Every finding on record at Longview Hill Nursing and Rehabilitation Center

Based on interviews and record reviews, the facility failed to ensure residents received mail delivered to the facility for 3 of 3 confidential residents reviewed for right to communication.The facility failed to ensure residents received their mail unopened and on Saturdays.This failure could place residents at risk of potentially being denied their rights and receiving and opening mail in a timely manner and a diminished quality of life.Findings included:During a confidential group interview on undisclosed date and time, 3 of 3 residents interviewed said their supplies and mail would come to them open. A resident said every piece of mail he had received was open. Another resident reported he had received his bank card through the mail, and the staff had removed the bank card and brought it to him. He was concerned with someone getting his personal information from the card. The residents interviewed stated they did not receive mail on Saturdays.During an interview on 3/18/2026 at 8:55 AM, Receptionist H said she received mail and packages through multiple carriers. She said the packages were stored across the hall near the Administrators office. She said she sorts the mail and places the mail in the department head trays. She stated the bills go to the Business Office Manager. Receptionist H said she opens all the mail. She stated if there was a check in the mail, she would make a copy of it and place it back in the envelope and give it to the Business Office Manager. She said she opened all mail. Receptionist H recanted and stated that she only opened magazine mail. She said she did not know when the residents received their mail. She said the Activity Director gets the cards and she did not know who delivers the mail on Saturdays.During an interview on 3/18/2026 at 11:20 AM, the Assistant Activity Director said the mail was delivered to the front receptionist area. She said she does not open the residents' mail unless one of the nurses opens the mail. The Assistant Activity Director said she does not deliver the mail on Saturdays because she forgot. She said her activity schedule was full of activities. She said she could not recall the last time she delivered mail on Saturdays. During an interview on 3/18/2026 at 2:31 PM, the Business Office Manager said the mail goes to the receptionist. She said if there was mail from Health and Human Services, she opened it. She said it would have her name or the facility's name on it. The Business Office Manager said she did not open the mail unless the Power of Attorney asked them to open the mail because the family asked them to open it for the financial renewal. She said the resident mail goes to the tray and the Activity Director delivers the mail. She said the mail should not be opened. The Business Office Manager said no one delivered mail on Saturdays that she was aware of. She rephrased and stated she was not sure who delivered mail on Saturday. The Business Office Manager said no one had reported to her that their mail had been opened. She did not know who was responsible for ensuring the mail was delivered on Saturdays. She said it could make a resident upset.During an interview on 3/18/2026 at 2:42 PM, the ADON said the mail came to the front receptionist and then it goes to the Business office and then the Activity Director hands out the resident mail. She said the mail should not be opened by any staff member. She said a resident could get upset if someone opened their mail. She said no one had reported their mail being opened. The ADON said if the post office is open, then the mail should be delivered to the residents.During an interview on 3/18/2026 at 3:16 PM, the DON said the Activity Director passes out the mail. She said the residents open their own mail. The DON said the resident rights would be violated if someone opened their mail. She said there was a manager on duty on the weekends. She said she was not sure who delivered the mail on the weekends.During an interview on 3/18/2026 at 3:30 PM, the ADM said he had one resident who alleged their mail was open. He stated the facility wrote a grievance on a resident who received a letter from a family member. He said if the resident's bank card or statement were addressed to the facility and resident, it would go to the business office. He said he did not know how a resident would feel. He said they may get upset if their mail was open. The ADM said he talked to the Activity Director, and she did not open the mail. He said you could assume it came damaged but understood the concern. The ADM said the receptionist received the mail on Saturday and put the mail in the box. The ADM said the mail should be delivered on Saturdays.Record review of a policy titled Resident Personal Belongings dated 10/24/2022 indicated .It is the policy of this facility to protect the resident's right to possess personal belongings.7. The facility will exercise reasonable care for the protection of the resident's property from loss or theft.Requested review of a policy on mail delivery and resident rights but was only provided Resident Personal Belongings.

Based on observations, interviews and record reviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 12 residents with limited range of motion (Resident #64, Resident #103 and Resident #53).1. The facility failed to ensure Resident #53 had hand roll on right hand and palm guard splint on left hand for up to 8 hours during the day on 03/16/26, 03/17/26 and 3/18/26.2. Resident #64 had limited range of motion to upper right extremity with no services to prevent further decrease in range of motion.3. The facility failed to ensure Resident #103 had a contracture prevention device in place for the treatment of his left-hand contracture on 03/16/26 and 03/17/26.These failures could place residents at risk of not having their individualized needs met, decreased range of motion and a decline in their quality of care and life.1. Record review of Resident #53's face sheet, dated 3/17/26, indicated a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #53 had diagnoses which included cerebral infarction (a serious medical emergency where a blood clot blocks blood vessels supplying the brain, causing tissue death), contracture, left hand (a permanent or long-lasting tightening, shortening, or hardening of muscles, tendons, skin, or joint tissue, restricting movement and causing deformity) contracture, right hand, aphasia (a neurological disorder that impairs a person's ability to communicate) and anxiety disorder. Record review of Resident #53's nursing home comprehensive MDS assessment, dated 12/8/25, indicated Resident #53 was rarely/never understood by others and usually understood others. There was not a brief interview for mental status completed on Resident #53. Resident #53 was dependent on ADLs. Restorative nursing program indicated no splint or brace assistance for Resident #53. Record review of Resident #53's care plan, dated 10/4/25, indicated Resident #53 has limited physical mobility related to bilateral hand contractures and neurological deficits. Interventions included, monitor, document, report as needed any signs and symptoms of immobility, contracture forming or worsening, thrombus (a stationary blood clot) formation, skin breakdown and fall related injury. Record review of progress notes dated from 2/15/26 to 3/18/26 did not indicate Resident #53 refused to wear hand roll on right hand and palm guard splint on left hand for up to 8 hours. Review of occupational therapy discharge summary signed 10/03/2025 indicated; Long term goal: Patient will safely wear hand roll on right hand and palm guard splint on left hand for up to 8 hours with minimal signs and symptoms of redness, swelling, discomfort or pain in order to manage contracture and prevent skin breakdown. During an observation on 3/16/26 at 11:26 A.M., Resident #53 was lying in bed with feeding running with bed in lowest position. Resident #53's right and left hand were contracted; there was no palm guard splint or hand roll in place. During an observation on 3/16/26 at 2:03 P.M., Resident #53 was lying in bed watching T.V. Resident #53 could not speak. Resident #53's right and left hand were contracted; there was no palm guard splint or hand roll in place. During an observation on 3/17/26 at 10:41 A.M., Resident #53 was sitting in a broda chair (specialized medical seating) resting. Resident #53 had contractures to right and left hand and no palm guard splint or hand roll was applied. During an observation on 3/17/26 at 2:13 P.M., Resident #53 was sitting up in a broda chair (specialized medical seating) in her room and there was no palm guard splint or hand roll in place. During an observation on 3/17/26 at 4:19 P.M., Resident was lying in bed resting. Resident #53 did not have a palm guard splint or hand roll applied to bilateral contracted hands. During an observation on 3/18/2026 at 10:48 A.M., Resident #53 was lying in bed asleep. Resident #53 did not have a palm guard splint or hand roll applied to bilateral contracted hands. During an interview on 3/17/26 at 4:26 P.M., CNA L said Resident #53 fought and she would not let staff put the hand roll and palm guard splint in her hands. She said the nurse went to Resident's room to attempt to apply the splint and hand roll but was not successful. She said usually the CNAs tried to apply the splints and hand rolls first. She said Resident #53 wears the splints, because both of her hands are contracted. She said usually, the therapy people came and in-serviced the CNAs and nurses on who had splints and hand rolls and how to apply them to the residents. She said the CNAs did not document applying or refusal of palm guard splint or hand roll. She said CNAs just notified the nurse of the refusal. She said a risk with the resident's hands being contracted could cause an opened area to the hands. During an interview on 3/17/26 at 5:08 P.M., LVN P said Resident #53 does not have her palm guard splint and hand roll in because she was combative. She said a family member of Resident #53'shad her palm guard splint and hand roll; she said a family member of Resident #53's took the items home to wash them. She said she honestly did not know how long Resident #53 had been without the splint and hand roll. She said the nurse or a family member of Resident #53's usually put on the palm guard splint and hand roll. She said the nurses know what residents had contractures, because it was in their orders. She said the nurses usually document in a progress note or where they click off the tasks in the point click care (electronic health records). She said the hand palm guard splint and hand roll prevent Resident #53's fingers from digging into her skin. She said the risk of Resident #53 not wearing the palm guard splint and hand roll was potential for infection; she could cut her hand, and she could dig a wound in her hands. During an interview on 3/18/26 at 1:50 P.M., PTA N said if therapy applied a palm guard splint or hand roll depends on the resident. She said if the resident was on therapy services, therapy usually ensured the resident's splints or hand rolls were in place, but after therapy was completed, the nurses were responsible for applying the splints and hand rolls. She said the palm guard splint and hand roll was to keep the resident's hand from completely closing. She said the negative effect of not using the palm guard splint or hand roll could cause a wound and it could also cause an infection with the hands being closed and not cleaned; bacteria could set up in the area. During an interview on 3/18/26 at 2:18 P.M., ADON K said Resident #53 refused most care. She said she knew a family member of Resident #53's took her things home to wash them. She said sometimes Resident #53 would let staff do things for her, but that was very seldom. She said the nurses should be documenting that Resident #53 refused the palm guard splint and hand roll. She said if staff could get Resident #53 to wear the palm guard splint and hand roll, they should apply them. She said the nursing staff were responsible for applying the palm guard splint and hand roll. She said the risk of Resident #53 not wearing the palm guard splint and hand roll was infection. During an interview on 3/18/26 at 2:41 P.M., the Director of Nursing said she expected all staff to apply palm guard splint and hand roll to the residents with contractures. She said the nurses were responsible for applying the palm guard splint and hand rolls. She said a risk was it could lead to worsening of the contractures. During an interview on 3/18/26 at 2:58 P.M., the Administrator said he expected the staff to apply the palm guard splint and hand rolls to the residents with contractures. He said the nurses and therapy were responsible for applying the palm guard splint and hand roll. He said the risk depended on the baseline of the resident with the contracture; the condition could get worse without the palm guard splint or hand roll. He said the facility did not have a policy for contractures. The findings included: 2. Record review of the face sheet dated 08/31/2019 indicated Resident #64 was [AGE] years old and was initially admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses including Contracture Right Hand (a condition where the palmar fascia thickens, forming cords that pull one or more fingers into a bent position), Muscle Wasting and Atrophy (Muscle atrophy is the loss of muscle tissue, causing reduced muscle mass and strength, usually resulting from inactivity, aging, or disease), Atrial Fibrillation (the most common type of treated heart arrhythmia, characterized by a rapid, irregular heartbeat caused by chaotic electrical signals in the heart's upper chambers.) Record review of Resident #64's Quarterly MDS dated [DATE] indicated Resident #64 was understood and understood others. The MDS indicated a BIMS score of 04 indicating Resident #64 had severe cognitive impairment. The MDS indicated that Resident #64 had a contracture. The MDS indicated that Resident #64 did not reject care. Record review of a care plan revised on 01/03/2026 revealed a lack of care planning regarding Resident #64's contracture. There was no information listed regarding Resident #64's contracture. Record review of Resident #64's diagnosis sheet revealed a diagnosis of a contracture dated 10/29/2024. Record review of Resident #64's Occupational Therapy Plan of Treatment showed that she received treatment for her contracture by occupational therapy from 2/18/25 to 2/27/25. Shows that Resident #64 successfully went from 2 minutes of using her hand splint to 4 hours using her hand splint. During an observation on 3/16/26 at 10:38 a.m. Resident #64's right hand was observed contracted. Her pinky and ring finger was touching her palm. Resident #64 did not have a hand splint in her hand to open her hand. During various observations throughout the day on 3/17/26 Resident #64 did not have a hand splint in her hand. During an interview on 3/17/26 at 1:20 p.m. Resident #64 said that she used to have a hand roll in her hand daily. She said that it must have been 6 months since the last time she had a hand roll in her hand. She said that the hand roll really helped her so that she could keep her hand open more. She said she does not know why she does not have the hand roll anymore. She said that she could not open her pinky or ring finger anymore and it stayed closed. It was observed that Resident #64's pinky and ring finger was touching the palm of her hand and she was unable to fully open her hand. During an interview on 03/17/2026 at 1:40 p.m. the Director of Rehab said that Resident #64 was most recently on speech therapy, but she did receive occupational therapy for her contracture starting on 2/18/25 and met her goals ending occupational therapy on 2/27/25. He said that Resident #64 had a splint that she was supposed to be wearing daily since she was currently on the active contracture list. He said he was not sure how long it had been since she wore the hand splint. He said that nursing may know more if she was allowing staff to place the hand roll in her hand. During an interview on 3/17/26 at 2:10 p.m. the [NAME] President of Operations said that he was looking into the issue with Resident #64's contracture. He said he will look into why her contracture was not listed on her care plan or orders. He said his staff will do a sweep of the building to ensure every resident's needs with contractures were being met. During an interview on 3/18/26 at 1:40 p.m. the Administrator said that it was the responsibility of nursing staff to ensure that residents on the contracture list are receiving appropriate care. He said that residents could be placed at a risk of decreased quality of life if they did not receive all the services and care they require. During an interview on 3/18/26 at 1:50 p.m. the Director of Nursing said that residents on the contracture list should be receiving services to prevent further complications of their contractures. She said that it was the responsibility of nursing staff and therapy to ensure that Resident #64 had a splint in her hand. She said that residents who do not receive all the services they need could be placed at risk of a lower quality of life. 3. Record review of the face sheet, dated 03/17/26, reflected Resident #103 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of contracture (permanent tightening, shortening, or stiffening of muscles, tendons, ligaments, or skin, causing joints to become fixed in a bent or twisted position) to left hand. Record review of the quarterly MDS assessment, dated 02/04/26, reflected Resident #103 had unclear speech, was understood, and was usually able to understand others. Resident #103 had a BIMS score of 13, which indicated no cognitive impairment. He had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #103 had functional limitation in range of motion that interfered with daily functions or placed him at risk for injury to one side of his upper and lower extremity. Record review of Resident #103's comprehensive care plan, dated 03/17/26, did not address contracture management. Record review of the order summary report, dated 03/17/26, reflected Resident #103 had no orders for a contracture management device or splint. Record review of Resident #103's ADL task list, reflected there were no tasks for contracture management or application of contracture device for range of motion. Record review of the occupational therapy Discharge summary, dated and signed on 12/24/25, reflected Resident #103 was discharged from occupational therapy for contracture management. The goals included Resident #103 will tolerate wearing of resting hand splint to left hand 8 hours. During an observation and interview on 03/16/26 beginning at 10:58 a.m., Resident #103 was sitting in his wheelchair. His left hand was curled up in a fist. He had no splint or devices on his left hand or arm. Resident #103 stated he was unable to extend his left hand because of an accident that caused a brain bleed. Resident #103 stated he did not wear a splint on his left arm or hand. During an observation on 03/17/26 at 11:13 a.m., Resident #103 was sitting in his wheelchair in the therapy room. He had no splint to his left hand or arm. During an observation and interview on 03/17/26 at 11:45 a.m., Resident #103 was sitting in the doorway of his room. Resident #103 had no splint or device to his left arm or hand. He said that he did not wear a splint or brace, even during the night. During an interview on 03/18/26 at 11:01 a.m., CNA B stated when residents had contractures to their hands, she would have washed their hands and looked for a device or hand roll. She stated if there were no devices or hand rolls available in the room, she would have rolled up a washcloth and placed it gently in their hand. CNA B stated Resident #103 had a splint for his left hand contracture. She stated therapy staff were the ones who put on his splint. She stated therapy explained it was okay to wear his left hand splint when he was sitting up but it should have been taken off while in the bed. CNA B stated she was unsure why Resident #103 had not worn his splint on 03/16/26 or 03/17/26. CNA B stated there was no place to document or sign-off on application or removal of contracture devices or splints. CNA B stated she depended on therapy to communicate when residents had contractures or needed splints. During an interview on 03/18/26 at 11:05 a.m., the Director of Rehabilitation stated when residents had new or discovered contractures, he would perform a screening and evaluation and pick them up on services. He said if he was aware of the contractures, he periodically re-evaluated the residents and picked them up as needed. He said when the residents were discharged from therapy, nursing staff were responsible for picking up and maintaining the contractures or applying any contracture management devices. He said that in-service education was provided in the past when residents came off of therapy services, but he was unsure if in-service education had been provided in the past year. He said during the past year, he had just verbally communicated with the nursing staff when residents were coming off of therapy services. He said he communicated the contracture management device needed and instructions for use. The Director of Rehab stated Resident #103 was not currently on therapy services for contracture management. He stated nursing was responsible for applying Resident #103's resting hand splint. He stated Resident #103 should have been wearing it for at least 8 hours per day. He stated he applied Resident #103's hand splint today, because he noticed he did not have it on. The Director of Rehab stated it was important to ensure contracture management devices were applied as directed to prevent hand deformities or prevent the contracture from getting worse. He stated it could have caused skin breakdown and decreased hygienics. During an interview on 03/18/26 at 11:11 a.m., LVN C stated she worked as needed at the facility and did not work regularly. LVN C stated when contractures were identified the nurses assessed the extent of the contracture, made sure the contracture was kept clean, and followed orders for contracture management or devices. She stated contracture management devices should have been placed in the orders and then been included in the care plan. She stated the orders and care plan were how she determined what contracture management devices were needed and how often. LVN C stated she was aware Resident #103 had a contracture to his left hand. She said she was unsure if he required the use of a hand splint. She stated it was important to ensure contracture management devices were used to prevent worsening of the contracture and maintain the resident's independence for as long as possible. During an interview on 03/18/26 at 1:54 p.m., the DON stated when residents had contractures, therapy performed a screening, then reported the contracture management care or devices to the nursing staff. She said the nursing staff should have placed the order into the computer, then updated the care plan. She said the nursing staff were responsible for applying the device and maintaining the contracture after the residents were discharged from therapy. She stated the nurses were responsible for monitoring to ensure contracture management devices were utilized. She stated it was important to ensure contracture management devices were used to prevent a decrease in range of motion and prevent worsening of the contracture. During an interview on 03/18/26 at 1:57 p.m., the Administrator stated he expected the nursing staff to ensure contracture management devices were used as directed. The Administrator stated nursing staff were responsible for monitoring to ensure contracture management devices were used. He stated it was important for the resident's quality of life and to maintain the resident's independence. During an interview on 03/18/26 at 4:12 p.m., the DON stated the facility did not have a policy on contractures or contracture management.

Based on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 5 residents (Resident #49) reviewed for PASRR services. The facility did not ensure Resident #49's significant change MDS assessment was accurately coded to reflect his level II PASRR status for intellectual and developmental disabilities. This failure could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated 03/18/26, reflected Resident #49 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosesis of Down syndrome (a genetic condition caused by the presence of an extra copy of chromosome 21, leading to developmental delays and distinct physical features), severe intellectual disabilities (developmental condition characterized by significant limitations in intellectual functioning and adaptive behavior, requiring daily support for basic self-care and communication), and neurofibromatosis (group of genetic conditions involving the development of tumors that may affect the brain, spinal cord, and the nerves that send signals between the brain and spinal cord and all other parts of the body). Record review of the significant change MDS assessment, dated 05/20/25, reflected Resident #49 was not currently considered by the state level II PASRR process to have serious intellectual disability or related condition. Record review of the comprehensive care plan, dated 09/01/25, reflected Resident #49 was PASRR positive for intellectual or developmental disabilities. Record review of the PASRR Evaluation (level II), dated 08/15/24, reflected Resident #49 had intellectual and developmental disabilities and was eligible for PASRR services. During an interview on 03/18/26 at 1:34 p.m., MDS Coordinator D stated she was the one who completed the significant change MDS assessment for Resident #49. She stated Resident #49 had readmitted to the facility for skilled services during the time he readmitted to the facility. She stated she just overlooked the PASRR section in section A and miscoded the significant change MDS assessment. She said Resident #49 was clearly PASRR positive and was currently receiving services in the facility. She stated it was important to ensure MDS assessments were coded accurately so residents received the care and services they needed. During an interview on 03/18/26 at 1:57 p.m., the Administrator stated he expected the MDS assessments to be coded accurately. The Administrator stated the care management staff were responsible for monitoring to ensure the MDS assessments were coded correctly. He said it was important to ensure MDS assessments were coded correctly to develop the care plan and to ensure residents received the care and services they needed. Record review of the Assessments Frequency/Timeliness policy, dated 10/24/22, did not address MDS accuracy. During an interview on 03/18/26 at 4:12 p.m., the DON stated the Assessments Frequency/Timeliness policy was the policy used for MDS accuracy.

Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 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 2 (Resident #20 and Resident #111) of 18 residents reviewed for care plans. 1. The facility failed to ensure Resident #20 had a comprehensive care plan for limited range of motion to her lower extremity.2. The facility failed to ensure Resident # 111 had a comprehensive care plan for limited range of motion to her lower extremity. These failures could place residents at risk of not having their individualized needs met, falls, decreased range of motion and a decline in their quality of care and life.Findings included: 1.Record review of the face sheet, dated 03/18/2026, reflected Resident #20 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (a general term for a decline in mental ability-such as memory loss, impaired reasoning, and behavioral changes-severe enough to interfere with daily life), diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and COPD (a progressive, treatable lung disease-commonly caused by smoking or pollution-that blocks airflow and causes long-term breathing difficulties, including emphysema and chronic bronchitis). Record review of the quarterly MDS assessment, dated 02/23/2026, reflected Resident #20 had a BIMS of 05, which indicated a severe memory impairment. Resident #20 had limited range of motion to her lower extremities on one side and a history of left hip fracture. Record review of Resident #20's comprehensive care plan, dated 03/17/2026, reflected no care plan related to limited range of motion to her lower extremities and no interventions to prevent worsening. 2.Record review of an undated face sheet revealed Resident #111 was an [AGE] year-old female admitted on [DATE] with diagnoses of dementia (a general term for a decline in mental ability-such as memory loss, impaired reasoning, and behavioral changes-severe enough to interfere with daily life), diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and left femur fracture (broken hip). Record review of the quarterly MDS assessment, dated 02/23/2026, reflected Resident #111 had a BIMS of 01, which indicated a severe memory impairment. Resident #111 had limited range of motion to her lower extremities on one side and a history of left hip fracture. Record review of Resident #111's comprehensive care plan, dated 03/18/2026, reflected no care plan related to limited range of motion to her lower extremities and no interventions to prevent worsening. During an interview on 03/18/2026 at 12:40 p.m., the MDS Coordinator stated care plans were to include all things that were coded on the MDS. She stated the care plan should be reviewed by the nursing staff to know the individual care instructions for each resident. The MDS Coordinator stated items such as falls, high risk medication usage, hospice services, and diagnoses should be care planned for resident safety. She stated not care planning an important item with the interventions could result in the staff not knowing what is needed for the management of the individual resident condition. She stated the MDS Coordinator was responsible for comprehensive care plans and the administrative nurses were responsible for acute care planning. During an interview on 03/18/2026 at 1:00 p.m., the DON stated it was the floor nurse and the administrative nurses' responsibility to ensure that staff were educated about interventions for all aspects of the resident's care. She stated all major diagnoses, conditions, medications, and falls should be care planned with interventions to alert the staff of the potential of these situations recurring and to give instructions on what to do in those cases. The DON stated not care planning important information could lead to the residents not receiving personalized care. During an interview on 03/18/2026 at 1:30 p.m., the Administrator stated he expected the staff to follow the interventions decided on by the MDS Coordinator and interdisciplinary team. He stated the interventions were in place, so all residents received the best quality of care possible in their situation. He stated not having the care items planned could potentially lead to the residents not receiving individualized care. Record review of the Care Plans, Comprehensive Person-Centered policy, dated April 2021, reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.the comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;.and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.the interdisciplinary team reviews and updates the care plan. at least quarterly.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 6 residents reviewed for activities. (Resident #108)The facility failed to provide Resident #108 with consistent, scheduled, one-on-one activities.This failure could place residents at risk of not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.Findings included:Record review of a face sheet dated 3/17/2026 indicated Resident #108 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of Alzheimer's disease (a progressive mental deterioration that can occur in middle or old age, due to degeneration of the brain), chronic atrial fibrillation (a type of heart arrhythmia characterized by an irregular and often rapid heartbeat), protein-calorie malnutrition (an imbalance between the nutrients your body needs and nutrients it gets) and diverticulosis of intestine (a condition characterized by the formation of small pouches in the colon and depression (a common and serious mood disorder characterized by persistent feelings of sadness, loss of interest and a range of emotional and physical problems.) Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #108 usually understood and usually was understood by others. Resident #108's vision was impaired. The MDS indicated Resident #108's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #108 required motorized wheelchair and required substantial assistance with transfers.Record review of the care plan initiated on 5/17/2025 and last revised on 11/24/2025 indicated Resident #108 was dependent on staff for emotional, intellectual, physical, and social needs due to physical limitations. Interventions included all staff converse with residents while providing care, invite residents to scheduled activities. The Care plan also included the resident prefers the following radio stations: gospel, oldies but goodies and preferred activities included music, bingo with help and trivia. The care plan indicated Resident #108 required assistance and escort to activities.During an interview and observation on 3/16/2026 at 10:51 AM, Resident #108 was lying in bed with no activities. Resident stated the staff do not offer to get her out of bed to go to activities. She said she would like to be out of bed. Resident #108 did not have her TV on or any music playing in her room.During an observation on 3/16/2026 at 12:07 PM, Resident #108 was lying in bed in the same position. Resident #108 was yelling she needed help. There were no observed activities in room during observation. During an observation on 3/18/2026 at 8:33 AM, Resident #108 was sitting up in bed. There were no observed activities during observation.During an interview on 3/18/2026 at 1:46 PM, CNA E said Resident #108 was blind. CNA E said she would get up to eat but she would want to go back to bed. CNA E said she got Resident #108 up on 3/17/2026 for lunch and took her to the dining room and Resident #108 complained that her back was hurting and went back to bed. CNA E said Resident #108 enjoyed bingo and she would help her. CNA E said she enjoyed getting her nails done. CNA E said Resident #108 would tell staff what she wants. CNA E said Resident #108 would say You know I can't see. CNA E said Resident #108 does not like the TV and wanted it off. CNA E said Resident #108 likes to sleep when she was in her room. CNA E said the nurse should encourage Resident #108 more and CNA E was responsible for getting the residents up. She said a resident could become depressed if she did not have activities available.During an interview on 3/18/2026 at 2:03 PM, RN F said Resident #108 did not get out of bed yesterday for lunch. RN F said Resident #108 enjoyed going to Bingo. RN F said Resident #108 would hear the loudspeaker for bingo and she wanted to go. RN F said the Activity Director would go around and ask each resident if they wanted to attend. RN F said Resident #108 liked to be by herself and did not like to be bothered. RN F said Resident #108 did not like music or TV. RN F said Resident #108's preferences would be on her care plan. RN F said she reviewed the care plan when there was a change in condition. She said all staff were responsible for ensuring Resident #108's preferences were being honored. RN F said Resident #108 had days she was ready to get up and then she wanted to go back to bed. RN F said not having activities could make a resident bored, lonely or make them feel nobody cared about them.During an interview on 3/18/2026 at 2:20 PM, the Activity Director said Resident #108 participated in bingo. She said Resident #108 sat next to her. The Activity Director said she did not do any activities with Resident #108 this week. She said Resident #108 was yelling in the dining hall yesterday and did not want to eat, so Resident #108 returned to bed. The Activity Director said Resident #108 enjoyed small talk, music and loved to sing. The Activity Director said Resident #108's preferences were care planned. The Activity Director said Resident #108 was able to tell staff what she wanted and at times would refuse. The Activity Director said she was responsible for ensuring residents participated in activities, but the CNAs assisted the residents up for the activities. The Activity Director said in-room activities were on Monday, Wednesday, and Fridays. She said a resident could get depressed if they were in their room all day.During an interview on 3/18/2026 at 2:42 PM, the ADON said Resident #108 enjoyed getting her nails done and played bingo. The ADON said Resident #108 was blind but could tell you what she wanted. The ADON said the staff brought Resident #108 to the dining room yesterday, but she wanted to return to bed. The ADON said Resident #108's preferences would be care planned. She said the Activity Director was responsible for activities. The ADON said the residents should be asked every day if they wanted to participate in activities. She said not having activities could make a resident feel isolated or depressed.During an interview on 3/18/2026 at 3:16 PM, the DON said the care plan would have the residents' preferences with activities. The DON said the Activity Director should offer activities daily. She said she expected the staff to play music or turn the TV on if those were the residents' preferences. The DON said residents should be able to participate if they wanted up. The DON said a resident could have psychosocial issues and prolong a resident's time in bed, which could cause skin breakdown. The DON said the Activity Director was responsible for activities.During an interview on 3/18/2026 at 3:30 PM, The ADM said activities should be based on resident preferences. He said she may not want to do anything. He said Resident #108 should be offered based off her preferences listed. The ADM said the preference should be on the residents' care plan. The ADM said he did not know what kind of negative impact could have on the residents if activities were not provided.The facility was unable to provide a policy related to activities when requested on 3/18/2026.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 5 residents (Resident #4 and Resident #14) reviewed for skin integrity. The facility failed to ensure Resident #4 and Resident 14's pressure- redistribution mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings include: 1. Record review of Resident #4's face sheet, dated 3/17/26, indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #4 had diagnoses which included cerebral infarction (a serious medical emergency where a blood clot blocks blood vessels supplying the brain, causing tissue death), hemiplegia (paralysis affecting one side of the body) and hemiparesis (neurological condition characterized by mild to moderate muscle weakness), muscle wasting and atrophy (the wasting away of body tissue, muscles or organs), pressure ulcer of right buttocks, stage 3 (a full thickness skin injury extending into subcutaneous tissue). Record review of Resident #4's nursing home comprehensive MDS assessment, dated 1/21/26, indicated Resident #4 understand others and made herself understood. Resident #4's BIMS score was 14, which indicated cognition was intact. Resident #4 was dependent on ADLs. Resident #4 weighed 162 pounds. Resident #4 was at risk of pressure ulcer/injuries. Resident #4 received a pressure-reduced device for bed. Record review of Resident #4's care plan, dated 9/5/23, indicated Resident #4 has history of pain related to diabetic neuropathy and pressure ulcers. Interventions include notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Record review of Resident #4's physicians order, dated 2/18/26, indicated low air loss mattress, every shift. Record review of Resident #4's physicians order, dated 3/16/26, indicated low air loss mattress for pressure redistribution mattress, ensure mattress is functioning properly, every shift. Record review of Resident #4's weight record, dated 3/17/26, indicated: *3/10/26 - 169.0 pounds *2/10/26 - 167.4.0 pounds *2/3/26 - 167.4 pounds *1/10/26- 162.1 pounds *12/17/25- 165.9 pounds During an observation on 3/16/26 at 11:18 A.M., revealed Resident #4 was lying in bed watching television. Resident #4's pressure redistribution mattress weight setting was 250 pounds. During an observation on 3/17/26 at 10:31 A.M., revealed Resident #4 was lying in bed resting. Resident #4's pressure redistribution mattress weight setting was 250 pounds. During an observation on 3/17/26 at 2:15 P.M., revealed Resident #4 was lying in bed. Resident #4's pressure redistribution mattress weight setting was 250 pounds and the mattress was unplugged. Resident #4 said her bed was not comfortable, because the bed was too hard. During an observation on 3/17/26 at 4:24 P.M., Resident #4 was lying in bed resting. Resident #4's pressure redistribution mattress weight setting was 250 pounds. 2. Record review of Resident #14 face sheet, dated 3/16/26, indicated an 85-years-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included mild protein-calorie malnutrition, muscle wasting and atrophy (the wasting away of body tissue, muscles or organs), cognitive communication deficit and muscle weakness (generalized). Record review of Resident #14's care plan, dated 2/23/26, indicated Resident #14 has potential for pressure ulcer development related to reduced mobility sacrum stage 2 (a partial-thickness injury, appearing as a shallow, open pink/red wound over the tailbone). Interventions included educating the resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating immobility, good nutrition and frequent repositioning. Record review of Resident #14's nursing home comprehensive MDS assessment, dated 2/21/26, indicated Resident #14 usually understood others and usually made herself understood. Resident #14's had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #14 was dependent on ADLs. Resident #14 weighed 161 pounds. Resident #14 was at risk of pressure ulcer/injuries. Resident #14 received a pressure reducing device for bed. Record review of Resident #14's physicians order, dated 2/19/26, indicated mattress: pressure redistribution mattress, every shift. Record review of Resident #14's weight record, dated 3/17/26, indicated: *3/10/26 - 169.7 pounds *2/10/26 - 160.5 pounds *1/10/26 - 174.3 pounds *12/30/25- 174.0 pounds *12/23/25- 174.0 pounds During an observation and interview on 3/16/26 at 1:53 P.M., revealed Resident #14 was lying in bed resting. Resident #14's pressure redistribution mattress weight setting was greater than 350 pounds. Resident #14 said her bed was uncomfortable and she needed another mattress, because that mattress hurt her butt. Resident #14 said she has a sore between her rectum and private area. During an observation and interview on 3/17/26 at 10:35 A.M., revealed Resident #14 was lying in bed resting. Resident #14's pressure redistribution mattress weight setting was 210 pounds. Resident #14 said her bed was not comfortable and she wanted another mattress. During an observation on 3/17/26 at 2:20 P.M., revealed Resident #14 was lying in bed asleep. Resident #14's pressure redistribution mattress weight setting was 200 pounds. During an interview on 3/18/26 at 10:51 A.M., Treatment Nurse said the bed should be set to the resident's weight. She said the nurses were responsible for checking the bed setting of the residents. She said if the residents' beds were set too high that meant the beds were too firm. She said the risk was more of a potential to cause pressure injury to a resident. During an interview on 3/18/26 at 1: 58 P.M., LVN M said the nurses were responsible for monitoring the settings on the low air loss mattresses of the residents. She said she thought the setting should be set according to the resident's weight, give or take 5 to 10 pounds. She said the negative effect of the bed set too high was it would be too firm and a risk for pressure injury. During an interview on 3/18/26 at 2: 18 P.M., ADON K said the low air loss mattress beds should be set at the resident's weight. She said it was brought to her attention that the hospice aides were turning up the pressure setting of the residents' beds to make the mattress firmer to make the bed harder to perform care. She said there was a malfunction with Resident #14's bed, but hospice provided her with a new mattress. She said the risk of not having the redistribution mattress set at the correct setting was pressure and it could cause wounds. During an interview on 3/18/26 at 2:41 P.M., the Director of Nursing said she expected the resident's pressure redistributing mattress to be on the correct settings. She said the mattress should be set according to the resident's weight. She said the nurses were responsible for monitoring the bed settings. She said the risk was increased skin breakdown. During an interview on 3/18/26 at 2:58 P.M., the Administrator said he expected the resident's redistribution beds to be set in the correct setting. He said the nurses were responsible for ensuring the settings were set for the pressure redistribution mattress. He said the risk was skin breakdown. Record review of the facility's Pressure Injury Prevention and Management policy, dated 8/15/2022, indicated .The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. 4. Interventions for Prevention and to Promote Healing: c. Evidence-based interventions for prevention will be implanted for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as reposition, protecting and/or offloading heels, etc.) Provide appropriate, pressure-redistributing, support surfaces.

Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (Resident #108) reviewed for fluid intake.The facility failed to ensure Resident #108's water pitcher was in reach on 3/16/2026 and 3/17/2026.This failure could place residents at risk of dehydration.Findings included: Record review of a face sheet dated 3/17/2026 indicated Resident #108 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of Alzheimer's disease (a progressive mental deterioration that can occur in middle or old age, due to degeneration of the brain), chronic atrial fibrillation (a type of heart arrhythmia characterized by an irregular and often rapid heartbeat), protein-calorie malnutrition (an imbalance between the nutrients your body needs and nutrients it gets) and diverticulosis of intestine (a condition characterized by the formation of small pouches in the colon and depression (a common and serious mood disorder characterized by persistent feelings of sadness, loss of interest and a range of emotional and physical problems.) Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #108 usually understood and usually was understood by others. Resident #108's vision was impaired. The MDS indicated Resident #108's BIMS score was 7 indicating severe cognitive impairment. The MDS indicated Resident #108 required setup assistance to bring food or liquid to mouth once the were placed before the resident.Record review of the care plan initiated on 5/17/2025 and last revised on 11/24/2025 indicated Resident #108 had potential for impairment to skin integrity related to bowel and bladder incontinence and fragile skin. Interventions included good nutrition and hydration to promote healthier skin.Record review of the consolidated physician orders dated 3/18/2026 indicated Resident #108 was ordered mechanical soft texture with regular liquid consistency. There was no fluid restrictions ordered.During an observation and interview on 3/16/2026 at 10:51 AM, Resident #108 said she was treated well, and she was able to use her call light. Resident #108 was observed to have her water pitcher out of reach, and she said she was blind. Resident #108 said she did not know where her water pitcher was and she was thirsty and her mouth was dry. Resident #108 said she did not have any swallowing issues and was not on any restrictions. She said she did use a straw.During an observation on 3/16/2026 at 12:07 PM, Resident #108 was observed lying in bed and water was out of reach on the bedside tray. Resident was yelling for help, and a staff member was located to provide assistance to Resident #108.During an observation on 3/17/2026 at 8:33 AM, Resident #108 had her water pitcher out of reach and an empty cup of orange juice on her bedside table. RN G came in the room and removed the empty cup of orange juice and placed Resident #108's water pitcher within reach and made her aware of the location.During an interview on 3/18/2026 at 4:46 PM, CNA E said Resident #108 was blind. CNA E said she fills Resident #108's water pitcher twice a shift. CNA E said Resident #108 liked her water at room temperature. She stated that Resident #108 did not like water. She said Resident #108 liked her bedside tray to the left or right of her and not over her bed. CNA E said she placed her water pitcher next to her so she could reach it. CNA E said everyone was responsible for ensuring the water pitcher was within reach of the resident. CNA E said Resident #108 had a call light and she knew how to use it to call for assistance. CNA E said Resident #108 pushes her table away because she likes to move her bed up and down.During an interview on 03/18/2026 at 2:03 PM, RN F said the aides go around every 2 hours. RN F said the water pitcher should be kept within reach of her. RN F said Resident #108 was not fully blind and stated she had cataracts. RN F said Resident #108 could see someone coming in. She said a resident could get dehydrated. RN F said she had never complained of dry mouth but indicated she loved suckers.During an interview on 3/18/2026 at 2:42 PM, the ADON said the water pitcher should be located within reach. The ADON said Resident #108 did not like water right now. The ADON said the CNA would tell her where everything was located on her table. The ADON said the nurses and aides were responsible for ensuring the water pitcher was within reach. The ADON said residents could become dehydrated if they were not able to reach their water.During an interview on 3/18/2026 at 3:16 PM, the DON said she expected nursing staff to keep water pitcher within resident reach. She said a resident could get dehydrated. The DON could not recall if Resident #108 were blind. The DON said the water should be within reach.During an interview on 3/18/2026 at 3:30 PM, the ADM said he expected nurses and staff to keep water pitcher within reach of resident. He said nursing was responsible for ensuring the water was within reach. He said it could negatively impact a resident because they would not be able to reach their water.The facility was unable to provide a policy related to hydration when requested on 3/18/2026.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 1 residents (Resident #95.)The facility medication aide failed to ensure that Resident #95 took his medication before leaving the room. This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion. Findings included:Record review of the face sheet dated 11/14/23 indicated Resident #95 was [AGE] years old and was admitted on [DATE] with diagnoses including Paraplegia (impairment or loss of motor and sensory function in the lower extremities and sometimes the torso, generally caused by spinal cord injury or disease below the neck), Cognitive Communication Deficit (a communication impairment resulting from underlying cognitive issues rather than primary language deficits, often caused by brain injuries, strokes, or dementia), and Muscle Weakness (a reduced ability to contract muscles, resulting in decreased strength). Record review of Resident #95's Quarterly MDS dated [DATE] indicated Resident #95 was understood and understood by others . The MDS indicated a BIMS score of 15, indicating Resident #95 was cognitively intact. Record review of a care plan revised on 09/20/23 indicated Resident #95 had an activity of daily living self-care deficit. Showed that Resident #95 needed assistance with most of his activities of daily living . During an interview and observation on 3/16/26 at 9:55 a.m. Resident #95 was observed with a small plastic pill cup with approximately 4-6 pills inside. Upon approaching Resident #95 he took the cup of pills, put them into his mouth and swallowed them. He said that the med aide gave him his meds a few minutes ago. He asked why he was being asked about his medications and stated he did not want to speak to the surveyor. During an interview on 3/16/26 at 10:09 a.m. MA A said that she just passed medications in the hall Resident #95 was located in. She said that she was supposed to watch residents actually take their medications so she could document whether they took the medication or not. She said she would then be able to notate if the resident refused.During an interview on 03/18/26 at 1:40 p.m., the Administrator said the medications left at the bedside of Resident #95 could place other residents and Resident #95 at risk for harm. He said that he expects that the medication aides ensure that Residents take their medication before leaving the room. He said that residents can either refuse their medications or take them, but medications should not be left in residents' rooms. During an interview on 03/18/26 at 1:50 p.m., the Director of Nursing said she would have expected that medication aides would ensure that residents took their medications before leaving their room. She said that there could be risk that other residents could get ahold of medications that did not belong to them, take them and cause harm. She said that it also put residents at risk as they could not document whether the resident actually took their medication or not. Record review of a facility policy titled, Medication Administration' dated 10/24/22 shows that the purpose of this policy was to, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection Observe resident consumption of medication.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #11). The facility failed to ensure the refrigerator and dry storage foods for Resident #11 was inspected for expired food and expired food disposed of. This failure could place residents at risk for food borne illnesses.Findings include: Record review of a face sheet dated 11/23/2025 indicated Resident #11 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (an infection in any part of the urinary system—most commonly the bladder and urethra—often caused by bacteria, resulting in pain, burning, and a persistent urge to urinate), Major Depressive Disorder ( a serious, common mood disorder characterized by at least two weeks of persistent, low mood, sadness, and loss of interest in activities), Chronic Obtrusive Pulmonary Disease (a progressive, incurable lung disease—primarily caused by smoking—that restricts airflow, causing severe breathing problems, chronic cough, and mucus production). Record review of the MDS dated [DATE] indicated Resident #11 understood others and made himself understood. The MDS indicated Resident #11 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #11 did not reject evaluation or care. Record review of a care plan for Resident #11 dated 03/12/2026 revealed Resident #11 required assistance with activities of daily living. During an observation on 3/16/26 at 9:53 a.m. Resident #11 had a bag of shredded cheddar cheese in his personal refrigerator with an expiration date of September 20, 2024. Salsa observed in Resident #11's room expiration dated August 2, 2025, and peanut butter expiration date of January 22, 2024. Resident was not in the room to interview. During an interview on 3/17/26 at 10:15 a.m. Resident #11 said that he does eat the food in his room that he buys. He said that he orders the food to be delivered from a local grocery store. He said that he does not check the expiration dates on his food before he eats it. He said no one comes into his room to check the expirations of his food. He said he did not realize that he had food that expired nearly 2 years ago. During an interview on 03/18/2026 at 1:40 p.m. with the Administrator he said it was the responsibility of department heads to ensure that personal refrigerators were clean of expired foods. He said that residents could get sick if they ate cheese or peanut butter that was decomposing or moldy. During an interview on 03/18/2026 at 1:50 p.m. the Director of Nursing said that department heads were responsible to clean out the personal refrigerators for residents. She said that residents could be placed at risk for foodborne illness if they ate expired or moldy food. She said she expected department heads to clean out the personal refrigerators of all residents and dispose of expired food. Record review of a facility document titled, Resident Refrigerators dated 7/3/23 shows that the purpose of this policy was to, This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators.The refrigerator is inspected by maintenance personnel and deemed safe prior to use and upon routine inspections. The refrigerator maintains proper temperatures.A thermometer shall remain in the refrigerator. It shall be calibrated prior to use and periodically thereafter. Temperatures will be at or below 41 degrees Fahrenheit, and freezers will be cold enough to keep foods frozen solid to the touch (or in accordance with state regulations). If temperatures are out of range, staff shall notify nursing department to discard any foods that require refrigeration and take measures to remedy the problem. If problems persist with maintaining proper temperatures, the refrigerator shall be removed from use and the resident/family notified.Staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

Based on observation, interview, and record review the facility failed to maintain all essential equipment in a safe operating condition, for 1 of 4 refrigerators in a medication room reviewed for food service in that: The facility failed to ensure the refrigerator in medication room on hall 4 was cleaned, defrosted and food stored at an appropriate temperature on 3/17/26. This failure could place residents at risk for food borne illnesses.Findings include: Record review of the refrigerator temperature log sheet indicated the refrigerator should be 40 degrees Fahrenheit or below.During an observation on 3/17/26 at 5: 22 P.M., the med room on hall 4 with RN Q. The refrigerator in the medication room was used to store food for residents that did not have refrigerators in their rooms was covered in the inside with a brown substance splatter throughout. The refrigerator had a large buildup of ice on the cooling element, and the thermometer reading was on the red level at 42 degrees Fahrenheit. The refrigerator contained sour cream packets, yogurt, cranberry juice, strawberry shake, coffee creamer, can of coke, salad dressing and protein liquid container.During an interview on 3/17/26 at 5:28 P.M., RN Q said the refrigerator did not look good to her and it was not sanitary to eat the food in the refrigerator. She said housekeeping was responsible for keeping the refrigerators in the medication room and resident rooms clean. She said she needed to address the issue of the refrigerator. She said she would not want her refrigerator to look like that. She said a risk of the condition of the refrigerator was the food could be freezer burnt and it could introduce bacteria to the resident. During an interview on 3/18/26 at 2:10 P.M., the Environmental Supervisor said she was not responsible for ensuring the refrigerators in the medication rooms were cleaned and defrosted. She said the nurses were responsible for ensuring the refrigerators in the medication rooms were cleaned and defrosted. She said the refrigerator in the medication room on hall 4 needed to be cleaned. She said the housekeeping staff were not allowed in the medication rooms unless the nurse were present. She said a negative effect of the refrigerator not being clean, needing to be defrosted and elevated temperature was spoiled food. During an interview on 3/18/26 at 2:18 P.M., ADON K said the nurses were responsible for the refrigerators in the medication rooms and she expected the refrigerators to be clean. She said the refrigerator in the medication room on hall 4 needed to be pulled and checked to see why it was freezing over. She said staff should be making sure everything was within date in the refrigerator. She said the refrigerators should be checked daily. She said a negative effect of the condition of the refrigerator was that the food could be spoiled. During an interview on 3/18/26 at 2:41 P.M., the Director of Nursing said the refrigerator on hall 4 in the medication room was unacceptable in the condition it was in. She said the nurses and unit managers were responsible for ensuring the refrigerators were cleaned, defrosted and functioning at the appropriate temperature in the medication rooms. She said a negative effect from the refrigerator was the food in it could make the residents sick.During an interview on 3/18/2026 at 2:58 P.M., the Administrator said he excepted for the staff to keep the refrigerators clean, defrosted and at a safe storage temperature in the medication rooms. He said the unit manager, Director of Nursing and nursing services were responsible for ensuring the refrigerators were cleaned, defrosted and safe temperature. He said a negative effect was possible food spoilage.

