serous exudate. 6/22/15-Right buttock wound unstageable due to necrosis. Wound size 6 X 4 cm with moderate serous exudate. The wound was debrided. Left buttock stage III. Wound size 4.5 X 4.0 X 0.2 cm with moderate serous exudate. Record review of Resident #11 ' s progress notes revealed the following: 6/20/15 12:30 P.M.-week-end treatment nurse documented left buttock had small serosanguinous discharge and odor was present. 6/26/15 8:49 P.M.-week-end treatment nurse documented cleansed and dressed buttock wound twice, one in a.m. and another at 8:30 p.m. since family requested to change. Mother verbalized wound is smelling foul. CNA and wound care nurse dressed the wound again. Wound had scant discharge, wound bed with 30% slough, foul smell was noted. Treatment in place and informed the family that resident is on antibiotic twice daily and stop date would be 7/18. Family said that every night when they come the resident has fever. Informed the charge nurse regarding it and the LVN charge nurse took temperature and called the NP for the condition. Charge nurse relayed the NP is coming tomorrow to assess the patient. 6/28/15-LVN documented at 5:00 P.M. on 6/27/15 the resident had fallen to the floor from a Hoyer stretcher. NP notified and the resident was transferred to the hospital ER 911. Record review of the hospital ED physician note revealed the following: Additional physical exam information large sacral decubitus ulcer with foul smelling discharge. Hemoglobin 6.2 Hematocrit 20.1 Critical values. The resident was admitted as an in-patient to the telemetry unit. Record review of the physician H&P for Resident #11 dated 7/27/15 revealed the following documentation: Last month had a fall and was transferred to the hospital There he was treated for [REDACTED]. Interview on 7/30/15 at 12:30 P.M. RN #3 treatment nurse stated she works Monday through Friday and hadn ' t noted any odors to the wounds for Resident #11. She said the week-end RN documented odors but did not leave her a message in her report of any odor. She stated the week-end treatment nurse usually communicated to her by leaving a written report and the wound doctor saw the resident every Monday. Attempt to contact week-end treatment nurse for interview was unsuccessful. Resident #80 Record Review of Admission Record revealed Resident #80 was a [AGE] year old male originally admitted on [DATE] with [MEDICAL CONDITION] with Paralysis Agitans, Pressure Ulcer, Contracture of Joint Multiple Sites, Muscular Wasting, Muscle Weakness, and Dysphagia. Resident #80 was readmitted to the facility on [DATE] with Gastrointestinal Tract Hemorrhage, [MEDICAL CONDITION], and Gastrostomy. Record Review of MDS dated [DATE] revealed Resident #80 was rarely/never understood with severely impaired cognitive skills for daily decision making. Resident #80 was totally dependent on staff for bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene, and bathing. Resident #80 had impaired range of motion to both sides of his upper and lower extremities and was always incontinent of both bowel and bladder. Resident #80 had one Stage IV pressure ulcer and one unstageable pressure ulcer due to eschar. Record Review of MDS dated [DATE] revealed Resident #80 was rarely/never understood with severely impaired cognitive skills for daily decision making, altered level of consciousness, and psychomotor [MEDICAL CONDITION]. Resident #80 remained totally dependent on staff for bed mobility, transfers, ambulation, dressing, eating, toileting, hygiene, and bathing. Resident #80 continued to have impaired range of motion to both sides of his upper and lower extremities and remained always incontinent of bowel. Resident #80 had an indwelling catheter for urination. Resident #80 had one Stage IV pressure ulcer with granulation tissue. Record Review of Resident #80 ' s Care Plan initiated on 2/20/2015, revised on 7/30/2015 revealed Resident #80 was admitted on [DATE] with an unstageable 6cm x 7 cm x 0.3 cm decubitus ulcer to the sacral area. Resident #80 was discharged to the hospital on [DATE] due to a change of condition. He was discharged with Stage IV sacral 2.7 cm x 2 cm x 0.5 cm pressure ulcer. He was readmitted back to the facility on [DATE] with a Stage IV sacral pressure measuring 4 cm x 3 cm x 0.9cm. Care Plan Interventions initiated 2/20/2015 include Notify physician for any signs and symptoms of infection to the site. and Position off wound, if possible. Record review of Resident #80's care plan dated 3/01/2015 revealed a focus the resident was at risk of developing new skin breakdown due to incontinence. The intervention revealed to keep resident clean and dry. Record review of Resident #80's care plan dated 4/27/2015 revealed a focus of the resident having an indewelling catheter. In the section marked interventions the following areas were listed to monitor/record. report to MD of signs and sypmtoms of UTI, pain , burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp. urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns (resident was feed by [DEVICE]). The same care plan revealed the catheter was to be changed every three weeks. Record review of Resident #80's current physician's orders [REDACTED]. 30 ml bulb catheter on the first of each month and as needed for non working catheter. The original order date of this order was 5/17/2015. Record Review of Nurses Notes revealed Resident #80 had a leaking catheter that soiled the brief on 6/25/2015, 6/29/2015, 7/5/2015, and 7/19/2015. The catheter size remained an #18 with a 30ml bulb. There was no documentation on any of the dates where leakage was noted, or consulting with the physician. Record Review of Wound Care Specialist Evaluation dated 7/6/2015 revealed Stage IV sacral wound duration greater than 161 days improving with decreased necrotic tissue and surface area, wound size 2.7 cm x 1.9 cm x 0.4 cm surface area 5.13 cm2. Wound dressing order changed from previous order of Lodosorb and PRN Barrier cream surrounding wound bed. New order cleanse sacral wound with normal saline, pat dry, apply silver absorbing agent and PRN Barrier cream surrounding skin and cover with dry protective dressing every day. Record review of Wound Care Specialist Evaluation dated 7/13/2015 revealed Stage IV sacral wound duration greater than 167 days Deteriorated with generalized decline of patient, recommendation to reposition side to side only, wound size 3.2 cm x 2.3 cm x 0.5 cm surface area 7.36 cm2. Wound dressing order changed to cleanse sacral wound with normal saline, pat dry, apply pack of dakins (wet to dry dressing) and cover with dry protective dressing every day. Record Review of Wound Care Specialist Evaluation dated 7/20/2015 revealed Stage IV sacral wound duration greater than 174 days Deteriorated with generalized decline of patient, wound size 3.5 cm x 2.6 cm x 0.5 cm surface area 9.10 cm2. Wound dressing order changed to cleanse sacral wound with normal saline, pat dry, apply polymem silver and Barrier cream surrounding wound, cover with dry protective dressing every day. Record Review of Wound Care Specialist Evaluation dated 7/27/2015 revealed Stage IV sacral wound duration greater than 180 days Deteriorated with Infection, procedure to surgically excise subcutaneous tissue along with infected tissue, wound size 4.1 cm x 2.8 cm x 0.5 cm surface area 11.48 cm2. Wound dressing order changed to cleanse sacral wound with normal saline, pat dry, apply [MEDICATION NAME] Blue and cover with dry protective dressing every day. Record Review of Resident #80 Medical Record revealed no communication with primary physician of deteriorating wound condition or the infection documented by the wound care specialist. Observation on 7/28/2015 at 9:30 am revealed Resident #80 dressed in a hospital gown, lying on an air mattress with eyes closed, arms crossed over chest. He had a catheter in place. Interview on 7/28/2015 at 9:31 am with RNA #5 revealed Resident #80 was alert and oriented times one, bedfast, incontinent of bowel, contracted in bilateral upper and lower extremities and had an indwelling catheter, gastrostomy tube, and a wound on his bottom. Record Review of Nurse Note for Resident #80 dated 7/30/2015 revealed Resident #80 had a temperature of 104.4 degrees. Nurse Practitioner was notified and ordered a Stat Chest X-ray, CBC, CMP, increase bolus flushes, one time dose Tylenol 650 mg via gtube, and one time dose [MEDICATION NAME] 1GM injection. Tylenol was administered at 12:30 pm and [MEDICATION NAME] was administered at 1:00 pm. Temperature was 103.7 degrees at 1:45 pm and 102.8 degrees at 3:00 pm. (Family member) requested that Resident #80 be sent to the hospital. Interview with LVN #16 on 7/30/2015 at 4:48 pm revealed Resident #80 is being sent to the hospital because he has an elevated temperature, I was told during shift change and up until now he has not had a fever. When asked if Resident #80 was receiving an antibiotic, LVN #16 stated The Nurse Practitioner ordered a one-time dose of [MEDICATION NAME] IM today just [MEDICATION NAME]. Record Review of Situation Background Assessment Recommendation (SBAR) dated 7/30/2015 and completed by LVN #16 revealed Resident #80 had a Change of Condition to include a fever of 104.4 degrees axillary, other things that have occurred with this change are swelling, shaking, chills and increased respirations . Record Review of Access Clinical Laboratory Wound Culture collected 7/28/2015 and released 7/30/2015 revealed sacral wound contained Heavy Providencia Stuartii organism. Record review of the National Center for Biotechnology Information revealed Providencia Stuartii is a common cause of antibiotic-resistant bacteriuria in patients with long-term indwelling catheters. Resident # 74 Record review of Resident #74 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. Resident # 74 ' s [DIAGNOSES REDACTED]. Record review of Resident #74 ' s physician's orders [REDACTED]. Record review of Resident #74 ' s MAR dated July 2015 revealed [MEDICATION NAME] tablet 50 mg, give three tablets via G- tube two times a day for hypertension, hold for SPB less than 90, call if pulse was greater than 105. Medication times were 8 am and 4pm. The medication was documented as given every day for July 2015 and there were no documented Pulse with each administration time. Further review of Resident #74 ' s MAR dated July 2015 revealed the following pulse rates: 7/13/15 -112, 141, 118 and 112. 7/14/15- 120, 124 and 118. 7/15/15- 112. 7/17/15- 109 and 110. 7/18/15- 115. 7/19/15-125. 7/20/15- 137, and 112. 7/21/15- 109, and 109. 7/23/15-118. 7/24/15- 112, -108. 7/25/15- 117, 122, 108 and 120. 7/26/15- 128 and 131. 7/27/15-121, 121 and 121. 7/28/15-121. Record review of Resident # 74 ' s nurse ' s notes did not reveal any documentation indicating the resident ' s physician was consulted for any of the elevated heart rates on any of the above dates. Observation on 7/29/15 at 11:58 a.m., Resident #74 was in bed with a [MEDICAL CONDITION] and [DEVICE] in place. The resident was non- responsive and made no eye contacts. Interview on 7/30/15 at 10:30 a.m., LVN#2 said Resident #74' s heart rate was 130 at 9:00 AM. She said the resident ' s physician was not notified of the elevated heart rate because she was busy trying to administer medications to other residents. LVN # 2 agreed the resident ' s heart rate was elevated. She reviewed Resident # 74 ' s MAR and expressed she was not aware of the order to call the physician if the heart rate was greater than 105. LVN #2 however said an elevated heart rate of 130 should be reported to the physician immediately. Interview on 7/30/15 at 430 p.m., RN# 3 said she had been doing wound treatments in the facility for about 3 months , she expressed prior to the facility she had 3 month wound care experience somewhere else. RN# 3 said she did not receive wound management training prior to resuming the position. She said the wound specialist would contact and notify the residents primary care physicians or their wound progress. A policy concerning the consulting with physicians was requested but not provided prior to exit. The facility's CMS form 672 dated 7/28/15 revealed a census of 92.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the comprehensive assessment to manage pain to attain or maintain the highest practicable physical and mental well-being for two of 11 residents (Residents #1 and # 2) reviewed for pain management. Resident # 1 and Resident #2 both had pain that was not effectively managed . This failure affected two residents who were observed in pain which restricted them from normal activities and sleep and placed 97 residents at risk of their needs not being assessed and managed which could lead to a decline in both physical abilities and psychosocial well-being. Findings included: Intake 4 Record review of Resident #1's record revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1 ' s care plan with target date 3/31/15 revealed the resident was at risk of pain or discomfort related to a wound and debility take [MEDICATION NAME] and Tylenol as needed. Goal was the resident would maintain current ADLs and pain /discomfort would be relieved within one hour after interventions over the next 90 days. Approaches were staff was to administer medications as ordered and monitor /document for efficacy. Record review of Resident #1 ' s MDS dated [DATE] , revealed the resident's cognition score was a four which meant she was severely impaired with no acute change in mental status. The form indicated a pain assessment should be conducted but there was no assessment documented on this form. Record review of Resident # 1 ' s MAR indicated [REDACTED]. Record review of Resident # 1 ' s MAR indicated [REDACTED]. The MAR further revealed the medication was administered once on 6/6/15 at 7:56 p.m., (pain assessment was documented as assessed with [REDACTED]. Record review of Resident # 1 ' s MAR indicated [REDACTED]. The medication was ordered 6/13/15. Record review of Resident # 1's grievance report dated 6/9/15 revealed Resident #1 ' s family member reported the resident had said yesterday (6-8-2015), during the 6 AM -2 PM shift a woman told her to shut up. Further review of the report revealed an interview with the resident stated she was told to shut up and not say nothing or she wouldn ' t get any pain medication. The resident stated she was in pain and the incident occurred in the morning. She stated she suffered the whole day. Record review of facility ' s investigation worksheet dated 6/9/15 revealed Resident #1 was escorted around the facility and she identified the alleged perpetrator by pointing at the facility's medication aide assigned to her hall on 6/8/15 for the 6-2 shift. The medication aide was terminated for substandard quality of care. The investigation summary revealed Resident #1 was interviewed again on 6/10/15 and asked about the event when the staff member told her to shut up. Resident #1 responded oh yeah, I didn't get no pills. They didn ' t give me any. They would see me but wouldn ' t hear me, and I aint telling a story. When asked if she was getting her medication , she stated now they have ,then I could not sleep . Investigation summary further revealed the resident did not appear to have suffered any