Based on observation, interview, and record review, the facility failed to ensure treatment was provided, consistent with professional standards of practice, to prevent new pressure injuries from developing for 2 of 4 residents reviewed for pressure injuries (ulcers). (Resident #1, Resident #2)1. The facility failed to complete weekly skin assessments for Resident #1 since 01/27/26. 2. The facility failed to complete quarterly Braden Scale Assessments on Resident #1 and Resident #2. There were no quarterly Braden Scale Assessments for Resident #1 since 06/04/25 and for Resident #2 since 02/08/24.These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.1. Record review of a face sheet dated 02/28/26 indicated Resident #1 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of heart failure, muscle weakness, and diabetes. The face sheet indicated Resident #1 had been discharged to an acute care hospital on [DATE]. There was no indication Resident #1 had been re-admitted to the facility.Record review of a quarterly MDS dated [DATE] indicated Resident #1 was understood and usually understood others. The MDS indicated a BIMS score of 02 which indicated severe cognitive impairment. The MDS indicated Resident #1 was at risk of developing pressure ulcers/injuries. The MDS did not indicate any unhealed pressure ulcers/injuries.Record review of the care plan last revised on 10/15/25 indicated Resident #1 was at risk for impairment to skin integrity related to fragile skin, incontinence, impaired mobility, diabetes, and nutritional and hydration risk. There was an intervention to identify and document potential causative factors and eliminate and resolve where possible.Record review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] indicated a score of 21 which indicated Resident #1 was not at risk for pressure injury. The electronic medical record for Resident #1 did not indicate any further assessments from 06/04/25 - 02/28/26.Record review of a Skin Check assessment dated [DATE] indicated Resident #1 had no skin issues. The electronic medical record for Resident #1 did not indicate any further assessments from 01/27/26 - 02/28/26.Record review of an At Risk Skin Assessment Visit by wound care nurse practitioner dated 02/02/26 for Resident #1 indicated, .no new skin abnormalities were observed.no active wounds.Routine skin assessment was performed in a high - risk patient. Patient remains at increased risk due to age, History of Fall.Other Reduced Mobility. Continue skin surveillance at routine intervals. Record review of a Change of Condition Progress note dated 02/25/26 at 1:00 p.m. for Resident #1 indicated, .Resident has small wound on buttock. The note was signed by LVN A.Record review of a Progress Note dated 02/25/26 at 1:59 p.m. for Resident #1 indicated, .Resident has small wound to buttock upon checking aide noticed that stool was dark. Resident appeared to have black tarry stool.EMS (emergency medical services) was called and resident was sent to (hospital). The note was signed by LVN A.Record review of a hospital Wound Care Nurse Note dated 02/26/26 at 1:20 p.m. for Resident #1 indicated the resident had been admitted to the hospital on [DATE] for [NAME] (the passage of black, tarry, foul-smelling stools, indicating upper gastrointestinal bleeding where blood has been digested). The note indicated, .Patient was seen.for a new consult.Concerns of pressure.on admission. Wound Care consulted on 02/26/26.Patient's Braden Score 14: Moderate risk for pressure injury development.Requires maximum assistance for turning and repositioning.incontinent of stool.Patient is saturated in urine, foley catheter bag is dry.Primary RN notified of this finding.Patient with POA stage 2 pressure injury to the left buttock that measures 1.2 cm x 1 cm, partial thickness loss with pale pink viable wound bed, open wound edges. There is macerated tissue (skin that has become white, wrinkled, soggy, or soft due to prolonged exposure to excessive moisture) noted to the bilateral buttocks concerning for moisture component. There is no edema or periwound erythema (redness of the skin within 4 cm of a wound edge, indicating localized inflammation, infection, or tissue damage), area is not hot to touch, no induration, odor, or fluctuance is present at this time, wound is not cellulitic at this time (there were no signs of infection). There is pale pink intact scar tissue noted to the right buttock, no ulceration.During an observation and interview on 02/28/26 at 10:40 a.m., Resident #1 was a patient at the hospital. She said she could not remember if she was receiving wound care at the nursing facility. Resident #1 said she could not remember if she was being repositioned by staff or if she was kept clean and dry. Unable to observe the resident's wound in the hospital.2. Record review of a face sheet dated 02/28/26 indicated Resident #2 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of diabetes, dementia, and protein-calorie malnutrition (a severe, often life-threatening condition caused by insufficient intake or absorption of protein and energy (calories). Record review of a quarterly MDS dated [DATE] indicated Resident #2 was understood and understood others. The MDS indicated a BIMS score of 04 which indicated severe cognitive impairment. The MDS indicated Resident #2 was at risk of developing pressure ulcers/injuries. The MDS did not indicate any unhealed pressure ulcers/injuries.Record review of the care plan last revised on 11/18/25 indicated Resident #2 had a diagnosis of diabetes and had bowel incontinence related to a cognitive decline.Record review of a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] indicated a score of 16 indicated Resident #2 was at risk for pressure injury. The electronic medical record for Resident #2 did not indicate any further assessments from 02/08/24- 02/28/26.Record review of a Wound Evaluation and Management Summary by wound care nurse practitioner dated 02/23/26 for Resident #2 indicated a diabetic wound of the right first toe. The evaluation did not indicate any pressure injuries. Record review of a Skin Check dated 02/26/26 for Resident #2 did not indicate any new skin issues.During an interview on 02/28/26 at 11:35 a.m., the DON said the last Braden Scale for Predicting Pressure Sore Risk assessment she could find for Resident #1 was dated 06/04/25. She said the last skin assessment she could find for Resident #1 was dated 01/27/26. She said Braden Scale for Predicting Pressure Sore Risk assessments were to be done quarterly. She said skin assessments were to be done weekly. She said Resident #1 had a previous wound to the left buttock and was prone to getting ulcers in that spot.During an interview on 02/28/26 at 12:18 p.m., LVN A said Resident #1 had a small wound to her buttock. She said it was found just before the resident transferred to the hospital. She said Resident #1 was transferred for having blood in her stool. She said the resident got up out of bed every morning. She said when the resident was in bed, they position her with pillows every two hours. She said the resident was independent in bed mobility and will position herself too. She said the resident would even get herself up. She said the charge nurses were responsible for completing the skin checks. She said she had completed skin checks on Resident #1, but she could not say when was the last time she completed a skin check on the resident. She was not made aware of the current wound until she was getting ready to send the resident out to the hospital.During an interview on 02/28/26 at 12:28 p.m., the Treatment Nurse said Resident #1 had a history of pressure injuries and shearings (a mechanical force occurring when skin remains stationary (due to friction) while underlying tissue and bone move in the opposite direction, causing blood vessel distortion, tissue damage, and deep pressure injuries) on her left and right buttock. She said the resident had not had any recent wounds until she left for the hospital on [DATE]. She said the nurses were responsible for weekly skin assessments. She said they also did routine skin sweeps. She said the last skin sweep was completed on 02/02/26 and was done with the wound care nurse practitioner. She said Resident #1 had no wounds at that time. She said the resident positions herself in the bed. She said she did observe Resident #1's wound right before she left for the hospital because she was helping the aide clean up the resident. She said the wound was very small. She said it was not even open at that time.During an interview on 02/28/26 at 12:43 p.m., the Administrator said there was a glitch in their electronic charting system and it was not triggering Braden Scale assessments or skin assessments on Resident #1 and that was why they had not been done. He said corporate staff were working to get the system fixed.During an interview on 02/28/26 at 1:37 p.m., the DON said they feel there was a glitch in the electronic charting system since they switched over to the current module and that was why they did not have current skin assessments or a current Braden Scale assessment on Resident #1 and a current Braden Scale assessment for Resident #2. She said she expected residents to have weekly skin assessments and quarterly Braden Scale assessments. She said residents that do not have weekly skin assessments could possibly cause a resident to have skin problems that have not been identified that could lead to pressure injuries or infection. She said Braden Scale assessments not being completed might lead to staff not identifying a risk for skin issues. She said if Braden Scale assessments were not completed, proper interventions might not be initiated and could lead to pressure injuries.During an interview on 02/28/26 at 1:51 p.m., the Administrator said Resident #1's wound was identified by nursing staff just prior to her being transferred to the hospital. He said he understood this was a reoccurring wound. He said they have wound prevention interventions in place for Resident #1. He said he expected skin assessments to be completed based on the generation of the skin schedule. He said if issues were found staff should put appropriate interventions in place. He said it was the same for the Braden Scale assessment. He said not having assessments could lead to skin breakdown. He said the Braden Scale assessment would tell if a resident was at risk or not. He said if a Braden Scall assessment was not completed, interventions might not be put in place to prevent skin breakdown.Record review of a Skin Assessment facility policy dated 04/24/25 indicated, .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter.Record review of a Pressure Injury Prevention and Management facility policy dated 08/15/22 indicated, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.Licensed nurses will conduct a pressure injury risk assessment, on all residents upon admission/re-admission, or whenever the resident's condition changes significantly.Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury.Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment.

Based on interview and record review, the facility failed to ensure the resident or the resident's representative had the right to access all records pertaining to the resident, including current clinical records, within 24 hours (excluding weekends and holidays) upon oral or written request, and to obtain copies of such records within two working days upon request for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility did not provide Resident #1's MPOA access to Resident #1's urinalysis (UA) lab results in December 2025 when she verbally requested access. This failure could place residents at risk for delayed medical decision-making, lack of informed consent, and potential harm due to the representative's inability to timely review laboratory results and participate in care planning.Findings included: Record review of an admission record dated 02/07/26 indicated Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Cerebral Infarction due to unspecified occlusion or stenosis of right middle cerebral artery (a stroke affecting the right side of the brain, which can cause left-sided bodily weakness, speech issues, and vision problems), dementia without behavioral disturbance (a diagnosis of dementia where the patient experiences cognitive decline (memory, language, reasoning) without accompanying behavioral issues like aggression, wandering, or psychosis), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (complete paralysis of the arm, leg, and often the face on one side of the body), cognitive communication deficit (This impairment can lead to difficulty with aspects of cognition such as attention, memory, organization, problem-solving and reasoning, processing speed, language, and executive function. A cognitive communication disorder can affect many aspects of a person's life, in a variety of ways. Activities of daily living that were once manageable and automatic, may be more challenging.) and seizures (sudden, uncontrolled bursts of electrical activity in the brain that cause temporary, involuntary changes in body movement, behavior, sensation, or awareness). Record review of Resident #1's Medical Power of Attorney documents dated 1/6/23, indicated that Resident #1 appointed Family member #1 as his Medical Power of Attorney (Agent) under the laws of the State of Texas. The document grants the Agent (Family Member #1) authority to make healthcare decisions on his behalf if Resident #1 is unable to make decisions independently. Article Three - Legal and Administrative [NAME] and Provisions: Section 3.01 Health Insurance Portability and Accountability Act - In addition to the other powers granted by this document, my Agent may serve as my personal representative for all purposes of the Health Insurance Portability and Accountability Act of 1996 and its regulations (HIPAA) immediately upon my signing this document. Pursuant to HIPAA, I specifically authorize my Agent as my personal representative under HIPAA to do any of the following via traditional or electronic means: (i) request, receive , and review any information regarding my physical or mental health, including , without limitation all medical and hospital records and other HIPAA protected health information; (ii) execute on my behalf any authorization, release, or other documents that may be required in order to obtain this information; and (iii) consent to the disclosure of this information to others and execute valid authorizations for the release of HIPAA protected health information. Record review of Resident #1's undated revised care plan indicated the following:-Problem: [Resident#1] had impaired cognitive function/dementia or impaired thought processes due to Dementia and history of stroke. Initatiated:1/1/24; Revised:1/22/24-Goal: [Resident #1] will be able to communicate basic needs on a daily basis through the review date. Initatied:1/1/24; Target Date:3/27/26-Interventions: *Ask yes/no questions in order to determine [Resident #1] needs.*Communicate with the resident/family/caregivers regarding resident's capabilities and needs. * Discuss concerns about confusion, disease process, NH placement with resident/family/caregivers. Initatied:1/1/24 Record review of the quarterly MDS assessment, dated 12/01/25, indicated Resident #1 had unclear speech, his ability was limited to making concrete requests; usually understood but missed some parts of conversations. He had a BIMS score of 00 out of 15 indicating he had severe cognitive impairment with thinking and memory. He required maximal assistance or was dependent with most ADLs. Record review of Resident #1's medical chart indicated laboratory specimens were collected in December 2025 on 12/05/25, 12/06/25, 12/24/25, and 12/29/25. Record review of an undated letter written by the medical records staff indicated On 12/30/25, I [Medical Records staff], went to [Resident #1's room] to speak with [Family member #1] about a medical records release form. I [Medical records staff] explained to [Family member #1] that the form needed to be filled out and signed. [Medical records staff] would then send it in to corporate, and they would gather the records that she is asking for. [Family member #1] started stating that she had filled this out once before, and what happened with the form that she had already completed. I [Medical records staff] explained that I am unsure since that was before my [Medical records staff] time. [Family member #1] then stated that she was told when she first came to [facility] that all she had to do was ask for [Resident #1's] medical records, and that she would be able to get them from the staff here because she had already filled that form out once before and continued to ask [medical records staff] where that form was. I [medical records staff] again explained that we do not give out medical records without going through corporate first, and they are the ones that handle that. The only thing that I [Medical records staff] do is email the request form and the MPOA to help her get what she wants. [Family member #1] asked when the policy changed from requesting records from [facility], to which I [Medical records staff] informed her that I [medical records staff] started working [at facility] in November of 2024, and this is the only policy I [medical records staff] known of. [Family member #1] took the paper but did not fill it out, stating that she would hold onto it and look over it. As I [medical records staff] was leaving, I [medial records staff] informed her that I would follow up with Admissions and see exactly what form she was talking about. [Family member #1] thanked me [Medical records staff] and I told that shh was welcomed and left, closing the door behind me. The conversation was casual, but she [family member #1] she did seem to be a little on edge for not being able to get what she wanted asap. Record review of a typed letter dated 1/2/26 addressed to Medical records at facility from family member #2 Re: Request for Reason for Denial of Medical Records.On 12/30/25 [Resident #1] spoke to a representative in Medical Records and requested his most recent test results (labs, urinalysis) from a UTI that began on 12/24/25. [Resident #1] was denied with no reason given. Please provide a detailed written explanation as to why [Resident #1] was denied his medical records and instructions for appeal. Kindly send your correspondence vis US mail, email or fax supplied above. Record review of a typed letter dated 1/9/26 from legal department to Family member #2 indicated [Legal department] received her correspondence dated 1/2/26. [Their] office represented [Name of facility] and are responsible for reviewing records requested to ensure compliance with applicable federal and state law such as the Health Insurance Portability and Accountability Act (HIPAA). Our [legal department] records currently show [Family member #1] as [Resident #1's] Medical Power of Attorney, and those files are in [Resident #1's] admission packet. Those files are not missing nor has there been a security breach. Regarding [Resident #1s] medical records, pursuant to 45 C.F.R. S 164.524(b)(1), we [legal department] may require requests for medical records in writing. To date, we [legal department] have not received a written request for [Resident #1's] recent test results (labs, UA) from [Family member #1]. [Family member #1] may submit a written request for the requested records. During an attempted interview on 2/7/26 at 4:55 p.m., Resident #1 was unable to respond appropriately to the questions asked. During an interview on 2/7/26 at 6:05 p.m. LVN B, said she was trained that if a resident or the resident's representative requested any information regarding the resident's medical records or chart, she was to provide them with a medical release form to complete and instruct them to submit it to the medical records department. She reported that this instruction applied regardless of whether the individual was requesting a verbal explanation of a test result or a hard copy of the medical records. LVN B stated she was instructed not to provide any information directly. During an interview on 2/9/26 at 4:23 p.m., the Medical Records staff member stated that Resident #1's MPOA verbally requested Resident #1's urinalysis (UA) lab results in December 2025. She reported that she provided the MPOA with a medical release form to complete, explaining that it is facility policy for the form to be completed prior to releasing any records. She stated the completed form would then be forwarded to the company's legal department to process the request. The Medical Records staff member reported that she had not received the completed paperwork and, therefore, had not provided the MPOA with the requested documents in accordance with facility policy. During a telephone interview on 2/9/26 at 5:09pm, the General Counsel from the company's legal department stated he was aware that Resident #1's family had requested information from the resident's medical chart. He reported that because the MPOA had not completed a medical release form in accordance with facility policy and HIPAA provisions, the family was not permitted access to the records. He stated that a written request must be submitted prior to releasing any medical information. He further stated that he received a certified letter from Family Member #2 requesting information and responded in writing to inform her that she was not the MPOA and that a completed authorization form would be required before any records could be released. During an interview on 2/9/26 at 7:00pm with Family member #1 and #2 they said they never received Resident #1's lab results. Family member #1 said she was Resident #1's MPOA and should have access to everything. She said she asked LVN B for the verbal results and was told she was instructed NOT to release it. Family member #2 said she sent a certified letter to corporate requesting an explanation for refusing Resident #1 his labs results. Resident #1's MPOA said she felt she should not have to go on a wild goose chase to hunt down a ghost in medical records that no one has any knowledge of; sign a form for every little thing and wait for corporate approval every time she wanted to see a lab result. Record review of undated Release of Medical and [NAME] Records Policy indicated To protect the integrity of requested medical records and billing records by ensuring that it is:. This Facility has adopted a system-wide policy regarding the release of medical and billing records, adopted and approved by the governing body, effective February 22, 2016, as amended. In order to ensure compliance with this Policy, all requests for medical and billing records must be cleared through the Legal Department prior to the release of any information.The procedure for medical and billing records requests is as follows:1. A fully completed medical, or billing records release authorization form must be submitted either by theResident, if a Resident is able to complete such a form, or by the appropriate Authorized Party.If the medical records release request is executed by an Authorized Party, the appropriate appointment paper should be attached for review by the Legal Department. The appropriate documentation may be a durable business power of attorney, a medical power of attorney (if the medical power of attorney allows for the release of medical records and not just for decision making related to care), or an order of the court appointing a person guardian over the person or estate of Resident.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 2 residents (Resident #1) reviewed for abuse. The facility failed to thoroughly investigate an allegation of abuse reported to the Administrator regarding Resident #1 on 08/25/25. The Administrator did not interview Resident #1, her representative, or the caregiver that verbalized the allegation of abuse. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and injuries of unknown source.Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female, admitted to the facility on [DATE], and discharged on 08/25/25. Her diagnoses included dementia (a general term for a decline in mental ability that affects memory, thinking, and social skills to the point of interfering with daily life). Record review of the facility's Provider Investigation Report, dated 09/02/25, reflected: .Resident Profile[Resident #1] is a [AGE] year-old female who was admitted to the skilled unit on August 21, 2025. She has a BIMS of 10 [Moderately Impaired Cognition]. She has impaired cognition function/dementia or impaired thought processes.[Resident #1] has a deficit in self-care activities of daily living., as well as communication difficulties.Additionally she has a sitter to be with her.Description of the Allegation:On August 25, 2025, [Resident #1] was discharged from the facility at the request of her family. On the day of discharge, EMS was on-site to assist with [Resident #1's] transportation home. during this time, Resident #1's sitter was overheard telling EMS personnel that [Resident #1] had been abused and that hospice staff were aware.Provider Response:Upon receiving the verbal allegation of abuse on August 25, 2025, the facility immediately followed internal reporting protocols. The allegation was promptly communicated to the Charge Nurse.and escalated to the Administrator.However, no further protective actions or assessment were taken by the facility because the resident's family elected to discharge [Resident #1] from the facility.The facility conducted staff re-education focusing on Abuse and Neglect. The following individuals were also notified:* DON Notification* ADON Notification*[Corporate [NAME] President] Notification*MD/NP Notification*HHSC Notification.Investigation Summary:.Allegations of Abuse (August 25,2025):At approximately 6:45PM, CNA overheard the sitter telling EMS that [Resident #1] had been abused and that hospice staff were aware. The incident was reported to the charge nurse and administrator.Conclusion:The internal investigation into the abuse allegation revealed no witnesses or identified perpetrators. As a result, the facility concluded that the findings of the investigation were unconfirmed. No further incidents were reported following the resident's discharge.Provider action taken Post-Investigation:Continue staff education on facility policies to prevent and protect residents from all forms of Abuse and Neglect. During an interview on 09/09/25 at 9:54AM, the DON said she was the nurse who assessed the resident for discharge. She said she was not informed of any abuse allegation during her assessment. She said the resident and family were happy with everything that was done leading up to the discharge. She said the Administrator conducted the investigation into this incident. During an interview on 09/09/25 at 9:58AM, the Administrator said that on the evening of 08/25/25, he received a phone call reporting that a CNA had overheard Resident #1's sitter saying the resident had been abused in the facility. He said the resident had already left the building when he received the call. He said he did not investigate the allegation further because the resident had already left the building. He said he was unsure whether he had contact information for the sitter. He said he had been in Resident #1's room prior to discharge and no one had brought any concerns of abuse to his attention. He said Resident #1's family member was happy with Resident #1's care when he spoke with her prior to the abuse allegation. He said he did not speak with the family member about this allegation of abuse. He said he interviewed the CNA that overheard the conversation. He said he conducted safe surveys with the residents. During an interview on 09/09/25 at 10:26AM, ADON A said she was not present at the facility at the time of the abuse allegation involving Resident #1 on 08/25/25. She said she felt the Administrator should have talked to the family or the sitter regarding the abuse allegation to obtain more information. She said the risk was that abuse could be going on in the facility. During an interview on 09/09/25 at 10:31AM, the DON said she conducted a discharge assessment of Resident #1 and that neither the family nor the sitter reported any allegations of abuse. She said she did not feel like the caregiver should have been called because the family member and caregiver were together at the time of discharge. She said she had a conversation with the sitter on the day of discharge and she did not make an allegation of abuse to her. She said she tried to call the family member one time after the allegation of abuse and she did not answer. She said she felt like she should have attempted to call the family more than once. She said the risk was it was possible there could be abuse going on in the facility. During an interview on 09/09/25 at 10:46AM, the Administrator said the DON attempted to call Resident #1's family member, but no one tried to call the caregiver. He said no one had made any indication to the Administrator or the DON that there were any abuse concerns. He said he did not think someone should have called the family member after the abuse allegation came out because they had spent time with the family and no allegation of abuse had been reported to them. He said he felt that they followed the policy because the DON attempted to contact the family member who was responsible for her care. He said he felt this issue was resolved because the family left with the resident under a safe discharge plan. He said the family and the caregiver did not indicate to them that there were any concerns or abuse allegations. Record review of the facility's policy, Abuse, Neglect and Exploitation, reflected: .It is the policy of this facility to provide protections for the health, welfare and implementing written policies and procedures that prohibit and prevent misappropriation of resident property.V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents reviewed for medications. (Resident #1) The facility failed to ensure: 1. Resident #1 was administered his regular evening medication as ordered along with Resident #2's evening medication on the evening of 5/5/2025. Resident #1's medication included Gabapentin 200 mg at bedtime ( a medication used to treat peripheral neuropathy, chronic pain) Hemp gummies 20,000 2 gummies at bedtime ( a supplement used to treat anxiety, depression, pain, inflammation and improve sleep), Melatonin 9 mg at bedtime (a supplement to assist in sleep), Tamsulosin 0.4 mg at bedtime ( a medication used to treat an enlarged prostate), Docusate Sodium 100 mg twice daily (a stool softener), Eliquis 5 mg every 12 hours (a blood thinner), Furosemide 40 mg twice daily ( a medication used to treat fluid), Metoprolol 50 mg twice daily and acetaminophen-codeine 300-60 mg three times daily. 2. Resident #2's medications was administered to Resident #1 on 5/5/2025 which included clobazam 20 mg 1 tablet twice daily ( a medication used to treat seizures), diazepam 5 mg 1 tablet twice daily (a medication used to treat seizures), Docusate sodium 100 mg 1 capsule twice daily (a stool softener used to treat constipation), Keppra 1000 mg twice daily (a medication used to treat seizures), lamotrigine 200 mg 1 tablet three times daily (a medication used to treat seizures), Metformin 500 mg 1 tablet twice daily ( a medication used to treat diabetes), Mirtazapine 15 mg 1 tablet at bedtime (a medication used to treat depression), Singular 10 mg 1 tablet at bedtime (a medication used to treat allergies), Topamax 200 mg 1 tablet twice daily (a medication used to treat seizures), and Trazadone 50 mg 1 tablet at bedtime (a medication to treat insomnia). 3. Resident #1's orders indicated he had an allergy to Trazodone with documented reaction indicating an intolerance and reaction manifestation of altered mental status. An Immediate Jeopardy (IJ) was identified on 5/15/2025 at 9:30 AM. The IJ template was provided to the facility on [DATE] at 10:03 AM. While the IJ was removed on 5/16/2025 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of physical complications, hospitalization , and possible death. Findings included: Record of Resident #1's face sheet dated 5/14/2025 indicated he was an [AGE] year-old male readmitted to the facility on [DATE]. Resident #1's diagnosis included COPD (a group of lung diseases that block airflow and make it difficult to breathe), transient cerebral ischemic attack (a brief stroke-like attack that despite resolving within minutes to hours, requires immediate medical attention), acute and chronic respiratory failure (a condition where the lungs are unable to adequately transfer oxygen into the blood, leading to low oxygen levels in the body), benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate gland which can put pressure on the urethra and cause urinary symptoms), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of an annual MDS assessment, dated 1/14/2025, indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had a BIMS score of 13 which indicated he was cognitively intact, and he required partial assistance with oral hygiene, dressing upper body, and dressing lower body. Resident #1 required maximal assistance with bathing and was dependent with toileting and putting on and taking off footwear. Record review of Resident #1's care plan revised on 1/29/2025 indicated ADL self-care performance deficits related to fatigue, COPD and recurrent pneumonia. Some of the interventions included level of assistance may vary slightly from day to day. OT started on 4/3/2025 and completed on 4/18/2025 related to muscle wasting and pain to right hand. The resident required assistance from staff for bathing and required extensive assistance for bed mobility. Resident #1 had a decreased cognitive function/memory impairment related to his diagnosis of Dementia. Some interventions included to administer medications as ordered. Monitor and document for side effects and effectiveness, ask yes/no questions to determine the resident's needs, cue, reorient and supervise as needed, and keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Record review of Resident #1's order summary report dated 5/13/2025 indicated Resident #1 was prescribed the following evening medications: Gabapentin 200 mg at bedtime ( a medication used to treat peripheral neuropathy, chronic pain) Hemp gummies 20,000 2 gummies at bedtime ( a supplement used to treat anxiety, depression, pain, inflammation and improve sleep), Melatonin 9 mg at bedtime (a supplement to assist in sleep), Tamsulosin 0.4 mg at bedtime ( a medication used to treat an enlarged prostate), Docusate Sodium 100 mg twice daily (a stool softener), Eliquis 5 mg every 12 hours (a blood thinner), Furosemide 40 mg twice daily ( a medication used to treat fluid), Metoprolol 50 mg twice daily and acetaminophen-codeine 300-60 mg three times daily. Resident #1 had orders for side effect monitoring for antidepressants. Resident #1 did not have any new orders for vital signs or neuro checks ordered. Record review of Resident #1's TAR dated 5/1/2025-5/31/2025 indicated Resident #1's behavioral monitoring for side effects of antidepressants did not indicate by O- None that Resident was experiencing any side effects of his medications. Record review of Resident #1's MAR dated 5/1/2025-5/31/2025 indicated Resident #1 was administered his evening medication which included Gabapentin 200 mg at bedtime ( a medication used to treat peripheral neuropathy, chronic pain) Hemp gummies 20,000 2 gummies at bedtime ( a supplement used to treat anxiety, depression, pain, inflammation and improve sleep), Melatonin 9 mg at bedtime (a supplement to assist in sleep), Tamsulosin 0.4 mg at bedtime ( a medication used to treat an enlarged prostate), Docusate Sodium 100 mg twice daily (a stool softener), Eliquis 5 mg every 12 hours (a blood thinner), Furosemide 40 mg twice daily ( a medication used to treat fluid), Metoprolol 50 mg twice daily and acetaminophen-codeine 300-60 mg three times daily. Record review of Resident #1's progress note dated 5/5/2025 at 8:45 PM, LVN A noted Resident #1 was inadvertently given the wrong medications. LVN A noted vital signs were taken, resident was alert and answering appropriate questions at this time. LVN A documented the NP was notified and orders were received to check neuros every 30 minutes for 4 hours and then every hour throughout the shift. The progress note indicated to refer to neuro notes and oxygen saturation notes and the DON was notified. Record review of Resident #2's order summary report dated 5/16/2025 indicated Resident #2's evening medications were clobazam 20 mg 1 tablet twice daily ( a medication used to treat seizures), diazepam 5 mg 1 tablet twice daily (a medication used to treat seizures), Docusate sodium 100 mg 1 capsule twice daily (a stool softener used to treat constipation), Keppra 1000 mg twice daily (a medication used to treat seizures), lamotrigine 200 mg 1 tablet three times daily (a medication used to treat seizures), Metformin 500 mg 1 tablet twice daily ( a medication used to treat diabetes), Mirtazapine 15 mg 1 tablet at bedtime (a medication used to treat depression), Singular 10 mg 1 tablet at bedtime (a medication used to treat allergies), Topamax 200 mg 1 tablet twice daily (a medication used to treat seizures), and Trazadone 50 mg 1 tablet at bedtime (a medication to treat insomnia). These medications were administered to Resident #1 on 5/5/2025. Record Review of an allergy alert dated 6/24/2024, indicated Resident #1 had an allergy to Trazodone with a reaction manifestation noted altered mental status. Record review of neurological assessment dated [DATE] at 8:45 PM, LVN A noted Resident #1 did not refuse neuro checks. She indicated his blood pressure was 109/50, pulse 96, respirations 18 and temperature 97.9. The neurological assessment indicated Resident #1 was alert, hand grasp was equal, he moved all extremities, his pupils were equal and reactive to light. LVN A documented Resident # 1's right and left pupils were dilated and responded appropriately to pain. Record review of neurological assessment dated [DATE] at 9:15 PM, LVN A noted Resident #1 did not refuse neuro checks. She documented NA for the blood pressure, pulse, respirations, and temperature indicating the vital signs were not assessed. The neurological assessment indicated Resident #1 was alert, hand grasp was equal, he moved all extremities, his pupils were equal and reactive to light. LVN A documented Resident # 1's right and left pupils were dilated and there was no response to pain. Record review of neurological assessment dated [DATE] at 10:45 PM, LVN A noted Resident #1 did not refuse neuro checks. She documented NA for the blood pressure, pulse, respirations, and temperature indicating the vital signs were not assessed. The neurological assessment indicated Resident #1 was lethargic/drowsy, hand grasp was equal, he moved all extremities, his pupils were not equal and reactive to light. LVN A documented Resident # 1's right and left pupils were sluggish and Resident #1 response to pain was appropriate. Record review of Resident #1's progress note dated 5/5/2025 at 11:00 PM, Resident #1 was awake and trying to get out of bed, wanted something to eat. He wanted a can of Vienna [NAME] and ate them all. Resident #1 then wanted pizza he had left and ate it all. LVN A indicated Resident #1 continues to be drowsy but alert and appeared too sleepy to open eyes. Record review of neurological assessment dated [DATE] at 11:45 PM, LVN A indicated Resident #1 did not refuse neuro checks. She indicated his blood pressure was 124/75, pulse 113, respirations 18 and no temperature was taken. The neurological assessment indicated Resident #1's level of consciousness was lethargic/drowsy, hand grasp was equal, moved all extremities, pupils were not equal or reactive to light, right and left pupil were sluggish, and Resident #1 responded appropriately to pain. Record review of neurological assessment dated [DATE] at 12:15 AM, LVN A indicated Resident #1 did not refuse neuro checks. She indicated NA on his blood pressure, pulse, respirations, and temperature indicating vital signs were not obtained. LVN A noted Resident #1's level of consciousness was lethargic/drowsy, hand grasp was equal, moved all extremities, pupils were not equal or reactive to light, right and left pupils were sluggish, and Resident #1 responded appropriately to pain. Record review of neurological assessment dated [DATE] at 12:45 AM, LVN A indicated Resident #1 did not refuse neuro checks. She indicated NA on his blood pressure, pulse, respirations, and temperature indicating vital signs were not obtained. LVN A noted Resident #1's level of consciousness was alert, hand grasp was equal, he moved all extremities, pupils were not equal and reactive to light, right and left pupil were sluggish, and Resident #1 responded appropriately to pain. Record review of a neurological assessment dated [DATE] at 1:45 AM indicated Resident #1 refused neuro checks. Record review of Resident #1's progress note dated 5/6/2025 at 1:45 AM, LVN A indicated Resident #1 would not open his eyes when nurse asked him to open his eyes but did shake his head no. LVN A noted she had been able to obtain oxygen saturations and the readings were in the high 90's. Record review of a neurological assessment dated [DATE] at 2:45 AM indicated Resident #1 refused neuro checks. Record review of a neurological assessment dated [DATE] at 3:45 AM indicated Resident #1 refused neuro checks. Record review of a neurological assessment dated [DATE] at 4:45 AM indicated Resident #1 refused neuro checks. Record review of a neurological assessment dated [DATE] at 5:45 AM indicated Resident #1 refused neuro checks. Record review of a Physician Progress note dated 5/7/2025 at 11:15 AM indicated Resident #1 was out of room in his wheelchair. The Pain Management NP documented Resident #1 required full assist with transfers and ADL's. The progress note indicated Resident #1 was prescribed Tylenol #4 every 4 to 6 hours as needed but because of increased pain on April 13, the dose was changed to Tylenol #4 scheduled 3 times a day and every 6 hours as needed for rescue pain treatment. The progress note indicated Resident #1 had no adverse effects from medications and was pleasant. He indicated Resident #1 had an allergy to Trazodone. The Pain Management NP's progress note indicated Resident #1 reported fatigue and arthralgia/joint pain. The progress note indicated Resident #1 was oriented to self, place, and time and his affect was appropriate. During an interview on 5/14/2025 at 1:33 PM, LVN A said she worked at the facility part-time. LVN A said she had gone into Resident #1 and Resident #2's room while holding Resident #2's evening medications. She said Resident #1 was wanting a breathing treatment and she handed him Resident #2's medications and he took them. She said she realized what she had done and call the NP. LVN A said Resident #1 acted drunk and was slurring his words after taking the medications. She said Resident #1 was fine when she left. LVN A said she had notified Interim DON T and the Physician. LVN A said the NP instructed her to check Resident #1's vital signs every 30 minutes for 4 hours and then hourly. She said she was also instructed to complete neuro checks and oxygen saturations. LVN A said Resident #1 was getting upset and not letting her check his vital signs. LVN A said she could not recall the medications that were administered to Resident #1. LVN A said she completed a risk management form and completed the medication error form that populates in the EMR. LVN A said she did not recall completing an incident report. LVN A said Resident #1 received all of Resident #2's evening medications. LVN A said she could not recall if she checked to see if Resident #1 had any allergies to Resident #2's medications. LVN A said Resident #1 could have an adverse reaction and she could not recall if Trazadone was one of the medications she administered. LVN A said whatever was on Resident #2's MAR for the evening was what Resident #1 had received. During an interview on 5/14/2025 at 2:05 PM, LVN B said Resident #1 was transported to the hospital on 5/13/2025. LVN B said Resident #1 was bedbound and navigated the facility in his electric scooter. LVN B said Resident #1 was normally awake, alert, and oriented to person, place, time, and situation. LVN B said Resident #1 was sometimes confused. LVN B said the normal process to reporting an incident such as falls, or medication errors required the nurse to complete a form under risk management on the EMR. She said the first thing she would need to do would be to contact the Physician, DON, Supervisor, and family. She said then the nurse would need to write up an incident and document when it occurred. LVN B said the DON and ADM should investigate the issue and follow up. During an interview on 5/14/2025 at 2:33 PM, the RP said Resident #1 was currently in the hospital. He stated Resident #1 had not been the same since he was administered the wrong medication and stated he had gone downhill. RP said the medication that he took caused a reaction. RP said Resident #1 was taken by ambulance and he stayed in the ER for a while until he was stable. RP said Resident #1 was currently on oxygen and was in and out mentally. RP said he could hardly hear him when he talked, and Resident #1 does not know who he is. RP said it was from his understanding the medication was administered to him on Monday night. He said when the facility called, they told him Resident #1 was having an episode. Rp said he did not find out about the nurse administering the wrong medication until the next day. RP said the NP did not send Resident #1 out the day the medication was administered. RP said Resident #1 was currently in ICU. RP said the facility would not tell him what medications were administered. RP said Resident #1 had COPD and it had been controlled. RP said he was not sure if Resident #1 had any allergies. During a phone interview on 5/14/2025 at 3:02 PM, the NP said he was called about the medication error last week. He said the nurse had informed him she had administered Resident #1 the wrong medications. He said he was told the medications were Tegretol, Keppra and Metformin. He said he had asked her if she had administered the 5 rights of medication administration and she said no. He advised her to monitor the resident and he called the Physician to consult. NP said he was going to instruct the nurse to monitor Resident #1 every hour but changed it to every 30 minutes after discussing with the DON. NP said he did not assess Resident #1 on Thursday when he was at the facility because he saw him up and about. The NP said the main side effect could be sedation. The NP said with all the medications administered, it could affect the residents breathing. The NP said he did not feel the medication error could have caused Resident #1 to have pneumonia. During an interview on 5/14/2025 at 3:14 PM, the Interim DON U said Resident #1 was sent to the hospital because his eyes rolled back. Interim DON U said if there was a medication error, it would be entered by the nurse and brought to the charge nurse, ADON, DON and ADM. He said the physician and family would have been made aware. Interim DON U said there was an incident report in the computer, but it did not list the medications that were administered. Interim DON U said he would have listed the medications administered. Interim DON U said he would expect the orders to be in the computer but could not locate the neurological assessment orders or the vital sign orders. Interim DON U said medications administered to Resident #1 could cause an allergic reaction or adverse effect depending on the medication. He said Resident #1 could have respiratory issues or become too sleepy. Interim DON U said a resident with COPD can increase the risk with many medications. He said Resident #1 remained in the hospital. During an interview on 5/15/2025 at 7:35 AM, the ADON said the Interim DON T at the time was notified and the NP had called her. The ADON said the NP was upset. The ADON said the NP instructed staff to monitor Resident #1 until the next day. The ADON said the pain management provider came in and noticed Resident #1 was drowsy and wanted to adjust his pain medications. The ADON said she explained to the NP what had happened, and Resident #1 was not sedated from the pain medication but was administered the wrong medications. The ADON said Resident #1 was up in his wheelchair the next day and was doing fine. She said Resident #1 was ordered to have every 4-hour vital sign and neuro checks, but Interim DON T had advised vital signs to be checked more frequently. The ADON said there would not need to be an order written. The ADON said she would expect the nurse to have documented the vital signs in the computer. The ADON said the Interim DON T did not complete an investigation. The ADON said if the resident did not have a good renal function, it could have been bad. She said the medications administered to Resident #1 could have suppressed his respirations. The ADON said she was not aware Resident #1 had his evening medications as scheduled and the nurse did not tell the resident had any allergies. The ADON said she had provided the nurse a verbal in-service on the 7 Rights of Medication Administration. During an interview on 5/15/2025 at 9:01 AM, the NP said he had spoken with the Interim DON T and discussed she wanted the vital signs and neuro checks to be completed every 30 minutes. He said he would not have done anything differently if he had known Resident #1 was allergic to Trazadone. He said if Resident #1 was to have an allergic reaction, he would have advised the nurse to administer the resident a Benadryl and to call 911. He said it would have been nice to know the resident had slurred speech and was drowsy but that would be expected with the medications he was administered. The NP said it did not surprise him that the vital signs were not taken as he had ordered . He said the pain management NP came in the next day and assessed the resident and said he was fine. During an interview on 5/15/2025 at 1:30 PM, the Regional [NAME] President provided additional information. He said he provided the neurological assessment with vital signs that were documented on 5/5/2025. He said the vital signs were documented on the neurological assessment form and not in the computer. He said LVN A did not document in her charting Resident #1 was slurring his words or acting drunk. He said Resident #1 took CBD gummies and would be lethargic at bedtime. The Regional [NAME] President said one of the progress notes indicated Resident #1 woke up asking for food and it was provided to him. The Regional [NAME] President felt Resident #1 was alert enough to ask for food. He said he spoke with the Corporate Nurse, and she said the orders for neuro checks was fine in the progress note and a written order would not be necessary. The Regional [NAME] President reviewed neuro checks and acknowledged there was only 2 vital sign checks on the neuro check form. During a phone interview on 5/15/2025 at 3:20 PM, the Pain Management NP said he saw Resident #1 the next day. He said Resident #1 was sitting up in his wheelchair, oriented and listening to his podcast. The Pain Management NP said he had spoken with ADON due to reviewing a progress note on Resident #1 indicating he was fatigued. He said he was going to adjust his medications during the visit, but the ADON had informed him of the medication error causing Resident #1's documented fatigue. Pain Management NP said Resident #1 was fully oriented, was not impaired and was in great condition when he saw him, and he had no concerns at the time of his visit. During an interview on 5/15/2025 at 3:29 PM, the Interim DON T said she was there are at the time of medication error. She said she was the Interim DON for the last 2-3 months. Interim DON T said LVN A had called her and told her she had got some medications for Resident #2 and had the new medications in the cup. She said she was heading to administer the medications and stopped to answer the call light and handed the cup of medications to the wrong resident. She said LVN A called and notified the NP and informed him about what had happened. Interim DON T said the NP had asked LVN A if Resident #1 had any changes and she said no. Interim DON T said the NP called her and discussed vital signs checks to be ordered every 30 minutes through the night and arouse resident. Interim DON T said the NP also wanted neuro every hour. She said the staff checked him for 24 hours and family was notified. She said the wife was notified and monitored Resident #1 for 3 days. The Interim DON said the NP came and checked Resident #1 out and he was doing good. Interim DON T said she checked on Resident #1 during the day. Interim DON T said she did not find out what was administered and did not put it on the incident report. She said the nurse said what the medications were, and she said they did check the allergies and the NP visited. Interim DON T said Resident #1 had been doing good. She said the only allergy Resident #1 had been to Motrin. Interim DON T said Resident #1 was not lethargic and the RP had checked on Resident #1 and talked to DON T about it. Interim DON T said she asked the ADON to complete the in-service and she spoke with LVN A about the 7 rights of medication administration. During an interview on 5/15/2025 at 3:48 PM, the ADM said she was made aware of the medication error and what happened. She said she had spoken with the RP. The ADM said from what she knew, was the nurse had medications for another resident and Resident #1 received the medications instead. The ADM said LVN A handed Resident #1 the medications. The ADM said she was not aware of whose medication Resident #1 received and did not know if it was multiple medications. The ADM said in theory, it would be clinical and multiple departments assisting in the investigation. She said in her roll, she has checks and balances. She said she would involve HR to see if this had happened before. She said the investigation would be resident care and involve communication to NP or MD. The ADM said she did not know if each medication should have been listed on the investigation. She said the facility tries to identify and figure out during their investigation. The ADM said from her understanding, there was an investigation. She said she was made aware immediately what was happening. She said a medication error could negatively impact a resident that was not prescribed to him but would not elaborate. During an interview on 5/15/2025 at 4:30 PM, the ADM said she had spoken to the Corporate Nurse, and she was told the incident report was the investigation and there was not a separate investigation. 2. Record review of Resident #2's face sheet dated 5/16/2025 indicated he was readmitted to the facility on [DATE]. Resident #2's diagnosies included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), cognitive communication (difficulties arising from impairments in cognitive function like attention, memory and executive functions, rather than issues with speech or language itself), diabetes mellitus (a group of diseases that result in too much sugar in the blood), mild intellectual disabilities (deficits in intellectual functions pertaining to abstract/theoretical thinking) and depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities previously enjoyed). Record review of a quarterly MDS assessment, dated 1/14/2025, indicated Resident #2 was usually understood and usually understood others. The MDS indicated Resident #2 had a BIMS score of 7 which indicated he was severely cognitively impaired, and he required substantial assistance with toileting, bathing, and dressing lower body. Record review of Resident # 2's care plan dated 10/29/2018 indicated Resident #2 uses anti-anxiety medications related to seizures diagnosis. Interventions included to administer anti-anxiety (Ativan, valium) medications as ordered by physician and monitor for side effects and effectiveness every shift. Interventions included to monitor, document, and report any adverse reactions to anti-anxiety therapy such as drowsiness, lack of energy clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double visit. Record review of Resident #2's order summary report dated 5/16/2025 indicated Resident #2's evening medications were clobazam 20 mg 1 tablet twice daily ( a medication used to treat seizures), diazepam 5 mg 1 tablet twice daily (a medication used to treat seizures), Docusate sodium 100 mg 1 capsule twice daily (a stool softener used to treat constipation), Keppra 1000 mg twice daily (a medication used to treat seizures), lamotrigine 200 mg 1 tablet three times daily (a medication used to treat seizures), Metformin 500 mg 1 tablet twice daily ( a medication used to treat diabetes), Mirtazapine 15 mg 1 tablet at bedtime (a medication used to treat depression), Singular 10 mg 1 tablet at bedtime (a medication used to treat allergies), Topamax 200 mg 1 tablet twice daily (a medication used to treat seizures), and Trazadone 50 mg 1 tablet at bedtime (a medication to treat insomnia). Record review of Resident #2's MAR dated 5/1/2025-5/31/2025 indicated Resident #2 received his medications as ordered. The Administrator was notified on 5/15/2025 at 10:03 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 5/15/2025 at 10:08 AM and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 05/15/2025 at 2:37 PM and included: Plan of Removal F-760 Action: The Director of Nursing and/or Designee completed medication reconciliations to ensure that medications were given as ordered and documented on the MAR. The Director of Nursing and/or Designee reviewed the last 30 days of medication errors incidents to ensure that vital signs monitoring have been ordered and completed and documented include notification to physician of any allergies and adverse effects related to the medication error. Action/System Change: All licensed nurses and Certified Medication Aides were re-educated on 5/15/2025 by the Director of Nursing or designee on the following: Medication Administration Policy and Seven Rights of medication administration Medication errors to include writing orders as prescribed by Physician and Notification of adverse effects and resident allergies. Documentation and completion of vital signs as prescribed by the physician. Staff not in the facility on 5/15/2025 and/or on PTO/FMLA /Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. Beginning 5/15/2025 and ongoing, newly hired licensed nurses will receive this training during orientation proper to providing care to the residents. The training will include the above-stated educational components. Medication error incidents will be reviewed during the morning clinical meeting to ensure that physicians were notified of any resident allergies related to medications received. Review will also ensure that monitoring of adverse effects to include vital signs were ordered, completed, and documented and physician was notified for abnormal findings. Completion and time was 5/15/2025 at 11:59 PM. Monitoring: Beginning 5/15/2025 and going forward, the Director of Nursing will monitor compliance with medication administration policy and the seven rights of medication administration. Beginning 5/15/2025 and going forward, the Director of Nursing/designee will monitor compliance each weekday morning on review of medication administration report and medication errors incidents to ensure medications are administered as ordered and physician notifications with orders written for monitoring of vital signs and adverse effects, carried out and documented in the record. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the incident report and medication administration report during the clinical meeting. On 5/15/2025, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. On 05/16/2025 at 12:49 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the Chart audits on medications indicated they were completed, and all resident's medication were reconciled with hospital discharges. No errors found. Review of the facility in-service dated 5/15/2025 The 10 Rights' Medication Administration indicated following: Right Medication- verifying that the medication administered is the correct one. Right Patient- Positively identify the patient. Right Dose- Checking the MAR/prescription to ensure the correct dosage was administered. Right [TRUNCATED]

Based on record review and interview the facility failed to consult with the physician when there was a significant change in residents' physical status that was life threatening for 2 of 7 residents (Resident #1 and Resident #2) reviewed for change in condition. The facility failed notify Resident #1's physician on 2/5/25 when his PICC continued to be dislodged and he was unable to receive his IV antibiotics. Resident #1 did not receive his IV antibiotic medication from 2/6/25 through 2/7/25 (a total of 6 doses). The facility failed to notify Resident #1's physician of his x-ray results that were ordered on 2/7/25 with results that indicated they were sent back to the facility on [DATE]. Res #1's MD was notified on 2/10/25 that Res #1's x-ray indicated he had pneumonia, and he was transferred to the hospital. Resident #1 was admitted to the hospital on 2/10/25 with diagnoses of right lobe pneumonia due to ESBL(extended spectrum beta lactamase). The facility failed to notify Res #2's physician that his surgical wound had worsened. Resident #2 was admitted to the hospital on 2/9/25 with left lower leg pain and fever. He had a diagnosis of sepsis ( a life threatening complication of an infection) left below the knee amputation infection. The facility failed to follow their policy on notification of changes with significant health issues. An Immediate Jeopardy (IJ) situation was identified 2/13/25 at 5:00 p.m. While the IJ was removed on 2/14/25 at 7:35 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate threat with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures caused life threatening consequences for these two residents and put other residents at risk for not receiving timely medical interventions. Findings included: Record review of Resident #1's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was readmitted on [DATE] with diagnoses of Diffused traumatic brain injury, osteomyelitis, pneumonia, covid 19, quadriplegia, contracture of the right and left hand, and presence of left artificial elbow joint. Record review of Resident #1's admission MDS dated [DATE] indicated he was moderately impaired in decision making. He was unable to complete the BIMS. The resident had impaired range of motion on both sides of his upper extremity (shoulder, elbow, wrist, and Hand) and his lower extremity (hip, knee, ankle, and foot.) He required a wheelchair for mobility. He was dependent on staff for all activities of daily living. The MDS indicated the resident had an indwelling catheter and ostomy. Record review of Resident #1's care plan dated 1/28/25 indicated a problem of altered respiratory status/difficulty breathing related to recent hospitalization stay for Covid and pneumonia. The resident will be on IV antibiotics for pneumonia with an initiation date of 1/27/25 and a revision date of 2/7/25. Some of the interventions were to monitor and document changes in orientation. Monitor for signs and symptoms of respiratory distress and report to the physician increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, confusion, and cough. A care plan problem of IV medications related to pneumonia. The care plan interventions were related to complications related to IV therapy such as infiltrated IV, drainage, or inflammation. Record review of Resident #1's prior to facility admission hospital records dated 1/31/25 indicated a diagnosis of pneumonia due to covid dated 1/23/25, ESBL Extended spectrum beta lactamase: producing bacterial infection dated 9/17/24 still present, Acute osteomyelitis of the right elbow dated 12/24/24 still present. His discharge medication included meropenem 1 GM. Record review of Resident #1's nursing notes dated 1/31/25 at 6:17 p.m. indicated the resident was returning to the facility from the hospital. Signed by RN H. Record review of Resident #1's physician order indicated Meropenem Intravenous Solution Reconstituted use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days dated 2/1/25. Record review of Resident #1's MAR indicated Meropenem Intravenous Solution Reconstituted 1 GM use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days. With a start date of 2/1/25. The MAR indicated the medication was to be administered at 7:00 a.m., 3:00 p.m., and 11:00 p.m. The MAR indicated the mediation was given 3 times daily with the last dose 2/5/25 at 11:00 p.m. Record review of Resident #1's nursing notes indicated: On 2/6/25 at 1:27 p.m. meropenem intravenous Solution reconstituted 1GM was not given due to loss of PICC access. The PICC company was notified for replacement. The NP was made aware. Signed by LVN C. On 2/6/25 at 10:13 p.m. indicated the resident refused midline, would not let staff unbend arm to pace midline. Signed by LVN F. On 2/7/25 at 1:40 p.m. the company that replaced PICC lines was called to replace Resident #1's PICC line. Signed by LVN E On 2/7/25 at 2:58 p.m. no PICC line in place for administration of medication. Signed by LVN E On 2/7/25 at 10:12 p.m. no PICC line access. Signed by LVN F On 2/8/25 at 12:17 a.m. resident remained without IV access signed by LVN F. On 2/10/25 at 11:38 a.m. Resident #1's PICC line was dislodged on 2/5/25 and the NP was informed. An outside service provider attempted to replace and insert new PICC line in the facility. The technician was unsuccessful due to contraction of upper extremities of patient. The patient did not complete antibiotic therapy and missed several doses. The nurse contacted NP regarding situation and current symptoms to include cough, abnormal lung sounds, abnormal chest x ray. The nurse received an order to send Resident #1 to the ER. His blood pressure was 116/64, oxygen status on room air was 91 percent, his temperature was 98.8 and his pulse was 80. Signed by LVN E. Record review of a change in condition note dated 2/10/25 at 6:57 p.m. indicated Resident #1 had increased cough, a positive chest x ray, incomplete antibiotic therapy, these things made the condition worse. Signed by LVN E. Record review of Resident #1's x ray report dated 2/7/25 and signed electronically on 2/7/25 at 11:07 a.m. indicated Resident #1 had patch bilateral lung opacities (area of increased density or darkness in the lungs.) This was consistent with bilateral pneumonia. The findings are worse compared with prior. There was no indication the physician was notified. Record review of Resident #1's hospital records dated 2/10/25 indicated Resident #1 was receiving IV antibiotics for pneumonia. He lost his PICC line assess, and the facility attempted to have it replaced but was unsuccessful. The resident had an x ray showing he still had pneumonia and was sent to the hospital for PICC line replacement. He has a history of pneumonia. He is nonverbal and quadriplegic, unable to move upper or lower extremities, with severe contractions noted. The hospital records indicated they spoke with the RN at the facility and was informed the PICC line had been out since 2/5/25. He had a diagnosis of pneumonia of the right lower lobe due to infectious organism ESBL (extended spectrum beta -lactamase) producing bacterial infection. Record review of a nursing note dated 2/10/25 at 9:56 p.m. indicated the nurse called to check on Resident #1's status. He was admitted to the hospital with a diagnosis of right lower lobe pneumonia, acute osteomyelitis, ESBL. Signed by LVN E During an interview and record review on 2/12/25 at 3:21 p.m. LVN C said Resident #1 did not have PICC line access when she came in on 2/6/25. She said she had gotten the ADON/RN D to come in and help her assess the resident. She said the NP was in the building doing rounds. She said the NP told them to contact a company that replaced PICC lines. She said she had contacted that company on 2/6/25 for them to come out and replace Resident #1's PICC line. A review of the nursing notes with LVN C indicted Resident #1 had refused the reinsertion on 2/6/25. LVN C said she was not aware the company had been contacted again on 2/7/25 by LVN E and she did not know what had happened with Resident #1's PICC line. During an interview on 2/12/25 at 3:44 p.m. ADON/RN D said she was not sure if Resident #1's PICC line had been noted as displaced by the prior shift on 2/5/25. She said Resident #1's right arm was contracted, and he held it tightly to his biceps. The ADON/RN said she did not know how the PICC line came out. She said LVN C had asked her to come in and assess Resident #1 on the morning of 2/6/25. She said the NP was in the building and the NP and told them to contact a company that replaced PICC lines. She said she knew LVN C had called the company. She did not know Resident #1 had refused or how many times the company had been called or why the PICC line was not replaced. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he had gotten a text earlier on the morning of 2/6/25 that Resident #1's PICC line had come out. He said he told them to call the PICC line replacement company and have them to come out to replace the PICC line. He said the facility did not inform him they were unable to replace the PICC line. He said he was not informed Resident #1 was not taking the antibiotic. The NP said if they had informed him Resident #1 was not able to finish his antibiotic, he would have told them to send him to the hospital. During a telephone interview on 2/12/25 at 4:31 p.m. the DON said on 2/7/25 LVN E told her that the PICC line company said they would not come back to the facility to try and reinsert Resident #1's PICC line. They said they were unable to do so due to his contractures. She said she told LVN E to call the physician and let him know. The DON said on the morning of Monday, 2/10/25 after the x rays were reviewed, she told LVN E to call the physician and send Resident #1 to the hospital. During a telephone interview on 2/12/25 at 4:32 p.m. LVN E said she had talked to the PICC line company, and their nurse said they were not coming out. She said the nurse said Resident #1 was too contracted and they were not able to place the PICC line. LVN E said she was leaving for the day and told the DON what the company had said. The DON told her to make the physician aware. She told the oncoming nurse LVN F about the situation during report. She said she did not know what happened after then. She said she had not notified the physician. During a telephone interview on 2/12/25 at 4:55 p.m. LVN F said that on Friday 2/7/25 LVN E told her the PICC line company had refused to come out. She said it was mentioned in the conversation about notifying the physician, but she thought LVN E had notified the physician. LVN F said she had not notified the physician because she thought it was already done. During an interview on 2/13/25 at 7:21 a.m. LVN C said she did not know anything about Resident #1's x rays results until Monday, 2/10/25. She said she worked PRN and was under the impression x rays results would be sent by fax. She said that on Monday, 2/10/25 Resident #1 had a cough that was deeper than on 2/7/25 and she was told he had x ray results that indicated pneumonia and to send him out to the hospital. During an interview on 2/13/25 at 10:30 a.m. the Regional Nurse Consultant said ADON/RN D and Administrator did not find any nurse that admitted to seeing the x ray results for Resident #1 on the weekend. He said it appeared the first time the x rays were noted was on 2/10/25. During an interview on 2/13/25 at 10:34 a.m. the Administrator said they did not find any nurse that discovered the x ray results for Resident #1 over the weekend. She said she was aware of what the NP always said he would send a resident to the hospital if they had a change in condition. The Administrator said she had reached out to the nurses on the weekend they thought the order was complete for Resident #1's antibiotics because the completion date was 2/7/25 and it fell off the system orders. She said they did not see any issues and they did not review the records to see if there was a problem because they thought the antibiotic was completed. Resident #2 Record review of Resident #2's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was last admitted [DATE] with diagnoses of surgical amputation, absence of left leg below the knee, and absence of right leg below the knee. Record review of an admission MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment. The resident required substantial to maximum assistance with the helper doing more than half the effort for sit to lying, sit to stand, and transfers. Record review of Resident #2's care plan dated 12/26/24 and revised on 1/3/25 indicated a problem of the resident was at risk for skin integrity related to reduced mobility due to bilateral amputation, poor nutrition and immune comprised. Some of the interventions were to monitor and document size and location and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician. Record review of Resident #2's prior to facility admission hospital records dated 1/27/25 indicated to cleanse left BKA site daily with antibacterial soap and water or wound cleanser, apply no stick dressing and secure with ace wrap compression. Start taking Amoxicillin potassium-clavulanate (Augmentin) 875-125 mg oral one tablet two times a day for 10 days. Record review of Resident #2's MAR for February 2025 indicated Amoxicillin potassium-clavulanate (Augmentin) 875-125 mg give one tablet by mouth q 12 hours for cellulitis for 10 days with a start dated on 1/27/25. The medication was noted to be last given on 2/6/25 at 8:00 a.m. Record review of Resident #2's TAR for February 2025 indicated cleanse left BKA site with antibacterial soap and water or wound cleanser, apply nonstick dressing, secure with ace wrap compression one time a day every Tuesday, Thursday, and Saturday for wound care with start date of 1/30/25. The TAR indicated the last time wound care was provided was Tuesday 2/4/25. On Thursday 2/6/25 the TAR indicated to see the nurses' notes on Saturday 2/8/25 indicated the drug refused. Record review of Resident #2's nursing notes dated 2/6/25 indicated Resident #2 refused wound care. Signed by treatment nurse. Record review of Resident #2's wound evaluation dated 2/7/25 at 6:22 a.m. indicated a surgical wound with 38 staples on the left below the knee amputation site. The area of the wound was 44.65 cm, and the length was 8.14 cm and 7.58 cm. the wound was one to 3 months old. It had 50 percent granulation and 50 percent slough. There was evidence of infection such as increased drainage, increased pain, redness/inflammation, warmth, and bleeding. There was moderate sanguineous bloody drainage. The was pitting edema that extended 4 cm around the wound and was warm, the pain was at a level 4 with continuous frequency. The wound evaluation indicated the wound was deteriorating and the physician diagnosed the infection. The wound evaluation was signed by the treatment nurse. Record review of Resident #2's nursing note dated 2/7/25 at 11:09 a.m. indicated surgery for BKA revision rescheduled for 2/12/25 arrival at 9:30 a.m. for 11:30 a.m. procedure. Record review of Resident #2's nursing note dated 2/8/25 at 6:15 p.m. indicated cleanse left BKA site with antibacterial soap or wound cleanser and apply dressing. Record review of Resident #2's change in condition notes dated 2/9/25 at 1:00 p.m. indicated Resident #2 had a change in condition that consisted of lethargy, confusion, loss of appetite, elevated heart rate at rest started 2/9/25 and had stayed the same. His primary diagnosis was orthopedic aftercare following surgery. his blood pressure was 106/68, pulse 115 (irregular), respiration 16, temp 98.9, oxygen status 96. Signed by LVN A Record review of nursing notes dated 2/9/25 at 2:40 p.m. indicated Resident #2 was sent to the hospital. Record review of Resident #2's hospital records dated 2/9/25 indicated the resident was admitted at 12:53 p.m. He was admitted with complaints of left lower extremity wound pain and fever. He had a recent BKA performed at another hospital his blood pressure was 173/95, pulse 114, respirations 16, temp 100.4 and oxygen status 99 percent. The x rays were concerning for gas within the wound that could be either an abscess or gaseous gangrene. He was started on antibiotics and wanted to be transferred to another hospital. The disposition summary on 2/9/25 at 4:51 p.m. indicate a diagnosis of sepsis unspecified organism/left BKA infection. During an interview on 2/11/25 at 3:45 p.m. LVN B said Resident #2 was on antibiotics and had finished them a few days prior to going to the hospital. She said he was sent to the hospital to have surgery on an amputation that needed a revision. During an interview and observation on 2/12/25 at 2:00 p.m. with the treatment nurse and the RN C, the treatment nurse said Resident #2 came to the facility after he had an amputation. She said the wound care physician would not see him because his wound was surgical. She said the last time she completed an assessment on Resident #1 was Friday, 2/7/25. She said Resident #2's surgical wound had deteriorated by her assessment. She said she did not call NP or the physician because she thought Resident #2 was going to surgery center that day. She said she wanted to see the wound herself and document what was going on with the wound before he left for his surgery. She said on Friday, 2/7/25 she noted a change to the wound. She said it did not look like that the week before. She said she had taken a picture that was observed by the surveyor. She described the wound with drainage and yellow slough (a layer of dead tissue formed when cells and other debris are trapped in the wound, and do not get properly removed. It can impede wound healing) around the circumference of the wound. The treatment nurse said Resident #2's leg was cut below the knee, it black above the staples on the wound. The treatment nurse said LVN B had assisted her with wound care on 2/7/25. During a telephone interview on 2/12/25 at 2:20 p.m. LVN B said Resident #2 had an appointment on 2/7/25 for a surgical revision to his BKA. She said it was right on the computer, but it was placed on the transport log with the wrong date. LVN B said when they realized the resident was not at his appointment they had called the clinic and were initially told to bring the resident to the appointment late. She said in about an hour the clinic called back and said the physician said to reschedule. She said the appointment was rescheduled to 2/12/25. She had written the note about the rescheduled appointment, but had not notified anyone he missed the appointment. She said she had assisted the Treatment Nurse on 2/7/25 when she provided wound care to Resident #2. LVN B said Resident #2's surgical wound had drainage, no odor, and the darkness above the wound had grown larger. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he was informed Resident # 2 had a change in condition when they were sending him to the hospital. He said he was not informed Resident #2's wound had deteriorated. Review of the facility policy on Notification of Changes dated 10/24/22 indicated the purpose of the policy was to ensure the facility promptly informed the resident, consulted with the resident physician. The facility must inform the resident, consult with the resident's physician when there is a change requiring such notification such as a significant change. Such as life threatening conditions or clinical complications. Circumstances that require a need to alter treatment such as adverse consequences, acute condition or exacerbation of symptoms. Due to the above findings, it was determined the facility was in an Immediate Jeopardy (IJ) situation on 2/13/25 at 5:00 p.m. The Administrator, Regional Nurse Consultant, and ADON/RN G were informed on 2/13/25 at 5:00 p.m. an email was sent to the Administrator. The facility's Plan of Removal was accepted on 2/14/25 at 10:51 a.m. Plan of Removal for F580: [To Identify Any Other Residents to Have the Potential: Beginning 2/13/25, the Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record. All residents, evaluated, validated and documented on 2/13/25 with no additional cases identified. Education/ System Change: On 2/12/25, the Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: o Documentation in Medical Record o Medication Administration o Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results o When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. o Licensed Nurses will give shift report from the PCC generated 24 hour report. (PCC generated from clinical documentation). o Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training. Monitoring: Beginning 2/13/25, and going forward, the Director of Nursing / designee will review the 24- hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning 2/13/25, and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning 2/13/25, and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology to ensure that Medical Providers are notified of results. An Ad Hoc QAPI {quality assurance and performance improvement} Meeting was conducted on February 13, 2025, by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F580 Notification of Changes and plan to correct.] On 02/14/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of in-services dated 2/13/25 and 2/14/25 indicated staff were trained on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. Record review of 24-hour reports dated 2/13/25 and 2/14/25, the PCC Skin and Wound Module, and the PCC Results Module revealed no concerns. Record review of the facilty's QAPI meeting attendance sheet indicated they met on 2/13/25. Interviews on 2/14/25 with the ADON, Regional Clinical Specialist and Administrator indicated in-services were completed with staff on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. They said staff had knowledge and were able to explain procedures on notification of changes, changes in medication administration, wound care, radiology/lab results, and documentation in the medical record. They said staff were knowledgable on giving report during shift change from the 24 hour report that was generated from the clinical documentation. They said staff were able to explain procedures on changes of condition and notifying the provider of the change, and documentating in the clincial record. They said they went over the 24 hour reports during their morning meeting. Interviews and record reviews were conducted on 02/14/25 from 4:00 p.m. through 8:00 p.m. and included 3 RNs, 4 LVNs, ADON, Regional Clinical Specialist and Administrator. Staff were able to explain documentation in medical record and medication administration. Staff had knowledge on notification of changes policy and to include changes in medication administration, wound care, and abnormal radiology results. The staff successfully provided an explanation when a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. The staff was well-informed about licensed nurses will give shift report from the PCC generated 24-hour report. (PCC {point click care- facility medical records system} generated from clinical documentation). Also, Staff was able to explain licensed nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. All residents in the facility were evaluated for any change in condition, validated and documented on 2/13/25 with no additional cases identified. This was verified by interview with the ADON (DON Designee), the Administrator and record review of 24-hour summary listing resident name, room number and progress notes dated 2/13/25. During an observation on 2/14/25 at 6:35 p.m. of a shift change and reporting between LVN E and LVN I, there were no issues noted. The Administrator and ADON/RN G were informed on 2/14/25 at 7:35 p.m. the IJ was removed. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate threat with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on record review and interview the facility failed to provide care and treatment in accordance with professional standards of practice based on the comprehensive assessment for 2 of 7 residents (Resident #1 and Resident #2) reviewed for quality of care. The facility failed to ensure Resident #1 received IV antibiotics when his PICC line was dislodged on 2/5/25. Resident #1 did not receive his IV antibiotic medication from 2/6/25 through 2/7/25 (a total of 6 doses). The facility failed to address Resident #1's chest x-ray that was ordered and sent back to the facility on [DATE] until 2/10/25. The facility notified Resident #1's MD on 02/10/25 that Resident #1's x-ray indicated he had pneumonia, and he was transferred to the hospital. Resident #1 was admitted to the hospital on 2/10/25 with diagnoses of right lobe pneumonia due to ESBL(extended spectrum beta lactamase). The facility failed to ensure Resident #2's surgical wound did not worsen. Resident #2 was admitted to the hospital on 2/9/25 with left lower leg pain and fever. He had a diagnosis of sepsis ( a life threatening complication of an infection) left below the knee amputation infection. An Immediate Jeopardy (IJ) situation was identified 2/13/25 at 5:00 p.m. While the IJ was removed on 2/14/25 at 7:35 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures caused life threatening consequences for these two residents and put other residents at risk for not receiving timely medical interventions. Findings included: Record review of Resident #1's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was readmitted on [DATE] with diagnoses of Diffused traumatic brain injury, osteomyelitis, pneumonia, covid 19, quadriplegia, contracture of the right and left hand, and presence of left artificial elbow joint. Record review of Resident #1's admission MDS dated [DATE] indicated he was moderately impaired in decision making. He was unable to complete the BIMS. The resident had impaired range of motion on both sides of his upper extremity (shoulder, elbow, wrist, and Hand) and his lower extremity (hip, knee, ankle, and foot.) He required a wheelchair for mobility. He was dependent on staff for all activities of daily living. The MDS indicated the resident had an indwelling catheter and ostomy. Record review of Resident #1's care plan dated 1/28/25 indicated a problem of altered respiratory status/difficulty breathing related to recent hospitalization stay for Covid and pneumonia. The resident will be on IV antibiotics for pneumonia with an initiation date of 1/27/25 and a revision date of 2/7/25. Some of the interventions were to monitor and document changes in orientation. Monitor for signs and symptoms of respiratory distress and report to the physician increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, confusion, and cough. A care plan problem of IV medications related to pneumonia. The care plan interventions were related to complications related to IV therapy such as infiltrated IV, drainage, or inflammation. Record review of Resident #1's prior to facility admission hospital records dated 1/31/25 indicated a diagnosis of pneumonia due to covid dated 1/23/25, ESBL Extended spectrum beta lactamase: producing bacterial infection dated 9/17/24 still present, Acute osteomyelitis of the right elbow dated 12/24/24 still present. His discharge medication included meropenem 1 GM. Record review of Resident #1's nursing notes dated 1/31/25 at 6:17 p.m. indicated the resident was returning to the facility from the hospital. Signed by RN H. Record review of Resident #1's physician order indicated Meropenem Intravenous Solution Reconstituted use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days dated 2/1/25. Record review of Resident #1's MAR indicated Meropenem Intravenous Solution Reconstituted 1 GM use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days. With a start date of 2/1/25. The MAR indicated the medication was to be administered at 7:00 a.m., 3:00 p.m., and 11:00 p.m. The MAR indicated the mediation was given 3 times daily with the last dose 2/5/25 at 11:00 p.m. Record review of Resident #1's nursing notes indicated: On 2/6/25 at 1:27 p.m. meropenem intravenous Solution reconstituted 1GM was not given due to loss of PICC access. The PICC company was notified for replacement. The NP was made aware. Signed by LVN C. On 2/6/25 at 10:13 p.m. indicated the resident refused midline, would not let staff unbend arm to pace midline. Signed by LVN F. On 2/7/25 at 1:40 p.m. the company that replaced PICC lines was called to replace Resident #1's PICC line. Signed by LVN E On 2/7/25 at 2:58 p.m. no PICC line in place for administration of medication. Signed by LVN E On 2/7/25 at 10:12 p.m. no PICC line access. Signed by LVN F On 2/8/25 at 12:17 a.m. resident remained without IV access signed by LVN F. On 2/10/25 at 11:38 a.m. Resident #1's PICC line was dislodged on 2/5/25 and the NP was informed. An outside service provider attempted to replace and insert new PICC line in the facility. The technician was unsuccessful due to contraction of upper extremities of patient. The patient did not complete antibiotic therapy and missed several doses. The nurse contacted NP regarding situation and current symptoms to include cough, abnormal lung sounds, abnormal chest x ray. The nurse received an order to send Resident #1 to the ER. His blood pressure was 116/64, oxygen status on room air was 91 percent, his temperature was 98.8 and his pulse was 80. Signed by LVN E. Record review of a change in condition note dated 2/10/25 at 6:57 p.m. indicated Resident #1 had increased cough, a positive chest x ray, incomplete antibiotic therapy, these things made the condition worse. Signed by LVN E. Record review of Resident #1's x ray report dated 2/7/25 and signed electronically on 2/7/25 at 11:07 a.m. indicated Resident #1 had patch bilateral lung opacities (area of increased density or darkness in the lungs.) This was consistent with bilateral pneumonia. The findings are worse compared with prior. Record review of Resident #1's hospital records dated 2/10/25 indicated Resident #1 was receiving IV antibiotics for pneumonia. He lost his PICC line assess, and the facility attempted to have it replaced but was unsuccessful. The resident had an x ray showing he still had pneumonia and was sent to the hospital for PICC line replacement. He has a history of pneumonia. He is nonverbal and quadriplegic, unable to move upper or lower extremities, with severe contractions noted. The hospital records indicated they spoke with the RN at the facility and was informed the PICC line had been out since 2/5/25. He had a diagnosis of pneumonia of the right lower lobe due to infectious organism ESBL (extended spectrum beta -lactamase) producing bacterial infection. Record review of a nursing note dated 2/10/25 at 9:56 p.m. indicated the nurse called to check on Resident #1's status. He was admitted to the hospital with a diagnosis of right lower lobe pneumonia, acute osteomyelitis, ESBL. Signed by LVN E During an interview and record review on 2/12/25 at 3:21 p.m. LVN C said Resident #1 did not have PICC line access when she came in on 2/6/25. She said she had gotten the ADON/RN D to come in and help her assess the resident. She said the NP was in the building doing rounds. She said the NP told them to contact a company that replaced PICC lines. She said she had contacted that company on 2/6/25 for them to come out and replace Resident #1's PICC line. A review of the nursing notes with LVN C indicted Resident #1 had refused the reinsertion on 2/6/25. LVN C said she was not aware the company had been contacted again on 2/7/25 by LVN E and she did not know what had happened with Resident #1's PICC line. During an interview on 2/12/25 at 3:44 p.m. ADON/RN D said she was not sure if Resident #1's PICC line had been noted as displaced by the prior shift on 2/5/25. She said Resident #1's right arm was contracted, and he held it tightly to his biceps. The ADON/RN said she did not know how the PICC line came out. She said LVN C had asked her to come in and assess Resident #1 on the morning of 2/6/25. She said the NP was in the building and the NP and told them to contact a company that replaced PICC lines. She said she knew LVN C had called the company. She did not know Resident #1 had refused or how many times the company had been called or why the PICC line was not replaced. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he had gotten a text earlier on the morning of 2/6/25 that Resident #1's PICC line had come out. He said he told them to call the PICC line replacement company and have them to come out to replace the PICC line. He said the facility did not inform him they were unable to replace the PICC line. He said he was not informed Resident #1 was not taking the antibiotic. The NP said if they had informed him Resident #1 was not able to finish his antibiotic, he would have told them to send him to the hospital. During a telephone interview on 2/12/25 at 4:31 p.m. the DON said on 2/7/25 LVN E told her that the PICC line company said they would not come back to the facility to try and reinsert Resident #1's PICC line. They said they were unable to do so due to his contractures. She said she told LVN E to call the physician and let him know. The DON said on the morning of Monday, 2/10/25 after the x rays were reviewed, she told LVN E to call the physician and send Resident #1 to the hospital. During a telephone interview on 2/12/25 at 4:32 p.m. LVN E said she had talked to the PICC line company, and their nurse said they were not coming out. She said the nurse said Resident #1 was too contracted and they were not able to place the PICC line. LVN E said she was leaving for the day and told the DON what the company had said. The DON told her to make the physician aware. She told the oncoming nurse LVN F about the situation during report. She said she did not know what happened after then. During a telephone interview on 2/12/25 at 4:55 p.m. LVN F said that on Friday 2/7/25 LVN E told her the PICC line company had refused to come out. She said it was mentioned in the conversation about notifying the physician, but she thought LVN E had notified the physician. LVN F said she had not notified the physician because she thought it was already done. During an interview on 2/13/25 at 7:21 a.m. LVN C said she did not know anything about Resident #1's x rays results until Monday, 2/10/25. She said she worked PRN and was under the impression x rays results would be sent by fax. She said that on Monday, 2/10/25 Resident #1 had a cough that was deeper than on 2/7/25 and she was told he had x ray results that indicated pneumonia and to send him out to the hospital. During an interview on 2/13/25 at 10:30 a.m. the Regional Nurse Consultant said ADON/RN D and Administrator did not find any nurse that admitted to seeing the x ray results for Resident #1 on the weekend. He said it appeared the first time the x rays were noted was on 2/10/25. He said they did not have a policy on change in condition. During an interview on 2/13/25 at 10:34 a.m. the Administrator said they did not find any nurse that discovered the x ray results for Resident #1 over the weekend. She said she was aware of what the NP always said he would send a resident to the hospital if they had a change in condition. The Administrator said she had reached out to the nurses on the weekend they thought the order was complete for Resident #1's antibiotics because the completion date was 2/7/25 and it fell off the system orders. She said they did not see any issues and they did not review the records to see if there was a problem because they thought the antibiotic was completed. Resident #2 Record review of Resident #2's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was last admitted [DATE] with diagnoses of surgical amputation, absence of left leg below the knee, and absence of right leg below the knee. Record review of an admission MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment. The resident required substantial to maximum assistance with the helper doing more than half the effort for sit to lying, sit to stand, and transfers. Record review of Resident #2's care plan dated 12/26/24 and revised on 1/3/25 indicated a problem of the resident was at risk for skin integrity related to reduced mobility due to bilateral amputation, poor nutrition and immune comprised. Some of the interventions were to monitor and document size and location and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician. Record review of Resident #2's prior to facility admission hospital records dated 1/27/25 indicated to cleanse left BKA site daily with antibacterial soap and water or wound cleanser, apply no stick dressing and secure with ace wrap compression. Start taking amoxicillin potassium-clavulanate (Augmentin) 875-125 mg oral one tablet two times a day for 10 days. Record review of Resident #2's MAR for February 2025 indicated Amoxicillin potassium-clavulanate (Augmentin) 875-125 mg give one tablet by mouth q 12 hours for cellulitis for 10 days with a start dated on 1/27/25. The medication was noted to be last given on 2/6/25 at 8:00 a.m. Record review of Resident #2's TAR for February 2025 indicated cleanse left BKA site with antibacterial soap and water or wound cleanser, apply nonstick dressing, secure with ace wrap compression one time a day every Tuesday, Thursday, and Saturday for wound care with start date of 1/30/25. The TAR indicated the last time wound care was provided was Tuesday 2/4/25. On Thursday 2/6/25 the TAR indicated to see the nurses' notes on Saturday 2/8/25 indicated the drug refused. Record review of Resident #2's nursing notes dated 2/6/25 indicated Resident #2 refused wound care. Signed by treatment nurse. Record review of Resident #2's wound evaluation dated 2/7/25 at 6:22 a.m. indicated a surgical wound with 38 staples on the left below the knee amputation site. The area of the wound was 44.65 cm, and the length was 8.14 cm and 7.58 cm. the wound was one to 3 months old. It had 50 percent granulation and 50 percent slough. There was evidence of infection such as increased drainage, increased pain, redness/inflammation, warmth, and bleeding. There was moderate sanguineous bloody drainage. The was pitting edema that extended 4 cm around the wound and was warm, the pain was at a level 4 with continuous frequency. The wound evaluation indicated the wound was deteriorating and the physician diagnosed the infection. The wound evaluation was signed by the treatment nurse. Record review of Resident #2's nursing note dated 2/7/25 at 11:09 a.m. indicated surgery for BKA revision rescheduled for 2/12/25 arrival at 9:30 a.m. for 11:30 a.m. procedure. Record review of Resident #2's nursing note dated 2/8/25 at 6:15 p.m. indicated cleanse left BKA site with antibacterial soap or wound cleanser and apply dressing. Record review of Resident #2's change in condition notes dated 2/9/25 at 1:00 p.m. indicated Resident #2 had a change in condition that consisted of lethargy, confusion, loss of appetite, elevated heart rate at rest started 2/9/25 and had stayed the same. His primary diagnosis was orthopedic aftercare following surgery. his blood pressure was 106/68, pulse 115 (irregular), respiration 16, temp 98.9, oxygen status 96. Signed by LVN A Record review of nursing notes dated 2/9/25 at 2:40 p.m. indicated Resident #2 was sent to the hospital. Record review of Resident #2's hospital records dated 2/9/25 indicated the resident was admitted at 12:53 p.m. He was admitted with complaints of left lower extremity wound pain and fever. He had a recent BKA performed at another hospital his blood pressure was 173/95, pulse 114, respirations 16, temp 100.4 and oxygen status 99 percent. The x rays were concerning for gas within the wound that could be either an abscess or gaseous gangrene. He was started on antibiotics and wanted to be transferred to another hospital. The disposition summary on 2/9/25 at 4:51 p.m. indicate a diagnosis of sepsis unspecified organism/left BKA infection. During an interview on 2/11/25 at 3:45 p.m. LVN B said Resident #2 was on antibiotics and had finished them a few days prior to going to the hospital. She said he was sent to the hospital to have surgery on an amputation that needed a revision. During an interview and observation on 2/12/25 at 2:00 p.m. with the treatment nurse and the RN C, the treatment nurse said Resident #2 came to the facility after he had an amputation. She said the wound care physician would not see him because his wound was surgical. She said the last time she completed an assessment on Resident #1 was Friday, 2/7/25. She said Resident #2's surgical wound had deteriorated by her assessment. She said she did not call NP or the physician because she thought Resident #2 was going to surgery center that day. She said she wanted to see the wound herself and document what was going on with the wound before he left for his surgery. She said on Friday, 2/7/25 she noted a change to the wound. She said it did not look like that the week before. She said she had taken a picture that was observed by the surveyor. She described the wound with drainage and yellow slough (a layer of dead tissue formed when cells and other debris are trapped in the wound, and do not get properly removed. It can impede wound healing) around the circumference of the wound. The treatment nurse said Resident #2's leg was cut below the knee, it black above the staples on the wound. The treatment nurse said LVN B had assisted her with wound care on 2/7/25. During a telephone interview on 2/12/25 at 2:20 p.m. LVN B said Resident #2 had an appointment on 2/7/25 for a surgical revision to his BKA. She said it was right on the computer, but it was placed on the transport log with the wrong date. LVN B said when they realized the resident was not at his appointment they had called the clinic and were initially told to bring the resident to the appointment late. She said in about an hour the clinic called back and said the physician said to reschedule. She said the appointment was rescheduled to 2/12/25. She had written the note about the rescheduled appointment, but had not notified anyone he missed the appointment. She said she had assisted the Treatment Nurse on 2/7/25 when she provided wound care to Resident #2. LVN B said Resident #2's surgical wound had drainage, no odor, and the darkness above the wound had grown larger. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he was informed Resident # 2 had a change in condition when they were sending him to the hospital. He said he was not informed Resident #2's wound had deteriorated. Record review on the policy on Laboratory Services and Reporting dated 4/8/23 indicated. The facility must provide or obtain laboratory services when ordered. The facility responsible for the timeliness of services. The facility will promptly notify the ordering physician, or nurse practitioner of the laboratory results that fall outside the clinical reference range. Due to the above findings, it was determined the facility was in an Immediate Jeopardy (IJ) situation on 2/13/25 at 5:00 p.m. The Administrator, Regional Nurse Consultant, and ADON/RN G were informed on 2/13/25 at 5:00 p.m. an email was sent to the Administrator. The facility's Plan of Removal was accepted on 2/14/25 at 10:51 a.m. Plan of Removal for F684: [To Identify Any Other Residents to Have the Potential: Beginning 2/13/25, the Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record. All residents, evaluated, validated and documented on 2/13/25 with no additional cases identified. Education/ System Change: On 2/12/25, the Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: o Documentation in Medical Record o Medication Administration o Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results o When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. o Licensed Nurses will give shift report from the PCC generated 24 hour report. (PCC generated from clinical documentation). o Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training. Monitoring: Beginning 2/13/25, and going forward, the Director of Nursing / designee will review the 24- hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning 2/13/25, and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning 2/13/25, and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology to ensure that Medical Providers are notified of results. An Ad Hoc QAPI {quality assurance and performance improvement} Meeting was conducted on February 13, 2025, by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning [Quality of Care] and plan to correct.] On 02/14/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of in-services dated 2/13/25 and 2/14/25 indicated staff were trained on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. Record review of 24-hour reports dated 2/13/25 and 2/14/25, the PCC Skin and Wound Module, and the PCC Results Module revealed no concerns. Record review of the facilty's QAPI meeting attendance sheet indicated they met on 2/13/25. Interviews on 2/14/25 with the ADON, Regional Clinical Specialist and Administrator indicated in-services were completed with staff on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. They said staff had knowledge and were able to explain procedures on notification of changes, changes in medication administration, wound care, radiology/lab results, and documentation in the medical record. They said staff were knowledgable on giving report during shift change from the 24 hour report that was generated from the clinical documentation. They said staff were able to explain procedures on changes of condition and notifying the provider of the change, and documentating in the clincial record. They said they went over the 24 hour reports during their morning meeting. Interviews and record reviews were conducted on 02/14/25 from 4:00 p.m. through 8:00 p.m. and included 3 RNs, 4 LVNs, ADON, Regional Clinical Specialist and Administrator. Staff were able to explain documentation in medical record and medication administration. Staff had knowledge on notification of changes policy and to include changes in medication administration, wound care, and abnormal radiology results. The staff successfully provided an explanation when a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. The staff was well-informed about licensed nurses will give shift report from the PCC generated 24-hour report. (PCC {point click care- facility medical records system} generated from clinical documentation). Also, Staff was able to explain licensed nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. During an observation on 2/14/25 at 6:35 p.m. of a shift change and reporting between LVN E and LVN I, there were no issues noted. All residents in the facility were evaluated for any change in condition, validated and documented on 2/13/25 with no additional cases identified. This was verified by interview with the ADON (DON Designee), the Administrator and record review of 24-hour summary listing resident name, room number and progress notes dated 2/13/25. The Administrator and ADON/RN G were informed on 2/14/25 at 7:35 p.m. the IJ was removed. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs to meet the needs of residents for 5 of 6 residents reviewed for medication administration. (Resident #3, Resident #4, Resident #5, Resident#6, and Resident #7.) Resident #3 had insulin that was past the 28-day labeled precautionary instructions. LVN E was going to administer the mediations. After she noted the insulin was past the 28- days, she had difficulty finding the correct medications. Residents # 4 # 5, and #7 had insulin in the medication cart that was past the 28-day labeled precautionary instructions. Resident #6's insulin had a space on the box for an opened date but there was not a date listed. These failures could place residents to receive medications that were not effective to control diabetic symptoms. Findings included: 1. Record review of Resident #3's face sheet dated 2/13/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He had a diagnosis of Diabetes mellitus. Record review of Resident #3's a physician order dated 12/5/24 indicated to administer Novolog insulin injection, inject 23 units subcutaneously before meals for diabetes mellitus(a disorder related to high blood sugars). During an observation on 2/13/25 at 7:30 a.m. Resident #3 was observed in his bed. LVN E checked his blood sugar, and it was 335. LVN E said Resident # 3 received 23 units of insulin three times a day before meals. Observation of Resident # 3's multi-use vial of Novolog indicated it was opened 1/12/25 (31 days prior). The package indicated to discard after 28 days. The LVN pulled up the Novolog and was about to enter Resident #3's room. She was asked if she was going to give him the insulin and she said yes. It was pointed out to her the medication had been opened more than 28 days ago. LVN E then put the insulin back. She checked and Resident #3 did not have any Novolog in the refrigerator in the medication room. She got the Refrigerated Emergency-Kit that was zip tied and had a list of medications on the front from the Emergency-kit box from the medication room for her hall. It had Novolog listed but it was not in the box. LVN E went to another hall to get Novolog from their refrigerated Emergency-Kit. At 7:51 a.m. Resident #3 was observed to get 23 units of Novolog via insulin pen. He said he did not like the pen, and he was almost finished eating. 2. Record review of Resident #4's face sheet dated 2/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of type 2 diabetes mellitus. Record review of Resident #4's physician order dated 6/24/24 indicated to give Humalog injection 100 unit /ml inject subcutaneously four times a day for diabetes mellitus. During an observation on 2/13/25 at 8:02 a.m. of the Medication cart for the 200 hall showed Resident #4's Humalog100 units was opened on 1/11/25(32 days prior.) Observation revealed the refrigerated Emergency-kit did have a pen for her Humalog. During an observation and interview on 2/13/15 at 8:07 a.m. Resident #4 said she was supposed to get her insulin before breakfast, and she had just finished eating. LVN E said Resident #4's blood sugar was 242. The nurse said she was to receive 4 units of Humalog at 8:10 a.m. Resident #4 received her Humalog injection in the right arm. 3.Record review of Resident #5's face sheet dated 2/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Diabetes mellitus due to underlying condition. Review of Resident #5's physician order dated 1/2/25 indicated to administer Novolog Solution 100 unit/ml (Insulin Aspart). Inject 5 unit subcutaneously with meals due to diabetes mellitus. Observation of the 200-hall medication cart on 2/13/25 at 8:12 a.m. revealed Resident #5's bottle of Insulin Aspart opened on 1/2/25 (41 days prior) box says expires 28 days after opened. Resident #5 opened Lantus dated 1/3/25 (40 days) box says expires 28 days after opened. 4. Record review of Resident #6's face sheet dated 2/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of diabetes mellitus. Record review of Resident #6's physician orders dated 6/7/24 indicated an order for insulin Glargine (Lantus) 10 units . During an observation on 2/13/25 at 8:12 a.m. Resident #6's opened multi-use vial of Lantus had no opened date but there was a place for the opened date to be written. 5. Record review of Resident #7's face sheet dated 2/13/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of diabetes Mellitus. Record review of Resident #7's physician order dated 8/5/24 indicated to administer Novolog per sliding scale for diabetes mellitus. During an observation and interview of the 200-hall medication cart on 2/13/25 at 8:14 a.m. revealed Resident#7's Novolog opened dated 1/11/25 (32 days prior.) The LVN said she worked PRN as was not responsible for the cart every day. She was not aware the medications were past the date of use. LVN E said she was aware the insulin was to be discarded after the recommend 28 days. Record review of instruction for use of Lantus (last revised June 2023) indicated Lants vials should be refrigerated but could be stored at room temperature for up to 28 days. The Lantus vial should be thrown away after 28 days or it the expiration date has passed even if it still had insulin left. Record review of the Food and Drug Administration indicated insulin storage and effectiveness dated 9/19/17. It is recommended insulin be stored in a refrigerator at approximately 35 to 46 degrees Fahrenheit. Insulin may be stored between 59- and 86-degrees Fahrenheit for up to 28 days and continue to work. However, insulin loses some effectiveness when exposed to higher temperatures or lower temperatures. Record review of the facility Medication Administration policy dated 10/1/19 indicated the policy was to administer medication via subcutaneous, intradermal, and intramuscular routes in a safe, accurate and effective manner. Prepare medications and check refrigerator temp, assure the label is attached, check expiration date. write the dated it was opened and expiration date on the container if new vile used. Refer to table of shortened expiration dates for expiration dates to use.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were sealed and dated. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness. Findings included: During an initial tour observation in the kitchen on [DATE] at 9:30 a.m. there were 2 undated containers of instant mashed potatoes in the dry storage, 1 unsealed box of biscuit in the freezer. During an observation in the kitchen on [DATE] at 9:40 a.m., [NAME] W was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] W's hair was visible outside of the hairnet in the back approximately four inches. During an observation in the kitchen on [DATE] at 11:15 a.m., [NAME] W was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] W's hair was visible outside of the hairnet in the back approximately four inches. During an interview on [DATE] at 10:15 a.m., the Dietician stated she expected food items to be labeled and dated when received. The Dietitian stated she expected food items to be sealed in the freezer. The Dietitian stated she expected hair nets to be worn properly while in the kitchen. The Dietitian stated if she noticed an issue in her sanitation audit, she had an in-serviced. The Dietitian stated there was a daily and weekly cleaning schedule that each staff member should have signed off prior to completing their shift. The Dietitian stated the Administrator was responsible for monitoring and overseeing in between. The Dietitian stated these failures mentioned above put residents at risk for food contamination. During an interview on [DATE] at 1:20 p.m., [NAME] W stated food in the dry storage, refrigerator and freezer should be labeled with the expiration date. [NAME] W stated all food items should have a received date and an open date. [NAME] W stated the person who put an item in the dry storage, refrigerator, or the freezer should make sure it was labeled correctly, and the person that opened an item was responsible for putting an open date on the food item. [NAME] W stated food in the freezer should be sealed. [NAME] W stated she did not know why food items in the dry storage and freezer were not dated and not sealed. [NAME] W stated it was important for food items to be labeled, and sealed, so the residents would not get sick because bacteria could grow on the food if it was expired. [NAME] W stated she did not realize her hair was not covered. [NAME] W stated it was important to keep the hair cover, so it does not fall in the food. [NAME] stated the harm to the resident was they could get sick from germs. During an interview on [DATE] at 1:51 PM, the Dietary Manager stated all food items should have a receive date, open date, and if a box was opened it needed to be sealed and dated. The Dietary Manager stated she was responsible for making sure everything was labeled and stored correctly. The Dietary Manager stated she went through the refrigerator and freezer and did a walkthrough weekly to make sure everything was labeled and stored correctly, and food items were discarded and to check for cleanliness. The Dietary Manager stated she did trainings weekly to educate staff on labeling food items. The Dietary Manager stated it was important to label and store food items correctly and for the kitchen to be clean so the residents would not get sick. The Dietary Manager stated the cook should have all of her hair covered. The Dietary Manager stated it was important for to keep hair from getting in the food. The Dietary Manager stated the residents may not want to eat if they find hair in the food and could lose weight. During an interview on [DATE] at 3:15 p.m., the Administrator stated she did random walkthroughs of the kitchen twice a week sometimes more depending on the week. The Administrator stated the Dietary Manager was responsible for ensuring hairnet were worn correctly, food items were labeled, dated, stored properly and for cleanliness of the kitchen. The Administrator stated it was important for hairnets to be worn correctly, the food items to be labeled, dated, stored properly and for the kitchen to be clean so the residents did not get sick, and it was required by the state of Texas. Record review of the facility's policy titled, Food Storage, dated [DATE] indicated, All containers must be labeled and dated Store frozen foods in moisture-proof wrap or containers that are labeled and dated Record review of the facility's policy titled, Employee Sanitation, dated [DATE] indicated, .Hairnets, headband, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces .

Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 4 of 34 residents (Resident #17, Resident #21, Resident #79, and Resident #110) reviewed for care plans. 1. The facility failed to care plan Resident #17's verbal and other behavioral symptoms, the diagnosis of COPD (is a chronic lung disease that makes it difficult to breathe) and use of an antiplatelet medication (work to make your platelets less sticky and thereby help prevent blood clots from forming in your arteries). 2. The facility failed to care plan Resident #110's use of an antiplatelet medication, risk for pressure ulcers (is a localized area of skin damage caused by prolonged pressure on the skin), and the diagnosis of dehydration (occurs when your body loses more water and fluids than it takes in). 3. The facility failed to ensure a care plan was developed and implemented for Resident #21's use of dentures. 4. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #79's high risk for falls evaluation. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #17's face sheet dated 1/13/25 indicated Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #17 had diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), chronic obstructive pulmonary disease (COPD), and generalized atherosclerosis (is a condition where plaque builds up in the walls of arteries). Record review of Resident #17's quarterly MDS assessment dated [DATE] indicated Resident #17 was understood and understood others. Resident #17 had a BIMS of 09 which indicated moderate cognitive impairment. Resident #17 experienced verbal behavioral symptoms directed toward others that occurred one to three days a week. Resident #17 experience other behavioral symptoms not directed toward others that occurred four to six days, but less than daily. Resident #17 had an active diagnosis of asthma, chronic obstructive pulmonary disease, or chronic lung disease. Record review of Resident #17's care plan revised 11/30/24 did not indicate verbal and other behavioral symptoms, the diagnosis of COPD and use of an antiplatelet medication. Record review of Resident #17's consolidated physician order active orders as of 1/13/25 indicated: *Aspirin (the antiplatelet agent aspirin is recommended in secondary prevention of atherothrombotic events in most patients with established atherosclerotic cardiovascular disease (ASCVD is a condition that occurs when plaque builds up in the arteries, reducing blood flow to the heart and other organs)) Oral Capsule 81mg, give 1 capsule by mouth one time a day for atherosclerosis. Start date 12/05/24. *Trelegy Ellipta (is a prescription inhaler that treats chronic obstructive pulmonary disease (COPD) and asthma in adults) Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT, 1 inhalation inhale orally one time a day for COPD. Start date 11/08/24. Record review of Resident #17's MAR dated 1/01/25-1/31/25 indicated: *Aspirin Oral Capsule 81mg, give 1 capsule by mouth one time a day for atherosclerosis. Start date 12/05/24. Received 15 of 15 doses. *Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT, 1 inhalation inhale orally one time a day for COPD. Start date 11/08/24. Received 15 of 15 doses. Record review of Resident #17's progress notes dated 10/01/24-01/14/25 indicated: *12/04/24 at 3:06 p.m. by Social Service indicated .social worker, nurse case manager [MDS Nurse A], AD present for care plan meeting .she has new aspirin medicine .referring to Cardiologist . *12/04/24 at 3:31 p.m. by LVN K indicated, .N.O. [new order] Aspirin 81mg QD and refer to vascular .R/T ECA stenosis 70% . *12/28/24 at 3:59 a.m. by LVN S indicated, .Resident #17 has remained awake for the entire night talking to .cleaning out drawers .continues to insist on leaving all lights on, tv on, awakens roommate .has continued to keep 3 residents awake . *1/01/25 at 12:36 a.m. by LVN S indicated, .refusing to quit visiting back and forth between her room .continue to wake up both roommates that were attempting to sleep . *1/03/25 at 9:20 p.m. by RN T indicated, .resident #17 observed bullying another resident who is wheelchair bound and unable to make needs known . *1/09/25 at 2:00 p.m. by Social Service indicated, .DON, LVN K, and Social Worker are present for care plan meeting .family member of Resident #17 was called to discuss Resident #17 taking other residents' property .will be referred to a local mental health provider to assist her with change in behaviors . *01/09/25 at 5:44 p.m. by LVN K indicated, .Resident #17 yelled across room twice to another residents 'I'll kick your butt!' .Redirected and explained that this behavior was not acceptable . 2. Record review of Resident #110's face sheet dated 1/13/25 indicated Resident #110 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #110 had diagnoses including cerebral infarction (is a type of stroke that occurs when brain tissue dies due to a lack of blood flow), dehydration, chronic kidney disease (is a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), dementia (a decline in mental abilities that affects a person's ability to perform everyday activities), muscle wasting and atrophy (shortening), and altered mental status (is a general term for a change in a person's level of consciousness, awareness, attention, or cognition). Record review of Resident #110's significant change in status MDS assessment dated [DATE] indicated Resident #110 was understood and understood others. Resident #110 had a BIMS of 04 which indicated severe cognitive impairment. Resident #110 had an additional active diagnosis of dehydration. Resident #110 was at risk for developing pressure ulcers/injuries. Resident #110 had received an antiplatelet medication during the last 7 days, since admission/entry, or reentry if less than 7 days. Record review of Resident #110's Care Area assessment dated [DATE] indicated care areas of cognitive loss/delirium, urinary incontinence, behavioral symptoms, falls, nutritional status, pressure ulcer (at risk for breakdown related to weight loss, reduced mobility), psychotropic drug use, and pain. Record review of Resident #110's care plan revised 12/27/24 did not indicate use of an antiplatelet medication, risk for pressure ulcers, and the diagnosis of dehydration. Record review of Resident #110's consolidated physician orders active orders as of 01/13/25 indicated: *Aspirin Low Dose Oral Tablet Delayed Release 81 MG, give 1 tablet by mouth one time a day for blood clot. Start date 12/09/24. *Clopidogrel Bisulfate Tablet 75 MG, give 1 tablet by mouth one time a day for blood clot prevention. Start date 12/09/24. Record review of Resident #110's MAR dated 01/01/25-01/31/25 indicated: *Aspirin Low Dose Oral Tablet Delayed Release 81 MG, give 1 tablet by mouth one time a day for blood clot. Start date 12/09/24. Received 15 of 15 doses. *Clopidogrel Bisulfate Tablet 75 MG, give 1 tablet by mouth one time a day for blood clot prevention. Start date 12/09/24. Received 15 of 15 doses. Record review of Resident #110's hospital paperwork dated 12/06/24 indicated, .labs are consistent with significant volume depletion and dehydration . During an interview on 1/15/25 at 11:19 a.m., MDS Nurse O, with MDS Nurse A present said the resident's care plan was the interdisciplinary team responsibility. MDS Nurse A said she was responsible for long term care residents. MDS Nurse A said she did the Medicaid, hospice, and private pay residents care plans. MDS Nurse O said she was responsible for skilled nursing, Medicare, and managed care residents. MDS A and MDS O said they had morning meetings with clinical staff and discussed things and the nurses on the floor would also give them clinical updates. MDS Nurse A said care plans were done on admission, quarterly, and with changes in condition. They both said Resident #17's verbal and other behavioral symptoms should have been on her care plan. They said diagnoses that were receiving treatment should be care planned. They said the diagnosis of COPD should be care planned on Resident #17's care plan especially since she received nebulizer medication for it. They said sometimes residents admitted with a diagnosis of COPD but did not take medication for it and may not be care planned. They said they were not aware Resident #17 had started a new medication to treat her COPD. They said if a resident was admitted on an antiplatelet then the MDS Nurses were responsible for care planning it. They said if the resident was recently started on the antiplatelet, then that would be considered an acute change. They said acute changes or new orders were normally care planned by the ADONs. MDS Nurse O said Resident #110 being at risk for pressure ulcers and her new diagnosis of dehydration should have been care planned. They said if Resident #110's dehydration diagnosis was on her hospital paperwork and coded on the MDS then it should be care planned. MDS Nurse O said the care plans addressed the resident's needs. During an interview on 1/15/25 at 1:58 p.m., LVN N said the ADONs, AD, and nursing management were responsible for care plans. She said Resident #17's behaviors, diagnoses, and medication use should be care planned. She said Resident #110's medication and diagnosis should also be care planned. She said she did not review the resident's care plan regularly but nursing management notified staff if there were changes or not to do old interventions. She said the care plans were used to know how to care for the residents. She said the care plans let staff know what appropriate interventions to use. She said care plans helped with prevention, knowing about changes, and family wishes. She said if care plans were not done, the residents may not get the individualized care they needed. During an interview on 1/15/25 at 3:33 p.m., ADON P said the MDS nurses and IDT were responsible for care plans. She said baseline care plans were done by the bedside nurse. She said acute changes were care planned by the IDT. She said comprehensive care plan were done with changes and quarterly. She said behaviors, psychotropic medications, diagnoses, fall and pressure ulcer risk, and dehydration should be care planned. She said the care plans were used to know how to care for the residents, getting to know the resident, and the resident's and family wishes. During an interview on 1/15/25 at 4:27 p.m., the DON said she would expect diagnoses that received treatments, medications, and at-risk problems to be care planned. She said the DON and MDS Coordinators were responsible for comprehensive care plans. She said the MDS Coordinator and IDT were responsible for acute care plans. She said the residents were discussed during wellness Wednesday with and IDT and NP. She said care plans were used as guidelines on how to meet the resident's needs with developed problems, goals, and interventions. During an interview on 1/15/25 at 6:00 p.m., the ADM said she would expect the resident's care plan to address diagnoses, medications, and at risk for pressure ulcers. She said nursing management was responsible for resident's acute and comprehensive care plans. 30527 3. Record review of the face sheet dated 1/15/2025 indicated, Resident #21 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (affects the blood vessels of the brain and circulation), hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), history of stroke, and dysphagia (difficulty swallowing). Record review of the quarterly MDS dated [DATE] indicated, Resident #21 was understood by others and understood others. The MDS indicated Resident #21 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #21 was dependent with toileting, dressing, and bathing and required supervision for eating. Section GG - Functional Abilities B. Oral Hygiene indicated Resident #21 required assistance with her dentures. Record review of the care plan dated 1/22/2024 and did not indicate Resident #21 wore dentures for eating. Record review of the order summary report dated 1/15/2025 indicated remove and wash Resident #21's teeth every day and every shift for clean dentures. During an observation on 1/13/2025 at 12:32 PM, Resident #21 was sitting in the dining hall eating her lunch without her dentures. Resident #21 was chewing slowly and stated she was eating ok today. During an observation and interview on 1/14/2025 at 08:30 AM, Resident #21 was in her room eating from her breakfast without dentures in her mouth. Resident #21's family member stated, She needs her dentures so she can chew her food without choking. She already has difficulty swallowing. The dentures have been in the bathroom soaking in the same brown dirty water for over a week. The family member stated she had requested the staff put in the dentures on several different occasions. During an observation on 1/14/2025 at 12:35 PM, Resident #21 was in the dining hall without her dentures in her mouth for the lunch meal. During an observation on 1/15/2025 at 08:45 AM, Resident #21 was in her room eating breakfast without dentures in her mouth. During an interview on 1/15/2025 at 09:10 AM, CNA U said Resident #21 should have her dentures in her mouth at mealtime. CNA U said after Resident #21 had her meal, her dentures should be removed, brushed, cleaned, and soaked in the water with the blue cleansing tablet. CNA U said Resident #21 did not have the dentures in at breakfast time. CNA U said she had not remembered to put in Resident #21's dentures. CNA U said it was important for the residents to have their dentures in when eating to prevent choking and swallowing issues. During an observation at 12:30 PM on 1/15/2025, Resident #21 was eating in the dining hall without dentures in her mouth. During an interview on 1/15/2025 at 02:00 PM, the ADON said clinical nursing and the MDS Coordinator were responsible for updating the care plans. The ADON said Resident #21's care plan should have reflected and included that she wore dentures for eating. The ADON said it was important for Resident #21's care plan to include that she wore dentures to make sure she was able to meet her nutritional needs and to prevent choking and swallowing difficulties. During an interview on 1/15/2025 at 02:15 PM, the DON said the clinical nursing staff were responsible for updating the care plans. The DON said Resident #21's care plan should have reflected and included that she required dentures. The DON said she did not know why it was not in her care plan. The DON said it was important to include in the care plan that Resident #21 required dentures, so staff knew how to assist and provide the care the residents needed. During an interview on 1/15/2025 at 5:45 PM, the Administrator said she expected the clinical nursing staff which included DON, ADON, and the MDS Coordinators to update and implement the residents' care plans quarterly and yearly. The Administrator said Resident #21's care plan should have included that she required dentures. The Administrator stated it was important for the care plans to be accurate to ensure all residents were provided with continuity of care. 46062 4. Record review of Resident #79's face sheet dated 1/14/25 revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #79 had diagnoses including multiple rib fractures (broken bones), repeated falls, lack of coordination, shortness of breath, heart failure, and high blood pressure. Record review of Resident #79's admission MDS assessment dated [DATE] indicated she had a BIMS of 13, which indicated she was cognitively intact. The MDS indicated Resident #79 required total to maximum assistance for most ADLs. The MDS indicated Resident #79 was always incontinent of bowel and bladder. The MDS indicated Resident #79 had fallen in the last month prior to admission and had a fall related fracture in the past six months. Record review of Resident #79's Care Plan with an admitted [DATE] revealed there was not a problem area or interventions related to high risk for falls. Record review of Resident #79's Fall Risk Evaluation dated 12/12/24 reflected she scored 13, which indicated she was at high risk for falls. Record review of Resident #79's Progress Notes dated 1/11/25 indicated she rolled out of bed while asleep and was found on the floor with a bruise on her forehead and a skin tear on her left elbow. Record review of Resident #79's Fall Risk Evaluation dated 1/11/25 reflected she scored 14, which indicated she was at high risk for falls. Record review of Resident #79's Progress Notes dated 1/13/25 indicated she was found on the floor and she informed staff she had rolled out of bed again. Record review of Resident #79's Fall Risk Evaluation dated 1/14/25 reflected she scored 10, which indicated she was at high risk for falls. During an observation and interview on 1/13/25 at 2:18 PM, Resident #79 was lying in bed and had wound closure strips to her left elbow and the wound dressing had slid down to her forearm. Resident #79 said she slid out of the bed the night before last (1/11/25) and tore her skin on her elbow. Resident #79 had a fall mat on the floor of Resident's left side of bed. Resident #79's right side of the bed was approximately two foot from the wall and there was no fall mat on the floor. During an observation and interview on 1/15/25 at 11:14 AM, Resident #79 was reclined in her recliner and said she did not know why she rolled out of the bed twice and wished everyone would quit asking her. During an interview on 1/15/25 beginning at 11:19 AM with MDS A and MDS O, they both said they had worked at the facility for thirteen years. MDS A and MDS O said the Comprehensive Care Plans were done upon admission, change of conditions, quarterly, and as needed. They said they both were responsible for doing the care plans. MDS O said they used things that triggered on the MDS assessment, ADLs, fall risks, medications, pressure ulcer risks, amount of assistance needed, and mainly the at risk things to develop the Comprehensive Care Plan. MDS A said everyone was a fall risk and she put fall risks on everyone's care plan. MDS O said the acute care plans were the nursing management's responsibility to update. MDS A and MDS O said they had morning meetings with clinical staff and discussed things and the nurses on the floor would also give them clinical updates. MDS O said Resident #79 should have had a high risk for falls care plan on her comprehensive care plan from admission. MDS O said she did not think, not having a high risk for falls care plan would affect the resident, because all the staff treated the residents as fall risks. MDS A said the CNAs all know to keep the call lights in reach and beds in low position. MDS O said the CNA's ADL care plan addressed all the transfer and care assistant needs. During an interview on 1/15/25 at 1:46 PM, LVN G said she had worked at the facility for about three years and normally worked the day shift. LVN G said she could initiate the care plan on admission, but the RN would be responsible for completing the comprehensive care plan because she was an LVN and could not sign off on it. LVN G said the MDS nurses and nurse management were responsible for the comprehensive care plan. LVN G said she would expect high fall risk would be included on the comprehensive care plan. LVN G said not having a care plan for high risk for falls, could cause the resident not to have the needed interventions in place to prevent falls and could negatively affect the resident. During an interview on 1/15/25 at 3:07 PM, ADON P said the Comprehensive Care Plans were done by the MDS Coordinators. ADON P said the floor nurses and nurse management were responsible for the Base Line Care Plan. ADON P said the high risk for falls should be included in the Comprehensive Care Plan. ADON P said the purpose of the Comprehensive Care Plan was to hold all the data of the resident and so the staff know how to meet the resident's needs. ADON P said if the high risk for falls was not included on the care plan, they were not identifying the risks of the resident and putting interventions in place to reduce the risk of falls. During an interview on 1/15/25 at 3:32 PM, the DON said the MDS coordinators were responsible for the Comprehensive Care Plans. The DON said the purpose of the care plan was to identify what the plan of care was for the resident, which included identifying safety needs, nutrition, and how they were going to take care of the resident. The DON said the care plan was used as a guideline to treat and to meet the resident's needs with problems, goals, and interventions to meet the needs of the resident. The DON said high risk for falls should be included in the Comprehensive Care Plans. The DON said if the resident was deemed as high risk for falls, and it was not in the care plan, it could prevent them from having things in place to prevent future falls. The DON said the care plan would alert them to be watchful to keep the resident safe. During an interview on 1/15/25 at 4:20 PM, the ADM said a resident at high risk for falls should have been care planned based off the fall assessment. The ADM said the purpose of the care plan was a tool to direct the resident's care. The ADM said the nursing department was responsible for ensuring the Comprehensive Care Plan was accurate. The ADM said by not having high risk for falls care planned, they could miss something and not meet the resident's needs. The ADM said she would expect the care plans to be accurate to the best of the staff's abilities. Record review of the facility's policy dated 10/24/22 and titled Comprehensive Care Plans, indicated . it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident . that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment . comprehensive care plan would describe, at a minimum, . the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . resident specific interventions that reflected the resident's needs and preferences .

Based on interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 3 of 6 residents reviewed for unnecessary medications. (Resident #66, Resident #71, and Resident #78) The facility failed to ensure Resident #66 did not receive an antibiotic, Cephalexin 250mg BID for an UTI, without appropriate lab work. The facility failed to ensure Resident #71's antibiotic, Macrobid 100mg BID, was discontinued after her urine culture (checks urine for germs (microorganisms) that cause infections) results showed no organism growth. The facility failed to ensure Resident #78 did not receive antibiotics, Rocephin (Ceftriaxone) 2gm IM 1 time dose and Levaquin (Levofloxacin) 750mg one time a day for 7 days without an appropriate indication of use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections (happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them). Findings included: 1. Record review of Resident #66's face sheet dated 01/15/25 indicated Resident #66 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #66 had diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), weakness and malaise (is a feeling of weakness, overall discomfort, illness, or simply not feeling well). Record review of Resident #66's significant change in status MDS assessment dated [DATE] indicated Resident #66 was sometimes understood and rarely/never understood others. Resident #66 was unable to complete a BIMS due to being rarely/never understood. Resident #66 had short- and long-term memory recall problems. Resident #66 was severely impaired of cognitive skills for daily decision making. Resident #66 had received an antibiotic during the last 7 days. Record review of Resident #66's care plan dated 03/31/22 indicated Resident #66 had recurrent UTIs. Intervention included follow facility policy for line listing, summarizing, and reporting infections. Record review of Resident #66's consolidated physician orders active as of 10/01/24 indicated Cephalexin Oral Tablet 250 mg, give 1 tablet by mouth two times a day for suspected UTI until 10/07/24. Start date 09/30/24. End date 10/07/24. Record review of Resident #66's MAR dated 10/01/24-10/31/24 indicated Cephalexin Oral Tablet 250 mg, give 1 tablet by mouth two times a day for suspected UTI until 10/07/24. Start date 09/30/24. Resident #66 received 14 of 14 doses. Record review of Resident #66's progress notes dated 10/01/24-01/15/25 indicated: *10/01/24 at 2:15 a.m. by LVN S indicated, .eating desserts and supplement .initiating Cephalexin 250mg bid for possible UTI . *10/04/24 at 1:13 p.m. by LVN K indicated, .appetite remains poor .Resident #66 appears to be in acute distress or discomfort .Continues Cephalexin 250mg r/t possible UTI per daughter . Record review of the facility's Infection Control Log dated September 2024 indicated Resident #66, onset date of 09/30/24, symptoms of UTI, no culture, Treatment of Cephalexin, date resolved 10/06. Record review of the facility's Consultant Pharmacist Report dated October 2024 indicated Resident #66, Cephalexin 250 mg BID for UTI, add culture and screen to chart when available. 2. Record review of Resident #71's face sheet dated 01/15/25 indicated Resident #71 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #71 had diagnoses including Alzheimer's (is a brain disorder that gradually destroys memory and thinking skills), cerebral infarction (stroke), and senile degeneration of brain (is a general term for a group of neurological disorders that cause a decline in cognitive function). Record review of Resident #71's admission MDS assessment dated [DATE] indicated Resident #71 was understood and usually understood others. Resident #71 had a BIMS of 00 which indicated severe cognitive impairment. Resident #71 was always continent of urine and bowel. Record review of Resident #71's care plan dated 11/08/24 did not indicate a care plan problem for infections. Record review of Resident #71's consolidated physician order active as on 10/01/24 indicated Macrobid Oral Capsule 100mg (Nitrofurantoin Monohyd Macro), give 1 capsule by mouth two times a day for suspected UTI until 10/12/24. Start date 10/02/24. Record review of Resident #71's MAR dated 10/01/24-10/31/24 indicated Macrobid Oral Capsule 100mg (Nitrofurantoin Monohyd Macro), give 1 capsule by mouth two times a day for suspected UTI until 10/12/24. Start date 10/02/24. Resident #71 received 21 out of 21 doses. Record review of Resident #71's UA received on 10/01/24 indicated no pathogens detected. Record review of Resident #71's progress notes dated 10/01/24-01/15/25 indicated: *10/01/24 at 1:54 a.m. by LVN S indicated, .u.a. negative . *10/02/24 at 11:42 a.m. by LVN N indicated, .Hospice Nurse visited with resident [Resident #71] .N.O. received for Macrobid 100 mg capsule 1 cap PO 4 times daily x 5 days for suspected UTI .Lorazepam 0.5 mg tablet PO 1 tab every 4 hours PRN for anxiety . * 10/09/24 at 1:14 p.m. by LVN K indicated, .Day 8/10 Macrobid 100 mg po BID x10 days related to suspected UTI .no s/s of UTI apparent . Record review of Resident #71's antibiotic clinical review 10/09/24 indicated Resident #71's symptoms were first noted on 10/06/24, daughter suspected that resident had UTI because of behaviors during outing with family, including polyuria, requested UA , unable to collect urine due to dementia, antibiotics ordered by hospice for suspected UTI, potential urinary infection, community acquired, no catheter, no fever, no leukocytosis or labs incomplete, acute onset, new or increased burning pain on urination, frequency or urgency, new or increased incontinence, Macrobid 100mg bid x 10 days ordered. 3. Record review of Resident #78's face sheet dated 01/15/25 indicated Resident #78 was a 64-years-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #78 had diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), neuromuscular dysfunction of bladder (is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), artificial openings of urinary tract (is the body's system for producing and removing urine) status, and pressure ulcer (is a localized area of skin damage caused by prolonged pressure on the skin) of sacral, right and left buttock. Record review of Resident #78's quarterly MDS assessment dated [DATE] indicated Resident #78 was understood and understood others. Resident #78 had a BIMS of 15 which indicate intact cognition. Resident #78 had an indwelling catheter (is a thin, flexible tube that is inserted into the bladder to drain urine) and ostomy (is a surgical procedure that creates an opening in the body to allow waste to exit). Resident #78 had three stage 4 pressure ulcers (full thickness tissue loss with exposed bone, tendon, or muscle). Resident #78 had received antibiotics during the last 7 days. Record review of Resident #78's care plan revised 12/03/24 indicated Resident #78 was on long term prophylactic antibiotics for recurrent UTIs. Intervention included follow facility policy for line listing, summarizing, and reporting infections. Record review of Resident #78's consolidated physician order active as of 01/01/25 indicated: *Levaquin Oral tablet 750 mg (Levofloxacin), give 1 tablet by mouth one time a day for ID now for 7 days. *Ceftriaxone Sodium Injection Solution Reconstituted 2 gm, inject 2 grams intramuscularly one time only for preventative/fever for 1 day. Start date 12/22/24. Record Review of Resident #78's MAR dated 12/01/24-12/31/24 indicated: *Levaquin Oral tablet 750 mg (Levofloxacin), give 1 tablet by mouth one time a day for ID now for 7 days. Start date 12/23/24. Received 6 out of 7 doses. *Ceftriaxone Sodium Injection Solution Reconstituted 2 gm, inject 2 grams intramuscularly one time only for preventative/fever for 1 day. Start date 12/22/24. Received 1 of 1 dose. Record review of Resident #78's progress notes dated 10/01/24-01/15/25 indicated: *12/22/24 at 4:01 a.m. by LVN AA indicated, .0200 resident [Resident #78] c/o being very cold, this CN [LVN AA] noted resident shaking profusely with numerous of blankets covering him .100.9 T .resident denies pain, discomfort or any other symptoms .prn Tylenol administered and effective with 98.0 temp noted at 0300 . NPBB notified .n.o. cbc (is a blood test that providers use to monitor or diagnose health conditions), cmp (is a blood test that measures the levels of various substances in your blood), and Rocephin 2gm IM x1 time only . *12/23/24 at 12:00 a.m. by author unknown indicated, .NP called on 12/22 with pt [Resident #78] having complaints of chills and fever .PT [Resident #78] was recently discharged from hospital with UTI admission however, he was treated for wound infection per hospital records .pt [Resident #78] urine in hospital was wnl with no concerns .told nurse this is most likely r/t his wound and nurse stated pt [Resident #78] wound did appear to have drainage .Pt [Resident #78] given IM Rocephin r/t fever/chills and Levaquin PO 750mg ordered for wound infection . *12/23/24 at 1:44 a.m. by LVN AA indicated, .d1 post Rocephin 2gm IM x1 time only r/t low grade fever chills .resident [Resident #78] afebrile with other vs wnl . *12/23/24 at 6:20 p.m. by LVN CC indicated, .new order noted to start Levaquin 750 mg 1 po qd x7 days for infection . *12/23/24 at 9:45 p.m. by LVN AA indicated, .d1 Levaquin 750mg po daily x 7days r/t preventative/post low grade fever . resident [Resident #78] afebrile with other vs wnl . *12/24/24 at 10:10 p.m. by LVN DD indicated, .resident [Resident #78] day 2 post cbc and cmp r/t low grade fever .Levaquin 750 for 7 days r/t preventative post low grade fever . *12/27/24 at 6:05 p.m. by LVN EE indicated, .Day 5/7 of Levaquin 750mg po qd x7 days for low grade fever/chills . Record review of Resident #78's lab results dated 12/23/24 indicated normal lab results related to percentage and amount of WBC (is a count of your total white blood cells (of all types).), Neutrophil (these are the first responders of white blood cells. They fight bacterial and fungal infections), Lymphocytes (are a type of white blood cell that fights viral infections and helps your immune system remember previous infections.), Eosinophils (white blood cells fight parasitic infections and cause allergic reactions), Basophils (are a type of white blood cell that releases histamine during allergic reactions and heparin, which prevents blood from clotting) and Monocytes (Monocytes are white blood cells that clean up cell debris during an infection) percentage slightly elevated (14.4% (4.0-12.0 reference range)) and Monocytes number slightly elevated (1.2 (0.1-1.1)). Record review of the facility's Infection Control Log Report dated December 2024 indicated Resident #78 had a UTI with a catheter, did not meet McGreers criteria (a set of guidelines for identifying infections in long-term care facilities), and Levaquin 750mg 1 po qd x 7 days. During an interview on 01/15/25 at 1:58 p.m., LVN N said the ADONs were responsible to ensure the residents only received antibiotic when needed. She said the resident's urinalysis with culture and sensitivity was important to know what to treat. She said if the resident had signs and symptoms of an UTI and refused a urinalysis, then antibiotics may have to be started. She said lab work was important because to treat the infection, you needed the right antibiotics to kill the bacteria and fix behaviors caused by the UTI. She said when the antibiotics were given without the known organism then the residents could develop MDROs. She said it could be considered an unnecessary medication. During an interview on 01/15/25 at 3:33 p.m., the ICP, ADON P, said she had been at the facility since 07/02/24. She said she was responsible for the antibiotic stewardship program. She said she was responsible for monitoring infections, ensuring the antibiotic stewardship program was followed, make sure the facility was clean, education on EBP and immunizations of staff and residents. She said the facility used the McGreers criteria to define and treat infections. She said the McGreers criteria for UTI treatment required certain symptoms, experiencing several of the symptoms, and positive cultures. She said the facility had a system that made a prepopulated form that indicated if McGreers criteria was met or not. She said the residents and the antibiotic orders were discussed during morning meeting with the IDT. She said some nursing management and NPs ordered lab work and antibiotics without an appropriate indication and unnecessarily. She said Resident #71's antibiotics should have stopped when the UA C/S result was negative. She said when families, like Resident #66's family member, requested antibiotics the facility staff and/or NP/MD should educate the family on antibiotic stewardship. She said Resident #78's infection was logged as an UTI not a wound infection on the December 2024 infection control log. She said Resident #78 received antibiotics without a culture and it did not meet McGreers criteria. She said all antibiotics ordered should have an indication for use. She said prescribing antibiotics without appropriate signs and symptoms and lab work placed the residents at risk for MDROs. During an interview on 01/15/25 at 4:27 p.m., the DON said the ICP was responsible for the antibiotic stewardship program. She said the ICP was responsible for ensuring antibiotics were appropriately prescribed and looked for lab work results. She said Resident #66 and Resident #71 prescribed antibiotics were unnecessary medications. She said if the McGreers criteria was not met then antibiotics treatment was appropriate. She said she spoke with NP BB about Resident #78's infection in December 2024. She said NP BB said she had not prescribed the antibiotic for an UTI but a possible wound infection. She said NP BB placed a note in Resident #78's chart today explaining what she was treating. She said Resident #78's antibiotic order should have been clear for what it was treating. She said the facility wanted to make sure the resident's treatment was for the right organism and received the benefits. During an interview on 01/15/25 at 6:00 p.m., the ADM said IDT and ICP were responsible in make sure the McGreer criteria was followed for ordering antibiotics. She said new antibiotics orders and the resident's chart were reviewed in the morning meeting. She said also during the morning meeting, staff were asked for things missing like labs. She said the antibiotic use was also discussed in QAPI. She said the resident could develop drug resistance organisms when antibiotics were prescribed without a good reason. During an interview on 01/16/25 at 2:13 p.m., NP BB said LVN AA called her about Resident #78 in December 2024. She said LVN AA reported Resident #78 had a fever and chills. She said Resident #78 thought it was an infection in his suprapubic catheter. She said she ordered Rocephin and Levaquin, CBC, and CMP. She said Resident #78 had recently returned from the hospital and they believed his suprapubic catheter was colonized. She said because the hospital felt his suprapubic catheter was colonized, she felt his pressure ulcers had a possible infection. She said when she told LVN AA it could be a wound infection, LVN AA said there was some drainage from his wounds. She said she ordered Levaquin because it was a broad-spectrum antibiotic. She said the broad-spectrum antibiotic could also treat an UTI, if Resident #78 indeed had one. She said she did not usually order wound culture for a possible infection. She said wound cultures were not picked up by the lab soon enough to prevent colonization. She said after 24 hours of the wound culture being drawn, it was colonized. She said she would only send a wound culture if an antibiotic was prescribed for a possible wound infection and it seemed like it was not working. She said Resident #78's CBC results looked okay. She said she did not know what diagnosis LVN AA put on the antibiotic orders. She said she thought LVN AA left the indication of use blank on the antibiotic order. She said she normally put her orders in herself except when she was on call. Record review of a facility's Infection Prevention and Control Program policy dated 05/13/23 indicated .Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. c. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program. d. The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program . Record review of a facility's Antibiotic Stewardship Program policy dated 10/24/22 indicated .It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: Laboratory testing shall be in accordance with current standards of practice. b. The facility uses the updated McGeer criteria to define infections. c. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. d. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. e. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized. f. Monitoring antibiotic use: g. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out) .