negative impact from the incident. The facility reviewed her pain assessment sheet that monitored her pain, which revealed Resident #1 did not show any major pain on 6/8/15 and the allegation of abuse was unfounded . Observation/interview on 6/23/15 at 10:30 a.m., revealed Resident # 1 in bed, alert and oriented. She complained of pain to the right side of the neck and right leg area. Resident # 1, who was hard of hearing especially to her right ear (had no hearing aid), read a question and responded her pain level was a 9 on a scale of 1-10 with 10 being the worst. When asked about the alleged abuse incident, Resident # 1 stated they treat me bad. They don ' t hear me when I call. They don ' t answer me, don ' t give me no pain medication. I was let in pain the whole day, I suffered all day, I couldn ' t sleep because it hurt too much. Resident #1 appeared frustrated when talking about the incident and stated she was disappointed with the way she was treated, and continued to verbalize pain to her neck and leg . Observation on 6/23/15 about 12:05 p.m., revealed Resident # 1 sitting in a wheelchair in her room. She again verbalized pain to her right leg. Interview at the time of the observation on 6/23/2015 at 12:05 pm, RN#1 stated an aide brought the resident back to her room from the activity area and notified her that she was in pain. RN# 1 said she went to her and noted the resident was rubbing her right knee, and confirmed she was in pain. RN # 1 stated she did not ask how much pain the resident was having but believed she was in pain due to her rubbing her knee area. She then stated she administered Tylenol 650 mg to her at 11:47 a.m. RN# 1 said she would say the resident's pain was about 3 on the scale 1-10. RN # 1 reviewed the resident's MAR indicated [REDACTED]. When RN #1 was asked how she knew the mediation was already effective, she stated the resident wasn ' t rubbing her knee so she went ahead and documented it was effective. She then said I guess I should have waited. Observation on 6/23/15 at 12:20 p.m., Resident #1 was still sitting in her wheelchair in her room and verbalized the pain to her right leg was the same . She stated she was given some medication but it still hurt. Interview on 6/23/15 at 1:37 p.m., CNA# 2 said the resident was usually quite but would speak up when she was hurting. She reported that a few minutes ago the resident was hurting and had pain in her right leg which was reported to her nurse . Record review of Resident # 1 ' s MAR indicated [REDACTED]. Medication was ordered on [DATE]. The Medication was administered as follows; 6/23/15-pain level of 5 at 5:50 p.m. 6/24/15- pain level of 5 at 10:47 a.m. 6/27/15- pain level of 4 at 11:17 a.m. 6/28/15- pain level of 3 at 7: 28 a.m. 6/29/15- pain level of 3 at 11:06 a.m. 6/30/15 -pain level of 5 at 9:10 a.m. and pain level of 4 at 5:30 p.m. Record review of Resident # 1 ' s MAR indicated [REDACTED]. The medication was ordered 6/23/15. The medication was administered as follows; 7/1/15-pain level of 1 at 2:06 p.m. 7/2/15-no documentation. 7/3/15-pain level of 3 at 5:03 a.m. 7/4/15-pain level of 1 at 12:25 p.m., and pain level of 4 at 7:5 3 p.m. 7/5/15-pain level of 3 at 6:22 p.m. 7/6/15-pain level of 3 at 9.41 a.m. 7/7/15-pain level of 4 at 8:37 a.m. Record review of Resident # 1 ' s MAR indicated [REDACTED] On 7/1/15 (pain score of 0) was documented for 6-2 and 2-10 p.m., shifts but resident was medicated for pain at 2:06 p.m. On 7/2/15, pain score of 3 was documented for 6-2 shift, pain score of 3 was documented for 2-10 shift and no pain for 10-6 shift, but no pain medication was administered. On 7/3/15, pain score of 2 was documented for 2-10 shift, no pain 10-6 shift but was medicated at 5:03 a.m. On 7/4/15, assessment revealed no pain for 2-10 and 10-6 shifts but resident was medicated at 7:53 p.m. On 7/5/15, assessment revealed no pain for all three shifts but resident was medicated at 6.22 p.m. Observation on 7/7/15 at 8:25 a.m., revealed Resident #1 bed complaining of pain to her right leg. She reported her right leg was stuck in a flexed position and she needed to make it straight but it was hurting a lot. The resident was moaning while attempting to adjust herself in bed. Interview on 7/7/15 at 8:25 A.M. LVN # 1 upon entering the resident ' s room said the resident had as needed pain medication which would be given and the nurse practitioner would be notified to evaluate the resident during rounds today. Interview on 7/7/15 at 1:15 p.m., LVN # 1 said the resident does not always ask for her pain medication but can be in pain. Resident # 2 Record review of Resident # 2 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 2 ' s care plan dated 6/14/15 revealed the resident required extensive assistance with ADLs, related to debility and pain. Goal and approaches outlined did not address the resident's pain. Record review of Resident #2 ' s MDS dated [DATE] revealed the resident was moderately impaired. The pain assessment revealed the resident received scheduled pain medication and had occasional pain with intensity of 4. Record review of Resident #2 ' s MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of Resident # 2 ' s MAR indicated [REDACTED]. Observation and interview on 6/23/15 at 10:25 a.m., revealed Resident #2 in bed who appeared to have just awoken from sleep and was moaning in pain. She reported pain to her knees. Observation/interview on 7/6/15 at 9:10 a.m., revealed Resident #2 in bed hollering out due to pain in her leg. The resident was asking for her pain ointment to be applied to her right leg. Interview on 7/6/2015 at 9:15 A.M. after LVN # 1 was notified of the resident's complaint of pain reported the resident had a pain cream that was applied once her shift and that Resident # 2 also received [MEDICATION NAME] every 6 hours. LVN # 1 reported the next medication was due at 11:30 a.m. Observation and interview on 7/7/15 at 8:27 a.m., Resident #2 complained of pain to her leg. When asked how much pain she had, she stated it hurt a lot and seemed to be worse in the mornings. She said they (staff) give her pain medication but it was not helping her. Resident #2 stated she could not get out of bed due to her pain. Further observation and interview revealed CNA# 3 told the resident it was her shower day, and she was ready to give her a shower. Resident # 2 said she did not want a shower because her leg hurt to much to get out bed. She said she did not like to shower because she would be hollering in pain the whole time. Resident # 2 said she preferred a bed bath. Interview on 7/7/15 at 11:55 a.m.,LVN # 1 reported Resident # 2 had scheduled medications every 6 hours. She expressed the resident almost always complained of pain despite the medication she received. LVN # 1 also said the resident had topical creams. She said maybe the physician needed to be contacted for further orders. Observations throughout investigation on 6/23/15, 7/6/15 and 7/7/16 revealed Resident #2 was never out of bed. Record review of Resident #2's Nurse's Notes revealed no documentation that the physician was consulted concerning the resident's pain. Record review of Facility ' s pain management policy dated January 2014 revealed pain evaluation must be completed for a patient upon the onset or an increase in pain. The pain management flow sheet must be completed prior to or one hour following the administration of pain medication. If a patient is assessed for unrelieved pain, the nurse must notify the attending physician to obtain an order for [REDACTED]. Facility census dated 6/23/15 listed 99 residents

Based on interview and record review the facility failed to ensure one of 11 residents reviewed for accidents and supervision (Resident # 4) received adequate supervision to prevent injury. Resident # 4, who had a history of [REDACTED]. She fell to the floor and sustained a laceration requiring her to be transfered to the hospital. This failure affected one resident requiring her to have sutures to her head and pain and placed 98 residents at increased risk of injuries from falls and lack of supervision. Findings include: Intake # 2 Record review of Resident #4's face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #4 ' s care plan, date revised 1/26/15, revealed Resident # 4 was at a high risk for falls related to confusion, deconditioning, gait/balance problem and because the resident had a fall risk assessment score of 15 (high). The goal was the resident would remain free from falls or injury. The approaches included: anticipate needs and provide prompt assistance. Encourage the resident to ask staff for assistance and respond promptly to needs. Ensure call light was within resident's reach and respond promptly. Ensure lighting was adequate and walking area free of clutter. Re-direct and or re-orient resident during episodes of increased confusion and assist with ambulation and transfers. Therapy services was to treat as indicated /ordered. Record review of Resident # 4 ' s incident report dated 5/12/15 at 12:30 p.m., revealed the charge nurse was called to the resident ' s bedside to assist with a resident assessment status [REDACTED]. Charge nurse from the 100 hall was already at the bedside and assessing for injury. Blood was noted to resident ' s face and forehead and swelling was also noted. Upon charge nurse cleansing resident ' s face with sterile gauze and normal saline, it revealed resident only bleeding from hematoma site in center of forehead approximately 5cm in length. Resident was alert and oriented to name with equal hand grasp as neuro checks observed being completed by charge nurse. EMS on sight, brief report given and resident transferred to hospital for further evaluation and treatment. Record review of Resident # 4 ' s incident report revealed injuries were laceration to forehead, resident was confused with impaired memory. Record review of Resident # 4 ' s incident report revealed a statement written by the Activity Director dated 5/12/15. The report read she observed Resident #4 leaning over in her chair. She took the resident to her hall and placed her outside her room with the call light on . Record review of Resident # 4 ' s incident report statement from the Rehab staff revealed the rehab staff member was coming from the nursing office, this was between 1:30 p.m., to 2:00 p.m., on 5/12/15 when she saw the Activity Director pushing the resident to the 100 hall . Record review of Resident #4 ' s hospital discharge record dated 5/13/15 revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #4 ' s care plan updated 5/20/15 revealed the resident had an actual fall with injury on 5/12/15. She suffered a 3.5 cm by 0.5 cm laceration to the left side of her forehead requiring a trip to the ER (emergency room ) for sutures. She had hematomas to both of her eyes more prominent to the left side. Goal was the resident ' s falls would resolve without complications by the next review date. Further review of the care plan revealed no new fall preventative measures/approaches were outlined. Record review of Resident # 4 ' s MDS dated [DATE] revealed the resident was moderately impaired for cognition , required extensive assistance with eating and was dependent on staff for ADLs. The MDS also revealed the resident had no falls and no injuries from falls since last assessment. Interview on 7/6/15 at 3:50 p.m., the DON said Resident #4 had declined in her functional abilities and did not walk anymore. She stated staff put the resident back to bed after meals. The DON said she believed the resident had a fall with injury and was transferred to hospital for treatment. The DON said Resident #4 ' s fall incident was investigated and it was unclear how she fell . When the investigation was requested the DON did not provided any evidence that Resident #4's fall was investigated. The DON said she reviewed the criteria for reportable incidents and did not believe the incident that occurred with Resident #4 should be reported. Interview on 7/7/15 at 9:00 a.m., the Activity Director said on 5/12/15 about lunch time, she saw Resident #4 in the dining /activity area in her wheelchair sleeping and leaning over. She stated she took the resident to the front of her room and put the resident's call light on for the aides to put her in bed. The Activity Director said she did not tell anyone to put the resident back to bed but she later heard the resident fell in her room. Interview on 7/7/15 10:39 a.m., LVN # 1 said Resident #4 was known to have an unsteady gait, was at risk of falls, and used a chair/bed alarm. The resident would try to self-ambulate but was no longer able to do that independently and the resident appeared to have declined in her ability to sustain her gait. LVN #1 further said she was called to the resident ' s bedside on 5/12/15 around lunch time and she found her face down in front of her wheelchair in her room with lots of blood. LVN#1 said she cleaned the area and noted the laceration to the resident ' s forehead. The staff called 911 and the resident was transferred to the hospital. LVN #1 said the resident was unable to tell her what happened. Interview on 7/7/15 10:50 a.m., LVN #2 said the aides called her to Resident #4' s room when she was found face down on the right side of the bed by the window. The resident had a lot of blood on her face and she called 911. Interview on 7/7/15 10:59 a.m., CNA #1 said Resident #4 was unable to ambulate, she was wheelchair bound, required extensive assistance with ADLs, and was at risk for falls .CNA # 1 said on 5/12/15 during the morning the resident was up for breakfast. She stated she was usually put back to bed after breakfast before therapy. She recalled the resident was last seen at the dining/activity area, while she was assisting other residents down the hall. CNA#1 said she heard the alarm go off and when she got to Resident #4' s room, she saw the resident on the floor close to her bed. She stated she believed the resident tried to get into bed from her wheelchair and fell . She said she was not told the resident needed to be put back to bed. CNA #1 said she was coming out of another resident ' s room when she heard the alarm going off. Observation on 7/7/14 at 1:40 p.m., Resident # 4 was in bed with limited range motion to bilateral lower extremities. The resident was alert to name only. The resident was , disoriented and unable to make needs known. Interview on 7/7/15 at 1:51 p.m., the Physical therapist said Resident # 4 was currently receiving physical and occupational therapy services for strengthening. He expressed the resident declined following the fall in May 2015 and was no longer able to do the things she could do prior to the fall. He stated the resident now required maximum assistance with ADLs. Therapy plans for Resident #4 were to treat 5 days a week. Interview on 7/7/15 at 3:50 p.m., the DON said the resident returned to the facility with sutures to the injury on her forehead a few days after the transfer to the hospital. She agreed Resident # 4 should not have been left in her room unsupervised when she was found by the Activity Director. Policy on accident/incident dated January 2014 did not address above concerns and fall policy was not provided prior to exit. Facility census dated listed 99 residents.