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The facility failed to ensure ADON D and LVN E performed a skin assessment on Resident #1, after her family member reported concerns regarding worsening of moisture associated skin damage (inflammation and erosion of the skin, results from prolonged exposure to different sources of moisture such as feces, urine, sweat and other bodily fluids) to her buttocks on 02/23/2024. 2. The facility failed to ensure LVN A applied Resident #1's nystatin (cream used to treat fungal infections), hydrocortisone (Medication applied to the skin used to treat skin conditions such as insect bites, poison oak/ivy, eczema, dermatitis, allergies, rash, itching of the outer female genitals, anal itching. This medication reduces the swelling, itching, and redness that can occur in these types of conditions), and zinc (ointment typically used to treat diaper rashes) to her buttocks on 02/24/2024. 3. The facility failed to ensure LVN A applied hydrocortisone cream to Resident #1's face and both arms on 02/24/2024. 4. The facility failed to ensure LVN B and LVN C documented accurate skin assessments for Resident #1. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Findings included: Record review of a face sheet dated 02/24/2024 indicated Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute pyelonephritis (sudden and severe infection of the kidney due to a bacterial infection), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and diabetes mellitus due to underlying condition without complications (condition results from insufficient production of insulin, causing high blood sugar due to other conditions). Record review of the Comprehensive MDS assessment dated [DATE], indicated Resident #1 was able to make herself understood and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 9, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #1 required supervision or clean-up assistance with eating, partial/moderate assistance with oral hygiene, upper body dressing, dependent for toileting hygiene, lower body dressing, and putting on/taking footwear off, substantial/maximal assistance with personal hygiene and shower/bathe self. The MDS assessment indicated Resident #1 was at risk for developing pressure ulcers/injuries. The MDS assessment indicated Resident #1 had a Stage 2 pressure ulcer (a shallow, open wound that has broken through both the top and bottom layers of the skin) that was present upon admission/entry or reentry to the facility. The MDS assessment indicated Resident #1 had moisture associated skin damage. Record review of Resident #1's care plan with date initiated 02/08/2024 indicated she had an impaired cognitive function or impaired thought processes related to short-term memory loss with interventions which included: administer medication as ordered monitor/document for side effects and effectiveness. Resident #1's care plan indicated she had diabetes mellitus to check all of her body for breaks in skin and treat promptly as ordered by the doctor. Resident #1 had a stage II pressure ulcer to buttocks related to immobility that she readmitted from the hospital with a goal of the resident will show signs of healing and remain free from infection by/through review date, and interventions included administer medications as ordered and monitor/document for side effects and effectiveness, administer treatments as ordered and monitor effectiveness. Resident #1 had an ADL self-care deficit related to impaired balance, limited mobility, and severe weakness with interventions that included avoid scrubbing and pat dry sensitive skin, the resident required extensive assistance with bathing, bed mobility, personal hygiene, toileting, and transfers. Record review of the Order Summary Report dated 02/24/2024 indicated Resident #1 had orders for hydrocortisone external cream 1% (Medication applied to the skin used to treat skin conditions such as insect bites, poison oak/ivy, eczema, dermatitis, allergies, rash, itching of the outer female genitals, anal itching. This medication reduces the swelling, itching, and redness that can occur in these types of conditions) apply to arms topically one time a day for allergic dermatitis (condition that causes swelling and irritation of the skin)/eczema (skin condition characterized by red itchy rashes) with a start date of 02/21/2024. Hydrocortisone external cream 1% apply to sacrum and buttocks topically (applied to the skin) as needed for moisture associated skin damage (inflammation and erosion of the skin, results from prolonged exposure to different sources of moisture such as feces, urine, sweat and other bodily fluids) mix with zinc (zinc ointment commonly used to treat diaper rashes) and nystatin (used to treat fungal infections) with a start date of 2/23/2024. Hydrocortisone External Cream 1 % (Hydrocortisone Topical) Apply to Sacrum and Buttocks topically every shift for MASD mix with Zinc and Nystatin with a start date of 02/23/2024. Hydroxyzine hydrochloride Oral Tablet 10 MG (medication used for itching and allergic reactions) Give 1 tablet by mouth every 6 hours as needed for itching with a start date of 01/10/2024. Hydroxyzine hydrochloride Oral Tablet 10 MG (medication used for itching and allergic reactions) Give 1 tablet by mouth every 6 hours as needed for itching with a start date of 01/10/2024. Lantiseptic Skin Protectant External Ointment 50 % (skin protectant ointment) Apply to bottom topically two times a day for preventative barrier with a start date of 01/11/2024. Nystatin External Cream 100000 UNIT/GM (Nystatin Topical) Apply to sacrum and buttocks topically as needed for moisture associated skin damage with a start date of 02/23/2024. Nystatin External Cream 100000 UNIT/GM (Nystatin Topical) Apply to sacrum and buttocks topically every shift for moisture associated skin damage mix with zinc and hydrocortisone with a start date of 02/23/2024. Zinc Oxide External Cream 10 % (Zinc Oxide Topical) Apply to sacrum and buttocks topically as needed for moisture associated skin damage mix with Nystatin & Hydrocortisone with a start date of 02/23/2024. Zinc Oxide External Cream 10 % (Zinc Oxide Topical) Apply to sacrum and buttocks topically every shift for moisture associated skin damage mix with Nystatin & Hydrocortisone with a start date of 02/23/2024. Record review of the February 2023 MAR indicated: Apply Zinc to Sacrum every day for moisture associated skin damage one time a day for Wound Management with a start date of 02/06/2024 at 8:00 AM with a discontinue date of 02/09/2024 with dates administered of 02/06/2024-02/08/2024. Apply Zinc to Sacrum every day for Stage 2 one time a day for Wound Management -Start Date 02/09/2024 discontinued Date 02/13/2024 indicated administered from 02/09/24-02/12/24. House Barrier cream to left buttocks ever day one time a day start date 02/21/24 and discontinue date 02/23/24 was applied on 2/21/24-02/23/24. Hydrocortisone External Cream 1 % (Hydrocortisone (Topical)) Apply to Arms topically one time a day for Allergic Dermatitis/Eczema Start Date 02/21/2024 indicated it was administered on 02/21/24-02/24/24. Apply Zinc to Sacrum every shift to prevent redness or skin breakdown every shift for Wound Treatment/Prevention Start Date 02/13/2024 discontinued on 02/23/2024 indicated it was administered on 02/13/24-02/23/24 on the day shift and night shift. Hydrocortisone External Cream 1 % (Hydrocortisone (Topical)) Apply to Sacrum & Buttocks topically every shift for moisture associated skin damage mix with Zinc & Nystatin Start Date 02/23/2024 indicated administered on 02/23/24 and 02/24/24. Zinc Oxide External Cream 10 % (Zinc Oxide (Topical)) Apply to Sacrum & Buttocks topically every shift for MASD mix with Nystatin & Hydrocortisone Start Date 02/23/2024 indicated it was administered on 02/24/24. Lantiseptic Skin Protectant External Ointment 50% (Skin Protectants) Apply to bottom topically two times a day for preventative barrier Start Date 01/11/2024 indicated it was administered from 02/01/24-02/24/24. Nystatin External Cream 100000 UNIT/GM (Nystatin (Topical)) Apply to Sacrum & Buttocks topically every shift for MASD mix with Zinc & Hydrocortisone Start Date 02/23/2024 indicated it was administered on 02/24/24. Venelex External Ointment ([NAME]-[NAME] Oil) Apply to bottom topically two times a day for treatment Start Date 02/01/2024 discontinued 02/13/2024 indicated administered 02/01/24-02/13/24. Record review of Resident #1's skilled nurse's note dated 2/19/24 signed by LVN C indicated Resident #1's skin was intact. Record review of Resident #1's unsigned skilled nurses note dated 02/20/24, did not indicate Resident #1 had any skin issues. Record review of Resident #1's wound evaluation conducted by the wound care physician dated 02/20/24, indicated Resident #1 had a non-pressure wound to the left buttock with partial thickness. The wound evaluation indicated the etiology of the wound was moisture associated skin damage with wound measurements of 0.4cm x 0.3 cm x 0.1 cm. The wound dressing treatment plan was to apply barrier cream once daily for 30 days. The wound evaluation also indicated Resident #1 had allergic dermatitis/eczema to bilateral arms and face with the treatment to apply hydrocortisone 1% twice daily to affected areas. Record review of Resident #1's skilled nurses note dated 02/22/24 and signed by LVN C indicated Resident #1's skin was not intact. The nurses note indicated Resident #1 continued with order for zinc to buttocks every shift. The nurse failed to acknowledge Resident #1's allergic dermatitis/eczema to bilateral arms and face. Record review of Resident's #1's weekly skin assessment completed by LVN B and dated 02/24/24, indicated Resident #1 had abnormal skin issues and pressure ulcer(s). The skin assessment indicated some of those wounds were new since last assessment. LVN B indicated Resident #1 had extreme excoriation to right and left buttock. LVN B failed to acknowledge Resident #1 had allergic dermatitis/eczema to her bilateral arms and face. During an interview on 02/24/2024 at 11:30 AM, Resident #1's family member said her immediate concern was Resident #1's backside (buttocks) because it had deteriorated quickly in one week Resident #1's family member said she had a rash or something on her skin that she had been concerned about and it kept getting dismissed by the nurses at the facility. Resident #1's family member said Resident #1's issues with her buttocks started after a hospitalization from which she returned on 02/01/24 to the facility. The Family Member said the facility was not applying anything to Resident #1's bottom. Family member said Resident #1's bottom was worsening for about a week on the interview on Saturday 02/24/24 and Tuesday (2/20/24) was when she noticed the rash to her body. She had been expressing her concerns about the creams to Resident #1's bottom since her return from the hospital, and on Tuesday added the concerns regarding the rash to her body. Resident #1's family member said she asked them about the cream and treatment every day. She said the nurses kept telling her they were waiting for the cream to come in. On Friday she noticed her buttocks had worsened from what she said was a pinpoint area on Tuesday to both of her buttocks on Friday (the Treatment Nurse in an interview confirmed that Resident #1 had a tiny area to one buttock on Tuesday and it had worsened). Resident #1's family member said yesterday (02/23/2024) she had requested to speak with the DON regarding Resident #1's buttocks, but ADON D had spoken with her. Resident #1's family member said she had shown pictures of Resident #1's buttocks to ADON D, but she refused to look at Resident #1's buttocks. Resident #1's family member said ADON D said she would notify the NP of Resident #1's buttocks to see if he would order something. Resident #1's family member said ADON D did not return to provide them any information regarding new orders. Resident #1's family member said they had gone to look for ADON D and were told by the charge nurse that ADON D had left for the day. Resident #1's family member said the nurses told her the cream for Resident #1's buttocks and rash had not been delivered. Resident #1's family member said the nurses were not applying any creams or ointments to Resident #1's buttocks, arms, or face, and her rash was spreading. During an observation and interview on 02/24/2024 at 1:55 PM, Resident #1's family member was at her bedside. Resident #1 had patchy red like areas that covered her arms, face, scalp, neck, chest area, bends of her arms and underarms. Resident #1 had deep red, irritated skin under both of her breasts and under her abdominal skin fold, the skin was observed to be peeling. Resident #1's vaginal area was red and irritated. Resident #1's buttocks, approximately 75% of the surface area, was deep red, irritated, and inflamed. No ointments or creams appeared to be on any of the areas noted above. Resident #1's family member said nobody had been into Resident #1's room to apply any ointments or creams. Resident #1 did not appear to be in pain at the time. Resident #1's family member said Resident #1 had expressed pain and discomfort related to her buttocks the previous days. Resident #1 had confusion. During an interview on 02/24/2024 at 4:31 PM, the Treatment Nurse said Resident #1 was seen by wound care for a stage 2 pressure ulcer that resolved on 02/13/24, but then the wound care doctor started seeing her again for moisture associated skin damage. The Treatment Nurse said the nurses should be applying a mix of nystatin, hydrocortisone, and zinc to Resident #1's buttocks. During an interview on 02/24/2024 at 6:36 PM, LVN A said Resident #1 had orders to apply Lantiseptic, nystatin and hydrocortisone to her buttocks and sacral area. LVN A said he had mixed the ointments and given it to the CNAs to apply to Resident #1's buttocks and sacral area. LVN A said he had not performed a skin assessment on Resident #1 because the weekly skin assessment was not due on his shift. During an observation and interview on 02/25/2024 at 9:08 AM, surveyor asked LVN A to allow observation of Resident #1's zinc, hydrocortisone, and nystatin ointments. LVN A said he could not find Resident #1's hydrocortisone on his medication cart. Resident #1's zinc and nystatin were on the medication cart. LVN A checked the medication storage room and said he could not find any hydrocortisone cream there either. During an observation and interview starting on 02/25/2024 at 9:25 AM, the Treatment Nurse performed a skin assessment on Resident #1 with the assistance of LVN A. The Treatment Nurse said she had last observed Resident #1's skin on Tuesday (02/20/2024) with the wound care doctor. The Treatment Nurse said the allergic dermatitis on the arms and face was present on Tuesday (02/20/2024), but the other areas were not. Resident #1 had redness and irritation to her vaginal area. The Treatment Nurse said the redness and irritation to Resident #1's vaginal area was not there on Tuesday (02/20/2024). The Treatment Nurse said the reddened, irritated areas under her breasts and abdominal fold appeared raw and like a yeast-like rash. The Treatment Nurse confirmed Resident #1's moisture associated skin damage to her buttocks had worsened from Tuesday (02/20/2024). The Treatment Nurse said on Tuesday (02/20/2024) Resident #1 only had a small area to the left buttock. The Treatment Nurse said she was not aware of the areas under Resident #1's breasts and abdominal fold. She said she was only aware of the areas to Resident #1's arms and face. The Treatment Nurse said the areas to Resident #1's arms and face appeared to have worsened. The Treatment Nurse said the charge nurses should have notified the NP that Resident #1's rash had worsened, and her moisture associated skin damage had worsened. The Treatment Nurse said the nurses should have been applying hydrocortisone cream to Resident #1's arms and face because the wound care doctor had given an order for it on Tuesday 02/20/2024. The Treatment Nurse said it appeared like the redness underneath Resident #1's breasts and abdominal fold had been there for a couple of days at least. During an interview on 02/25/2024 at 9:57 AM, for further clarification regarding Resident #1's ointments, LVN A admitted that he had not applied any ointments to Resident #1's buttocks or arms or face yesterday (02/24/2024). LVN A said he had documented on the MAR that he administered them, but he had not. LVN A said he was not aware Resident #1 was supposed to get hydrocortisone cream on her arms and face. LVN A said he had missed seeing it on the MAR. LVN A said it was important to apply ointments as ordered because skin conditions could worsen, and the residents could be itchier. During an interview on 02/25/2024 at 10:12 AM, ADON D said the DON had walked out (quit with no notice) on Friday (02/23/2024). ADON D said Resident #1's family member had reported to her on Friday (02/23/2024) that Resident #1's excoriation to her buttocks had worsened. ADON D said she had not performed a skin assessment or looked at Resident #1's buttocks because she had told LVN E to do the skin assessment and get an order from the NP. ADON D said if the nurses noted new skin concerns, they should notify the Treatment Nurse or DON , do a skin assessment, and notify the NP and the family. During an interview on 02/25/2024 at 10:24 AM, the NP said he was aware Resident #1 had a rash to her buttocks, face, and arms. The NP said he had ordered nystatin for her buttocks, and the staff was applying hydrocortisone to her face and arms. The NP said the nurses had told him on Thursday (02/22/2024) that Resident #1's rash had improved. The NP said he was not aware that Resident #1's skin condition had worsened. During an interview on 02/25/2024 at 12:28 PM, LVN B said when she arrived for her shift on Friday (02/23/24), Resident #1's buttocks were very excoriated, and she was all red and stuff on the side of her neck and she had 2 bumps on her face. LVN B said she had not notified the doctor or the NP because this was something that had been going on with Resident #1. LVN B said there was an order for Resident #1's buttocks it was a mixture of ointments, and she was waiting for it to arrive from the pharmacy, but it had not arrived at the facility yet. LVN B said she had not applied any ointments to Resident #1's buttocks because it had not arrived from the pharmacy. LVN B said she did not notice any other skin issues for Resident #1. LVN B said her left arm had some redness, but it was a redness like white people get. LVN B said she did not think it was a skin concern. During an interview on 02/25/2024 at 1:33 PM, LVN E said she had not performed a skin assessment on Resident #1. LVN E said Resident #1's family member had shown her pictures of Resident #1's buttocks, and then ADON D went into the room to handle the situation. LVN E said she assumed ADON D had done a skin assessment. LVN E said ADON D had ended up leaving and the family member came back to her, and she called the NP and received an order for nystatin, zinc, and hydrocortisone cream for Resident #1's sacrum and buttocks. LVN E said Resident #1 had a rash on her body on her neck, arms, and chest area, and she had applied hydrocortisone to Resident #1's arms. LVN E said it was important to apply the hydrocortisone, nystatin, zinc so the areas could heal. During an interview on 02/25/2024 at 2:19 PM, the Treatment Nurse said she had not notified the NP of Resident #1's worsened skin condition, and of the reddened, irritated, peeling areas under her breasts and abdominal skin folds. During an interview on 02/25/2024 at 3:16 PM, the Administrator said she expected for the nurses to report any new skin concerns to the physician and for them to document it at least in the progress notes. The Administrator said it was important for skin assessments to be completed accurately to prevent any worsening of skin conditions. The Administrator said she expected the nurses to follow the physician's orders. The Administrator said she expected Resident #1 to receive care according to her physician's orders. The Administrator said it was important for the nurses to follow the physician's orders to ensure the residents received the care they required. The Administrator said nurse management was responsible for ensuring the nurses followed the physician's orders. During an interview on 02/25/2024 at 3:35 PM, LVN C said she had made a mistake on Resident #1's skin assessments and skilled nurses notes. LVN C said she should have documented Resident #1's redness to her buttocks and the rash to her arms/face. LVN C said she was not aware Resident #1 had redness underneath her breasts and abdominal skin folds. LVN C said it was important for skin assessments to be done properly and documented because the residents' skin could breakdown very quickly and could lead to an infection and sepsis (an infection in the blood). Record review of the facility's policy titled, Skin Assessment, dated 12/07/2022, indicated, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury preventions and management. This policy includes the following procedural guidelines in performing the full body skin assessment. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, weekly for three weeks, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .

Based on interview and record review the facility failed based on the comprehensive assessment to ensure residents received the care and services in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility failed to assess the resident when she complained of pain or document where the pain was located. The facility failed to ensure the complete/accurate documentation of the resident's bowel elimination. Resident #1 was transferred to the hospital and diagnosed with fecal impaction. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/25/23 at 3:00 p.m. While the IJ was removed on 5/26/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving thorough assessments, fecal impactions, and decreased quality of care resulting in hospitalization or death. Findings included: Record review of Resident #2's face sheet with a print date of 4/20/23 indicated this 68 -year- old female was admitted to the facility on [DATE]. Some of her diagnoses were heart failure, schizoaffective disorder (combination of psychotic disorder with mood disorder), lack of coordination, and pacemaker. Record review of Resident #2's 5-day MDS indicated she had moderate cognitive impairment. The MDS indicated Resident #2 required limited assistance of one person for bed mobility, extensive assistance for transfers with one person. The resident required existence assistance of one person for toilet use Record review of Resident #2's care plan with an initiated date of 2/14/23 indicated Resident #2 had a problem with bowel and bladder incontinence related to impaired mobility. The interventions were, clean peri-area with each incontinence episode, ensure the resident had an unobstructed path to the bathroom. When incontinent, check every 2 hours and as need as required for incontinence. The resident had a problem of pain and history of gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and generalized pain and a frozen shoulder. Some of the interventions were administer pain relief cream, monitor, and document for probable causes of each pain episode, monitor, record, and report complaints of pain and or pain medication requests. Review of Resident #2's computerized physician orders indicated she had an order dated 2/9/23 for tramadol one table 50 mg by mouth as needed for pain two times a day. An order for Tylenol (Acetaminophen) (no dosage) give two tablets by mouth as need for mild pain and fever. A side effect of Tramadol is constipation. There were no orders for any stool softeners. An order dated 3/11/23 indicated to assess and document pain level for 0-10 every shift. Record review of Resident #2 bowl elimination record indicated: On 3/21/23 Morning no documentation- Evening -2 for no BM- Night- had X (no explanation for what X stood for) On 3/22/23 Morning no documentation - Evening -2 - no bowel movement- Night-2 no bowel movement On 3/23/23 Morning 1- incontinence, medium- formed BM - Evening no documentation -Night- X (no explanation for what X stood for) On 3/24/23 Morning 1 for incontinent, size small and formed BM- Evening 2 no BM -Night- X (no explanation for what X stood for) On 3/25/23 Morning 2 for no BM- Evening -no documentation -Night- had X (no explanation for what X stood for) On 3/26/23 Morning no documentation -Evening no documentation Night-X (no indication of what that means in the table of contents) On 3/27/23 Morning 1 for incontinent medium formed BM- initialed by CNA L- Evening incontinent large Putty (mushy) like- Initialed by CNA M- Night- incontinent large putty like- Initialed by CNA M On 3/28/23 Morning- incontinent medium formed/normal initialed by CNA J Record review of Resident #2's MAR indicated she received Tramadol HCL 50 mg tablet as needed for pain on 3/24/23 and 3/25/23. She received Tylenol (no mg listed) give two by mouth as need for mild pain or fever on 3/26/23 and 3/27/23 both time by LVN H. Record Review of Resident #2's MAR for assess and document pain level 0-10 every shift indicated on 3/24/23, 3/25/23, 3/26/23 was checked indicating the pain level was assessed. Record review of Resident #2's nursing notes dated 03/24/23 at 10:39 p.m. indicated Tramadol 50 mg was given. The nursing note did not address where Resident #2's pain was located or the indication of why Tramadol was given. The nursing note indicated the Tramadol 50 mg was effective. Record review of Resident #2's nursing notes dated 03/25/23 at at 6:43 p.m. indicated Tramadol 50 mg was given for arm and leg pain and it was effective. Record review of Resident #2's nursing note dated 3/26/23 at 10:33 p.m. indicated Resident #2 received Tylenol two tablets as need for mild pain or fever of 100.6 or greater. The nursing note did not indicate if Resident #2 had pain or fever. The nursing note indicated the Tylenol was effective. Record review of Resident #2's nursing note dated 3/27/23 at 9:09 p.m. indicated Resident #2 received Tylenol two tablets as need for mild pain or fever of 100.6 or greater. The nursing note did not indicate if Resident #2 had pain or fever. The nursing note indicated the Tylenol was effective. Written by LVN H. Record review of Resident #2's nursing note dated 3/28/23 at 8:34 a.m. the NP was notified this morning regarding large blood clots in Resident #2's brief during care. At 8:45 a.m. the NP ordered stat labs. At 10:38 a.m. the resident was seen by the wound care doctor for wound on the right buttock. At 1:03 p.m. Resident #2 complained of lower abdominal pain, distended abdomen noted. The NP was notified, and resident was sent to the hospital. Written by LVN I. Record Review of Resident #2's Change of Condition Communication Form dated 3/28/23 at 2:20 p.m. indicated the change in condition was lower abdominal discomfort that had worsened. The abdomen was distended, and decreased appetite. The dated of last BM was blank. Urine output indicated not applicable. Filled out by LVN I. Record review of Resident #2's hospital records dated 3/28/23 indicated she was admitted to the hospital due to stomach pain. The record indicated the Nursing Home said she had not had a Bowel Movement in 5 days. She had large clots of blood in her brief. Her diagnosis at the hospital was Fecal Impaction (hard stool stuck in the rectum). There was a manual dis-impaction preformed and aggressive bowel regimen with stool softeners. She had Stercorol Colitis (occurs when the patient had chronic constipation leading to a stagnation of fecal matter and a diagnosis of Adynamic ileus (pathological obstruction of the bowel due to failure of smooth muscle to contract.) The resident also had a diagnosis of Acute Kidney Failure. The hospital records indicated constipation caused the bladder outlet syndrome of urinary retention. A Foley Catheter was inserted with initial output of 1 liter of urine with 900 ml more slowly. During a telephone interview on 4/26/23 at 9:33 a.m. LVN H said she did not remember Resident #2. Her nursing note indicated she had given the Resident #2 pain medication on at least two occasions prior to her going to the hospital. She said if she gave pain medication she did not know why or what Resident #2's pain complaint was. LVN H said she had not worked at the facility in a while and could not remember anything about Resident #2. During an interview on 4/26/23 at 9:44 a.m. LVN I said she had been off for 3 days and did not know how the resident had done while she was off. She said she was the nurse that sent Resident #2 to the hospital on 3/28/23. She said CNA J called her to the room. She said when she arrived Resident #2 had abnormal bleeding that had saturated her brief pad, and she notified NP- N. He wanted to complete stat labs. She said the resident was complaining of pain and not having a bowel movement. The LVN said she heard Resident #2 tell the paramedics she had not had a BM in days. LVN I said she did not tell the paramedics it had been days, the resident did. LVN I said Resident #2 was incontinent and required assistance with going to the bathroom. LVN I said she looked at the ADL sheets on 3/28/23 to determine if the resident was having BMs. She said she could not tell for sure if the resident was having bowel movements or not. She said she could tell nothing by the ADL sheets. She was also afraid the staff especially agency did not always document correctly. The LVN said by the amount of blood in her brief the recommendations for labs did not sit right. LVN I said she called the NP back and told him Resident #2 was still bleeding, complaining of pain, and she wanted to go to the hospital. The resident was sent out. During an interview and record review on 4/26/23 at 10:30 a.m. CNA K/ staffing coordinator said they work 12-hour shifts. She reviewed Resident #2's ADL sheet for bowel and bladder elimination the last few days prior to the resident's hospitalization . She said that the two aides, CNA L and CNA M, were agency staff that had signed those sheets. During a telephone interview on 4/26/23 at 10:24 a.m. CNA L said she did not know Resident #2, she did not remember her at all. If there was something going on with her, she said she did not remember. CNA L said she cannot recall what she wrote on ADL sheets. She said she worked for agency and had been to multiple other facilities since 3/28/23. During a telephone interview on 4/26/23 at 10:51 a.m. CNA M said she did not remember Resident #2 and did not recall any care she may have provided for her. CNA M said she was in and out of lot of facility, some residents were memorable, and some were not. During a telephone interview on 4/26/23 at 11:15 a.m. CNA J said she had been off for 3 days and did not know how Resident #2 had done during that time. CNA J said on the morning of 3/28/23 Resident #2 was noted with big clumps of blood clots, coming out with BM. The BM was not a lot, but it just kept coming out. CNA J said the BM was soft and still running when wiped. She said she continued to wipe, and it continued to run. CNA J said she had never saw anything like that and had sent for LVN I. CNA J. She said she did not recall what she documented on the ADL sheet. She said Resident #2 did have a BM, but it was not like anything she had ever seen, it was bad. During an interview on 4/26/23 at 11:22 a.m. RN/ADON F said a fecal impaction can cause nausea vomiting, loss of appetite, loose watery stool, or soft stool. During an interview on 4/26/23 at 11:29 a.m. the NP-N said he was informed on yesterday by the facility that Resident #2 had a fecal impaction. He said as far as he knew her symptoms started on the morning of 3/28/23. He said the nurse called him and told him the resident had some blood and abdominal pain. He remembered he had ordered some labs. He did not remember if anyone else had called him about the resident prior to 3/28/23. He said a stool softener could have helped to prevent the fecal impaction. However, as far as he knew no one had told him she had any issues. He said she did not have a history of constipation. During an interview on 4/26/23 at 12:20 p.m. LVN I said she did not know if she wrote a note about the change in condition; she said Resident #2 complained of pain in her stomach and her stomach was distended. She said she checked for bowel sounds and they were present. LVN J said she did not know if she had written that in a note either. LVN I said the CNA J had called her to the room on 3/28/23. She said the resident did have BM or something mixed with the blood, but it was not really a BM. LVN I said it was not formed (ADL sheet documented formed/normal and medium) She said it was just runny slimy stuff. During an interview and record review on 4/26/23 at 12:30 p.m. the DON reviewed Resident #4's Bowel and bladder sheets. She said on 3/25/23 and 3/26/23 Resident #2 did not have any documentation. She said on 3/27/23 the charting indicated she had a medium BM that was Formed and during the night shift a large Putty BM. She said perhaps their documentation needed work, but it indicated on the 3/27/23 she had a BM. During an interview on 4/26/23 at 1:03 p.m. the Interim Administrator said the staff did what they were supposed to do. He said the nurse saw the signs and symptoms of distress on the morning, of 3/28/23 with Resident #2, the physician was notified, and the resident was sent to the hospital. During an interview on 4/26/23 at 1:10 p.m. the DON said they saw a change in Resident #2's condition, notified the physician and sent her to the hospital which is what they were supposed to do. The DON said they did not have a policy on fecal impaction. During an interview on 5/9/23 at 3:18 p.m. the Medical Director said he had reviewed Resident #2's hospital records and they indicated they got their information from the paramedics and had not consulted the resident about her bowel movements. The Medical Director said Resident # 2 was fully capable to telling them when the last time she had a BM. He said the resident had contributing factors that led to her fecal impaction such and bed bound, and diabetes. He said there were also other factors that could have led to the urinary retention other than a fecal impaction. He said she had several chronic issues. He said he could not say how long it took the resident to have a fecal impaction. It depended on her hydration. Some people it could take from 1 day to 5. He said some people have BMs with fecal impactions. Some of the major indicators of fecal impaction were distended abdomen, pain, nausea, and vomiting. Record review of the facility policy on Pain Management implemented 8/15/22 indicated the facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring pain. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status to assist staff in consistent assessment of resident pain. Identifying key characteristics of pain: duration, frequency, location, timing, pattern, and radiation of pain. Facility staff will reassess residents pain management for effectiveness and or adverse consequences (such as constipation, sedation, anorexia, change in mental status, delirium, respiratory depression, nausea, or vomiting. The facility was notified of the Immediate Jeopardy (IJ) on 5/25/23 at 3:00 p.m. and the Administrator was provided the Immediate Jeopoardy template. The facility was asked to provie a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal (POR) was accepted on 5/26/23 at 4:15pm and indicated the following: Plan of Removal - F684 Quality of Care On May 25, 2023, the facility learned that an IJ was being called due to F684 Quality of Care. The Facility failed to: Provide effective treatment and care for Resident #2 to prevent the development of a fecal impaction. Monitor Resident #2 for constipation/fecal impaction. (Resident #2 was prescribed Tramadol for pain as needed, which has the side effect of constipation). Accurately document and monitor Resident #2's BM, hydration, and meal intake to prevent a fecal impaction. Assess and document pain when giving PRN pain medication. Properly document Resident #2's BMs from 3/21/2023 through 3/28/2023. Have a policy and procedure in place for assessing residents and monitoring BMs to prevent a fecal impaction when residents are at risk for constipation. The facility needs to take immediate action to correct this noncompliance to ensure residents receive the care and services needed to prevent the development of a fecal impaction which could lead to serious harm or death. Director of nursing and ADON performed 100% rounds for building census of 109 residents that are at risks for fecal impaction on May 25, 2023, to ensure we are providing effective treatment and prevention the development of a fecal impaction. No immediate intervention was needed after sweep. All proper orders were in place regarding prevention of fecal impaction. On May 25, 2023, the Director of Nurses reeducated Licensed Nurses, CNAs, and CMAs to observe sign and symptoms of fecal impaction and prevention of fecal impaction. Additionally, reeducated nursing staff on documenting all bowel movements, meal intakes and snacks in the medical record. Charge nurses will ensure all documentation from their shift is entered in the electronic point of care and EMAR before shift ends. The Director of nursing / designee will monitor the proper documentation of bowel movements, meal intakes, and snacks in the medical record three times per week for one month. Nursing staff includes agency that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on-one setting on paper. On May 25, 2023, The CNAs were reeducated by the Director of Nursing on reporting any changes in bowel elimination to the Charge Nurses. The Charge Nurses were reeducated by the Director of Nursing on May 25, 2023, that they must then look at alerts in the medical record reported and document the results of the examination in the medical record. The Charge Nurse will contact the attending physician to notify of a change in condition in bowel movements and to obtain stool softeners, interventions, or orders as indicated. The Charge Nurse will notify the DON and/or ADON of changes of bowel elimination when identified. The Director of Nursing / designee will monitor compliance three times per week by audit of clinical charts for one month. Nursing staff including agency staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on-one setting on paper. Director of nursing and ADON performed 100% rounds for all residents on pain medication on May 25, 2023, to ensure pain medication that is schedule and as needed is documented properly to include effectiveness, source, and location of pain. No immediate intervention was needed after sweep. On May 25, 2023, the Director of Nursing reeducated Licensed Nurses on proper documentation of pain medication that includes assessment for pain including effectiveness of pain medication, source of pain, and location of pain. Additionally, Licensed Nurses were reeducated on the pain medication side effects that includes but not limited to a fecal impaction. The Director of Nursing / designee will monitor compliance three times per week by audit of clinical charts three times a week for one month. Nursing staff including agency staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on- one setting on paper. On May 25, 2023, the Director of Nurses reeducated Licensed Nurses, CNAs, and CMAs, including the Director of Nursing on revised policy on Activities of Daily Living that will include documentation of ADLs in the electronic record. The Administrator / designee will monitor compliance three times per week for one month. Nursing staff including agency staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on-one setting on paper. The Director of Nursing / designee will educate the newly hired nursing staff upon hire, prior to working including agency staff which includes and nurses and CNAs, on-going. 90% of all staff have been reeducated in a one-on-one setting on paper. Director of Nursing will monitor daily during morning clinical meeting to ensure proper documentation on pain medication, bowel movements, meal intake, and prevention of fecal impaction are report and follow up on any order related to change. The results will be discussed in the monthly QAPI meeting for three months and continued as needed. An AdHoc QAPI was conducted on May 25, 2023 at 1630, by the Administrator, with the Medical Director, Nurse Practitioner, Social Worker, Director of Nursing, Medical Records, Treatment Nurse, MDS' nurses, Maintenance Director, Dietary Manager, Activities Director, ADONs, Regional [NAME] President, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning quality of care related to proper documentation on pain medication, bowel movements, meal intake, and prevention of fecal impaction are reported and to develop the above-mentioned plan of care. On 05/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: All residents on pain medication were assessed and charts was audited to ensure pain medication that is schedule and as needed is documented properly to include effectiveness, source, and location of pain by Director of nursing and ADON. This was verified by interview with DON and record review of audit sheets listing resident name and room number, pain: yes or no, pain location, pain medication, pain med effective, notification, and intervention. All residents' charts were reviewed that are at risk for fecal impaction to ensure they were provided effective treatment and preventing the development of a fecal impaction, completed by Director of nursing and ADON. This was verified by interview with DON and record review of audit sheets listing resident name and room number, last BM, GI system, GI Pain, Notification and Intervention. Chart audit was done on all residents to ensure bowel elimination was being documented completed by Regional Clinical Specialist (RCS). This was verified by interview with RCS and record review of 29-page B&B- Bowel Elimination audit date range 5/22/23 to 5/26/23 on all the residents. In-Services addressed bowel movements, meal intakes, documentation, reporting and observing. Staff was in-serviced to assess for sign and symptoms of fecal impaction and prevention of fecal impaction. Additionally, reeducated nursing staff on documenting all bowel movements, meal intakes and snacks in the medical record. Charge nurses will ensure all documentation from their shift is entered in the electronic point of care and EMAR before shift ends. CNAs will be asked if they don't have a log in and will document before leaving their shift and to report any changes in bowel elimination to the Charge Nurses. The Charge Nurses must then look and report alerts in the medical record and document the results of the examination in the medical record. Also, nurses will contact the attending physician to notify of a change in condition in bowel movements and to obtain stool softeners, interventions, or orders as indicated. Licensed Nurse will properly document the pain medication that includes assessment for pain including effectiveness of pain medication, source of pain, and location of pain. Additionally, Licensed Nurses were reeducated on the pain medication side effects that includes but not limited to fecal impaction. The training was completed on 05/25/23 and is ongoing. This was verified by record review of staff in-services signature sheets and staff interviews. Interviews and record reviews were conducted on 05/26/23 from 1:00 p.m. through 4:15 p.m. and included 4 LVNs, 7 CNAs, DON, and Regional Clinical Specialist. Staff were able to explain how to assess for sign and symptoms of fecal impaction and prevention of fecal impaction. Staff had knowledge on documenting all bowel movements, meal intakes, pain medications that includes assessment for pain including effectiveness of pain mediation, source of pain, and location of pain and snacks in the medical records. Revised policy on Activities of Daily Living included documentation of ADLs in the electronic record. This was verified by interviews with staff and record review of revised policy titled Activities of Daily Living dated 5/26/23. The Director of Nursing / designee will educate the newly hired nursing staff upon hire, prior to working including agency staff which includes and nurses and CNAs, on-going. 90% of all staff have been reeducated in a one-on-one setting on paper. This was verified by interview with DON that it will occur and record review of staff signature sign-in sheets. Interview with Regional Clinical Specialist verified an AdHoc QAPI was conducted to discuss the immediate jeopardy concerning quality of care related to proper documentation on pain medication, bowel movements, meal intake, and prevention of fecal impaction are reported and to develop the above-mentioned plan of care. On 05/26/23 at 4:15 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for 1 of 2 residents reviewed for pressure ulcers (Resident #1), in that: 1. The facility failed to turn and reposition Resident #1 for about 5 hours; 2. Resident #1 was left in her feces and urine for about 5 hours; 3. Resident #1 did not have the physician ordered bandage covering her wound on the right buttock which had prolonged exposure to urine and feces; 4. Resident #1's wound increased in size in 7 days, on 4/18/23 the wound measured 2.5 x 1x 0.3 and on 4/25/23 it measured 9 x8 x0.3 cm; 5. Resident #1's wound was noted to be infected on 5/1/23. An Immediate Jeopardy (IJ) situation was identified on 05/08/23 at 5:14 p.m. While the IJ was removed on 05/9/23 at 4:51 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems These failures could cause resident skin breakdown and the development/worsening of pressure sores and infection. Findings included: Record review of a face sheet with a print date of 4/20/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, contracture to the right hand, paralysis of one side of the body and hemoptysis following traumatic stroke, muscle weakness, cognitive deficit, muscle wasting, pressure ulcer to the right buttock stage 3 (a wound that was full thickness tissue loss, subcutaneous fat may be visible). unspecified protein calorie malnutrition and diabetes. Record review of a brief interview for mental status dated 2/15/23 indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's MDS dated [DATE] indicted she required extensive assist with all ADLs. The MDS indicated Resident #1 had one pressure ulcer that was a stage 3. Review of Resident #1's Care Plan with initiated date of 11/20/18 indicated Resident #1 had a problem of ADL self-care performances deficit due to Paralysis and right-hand contracture. Interventions were the resident is a two person transfer with lift and extensive assist from one to two people for grooming, bathing, toileting, and bed mobility. The resident is totally dependent on one staff for repositioning and turning in bed frequently and as necessary. The resident is bedfast most of the time, the resident is totally dependent on one staff for addressing, the resident is not toileted. A problem dated 11/20/18 indicated Resident # 1 had a problem with bladder and bowel incontinence related to mobility. The interventions were clean peri area with each incontinent episode. Resident #1 had a care plan problem with an initiate date of 1/16/23 of a Stage 3 pressure ulcer of the right buttock. The interventions were to administer treatments as ordered and monitor for effectiveness. Follow facility policies and protocols to prevent skin breakdown. The resident is seen weekly by wound physician. Record review of Resident #1's computerized physician orders dated 11/21/22 indicted multivitamin tablet, and liquid protein. Record review of Resident #1's [NAME] Scale (measured the risk of getting a pressure sore) dated 4/15/23 indicated her physical condition was fair, her mental status was fair, and she was bedfast. Her mobility was slightly limited and she could make frequent though slight changes in body or extremities to position independently. Resident #1 was double incontinent and no control of bowel or bladder indicated frequent fecal soiling. Her score was 11 High Risk (14-10 High Risk.) Record review of Resident #1's Wound evaluation and Management Summary dated 4/18/23 indicated Resident #1 had a stage 3 pressure wound that measured 2.5 x 1 x 0.3. The wound had serous drainage (thin watery fluid that is produced in response to local inflammation), with slough (yellow material covering the wound bed) covering 10 percent of the wound and 90 percent with granulation tissue (healthy tissue). The surface of the area was 2.5 cm. The wound had improved. Resident #1's dressing treatment was alginate calcium, apply once daily for 30- days, and collagen powder applied once daily for 30 days. The secondary dressing was Gauze Island (a sterile dressing indicated for surgical as well and nonsurgical wounds). The Dakin's was to be discontinued. The Recommendations were to limit sitting to 60 minutes, repositioned per facility protocol, off load wound, and turn side to side, and front to back in bed every 1 to 2 hours. Surgical debridement (surgical removal of dead tissue to promote wound healing) procedure the wound surgically remove tissue including slough with removal at a depth of 0.3 centimeters and healthy bleeding tissue was observed because of this procedure. The non-visible tissue in the wound decrease from 10% to 0% no bleeding was achieved, and a clean dressing applied. Record review of Resident #1's computerized physician orders indicated an order dated 4/5/23 to cleanse the right buttocks with normal saline and apply Dakins (a topical antibiotic) soaked gauze and dry dressing. Record review of Resident #1's TAR indicated a treatment to cleanse the right buttock with normal saline, apply Dakin's soaked gauze and a dry dressing, daily. The order started 4/6/23. The record indicated that treatment was not provided on Saturday and Sunday 4/8/23 and 4/9/23. Treatments appeared to have been applied daily after that. The record indicated that the treatment was provided on 4/18/23 and 4/19/23 after there were recommendations to change the treatment from the wound care doctor on 4/18/23. During an interviews and observation on 4/20/23 between 9:25 a.m. to 9:53 a.m. Resident #1 was observed in bed and had a feeding tube infusing. LVN A was asked to check Resident #1 to see if she was wet. She said Resident #1 required two people to turn and left the room. Resident#1 did not speak when spoken to. LVN A went to get help and was gone for quite a few minutes. LVN A said the aides were busy, so she got LVN B to assist. LVN B went to the far side of the bed. Once the investigator got closer to the bed the smell of urine was strong. When asked if Resident #1 was wet LVN A pulled her wet gown down around Resident#1's legs and said yes. LVN B pulled back the covers on her side and said, there is bigger problem here. Observation of Resident #1 showed she had on a brief and her legs were opened. In between her legs was a pile of BM that was a shade of green and the outer edges were a darker color. The pile was about 3 inches around with a height of about 3 to 4 inches. A larger ring in between the resident's legs showed some darker colored liquid BM that was about 4 to 5 inches in a [NAME] circle, and the edges of that BM were also darker. There was a brown ring of urine from one side of the bed to the other around the resident's legs. Resident#1 was positioned with pillows. The pillows on both sides of the resident had pillow covers that were wet with brown rings. Her hospital gown was wet from the waist down. LVN A said she was really saturated. LVN A said she needed an aide to help turn Resident #1. She could not turn Resident #1 by herself. CNA C and CNA D entered the room and said this was their first time in the room this morning to provide care to Resident #1. CNA D said she had assisted the roommate with eating breakfast. She had asked Resident #1 if she wanted anything for breakfast (she had feeding tube but ate sometimes) and she said the resident said no. CNA D said she had not gone to that side of the room. CNA C said they had just finished with breakfast. CNA C said she had started on her rounds but had not gotten into this room today. CNA C and CNA D cleaned Resident #1, Resident #1 asked for them to put cream between her legs when they finished. Resident #1 said this was the first time someone had cleaned her since last night. LVN A said Resident #1 had a pressure sore on her bottom, and when they rolled her over, CNA C and LVN A said there was no bandage on the wound. CNA D said the whole bed was wet. LVN B said the whole bed was wet and the smell of urine was strong. During an observation and interview on 4/20/23 at 9:42 a.m. RN/ ADON F came into the room, and she looked at the wound on Resident #1's bottom. The aides were still cleaning Resident #1. The RN/ADON F said the wound should have had a bandage on it. She said Resident #1had a stage 3, an open wound with no eschar. During an observation and interview on 4/20/23 at 9:52 a.m. LVN G/ treatment nurse said 4/18/23 was the last time Resident#1 was seen by the wound care doctor, and her wound was 2.5 x 1x 0.3 and was staged at a stage 3. The RN/ADON and LVN G/ wound care nurse measured her wound at that time and it was 3 by 1.2 depth 0.7. The aides were still cleaning Resident #1. During an interview on 4/20/23 at 9:57 a.m. CNA C and CNA D said they have not provided care to Resident #1 today. They had not been in to conduct two-hour rounds and had not checked her when they arrived at work. They said the night shift must have left her dirty due to the poor condition Resident #1 was in. They said the BM had not dried but it was obvious she had more BMs than one. They said the BM was up the front of her brief to almost her waist. CNA C and CNA D said with the brown rings on the sheets, and the condition of Resident #1, it had been more than a few hours since she was changed. During an interview on 4/20/23 at 10:05 a.m. LVN E/Treatment nurse said Resident # 1's treatment orders changed on 4/18/23. He said he had not changed the order in the chart as of today 4/20/23. He said he is the nurse that completed her treatments and knew what they were. He said he was not always at the facility and admitted other nurses might not be aware of the change in treatment. During an interview on 4/20/23 at 11:00 a.m. the former Administrator said the roommate, Resident #3's family had a camera in the room. The Family member said two aides had come in around 4:30 a.m. and had gone to Resident #1's side of the room. The family member said she thought they changed Resident #1 at that time. The family member said the nurse (LVN A) came in and checked on Resident #1 about 7 a.m. The family member said they came in and brought Resident #3 a tray and asked Resident #1 if she wanted anything to eat about 8:00 a.m. and she said no. The Former Administrator said she wrote up CNA C, CNA D, CNA AA, and LVN A. The former Administrator said LVN A could have checked on Resident #1 and she could have provided her care. The former Administrator said she was terminating the aide that said Resident #1 was not her resident and refused to help. She said she was probably going to terminate the nurse because by all the accounts she had gotten. The nurse had been in the room at 7:00 a.m. and the smell of urine was strong enough for her to smell. The former Administrator said LVN A likely knew the resident was dirty and did not try to clean her, or get the aides to do so at that time. During an interview on 4/20/23 at 11:20 a.m. Resident #1 said she stayed in bed all the time and they did not put her to bed last night. She said they only changed her one time during the night. She said she was very uncomfortable, and it was burning between her legs and she wanted some cream on her legs and bottom to stop the burning. During an interview on 4/20/23 at 11:45 a.m. LVN B said when she walked on the side of Resident #1's bed she smelled a strong urine odor. She said the resident should have been changed. LVN B said even if Resident #1 was a heavy wetter, she should not have been found in that condition. During an interview on 4/20/23 at 12: 06 p.m. CNA C said LVN A stopped her and CNA AA earlier in the hallway and told them to provide care to a resident right away, but she did not hear who it was. She said CNA AA heard her because she said that resident was not her resident. CNA C said it took a long time to clean Resident #1 because she was so soiled. She said the night shift must have left her that way. She had not done rounds this morning when she arrived late to work. During an interview on 4/20/23 at 12:26 P.M. CNA D said she had gone in the room earlier that morning to feed Resident # 3 around 8:00 a.m. and the curtain between the beds was pulled. She said she asked Resident #1 if she wanted breakfast, and she said no. CNA D said she did not smell anything at that time. She said when she was summoned to the room by LVN A, and when she walked to Resident #1's side of the room there was a strong smell of urine. She said she smelled both urine and BM. CNA D said Resident #1 was not a heavy wetter. She said she had never seen her look like that, and usually Resident #1 would pull the call light for care. CNA D said Resident #1 often asked for cream on her bottom and between her legs. She said the whole time they were cleaning Resident #1 she kept saying over and over I am sorry, I am sorry. CNA D said she had been an aide for [AGE] years and had never seen any resident in that poor of condition. She said there were dried brown rings of urine, the resident was saturated, and it looked like Resident #1 had more than one BM. CNA D said it looked like she had been that way for some time. She said the BM was up in the front of the brief and it took them about 20 minutes to clean her up. CNA D said when they finished the sheets were in such bad condition, she did not think they could be cleaned, and they put them in the trash. During an interview on 4/20/23 at 4:48 p.m. the former Administrator said Resident #1 feces consistency may be due a recent completion of antibiotic regimen due to C Diff- Her flora in her stomach had not builder back up. She said however it did not really matter. The former Administrator said Resident #1 should not have been left in that condition. Record review of Resident #1's nursing note dated 4/1/23 indicted on 4/1/23 the resident returned from the hospital with a diagnosis of C-Diff, and acute blood loss. She had a new order for Vancomycin 125 mg every 6 hours until 4/10/23. During an interview with the former Administrator on 4/20/23 at 5:45 p.m. she said she had suspended LVN A and CNA AA. She said she would likely fire them. She said the nurse was aware of the condition the resident was in at 7:00 a.m. and did not assist Resident #1 in any way. The former Administrator said she had written up all staff involved. The condition of Resident #1 was unacceptable. She had also put a do not allow to return on the two aides that worked for the agency on the night shift. She said the aides should have checked Resident #1 before they left, and the oncoming aides should have checked Resident #1 when they arrived. During a telephone interview on 5/8/23 at 3:39 p.m. the family member of Resident #3 said she was asked by the former administrator to look at her camera footage on the morning of 4/20/23. The family member said she did not go back and look at the whole night but around 4:30 a.m. two aides came in and provided care to Resident #3. The family member said they went to the other side of the room and possibly provided care to Resident #1. The family member said they could not be sure because the curtain was pulled. The next time the family member noted someone in the room was around 7:00 a.m. and that was the nurse. Then around 8:00 a.m. they passed breakfast trays. The aide who assisted their family member with eating asked Resident #1 if she wanted breakfast and she said no. The family member said that staff are usually good about going into the room to provide care. She said Resident #1 would pull the call light, sometimes quite a bit. The family member said they thought staff did not turn Resident #1 often enough because she was always on her back. The family member said staff went in regularly generally every two hours and they had no real concerns. Record review of Resident #1's nursing note dated 4/20/23 created at 4:29 a.m. indicated at approximately 9:20 a.m. this morning Resident #1 was lying in bed with stage 3 to right buttock measuring 3.0 x 1.2 x 0.7 with no eschar, no slough and no odor noted to wound. The NP was in the building and notified of the wound and measurements and order from the Wound physician stated to start a new order today for Dakins. The new order was placed on the TAR. Record review of in-service training dated 4/20/23 indicated to check and change every two hours and must be completed and as needed. The training requirements were to recognize task, activities that pose risk or risk potential. Record review of in-service dated 4/20/23 indicated staff were in serviced on wounds and dressings. All wounds must be dressed per orders. If the dressing is missing or out of place or anything wrong, you must notify the nurse. Any changes notification must be placed and completed. If the order does not have an as needed order, you should obtain one as needed. If the order changes it must be updated. Record review of LVN G/Treatment Nurse Employee Counseling report dated 4/20/23 indicated he had a level 2 warning for failing to meet job expectations. He failed to enter physician orders in a timely manner. During an interview on 5/8/23 at 11:15 a.m. the DON said when an order is received from the physician it is to be put into the computer system immediately. She said there should not be a delay, and it should be put in a timely manner. She said LVN G was educated on 4/20/23 on putting orders in timely. She said on 4/20/23 staff were educated on what is expected for dependent resident care. The residents are to be turned and repositioned every 2 hours and as needed. Record Review of Resident #1's computerized physician orders dated 4/24/23 indicated may have foley catheter for wound management. Record review of Resident #1's Wound Management Summary dated 4/25/23 indicated the resident had a pressure sore stage 3 on the right buttock. There is moderate serous exudate (a clear thin, watery fluid with relatively low protein content, usually observed in acute or mild inflammation). The wound size was 9 x8 x0.3 cm with a surface area of 72 cm. with 100 percent granulation tissue. The wound had deteriorated. The wound was worse from urine, but foley was replaced. The wound dressing was alginate calcium apply twice daily with gauze island and apply twice daily. Record review of an in service completed on 4/28/23 indicated staff were in serviced on turning and rotating patients after changing them and every two hours. The training session summary indicated to make sure patients were being changed, if the brief is soiled, and check on patients every two hours. If the patient was changed be sure to turn and rotate them, these actions would help the patient be more comfortable and prevent skin breakdown. If they have a wound dressing and it came off during care stop and get the nurse to re-apply the dressing. Record review of Resident # 1's computerized physician order dated 5/1/23 indicated to cleanse the wound with Dakin's, pat dry, and apply Calcium Alginate two times daily. Record review of Resident #1's TAR for May 1, 2023 indicated the resident received treatment of cleanse wound with Dakins, pat dry, and apply Calcium alginate two times daily. She also had an as needed order to apply if the wound becomes soiled or the dressing came off. Record review of Resident #1's comprehensive metabolic panel (labs) dated 5/1/23 indicated BUN (too little fluid in the body) was high at 42 (range 7-24). Her Albumin (is protein made by the liver) was low (2.9 (range 3.5-5.0). Record review of Resident #1's dietary note dated 5/2/23 at 10:23 indicated the NP notified the dietician the resident needed to be evaluated due to the pressure sore protocol. The resident was on nocturnal feeding currently. Her current weight was 143.6 pounds, and her body mass index was 25.8 which was healthy for her age with a plus 6.53-pound weight gain in 30 days. The resident had a stage 3 to the right buttock. She was likely meeting her estimated needs at this time. Her by mouth intake is noted at 75 to 100 percent in last 3 days. She had fortified cereal recommended three times daily. She was to receive Glucerna 1.5 continuous via tube for 12 hours at a rate of 50 ml per hour from 6 p to 6a and 455 ml free water. Water flushes of 250 ml every 6 hours. Record review of Resident #1's wound care note dated 5/2/23 indicated a stage 3 pressure ulcer measured 9 x 8x 0.3 cm, with moderate serous exudate, there was 20 percent slough and 80 percent granulation tissues. The progress of the wound and the context surrounding the progress were considered in greater depth today. Diabetes is a relevant condition that effect wound healing and was considered. Recommended pain medication be give 30 min prior to wound care. The treatment was alginate calcium apply twice daily for 30 days. The wound was debrided. Record review of Resident #1's Clinically Unavoidable Pressure Ulcer form dated 5/4/23 indicated the resident had interventions in place prior to the development of the pressure ulcer, such as abnormal labs with interventions, turn every two hours, vitamin supplements, draw sheet, low air loss mattress, bed positioning wedge, and nutritional supplements. Contributing factors were pressure ulcer, history of ulcer, [NAME] score indicating high risk, impaired mobility, bowel incontinence, and head of bed elevated due to medical necessity. The contributing lab factors were low serum prealbumin less than 16. Record review of Resident #1's computerized physician orders dated 5/8/23 indicted Augmentin (antibiotic) 500 mg to be given via tube and Tramadol (pain medication). Record review of two statements both signed by the DON with no dates indicated CNA Z said she changed Resident #1 three times during the night of 4/19/23 and the last time was about 4:45 a.m. Another statement from CNA M indicated she had changed Resident #1 throughout the night on 4/19/23 and the last time was about 4:55 a.m. Record review of an email dated 5/9/23 at 12:57 p.m. indicated LVN Y sent an email indicating that on the night of 4/19/23 to 4/20/23 she had gone into Resident #1's room several times that night and witnessed the aides providing care. They said on her final round around 6:10 a.m., Resident #1 was awake and alert and had no complaints. During a telephone interview on 4/26/23 at 10:51 a.m. CNA M (worked for none facility staffing agency) said she remembered what happened on the night of 4/19/23. She said around 4:30 a.m. she and another aide had gone into Resident #1's room to change her. She said Resident #1was saturated. She said she had cleaned her and changed her. She said they put the draw sheet under her, positioned her with pillows behind her, and pulled her up in the bed. During an interview on 5/8/23 at 11: 20 a.m. Resident #1 said she knew when she is wet. Resident #1 said she did not pull the call light on 4/20/23 because she did not have the call light within reach. Resident #1 said she was left dirty for long periods of time occasionally, but not often. She said they came in to turn her about every two hours, and they put pillows and wedges under her sides to keep her off her bottom. She said she thought her bottom was better. During an interview on 5/8/23 at 11: 25 a.m. LVN P said Resident #1 was on Augmentin, an antibiotic for a pressure sore for 10 days. She said Resident #1 was placed on the antibiotic on 5/1/23 due to infection in her wound. During an interview on 5/8/23 at 11:27 a.m. LVN G/treatment nurse said he started at the facility in April and on 4/20/23 he had been in that position of treatment nurse for about 4 days. He said Resident #1 had a Foley Catheter placed on 4/25/23. He said Resident #1 had a catheter in the past, and the wound was getting better. He did not know why they removed the catheter. He said on 4/20/23 he was counseled by the ADON and DON on putting orders in the Resident computer record timely. LVN G said he had found Resident #1 wet a few times. He said he would change her but had never walked in and she was saturated. He said Resident #1 had the wound on her right buttock since 2019 and looking at the chart it had never healed. It would get worse, then better, and then worse. LVN G said when Resident #1's wound got worse he called the wound care doctor on 5/1/23. The doctor ordered antibiotics but did not have the wound cultured. LVN G said when he looked at the wound it looked worse, and the outside skin looked a little more macerated (occured when skin is in contact with moisture too long). He said when the wound care doctor saw her on 5/2/23 he confirmed the wound was infected. He said he had completed an unavoidable pressure ulcer form on Resident #1 on 5/4/23. He said the physician did not sign the document, but he knew they had talked to the wound care physician. During an interview on 5/8/23 at 11:44 a.m. the Wound Care Doctor said they took the foley out and he thought Resident #1 was a heavy wetter. He said he felt that was what caused her wound to worsen. He said he did not know why the catheter was removed. The Physician said he had not seen her wet when he was at the facility, but he was only at the facility for about an hour a week. He said he had put Resident #1 on an antibiotic, due to her wound having an odor and more drainage on 5/1/23. He did not get the wound cultured, he prescribed antibiotics from a previous culture result. He said they had gotten cultures in the past and she had done well on antibiotics to increase her changes of healing. The Physician said he was not sure what Resident #1's blood sugars were, but her diagnosis of diabetes was a contributing factor for a non-healing wound. He said the facility had talked to him about the wound being unavoidable due to the wound not healing for years. He said they try to keep her off the area, keep her dry, and clean which are also contributing factors. He said he was not sure if he signed anything saying she was an unavoidable pressure sore or not. However, it was likely Resident #1's condition indicated she had an unavoidable pressure sore. Record review of a Wound Culture dated 1/24/23 indicated Resident #1 had a many Group B streptococcus (an infection caused by common bacterium.) Record review of Resident #1's the Wound Care Physician progress note dated 5/8/23 at 2:59 p.m. indicated: Discussion with treatment nurse, DON, Administrator, and State regarding the wound. as stated previously, this wound is very difficult to heal from multiple reasons. We have tried to offload the wound as best as possible with the level two mattress and wedges. However, the patient does not wish to turn to her side. The patient has diabetes and blood sugars that are stable. We have treated this wound in the past with IV antibiotics, with improvement. However, the wound worsened when the foley was removed. The patient is a heavy wetter, and the urine caused the wound to break down. We have subsequently replaced the foley. We have restarted her on oral antibiotics last week per the previous wound culture sensitivities. During an interview with the DON on 5/8/23 at 12: 45 p.m. she said Resident #1's wound developed back in 2019. She said she had worked at the facility for about a year but during that time Resident #1's wound had been up and down and good and bad. It had not healed. During an interview on 5/8/23 at 12:47 p.m. NP-O said she and the staff talked about Resident #1's pressure sore last week and she referred them to the Wound Care Doctor. She said she did not specialize in wounds and would agree with whatever the wound specialist thought was right. NP O said the catheter was taken out and restarted a couple of times, one time to see if Resident #1 could void her own. She said Resident #1's catheter stopped up a couple of times. The NP said Resident #1 had a decline a year ago. However, her labs looked good her BUN was high and her Albumin was low. The dietician was notified and made some changes. The NP said other than that, the resident appeared healthy as far as her labs were concerned. During an interview on 5/8/23 at 1:10 p.m. the Corporate Regional Nurse consultant of clinical operations said they do not have a policy for unavoidable pressure sores. She said they could not have completed an unavoidable pressure form on Resident #1without the physician agreement. She said they only use the form after discussing with physician. The pressure ulcer had not changed from a stage 3. During an interview on 5/9/23 at 2:37 p.m. CNA R said Resident # 1 would refuse to turn sometimes when she helped other aides. She said sometimes she would refuse food it appeared to be based on how she felt at the time. CNA R said and sometimes she was fine with anything they tried to do for her. She said she never refused to be cleaned. During an interview on 5/9/23 at 2:54 p.m. CNA D said she had received an in service on abuse and neglect today and many times in the past. CNA D said she was familiar with what neglect was and neglect was a failure to provide care to residents in a timely manner. She said failing to turn and reposition the resident, and failure to keep them clean and dry were neglect. She said the incident with Resident # 1 on 4/20/23 was a failure to provide care. She said if she had found her in that condition, she would have reported it as an allegation of neglect. She said she did not see a bandage, anywhere on 4/20/23 when she changed the resident. She said Resident #1 would not refuse to turn but did not like to turn. Resident #1 would sometimes scoot back to the position she liked to be in when turned. During an interview on 5/9/23 at 3:18 p.m. the Medical Director said he remembered Resident #1 had gone to the hospital the last of March 2023. He said Resident #1 had come back to the facility with a diagnosis of C-Diff. He said she had a stage 3 wound on her sacrum. He said at one time they were considering putting her on Hospice. The Medical Director said Resident #1's Albumin was low and that likely meant she was not getting enough nutrition even with the feeding tube. He said if they left the catheter in then there would be a different set of problems with urinary tract infections. He said the facility staff did talk to him about Resident #1's pressure sore being unavoidable. He said Resident #1 did not get out of bed and that was a factor. He thought they were talking about putting measures in place to help with the healing of the wound. He said he must have misunderstood; however, Resident #1 did have a multiplicity of underlying conditions that could contribute to the wound not healing. During an interview on 5/9/23 at 3:43 p.m. CNA V said Resident #1 was not a heavy wetter. She said she had not worked with Resident #1 lately. She said most of the time the resident was fine with turning and repositioning. She would refuse every now and then, but they used pillows and wedges to keep her off her bottom if she did. Record review of the facility Pressure Injury Prevention and Management policy implemented on 8/15/22 indicated interventions for prevention and to promote healing- evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to minimize exposure to moisture and keep the skin clean, especially of fecal contamination. Treatments for an identified area were documented on the treatment administration record. The facility was notified of the Im [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure a resident had the right to be free from neglect for 1 of 6 residents reviewed for neglect (Resident #1). Resident #1 was found to be incontinent of urine and feces. She had not been turned, repositioned, or changed in approximately 5 hours. The resident's wound increased in size in 7 days, on 4/18/23 the wound measured 2.5 x 1x 0.3 and on 4/25/23 it measured 9 x8 x0.3 cm. The facility neglected to follow their policies on Abuse and neglect, Perineal Care, and Pressure Injury Prevention. This failure could place residents at risk of abuse/neglect due to failure to provide necessary services for care. Findings included: Record review of a face sheet with a print date of 4/20/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, contracture to the right hand, diabetes, paralysis of one side of the body, muscle weakness, cognitive deficit, muscle wasting, pressure ulcer to the right buttock stage 3 (a wound that was full thickness tissue loss, subcutaneous fat may be visible), and unspecified protein calorie malnutrition and diabetes. Record review of a brief interview for mental status dated 2/15/23 indicated Resident #1 had moderate cognitive impairment. Review of Resident #1's Care Plan initiated on 11/20/18 indicated Resident #1 had a problem of ADL self-care performances deficit due to Paralysis and right-hand contracture. Interventions were the resident was a two person transfer with lift extensive assist. She required assistance of one to two people for grooming bathing toileting bed mobility. The resident was totally dependent on one staff for repositioning and turning in bed frequently as necessary. The resident was bedfast most of the time. Resident #1 was totally dependent on one staff for addressing, the resident was not toileted. The Resident had a problem of communication related to slight hearing deficit and a low tone voice. One of the interventions communicate and allow time to respond. Do not rush, request clarification from the resident to ensue understanding. A problem dated 11/20/18 indicated the Resident # 1 had a problem with bladder and bowel incontinence related to mobility. The interventions were clean peri area with each incontinent episode. Resident #1 had a care plan problem with an initiate date of 1/16/23 of a Stage 3 pressure ulcer of the right buttock. The interventions were administered treatments as ordered and monitor for effectiveness. Follow facility policies and protocols to prevent skin breakdown. The resident was seen weekly by the wound physician. Record review of Resident 1's MDS dated [DATE] indicted she required extensive assist with all ADLs. The MDS indicated Resident #1 had a pressure ulcer that was a stage 3. Record review of Resident #1's Wound evaluation and Management Summary dated 4/18/23 indicated Resident #1 had a stage 3 pressure wound that measured 2.5 x 1 x 0.3. The wound had serous drainage (thin watery fluid that is produced in response to local inflammation), with slough (yellow material coving the wound bed) covering 10 percent of the wound and 90 percent with granulation tissue. The surface of the area was 2.5 cm. The wound had improved. Record review of Resident #1's ADL sheet indicated for 4/19/23 Her bowel and bladder elimination were blank with no documentation. On 4/20/23 it was initialed by CNA M at 11:50 p.m. with no other details. During an interview on 4/20/23 at 9:23 a.m. LVN A stopped CNA C and CNA AA in the hallway and was overheard. LVN A told them something about providing care right now. When asked what she said, and she said she told them to check their residents to make sure they were okay. During an interviews and observation on 4/20/23 between 9:25 a.m. to 9:53 a.m. Resident #1 was observed in bed and had a feeding tube infusing. LVN A was asked to check Resident #1 to see if she was wet. She said Resident #1 required two people to turn and left the room. Resident#1 did not speak when spoken to. LVN A went to get help and was gone for quite a few minutes. LVN A said the aides were busy, so she got LVN B to assist. LVN B went to the far side of the bed. Once the investigator got closer to the bed the smell of urine was strong. When asked if Resident #1 was wet LVN A pulled her wet gown down around Resident#1's legs and said yes. LVN B pulled back the covers on her side and said, there is bigger problem here. Observation of the Resident #1 showed she had on a brief and her legs were opened. In between her legs was a pile of BM that was a shade of green the outer edges were a darker color. The pile was about 3 inches around with a height of about 3 to 4 inches. A larger ring in between the resident leg showed some darker colored liquid BM that was about 4 to 5 inches in a [NAME] circle, the edges of that BM was also darker. There was a brown ring of urine from one side of the bed to the other around the resident legs. Resident#1 was positioned with pillows The pillows on both sides of the resident had pillow covers that were wet with brown rings. Her hospital gown was wet from the waist down. LVN A said she was really saturated. LVN A said she needed an aide to help turn her Resident #1. She could not turn Resident #1 by herself. CNA C and CNA D entered the room and said this was their first time in the room this morning to provide care to Resident #1. CNA D said she had assisted the roommate with eating breakfast. She had asked Resident #1 if she wanted anything for breakfast (she had feeding tube but ate sometimes) she said the resident said no. CNA D said she had not gone to that side of the room. CNA C said they had just finished with breakfast. CNA C said she had started on her rounds but had not gotten into this room today. CNA C and CNA D cleaned Resident #1, Resident #1 asked for them to put cream between her legs when they finished. Resident #1 said this was the first time someone had cleaned her since last night. LVN A said Resident #1 had a pressure sore on her bottom, when they rolled her over, CNA C and LVN A said there was no bandage on the wound. CNA D said the whole bed was wet. LVN B said the whole bed was wet and the smell of urine was strong. During an interview on 4/20/23 at 9:42 a.m. RN/ ADON F came into the room she looked at the wound on Resident #1's bottom. The aides were still cleaning Resident #1. The RN/ADON F said the wound should have had a bandage on it. She said Resident #3 had a stage 3, an open wound with no eschar (dead tissue). During an interview on 4/20/23 at 9:52 a.m. LVN G/ treatment nurse said on 4/18/23 was the last time Resident#1 was seen by the wound care doctor, her wound was 2.5 x 1x 0.3 and was staged at a stage 3. The RN/ADON and LVN G/ wound care nurse measured her wound at that time, and it was 3 x 1.2 x 0.7. The aides were still cleaning Resident #1. During an interview on 4/20/23 at 9:57 a.m. CNA C and CNA D said they have not provided care to Resident #1 today. They had not been in to conduct two-hour rounds and had not checked her when they arrived at work. They said the night shift must have left her dirty due to the poor condition Resident #1 was in. They said the BM had not dried but it was obvious she had more BMs than one. They said the BM was up the front of her brief to almost her waist. CNA C and CNA D said with the brown rings on the sheets, the condition of Resident #1, it had been more than a few hours since she was changed. During an interview on 4/20/23 at 10:05 a.m. LVN E/Treatment nurse said Resident # 1's treatment orders changed on 4/18/23. He said he had not changed the order in the chart as of today 4/20/23. He said he is the nurse that completed her treatments and knew what they were. He said he was not always at the facility and admitted other nurses might not be aware of the change in treatment. During an interview on 4/20/23 at 11:00 a.m. the former Administrator said the roommate, Resident #3's family had a camera in the room. The Family member said two aides had come in around 4:30 a.m. and gone to Resident #1's side of the room. The family member said she thought they changed Resident #1 at that time. The family member said the nurse (LVN A) came in and checked on Resident #1 about 7 a.m. The family member said they came in and brought Resident #3 a tray and asked Resident #1 if she wanted anything to eat about 8:00 a.m. and Resident #1 said no. The Former Administrator said she wrote up CNA C, CNA D, CNA AA, and LVN A. The former Administrator said LVN A could have checked on Resident #1 and she could have provided her care. The former Administrator said she was terminating the aide that said Resident #1 was not her resident and refused to help. She said she was probably going to terminate the nurse because by all the accounts she had gotten. The nurse had been in the room at 7:00 a.m. and the smell of urine was strong enough for her to smell. The former Administrator said LVN A likely knew the resident was dirty and did not try to clean her or get the aides to do so at that time. During an interview on 4/20/23 at 11:20 a.m. Resident #1 said she stayed in bed all the time. She said staff only changed her one time last night. She said she was very uncomfortable and was burning between her legs and wanted some cream on her legs and bottom to stop the burning. During an interview on 4/20/23 at 11:45 a.m. LVN B said when she walked on the side of the bed Resident #1's bed she smelled a strong urine odor. She said she said the resident should have been changed. LVN B said even if Resident #1 was a heavy wetter, she should not have been found in that condition. During an interview on 4/20/23 at 12: 06 p.m. CNA C said LVN A stopped her and CNA AA earlier in the hallway and told them to provide care to a resident right away, but she did not hear who it was. She said the CNA AA heard her because she said that resident was not her resident. CNA C it took a long time to clean Resident #1 because she was so soiled. She said the night shift must have left her that way. She had not done rounds this morning when she arrived late to work. During an interview on 4/20/23 12:26 P.M. CNA D said she had gone in the room earlier that morning to feed Resident # 3 around 8:00 a.m. and the curtain between the beds were pulled. She said she asked Resident #1 if she wanted breakfast, and she said no. CNA D said she did not smell anything at that time. She said when she was summoned to the room by LVN A, and when she walked to Resident #1's side of the room there was strong smell of urine. She said she smelled both urine and BM. CNA D said Resident #1 was not a heavy wetter. She said she had never seen her look like that, and usually Resident #1 would pull the call light for care. CNA D said Resident #1 often asked for cream on her bottom and between her legs. She said the whole time they were cleaning Resident #1 she kept saying over and over I am sorry, I am sorry. CNA D said she had been an aide for [AGE] years and had never seen any resident in that poor of condition. She said there were dried brown rings of urine, the resident was saturated, and it looked like Resident #1 had more than one BM. CNA D said it looked like she had been that way for some time. She said the BM was up in the front of the brief and it took them about 20 minutes to clean her up. CNA D said when they finished the sheets were in such bad condition, she did not think they could be cleaned, and they put them in the trash. During an interview on 4/20/23 at 4:48 p.m. the former Administrator said Resident #1's feces consistency may have been due a recent completion of antibiotics due to C Diff and her flora in her stomach had not built back up. She said however it did not really matter. The former Administrator said Resident #1 should not have been left in that condition. During an interview with the former Administrator on 4/20/23 at 5:45 p.m. she said she had suspended LVN A and CNA AA. She said would likely fire them. She said the nurse was aware of the condition the resident was in at 7:00 a.m. and did not assist Resident #1 in anyway. The former Administrator said she had written up all staff involved. The condition of Resident #1 was unacceptable. She had also put a do not allow to return on the two aides that worked for the agency on the night shift. She said the aides should have checked Resident #1 before they left, and the oncoming aides should have checked Resident #1 when they arrived. Record review of a nursing note dated 4/20/23 at 4:29 a.m. indicated at approximately 9:20 a.m. on 4/20/23 Resident #1 #1 was lying in bed with a stage 3 pressure ulcer to the right buttock measuring 3.0x 1.2 x 0.7 with no eschar, no slough and no odor noted. The note indicated NP-O was in the building and was notified of the wound measurements and an order from the wound care doctor was started. New order initiated and placed on the treatment administration record. Record review of Employee Counseling Reports indicated on 4/20/23 LVN A, CNA C, CNA AA, and CNA D received a level two offense for failure or unwillingness to perform work as required or directed. The description of the incident was failure to ensue Resident #1 was checked and changed. Also, failure to ensure wound dressing was in place. Signed by the DON. Record review of in-service training dated 4/20/23 indicated to check and change residents every two hours and must be completed and as needed. The training requirements were to recognize task, activities that pose risk or risk potential. Record review of Resident #1's Wound Management Summary dated 4/25/23 indicated the resident had a pressure sore stage 3 on the right buttock. There was moderate serous exudate (a clear thin, watery fluid with relatively low protein content, usually observed in acute or mild inflammation). The wound size was 9 x8 x0.3 cm with a surface area of 72 cm. with 100 percent granulation tissue. The wound had worsened due to urine and a urinary catheter was placed. Record review of an in service competed on 4/28/23 indicated staff were in service on turning and rotating residents after changing them and every two hours. The training session summary indicated to make sure patients were being changed, if the brief was soiled, and check on residents every two hours. The in service indicated if the resident was changed be sure to turn and rotate them, these actions would help the patient be more comfortable and prevented skin breakdown. The in service indicated if the resident had a wound dressing and it came off during care stop, and the get nurse to re-apply the dressing. Signed by LVN G/Treatment nurse. During a telephone interview on 4/26/23 at 10:51 a.m. CNA M (agency) said she remembered what happened on the night of 4/19/23. She said around 4:30 a.m. she and another aide had gone into Resident #1's room to change her. She said Resident #1was saturated. She said she had cleaned her and changed her. She said they put the draw sheet under her, positioned her with pillows behind her, and her pulled up in the bed. During an interview on 5/8/23 at 11: 20 a.m. Resident #1 said she knew when she is wet. Resident #1 said she did not pull the call light on 4/20/23 because she did not have the call light within reach. Resident #1 said she was left dirty for long periods of time occasionally, not often. She said they came in to turn her about every two hours, they put pillows and wedges under her sides to keep her off her bottom. She said she thought her bottom was better. During an interview on 5/8/23 at 11:27 a.m. LVN G said he had gone in to provide Resident #1 wound care a few times and found her wet. He said if she was wet, he would just go ahead and change her, but he had never found her saturated. During a telephone interview on 5/8/23 at 3:39 p.m. the family member of Resident #3 said she was asked by the former administrator to look at her camera footage on the morning of 4/20/23. The family member said she did not go back and look at the whole night but around 4:30 a.m. two aides came in and provided care to Resident #3. The family member said they went to the other side of the room and possibly provided care to Resident#1. The family member said they could not be sure the curtain was pulled. The next time family member noted someone in the room was around 7:00 a.m. and that was the nurse. Then around 8:00 a.m. they passed breakfast trays. The aide who assisted their family member with eating asked Resident #1 if she wanted breakfast and she said no. The family member said that staff are usually good about going into the room to provide care. She said Resident #1 would pull the call light, sometimes quite a bit. The family member said they thought staff did not turn Resident #1 often enough because she was always on her back. The family member said staff went in regularly generally every two hours and they had no real concerns. Record review of an email dated 5/9/23 at 12:57 p.m. indicated LVN Y sent an email indicating that on the night of 4/19/23 to 4/20/23 she had gone into Resident #1's room several times that night and witnessed the aides providing care. She said on her final round around 6:10 a.m. Resident #1 was awake and alert and had no complaints. Record review of two statements presented on 5/9/23 at 1:57 p.m. buy the interim Administrator. A statement indicated CNA Z said she changed Resident #1 three times during the night of 4/19/23 and the last time was about 4:45 a.m. Another statement from CNA M that indicated she had changed Resident #1 throughout the night on 4/19/23 and the last time was about 4:55 a.m. Both were signed by the DON with no dates. During an interview on 5/9/23 at 2:06 p.m. the interim Administrator said he was the abuse coordinator. He said they monitor abuse by doing daily rounds, looking at residents. His phone number is posted throughout the facility for anyone to call with their concern. He said they in service staff frequently on abuse and neglect. The Administrator said any time there is a suspicion of abuse or neglect they investigate and notify they proper agencies if necessary. He said he was not the Administrator on 4/20/23 During an interview on 5/9/23 at 2:37 p.m. CNA R said Resident # 1 would refuse to turn sometimes when she helped other aides. She said sometimes she would refuse food it appeared to be based on how she felt at the time. CNA R said and sometimes she was fine with anything they tried to do for her. She said she never refused to be cleaned. During an interview on 5/9/23 at 2:54 p.m. CNA D said she had received an in service on abuse and neglect today and many times in the past. CNA D said she was familiar with what neglect was and neglect was a failure to provide care to residents in a timely manner. She said failing to turn and reposition the resident, failure to keep them clean and dry were neglect. She said the incident with Resident # 1 on 4/20/23 was a failure to provide care. She said if she had found her in that condition, she would have reported it as an allegation of neglect. She said she did not see a bandage, in her brief or in the bed on 4/20/23 when she changed the resident. She said Resident #1 would not refuse to turn but did not like to turn. Resident #1 would sometimes scoot back to the position she liked to be in when turned. During an interview on 5/9/23 at 3:43 p.m. CNA V said Resident #1 was not a heavy wetter. She said she had not worked with Resident #1 lately. She said most of the time the resident was fine with turning and repositioning. She would refuse every now and then, but they used pillows and wedges to keep her off her bottom if she did. During an interview on 5/9/23 at 4:14 p.m. LVN B said she was in service on abuse and neglect. She said neglect was failure to provide care to a resident, or if the resident had to wait long times for care, or repositioning. She said if she had found any resident in the condition Resident #1 was in on 4/20/23 she would have let her aides know that was unacceptable and reported the incident to administration. Record review of the facility in service indicated staff were in service on the facility abuse policy on 4/4/23. Record review of the facility Abuse, Neglect and Exploitation policy dated 8/15/22 indicated: it was the policy of the facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The definition for Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident necessary to avid physical harm, pain, mental anguish, or emotional distress. Record review of the facility Perineal Care policy implemented 10/24/22 indicated: it is the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Record review of the facility Pressure Injury Prevention and Management policy implemented on 8/15/22 indicated interventions for prevention and to promote healing- evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: minimize exposure to moisture and keep the skin clean, especially of fecal contamination. Treatments for an identified area were documented on the treatment administration record.