Based on interview, and record review, the facility failed to consult with the resident's physician when a change in condition occurred in one of 14 residents (CR #1) reviewed for residents ' physicians being consulted concerning the resident's care when a change in condition has occurred. On [DATE],CR# 1 had a fall and was identified to have a change in condition with increased pain and unstable vital signs. CR #1's physician was not consulted with nor was CR# 1 provided prompt medical interventions when the resident was assessed with [REDACTED]. CR#1 expired in the facility approximately 6 hours after the fall. An immediate jeopardy (IJ) was identified on [DATE] at 10:15 a.m. While the IJ was removed on [DATE] at 10:17 a.m., the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that is not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. This failure affected one resident who expired in the facility and placed 100 residents at risk of not having their physicians promptly consulted with when a change in condition occurs which would cause a delay in the resident receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 4 CR# 1 Record review of CR# 1 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1 ' s MDS assessment dated [DATE], revealed a BIMS score of 06 out of 15 indicating the resident was severely impaired for cognition. She required supervision for transfers and mobility, and limited assistance for dressing, eating and hygiene. CR # 1 had contractures on both sides of her upper and lower extremities. The MDS also identified that CR# 1 had no falls. Interview on [DATE] at 11:55 a.m., the DON explained CR #1 had a fall on [DATE] around 4 p.m. The DON said she assessed the resident and stayed in the facility late, but left about 8 p.m. She said that shortly after she got home, staff called to say CR# 1 was dead. The DON reported she was aware the resident had a fall and that the physician was called to notify him of the fall. She said that staff had got an order to do an X-ray of the affected area. Interview on [DATE] at 12:52 p.m., LVN # 1 said she was notified of CR# 1 ' s fall about 4 p.m. on [DATE]. She said the DON and another nurse went to check on the resident. She said the resident's blood pressure was a little high and the resident complained of pain to her hip. An X-ray was done later because the x-ray guys were late that day and did not come till around 9 p.m. LVN# 1 said everything was happening so quickly. LVN #1 said she tried calling the physician to report the resident needed a stronger pain medication but did not get a response from the physician. She stated she was monitoring the resident and noticed she was changing fast. CR #1 kept saying she had really bad pain. LVN #1 said the resident was losing consciousness towards the end of the shift, but around 30 minutes before the end the resident was ok. When LVN # 1 was asked why CR# 1 was not transferred to the hospital she stated she thought the resident was sleeping or maybe it was the pain medication that was making her sleepy. She said it was then the resident passed away. She said she was about to give CR #1 oxygen when she started breathing heavily. LVN # 1 said she was very overwhelmed with the whole incident with CR#1. LVN #1 said she did not seek help from any other staff in the facility during her shift. LVN # 1 said she was not aware she could call the facility's medical director when she could not reach CR#1 ' s physician. Record review of CR# 1 ' s nurses notes dated [DATE] at 12:45 p.m., LVN # 1 wrote a late entry: " (CR# 1) had a fall on [DATE] at 4:15 p.m. Nurse was notified of fall by w/c (wound care) nurse. Went to check on the patient. Patient was on the floor, complaining of hip pain. Vital signs post fall were taken, blood pressure of ,[DATE], pulse was 116, respiration was 22. Patient assisted back to bed with 3 person assist using a sheet for transfer. Patient's physician was notified of the fall at 5:00 p.m., and X-Ray order was given. Family was notified of the fall at 5:45 p.m. Patient was given [MEDICATION NAME] 325 mg, one tablet per order. Vital signs were taken again at 6:30 p.m., following blood pressure of ,[DATE], pulse was 80, physician was paged for stronger pain medication awaiting for MD response. At 8:00 p.m., blood pressure was ,[DATE], pulse was 107, x-ray was taken of the hip and shoulders at 9 p.m. At 9:50 p.m., patient was assessed , patient seemed unconscious , oxygen saturation rapidly changed from 75 to 83, unable to obtain blood pressure. At 10:30 p.m., patient was pronounced as expired by registered nurse on duty. At 10:45p.m., physician and family member was notified of the patients change in condition. MD notified of code status and X-ray report." Record review of CR# 1 ' s neurological assessment flow sheet (provided by the DON on [DATE]) revealed on [DATE] at 4:15 P.M. the resident was alert, had appropriate pain response (appropriate not defined in the coding section of the form) and vital signs of BP ,[DATE] and pulse of 116. On the same form on [DATE] at 9:00 P.M. the resident is drowsy, and has inappropriate pain response (not defined in the coding section of the form) and vital signs of BP ,[DATE] and pulse of 98. Record review of CR #1's Medication Administration Record [REDACTED]. Her blood pressures documented for [DATE] were ,[DATE] and ,[DATE], for [DATE] ,[DATE] and ,[DATE], for [DATE] ,[DATE] and ,[DATE] and for the morning of [DATE] ,[DATE]. Further record review of CR #1's medical record revealed there was no SBAR (Situation, Background, Assessment Recommendation) form concerning the incident for [DATE]. A request was made to the DON for this form but one was not provided for review prior to exit. Interview on [DATE] at 4:00 p.m., the DON said staff was required to complete an SBAR (an assessment tool that contains screening, background information, assessment and reporting) with every change in condition identified on a resident. The physician should be called to report the findings. The DON said CR# 1 was not sent to the hospital because she was stable despite deterioration evidenced by her vital signs. The DON further said CR#1 did not complain of pain evidenced by the neurological assessment flow sheet. Interview on [DATE] at 10:38 a.m., RN # 1 said she was working on a different hall on [DATE] for the evening shift (,[DATE] shift) and she was the only registered nurse on the shift. She said she was called to see CR#1 at about 10:30 p.m. When she got to the resident's room the resident ' s skin was pale, no pulse, no blood pressure, no sign of life. The resident's nails were blue in color, there were no palpitations and no movement. RN# 1 said she was not notified by anyone throughout the shift of CR# 1's condition. She said she was called when CR #1 was already dead. She further said she pronounced the resident dead at 10:30 p.m. Interview on [DATE] at 3:50 p.m., the DON said LVN # 1 called her after CR#1 expired, and told her what happened. The DON said the nurse reported being overwhelmed with the events and was not able to document about the incident in the resident's record. The DON said she told LVN # 1 that she must come back to the facility and document the incident. The DON also reported she put LVN # 1 back into orientation and an in-service was provided on documentation, and falls. The DON said LVN # 1 was a new nurse to the facility system who was trained about the facility policies prior to work resumption. The DON said she had reviewed the incident regarding the death of CR# 1 but did not identify any other issues regarding delay in getting medical help as well as pain medication for CR# 1 following the fall on [DATE]. The DON said she would expect staff to call the medical director and herself when a resident's physician could not be reached. The DON said staff should use their nursing judgment in getting medical help for a resident with a change in condition. During this interview the DON did not identify a delay in getting medical help for CR# 1. The DON said she left the facility at about 8 p.m. Record review of facility's policy on resident rights dated February 2008 revealed purpose was to ensure the resident ' s personal dignity , wellbeing and self-determination is maintained to assure that patients are knowledgeable to their rights and responsibilities in this regard. The patients ' bill of rights is posted throughout the facility and is legibly to the visually impaired .Facility staff is in-serviced on patient ' s rights and responsibilities on hire , at orientation an d annually thereafter. " Record review of facility policy on recognizing changes in condition and interact not dated revealed " ... tools for early identification of a patient ' s change in condition and to reduce unnecessary readmission to the hospital includes: ambassador rounds, legend round, Triage rounds, interact. Purpose of InterACT - interventions are designed to improve the identification, evaluation and communication about changes in resident status " . Record review of facility policy titled Implemention Guide Communication Tools by InterACT dated 2011 revealed the SBAR (Situation, Background, Assessment Recommendation) form/ acute change in condition progress note is designed to enhance the nursing evaluation of and documentation on residents who have a change in condition. The policy goes on to read that all nursing home licensed nursing staff evaluate and communicate acute changes to the doctor, nurse practitioner or physician assistant and documentation of the evaluation and communications. An immediate jeopardy (IJ) was identified on [DATE] at 10:05 a.m. and Administrator and DON were informed at that time. A Plan of Removal (POR) of the IJ was submitted on [DATE] at 2:55 p.m. Several revisions were required and the plan was accepted on [DATE] at 5.35 p.m. The POR included: Plan to remove immediate jeopardy. [DATE] 1. All residents will be assessed by our Administrative Nursing team on [DATE]. Any residents found to require medical care, physicians were consulted. All residents with a recent change of condition will be audited on [DATE] to make sure attending physician was consulted with, and that all orders were implemented. 2. Our Medical Director Designee in-services all Department Heads on [DATE], on protocols for calling in a change of condition to the physician, and the procedures to follow for a 911 transfer. An in -service was provided to all licensed staff on [DATE] on the 6am-2p.m., and 2p.m.-l0p.m. Shifts on these protocols. All other staff scheduled to work will not be allowed to work until they are in-serviced on these protocols. New hired staff will be in-serviced on these protocols during the first three days of orientation. 3. All licensed staff from 6am-2p.m., and 2p.m.-l0p.m. was in-serviced on [DATE] on proper assessment documentation of change of condition and pain re-assessment with appropriate interventions. All other staff scheduled to work will not be allowed to work until they are in -serviced. New hired staff will be in-serviced on this during the first three days of orientation. 4. All licensed staff from 6am-2p.m., and 2p.m.-l0p.m. was in-serviced on [DATE] on current policies and procedures: Incidents and Accidents, Falls, and Pain Management, and the use of the Interact Program (SBAR, Describe the current Situation of the change of condition, the history Background of the resident, the current Assessment status of the resident, and the Response of the physician and Nursing staff to address the change of condition) All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 5. Facility in-serviced licensed staff from 6am-2p.m., and 2p.m. to 10p.m., on [DATE], that they are to notify the admitting physician or designee immediately upon change of condition or no pain relief with current measures. All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 6. All Licensed staff from 6am-2p.m., and 2p.m.-l0p.m. were in-serviced on [DATE] that if they are unable to reach the attending physician within 30 minutes from the change of a non-emergent condition identified, then the staff will notify a registered nurse on duty. If the registered nurse is not available or on duty, staff will notify the Assistant Director of Nursing. If Assistant Director of Nursing cannot be reached, staff will notify the Director of Nursing, or admitting physician. If they cannot be reached, staff will notify Medical Director. If Medical Director cannot be reached, facility will call 911. All incident and accidents will be reviewed during morning meeting and MDS coordinator will update/review care plans to prevent or minimize injuries related to falls. All PRN staff will be notified that they must attend these in-services before they can return to work. Interview on [DATE] at 4:14 p.m., the Administrator said he was made aware of the incident a day after CR# 1 expired. He explained that staff was educated on abuse and neglect and LVN # 1, who was not a regular staff to the facility, was put back on orientation to help her. The Administrator agreed that prompt medical help should always be available to residents. Interview on [DATE] about 3:00 p.m., facility Administrator stated he understood the issues at hand and he was working on getting the staff educated to ensure no re-occurrences. He explained the safety of the residents were his priorities. The plan was monitored on [DATE] and [DATE] by the surveyor with the following results: Facility protocols concerning changes of condition, notifying physicians and when to call 911 were reviewed. In-services on procedures concerning falls, incidents, changes of condition, proper assessment documentation, pain re-assessment with appropriate interventions were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed on 1-/16 and [DATE] and all expressed up to date knowledge on communication procedures. Interviews with nursing the staff on two shifts revealed positive response from the physicians they had contacted on [DATE] and [DATE] concerning changes of conditions with residents. Review of two changes of conditions that occurred on two different shifts over two days ([DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The Administrator was informed on [DATE] at 10:17 a.m. That the IJ was lowered after verification of the plan implementation had occurred. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. The facility provided a census which revealed 100 residents.

Based on interview and record review, the facility failed to implement policies and procedures that would have prohibited the neglect for one of 13 residents (CR# 1) reviewed for care provided after a change of condition had been identified. On [DATE], CR# 1 had a fall and was identified to have a change in condition with increased pain and unstable vital signs. CR# 1 was not provided prompt medical interventions when the resident was assessed with [REDACTED]. CR#1 expired in the facility approximately 6 hours after the fall. The facility neglected to seek alternate medical services when CR# 1 ' s physician did not promptly respond to a consultation concerning the resident ' s increase in pain and a change in condition following a fall on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 10:15 A.M. While the IJ was removed on [DATE] at 10:17 A.M., the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. This failure affected one resident who died in the facility and placed 100 residents at risk of neglect, not having prompt interventions when a change in condition occurs and a delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 4 CR# 1 Record review of CR# 1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR #1 ' s MDS dated [DATE], revealed a BIMS score was 06 out of 15 indicating the resident was severely impaired for cognition. She required supervision for transfers and mobility, and limited assistance for dressing, eating and hygiene. CR # 1 had contractures on both sides of upper and lower extremities. The MDS also identified that Resident CR# 1 had no falls. Interview on [DATE] at 12:52 p.m., LVN # 1 said she was notified of CR# 1 ' s fall about 4 p.m. on [DATE]. She said the DON and another nurse went to check on the resident. She said the resident's blood pressure was a little high and the resident complained of pain to her hip. An X-ray was done later because the x-ray guys were late that day and did not come till around 9 p.m. LVN# 1 said everything was happening so quickly. LVN #1 said she tried calling the physician to report the resident needed a stronger pain medication but did not get a response from the physician. She stated she was monitoring the resident and noticed she was changing fast. CR #1 kept saying she had really bad pain. LVN #1 said the resident was losing consciousness towards the end of the shift, but around 30 minutes before the end the resident was ok. When LVN # 1 was asked why CR# 1 was not transferred to the hospital she stated she thought the resident was sleeping or maybe it was the pain medication that was making her sleepy. She said it was then the resident passed away. She said she was about to give CR #1 oxygen when she started breathing heavily. LVN # 1 said she was very overwhelmed with the whole incident with CR#1. LVN #1 said she did not seek help from any other staff in the facility during her shift. LVN # 1 said she was not aware she could call the facility's medical director when she could not reach CR#1 ' s physician. Interview on [DATE] at 1:51 P.M.,RN # 2 said he was notified of CR# 1 ' s fall on the afternoon of [DATE]. He stated he assisted the nurse to call the physician and requested an X-ray to the affected area. He stated the resident complained of pain to the hip area. RN # 2 said the physician ordered the X-ray about 4:45 P.M. He called the X-Ray Company and got a confirmation for the STAT X-ray. RN # 2 said he left the facility about 6:30 p.m. He stated when he left the X-ray had not been done and the DON was in the building. Record review of CR# 1 ' s