Based on interview and record review, the facility did not ensure the NP was promptly notified of x-ray results for 1 of 6 residents reviewed for radiology services. (Resident #1). The facility did not notify Resident #1's NP promptly when his KUB (an x-ray of the kidneys, ureters - the tubes leading from the kidneys to the bladder, and the bladder) indicated he had a possible bowel obstruction (a condition where digested material cannot pass through the bowel) or ileus (a temporary lack of muscle contraction in the intestine) on 10/21/22. Resident #1 was sent to the hospital on 10/23/22 and was diagnosed with bowel obstruction. This failure could place residents at risk for undiagnosed illness, hospitalization , or death. Findings included: Record review of Resident #1's face sheet, with a print date of 10/31/22, indicated he was [AGE] years old, readmitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's October order summary report, with a print date of 10/31/22, indicated he had a regular diet with regular liquids. He was to receive [CONDITION(S)] care every shift and as needed, one Lactobacillus tablet a day (a tablet containing good bacteria to aid with gut health), one Senna 8.6mg tablet a day (a stool softener) and one [MEDICATION(S)]-Acetaminophen 10-325mg tablet (an opioid pain reliever that can cause constipation) every 6 hours as needed for pain. Record review of Resident #1's care plan indicated he had a [CONDITION(S)], with a problem initiation date of 06/24/22, and was to receive assistance with the [CONDITION(S)] as needed, receive medications as ordered, and staff were to monitor the stoma (a part of the bowel that is brought to the outside of the body to release feces) site every shift. He had a problem of constipation (inability to pass feces) related to the use of pain medication, with an initiation date of 09/30/22, and was to be monitored for complications of constipation, such as vomiting, tenderness, confusion, and sweating. Record review of Resident #1's most recent MDS, dated [DATE], indicated he had adequate hearing, clear speech, understood and was understood by others, and had adequate vision. He was cognitively intact and was totally dependent on two staff members with bed mobility and transfers. He required the limited assistance of two staff members with dressing, the limited assistance of one staff member with personal hygiene, and the extensive assistance of two staff members with toilet use. He was able to feed himself and used an electric wheelchair for mobility. The MDS addressed his ostomy and pain medication usage. Record review of a nurse's note written by LVN A, dated 10/21/22 at 2:04 p.m., indicated LVN A had obtained new orders from the NP to change Resident #1's foley catheter, get a STAT urinalysis (a lab test that can check for bacteria in the urine), and a STAT KUB (an x-ray of the kidneys, ureters - the tubes leading from the kidneys to the bladder, and the bladder) due to a complaint of severe abdominal pain. LVN A notified the resident of these orders while he was outside smoking, and he told her he would be ready once he was done smoking. Record review of a nurse's note written by LVN A, dated 10/21/22 at 2:16 p.m., indicated LVN A notified the facility's contracted x-ray company of Resident #1's STAT KUB order. Record review of a nurse's note written by LVN A, dated 10/21/22 at 5:49 p.m., indicated LVN A assisted Resident #1 to bed for his KUB, the KUB was completed, and results were pending. Record review of Resident #1's chart during the investigation between 10/26/22 and 10/31/22, yielded no nurse's notes throughout the day or night of 10/22/22. No documentation was found regarding physician notification of the KUB results. Record review of the nurse's 24-hour report for 10/21/22 indicated the 6 a.m. to 6 p.m. nurse communicated Resident #1 had a foley catheter change, a STAT urinalysis, and a STAT KUB related to severe abdominal pain. The report also indicated the urine specimen was picked up by the lab, the STAT KUB was completed, and the results would be faxed. Staff were to notify the NP that gave the orders. The 6 p.m. to 6 a.m. nurse communicated to watch for Resident #1's catheter position when up in the chair. No communication was noted regarding the KUB results or physician notification. Record review of the nurse's 24-hour report for 10/22/22 indicated the 6 a.m. to 6 p.m. nurse communicated Resident #1 had nausea and vomiting once. The 6 p.m. to 6 a.m. nurse communicated again to watch the resident's foley catheter placement when up in the chair. No communication was noted regarding the KUB results or physician notification. Record review of a nurse's note written by LVN B, dated 10/23/22 at 7:00 a.m., indicated Resident #1 was sitting up in bed vomiting green bowl. The resident had faint upper bowel sounds and no lower bowel sounds. The resident said he had an abdominal pain rating of 8 (on a scale of 1 to 10) and requested to be sent to the hospital. LVN B called 911 and the resident left the floor in stable condition, with his vital signs in normal parameters. Record review of the nurse's 24-hour report for 10/23/22 indicated the 6 a.m. to 6 p.m. nurse had no communication, as Resident #1 transferred to the hospital before the day shift nurse could write anything. The 6 p.m. to 6 a.m. nurse communicated to monitor Resident #1's foley catheter placement and that he had nausea and vomiting once, had active, but sluggish, bowel sounds in all four abdominal quadrants and to monitor him. No communication was noted regarding the KUB results or physician notification. Record review of Resident #1's hospital paperwork for his stay between 10/23/22 and 10/28/22 indicated Resident #1 said the pain was mostly in his lower abdomen and was a dull ache with nothing making it worse or better. A CT scan, performed on 10/23/22, at the hospital revealed he had a partial small-bowel obstruction and his foley catheter balloon was inflated in the prostatic urethra (the part of the urethra that runs through the prostate of a male). The resident was given an NG tube to assist with suctioning out his stomach. A small bowel test was given to the resident on 10/24/22, using a contrast that is administered either orally or anally. The test yielded no evidence of small bowel obstruction. During a phone interview on 10/28/22 at 2:20 p.m., LVN B said she was the nurse that sent Resident #1 out to the hospital on 10/23/22. She said he was having bowel movements because he blew his [CONDITION(S)] bag out and she had to change it since it was leaking everywhere. She said during her shift on 10/22/22 the resident was asking if they had received the results of his urinalysis. She said he was up in his wheelchair and was acting totally normal. She said as her shift was ending at 6 p.m. on 10/22/22, she and LVN C found the KUB paperwork and were trying to figure out if he had the KUB done or if they needed to have it done. She said she interpreted it as he may have had a blockage. She said she was not told by the night shift nurse, LVN D, on the morning of 10/22/22 that the resident had abdominal pain on 10/21/22 and thought the reason his foley catheter had been changed was because it was just time to change it. She said the night shift nurse, LVN D, was an agency nurse and only told her to make sure they monitored his catheter and to ensure it did not pull or pinch. She said when she came back on the morning of 10/23/22, she was told he had been sick throughout the night and to monitor him. She said she does not know if LVN C, the night shift nurse on 10/22/22, called the physician or not. During a phone interview on 10/28/22 at 3:58 p.m., LVN C said she got report from LVN B at around 6 p.m. on 10/22/22. She said LVN B said something about finding the KUB paperwork, but she hadn't seen any orders for it. She said at around 2 a.m. she sat down and looked over the KUB results that LVN B had shown her. She said she did not notify the doctor or send the KUB results to anyone. She said when she saw the results, she went to the resident and started listening to his bowel sounds, which were decreased. She said the resident told her he was feeling ok and wanted to stay in the facility for a little while longer. She said at around 4 a.m., he threw up for the first time, so she spoke with him and told him they needed to keep monitoring him. She said if he threw up again, she would need to send him out. He did not throw up again on her shift. She said at his morning medication pass at around 5-5:15 a.m. he said he was feeling good and did not need to be sent out. He took his medicines and had no further issues before she left. She said when LVN B returned at 6 a.m., she told LVN B they needed to be monitoring for an obstruction or ileus, but she did could not remember how LVN B had responded. During a phone interview on 10/28/22 at 4:10 p.m. the NP said she was on call for Resident #1's regular NP. She said she was not familiar with any of the residents in the facility. She said she did not exactly recall how things went the day of 10/21/22 since it had been a week ago, but she was pretty sure the nurse told her something to the effect of the catheter is backing up, so she told them to change the catheter, get a STAT urinalysis, and a STAT KUB. She said her shift ended at 5:00 p.m. and she would not have been the one to receive the results of the KUB. She believed the person that took call after her shift was over was a PA that worked in the clinic with her. During an interview on 10/28/22 at 4:35 p.m. the DON said on the evening of 10/21/22 before she left, she let former-ADON F know to follow up on the KUB that was ordered for Resident #1. She said she then left for the weekend and early on the morning of 10/23/22, she received a text message that they were sending Resident #1 out. She said she spoke with former-ADON F and asked her why the KUB had not been followed up on like she was told to do. She said former-ADON F spoke with agency nurse LVN D, who had worked the night of 10/21/22, and asked her why she had not notified anyone of the KUB results. Former-ADON F told the DON that LVN D had not given any reason for the lack in communication. The DON also said that LVN D had failed to transcribe the resident's KUB, urinalysis and foley catheter change on to the 24-hour report for the next shift to see. She said she would be putting LVN D on the do not return list for agency nurses so that errors like this would not occur again. During an interview on 10/28/22 at 4:50 p.m. agency nurse LVN D said she worked on the night of 10/21/22. She denied being notified of Resident #1 having a complaint of stomach pain. She said she was told he had been sitting on his catheter, and that was causing his catheter to stop up. She said she was to be monitoring for him sitting on it. She said she did not remember if she was told he had a KUB completed or not. She said she did not receive the KUB result, and she did not see it when she was on shift that night. She did not remember what she told LVN B the morning of 10/22/22 in report. She said when he went to bed that night that, she gave him his medications and he had no complaints of pain and was pleasant. She said she transcribed the KUB, urinalysis and foley catheter change to the next day's 24-hour report, despite her earlier saying she did not know he had a KUB. She was unable to find the 24-hour report sheet that she wrote the orders on and said someone must have thrown it away. During a phone interview on 10/31/22 at 12:46 p.m., the PA said he had been on call the weekend of 10/21-23/22 but had not received any calls or messages about Resident #1. He said he would remember if he had been notified of a possible bowel blockage or ileus. He said he would have done something about the imaging results had he known about it and had the resident sent out. Record review of a facility Notification of Changes policy, with an effective date of 10/24/22, indicated: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician .when there is a change requiring notification .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status .3. Circumstances that require a need to alter treatment .

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents reviewed for quality of care. (Resident #1) The facility failed to monitor Resident #1 for possible bowel obstruction (a condition where digested material cannot pass through the bowel) and abdominal pain between the evening of 10/21/22 and the morning of 10/23/22, as recommended following a KUB. Resident #1 was sent to the hospital on 10/23/22 and was diagnosed with bowel obstruction. This failure could place residents at risk of medical emergencies, delay in treatment, and hospitalization . Findings included: Record review of Resident #1's face sheet, with a print date of 10/31/22, indicated he was [AGE] years old, readmitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's October order summary report, with a print date of 10/31/22, indicated he had a regular diet with regular liquids. He was to receive [CONDITION(S)] care every shift and as needed, one Lactobacillus tablet a day (a tablet containing good bacteria to aid with gut health), one Senna 8.6mg tablet a day (a stool softener) and one [MEDICATION(S)]-Acetaminophen 10-325mg tablet (an opioid pain reliever that can cause constipation) every 6 hours as needed for pain. Record review of Resident #1's care plan indicated he had a [CONDITION(S)], with a problem initiation date of 06/24/22, and was to receive assistance with the [CONDITION(S)] as needed, receive medications as ordered, and staff were to monitor the stoma (a part of the bowel that is brought to the outside of the body to release feces) site every shift. He had a problem of constipation (inability to pass feces) related to the use of pain medication, with an initiation date of 09/30/22, and was to be monitored for complications of constipation, such as vomiting, tenderness, confusion, and sweating. He had a catheter, with a problem initiation date of 06/24/22, that staff were to monitor for pain or discomfort and monitor for symptoms of a [CONDITION(S)] such as pain, bloody urine, fever, or no urine output. Record review of Resident #1's most recent MDS, dated [DATE], indicated he had adequate hearing, clear speech, understood and was understood by others, and had adequate vision. He was cognitively intact and was totally dependent on two staff members with bed mobility and transfers. He required the limited assistance of two staff members with dressing, the limited assistance of one staff member with personal hygiene, and the extensive assistance of two staff members with toilet use. He was able to feed himself and used an electric wheelchair for mobility. The MDS addressed his urinary catheter, ostomy, and pain medication usage. Record review of a nurse's note written by LVN A, dated 10/21/22 at 2:04 p.m., indicated LVN A had obtained new orders from the NP to change Resident #1's foley catheter, get a STAT urinalysis (a lab test that can check for bacteria in the urine), and a STAT KUB (an x-ray of the kidneys, ureters - the tubes leading from the kidneys to the bladder, and the bladder) due to a complaint of severe abdominal pain. LVN A notified the resident of these orders while he was outside smoking, and he told her he would be ready once he was done smoking. Record review of a nurse's note written by LVN A, dated 10/21/22 at 2:16 p.m., indicated LVN A notified the facility's contracted x-ray company of Resident #1's STAT KUB order. Record review of a nurse's note written by LVN A, dated 10/21/22 at 2:30 p.m., indicated LVN A changed Resident #1's foley catheter using sterile technique and the resident had no complaints of pain or concerns. Record review of a nurse's note written by LVN A, dated 10/21/22 at 2:47 p.m., indicated LVN A notified the lab of Resident #1's urine being ready for pick up for his urinalysis. Record review of a nurse's note written by LVN A, dated 10/21/22 at 5:49 p.m., indicated LVN A assisted Resident #1 to bed for his KUB, the KUB was completed, and results were pending. Record review of the radiology report, dated 10/21/22 at 7:21 p.m., indicated the provider that read the x-ray only recommended close follow up of the resident to exclude bowel obstruction versus ileus. Record review of the nurse's 24-hour report for 10/21/22 indicated the 6 a.m. to 6 p.m. nurse communicated Resident #1 had a foley catheter change, a STAT urinalysis, and a STAT KUB related to severe abdominal pain. The report also indicated the urine specimen was picked up by the lab, the STAT KUB was completed, and the results would be faxed. Staff were to notify the NP that gave the orders. The 6 p.m. to 6 a.m. nurse communicated to watch for Resident #1's catheter position when up in the chair. No communication was noted regarding the KUB results. Record review of the nurse's 24-hour report for 10/22/22 indicated the 6 a.m. to 6 p.m. nurse communicated Resident #1 had nausea and vomiting once. The 6 p.m. to 6 a.m. nurse communicated again to watch the resident's foley catheter placement when up in the chair. No communication was noted regarding the KUB results. Record review of Resident #1's chart during the investigation between 10/26/22 and 10/31/22, yielded no nurse's notes throughout the day or night of 10/22/22. Record review of the nurse's 24-hour report for 10/23/22 indicated the 6 p.m. to 6 a.m. nurse communicated to monitor Resident #1's foley catheter placement and that he had nausea and vomiting once, had active, but sluggish, bowel sounds in all four abdominal quadrants and to monitor him. No communication was noted regarding the KUB results. The 6 a.m. to 6 p.m. nurse had no communication, as Resident #1 transferred to the hospital before the day shift nurse could write anything. Record review of a nurse's note written by LVN B, dated 10/23/22 at 7:00 a.m., indicated Resident #1 was sitting up in bed vomiting green bowl. The resident had faint upper bowel sounds and no lower bowel sounds. The resident said he had an abdominal pain rating of 8 (on a scale of 1 to 10) and requested to be sent to the hospital. LVN B called 911 and the resident left the floor in stable condition, with his vital signs in normal parameters. Record review of Resident #1's hospital paperwork for his stay between 10/23/22 and 10/28/22 indicated Resident #1 said the pain was mostly in his lower abdomen and was a dull ache with nothing making it worse or better. A CT scan, performed on 10/23/22, at the hospital revealed he had a partial small-bowel obstruction and his foley catheter balloon was inflated in the prostatic urethra (the part of the urethra that runs through the prostate of a male). The resident was given an NG tube to assist with suctioning out his stomach. A small bowel test was given to the resident on 10/24/22, using a contrast that is administered either orally or anally. The test yielded no evidence of small bowel obstruction. During an interview and observation on 10/26/22 at 1:20 p.m., Resident #1 said his foley catheter had not been in the right place in his penis and he had a [CONDITION(S)]. He said he was told by hospital staff he had a bowel obstruction. The resident had an NG tube connected to wall suction. The resident's nurse said the resident did not have a bowel obstruction, or the one he did have had resolved on its own. She said he has been having bowel movements, especially after the contrast he was given for his bowel study. She said that sometimes bowel obstructions will resolve themselves due to the NG suctioning at one end of the body and the contrast given for the bowel test coming out of the other end of the body. During a phone interview on 10/28/22 at 11:58 a.m., LVN A denied Resident #1 complaining of pain before the afternoon of 10/21/22. She said he had scheduled pain medication that she gave him for the wounds he had to his bottom. She said on 10/20/22 he complained of a headache and received a pain pill, but that was the only pain he complained of. She said his bowels appeared to be regular due to how often they had to empty and change his [CONDITION(S)] bag. She said he laid in bed all day on the 20th but continued to go out and smoke on the 21st. She said the resident tolerated the replacement of his catheter, but she did not know if it alleviated his pain at all. She said the KUB results did not come back before her weekend off started at 6 p.m. on the 21st. She denied him having any issues with eating or his appetite declining before his abdominal pain started. During a phone interview on 10/28/22 at 2:20 p.m., LVN B said she was the nurse that sent Resident #1 out to the hospital on 10/23/22. She said he was having bowel movements because he blew his [CONDITION(S)] bag out and she had to change it since it was leaking everywhere. She said during her shift on 10/22/22 the resident was asking if they had received the results of his urinalysis. She said he was up in his wheelchair and was acting totally normal. She said as her shift was ending at 6 p.m. on 10/22/22, she and LVN C found the KUB paperwork and were trying to figure out if he had the KUB done or if they needed to have it done. She said she interpreted it as he may have had a blockage. She said she was not told by the night shift nurse, LVN D, on the morning of 10/22/22 that the resident had abdominal pain on 10/21/22 and thought the reason his foley catheter had been changed was because it was just time to change it. She said the night shift nurse, LVN D, was an agency nurse and only told her to make sure they monitored his catheter and to ensure it did not pull or pinch. She said when she came back on the morning of 10/23/22, she was told he had been sick throughout the night and to monitor him. She said she does not know if LVN C, the night shift nurse on 10/22/22, called the physician or not. During a phone interview on 10/28/22 at 3:58 p.m., LVN C said she received report from LVN B at around 6 p.m. on 10/22/22. She said LVN B said something about finding the KUB paperwork, but she had not seen any orders for it. She said at around 2 a.m. she sat down and looked over the KUB that LVN B had shown her. She said she did not notify the doctor or send the KUB results to anyone. She said when she saw the results, she went to the resident and started listening to his bowel sounds, which were decreased. She said the resident told her he was feeling ok and wanted to stay in the facility for a little while longer. She said at around 4 a.m., he threw up for the first time, so she spoke with him and told him they needed to keep monitoring him. She said if he threw up again, she would need to send him out. He did not throw up again on her shift. She said at his morning medication pass at around 5-5:15 a.m. he said he was feeling good and did not need to be sent out. He took his medicines and had no further issues before she left. She said when LVN B returned at 6 a.m., she told LVN B they needed to be monitoring for an obstruction or ileus, but she did could not remember how LVN B had responded. During a phone interview on 10/28/22 at 4:10 p.m. the NP said she was on call for Resident #1's regular NP. She said she was not familiar with any of the residents in the facility. She said she did not exactly recall how things went the day of 10/21/22 since it had been a week ago, but she was pretty sure the nurse told her something to the effect of the catheter is backing up, so she told them to change the catheter, get a STAT urinalysis, and a STAT KUB. She said her shift ended at 5:00 p.m. and she would not have been the one to receive the results of the KUB. She believed the person that took call after her shift was over was a PA that worked in the clinic with her. During an interview on 10/28/22 at 4:35 p.m. the DON said on the evening of 10/21/22 before she left, she let former-ADON F know to follow up on the KUB that was ordered for Resident #1. She said she then left for the weekend and early on the morning of 10/23/22, she received a text message that they were sending Resident #1 out. She said she spoke with former-ADON F and asked her why the KUB had not been followed up on like she was told to do. She said former-ADON F spoke with agency nurse LVN D, who had worked the night of 10/21/22, and asked her why she had not notified anyone of the KUB results. Former-ADON F told the DON that LVN D had not given any reason for the lack in communication. The DON also said that LVN D had failed to transcribe the resident's KUB, urinalysis and foley catheter change on to the 24-hour report for the next shift to see. She said she would be putting LVN D on the do not return list for agency nurses so that errors like this would not occur again. During an interview on 10/28/22 at 4:50 p.m. agency nurse LVN D said she worked on the night of 10/21/22. She denied being notified of Resident #1 having a complaint of stomach pain. She said she was told he had been sitting on his catheter, and that was causing his catheter to stop up. She said she was to be monitoring for him sitting on it. She said she did not remember if she was told he had a KUB completed or not. She said she did not receive the KUB result, and she did not see it when she was on shift that night. She did not remember what she told LVN B the morning of 10/22/22 in report. She said when he went to bed that night that, she gave him his medications and he had no complaints of pain and was pleasant. She said she transcribed the KUB, urinalysis and foley catheter change to the next day's 24-hour report, despite her earlier saying she did not know he had a KUB. She was unable to find the 24-hour report sheet that she wrote the orders on and said someone must have thrown it away. During a phone interview on 10/31/22 at 12:46 p.m., the PA said he had been on call the weekend of 10/21-23/22 but had not received any calls or messages about Resident #1. He said he would remember if he had been notified of a possible bowel blockage or ileus. He said he would have done something about the imaging results had he known about it and had the resident sent out. During a phone interview on 10/31/22 at 3:52 p.m., agency nurse LVN E said she was the nurse that worked with LVN D on the night of 10/21/22. She denied seeing any x-ray results or lab results for Resident #1 during her shift. She also denied taking any calls regarding the results of his KUB. She said he was not her resident, but if she had pulled anything off the fax machine, she would have made a note for his nurse. She did not recall hearing anything about Resident #1 from LVN D. During an interview on 10/31/22 at 3:55 p.m. ADON G said she did not know if former-ADON F had followed up on Resident #1's KUB, but she did say that she should have. She said she would have followed up on the KUB since they have remote access to the electronic charting system, so former-ADON F should have been able to check in from home over the weekend. She said if it had been her resident, she would have checked up on the results, notified the doctor and probably sent the resident out herself to help the nurses since she understood how busy they were. During an interview on 10/31/22 at 4:00 p.m. Resident #1 was up in his electric wheelchair and watching tv in his room. He said he is feeling much better. He said the abdominal pain he experienced started abruptly on 10/21/22 when he notified his nurse. He said LVN C attempted to get him to leave early on the morning of 10/23/22 and he refused. He said when the next nurse came on, LVN B, she told him he had to go to the hospital, and she sent him out. He said his urine backed up into his bowels and that was what made him sick. Record review of a facility Notification of Changes policy, with an effective date of 10/24/22, indicated: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician .when there is a change requiring notification .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status .3. Circumstances that require a need to alter treatment .