nurses notes dated [DATE] at 12:45 p.m., LVN # 1 wrote a late entry: " (CR# 1) had a fall on [DATE] at 4:15 p.m. Nurse was notified of fall by w/c (wound care) nurse. Went to check on the patient. Patient was on the floor, complaining of hip pain. Vital signs post fall were taken, blood pressure of ,[DATE], pulse was 116, respiration was 22. Patient assisted back to bed with 3 person assist using a sheet for transfer. Patient's physician was notified of the fall at 5:00 p.m., and X-Ray order was given. Family was notified of the fall at 5:45 p.m. Patient was given [MEDICATION NAME] 325 mg, one tablet per order. Vital signs were taken again at 6:30 p.m., following blood pressure of ,[DATE], pulse was 80, physician was paged for stronger pain medication awaiting for MD response. At 8:00 p.m., blood pressure was ,[DATE], pulse was 107, x-ray was taken of the hip and shoulders at 9 p.m. At 9:50 p.m., patient was assessed , patient seemed unconscious , oxygen saturation rapidly changed from 75 to 83, unable to obtain blood pressure. At 10.30 p.m., patient was pronounced as expired by registered nurse on duty. At 10:45p.m., physician and family member was notified of the patients change in condition. MD notified of code status and X-ray report." Record review of CR #1's Medication Administration Record [REDACTED]. Her blood pressures documented for [DATE] were ,[DATE] and ,[DATE], for [DATE] ,[DATE] and ,[DATE], for [DATE] ,[DATE] and ,[DATE] and for the morning of [DATE] ,[DATE]. Record review of CR# 1 ' s neurological assessment flow sheet (provided by the DON on [DATE]) revealed on [DATE] at 4:15 P.M. the resident was alert, had appropriate pain response (appropriate not defined in the coding section of the form) and vital signs of BP ,[DATE] and pulse of 116. On the same form on [DATE] at 9:00 P.M. the resident is drowsy, and has inappropriate pain response (not defined in the coding section of the form) and vital signs of BP ,[DATE] and pulse of 98. Further record review of CR #1's medical record revealed no SBAR (Situation, Background, Assessment Recommendation) form concerning the incident for [DATE]. A request was made to the DON for this form but one was not provided for review prior to exit. Interview on [DATE] at 4:00 p.m., the DON said staff was required to complete an SBAR (an assessment tool that contains screening, background information, assessment and reporting) with every change in condition identified on a resident. The physician should be called to report the findings. The DON said CR# 1 was not sent to the hospital because she was stable despite deterioration evidenced by her vital signs. The DON further said CR#1 did not complain of pain evidenced by the neurological assessment flow sheet. Interview on [DATE] at 10:38 a.m., RN # 1 said she was working on a different hall on [DATE] for the evening shift (,[DATE] shift) and she was the only registered nurse on the shift. She said she was called to see CR#1 at about 10:30 p.m. When she got to the resident's room the resident ' s skin was pale, no pulse, no blood pressure, no sign of life. The resident's nails were blue in color, there were no palpitations and no movement. RN# 1 said she was not notified by anyone throughout the shift of CR# 1's condition. She said she was called when CR #1 was already dead. She further said she pronounced the resident dead at 10:30 p.m. Interview on [DATE] at 3:50 p.m., the DON said LVN # 1 called her after CR#1 expired, and told her what happened. The DON said the nurse reported being overwhelmed with the events and was not able to document about the incident in the resident's record. The DON said she told LVN # 1 that she must come back to the facility and document the incident. The DON also reported she put LVN # 1 back into orientation and an in-service was provided on documentation, and falls. The DON said LVN # 1 was a new nurse to the facility system who was trained about the facility policies prior to work resumption. The DON said she had reviewed the incident regarding the death of CR# 1 but did not identify any other issues regarding delay in getting medical help as well as pain medication for CR# 1 following the fall on [DATE]. The DON said she would expect staff to call the medical director and herself when a resident's physician could not be reached. The DON said staff should use their nursing judgment in getting medical help for a resident with a change in condition. During this interview the DON did not identify a delay in the resident receiving medical assistance for CR# 1. The DON said she left the facility at about 8 p.m. Record review of CR #1 ' s Nurse ' s notes dated [DATE] revealed the following: At 8:30 P.M., the DON documented CR#1 was alert and oriented lying in bed comfortably. status [REDACTED]. The DON also documented the resident ' s vital signs were stable and was awaiting for X-Ray to be done. At 9:00 P.M., the DON wrote the X-ray was done. The resident was alert and oriented times three and complained of hip pain during the X-ray. At 10:00 P.M., the DON wrote the resident was unresponsive with low oxygen saturation at 80% at room air. Vital signs were taken, oxygen placed via nasal cannula. Registered nurse on duty called to assess the resident. MD and family members called to notify of resident ' s condition. Interview on [DATE] at 3:54 P.M., the Administrator said he was the abuse coordinator at the facility and that the facility administrative team investigated the incident during their daily morning meeting and decided it was not a reportable incident because the resident ' s cause of death was of a natural cause. The Administrator said according to the physician, the resident ' s cause of death was [MEDICAL CONDITION]. A copy of the investigation conducted by the facility was requested but none was provided for review prior to exit. Interview on [DATE] at 4:14 P.M., the Administrator said he was made aware of the incident a day after CR# 1 expired. He explained the nursing staff were educated on abuse and neglect. LVN # 1, who was not a regular staff to the facility, was put back into orientation. The Administrator agreed neglect of any resident was not tolerable and prompt medical help should always be available to residents. Record review of facility's policy on abuse and neglect dated [DATE] revealed the facility would prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all patients through the implementation of seven components. The seven components included screening, training, prevention, identification, investigation protection and reporting. Further review of facility's policy on abuse and neglect dated [DATE] defined neglect as " derivation by an individual , including a care taker of good or services that are necessary to attain or maintain physical , mental and psychosocial well-being ...The purpose of this policy was to ensure that the facility is doing all that is within its control to prevent occurrences of abuse , neglect and to treat all patients at the facility with dignity and respect at all times " . Record review of facility policy on recognizing changes in condition and interact not dated revealed " ... tools for early identification of a patient ' s change in condition and to reduce unnecessary readmission to the hospital includes: ambassador rounds, legend round, Triage rounds, interact. Purpose of InterACT - interventions are designed to improve the identification, evaluation and communication about changes in resident status " . Record review of facility policy titled Implemention Guide Communication Tools written by InterACT dated 2011 revealed the SBAR (Situation, Background, Assessment Recommendation) form/ acute change in condition progress note is designed to enhance the nursing evaluation of and documentation on residents who have a change in condition. The policy goes on to read that all nursing home licensed nursing staff evaluate and communicate acute changes to the doctor, nurse practitioner or physician assistant and documentation of the evaluation and communications. An immediate jeopardy (IJ) was identified on [DATE] at 10:05 a.m. and Administrator and DON were informed at that time. A Plan of Removal (POR) of the IJ was submitted on [DATE] at 2:55 p.m. Several revisions were required and the plan was accepted on [DATE] at 5.35 p.m. The POR included: Plan to remove immediate jeopardy. [DATE] 1. All residents will be assessed by our Administrative Nursing team on [DATE]. Any residents found to require medical care, physicians were consulted. All residents with a recent change of condition will be audited on [DATE] to make sure attending physician was consulted with, and that all orders were implemented. 2. Our Medical Director Designee in-services all Department Heads on [DATE], on protocols for calling in a change of condition to the physician, and the procedures to follow for a 911 transfer. An in -service was provided to all licensed staff on [DATE] on the 6am-2p.m., and 2p.m.-l0p.m. Shifts on these protocols. All other staff scheduled to work will not be allowed to work until they are in-serviced on these protocols. New hired staff will be in-serviced on these protocols during the first three days of orientation. 3. All licensed staff from 6am-2p.m., and 2p.m.-l0p.m. was in-serviced on [DATE] on proper assessment documentation of change of condition and pain re-assessment with appropriate interventions. All other staff scheduled to work will not be allowed to work until they are in -serviced. New hired staff will be in-serviced on this during the first three days of orientation. 4. All licensed staff from 6am-2p.m., and 2p.m.-l0p.m. was in-serviced on [DATE] on current policies and procedures: Incidents and Accidents, Falls, and Pain Management, and the use of the Interact Program (SBAR, Describe the current Situation of the change of condition, the history Background of the resident, the current Assessment status of the resident, and the Response of the physician and Nursing staff to address the change of condition) All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 5. Facility in-serviced licensed staff from 6am-2p.m., and 2p.m. to 10p.m., on [DATE], that they are to notify the admitting physician or designee immediately upon change of condition or no pain relief with current measures. All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 6. All Licensed staff from 6am-2p.m., and 2p.m.-l0p.m. were in-serviced on [DATE] that if they are unable to reach the attending physician within 30 minutes from the change of a non-emergent condition identified, then the staff will notify a registered nurse on duty. If the registered nurse is not available or on duty, staff will notify the Assistant Director of Nursing. If Assistant Director of Nursing cannot be reached, staff will notify the Director of Nursing, or admitting physician. If they cannot be reached, staff will notify Medical Director. If Medical Director cannot be reached, facility will call 911. All incident and accidents will be reviewed during morning meeting and MDS coordinator will update/review care plans to prevent or minimize injuries related to falls. All PRN staff will be notified that they must attend these in-services before they can return to work. Interview on [DATE] about 3:00 p.m., facility Administrator stated he understood the issues at hand and he was working on getting the staff educated to ensure no re-occurrences. He explained the safety of the residents were his priorities. The plan was monitored on [DATE] and [DATE] by the surveyor with the following results: Facility protocols concerning changes of condition, notifying physicians and when to call 911 were reviewed. In-services on procedures concerning falls, incidents, changes of condition, proper assessment documentation, pain re-assessment with appropriate interventions were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed on 1-/16 and [DATE] and all expressed up to date knowledge on communication procedures. Interviews with nursing the staff on two shifts revealed positive response from the physicians they had contacted on [DATE] and [DATE] concerning changes of conditions with residents. Review of two changes of conditions that occurred on two different shifts over two days ([DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The Administrator was informed on [DATE] at 10:17 a.m. That the IJ was lowered after verification of the plan implementation had occurred. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. The facility provided a census which revealed 100 residents.

Based on interview and record review, the facility failed to follow their written policies and procedures concerning the reporting and investigation of neglect for one of 13 residents (CR# 1) reviewed for care provided after a change of condition had been identified. The facility failed to report or investigate the neglect of services to CR #1 by LVN #1 after a change of condition was identified after a fall and CR #1 ' s physician did not respond to the attempted notification of increased pain and the change in the resident ' s condition. An immediate jeopardy (IJ) was identified on [DATE] at 10:15 A.M. While the IJ was removed on [DATE] at 10:17A.M., the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an immediate jeopardy because all staff had not been trained on the procedure on notifying physicians, providing services to resident's experiencing a change of condition reporting and investigating allegations of neglect. This failure affected one resident who died in the facility and placed 100 residents at risk of neglect, not having prompt interventions when a change in condition occurs and a delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 4 Record review of facility's policy on abuse and neglect dated [DATE] revealed the facility will prohibit abuse ,neglect, involuntary seclusion and misappropriation of property for all patients through the implementation of seven components including the reporting of incidents, investigations and facility response to the result of their investigations. The administrator or designee would ensure that the following persons were notified immediately of the allegation of abuse and neglect and that an investigation was performed within required timeframes as required by state and local laws. Further review of facility's policy on abuse and neglect dated [DATE] defined neglect as " derivation by an individual , including a care taker of good or services that are necessary to attain or maintain physical , mental and psychosocial well-being ...The purpose of this policy was to ensure that the facility is doing all that is within its control to prevent occurrences of abuse , neglect and to treat all patients at the facility with dignity and respect at all times " . Record review of facility policy on recognizing changes in condition and interact not dated revealed " ... tools for early identification of a patient ' s change in condition and to reduce unnecessary readmission to the hospital includes: ambassador rounds, legend round, Triage rounds, interact. Purpose of InterACT - interventions are designed to improve the identification, evaluation and communication about changes in resident status " . Record review of facility policy titled Implemention Guide Communication Tools written by InterACT dated 2011 revealed the SBAR (Situation, Background, Assessment Recommendation) form/ acute change in condition progress note is designed to enhance the nursing evaluation of and documentation on residents who have a change in condition. The policy goes on to read that all nursing home licensed nursing staff evaluate and communicate acute changes to the doctor, nurse practitioner or physician assistant and documentation of the evaluation and communications. CR# 1 Record review of CR# 1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR #1 ' s MDS dated [DATE], revealed a BIMS score was 06 out of 15 indicating the resident was severely impaired for cognition. She required supervision for transfers and mobility, and limited assistance for dressing, eating and hygiene. CR # 1 had contractures on both sides of upper and lower extremities. The MDS also identified that Resident CR# 1 had no falls. Interview on [DATE] at 12:52 p.m., LVN # 1 said she was notified of CR# 1 ' s fall about 4 p.m. on [DATE]. She said the DON and another nurse went to check on the resident. She said the resident's blood pressure was a little high and the resident complained of pain to her hip. An X-ray was done later because the x-ray guys were late that day and did not come till around 9 p.m. LVN# 1 said everything was happening so quickly. LVN #1 said she tried calling the physician to report the resident needed a stronger pain medication but did not get a response from the physician. She stated she was monitoring the resident and noticed she was changing fast. CR #1 kept saying she had really bad pain. LVN #1 said the resident was losing consciousness towards the end of the shift, but around 30 minutes before the end the resident was ok. When LVN # 1 was asked why CR# 1 was not transferred to the hospital she stated she thought the resident was sleeping or maybe it was the pain medication that was making her sleepy. She said it was then the resident passed away. She said she was about to give CR #1 oxygen when she started breathing heavily. LVN # 1 said she was very overwhelmed with the whole incident with CR#1. LVN #1 said she did not seek help from any other staff in the facility during her shift. LVN # 1 said she was not aware she could call the facility's medical director when she could not reach CR#1 ' s physician. Interview on [DATE] at 1:51 P.M.,RN # 2 said he was notified of CR# 1 ' s fall on the afternoon of [DATE]. He stated he assisted the nurse to call the physician and requested an X-ray to the affected area. He stated the resident complained of pain to the hip area. RN # 2 said the physician ordered the X-ray about 4:45 P.M. He called the X-Ray Company and got a confirmation for the STAT X-ray. RN # 2 said he left the facility about 6:30 p.m. He stated when he left the X-ray had not been done and the DON was in the building. Record review of CR# 1 ' s nurses notes dated [DATE] at 12:45 p.m., LVN # 1 wrote a late entry: " (CR# 1) had a fall on [DATE] at 4:15 p.m. Nurse was notified of fall by w/c (wound care) nurse. Went to check on the patient. Patient was on the floor, complaining of hip pain. Vital signs post fall were taken, blood pressure of ,[DATE], pulse was 116, respiration was 22. Patient assisted back to bed with 3 person assist using a sheet for transfer. Patient's physician was notified of the fall at 5:00 p.m., and X-Ray order was given. Family was notified of the fall at 5:45 p.m. Patient was given [MEDICATION NAME] 325 mg, one tablet per order. Vital signs were taken again at 6:30 p.m., following blood pressure of ,[DATE], pulse was 80, physician was paged for stronger pain medication awaiting for MD response. At 8:00 p.m., blood pressure was ,[DATE], pulse was 107, x-ray was taken of the hip and shoulders at 9 p.m. At 9:50 p.m., patient was assessed , patient seemed unconscious , oxygen saturation rapidly changed from 75 to 83, unable to obtain blood pressure. At 10.30 p.m., patient was pronounced as expired by registered nurse on duty. At 10:45p.m., physician and family member was notified of the patients change in condition. MD notified of code status and X-ray report." Further record review of CR #1's medical record revealed no SBAR (Situation, Background, Assessment Recommendation) form concerning the incident for [DATE]. A request was made to the DON for this form but one was not provided for review prior to exit. Interview on [DATE] at 4:00 p.m., the DON said staff was required to complete an SBAR (an assessment tool that contains screening, background information, assessment and reporting) with every change in condition identified on a resident. The physician should be called to report the findings. The DON said CR# 1 was not sent to the hospital because she was stable despite deterioration evidenced by her vital signs. The DON further said CR#1 did not complain of pain evidenced by the neurological assessment flow sheet. Interview on [DATE] at 10:38 a.m., RN # 1 said she was working on a different hall on [DATE] for the evening shift (,[DATE] shift) and she was the only registered nurse on the shift. She said she was called to see CR#1 at about 10:30 p.m. When she got to the resident's room the resident ' s skin was pale, no pulse, no blood pressure, no sign of life. The resident's nails were blue in color, there were no palpitations and no movement. RN# 1 said she was not notified by anyone throughout the shift of CR# 1's condition. She said she was called when CR #1 was already dead. She further said she pronounced the resident dead at 10:30 p.m. Interview on [DATE] at 3:50 p.m., the DON said LVN # 1 called her after CR#1 expired, and told her what happened. The DON said the nurse reported being overwhelmed with the events and was not able to document about the incident in the resident's record. The DON said she told LVN # 1 that she must come back to the facility and document the incident. The DON also reported she put LVN # 1 back into orientation and an in-service was provided on documentation, and falls. The DON said LVN # 1 was a new nurse to the facility system who was trained about the facility policies prior to work resumption. The DON said she had reviewed the incident regarding the death of CR# 1 but did not identify any other issues regarding delay in getting medical help as well as pain medication for CR# 1 following the fall on [DATE]. The DON said she would expect staff to call the medical director and herself when a resident's physician could not be reached. The DON said staff should use their nursing judgment in getting medical help for a resident with a change in condition. During this interview the DON did not identify a delay in the resident receiving medical assistance for CR# 1. The DON said she left the facility at about 8 p.m. Record review of CR #1 ' s Nurse ' s notes dated [DATE] revealed the following: At 8:30 P.M., the DON documented CR#1 was alert and oriented lying in bed comfortably. status [REDACTED]. The DON also documented the resident ' s vital signs were stable and was awaiting for X-Ray to be done. At 9:00P.M., the DON wrote the X-ray was done. The resident was alert and oriented times three and complained of hip pain during the X-ray. At 10:00P.M., the DON wrote the resident was unresponsive with low oxygen saturation at 80% at room air. Vital signs were taken, oxygen placed via nasal cannula. Registered nurse on duty called to assess the resident. MD and family members called to notify of resident ' s condition. Interview on [DATE] at 3:54 P.M., the Administrator said he was the abuse coordinator at the facility and that the facility administrative team investigated the incident during their daily morning meeting and decided it was not a reportable incident because the resident ' s cause of death was of a natural cause. The Administrator said according to the physician, the resident ' s cause of death was [MEDICAL CONDITION]. A copy of the investigation conducted by the facility was requested but none was provided for review prior to exit. Interview on [DATE] at 4:14 P.M., the Administrator explained the nursing staff were educated on abuse and neglect. LVN # 1, who was not a regular staff to the facility, was put back into orientation. The Administrator agreed neglect of any resident was not tolerable and prompt medical help should always be available to residents. An immediate jeopardy (IJ) was identified on [DATE] at 10:05 a.m. and Administrator and DON were informed at that time. A Plan of Removal (POR) of the IJ was submitted on [DATE] at 2:55 p.m. Several revisions were required and the plan was accepted on [DATE] at 5.35 p.m. The POR included: Plan to remove immediate jeopardy. [DATE] 1. All residents will be assessed by our Administrative Nursing team on [DATE]. Any residents found to require medical care, physicians were consulted. All residents with a recent change of condition will be audited on [DATE] to make sure attending physician was consulted with, and that all orders were implemented. 2. Our Medical Director Designee in-services all Department Heads on [DATE], on protocols for calling in a change of condition to the physician, and the procedures to follow for a 911 transfer. An in -service was provided to all licensed staff on [DATE] on the 6am-2p.m., and 2p.m.-l0p.m. Shifts on these protocols. All other staff scheduled to work will not be allowed to work until they are in-serviced on these protocols. New hired staff will be in-serviced on these protocols during the first three days of orientation. 3. All licensed staff from 6am-2p.m., and 2p.m.-l0p.m. was in-serviced on [DATE] on proper assessment documentation of change of condition and pain re-assessment with appropriate interventions. All other staff scheduled to work will not be allowed to work until they are in -serviced. New hired staff will be in-serviced on this during the first three days of orientation. 4. All licensed staff from 6am-2p.m., and 2p.m.-l0p.m. was in-serviced on [DATE] on current policies and procedures: Incidents and Accidents, Falls, and Pain Management, and the use of the Interact Program (SBAR, Describe the current Situation of the change of condition, the history Background of the resident, the current Assessment status of the resident, and the Response of the physician and Nursing staff to address the change of condition) All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 5. Facility in-serviced licensed staff from 6am-2p.m., and 2p.m. to 10p.m., on [DATE], that they are to notify the admitting physician or designee immediately upon change of condition or no pain relief with current measures. All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 6. All Licensed staff from 6am-2p.m., and 2p.m.-l0p.m. were in-serviced on [DATE] that if they are unable to reach the attending physician within 30 minutes from the change of a non-emergent condition identified, then the staff will notify a registered nurse on duty. If the registered nurse is not available or on duty, staff will notify the Assistant Director of Nursing. If Assistant Director of Nursing cannot be reached, staff will notify the Director of Nursing, or admitting physician. If they cannot be reached, staff will notify Medical Director. If Medical Director cannot be reached, facility will call 911. All incident and accidents will be reviewed during morning meeting and MDS coordinator will update/review care plans to prevent or minimize injuries related to falls. All PRN staff will be notified that they must attend these in-services before they can return to work. Interview on [DATE] about 3:00 p.m., facility Administrator stated he understood the issues at hand and he was working on getting the staff educated to ensure no re-occurrences. He explained the safety of the residents were his priorities. The plan was monitored on [DATE] and [DATE] by the surveyor with the following results: Facility protocols concerning changes of condition, notifying physicians and when to call 911 were reviewed. Procedures concerning falls, incidents, changes of condition, proper assessment documentation, pain re-assessment with appropriate interventions were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed on 1-/16 and [DATE] and all expressed up to date knowledge on communication procedures. Interviews with nursing the staff on two shifts revealed positive response from the physicians they had contacted on [DATE] and [DATE] concerning changes of conditions with residents. Review of two changes of conditions that occurred on two different shifts over two days ([DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The Administrator was informed on [DATE] at 10:17 a.m. That the IJ was lowered after verification of the plan implementation had occurred. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of patterned and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians, providing services to resident's experiencing a change of condition, reporting and investigating allegations of neglect. The facility provided a census which revealed 100 residents.

Based on interview and record review the facility failed to provide the necessary care and services to attain the highest practicable mental and physical well-being for one of 13 residents (CR# 1) reviewed for receiving timely medical care after a change in condition. On [DATE], CR# 1 had a fall and was identified to have a change in condition with increased pain and unstable vital signs. CR# 1 was not provided prompt medical interventions despite her deteriorating condition as evidenced by unstable oxygen saturation, blood pressure, pulse rate , increased pain and altered mental status. CR#1 expired in the facility within six hours after the fall. The facility did not seek alternate medical care when CR# 1 ' s physician did not promptly respond to a consultation concerning the resident's increased pain and change in condition following the fall on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 10:15 A.M. While the IJ was removed on [DATE] at 10:17 A.M., the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. This failure affected one resident who died in the facility and placed 100 residents at risk of not having prompt medical interventions provided when a change in condition occurs and a delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 4 CR# 1 Record review of CR# 1 ' s face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR #1 ' s MDS dated [DATE], revealed a BIMS score was 06 out of 15 indicating the resident was severely impaired for cognition. She required supervision for transfers and mobility, and limited assistance for dressing, eating and hygiene. CR # 1 had contractures on both sides of her upper and lower extremities. The MDS also identified that Resident CR# 1 had no falls. Interview on [DATE] at 12:52 p.m., LVN # 1 said she was notified of CR# 1 ' s fall about 4 p.m. on [DATE]. She said the DON and another nurse went to check on the resident. She said the resident's blood pressure was a little high and the resident complained of pain to her hip. An X-ray was done later because the x-ray guys were late that day and did not come till around 9 p.m. LVN# 1 said everything was happening so quickly. LVN #1 said she tried calling the physician to report the resident needed a stronger pain medication but did not get a response from the physician. She stated she was monitoring the resident and noticed she was changing fast. CR #1 kept saying she had really bad pain. LVN #1 said the resident was losing consciousness towards the end of the shift, but around 30 minutes before the end the resident was ok. When LVN # 1 was asked why CR# 1 was not transferred to the hospital she stated she thought the resident was sleeping or maybe it was the pain medication that was making her sleepy. She said it was then the resident passed away. She said she was about to give CR #1 oxygen when she started breathing heavily. LVN # 1 said she was very overwhelmed with the whole incident with CR#1. LVN #1 said she did not seek help from any other staff in the facility during her shift. LVN # 1 said she was not aware she could call the facility's medical director when she could not reach CR#1 ' s physician. Interview on [DATE] at 11:55 A.M., the DON said she got a call from staff on [DATE] that CR#1 had expired. She explained the resident had a fall on [DATE] about 4 pm. She stated she assessed the resident and stayed in the facility. She said she left about 8pm and shortly after she got home, staff called to say CR# 1 was dead. The DON reported she was aware the resident had a fall and the physician was called to notify him of the fall and staff had gotten an order to do an X-ray of the affected area. The DON however agreed she did not delegate the RN in the building to monitor CR# 1 and did not instruct LVN # 1 to call the facility ' s medical director when CR#1 ' s physician did not respond . The DON did not instruct LVN # 1 to initiate or plan a possible hospital transfer should CR# 1 ' s physician not respond. Interview on [DATE] at 1:51 P.M., RN # 2 said he was notified of CR# 1 ' s fall on the afternoon of [DATE]. He stated he assisted the nurse to call the physician and requested an X-ray to the affected area. He stated the resident complained of pain to the hip area. RN # 2 said the physician ordered the X-ray about 4:45 P.M. He called the X-Ray Company and got a confirmation for the STAT X-ray. RN # 2 said he left the facility about 6:30 p.m. He stated when he left the X-ray had not been done and the DON was in the building. Interview on [DATE] at 4:00 p.m., the DON said staff was required to complete an SBAR (an assessment tool that contains screening, background information, assessment and reporting) with every change in condition identified on a resident. The physician should be called to report the findings. The DON said CR# 1 was not sent to the hospital because she was stable despite deterioration evidenced by her vital signs. The DON further said CR#1 did not complain of pain evidenced by the neurological assessment flow sheet. Record review of CR#1 ' s MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. CR# 1 had no other ordered pain medication and no other pain medication was administered. Record review of CR# 1 ' s neurological assessment flow sheet (provided by the DON on [DATE]) revealed on [DATE] at 4:15 P.M. the resident was alert, had appropriate pain response (appropriate not defined in the coding section of the form) and vital signs of BP ,[DATE] and pulse of 116. On the same form on [DATE] at 9:00 P.M. the resident is drowsy, and has inappropriate pain response (not defined in the coding section of the form) and vital signs of BP ,[DATE] and pulse of 98. Record review of CR# 1 ' s nurses notes dated [DATE] at 12:45 p.m., LVN # 1 wrote a late entry: " (CR# 1) had a fall on [DATE] at 4:15 p.m. Nurse was notified of fall by w/c (wound care) nurse. Went to check on the patient. Patient was on the floor, complaining of hip pain. Vital signs post fall were taken, blood pressure of ,[DATE], pulse was 116, respiration was 22. Patient assisted back to bed with 3 person assist using a sheet for transfer. Patient's physician was notified of the fall at 5:00 p.m., and X-Ray order was given. Family was notified of the fall at 5:45 p.m. Patient was given [MEDICATION NAME] 325 mg, one tablet per order. Vital signs were taken again at 6:30 p.m., following blood pressure of ,[DATE], pulse was 80, physician was paged for stronger pain medication awaiting for MD response. At 8:00 p.m., blood pressure was ,[DATE], pulse was 107, x-ray was taken of the hip and shoulders at 9 p.m. At 9:50 p.m., patient was assessed , patient seemed unconscious , oxygen saturation rapidly changed from 75 to 83, unable to obtain blood pressure. At 10.30 p.m., patient was pronounced as expired by registered nurse on duty. At 10:45 p.m., physician and family member was notified of the patients change in condition. MD notified of code status and X-ray report." Record review of CR #1's Medication Administration Record [REDACTED]. Her blood pressures documented for [DATE] were ,[DATE] and ,[DATE], for [DATE] ,[DATE] and ,[DATE], for [DATE] ,[DATE] and ,[DATE] and for the morning of [DATE] ,[DATE]. Further record review of CR #1's medical record revealed no SBAR (Situation, Background, Assessment Recommendation) form concerning the incident for [DATE]. A request was made to the DON for this form but one was not provided for review prior to exit. Interview on [DATE] at 10:38 a.m., RN # 1 said she was working on a different hall on [DATE] for the evening shift (,[DATE] shift) and she was the only registered nurse on the shift. She said she was called to see CR#1 at about 10:30 p.m. When she got to the