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and comprehensive assessment for 2 of 11 residents reviewed for quality of care. (Resident #2 and Resident #5) The facility failed to ensure Resident #2 was assisted to eat his dinner meal after receiving 8 units of a fast-acting insulin. On 2/1/22 Resident #2 was found unconscious, with a blood sugar of 26 and was sent to hospital for further treatment. The facility failed to ensure Resident #5 was assessed and treated appropriately when he showed signs of fecal impaction and decline in condition. Resident #5 declined for 5 days and was sent to the hospital where he was found to have [CONDITION(S)], a large fecal impaction, and dehydration. An Immediate Jeopardy (IJ) situation was identified on 2/17/22. While the IJ was removed on 2/18/22, the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of not receiving necessary treatment and care which could result in decline in health, which could manifest into other health complications, and death. Findings included: 1. Review of Resident #2's face sheet with a print date of 2/15/22 indicated Resident #2's initial admission on 1/26/22 and readmission on 2/7/22. He was [AGE] years old and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan with an initiation date of 2/11/22 for the problem area of diabetes indicated the resident was to have medications as ordered by the doctor and was to be monitored for side effects. Staff were also to monitor, document and report any signs or symptoms of low blood sugar, such as sweating, confusion, and slurred speech. Staff were also to offer substitutes for foods not eaten. The care plan did not address the resident's diabetes/insulin use or his need for feeding assistance prior to the incident on 2/1/22. Review of Resident #2's MDS dated [DATE] indicated he had adequate hearing, unclear speech, understood others, and was understood. He had moderately impaired cognition. He required the extensive assistance of one staff member for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. He received insulin for the 6 days he had been in the facility. Review of Resident #2's January Order Summary Report with a print date of 2/15/22 indicated Resident #2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units; 131-180 = 4 units; 181-240 = 8 units; 241-300 = 10 units; 301-350 units; 351-400 = 16 units; 401+ = 20 units and call MD, subcutaneously before meals for diabetes. Review of Resident #2's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Location of Administration Report sheet indicated Resident #2 received his [MEDICATION(S)] insulin at 5:00 p.m. in his right arm on 2/1/22. Review of meal intake documentation for Resident #2 was not available for the day of 2/1/22. Review of a nurse's note by LVN J dated 2/1/22 at 10:48 p.m. indicated LVN J entered Resident #2's room to check his vital signs at 7:55 p.m. The resident appeared to be lethargic and was uneasy to arouse with verbal stimuli. She performed sternal rubs and the resident would open his eyes momentarily and close them back. The resident was unable to respond verbally to questions being asked. Vital signs were obtained and were recorded a blood pressure of 97/53, pulse 72, oxygen saturation 96% on room air, temperature 97.0. His blood sugar was checked and was found to be 27 (blood sugars below 70 is considered low and blood sugar below 55 is considered dangerously low). A dextrose (sugar water) infusion was administered via IV and started at 8:00 p.m. by RN K. A blood sugar re-check at 8:05 p.m. was found to be 26 and an injection of [MEDICATION(S)] (a hormone which helps reverse low blood sugar) was administered by RN K. The DON was notified, and EMS called. Blood sugar was rechecked at 8:15 p.m. after interventions and was found to be 35. EMS arrived at 8:20 p.m. and took over care of the resident. EMS transported the resident to the hospital for further treatment. Review of a nurse's note by LVN J dated 2/2/22 at 12:03 a.m. indicated the facility was notified that Resident #2 would be admitted to the hospital for low blood sugar and altered mental status. He had imaging done of his head and was found to be negative for any abnormalities. He was going to have other tests and imaging completed while in the hospital. Review of a hospital physician notes from 2/1/22 indicated the Resident #2 was found unresponsive in the facility and had low blood sugar. He was given dextrose and was described as alert by the hospital physician. The resident told the physician he thought he had missed a meal and that was why his blood sugar was low. During an interview and observation on 2/1/22 at 3:13 p.m. Resident #2 was sitting up in a chair. He said on May 1, 2002 he was initially diagnosed with diabetes and his A1C (a lab test that was used to see a person's overall glucose for the past 3 months) was 10.2. According to him his glucose level was about 900. He said he had diabetes for about 2 months and was instructed how to trick his body with different foods to make it think he did not have diabetes. He said he has had no problems since, and he did not remember getting any insulin or going to the hospital because of his blood sugars being low. During an interview on 2/15/22 at 12:00 p.m. LVN H said Resident #2 was on insulin. She said the resident received his evening dose of insulin on 2/1/22 and refused to eat his dinner. She said when the nightshift CNAs began their shift at 6 p.m., they did not feed him. She said his blood sugar dropped low and he was sent out to the hospital. During an interview on 2/16/22 at 11:27 a.m. LVN H said she was Resident #2's regular nurse. She said the resident had been doing well for himself after his hospital stay earlier in the month and when staff offered to feed him the other day he refused and wanted to do it himself. She said the resident needed to be assisted with feeding in the past. She said staff had to unwrap his silverware and pierce his food for him, he then could put the spoon or fork to his mouth. She said she was the nurse that gave him his insulin on 2/1/22. She said she was not sure what insulin she gave him that day, but she thought it was a fast-acting insulin. She said [MEDICATION(S)] was a fast-acting insulin. She said the dinner trays came out later than usual and she was not notified by the off going or on coming aides that he had not eaten before she left at shift change. She said she worked the 6 a.m. to 6 p.m. shift. She was able to provide the names of the two aides that were passing trays that night and said they were not the aides that usually worked on that hall. She said the aides that passed his tray that night would not have known to feed him since they were not his regular aides. She said if a fast-acting insulin was given and a resident did not eat, exactly what happened here can happen, the blood sugar can drop. She said when her relief walked in for the night shift at around 6 p.m., the aides were passing the dinner trays, so the oncoming nurse knew the trays were late. During a phone interview on 2/17/22 at 12:43 p.m. LVN J said her shift started at 6 p.m. on 2/1/22. She said during report she was told by the off-going nurse that Resident #2 was fine and had a good day. She said she usually did walking rounds because she liked to make sure the residents were alive and well. She said that night she didn't do walking rounds because she was relieving the same nurse from the day before. She said when she made a quick pass through her hall, Resident #2 appeared to be asleep. She said at around 6:30 or 6:40 p.m. she was told by the CNA that the resident hadn't eaten his dinner tray and that the resident seemed to be lethargic. She said she tried to feed him herself but at that point she didn't know that he was insulin dependent since he didn't get any kind of diabetic medications on her shift. She said when she tried to feed him, he was unable to swallow and just held it in his mouth. She said she went to talk to RN K and asked what his baseline was. She said RN K didn't know what his baseline was because he was a new resident, but she said she figured it might be his baseline because he had a previous stroke. She said when she looked at his chart, she saw that he had been administered insulin earlier and she went to look for [MEDICATION(S)]. She said she didn't find any, so she went to nurse RN K and asked for [MEDICATION(S)]. She said at that point nurse RN K started an IV and administered dextrose, but they still couldn't find any [MEDICATION(S)]. She said after they started the dextrose, they found [MEDICATION(S)] on a different hall and administered it then, but his blood sugar wouldn't come up. During a phone interview on 2/17/22 at 11:21 a.m. CNA L said she found Resident #2 on the night his blood sugar dropped. She said she came in at about 6 p.m. She said her nurse, LVN J was an agency nurse. She said when she found the resident, he was leaned all the way over, couldn't talk or move and he was very disoriented. She said she had only worked with him once before, but she was pretty sure the last time she saw him that he could speak, so she notified the nurse. She said the nurse came to see the resident and said she was going to go look at his chart and see what his baseline was. The CNA said she left the resident's room and went into a different resident's room. She said when she came back to Resident #2's room later, and he was still altered, she again went to the nurse to ask what she found out about the resident. The nurse said she called someone who told her it was the resident's baseline due to his previous stroke. She said she did not know who the nurse called. She said when the nurse went to see the resident, she did not do any kind of assessment, she only said she would look at his chart. She said she stressed it to the nurse that the resident seemed off to her and that he was not quite right. She said when she went to the nurse, the nurse was getting vital signs on a different hall. She said the nurse worked her way down the halls and when she got to Resident #2's vital signs, that was when she realized his blood sugar was 27. The aide said she had been in a room with a different resident and when she came out of that room, she saw the LVN J and RN K in Resident #2's room. She said the nurses were freaking out about his blood sugar being so low. She said the nurses tried to give him 2 different medications and his blood sugar continued to be low, and he kept not responding, so the nurses called 911. She said she did not receive a change of shift report from any aide because they had already left by the time she arrived. She said she was not sure if the resident needed assistance with feeding. She said when she got there that evening, his dinner tray was in his room and was untouched. She said his dinner tray was right by his bed, and when she saw he was about to fall out of his chair, she helped him sit upright and moved the tray out of the way. During an interview on 2/16/22 at 3:40 p.m. CNA C said she had not worked with Resident #2 prior to 2/1/22. She said his aide had left that day at 2 or 3 that afternoon and the dinner trays came out late that evening. She said she and the other aide did not know he required assistance with eating, so they put the dinner trays out and they left because it was shift change. She said they saw one person coming in to relieve the aides and it was already after 6 p.m. Review of a daily staffing sheet for 2/1/22 indicated the CNA that would have worked on Resident #1's hallway worked from 6 a.m. to 3 p.m. and another aide worked from 6 a.m. to 2:30 p.m. Review of a clock in sheet for CNA L indicated she did not clock in for her shift until 6:18 p.m. During an interview on 2/16/17 at 4:35 p.m. the DON said she was aware Resident #2's blood sugar levels dropped, and he was sent out to the hospital, but she did not know the resident did not receive any food. She said she did not have a clue and the resident not receiving food with the insulin could have been detrimental to his health. During an interview on 2/17/22 at 11:50 a.m. the DON said she was not aware the reason for Resident #2's decline was due to insulin or the timeline of events that occurred on 2/1/22. During a phone interview 2/18/22 at 4:40 p.m. RN K said she was working the night that Resident #2's blood sugar dropped. She said LVN J came out of the resident's room and asked for [MEDICATION(S)]. She said she tried to get into the facility pyxis and but could not get into it, so she started an IV on him and administered dextrose. She said she found someone else's dextrose and administered it to the resident because she felt this was an emergency and he needed something quickly. She said LVN J was trying to find something like honey or [MEDICATION(S)] to put in his mouth. She said he wasn't awake enough to eat and it would have been dangerous to attempt to feed him. She said LVN J was told in report that the resident was in the facility for recovery from a stroke and that the resident was alert. She does not remember if she saw his food tray in his room or not. She said LVN J mentioned that she wondered if he had insulin on the previous shift and when she looked in his chart, she saw he was given insulin. She said LVN J also said she wondered if he was given the wrong insulin or more insulin than was supposed to be given. She said he never regained consciousness with them in the facility. During an interview on 2/18/22 at 11:54 a.m. CNA O said the aides were now supposed to stay until their relief arrives to give report. She said in the past it had been common for aides to leave before their relief arrived. During an interview on 2/18/22 at 3:14 p.m. CNA N said staff were supposed to wait on their relief to give and get report at shift change. She said this does not always happen and it depended on who they were relieving and who they were being relieved by. During an interview on 2/17/22 at 11:12 a.m. the DON said the facility had not taken any of the medication issues to QAPI because they had not had a QAPI meeting since the issues had occurred but said they would be discussing the issues at the next meeting. During an interview on 2/17/22 at 1:45 p.m. the DON said the facility did not have any kind of policy regarding insulin administration. Review of the [MEDICATION(S)] website, https://www.mynovoinsulin.com/insulin-products/[MEDICATION(S)]/home.html, accessed on 2/25/22, the following was noted: .[MEDICATION(S)]® starts acting fast. Eat a meal within 5 to 10 minutes after taking it . . Serious side effects can lead to death, including: Low blood sugar. Some signs and symptoms include: anxiety, irritability, mood changes, dizziness, sweating, confusion, and headache . .Get emergency medical help if you have: trouble breathing, shortness of breath, fast heartbeat, swelling of your face, tongue, or throat, sweating, extreme drowsiness, dizziness, or confusion . 2. Review of an Admission Record Face Sheet indicated Resident #5 was a [AGE] year-old male admitted to the facility on [DATE]. His last readmitted was 1/13/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Care Plan last revised on 10/27/21 indicated: The resident had a problem with constipation related to decreased mobility. The goal was the resident was to pass soft formed stool at the preferred frequency of every 2 to 3 days. Interventions were to give medications as ordered, to monitor, and document complications related to constipation. Monitor for a change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, slow or low pulse, abdominal distension, vomiting, small loose stools, fecal smearing, bowel sounds, diaphoresis (abdominal sweating), abdomen tenderness, guarding, rigidly fecal impaction. Record bowel movement pattern each day. Describe amount, color, and consistency. Review of Resident # 5's Quarterly Minimum Data Set (MDS) dated [DATE] indicated his Brief Interview for Mental Status (BIMS) score was 13 which indicated he was cognitively intact. For toilet use the resident was listed as totally dependence with the assist of one person. Review of Resident #5's Nursing written by RN E notes indicated: On 1/3/22 at 10:26 a.m. the family called and reported the resident seemed to be sleeping too much lately. They requested labs if possible. The NP was notified with new orders for complete blood count (CBC), Comprehensive Metabolic Panel (CMP), glycated hemoglobin (A1C) urine analysis (UA), a lipid profile to be completed. Review of Resident #5s Lab Report dated 1/4/22 indicated a glucose level as low 45 the range (70-110) Platelets count low at 31 range (134-319) the last lab completed on 11/23/21 his platelet count was 47. Blood Urea Nitrogen (BUN) measures the amount of nitrogen in your blood, the lab is done to see how well your kidneys are functioning. His level was 25 high ranges (7-24.) AST was high at 58 range (5-34) the las lap on 11/23/21 the AST was 21. Review of Resident #5's Nursing written by RN A notes indicated: On 1/4/22 at 6:44 p.m. The resident is sleepy and required mild stimulation for arousal, no pain complaints, slight facial drop noted on the right side, the resident was assessed by NP with no new orders. He was more awake and talkative in the evening. A UA was done, and the results faxed to the NP. On 1/5/22 at 7:14 p.m. Resident #5 sleepy arouses with mild stimulation. A new order noted for Fosfomycin- one dose. Order confirmed. He complained only of his feet hurting on this shift. No acute distress, continue to monitor level of awareness throughout the shift. On 1/6/22 at 12:00 a.m. listed as the time of encounter. The note was written by the NP. The chief complaint of Resident #5 was change in condition. History of present illness. The patient was seen for change in condition on 1/3/22 the patient was reported to be more lethargic per staff, labs were ordered. On 1/4/22 the labs came back with normal values. The UA was positive for [CONDITION(S)]. The Patient was treated on 1/5/22 with Fosfomycian (antibiotic) one day treatment) orally. On 1/6/22 the patient was reported to still be symptomatic, so fluids were ordered via PEG tube since the facility was out of clysis kits (infusion start up kit) and the patient has problematic veins. The Gastrointestinal exam revealed abdomen soft nontender and without masses, bowel sounds active, no guarding or rigidity, Gastronomy tube site skin dry, clean, and intact. The note was documented as e signed by NP on 1/7/22 at 10:20 a.m. On 1/6/22 at 1:19 a.m. Fosfomycin was given as ordered. On 1/6/22 at 10:56 a.m. Acetaminophen 600 mg was given by mouth every 6 hours as need for pain or fever. The note indicated the pain scale was a 3 and follow up effective. On 1/6/22 at 3:48 p.m. day 1 post Fosfomycin with no adverse reactions noted. The resident is resting in bed with eyes closed. He continues with increased lethargy. The NP is aware. He opens his eyes to verbal and tactile stimulations. Orders for 300 ml of H2o per tube every 4 hours times 4 doses. The resident was notified and voiced understanding. On 1/7/22 at 6:30 a.m. accuchecks two times a day for diabetes. The resident was given orange juice with sugar followed by ensure supplement. On 1/7/22 at 8:52 a.m. the resident continues with altered mental status, requiring extra stimulation to respond. He is not eating or drinking. His fasting blood sugar was 67 this am. The resident was given orange juice followed by ensure via peg tub. The NP was notified and awaiting response. The family was notified and requested the resident be sent to the emergency room . Emergency medical services notified and picked up the resident for transport via stretcher. Nursing notes dated 1/4/22 to 1/7/22 did not indicate bowel assessments were being completed. Review of Resident #5's facility Order Summary Report dated 1/13/22 indicated: an order dated 1/3/22 for UA, CBC, CMP, A1C, Lipid profile and discontinued. Fosfomycin [MEDICATION(S)] Packet 3 gm ordered 1/5/22 and completed 1/6/22 H2o fluid bolus given 300 ml bolus per tube every 4 hours for 4 doses dated 1/2/22 to be completed on 1/7/22. Send to the emergency from for evaluation per family request dated 1/7/22. Acetaminophen Tablet 650 mg order dated 1/6/22 discontinued [MEDICATION(S)] Sodium Capsule 100 mg give one capsule by mouth two times a day for constipation with an order date of 1/14/22. Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a hospital History and Physical dated 1/7/22 indicated Resident #5 was admitted to the hospital on 1/7/22 due to confusion. The physician said he could not get much information from him, he just moans. The emergency room investigation with [CONDITION(S)] (a condition in which you have a low blood platelet count) with platelet count of 42, black tarry stools, creatinine at 2.6 and a CT scan of his abdomen with significant fecal impaction. The vital sign indicated his blood pressure was 123/ 62. He physical exam indicated examined within the emergency room . Elderly male that moans. He will briefly open his eyes before drifting back to sleep. His abdomen is soft and appears to be moderately distended. He is sitting in black liquid stool. The Plan: Altered metal status unclear etiology probably metabatic [CONDITION(S)] (problems in the brain caused by a chemical imbalance in the blood usually due to an organ not working well). Cultures were collected to evaluate for bacteremia, empiric (directed against an anticipated and likely cause of infectious disease.) antibiotics with [MEDICATION(S)] ( a penicillin type antibiotic.) Possible urinary tract infection. Renal failure that appears to be acute, intravenous hydration and reassess, probable GI bleed with black tarry stools. He has a history of GI bleed, intravenous [MEDICATION(S)] and serial hemoglobin. Nutrition chronically via tube feeding which are on temporary suspension resume when he has adequate GI function. Significant fecal impaction of the lower colon and sigmoid and rectum. His bowels appear to be moving following the contrasted CT scan. Continue [MEDICATION(S)] and [MEDICATION(S)] and follow serial exams. Review of a hospital Imaging Report dated 1/7/22 indicated the impression consistent with [CONDITION(S)] involving the rectosigmoid colon, with extensive fecal matter in the colon. During an observation and interview of Resident # 5 with RN A on 2/15/22 at 1:28 p.m. Resident #5 was laying on his back asleep. RN A came into the resident's room and called his name loudly. He woke up and said he was fine. He could not remember the events that led up to his hospitalization . RN A said she was notified Resident #5 had a change in condition. She went into his room and tried to wake him. She said she had called his name and did a sternal rub. She notified the NP of the change in condition. The first day he was sleepy but woke up some that afternoon. RN A said she did not remember anyone telling her the resident may be constipated. RN A said she could not remember the exact events leading up to Resident #5's hospitalization . She said his only complaints during his time of decline was tired or sleepy. During an interview on 2/15/22 at 2:54 p.m. CNA B said on 1/4/22 she had gone into Resident 5's room and he was very sleepy. He was hard to wake him up and she had to wake him up several times to get him to eat his breakfast. She said he did get a little better later in the day, but he did not want to get up. He usually gets up every day. She said on the second day he was very confused. She did get him up, but he was so confused, she put him back to bed in about an hour. She said every day when it was her shift he was up from 10 a.m. to 2:00 p.m. He did not really have a bowel movement. She said he would have little smears in his brief, and she would wipe his bottom. However, he appeared to be constipated. She said she told the nurse(unknow). CNA B said they were provided information on textures of BM. She said Resident#5 only had smears. There was never any bowel movement in his brief. She said she did not dig but just wiped a small amount from his bottom. It was like it was stuck in the folds of his bottom. She said she documented in the kiosk that he had small bowel movements. She said since he has been back from the hospital, he now has big bowel movements. During an interview on 2/16/22 at 8:54 a.m. the DON said between 1/3 and 1/7/22 Resident #5 had a decrease in his level of consciousness. Resident #5 had orders written for labs on 1/3/22 and the UA came back on 1/4/22. The culture and sensitivity was completed on 1/6/22. The NP was in his room daily during that time. The NP was available from 8-5, five days a week, and for off hours she has someone on call for her. The DON said the signs of a bowel impaction, are oozing runny stool. It is not a bowel movement, and an educated (nurse) person knows the difference. She said they did not have a policy it was a clinical judgement or at the judgement of the clinician to determine if a resident needed to go to the hospital. She said she knew he had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/16/22 at 3:40 p.m. CNA C said Resident #5 was sick for about a week. CNA C said, her and CNA D told the facility about a week to send Resident #5 to the hospital. During an interview on 2/17/22 at 9:51 a.m. the NP-C Family nurse practitioner Certified said she recalled Resident #5 having a change in condition on 1/3/22. On 1/4/22 RN A told her, he was not his self and did not want to get up. She ordered labs; his vital signs were stable. He would wake up but would go back to sleep. On 1/5/22 she ordered an antibiotic. It came the next day. His vital signs were good, and they began giving him fluids down his tube. On 1/6/22 gave him the antibiotic. She tried not got give long course of antibiotic only one day treatment. She said there was not mention of constipation. The NP said from her understanding and the aide documentation he was having stools regularly . She said Resident #5 stayed the same on dates 4, 5, and 6th. He would say he was tired. On the 7th the family said send him out to the hospital. When the hospital records were reviewed with the NP. She said the stomach assessment was completed by her and she was not aware of any symptoms of constipation. She said the impaction did not happen over night. He had no complaints about pain when she conducted her evaluation. The NP said typically what happens was the fluid goes around the impaction. She was informed the aide said he was having smears and no real bowel movement just fecal matter just inside the folds of his bottom. The NP said having smears may be signs of a semi -impaction. During an interview on 2/17/22 at 10:33 a.m. CNA D said she worked on New Year's weekend and Resident #5 was already declining. She said the resident would usually get up daily. She said he gets up around 10:00 a.m. and goes back to bed around 2:00p.m. She said, A few days prior to hospitalization he did not want to get up. He did not remember things, he was more confused, and he could not stay awake. He could not feed himself, she had to feed him. She said the resident was really confused, he would answer two different things to the same question. She said he was so sleepy if he was awake while she was on one side of the bed. By the time she got to the other side he was asleep. She said his bowel movements were always small. They were soft but not runny. She said there was never anything in his diaper only smears. She said you had to wipe the bowel movement out of the canal. She said the last two days he was here on 1/6 and 1/7 he could not talk. He did not have the strength. He did not complain about any pain. She said he was not a complainer. He would not have complained even if he could. The family had called and wanted him to receive labs on the Monday 1/3/22. He was sent out on Friday 1/7/22. He was declining all week. The family had said he was slowing down prior to his actual change in condition. She said she reported everything to the NP. CNA D said Resident #5 never complained. Even when he was doing badly, he never complained of anything. During an interview on 2/17/22 at 10:47 a.m. RN E said Resident 5's family called on Monday 1/3/22 and wanted lab work completed on the resident. She said the resident had declined all week. RN E said she was off Tuesday and Wednesday and when she came back on Thursday 1/6/22 it was a noticeable decline. She said CNA D started feeding him because he was unable to feed himself. She said he never complained of any pain. He was not a complainer and would not even if he could. By Thursday 1/6/22 he was not even talking he was so weak. RN E said CNA D reported everything. CNA D was real concerned about Resident #5. She said the NP prescribed him antibiotic that was a one-time dose that did not appear to make him any better. They were ordered to give him H2o flushes and that did not help either. The family was asking how he was doing on 1/7/22. The family decided to send him to the hospital. The administrator and DON were notified on 2/17/22 at 3:08 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. During this time the administrator said the facility did not have many policies due to their corporate office's stance that not having policies meant that HHSC could not hold them to a policy when it was not followed. The administrator and DON were notified on 2/17/22 at 3:08 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. During this time the administrator said the facility did not have many policies due to their corporate office's stance that not having policies meant that HHSC could not hold them to a policy when it was not followed. The facility's Plan of Removal was accepted on 2/18/22 at 12:44 p.m. and it read: 1. The facility failed to care plan a resident to reflect an appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Plan of Correction are as follows: o 100% audit of resident Care Plans completed by MDS coordinator to ensure accuracy of plan of care for residents requiring assistance with meal services. Completed 2/17/22. This audit was reviewed by the Director of Nurse. o Re-education was conducted by administrator to the clinical management team on Purpose and Goals of Resid

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured accurate administering of all drugs to meet the needs of the residents, for 1 of 11 residents reviewed for medication regimen. (Resident #1) The facility failed to ensure Resident #1's [MEDICATION(S)] (blood pressure medication) patches were removed and replaced as ordered by the physician. On 2/11/22 Resident #1 was found sweating, with low blood pressure and altered mental status. Resident arrived at theER on ,d+[DATE] with low blood pressure, altered mental status, accidental overdose of medication, and a [CONDITION(S)]. An Immediate Jeopardy (IJ) situation was identified on 2/17/22. While the IJ was removed on 2/18/22, the facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for adverse effects, death, and decline in health. Findings included: 1. Review of Resident #1's face sheet with a print date of 2/15/22 indicated Resident #1's initial admission on 11/10/19 and readmission on 2/15/22. She was [AGE] years old and had diagnoses including: high blood pressure, acute kidney failure, diabetes, and heart failure. Review of Resident #1's care plan indicated an initiation date of 4/29/20 for the problem area of high blood pressure related to heart failure. Interventions for this problem included giving blood pressure medications as ordered and monitoring for side effects such as low blood pressure and high heart rate. The care plan did not specifically address the [MEDICATION(S)] patches. Review of Resident #1's MDS dated [DATE] indicated she had adequate hearing, clear speech, made herself understood and usually understood others. She had moderately impaired cognition. She required the extensive assistance of two staff members with bed mobility, dressing and toilet use and the limited assistance of one staff member with transfers. Record review of Resident #1's Order Summary Report with active orders as of 1/1/22 and with a print date of 2/15/22 indicated Resident #1 had an order for [MEDICATION(S)] patch weekly 0.2mg/24hr, with instructions to apply 1 patch transdermally (on the skin) every Friday for high blood pressure and remove during the night shift. Review of Resident #1's January MAR indicated the resident had an old [MEDICATION(S)] patch removed and a new patch placed on 1/28/22 by CNA F. Review of Resident #1's February MAR indicated the resident had an old [MEDICATION(S)] patch removed and a new patch placed on 2/4/22. Review of a nurse's note by LVN G dated 2/11/2022 at 2:35 p.m. indicated Resident #1 returned from therapy in her wheelchair and was sitting in her room, sweating profusely. She had noted altered mental status and was lethargic. Her blood sugar was checked and found to be 190. Her vital signs were checked, and her blood pressure was found to be 88/43, pulse of 48, respirations of 22, temperature of 99.1, and oxygen saturation of 95% on room air. The resident was transferred to the hospital for evaluation and treatment. Review of Resident #1's hospital records, dated 2/11/22, indicated the resident arrived at the ER with low blood pressure, altered mental status, accidental overdose of medication, and a [CONDITION(S)]. The physician indicated the resident was found to have 2 [MEDICATION(S)] patches and had a blood pressure of 80/40. She was given fluids to rehydrate her and had the patches removed and began showing noted improvement. During a phone interview on 2/24/22 at 3:06 p.m. LVN G said on 2/11/22 she was notified by another staff member that Resident #1 was lethargic and had altered mental status. She said the resident had recently returned from therapy. She said she checked the resident's blood sugar, and it was between 190 and 200. She said the resident's blood pressure was low and since she was acting differently, they chose to send her out. She said she was concerned the resident was having another stroke, since she had one in January. She said she wasn't aware at the time that the resident had more than one [MEDICATION(S)] patch on because at that time the medication aide was the one administering the patches. During an interview on 2/16/22 at 9:43 a.m. the DON said Resident #1 had returned from the hospital on 2/15/22. She said she was told after the resident was sent out to the hospital that the resident had 2 [MEDICATION(S)] patches on her body. She said she was told by staff that the resident got back from the therapy department and was sweating profusely, and her blood pressure was 80's/40's. She said her blood sugar was fine. She said the resident has vagaled down (a term for when the vagus nerve is stimulated which can cause numerous symptoms such as a decrease in blood pressure, sweating, nausea, and lightheadedness) before and had her blood pressure drop as well as with past [CONDITION(S)]'s, but they did not know what was wrong with her the day she was sent out. She said she was notified that the resident's family member had called the facility to notify them that the resident had 2 [MEDICATION(S)] patches on in the ER and that one of them was dated for the month of January. She said she had since moved the patches from the medication aide MAR to the skilled nurse's MAR for the nurses to begin changing the patches. She said she had been waiting for the hospital records to be sent to her to confirm if the resident had 2 patches on at the ER before she investigated it further. She said when she received the records, she saw they did confirm the resident had 2 patches on. She said at that point she made the changes to the MAR and began an in-service about the transdermal patches being moved to the skilled MAR and that the removal of the old patch and location of the new patch must be documented. She said she had not yet spoken with the medication aide that made the error. She said she was unaware of this issue ever happening before. She said the resident was ok now and this error could have led to the resident's death. During an interview on 2/16/22 at 10:42 a.m. Resident #1 was lying in bed. She said she remembered right before going to the hospital that she felt lightheaded and that she was going to faint. She said when she got to the hospital, the staff told her that her blood pressure was low. The resident said she had no complaints. She wore two patches, a pain medication patch and a blood pressure patch. She said she wore the patches on her back, and she did not know when she had them on and when she did not. During an interview on 2/16/22 at 10:48 a.m. CNA F said she gave Resident #1 her medications the morning of 2/11/22. She said she did not give the resident her [MEDICATION(S)] patch because the resident would not need one until Friday. She said she did not have any [MEDICATION(S)] patches on her cart. She said she looked at the resident's MAR and could not find the [MEDICATION(S)] patches. She said the medication may have been on the nurse's MAR, but she was unsure. She said she was not aware of leaving a medication patch on a resident and she took the patches off as far as she was aware. She said no one had said anything to her about leaving a patch on a resident. She said she had just placed a [MEDICATION(S)] patch on the back of Resident #1, which she got every day for pain. During an interview on 2/16/22 at 11:56 a.m. CNA F said she just recently was told that she wouldn't be administering [MEDICATION(S)] patches any longer because of Resident #1 having 2 patches on at the ER. She said she didn't see any other patches on the resident when she placed the new patch on the resident. She said she was sure staff were supposed to initial when they removed a patch, but she wasn't sure if she did or not. She said that medication patches could come off the residents in the shower or fall off on their own. She said she was told the patch loses strength over time but could still hurt the resident if more than one patch was on at a time. She said she did not think she was ever educated on what would happen if more than one patch was applied at a time, but it could have been in the directions on the box. She said the resident was getting sick kind of late in the day but that the resident had been sick in the same way in the past. During an interview on 2/18/22 at 11:24 a.m. LVN M said Resident #1's family member called and notified her of the resident having 2 blood pressure patches on at the ER. The nurse said the family member indicated she was sure it was an accident but wanted to know who she needed to speak to about it so that it didn't happen again. She said she believed Saturday 2/12/22 was when she received the call. She said she told the family member they would need to speak with the DON about it and the nurse notified the DON as well. She was unsure if the DON spoke with the family member or not. She said she was in-serviced the next day, on Sunday, on making rounds and checking on the residents. During an interview on 2/18/22 at 12:27 p.m. the ADON said she would expect the nurse's and medication aides to look for an old medication patch before administering a new one. Review of a transdermal patches in-service dated 2/15/22 indicated that effective immediately all transdermal patches would be placed on the skill nurse's MAR and that the LVN/RN would remove the old patch and place then new patch. The removal and administration location needed to be documented each time a patch was removed or a new one was placed. The in-service also stated that under no circumstances should a patch be placed if the old one could not be located. Review of the [MEDICATION(S)] Plus website, https://medlineplus.gov/druginfo/meds/a 9.html#overdose, accessed on 2/25/22, the following was noted: .In case of emergency/overdose If someone applies extra [MEDICATION(S)] patches, remove the patches from the skin. Then call your local poison control center .If the victim has collapsed or is not breathing, call local emergency services at 911. Symptoms of overdose may include the following: [CONDITION(S)], slow heart rate, difficulty breathing, shivering, slurred speech, tiredness, confusion, cold, pale skin, drowsiness, weakness, smaller pupils (black circles in the middle of the eyes) . During an interview on 2/17/22 at 11:12 a.m. the DON said the facility had not taken any of the medication issues to QAPI because they had not had a QAPI meeting since the issues had occurred but said they would be discussing the issues at the next meeting. The administrator and DON were notified on 2/17/22 at 3:08 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. During this time the administrator said the facility did not have many policies due to their corporate office's stance that not having policies meant that HHSC could not hold them to a policy when it was not followed. The facility's Plan of Removal was accepted on 2/18/22 at 12:44 p.m. and it read: 4. The facility failed to administer and remove a transdermal medication resulting in the hospitalization of a resident. The Plan of Correction are as follows: o 100% Order Audit completed for residents receiving transdermal medications to validate removal order in place for medication by the Director of Nurses initiated and completed on 2/17/22. o 100% skin audit conducted on 2/18/22 for all residents receiving transdermal medications, no adverse findings found on this day. o All transdermal medications transcribed to the Skilled Medication Administration Record for RN/LVNs to administer/remove medications on 2/15/22. o All RNs/LVNs/CMAs re-in-serviced on transdermal medication administration and removal process. In-service initiated 2/15/22. Employee is required to complete prior to the start of his/her next shift. A QAPI meeting was conducted, and the Medical Director was notified on 2/17/22. Facility has taken the steps to address the concerns of the survey team and we are requesting the removal of the IJ. On 2/18/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 3 CNAs on the 6a - 6p shift indicated they had received in-services from the facility regarding reporting to their charge nurse if any resident was noted to have multiple medication patches on their body. Interviews with 4 LVNs and 2 RNs indicated they had received the required in-services. Record review the QAPI Meeting Attendance and Agenda form indicated the facility conducted a QAPI meeting on 2/17/22 at 5:00 p.m. regarding the IJ. The administrator, DON, medical director, infection preventionist, social worker, dietary manager, activities director, and HR director were all present for the meeting. Record review of a reporting on and off duty in-service dated 2/17/22 indicated the facility expectations of staff reporting to their supervisors, and communication necessary to provide appropriate resident care. Record review of a director of nurses and physician notification in-service dated 2/17/22 indicated the expectations of facility staff on when and what to report to the DON and physician. Record review of a transdermal patches in-service dated 2/17/22 indicated that effective immediately all transdermal patches were to be administered by the LVN/RN and a new patch should not be placed without locating the old patch. Record review of an administering medications in-service dated 2/17/22 indicated the facility's expectations of staff when administering medications to residents, who could administer medications and how/when to administer them. Record review of an Order Listing Report dated 2/17/22 indicated the DON audited the residents for prescription patches. 9 residents were listed as having patches. Record review of a February 2022 Audit Information form indicated 9 residents had a transdermal patch, a location and removal order and it was now located on the skilled nurse's MAR. Record review of orders for 9 residents indicated the correct medications, class, order type, route, application, frequency, and schedule. Record review of the skilled MARS for 9 residents indicated the transdermal patches had been moved to the skilled nurse MARS and would be administered per the LVN/RN staff starting from 2/18/22. During an interview on 2/18/22 at 11:24 a.m. LVN M said she was in-serviced that morning before her shift started. She said a lot of information was covered including medication patches, on-going/off-going report, change of condition. She said she was told to make sure the residents with medication patches had the old patch removed before the new one was placed and if they observed more than 1 patch on the resident, they were to report it. During an interview on 2/18/22 at 11:54 a.m., CNA O said she was in-serviced on medication patches and to report if a resident had more than one of the same medication patches on. She said they were now supposed to stay until their relief arrived to give report. She said in the past it had been common for aides to leave before their relief arrived. During an interview on 2/18/22 at 2:53 p.m. RN E said she was in-serviced on transdermal patches. She said they were told to make sure to take off the previous blood pressure patch, date it and chart the location of the new patch. The MAR has been moved from med aides to the skilled nurses. During an interview on 2/18/22 at 3:14 p.m. CNA N said she was in-serviced on medication patches. She said that she was to report to the nurse if the resident had more than 1 patch on. During an interview on 2/18/22 at 3:33 p.m. LVN P said she was in-serviced on transdermal patches. She said staff were supposed to ensure the residents had only 1 patch on and remove the old patch before placing another. The medication aide was no longer to administer the patches and the skilled nurses were to administer them. She said they also addressed the 6 rights of medication administration. During an interview on 2/18/22 at 4:15 p.m. LVN Q said she was in-serviced on transdermal patches. She said they were to ensure the residents who receive medication patches only had one patch on and to remove the old patch before placing a new one. During a phone interview on 2/18/22 at 4:40 p.m. RN K said she was called today and was in-serviced on transdermal patches and to ensure that the residents only had one patch on them. On 2/18/22 at 5:04 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at level of actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards, comprehensive person-centered care plan and choices for 1 of 26 residents reviewed for quality of care. (Resident #51) The facility failed to properly assess, monitor or seek immediate medical intervention for Resident #51 when she verbalized [CONDITION(S)], display increased agitation and ingested an unknown quantity of pills. (Tylenol Extra Strength) This failure contributed to Resident # 50 being hospitalized due to an overdose of Tylenol after to a suicide attempt. An IJ was determined to have existed on 3/3/21. The IJ was removed on 3/4/21 because Resident #50 was sent for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents with [CONDITION(S)] at risk of harm or death. Findings included: Physician orders, dated July 2021, indicated Resident #51 was readmitted on [DATE] and was [AGE] years old. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS, dated [DATE], indicated Resident #51 had clear speech, was understood and could understand. The resident was cognitively intact and had the following mood symptoms present during the 14 days prior to the date of the assessment: little interest or pleasure in doing things for 7-11 days, Feeling down, depressed, or hopeless for 12-14 days Feeling bad about yourself-or that you are a failure or have let yourself or family down 2-6 days and Thoughts that you would be better off dead, or of hurting yourself in some way 12-14 days. The MDS noted Resident #51 was exhibiting verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. The resident's behaviors were noted to significantly interfere with the resident's participation in activities or social interactions. Resident #51 was noted to reject evaluation or care that was necessary to achieve goals for health and well-being and to wander with these behaviors occurring 1 to 3 days. The resident was noted to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated 03/03/21indicated Resident #51 was very protective for her belongings and did not allow staff to assist her with items in her drawers or her purse. The goal indicated Resident #51 would actively engage with staff to help meet her needs. The interventions included educate the resident or remain calm and explain what was being done to help her understand the need to retrieve items from her drawers and monitor items being brought by her family to ensure they were safe as the resident would not allow staff to look at them. Also initiated on 03/03/21 was a care plan indicating Resident #51 had attention seeking behavioral problem where she would make herself vomit and tell family members (per her son) she had ingested medications. Interventions included educate the family not to bring any medications for the resident from the outside, find activities for the resident so she can remain engaged and begin to enjoy her new environment, psych consult as indicated, refer the resident to outpatient psych or acute psych if the condition worsens, and give medications as prescribed. Resident #51's behavior of yelling was addressed in the care plan and was initiated 02/02/21. Initiated 02/12/21 the facility addressed adjustment issues in relation to her admission to the facility and relation to the loss of her home with crying spells. A review of Resident #51's nurses' notes revealed the following entries: 02/02/21- indicated Resident #51 was admitted to the facility to the warm unit (unit for new admissions to be monitored for signs/symptoms of COVID). The note indicated the resident kept saying she wanted to go home. 02/04/21- indicated Resident #51 kept leaving the warm unit. A referral for the in-house psychiatric evaluation. 02/08/21 at 4:34 p.m. indicated Resident #51 had removed her wander guard and refused to allow staff to reapply it. The resident notedly made frequent comments about leaving the facility and going home. Resident #51 was noted with crying episodes and frequent verbal outbursts. Resident #51's son reported the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The in-house psychiatric service agency was noted to not have evaluated Resident #51 yet (referred 02/04/21) 02/09/21 at 10:05 a.m. indicated Resident #51 noted the resident continued to refuse the wander guard to be reapplied. The NP notified of the resident's continued verbal outbursts, crying episodes and refusals of meds/meals and fluids. It was noted the NP was informed of Resident #51's history of suicidal and homicidal tendencies and history of requesting others to kill her. The facility noted the NP was informed the resident had received in-patient psychiatric hospitalization in June 2020 and had medications ordered at that time per records. No new orders provided at that time. -02/11/21 at 2:13 p.m. indicated Resident #51 was transferred to the facility's Secured Unit from the warm unit. 03/03/21 at 12:50 p.m. indicated Resident #51 noted to verbalize she, might as well just die, refused her medications, and refused lunch. There was no indication the resident's physician was notified of her suicidal verbalization or refusal of medications. 03/03/21 at 4:37 p.m. indicated the charge nurse for the Secured Unit was notified Resident #51 potentially ingested an unknown amount of Tylenol Extra Strength that the resident had in her possession. The note indicated the resident was acting out of her normal daily behavior. Resident #51 was noted to have stated, I don't want to be here, my son put me here, my daughter is dead, is my husband dead too. The resident was noted to have vomited x 2. The documentation indicated Resident #51 had been laying supine on her bed and her son was notified of the medication and stated it was in the patient's purse. It was noted that no family brought the medication. The resident's physician was not notified at this time. 03/03/21 at 4:51 p.m. indicated Resident #51 was found on the floor in the bathroom in her room crying, stating she wanted to die. The note indicated the roommate for Resident #51 came to the nurses' station and reported hearing a pill bottle shaking and she thought Resident #51 was taking medication. The roommate was noted to have indicated she did not know how many pills the resident had taken but it sounded like more than a few. Resident #51 was noted to say she had no reason to live. The nurse's note indicated an empty Tylenol bottle was found in the top drawer of her nightstand and Resident #51 was placed back in her bed and left alone in her room. 03/03/21 at 5:05 p.m. indicated Resident #51's physician was notified the resident had possibly taken an unknown amount of Tylenol. The nurse noted telling the physician it was unsure if Resident #51 had actually taken any Tylenol. The physician was noted as saying to monitor the resident. The nurses' note did not indicate the physician was not notified of Resident #51 verbalizing suicidal thoughts or having incidents of vomiting and being found on the floor. 03/03/21 at 7:15 p.m. indicated Resident #51 was found by the CNA beside the toilet on the floor. The resident was noted to have fallen, was cold, clammy, lethargic, with a blood pressure of 80/60 and a weak pulse. 9-1-1 was called at this time. 03/05/21 at 9:30 a.m. indicated Resident #51 returned to the facility from the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 03/07/21 at 6:44 a.m., Resident #51 verbalized several threats of suicide. She was noted to say she would use shoestrings, robe, rope to choke herself. Resident #51 was placed on 1 on 1 close observation, her shoelaces were removed, the nurse practitioner said to send the resident to the ER. It was documented Resident #51 was sent to a local psychiatric hospital. Records from Resident #51's hospitalization , dated 03/03/21 at 11:39 p.m., noted Resident #51's principal problem was accidental acetaminophen overdose. The report noted the nursing home staff apparently found the resident today with an empty bottle of Tylenol, no idea how many Resident #51 had taken or how long since ingestion. The report noted the facility contacted EMS and on their arrival the resident was somewhat hypotensive (bp 80/60), the resident was given fluids in route and again in the ER. It was noted on arrival to the ER the resident's Tylenol level was checked. Resident #51's Tylenol level result was 66.5 (safe range for Tylenol was 10-20). The ER physician contacted poison control. Poison Control recommended initiation of N-[MEDICATION(S)] and bolus dose was initiated in the ER. The report noted in talking with Resident #51's son it was reported the resident has a history of being somewhat manipulative telling people what they want to hear and confabulating to cover up her deficits in memory, as well attempting to leave from hospitalization s and nursing homes. During an interview on 07/06/21 at 10:32 a.m., Resident #51 said she at this time does not feel happy but was not depressed. The resident reported she had overdosed by taking an unknown amount of Tylenol she had brought with her to the facility from home. Resident #51 said when she took the Tylenol she had just been disgusted about being here (in the nursing home) and thought if this is my life, I might as well not be here. The resident said she had not told anyone she was depressed or suicidal because she had not felt that anyone would care. Resident #51 said after she took the pills as time progressed on that day she changed her mind about wanting to harm herself. During an interview on 07/08/21 at 9:14 a.m., the administrator said the facility did not have a policy addressing suicidal ideation. The administrator said if a resident verbalized [CONDITION(S)] the SW would get involved and make a referral in-house psychiatric evaluation or the resident would be sent out psychiatric hospitalization . Staff would be alerted and the resident would be have increased monitoring. During an interview on 07/08/21 at 12:13 p.m., Resident #51's family member said the resident did not have a history of taking medications. The family member said when the resident was admitted to the facility, she had been extremely depressed. Resident #51's family member said the resident had verbalized at that time she wanted to die and did not have a will to live. The family member said he did not know whether Resident #51 had told staff about the verbalizations. The family member said on 03/03/21 the facility notified him the resident was sent to the hospital to get checked out that night due to taking Tylenol but denied being informed Resident #51 had fallen that day. The family member said the ER ran test and found Resident #51 had too much Tylenol in her system and that she was given medicine to counter act it. The family member said he was not sure where Resident #51 obtained the Tylenol from. He said he had not provided her with any medicine as he had known the facility would supply her with the needed medications. During an interview on 07/08/21 at 3:25 p.m., the administrator said following the incident with Resident #51 taking the Tylenol staff were provided education regarding going through resident's items to the best of their ability without infringing on the resident's rights. The administrator said the facility now goes through resident's items and if there is any resistance they get the family involved within the next 24 hours. The administrator said this was always in effect but was just reinforced. The administrator said no policy related to [CONDITION(S)] or attempts was put in place but staff were educated about what to do if a resident verbalized suicidal thoughts. The administrator said a resident should not be left alone if making suicidal statements, staff should try to redirect the resident, keep them as calm as possible, and refer them for psychiatric services. He said in relation to Resident #51 the facility had not known if the pill bottle was already empty. The administrator said the facility, probably should not have waited 3 hours before calling someone to send Resident #51 out of the facility. The administrator said anytime anyone threatens to harm themselves it should be taken seriously and the resident closely monitored and not left alone. During an interview on 07/08/21 at 4:13 p.m., CNA N said she worked the 6 a.m. to 6 p.m. shift on 03/03/21 with Resident #51. The CNA said the resident was more depressed, crying and just shouting out. CNA N said Resident #51 said she wanted to die rather than being in the facility and that she wanted to kill herself. CNA N said she and LVN T were at the nurses' station on the Secured Unit when Resident #51's roommate came to the nurses' station and reported Resident #51 had taken a whole bottle of pills. CNA N said she thought she found the empty pill bottle in Resident #51's top drawer of her nightstand. The CNA reported taking the bottle to LVN T. CNA N said when the empty bottle was found the resident appeared the same (did not seem sick). CNA N said as time went by, however, Resident #51 became, real red in the face, was vomiting, sitting on the floor and saying she was sick after about an hour. The CNA said the resident was left to rest in her room during the time. CNA N said when Resident #51 voiced being suicidal she took the resident serious but was not sure that anyone else did, because nothing was done. The CNA said she worked at the facility approximately 15 months and had never received an in-service on working with a resident that verbalized suicidal thoughts. CNA N said following the incident she did not recall being in-serviced about suicidal resident care. The CNA said if an in-service was done it occurred after she left the facility at the end of March 2021. CNA N said she did not know where Resident #51 got the bottle of Tylenol from. The CNA said when residents were admitted to the facility their items were supposed to the checked for medications, weapons and hazardous materials. CNA N said Resident #51 was on the warm unit in isolation before being transferred to the Secured Unit. The CNA said the resident's items should have been searched before she came to the secured unit. During an interview on 07/08/21 at 4:37 p.m., CNA P said she worked as needed (prn) and tended to work 7:30 a.m. to 5:30 p.m. CNA P said with Resident #51 she was not sure why she was on the Secured Unit as the resident seemed to be more alert and oriented. CNA P said there was a 2 week gap between the time she worked with Resident #51 and when she got to work with the resident again, on the secured unit, she had changed. CNA P said Resident #51 was yelling, staying to herself, and stopped eating. The CNA said the resident appeared very depressed, sad, argumentative, and then stopped saying anything to her or anyone. The CNA said the resident had not verbalized any suicidal thoughts to her. CNA P said she had been employed for 3 ½ years and that she had received an in-service about working with residents that were suicidal about 2 years ago in relation to another resident who had tried to leave the facility and harm themself. CNA P did not recall an in-service regarding addressing suicidal residents following the incident with Resident #51. The CNA said if an in-service was done it was just a matter of the facility putting out something to read and then staff signed that they reviewed it. CNA P it was not a verbal in-service as she did not receive one. During an interview on 07/08/21 at 5:11 p.m., CNA Q said Resident #51 had Tylenol in her purse was what she was told following the incident. The CNA said the resident had not been herself on 03/03/21 with increased crying. CNA Q said she was not informed Resident #51 had verbalized wanting to kill herself, that she had taken Tylenol, nor that she needed to keep an eye on the resident. CNA Q said she had received training on what to do if a resident made suicidal threats, before and after Resident #51's incident. The CNA said if a resident verbalized suicidal thoughts staff were to stay with the resident and notify the nurse. CNA Q reported being in-serviced on searching resident's items, that residents were not allowed to keep certain items. During an interview on 07/08/21 at 4:54 p.m., corporate nurse said she had not participated in any of the in-service regarding suicide on 03/04/21. She said she had arrived to be the interim DON for the facility either mid-day or evening on 03/04/21. The corporate nurse said the administrator had completed some of the in-services related to residents displaying [CONDITION(S)] prior to her arrival. The corporate nurse denied there being a policy related to residents displaying [CONDITION(S)] but indicated the procedure in case a resident verbalized suicidal thoughts was that the resident would be placed on 1 to 1 close observation, the DON notified, and psych services to clear before the resident is removed from the 1 to 1. The corporate nurse said staff were educated that all residents should have their belongings searched with the responsible party's consent. During an interview on 07/08/21 at 12:15 p.m., the medical director said she was aware of Resident #51 expressing suicidal thoughts on 03/03/21. The director said she did not become the medical director said she was Resident #51's physician at the time of the overdose incident and said she was not the medical director at that time. She said if a resident verbalized [CONDITION(S)] the facility would get a psych consult. The medical director said she was contacted about Resident #51 on 03/03/21 and the resident was not sent out because nursing staff could not determine if the resident had taken the Tylenol and reported they thought the bottle could have been empty prior to the incident. Resident # 51 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record reviews indicated no other resident was sucidical in the facility. 6 nurses, the activity assistant, 4 CNAs, 2 MA, the AD, the ADON and the SW were interviewed on different shifts regarding the policy and procedure for addressing residents verbalizing suicidal thoughts and how to address it. All staff were able to verbalize the correct procedures, and able to identify suicidal threat/ideation warning signs including verbal, psychological, emotional, behavioral and situational. IJ was determined to have existed from 3/3/21 through 3/7/21. The IJ was removed on 3/8/21 because Resident #51 was no longer in the facility she was sent to a hospital to receive treatment. The facility remained out of compliance at actual harm which was isolated.