resident's room the resident ' s skin was pale, no pulse, no blood pressure, no sign of life. The resident's nails were blue in color, there were no palpitations and no movement. RN# 1 said she was not notified by anyone throughout the shift of CR# 1's condition. She said she was called when CR #1 was already dead. She further said she pronounced the resident dead at 10:30 p.m. Interview on [DATE] at 4:00 p.m., the DON said staff was required to complete an SBAR (an assessment tool that contains screening, background information, assessment and reporting) with every change in condition identified on a resident. The physician should be called to report the findings. The DON said CR# 1 was not sent to the hospital because she was stable despite deterioration evidenced by her vital signs. The DON further said CR#1 did not complain of pain evidenced by the neurological assessment flow sheet. Interview on [DATE] at 3:50 p.m., the DON said LVN # 1 called her after CR#1 expired, and told her what happened. The DON said the nurse reported being overwhelmed with the events and was not able to document about the incident in the resident's record. The DON said she told LVN # 1 that she must come back to the facility and document the incident. The DON also reported she put LVN # 1 back into orientation and an in-service was provided on documentation, and falls. The DON said LVN # 1 was a new nurse to the facility system who was trained about the facility policies prior to work resumption. The DON said she had reviewed the incident regarding the death of CR# 1 but did not identify any other issues regarding delay in getting medical help as well as pain medication for CR# 1 following the fall on [DATE]. The DON said she would expect staff to call the medical director and herself when a resident's physician could not be reached. The DON said staff should use their nursing judgment in getting medical help for a resident with a change in condition. During this interview the DON did not identify a delay in the resident receiving medical assistance for CR# 1. The DON said she left the facility at about 8 p.m. Record review of CR #1 ' s Nurse ' s notes dated [DATE] revealed the following: At 8:30 P.M., the DON documented CR#1 was alert and oriented lying in bed comfortably. status [REDACTED]. The DON also documented the resident ' s vital signs were stable and was awaiting for X-Ray to be done. At 9:00P.M., the DON wrote the X-ray was done. The resident was alert and oriented times three and complained of hip pain during the X-ray. At 10:00P.M., the DON wrote the resident was unresponsive with low oxygen saturation at 80% at room air. Vital signs were taken, oxygen placed via nasal cannula. Registered nurse on duty called to assess the resident. MD and family members called to notify of resident ' s condition. At 10.30 p.m., RN # 1 wrote that the resident was DNR ( Do not resuscitate ). She documented she pronounced the resident expired at 10.30 p.m., no respiration, no pulse, no reflex, no heart palpitations, pale color skin, no movement , communicated to doctor, communicated to patient family about the resident expiring . At 11:50 p.m., the DON wrote " X-Ray result received at 9:54 p.m., showing neck Femoral fracture, CR# 1 ' s physician paged " . Record review of CR# 1 ' s X-Ray report dated [DATE] revealed fax time of 9:54 P.M., further review of result revealed " an oblique displaced [MEDICAL CONDITION] femoral neck (the femur, upper leg, neck is a flat bone connecting the femor head to the femor shaft) is demonstrated , fractures of the left superior and inferior public rami ( the four areas in the front of the pelvis) are demonstrated. Impression read: oblique displaced fractures of the left femoral neck, comminuted fractures of left superior and inferior pubic rami " . Interview on [DATE] at 4:14 P.M., the Administrator said he was made aware of the incident a day after CR# 1 expired. He explained the staff were educated on abuse and neglect. LVN # 1, who was not a regular staff to the facility was put back into orientation. The Administrator agreed neglect of any resident was not tolerable and prompt medical help should always be available to residents. Record review of facility's policy on abuse and neglect dated [DATE] defined neglect as " derivation by an individual , including a care taker of good or services that are necessary to attain or maintain physical , mental and psychosocial well-being ...The purpose of this policy was to ensure that the facility is doing all that is within its control to prevent occurrences of abuse , neglect and to treat all patients at the facility with dignity and respect at all times " . Record review of facility policy on recognizing changes in condition and interact not dated revealed " ... tools for early identification of a patient ' s change in condition and to reduce unnecessary readmission to the hospital includes: ambassador rounds, legend round, Triage rounds, interact. Purpose of InterACT - interventions are designed to improve the identification, evaluation and communication about changes in resident status " . Record review of facility policy titled Implemention Guide Communication Tools written by InterACT dated 2011 revealed the SBAR (Situation, Background, Assessment Recommendation) form/ acute change in condition progress note is designed to enhance the nursing evaluation of and documentation on residents who have a change in condition. The policy goes on to read that all nursing home licensed nursing staff evaluate and communicate acute changes to the doctor, nurse practitioner or physician assistant and documentation of the evaluation and communications. An immediate jeopardy (IJ) was identified on [DATE] at 10:05 A.M. and Administrator and DON were informed at that time. A Plan of Removal (POR) of the IJ was submitted and accepted on [DATE] at 5.35P.M. The POR included: Legend Oaks Northwest Houston Plan to remove immediate jeopardy. [DATE] 1. All residents will be assessed by our Administrative Nursing team on [DATE]. Any residents found to require medical care, physicians were consulted. All residents with a recent change of condition will be audited on [DATE] to make sure attending physician was consulted with, and that all orders were implemented. 2. Our Medical Director Designee in-services all Department Heads on [DATE], on protocols for calling in a change of condition to the physician, and the procedures to follow for a 911 transfer. An in -service was provided to all licensed staff on [DATE] on the 6am-2pm, and 2pm-l0pm shifts on these protocols. All other staff scheduled to work will not be allowed to work until they are in-serviced on these protocols. New hired staff will be in-serviced on these protocols during the first three days of orientation. 3. All licensed staff from 6am-2pm, and 2pm-10 pm was in-serviced on [DATE] on proper assessment documentation of change of condition and pain re-assessment with appropriate interventions. All other staff scheduled to work will not be allowed to work until they are in -serviced. New hired staff will be in-serviced on this during the first three days of orientation. 4. All licensed staff from 6am-2pm, and 2pm-l0 pm was in-serviced on [DATE] on current policies and procedures: Incidents and Accidents, Falls, and Pain Management, and the use of the Interact Program (SBAR, Describe the current Situation of the change of condition, the history Background of the resident, the current Assessment status of the resident, and the Response of the physician and Nursing staff to address the change of condition) All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 5. Facility in-serviced licensed staff from 6am-2pm, and 2pm to 10pm, on [DATE], that they are to notify the admitting physician or designee immediately upon change of condition or no pain relief with current measures. All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 6. All Licensed staff from 6am-2pm, and 2pm-l0pm, were in-serviced on [DATE] that if they are unable to reach the attending physician within 30 minutes from the change of a non-emergent condition identified, then the staff will notify a registered nurse on duty. If the registered nurse is not available or on duty, staff will notify the Assistant Director of Nursing. If Assistant Director of Nursing cannot be reached, staff will notify the Director of Nursing, or admitting physician. If they cannot be reached, staff will notify Medical Director. If Medical Director cannot be reached, facility will call 911. All incident and accidents will be reviewed during morning meeting and MDS coordinator will update/review care plans to prevent or minimize injuries related to falls. All PRN staff will be notified that they must attend these in-services before they can return to work. Interview on [DATE] about 3:00 P.M., facility Administrator stated he understood the issues at hand and he was working getting the staff educated to ensure no re-occurrences. He explained the safety of the residents were his priorities. The plan was monitored on [DATE] and [DATE] by the surveyor with the following results: Facility protocols concerning changes of condition, notifying physicians and when to call 911 were reviewed. Procedures concerning falls, incidents, changes of condition, proper assessment documentation, pain re-assessment with appropriate interventions were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed on 1-/16 and [DATE] and all expressed up to date knowledge on communication procedures. Interviews with nursing the staff on two shifts revealed positive response from the physicians they had contacted on [DATE] and [DATE] concerning changes of conditions with residents. Review of two changes of conditions that occurred on two different shifts over two days ([DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The IJ was called on [DATE] at 10:15 A.M., and lifted on [DATE] at 10:17A.M. The Administrator was notified of the IJ being lifted after verification of the plan implementation had occurred. While the IJ was removed on [DATE], the facility remained out of compliance at a scope level of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. The facility provided a census which revealed 100 residents.

Based on observations, record review, and interviews, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical wellbeing of one of 13 residents (CR #1) who were reviewed for effective management of the facility to maintain the highest practicable physical and mental wellbeing of the residents. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on identifying changes of condition and the notifications of physicians. The Administrator failed to supervise the DON on training the nursing staff on contacting the facility medical director when a resident ' s primary physician did not respond to a consultation for a resident's change in condition. The DON failed to train the nursing staff on contacting the facility medical director when a resident ' s primary physician did not respond to a consultation when a resident experienced a change in condition. The DON did not recognize the change of condition of CR #1 and implement procedures when CR# 1 ' s physician did not promptly respond to a consultation concerning her change in condition following a fall on [DATE]. The DON failed to delegate to an RN in the building on ,[DATE] shift on [DATE] to oversee the care of CR# 1 who experienced a fall and change in condition. The resident expired 6 hours later in the facility without an medical interventions. An immediate jeopardy (IJ) was identified on [DATE] at 10:15 A.M. While the IJ was removed on [DATE] at 10:17A.M., the facility remained out of compliance at a scope of wide spread and a severity level of Actual Harm that is not immediate jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. This failure affected 1 resident who died in the facility and placed 100 residents at risk of neglect, not having prompt interventions when a change in condition occurs and a delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 4 CR# 1 Record review of CR# 1 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1 ' s nurses notes dated [DATE] at 12:45P.M., LVN # 1 wrote late entry " CR# 1 had a fall on [DATE] at 4:15P.M., nurse was notified of fall by nurse, went to check on the patient, patient was on the floor, complaining of hip pain, vital signs post fall were taken , blood pressure of ,[DATE], pulse was 116, respiration was 22, patient assisted back to be with 3 person ' s assist using sheet for transfers, patient ' s physician was notified of the fall at 5:00P.M., and X-Ray was order given. Family was notified of the fall at 5:45P.M., patient was given [MEDICATION NAME] 325mg, one tablet per order, vital signs were taken gain at 6:30P.M., following blood pressure ,[DATE], pulse was 80, physician was paged for stronger pain medication awaiting for MD response, at 8:00pm, blood pressure was ,[DATE], pulse was 107, x-ray was taken of the hip and shoulders at 9pm. At 9:50P.M.,, patient was assessed , patient seemed unconscious , oxygen saturation rapidly changed from 75 to 83, unable to obtain blood pressure , at 10.30p.m., , patient was pronounced as expired by registered nurse on duty, at 10:45p.m., physician and family member was notified of the patients change in condition , MD notified of code status and X-ray report " . Further record review of CR #1's medical record revealed no SBAR (Situation, Background, Assessment Recommendation) form concerning the incident for [DATE]. A request was made to the DON for this form but one was not provided for review prior to exit. Interview on [DATE] at 12:52P.M., LVN # 1 said she was notified of CR# 1 fall about 4pm on [DATE]. DON and another nurse went to check on the resident, she said the resident ' s blood pressure was a little high and the resident complained of pain to her hip. X-ray was done late because the x-ray guys was late that day about 9pm, LVN# 1 said everything was happening quickly, she called the physician for stronger pain medication without response, she was monitoring the resident and noticed she was changing fast, she kept saying she had a really bad pain, was losing consciousness towards the end of the shift-like 30 minutes to the end she was ok. LVN # 1 in response to why CR# 1 was not send out said they were thinking she was sleeping , maybe the pain medication was making her sleepy, she was there when she passed away, we were about to give her oxygen when she was breathing heavily. LVN # 1 said she was very overwhelmed with the whole incident with CR#1, she said she did not seek help from any other staff in the facility during her shift. LVN # 1 said she was not aware she could call the facility ' s medical director when she could not reach CR#1 ' s physician. LVN # 1 did not call DON and did not seek alternate intervention for CR#1. She said eh resident was given one tablet of 325mg [MEDICATION NAME] for pain " . Interview on [DATE] at 10:38A.M., RN # 1 said she was working on different hall on [DATE] for the evening shift (,[DATE] shift) , she was the only registered nurse on the shift, she was called to see CR#1 about 10:30P.M.,when she got there, the resident ' s skin was pale,, no pulse, no blood pressure, no sign of life, her nails were blue in color, no palpitation and no movement. RN# 1 said she was not notified by anyone throughout the shift of CR# 1 ' s condition. She was called when she was already dead. She further said she pronounced her dead at 10:30P.M. Interview on [DATE] at 11:55A.M., the DON said she was aware the resident (CR #1) had a fall and the physician was called to notify him of fall and staff got an order to do X-ray of the affected area. The DON however agreed she did not delegate the RN in the building to monitor CR# 1 and did not instruct LVN # 1 to call the facility ' s medical director when CR#1 ' s physician did not respond to LVN #1's call to report about the resident . The DON did not instruct LVN # 1 to initiate or plan possible hospital transfer should CR# 1 physician not respond before she left the facility about 8:00P.M., on [DATE]. Interview on [DATE] at 4:00 p.m., the DON said staff was required to complete an SBAR (an assessment tool that contains screening, background information, assessment and reporting) with every change in condition identified on a resident. The physician should be called to report the findings. The DON said CR# 1 was not sent to the hospital because she was stable despite deterioration evidenced by her vital signs. The DON further said CR#1 did not complain of pain evidenced by the neurological assessment flow sheet. Interview on [DATE] about 3:50 P.M., the DON said LVN # 1 called her after CR#1 expired, and told her what happened. The DON said the nurse (LVN #1) reported being overwhelmed with the events and was not able to document about the incident in the resident ' s record. The DON said she told LVN # 1 that she must come back and document the incident. The DON also reported she put LVN # 1 back into orientation and an in-service was provided on documentation and falls. The DON said LVN # 1 was a new nurse to the facility system who was trained about the facility nursing policies prior to working on the floor which included the . The DON said she had reviewed the incident regarding the death of CR# 1 but did not identify any other issues in regards to a delay in getting medical help as well pain medication for CR# 1 following the fall on [DATE]. The DON said she would expect staff to call the medical director and herself when a resident ' s physician could not be reached. The DON said staff should use their nursing judgment in getting medical help for a resident with a change in condition. The DON during this interview did not identify a delay in getting medical assistance for CR# 1. The DON did not delegate or notify the RN in the building about on-going incident. Interview on [DATE] at 1:20 P.M., the Administrator said he was made aware of the incident with CR #1 the day after her death. He further said the DON investigated the situation and corrective measures were put in place to include : LVN # 1 was provided in-service on the policies and procedures of the facility and the facility nursing staffs were given in-service on Abuse and neglect. He stated how he oversaw nursing care was through the morning meetings, meeting with residents and families, through resident and family council meetings, the grievance log, and through in-servicing staff of his open door policy. He stated the Quality Assurance meeting address concerns of the team. He continued by stating in the morning meetings issues of concern were addressed, system were reviewed to ensure effectiveness and policies and procedures were reviewed. He stated staff was inserviced monthly along with competency checks annually. Interview on [DATE] at 1:35P.M., the DON said immediate jeopardy and SQC were called because the surveyor, from record review, identified a delay in treatment and in notifying the Physician following a recognized change in condition. The DON said she ensured competency in nursing skills by educating the staff, making walking rounds daily, 24 hour reports and through monthly competency checks on on-going issues. The DON further explained LVN # 1 was put back into orientation when she verbalized she was overwhelmed on [DATE]. The DON said in-services provided following the incident included- falls and documentation. Record review of facility's policy on abuse and neglect dated [DATE] defined neglect as " derivation by an individual , including a care taker of good or services that are necessary to attain or maintain physical , mental and psychosocial well-being ...The purpose of this policy was to ensure that the facility is doing all that is within its control to prevent occurrences of abuse , neglect and to treat all patients at the facility with dignity and respect at all times " . Record review of facility policy on recognizing changes in condition and interact not dated revealed " ... tools for early identification of a patient ' s change in condition and to reduce unnecessary readmission to the hospital includes: ambassador rounds, legend round, Triage rounds, interact. Purpose of InterACT - interventions are designed to improve the identification, evaluation and communication about changes in resident status " . Record review of facility policy titled Implemention Guide Communication Tools written by InterACT dated 2011 revealed the SBAR (Situation, Background, Assessment Recommendation) form/ acute change in condition progress note is designed to enhance the nursing evaluation of and documentation on residents who have a change in condition. The policy goes on to read that all nursing home licensed nursing staff evaluate and communicate acute changes to the doctor, nurse practitioner or physician assistant and documentation of the evaluation and communications. Record review of facility ' s abuse and neglect policy dated [DATE] revealed " the facility administrator or designee is responsible for implementing policies and procedures that prohibit abuse , neglect , involuntary seclusion and misappropriation of property " . No evidence that facility investigated this was presented upon request. An immediate jeopardy (IJ) was identified on [DATE] at 10:05 A.M. and Administrator and DON were informed at that time. A Plan of Removal (POR) of the IJ was submitted and accepted on [DATE] at 5.35P.M. The POR included: Legend Oaks Northwest Houston Plan to remove immediate jeopardy. [DATE] 1. All residents will be assessed by our Administrative Nursing team on [DATE]. Any residents found to require medical care, physicians were consulted. All residents with a recent change of condition will be audited on [DATE] to make sure attending physician was consulted with, and that all orders were implemented. 2. Our Medical Director Designee in-services all Department Heads on [DATE], on protocols for calling in a change of condition to the physician, and the procedures to follow for a 911 transfer. An in -service was provided to all licensed staff on [DATE] on the 6am-2pm, and 2pm-l0pm shifts on these protocols. All other staff scheduled to work will not be allowed to work until they are in-serviced on these protocols. New hired staff will be in-serviced on these protocols during the first three days of orientation. 3. All licensed staff from 6am-2pm, and 2pm-10pm was in-serviced on [DATE] on proper assessment documentation of change of condition and pain re-assessment with appropriate interventions. All other staff scheduled to work will not be allowed to work until they are in -serviced. New hired staff will be in-serviced on this during the first three days of orientation. 4. All licensed staff from 6am-2pm, and 2pm-l0pm was in-serviced on [DATE] on current policies and procedures: Incidents and Accidents, Falls, and Pain Management, and the use of the Interact Program (SBAR, Describe the current Situation of the change of condition, the history Background of the resident, the current Assessment status of the resident, and the Response of the physician and Nursing staff to address the change of condition) All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 5. Facility in-serviced licensed staff from 6am-2pm, and 2pm to 10pm, on [DATE], that they are to notify the admitting physician or designee immediately upon change of condition or no pain relief with current measures. All other staff scheduled to work will not be allowed to work until they are in-serviced. New hired staff will be in-serviced on this during the first three days of orientation. 6. All Licensed staff from 6am-2pm, and 2pm-l0pm, were in-serviced on [DATE] that if they are unable to reach the attending physician within 30 minutes from the change of a non-emergent condition identified, then the staff will notify a registered nurse on duty. If the registered nurse is not available or on duty, staff will notify the Assistant Director of Nursing. If Assistant Director of Nursing cannot be reached, staff will notify the Director of Nursing, or admitting physician. If they cannot be reached, staff will notify Medical Director. If Medical Director cannot be reached, facility will call 911. All incident and accidents will be reviewed during morning meeting and MDS coordinator will update/review care plans to prevent or minimize injuries related to falls. All PRN staff will be notified that they must attend these in-services before they can return to work. Interview on [DATE] about 3:00 P.M., facility Administrator stated he understood the issues at hand and he was working getting the staff educated to ensure no re-occurrences. He explained the safety of the residents were his priorities. The plan was monitored by the surveyor with the following results being revealed: Facility parameters were established by the Medical Director, Managing Administration and the DON. New procedures concerning the communicating with physicians was developed and put into place. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed and all expressed up to date knowledge on new communication procedures and parameters. The medical staff had all received letters explaining the new procedures and parameters. Interviews with nursing staff on two shifts revealed positive response from the physicians they had contacted on [DATE] and [DATE]. Review of two changes of conditions that occurred on two different shifts over two days ([DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The IJ was called on [DATE] at 10:15 A.M., and lifted on [DATE] at 10:17A.M. The Administrator was notified of the IJ being lifted after verification of the plan implementation had occurred. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of wide spread and a severity level of actual harm that was not an Immediate Jeopardy because all staff had not been trained on the procedure on notifying physicians and providing services to resident's experiencing a change of condition. The facility provided a census which revealed 100 residents.

Based on record review and interview the facility failed to provide the necessary pain management to attain or maintain the highest practicable physical, mental and psychosocial wellbeing for 1 of 5 residents (#96) assessed for pain management. Resident # 96 ' s pain was not effectively controlled or managed during wound care. This failure affected one resident whose pain was not managed and placed 51 residents in the facility at risk of having increased pain which could cause a decline in their physical and mental health. Findings include: Record review of Resident #96's admission face sheet revealed she was a [AGE] year old female. The resident was admitted to the facility on [DATE]. Her admission [DIAGNOSES REDACTED]. Observation on 6/16/14 at 9:32 A.M. during initial tour revealed Resident #96 in bed on an air mattress. The resident was awake and alert and was able to answer questions. Resident #96 had bilateral lower extremity contractures, multiple pressure ulcers and a catheter in place. Record review of the admission MDS dated [DATE] revealed Resident #96's cognitive status was intact. Record review of Resident #96's Nurse Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED].M., 2:00 P.M and 8:00 P.M. Record review of Resident #96's Treatment Record dated June 2014 revealed the following wounds with dates treatments started. All treatments were scheduled to be completed daily at 8:00 A.M. Anus/groin wound area dated 5/16/2014 Left shoulder dated 5/21/2014. Right 4th toe dated 5/31/2014. Right 5th toe dated 6/10/2014. Right medial elbow dated 5/21/2014. Right medical foot dated 5/21/2014. Right medial shin dated 5/21/2014. Left 5th toe dated 6/10/2014. Left heel dated 5/21/2014. Left lateral distal foot dated 6/10/2014. Left hip dated 5/21/2014. Left proximal foot 5/21/2014. Observation on 6/17/14 at 11:20 A.M. of wound care revealed Resident #96 was on her right side. LVN #2 (wound care nurse) removed the dressing off the resident ' s left shoulder. Observation revealed a deep open pressure wound. LVN #2 clean the wound with wound cleanser the resident pulled her shoulder away and yelled "oh no." Observation on 6/17/14 as wound care continued revealed LVN #2 removed the dressing off the Resident #96 ' s left hip. Observation revealed a large deep open pressure wound. LVN#2 cleaned and packed the wound the resident yelled "oh no." Before moving toward the left foot wounds LVN #2 stated that these were the wounds that the resident was really going to be upset about having treated. Observation on 6/17/14 of wound care revealed LVN#2 removed the dressing wrap from the Resident #96 ' s left foot which revealed 3 large open pressure wounds. As the LVN cleaned the lateral left foot wound the resident tried to swing her arms towards the nurse. Resident #96 yelled "it hurts." Observation of the left foot wound revealed LVN #2 cleaned the left medial and left heel wounds. Resident #96 cried out "Help me please somebody help me Oh no." Resident # 96 was shaking the side rails when LVN #2 finished redressing the left foot. Interview on 6/17/14 at 12:05 P.M. when asked if Resident #96 had received any pain medication this A.M. LVN #1 (unit nurse) stated Resident #96 received her one [MEDICATION NAME] 5/325 mg and then after looking MAR indicated [REDACTED].M. Interview on 6/17/14 LVN#2 stated she would talk with the resident ' s nurse practitioner (NP) about getting her something for break through pain or something closer to and better for the wound care. She continued and stated she did not tolerate the procedure well and that her pain was not well controlled. Interview on 6/18/14 at 10:00 A.M. LVN #2 stated the NP got the resident something more for pain. She stated the resident ' s pressure wounds were staged as follows left shoulder wound was a stage IV, her left hip was a stage IV, left lateral foot was unstageable, left medial was unstageable and left heel was stage IV. Record review of the facility ' s policy on pain management dated December 2005 revealed "...All facility staff has a commitment to provide patients with a quick response to reports of pain, and will encourage patients to participate in the pain management ...The patient ' s pain status is monitored for improvement by: Reassessing ineffective pain management ...." CMS for 672 revealed 52 residents on pain management.

Based on observation, record review and interview, the facility failed to perform a comprehensive assessment to identify, prevent, and treat pressure ulcers. The facility further failed to provide and implement appropriate interventions, care and treatment to an existing pressure ulcer to minimize infections to promote healing and failed to notify the physician of the resident ' s condition or changes in the resident's wound in 1 of 8 residents reviewed for pressure ulcers. This failure affected 1 resident and placed 72 residents identified by the facility as at risk for developing pressure ulcers. Complaint # 8 Findings include: Record review of Resident #1 ' s face sheet revealed she was admitted to the facility on [DATE]. Review of her physician orders [REDACTED]. Additional [DIAGNOSES REDACTED]. Record review of the closed clinical record for Resident #1 revealed initial admission assessment dated [DATE] indicating that upon admission, she was awake, alert, and oriented. She was ambulating using a walker, and at times using a wheelchair and able to propel herself in the wheelchair. Record review of Resident #1 ' s Comprehensive Nursing Evaluation with admission date of [DATE] and signed complete 4/10/12 revealed the following under integumentary (skin) section - redness was noted to left heel, bruise was identified to left upper inner arm area and left breast area. Bruises/ecchymosis is checked. There was no skin treatments checked. The nurses noted below this section dated 4/10/12 at 11:30 PM reads in part " ...Pt has (unknown word scratched out) redness on Left heel, Bruises to The left Breast/Abdomen, Bruise on left arm ... " Record review of Resident #1 ' s Pressure Ulcer Report dated 4/25/12 revealed an area marked to resident 's right upper buttock, lateral to the sacral area. Stage: unstageable and DTI (deep tissue injury); Size in CM (length x width) 4.3x 6.5; Depth (cm) 0.1; odor: none; exudate amount: none; surrounding skin color: pink; wound bed: Black/Brown (eschar); surrounding tissue/wound edges: Normal for skin; Date family and physician are notified is 4/25. Record review of Resident #1 ' s Pressure Ulcer Report updated 5/2/12 revealed the area still as unstageable and DTI, size 6 x 6.0; Depth 0.2; exudate type: none and serous was checked, odor: none; exudate amount: small; wound bed: black/brown (Escher), surrounding skin color: pink; surrounding tissue/wound edges: normal for skin; response to treatment: deteriorated. Record review of Resident #1's Braden Scale (no date but with her Comprehensive Nursing Evaluation with admission date of [DATE]) revealed a risk score of 14 (moderate risk). Record review of Resident #1's significant MDS dated [DATE] revealed under section M (skin conditions) she was coded at risk for skin breakdown with no actual breakdown coded. Record review of Resident #1 ' s 14 day MDS dated [DATE] revealed under section M she was coded as at risk for skin breakdown with no actual breakdown coded. Record review of Resident #1 ' s discharge MDS dated [DATE] revealed under section M she was coded as having 1 unstaged pressure ulcer with slough/eschar that measured 6.0 x 6.2 x 0.2 cm. Record review of Resident #1's interim plan of care (no date but with her Comprehensive Nursing Evaluation with admission date of [DATE]) revealed under problem #6 (Actual/Potential urinary and bowel incontinence), goal #2 reads " Patient will not have skin breakdown over the next 90 days " . Approach # 5 reads " Perform skin assessments at least weekly and report any breakdown to MD " . Record review of Resident #1 ' s Comprehensive Plan of Care dated 4/16/12 list the problem/need as Resident is at risk for skin breakdown related to: incontinence, impaired bed mobility, hx of pressure ulcer, fragile skin, cognitive impairment, diabetes, [MEDICAL CONDITION]/[MEDICAL CONDITIONS]. The goal reads " skin will remain clean, dry and intact without evidence of breakdown over the next 90 days " . Approach #5 reads " monitor for skin breakdown, report to M.D. and R.P. (responsible party) " . Approach #7 reads " Assess skin weekly and record findings " . Record review of Resident #1 ' s Comprehensive Plan of Care dated 4/25/12 reads, under Problem, " Resident has a stage US (unstageable) pressure ulcer. Location: R Buttock. Goal #1 reads " Resident ' s pressure ulcer will improve over the next 2 weeks. " Goal #2 reads " Resident will have no further skin breakdown " . Approach #11 reads " Weekly head-to-toe skin assessment. " Review of Resident #1 ' s medical record from April 10, 2012 through May 5, 2012 revealed no weekly skin assessments. Record review of Resident #1 ' s daily skilled nurse ' s notes dated 5/1/12, 5/2/12, and 5/4/12 revealed skin was WNL (within normal limits) was checked as well as rash and skin tear/cut. Continued review of the closed clinical records revealed a recommendation by the wound care nurse to apply santyl ointment. However, there was no other preventive measures such as pressure relief device i.e. air mattress/ bed, schedule turning and repositioning to relieve pressure from sacrum to prevent further damage and promote healing. There was no check off or documentation by the C.N.A's that the resident was repositioned every one to two hours. There was no wound care consult to any physician or a notification to any physician in her closed clinical records about the discoloration noted on her sacrum. Record review of the medication administration records (MAR) dated ....through 5/5/12 revealed no documentation of the nurses applying santyl ointment to Resident #1 ' s sacrum. Record review of the insert booklet found in packet of santyl ointment revealed the following " SANTYL? is an enzymatic [MEDICATION NAME] ointment containing 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] ... .....It is usually recommended as an active enzymatic therapy that continuously removes necrotic tissue from wounds, allowing granulation to proceed and [MEDICATION NAME] to occur " . According to the wound assessment sheet, it reflected a discoloration mark on Resident #1 sacrum, reflecting that the area was not an open wound indicating the recommendation by the wound care nurse was inappropriate treatment. Record review of Resident #1closed clinical records of the lab section dated 4/9/12 through 5/5/12 revealed a lab result dated 03/26/2012 of which the resident was positive for C.difficile There was no lab relating to wound cultures. Record review of Resident #1's closed record revealed a transfer sheet indicating that the Resident was sent to an acute care emergency roiagnom on [DATE] for decreased mental status, febrile state, increase lethargy and unresponsiveness. Records review of Resident #1 has closed clinical records obtained from acute care hospital revealed ER (emergency room ) records that described Resident #1 ' s condition upon her arrival to emergency roiagnom on [DATE]. Resident #1 was brought in with a 101.2 fever, altered mental status, and was very lethargic. The Resident was also found to have multiple decubitus ulcers, with infection on her sacral wound, thigh, and heels. Her WBC (White Blood Cells) was 13.3 (normal range for WBC falls between 3.7 to 10.4). A urinalysis was also found to have been packed with WBCs up to 100,000. According to the ER doctor, the Resident's lower extremities had a 2-point indentation [MEDICAL CONDITION] and ulceration on the right thigh, heels, sacral, and [MEDICAL CONDITION] to bilateral lower extremities worsening on the right than left. According to the ER records Resident #1 had a catheter placed during her previous hospitalization at a different acute care hospital on an unknown date. Her [DIAGNOSES REDACTED]. " The Resident was immediately started on some IV [MEDICATION NAME] fluids and some IV antibiotics. The Foley catheter was changed and was maintained on oxygen support, O2 until stable " . Further record review revealed a physician physical examination that described the skin, as 2+ [MEDICAL CONDITION] with lichenification (thickening of the skin and exaggeration of the normal skin markings, giving the skin a leathery bark-like appearance) and thickening of the skin and superficial bilateral crusting of the skin of the lower extremity of the leg, [MEDICAL CONDITION] ([DIAGNOSES REDACTED] disease that affects the blood vessels and connective tissue; fibrous connective tissue is deposited in the skin). In addition, " pulses were barely palpable but cap refill was borderline Skin ulcer especially on the thighs and heel and sacral area with signs of [MEDICAL CONDITION], and the Resident has an indwelling catheter with mild bloody uremia " . Further record review revealed that Resident #1 was transferred to an Intermediate Care Unit, where she stayed for two days until she was stabilized. She was later transferred to a LTAC, (long-term acute care) facility for continuous IV (intravenous) antibiotic and wound care treatment. Observation on 5/24/12 at 8:30 AM of Resident #1 at the LTAC revealed her sitting in the geri-chair, awake, alert, oriented in making conversation with the staff while eating breakfast. Continuoued observation revealed Resident #1 had a special bed to prevent further skin breakdown in room, had waffle boots on; check off by the CNA was posted on the door that indicated Resident #1 was turned every two hours. Observation on 05/24/12 at 8:50 AM of wound care for Resident #1 performed by the wound care nurse at the LTAC revealed a pressure ulcer to the right posterior labia that appeared to have been created from in-dwelling catheter tubing. Observation on 05/24/12 at 8:50 AM further revealed there was a large pressure sore on the right heel covered with black Escher, a large wound on her left heel that is pink-colored and well granulated, a large sacrum wound; it appears to have been debrided. It had rough edges, covered with yellow slough, and some areas pink and red granulation tissue with tunneling and indentation to the wound and stage II pressure ulcer to above the right knee. Continued observation revealed both extremities had weeping [MEDICAL CONDITION] worse on the right than the left. Record review of ER records revealed that Resident #1 was admitted to the LTAC on 5/9/12 with multiple wounds infections and [MEDICAL CONDITION]. Record review of the " wound care progress note " dated 05/10/12, revealed a pressure ulcer measurement sheet reflecting her wounds. According to the records, the Resident had a pressure ulcer to right sacrum that was unstageable. The measurement was 10.8 cm x 7.7 cm length. The sacrum wound had a foul odor with moderate-to-large amounts of drainage. She had a wound/skin tear to the left sacrum, which measured 1.5 x 1.0 cm, a stage II on her right heel, measuring 2 x 1.5 cm, a pressure ulcer on her left heel, that was unstageable, measuring 12.5 x 6.5 cm, and had small amounts of " serosanguineous " drainage (drainage mix of clear serum and blood) with a foul odor. On her left labia, there was a 0.5 x 2.0 cm wound. It appeared to have been marked by in-dwelling catheter that was secured too tight. On her right thigh, there was a skin tear measuring 0.4 x 4.0 cm. Further record review of Lab section dated 05/10/12 revealed all the wounds were cultured and they were all positive [MEDICAL CONDITION], ([MEDICAL CONDITION]-resistant Staph aureus). In an interview on 5/24/12 at 2:00 PM LVN A stated Resident #1 had been in and out of the facility to the hospital. She stated on the most recent admission from the hospital (April 10, 2012) Resident #1 had an open area to the right lateral knee. She further stated she had a deep tissue injury on her bottom area which she remembered happening at the facility. She stated Resident #1 had medical issues and had deteriorated. She stated there was no eschar on her heels, only [MEDICAL CONDITION] to Resident #1 leg. She stated when Resident #1 transferred to the hospital on [DATE] she only was aware of the wound/deep tissue injury on her bottom area. . She stated she recommended that the nurses apply Santyl ointment to that area. She stated she did not identify any other pressure ulcer on the resident. She confirmed that there was no other preventative measure in place even when discoloration was noted on Resident #1 ' s sacrum. She denied ever seeing any wound on her heels, and she stated that none of the nurses or C.N.As reported to her that they found any wounds on the heels or anywhere else in the resident ' s body. She further stated because Resident #1did not have a pressure sore she would not continue to do weekly wound assessment and that the nurses supposed to document their daily assessment instead. In an interview on 5/24/12 at 2:15 PM the DON stated Resident #1 was transferred to the hospital in May due to a change in condition, fever and altered mental status. She stated she was unsure if Resident #1 was unresponsive when transferred to the hospital. She stated on admission the admitting nurse will do an initial skin assessment and note any areas, and then the treatment nurse will check the skin after the nurse. Further interview with the DON at this time revealed that she had reviewed Resident #1's chart and she stated she could not find weekly skin sheet assessments. She further reviewed the nurse ' s notes and she stated she could not find documentation of evidence that the resident had wounds on bilateral heels, labia, and her thigh. DON further agreed that a consult should have been made to the physician. In an interview on 5/24/12 at 2:20 PM LVN B stated Resident #1 had a fever that was not breaking and was on oral antibiotic. She stated Resident #1 was being treated for [REDACTED]. She stated it was a suspected deep tissue injury. She stated Resident #1 had no bruising that she was aware of. Record review of the facilities skin care system 1 (policy and procedure) dated January 2011 read in part " ... 4. A Weekly Head-to-Toe Skin Assessment Form (see Form 1-4) must be complete the day of admission (including readmission), once weekly, any change in skin condition and prior to discharge/transfer of a Patient. At the end of each month the Weekly Head-to-Toe Skin Assessment Form is filled in the Patent ' s medical record under the " Medication/Treatment " tab and a new form initiated ... " According to the CMS Form 672 there were 73 residents at risk for developing pressure ulcers. .

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services to prevent urinary tract infections, trauma, and pressure sore and to restore as much normal bladder function as possible for 3 of 4 residents (Residents #1, #4 and #9) reviewed for justification and positioning of an indwelling catheter. This failure affected 3 residents and placed 4 residents at risk for catheter blockage, urethral erosion, bladder spasms, hematuria, leakage around the catheter, poor urine flow, proteinuria, bladder stones, exacerbation of continued bladder incontinence and UTI's. Complaint # 8 Findings include: Resident #1 Record review of Resident #1 ' s face sheet revealed she was admitted to the facility on [DATE]. Review of her physician orders [REDACTED]. . Record review of the closed clinical record for Resident #1 revealed initial admission assessment dated [DATE] indicating that upon admission, she was awake, alert, and oriented. She was ambulating using a walker, and at times using a wheelchair and able to propel herself in the wheelchair. Record review of Resident #1 closed record revealed a transfer sheet indicating that the Resident was sent to an acute care emergency roiagnom on [DATE] for decreased mental status, febrile state, increase lethargy and unresponsiveness. Further record review of transfer sheet dated 5/9/12 revealed Resident #1 ' s final [DIAGNOSES REDACTED]. Record review of the Lab section of her closed clinical records, revealed a urinalysis sent on 02/13/12 revealed a negative for urinary tract infection; however, there has not been any further urinalysis sent since. Record review of the physician's orders [REDACTED]. Dx: Bilateral lower legs [MEDICAL CONDITION]. Change Foley bag on first and fifteenth of every month and change on the fifteenth every month". Continue review of the physician's orders [REDACTED]. Record review of the MAR indicated [REDACTED]. On the MAR, it was marked that the in-dwelling catheter was to be changed on the 15th. There was no documentation that the in-dwelling catheter was changed. Record review of care plan dated 04/09/2012 revealed Resident #1 was identified as having an in-dwelling catheter and she was at risk for increased urinary tract infection. According to the care plan, " The goal was that the Foley catheter will remain patent and that the resident will not develop incident of UTI over the next 90 days. The approach was to change the Foley catheter tubing and bag as ordered. Monitor for odor, color, pigmentation and amount of urine, etc., and report abnormal finding to the physician. To encourage the resident to drink fluid intake within the dietary limit and to keep the tubing in the bag below the bladder ... ... " Facility did not follow their planned approach/intervention to securing the Foley tubing below the bladder as indicated in her care plan. Record review of Resident #1 ' s Comprehensive Plan of Care dated 4/16/12 list the problem/need as Resident is at risk for skin breakdown related to: incontinence, impaired bed mobility, hx of pressure ulcer, fragile skin, cognitive impairment, diabetes, [MEDICAL CONDITION]/[MEDICAL CONDITIONS]. The goal reads " skin will remain clean, dry and intact without evidence of breakdown over the next 90 days " . Approach #5 reads " monitor for skin breakdown, report to M.D. and R.P. (responsible party) " . Approach #7 reads " Assess skin weekly and record findings " . Further review of the care plan, revealed the resident also at risk for developing skin breakdown. The goal was to " have the resident clean, dry and odor free, have no occurrence of skin breakdown for the next 90 days. The approach was to monitor the incontinent care every 2 hours and change as needed and apply protective barrier to the skin and monitor resident for skin breakdown, report to the physician and the responsible party and searched for the cause of the incontinence Record review of ER records dated 05/05/2012 Resident #1 was brought in with a 101.2 fever, altered mental status, and was very lethargic. The Resident was also found to have multiple decubitus ulcers, with infection on her sacral wound, thigh, and heels. Her WBC (White Blood Cells) was 13.3 (normal range for WBC falls between 3.7 to 10.4). A urinalysis was also found have been packed with WBCs up to 100,000. According to the ER records, resident had a catheter placed during her previous hospitalization at a different acute care hospital on an unknown date. Further record review revealed that the resident returned to the facility on [DATE] with an in-dwelling catheter, however, it had not been changed out since. Upon arriving to ER, the in-dwelling catheter was changed out. According to the ER records, Resident #1 had white thick discharge from her vagina and multiple pressure sores including one her labia. Continue record review revealed Resident #1 was transferred to Intermediate Care Unit, where she stayed for two days until she was stabilized. She was later transferred to the LTAC, a (long-term acute care) facility for continuous IV (intravenous) antibiotic and wound care treatment. Observation on 5/24/2012 at 8:50 AM of Resident #1 at the LTAC revealed the resident had developed a pressure ulcer due to the in-dwelling catheter: Foley catheter secured too tight to the abdomen creating upwards pressure on the skin creating tension and a pressure sore on the posterior right upper labia. In an interview on 5/24/12 at 2:15 PM the DON stated Resident #1 was transferred to the hospital in May due to a change in condition, fever and altered mental status. She stated she was not aware the resident had a pressure sore on her labia nor was unable to give explanation while the in-dwelling catheter was not changed on the 15th. DON further stated she would reeducate the nurses on how to secure the in-dwelling catheter below the bladder so that it can drain to gravity. Random Resident #9 Record review of care plan dated 5/10/12 revealed that Random Resident #9 was identified as having an in-dwelling catheter and was at risk for increased urinary tract infection. According to the care plan, " The goal was that the Foley catheter will remain patent and that the resident will not develop incident of UTI over the next 90 days. The approach was to change the Foley catheter tubing and bag as ordered. Monitor for odor, color, pigmentation and amount of urine, etc., and report abnormal finding to the physician. To encourage the resident to drink fluid intake within the dietary limit and to keep the tubing in the bag below the bladder ... ... " According to this care plan " Foley catheter will be changed as ordered and that resident's tubing and bag will be kept below the bladder and not allow leaking." Observation on 5/24/12 at 12:15 PM during incontinent care rounds, revealed Resident #9 in bed, awake, and able to carry out conversation. Further observation at this time revealed that Resident #9's catheter tubing was observed not anchored to the resident's thigh below her bladder instead it was secured above her bladder and it was stretched, creating tension and potential for reflux of urine back into the bladder and for infectious organisms to migrate to the bladder along the outside of the catheter tubing creatintg potential trauma and UTI. Interview with LVN B at this time, she stated Resident #9 was able to make her needs known and she was interviewable. However, record review of her entire clinical records revealed no evidence the she had been placed on any type of toileting program such as Habit Training/Scheduled Voiding. Observation on 5/24/12 at 12:15 PM of Resident #9's indwelling catheter revealed that the Foley was attached above her bladder making it impossible to allow appropriate gravity drainage indicating a common practice of this facility. Interview with the DON on 4:45 PM on 5/24/2012 she said that the resident was new to the facility, however, she had been in the facility more than 2 weeks. She further said that she admitted with the indwelling catheter and after reviewing the resident's entire chart, she said she could not find any other justification for the indwelling catheter. She further stated she would reeducate the nurses how to secure the indwelling catheter downwards below the bladder so that it could drain to gravity. Resident #4 Record review of Resident #4 ' s face sheet revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. In an interview on 5/24/12 at 11:50 AM Resident #4 stated staff was not always " available " to empty her catheter bag for her, especially at night. She stated staff was supposed to come in at night and empty her bag for her. Observation on 5/24/12 at 1:05 PM during incontinent care rounds, revealed Resident #4 was standing by her bedside holding her catheter bag. She was oriented and able to carry out a full conversation coherently. In an interview with the resident at this time she said "they (staff) were suppose to start her bladder training but they are yet to do it". Record review of Resident #4 ' s annual MDS dated [DATE] revealed under section H (Bladder and Bowel) she was checked yes for having an indwelling urinary catheter and under section G for toileting she was coded as needed supervision and set up for toileting care. The CMS Form 672 listed 7 Residents with indwelling catheters.