Based on interview, and record review the facility failed to ensure acceptable parameters of nutritional status based on the comprehensive assessment was maintained for 1 of 3 residents (Resident #3) reviewed with a gastrostomy tube (a tube that is surgically inserted into the abdomen and used to supply nutrition and hydration when an individual has trouble eating). The facility failed to ensure Resident #3 was provided fluids as ordered to maintain his hydration needs. Resident #3 was admitted to the hospital for dehydration, hypothermia, and acute kidney failure after the family initiated a call to 911 due to family's concern that he was not receiving proper nutrition and hydration. This failure could place dependent residents at risk for dehydration, illness, and decreased quality of life. Findings included: Review of Resident #3's face sheet indicated a re-admitted into the facility was 5/25/2021. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated Resident #3 was NPO related to dysphagia, was ordered flush PEG tube every 4 hours with 85 ml of water before and after each bolus, and [MEDICATION(S)] ([MEDICATION(S)]) via PEG (type of gastrostomy tube) tube one time a day. An MDS dated [DATE] indicated Resident #3's cognitive skills for daily decision making were severely impaired and no behavior was exhibited for rejection of care. The resident required extensive assistance of one-person physical assist for eating, he did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, and dehydration was not checked as a problem condition. A progress notes dated 5/25/2021 and timed 5:53 p.m. indicated Resident #3 was readmitted into the facility from the hospital with a PEG tube. A Dietitian/Nursing/Physician Communication Form dated 5/31/2021 indicated .1. D/C Nepro at 45 ml/hr, D/C 200 ml flush every 6 hours 2. Add [MEDICATION(S)] 1.5 (237-ml bolus feed every 4 hours). 3. Add 85 ml flush before and after feeds. Tube feeding will provide 2130 kcal, 90.6 grams protein, and 2100 ml fluids. The Dietitian signed the Dietitian/Nursing/Physician Communication form. A nutrition/dietary progress note dated 6/21/2021 and timed 1344 indicated . Resident receives Two Cal HN 237 ml four times a day with 85 ml water flush before and after bolus feeds. Tube feeding provides 1900 kcals, 7906 grams of protein, and 1344 ml fluids +med flush. Pertinent meds, [MEDICATION(S)]. Estimated needs 1805-1875 kcals, 65-81.3 grams of protein, and 2030 ml of fluids. RD recommends add 175 ml of water flush every 6 hours. The note was e-signed by the dietitian. An electronic skilled administration record dated 6/1/2021 - 6/30/2021 indicated nursing initials that tube feedings and flushes were administered as ordered. During an interview on 6/30/2021 at 12:53 p.m., the DON said the facility did not have a policy for hydration or tube feeding. She said the clinical evidence showed Resident #3 was dehydrated, therefore it probably meant the nursing staff falsified documentation regarding them administering the flushes and the bolus feedings as ordered. She said she would have to educated and monitor the nurses to ensure this was corrected. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was e-signed by the facilities nurse practitioner. A lab report dated 6/18/2021 and timed 9:14 a.m. indicated Resident #3's BUN was elevated at 38 and creatinine was elevated at 1.55. Normal rage parameters on the lab sheet for BUN was 8-23 MG/DL and 0.80 -1.40 MG/DL for creatinine. During an interview on 6/30/2021 at 8:19 a.m., the nurse practitioner said Resident #3 received all his nutrition and hydration needs through his PEG tube. She said she ordered STAT labs on 6/18/2021 to evaluate his fluids and nutrition. She said she reviewed the labs on 6/21/2021 and noticed that his BUN and creatinine was elevated. She said that an elevated BUN and creatinine indicated fluid depletion, so she ordered an additional 175 ml of water to be administered through his PEG tube every 6 hours. She reviewed the BUN and creatinine results from the hospital dated 6/27/2021 and stated it indicated significant volume depletion and fluid deficit. The nurse practitioner was asked if volume depletion and fluid deficit meant the same as dehydration and she said Yes. She said Resident #3 was on [MEDICATION(S)], but it was a low dose and that could have played a part in his dehydration, but it was not the contributing factor. She said the fluids ordered met the resident's hydration needs, therefore, he should not have become dehydrated unless he was not administered the fluids as ordered. She said she had discussed hospice with Resident #3's family in the past, but his medical issues did not contribute to his dehydration. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Note dated 6/26/2021 and timed 6:50 p.m. indicated Resident #3's daughter accused staff of just allowing resident to wither away and the daughter she said he needed to be sent to the hospital because she felt like he wasn't going to make it till Monday. Further documentation indicated that the daughter activated 911 and the paramedic transferred Resident #3 to the hospital. During an interview on 6/29/2021 at 4:04 p.m., LVN B said she was the nurse taking care of Resident #3 on 6/26/2021 prior to him going to the hospital. She said Resident #3's daughter wanted him sent out to the hospital because she felt he was not getting enough nutrition and hydration at the facility. LVN B said she called the ADON on 6/26/2021 and told her about Resident #3's daughter request and she stated the ADON told her to assess Resident #3 and to send him to the hospital if she found a need to do so based on her assessment. LVN B said she assessed the resident and did not see a reason to send him to the hospital. She said she called Resident #3's daughter and told her she would not be sending him to the hospital. LVN B stated that Resident #3's daughter told her she was going to call 911 herself. LVN B said shortly after getting off the phone with Resident #3's daughter, the daughter arrived back in the facility being accompanied by paramedics and Resident #3 was transferred to the hospital. During an interview on 6/29/2021 at 9:00 a.m., Resident #3's daughter stated that on 6/26/2021 she asked the nurse to send Resident #3 to the hospital because he would tell her that he was hungry and she was concerned that he was not getting enough nutrition and hydration. She said LVN B, declined to send him to the hospital, therefore she called 911 herself and had him transported to the hospital. Emergency Department Physician Documentation Note dated 6/26/2021 indicated Resident #3 arrived at the hospital at 9:22 p.m. It indicated at 9:45 p.m. his temperature was 91.6 rectally, blood pressure 100/67, and pulse was 56. He was admitted into the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital cumulative report dated 6/27/2021 and timed 4:39 a.m. indicated Resident #3's BUN was elevated at 52 and his creatinine was elevated at 2.1. Normal rage parameters on the cumulative report for BUN was 7-18 MG/DL and 0.60 -1.30 MG/DL for creatinine. A hospital progress note dated 6/27/2021 indicated Patient is severely ill with poor prognosis and if he makes it out of this hospital stay alive, hospice will need to be strongly considered. During an interview on 6/30/2021 at 7:22 a.m., LVN A said Resident #3 was NPO and he was totally dependent on the nursing staff for his hydration and nutritional needs. When asked how Resident #3 got dehydrated since he was totally dependent on staff for his hydration and nutritional needs, LVN A said, I do not know unless he was not getting enough fluids. During an interview on 6/30/2021 at 7:30 a.m., CNA B said she had worked with Resident #3 since 6/7/2021. She stated he was NPO, totally dependent on staff and he received all his nutrition and fluids through his PEG tube. During an interview on 6/29/2021 at 4:04 p.m., the Dietitian said Resident #3 was readmitted into the facility on [DATE] with a PEG tube. She said he received all his nutrition and hydration through the PEG tube. She said based her nutritional and hydration calculations and recommendations, it met his needs, therefore he should not have become dehydrated unless he was not given the fluids as ordered. During an interview on 6/30/2021 at 7:48 a.m., the DON said Resident #3 has been NPO since he returned to the facility from the hospital on 5/25/2021. She said he was totally dependent on staff for hydration and nutrition. When asked how Resident #3 got dehydrated since he was totally dependent on staff for his hydration and nutritional needs, DON said, I do not know, unless he wasn't getting it, but that is a question you need to ask the nurse practitioner. During an interview on 6/30/2021 at 11:22 a.m., the administrator said the facility did not have a policy and procedure for tube feeding or hydration to provide. According to lab test online website https://labtestsonline.org/conditions/dehydration assessed 7/1/2021indicated dehydration can occur whenever fluids are lost and not adequately replaced, especially when an individual does not drink enough fluids. In cases of severe dehydration, laboratory testing is frequently ordered to identify electrolyte and acid-base imbalances, to evaluate kidney function, and general health status. It also indicated in severe dehydration labs such as BUN and creatinine, can be tested to evaluate kidney function; these are often increased in dehydration.

Based on observation, interview and record review, the facility failed to immediately consult with the physician regarding a significant change of condition for 1 of 4 residents reviewed for physician notification. (Resident #1) The facility did not notify the physician when Resident #1 had a respiratory rate of 40 (normal respirations ,[DATE]) and abnormal wet breathing sounds (a rapid onset of [MEDICAL CONDITION] caused by the inability of the lungs to perform normal gas exchange), Resident #1 was found dead in his room approximately an hour and a half later. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with a change in condition at risk for delayed medical evaluation, serious impairment, and death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was a full code and had oxygen at 2 LPM via nasal cannula every 1 hour as needed. A care plan initiated [DATE] indicated Resident #1 had a full code status, interventions included: if the resident had a [MEDICAL CONDITION], initiate CPR and call 911, notify the MD/RP and follow MD orders after notification, and mark chart and all pertinent documents with full code. A nursing note dated [DATE] at 12:16 p.m., completed by LVN E indicated she inserted a catheter and noted yellow urine drainage. Resident #1 had slow respirations alternating with rapid respirations, the NP assessed the resident and was aware of respiratory status. PRN oxygen applied and oxygen at 99 percent with oxygen at 2 liters per nasal cannula. A nursing note dated [DATE] ([DATE]) at 11:40 p.m., completed by LVN C indicated Resident #1's blood pressure was ,[DATE] (Normal blood pressure is less than 120 over 80), pulse was 91( normal pulse ,[DATE] beats per minute), temperature was 98.9 , respirations were 40 breaths a minute (normal ,[DATE] breaths per minute), and oxygen saturation was 90% via nasal cannula (normal ,[DATE]%). The nurse increased the resident's oxygen to 3 liters. The resident was awake but unable to focus and withdrawn, had had generalized [MEDICAL CONDITION] in his bilateral upper extremities, had amber colored urine and was suctioned by previous nurse. LVN C indicated she would continue to monitor for changes. A nursing noted dated [DATE] at 1:10 a.m., completed by LVN C indicated Resident #1 had white frothy secretions in his mouth and no vital signs of life. During an interview on [DATE] at 9:30 a.m. LVN A said on [DATE] between 6:30 p.m. and 6:40 p.m. she checked on Resident #1 with no complications noted. She said between 10:10 p.m. and 10:15 p.m., she peeped into Resident's #1 room and from the door heard Resident #1 had wet abnormal breathing, LVN A said she did not assess the resident because he was not assigned to her, she said she did not immediately notify his nurse of the change of condition, and she did not notify the MD of the residents change of condition. During a telephone interview on [DATE] at 9:38 a.m., LVN B said during report on [DATE] at 6 p.m., LVN E notified her Resident #1 had breathing issues and the NP had seen the resident about the issue. LVN B said after report she went to check on Resident #1 and noted no issues. LVN B said she made another round at 11:30 p.m. and noticed the resident had difficulty breathing. The nurse said she gave the resident a PRN breathing treatment and the resident started coughing up phlegm with difficulty, so she suctioned the resident and he appeared to be breathing better. LVN B said she did not notify the NP or the MD about the abnormal breathing because LVN E said the NP was aware. The [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 3:56 p.m., LVN B said LVN A never mentioned to her Resident #1 had a change in condition. During a telephone interview on [DATE] at 7:16 a.m., LVN C said on [DATE] she received report from LVN B and made her initial assessment of Resident #1 and noted the he had increased breathing and sounded wet, she said she increased his oxygen to 3 liters. The nurse said she did not notify the MD, or the NP of the residents increased respirations because she was informed the NP was already aware of his condition. LVN C said on her second observation of Resident #1, he was sitting up in bed and had a mouth full of foam. LVN C said she suctioned the resident, she noticed the resident was not breathing. LVN C said she remembered during report LVN B said the resident needed hospice care. She said she assumed the resident was a DNR. She said she did not initiate CPR and did not verify if the resident had a DNR. The nurse said there was no reason to verify his status, because she thought he was a DNR. LVN C said the resident was still warm to touch and his skin was normal in color. During an interview on [DATE] at 5:07 a.m., LVN A said on [DATE] 10 to 15 minutes after she told LVN C the resident had wet and abnormal breathing sounds LVN C told her Resident #1 had coded and died . LVN A said she looked at Resident #1's hard chart and saw the resident was a full code. LVN A said she questioned the full code status and asked LVN C about attempting CPR and was told the resident was dead and CPR would not matter. LVN A said she did not know how to respond to LVN C, she said she questioned herself about whether she should start CPR on her own, but she did not want to over step the other nurses' decisions. During an interview on [DATE] at 7:44 a.m., ADON D said on [DATE] at 1:21 a.m. she received a call from LVN C who notified her Resident #1 had passed away. She said she asked LVN C if the resident was a DNR and she replied, yes. She said LVN C called her a second time at 1:51 a.m. to ask who was going to pronounce the resident due to the resident not being on hospice care. ADON D said she again asked if the Resident # 1 was a DNR and LVN C said she thought he was. ADON D said she asked was CPR performed and LVN C said CPR was not administered. The ADON said she was not aware Resident #1 was a full code until the following day ([DATE]). During an interview on [DATE] at 12:42 p.m., the NP said she nor the MD was notified of Resident #1's change of condition. She said a respiratory rate of 40 was very significant and they (NP/ MD) should have been notified. She said she saw the resident on [DATE]th or 28th for abnormal breathing. The NP said if she was notified of the resident's declined condition she would have sent him to the hospital. She said she expected the nurses to update her on a resident change of condition. The NP said she was concerned the nurse did not think a rapid respiratory rate was not significant. A provider investigation report was not available. An undated Change of Condition protocol indicated when you have a resident with a change of condition you must: complete a full assessment of the resident, document the assessment findings in PCC, notify the physician, DON, and RP of the residents change of condition, complete the change of condition form in PCC, carry out any orders the physician gives ., and follow up with the Don, Physician and RP. The administrator and DON were notified on [DATE] 12:44p.m., that an IJ situation was identified due to the above failure. The administrator was provided the IJ template on [DATE] at 12:43 p.m. The facility's Plan of Removal was accepted on [DATE] 4:47p.m., and included the following interventions: 1.LVN C was suspended on [DATE] and terminated on [DATE]; 2.LVN A was suspended on [DATE] have been removed from duties until ,[DATE] in-service provided by the DON on [DATE]; 3. All licensed nurses will be in-serviced on the facility protocols of completing assessments, documenting, reporting to DON/designee, and physician by [DATE]. 4. A change of condition form will be completed in PCC (e chart) reflecting change in the resident. 5. The DON/ designee will monitor change of conditions daily and follow-up for completion with interventions. Nurses will be in-serviced on notification to the physician, DON, and responsible party. Notification 6. licensed nurses will be in-serviced on facility protocol for notifying physician be [DATE]; 7. MD and DON will be notified of any changes of condition, new admit, and other concerns, as soon as possible. DON/ designee will review the 24-hour report and discuss in morning clinical meeting and change of conditions for follow up. All issues of any of the above will be addressed monthly in QAPI. Quality assurance measures The administrator of the facility held ADHOC QAPI committee meeting on [DATE] at 2p.m. with the MD to discuss POR. Discussion included steps taken to re-educate staff on assessing, documenting, and follow-up; physician notification of change of condition; and CPR-regarding code statues and when to initiate CPR. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 15 staff (DON, Administrator, 1 RN, 5 LVNs, 2 MAs, and 5 CNAs,) they were able to appropriately define full code status and DNR status, identify the location of the resident code status, provided the procedure for a resident found unresponsive with no vital signs that was a full code, provided a procedure for change of condition, accurately assess/ document/ and report a significant change of condition. Chart reviews were completed and reflected code status. Resident care plans included their code status. The crash cart was observed to have a list of all residents' names in alphabetical order with current code statuses. On [DATE] at 4:55p.m., the administrator and DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was provided in accordance with professional standards of practice for 1 of 4 residents reviewed for CPR. (Resident # 1) The facility did not provide CPR and call 911 for Resident #1 who was a full code (wanted all possible life saving measures in the event his heart or breathing stopped) when LVN C found the resident without vital signs, she did not verify his code status. Resident #1 expired in the facility. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents who are a full code status at risk of death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was a full code and had oxygen at 2 LPM via nasal cannula every 1 hour as needed. A care plan initiated [DATE] indicated Resident #1 had a full code status, interventions included: if the resident had a [MEDICAL CONDITION], initiate CPR and call 911, notify the MD/RP and follow MD orders after notification, and mark chart and all pertinent documents with full code. A nursing note dated [DATE] at 12:16 p.m., completed by LVN E indicated she inserted a catheter and noted yellow urine drainage. Resident #1 had slow respirations alternating with rapid respirations, the NP assessed the resident and was aware of respiratory status. PRN oxygen applied and oxygen at 99 percent with oxygen at 2 liters per nasal cannula. A nursing note dated [DATE] ([DATE]) at 11:40 p.m., completed by LVN C indicated Resident #1's blood pressure was ,[DATE] (Normal blood pressure is less than 120 over 80), pulse was 91( normal pulse ,[DATE] beats per minute), temperature was 98.9 , respirations were 40 breaths a minute (normal ,[DATE] breaths per minute), and oxygen saturation was 90% via nasal cannula (normal ,[DATE]%). The nurse increased the resident's oxygen to 3 liters. The resident was awake but unable to focus and withdrawn, had had generalized [MEDICAL CONDITION] in his bilateral upper extremities, had amber colored urine and was suctioned by previous nurse. LVN C indicated she would continue to monitor for changes. A nursing noted dated [DATE] at 1:10 a.m., completed by LVN C indicated Resident #1 had white frothy secretions in his mouth and no vital signs of life. During an interview on [DATE] at 9:30 a.m. LVN A said on [DATE] between 6:30 p.m. and 6:40 p.m. she checked on Resident #1 with no complications noted. She said between 10:10 p.m. and 10:15 p.m., she peeped into Resident's #1 room and from the door heard Resident #1 had wet abnormal breathing, LVN A said she did not assess the resident because he was not assigned to her, she said she did not immediately notify his nurse of the change of condition, and she did not notify the MD of the residents change of condition. During a telephone interview on [DATE] at 9:38 a.m., LVN B said during report on [DATE] at 6 p.m., LVN E notified her Resident #1 had breathing issues and the NP had seen the resident about the issue. LVN B said after report she went to check on Resident #1 and noted no issues. LVN B said she made another round at 11:30 p.m. and noticed the resident had difficulty breathing. The nurse said she gave the resident a PRN breathing treatment and the resident started coughing up phlegm with difficulty, so she suctioned the resident and he appeared to be breathing better. LVN B said she did not notify the NP or the MD about the abnormal breathing because LVN E said the NP was aware. The [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 3:56 p.m., LVN B said LVN A never mentioned to her Resident #1 had a change in condition. During a telephone interview on [DATE] at 7:16 a.m., LVN C said on [DATE] she received report from LVN B and made her initial assessment of Resident #1 and noted the he had increased breathing and sounded wet, she said she increased his oxygen to 3 liters. The nurse said she did not notify the MD, or the NP of the residents increased respirations because she was informed the NP was already aware of his condition. LVN C said on her second observation of Resident #1, he was sitting up in bed and had a mouth full of foam. LVN C said she suctioned the resident, she noticed the resident was not breathing. LVN C said she remembered during report LVN B said the resident needed hospice care. She said she assumed the resident was a DNR. She said she did not initiate CPR and did not verify if the resident had a DNR. The nurse said there was no reason to verify his status, because she thought he was a DNR. LVN C said the resident was still warm to touch and his skin was normal in color. During an interview on [DATE] at 5:07 a.m., LVN A said on [DATE] 10 to 15 minutes after she told LVN C the resident had wet and abnormal breathing sounds LVN C told her Resident #1 had coded and died . LVN A said she looked at Resident #1's hard chart and saw the resident was a full code. LVN A said she questioned the full code status and asked LVN C about attempting CPR and was told the resident was dead and CPR would not matter. LVN A said she did not know how to respond to LVN C, she said she questioned herself about whether she should start CPR on her own, but she did not want to over step the other nurses' decisions. During an interview on [DATE] at 7:44 a.m., ADON D said on [DATE] at 1:21 a.m. she received a call from LVN C who notified her Resident #1 had passed away. She said she asked LVN C if the resident was a DNR and she replied, yes. She said LVN C called her a second time at 1:51 a.m. to ask who was going to pronounce the resident due to the resident not being on hospice care. ADON D said she again asked if the Resident # 1 was a DNR and LVN C said she thought he was. ADON D said she asked was CPR performed and LVN C said CPR was not administered. The ADON said she was not aware Resident #1 was a full code until the following day ([DATE]). During an interview on [DATE] at 12:42 p.m., the NP said she nor the MD was notified of Resident #1's change of condition. She said a respiratory rate of 40 was very significant and they (NP/ MD) should have been notified. She said she saw the resident on [DATE]th or 28th for abnormal breathing. The NP said if she was notified of the resident's declined condition she would have sent him to the hospital. She said she expected the nurses to update her on a resident change of condition. The NP said she was concerned the nurse did not think a rapid respiratory rate was not significant. A provider investigation report was not available. An undated Change of Condition protocol indicated when you have a resident with a change of condition you must: complete a full assessment of the resident, document the assessment findings in PCC, notify the physician, DON, and RP of the residents change of condition, complete the change of condition form in PCC, carry out any orders the physician gives ., and follow up with the Don, Physician and RP. The administrator and DON were notified on [DATE] 12:44p.m., that an IJ situation was identified due to the above failure. The administrator was provided the IJ template on [DATE] at 12:43 p.m. The facility's Plan of Removal was accepted on [DATE] 4:47p.m., and included the following interventions: 1.LVN C was suspended on [DATE] and terminated on [DATE]; 2.LVN A was suspended on [DATE] have been removed from duties until ,[DATE] in-service provided by the DON on [DATE]; 3. All licensed nurses will be in-serviced on the facility protocols of completing assessments, documenting, reporting to DON/designee, and physician by [DATE]. 4. A change of condition form will be completed in PCC (e chart) reflecting change in the resident. 5. The DON/ designee will monitor change of conditions daily and follow-up for completion with interventions. Nurses will be in-serviced on notification to the physician, DON, and responsible party. Notification 6. licensed nurses will be in-serviced on facility protocol for notifying physician be [DATE]; 7. MD and DON will be notified of any changes of condition, new admit, and other concerns, as soon as possible. DON/ designee will review the 24-hour report and discuss in morning clinical meeting and change of conditions for follow up. All issues of any of the above will be addressed monthly in QAPI. Quality assurance measures The administrator of the facility held ADHOC QAPI committee meeting on [DATE] at 2p.m. with the MD to discuss POR. Discussion included steps taken to re-educate staff on assessing, documenting, and follow-up; physician notification of change of condition; and CPR-regarding code statues and when to initiate CPR. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 15 staff (DON, Administrator, 1 RN, 5 LVNs, 2 MAs, and 5 CNAs,) they were able to appropriately define full code status and DNR status, identify the location of the resident code status, provided the procedure for a resident found unresponsive with no vital signs that was a full code, provided a procedure for change of condition, accurately assess/ document/ and report a significant change of condition. Chart reviews were completed and reflected code status. Resident care plans included their code status. The crash cart was observed to have a list of all residents' names in alphabetical order with current code statuses. On [DATE] at 4:55p.m., the administrator and DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was a full code and had oxygen at 2 LPM via nasal cannula every 1 hour as needed. A care plan initiated [DATE] indicated Resident #1 had a full code status, interventions included: if the resident had a [MEDICAL CONDITION], initiate CPR and call 911, notify the MD/RP and follow MD orders after notification, and mark chart and all pertinent documents with full code. A nursing note dated [DATE] at 12:16 p.m., completed by LVN E indicated she inserted a catheter and noted yellow urine drainage. Resident #1 had slow respirations alternating with rapid respirations, the NP assessed the resident and was aware of respiratory status. PRN oxygen applied and oxygen at 99 percent with oxygen at 2 liters per nasal cannula. A nursing note dated [DATE] at 11:40 p.m., completed by LVN C indicated Resident #1's blood pressure was ,[DATE] (Normal blood pressure is less than 120 over 80), pulse was 91( normal pulse ,[DATE] beats per minute), temperature was 98.9 , respirations were 40 breaths a minute (normal ,[DATE] breaths per minute), and oxygen saturation was 90% via nasal cannula (normal ,[DATE]%). The nurse increased the resident's oxygen to 3 liters. The resident was awake but unable to focus and withdrawn, had had generalized [MEDICAL CONDITION] in his bilateral upper extremities, had amber colored urine and was suctioned by previous nurse. LVN C indicated she would continue to monitor for changes. A nursing noted dated [DATE] at 1:10 a.m., completed by LVN C indicated Resident #1 had white frothy secretions in his mouth and no vital signs of life. During an interview on [DATE] at 9:30 a.m. LVN A said on [DATE] between 6:30 p.m. and 6:40 p.m. she checked on Resident #1 with no complications noted. She said between 10:10 p.m. and 10:15 p.m., she peeped into Resident's #1 room and from the door heard Resident #1 had wet abnormal breathing, LVN A said she did not assess the resident because he was not assigned to her, she said she did not immediately notify his nurse of the change of condition, and she did not notify the MD of the residents change of condition. During a telephone interview on [DATE] at 9:38 a.m., LVN B said during report on [DATE] at 6 p.m., LVN E notified her Resident #1 had breathing issues and the NP had seen the resident about the issue. LVN B said after report she went to check on Resident #1 and noted no issues. LVN B said she made another round at 11:30 p.m. and noticed the resident had difficulty breathing. The nurse said she gave the resident a PRN breathing treatment and the resident started coughing up phlegm with difficulty, so she suctioned the resident and he appeared to be breathing better. LVN B said she did not notify the NP or the MD about the abnormal breathing because LVN E said the NP was aware. The [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 3:56 p.m., LVN B said LVN A never mentioned to her Resident #1 had a change in condition. During a telephone interview on [DATE] at 7:16 a.m., LVN C said on [DATE] she received report from LVN B and made her initial assessment of Resident #1 and noted the he had increased breathing and sounded wet, she said she increased his oxygen to 3 liters. The nurse said she did not notify the MD, or the NP of the residents increased respirations because she was informed the NP was already aware of his condition. LVN C said on her second observation of Resident #1, he was sitting up in bed and had a mouth full of foam. LVN C said she suctioned the resident, she noticed the resident was not breathing. LVN C said she remembered during report LVN B said the resident needed hospice care. She said she assumed the resident was a DNR. She said she did not initiate CPR and did not verify if the resident had a DNR. The nurse said there was no reason to verify his status, because she thought he was a DNR. LVN C said the resident was still warm to touch and his skin was normal in color. During an interview on [DATE] at 5:07 a.m., LVN A said on [DATE] 10 to 15 minutes after she told LVN C the resident had wet and abnormal breathing sounds LVN C told her Resident #1 had coded and died . LVN A said she looked at Resident #1's hard chart and saw the resident was a full code. LVN A said she questioned the full code status and asked LVN C about attempting CPR and was told the resident was dead and CPR would not matter. LVN A said she did not know how to respond to LVN C, she said she questioned herself about whether she should start CPR on her own, but she did not want to over step the other nurses decisions. During an interview on [DATE] at 7:44 a.m., ADON D said on [DATE] at 1:21 a.m. she received a call from LVN C who notified her Resident #1 had passed away. She said she asked LVN C if the resident was a DNR and she replied, yes. She said LVN C called her a second time at 1:51 a.m. to ask who was going to pronounce the resident due to the resident not being on hospice care. ADON D said she again asked if the Resident # 1 was a DNR and LVN C said she thought he was. ADON D said she asked was CPR performed and LVN C said CPR was not administered. The ADON said she was not aware Resident #1 was a full code until the following day ([DATE]). During an interview on [DATE] at 12:42 p.m., the NP said she nor the MD was notified of Resident #1's change of condition. She said a respiratory rate of 40 was very significant and they (NP/ MD) should have been notified. She said she saw the resident on [DATE]th or 28th for abnormal breathing. The NP said if she was notified of the resident's declined condition she would have sent him to the hospital. She said she expected the nurses to update her on a resident change of condition. The NP said she was concerned the nurse did not think a rapid respiratory rate was not significant. A provider investigation report was not available. An undated Change of Condition protocol indicated when you have a resident with a change of condition you must: complete a full assessment of the resident, document the assessment findings in PCC, notify the physician, DON, and RP of the residents change of condition, complete the change of condition form in PCC, carry out any orders the physician gives ., and follow up with the Don, Physician and RP. The administrator and DON were notified on [DATE] 12:44p.m., that an IJ situation was identified due to the above failure. The administrator was provided the IJ template on [DATE] at 12:43 p.m. The facility's Plan of Removal was accepted on [DATE] 4:47p.m., and included the following interventions: 1.LVN C was suspended on [DATE] and terminated on [DATE]; 2.LVN A was suspended on [DATE] have been removed from duties until ,[DATE] in-service provided by the DON on [DATE]; 3. All licensed nurses will be in-serviced on the facility protocols of completing assessments, documenting, reporting to DON/designee, and physician by [DATE]. 4. A change of condition form will be completed in PCC (e chart) reflecting change in the resident. 5. The DON/ designee will monitor change of conditions daily and follow-up for completion with interventions. Nurses will be in-serviced on notification to the physician, DON, and responsible party. Notification 6. licensed nurses will be in-serviced on facility protocol for notifying physician be [DATE]; 7. MD and DON will be notified of any changes of condition, new admit, and other concerns, as soon as possible. DON/ designee will review the 24-hour report and discuss in morning clinical meeting and change of conditions for follow up. All issues of any of the above will be addressed monthly in QAPI. Quality assurance measures The administrator of the facility held ADHOC QAPI committee meeting on [DATE] at 2p.m. with the MD to discuss POR. Discussion included steps taken to re-educate staff on assessing, documenting, and follow-up; physician notification of change of condition; and CPR-regarding code statues and when to initiate CPR. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 15 staff (DON, Administrator, 1 RN, 5 LVNs, 2 MAs, and 5 CNAs,) they were able to appropriately define full code status and DNR status, identify the location of the resident code status, provided the procedure for a resident found unresponsive with no vital signs that was a full code, provided a procedure for change of condition, accurately assess/ document/ and report a significant change of condition. Chart reviews were completed and reflected code status. Resident care plans included their code status. The crash cart was observed to have a list of all residents' names in alphabetical order with current code statuses. On [DATE] at 4:55p.m., the administrator and DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and choices for 1 of 5 residents reviewed for change of condition. (Resident # 1) LVN A, LVN B and LVN C did not provide interventions to address a significant change of condition for Resident #1. Resident #1 had abnormal breathing sounds that were wet (a rapid onset of [MEDICAL CONDITION] caused by the inability of the lungs to perform normal gas exchange), a respiratory rate of 40 (normal respirations ,[DATE]), and a decreased oxygen saturation level of 90% (normal blood oxygen level ,[DATE]%) while on 2 liters of oxygen, Resident #1 was found dead in his room approximately an hour and a half later. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was a full code and had oxygen at 2 LPM via nasal cannula every 1 hour as needed. A care plan initiated [DATE] indicated Resident #1 had a full code status, interventions included: if the resident had a [MEDICAL CONDITION], initiate CPR and call 911, notify the MD/RP and follow MD orders after notification, and mark chart and all pertinent documents with full code. A nursing note dated [DATE] at 12:16 p.m., completed by LVN E indicated she inserted a catheter and noted yellow urine drainage. Resident #1 had slow respirations alternating with rapid respirations, the NP assessed the resident and was aware of respiratory status. PRN oxygen applied and oxygen at 99 percent with oxygen at 2 liters per nasal cannula. A nursing note dated [DATE] ([DATE]) at 11:40 p.m., completed by LVN C indicated Resident #1's blood pressure was ,[DATE] (Normal blood pressure is less than 120 over 80), pulse was 91( normal pulse ,[DATE] beats per minute), temperature was 98.9 , respirations were 40 breaths a minute (normal ,[DATE] breaths per minute), and oxygen saturation was 90% via nasal cannula (normal ,[DATE]%). The nurse increased the resident's oxygen to 3 liters. The resident was awake but unable to focus and withdrawn, had had generalized [MEDICAL CONDITION] in his bilateral upper extremities, had amber colored urine and was suctioned by previous nurse. LVN C indicated she would continue to monitor for changes. A nursing noted dated [DATE] at 1:10 a.m., completed by LVN C indicated Resident #1 had white frothy secretions in his mouth and no vital signs of life. During an interview on [DATE] at 9:30 a.m. LVN A said on [DATE] between 6:30 p.m. and 6:40 p.m. she checked on Resident #1 with no complications noted. She said between 10:10 p.m. and 10:15 p.m., she peeped into Resident's #1 room and from the door heard Resident #1 had wet abnormal breathing, LVN A said she did not assess the resident because he was not assigned to her, she said she did not immediately notify his nurse of the change of condition, and she did not notify the MD of the residents change of condition. During a telephone interview on [DATE] at 9:38 a.m., LVN B said during report on [DATE] at 6 p.m., LVN E notified her Resident #1 had breathing issues and the NP had seen the resident about the issue. LVN B said after report she went to check on Resident #1 and noted no issues. LVN B said she made another round at 11:30 p.m. and noticed the resident had difficulty breathing. The nurse said she gave the resident a PRN breathing treatment and the resident started coughing up phlegm with difficulty, so she suctioned the resident and he appeared to be breathing better. LVN B said she did not notify the NP or the MD about the abnormal breathing because LVN E said the NP was aware. The [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 3:56 p.m., LVN B said LVN A never mentioned to her Resident #1 had a change in condition. During a telephone interview on [DATE] at 7:16 a.m., LVN C said on [DATE] she received report from LVN B and made her initial assessment of Resident #1 and noted the he had increased breathing and sounded wet, she said she increased his oxygen to 3 liters. The nurse said she did not notify the MD, or the NP of the residents increased respirations because she was informed the NP was already aware of his condition. LVN C said on her second observation of Resident #1, he was sitting up in bed and had a mouth full of foam. LVN C said she suctioned the resident, she noticed the resident was not breathing. LVN C said she remembered during report LVN B said the resident needed hospice care. She said she assumed the resident was a DNR. She said she did not initiate CPR and did not verify if the resident had a DNR. The nurse said there was no reason to verify his status, because she thought he was a DNR. LVN C said the resident was still warm to touch and his skin was normal in color. During an interview on [DATE] at 5:07 a.m., LVN A said on [DATE] 10 to 15 minutes after she told LVN C the resident had wet and abnormal breathing sounds LVN C told her Resident #1 had coded and died . LVN A said she looked at Resident #1's hard chart and saw the resident was a full code. LVN A said she questioned the full code status and asked LVN C about attempting CPR and was told the resident was dead and CPR would not matter. LVN A said she did not know how to respond to LVN C, she said she questioned herself about whether she should start CPR on her own, but she did not want to over step the other nurses' decisions. During an interview on [DATE] at 7:44 a.m., ADON D said on [DATE] at 1:21 a.m. she received a call from LVN C who notified her Resident #1 had passed away. She said she asked LVN C if the resident was a DNR and she replied, yes. She said LVN C called her a second time at 1:51 a.m. to ask who was going to pronounce the resident due to the resident not being on hospice care. ADON D said she again asked if the Resident # 1 was a DNR and LVN C said she thought he was. ADON D said she asked was CPR performed and LVN C said CPR was not administered. The ADON said she was not aware Resident #1 was a full code until the following day ([DATE]). During an interview on [DATE] at 12:42 p.m., the NP said she nor the MD was notified of Resident #1's change of condition. She said a respiratory rate of 40 was very significant and they (NP/ MD) should have been notified. She said she saw the resident on [DATE]th or 28th for abnormal breathing. The NP said if she was notified of the resident's declined condition she would have sent him to the hospital. She said she expected the nurses to update her on a resident change of condition. The NP said she was concerned the nurse did not think a rapid respiratory rate was not significant. A provider investigation report was not available. An undated Change of Condition protocol indicated when you have a resident with a change of condition you must: complete a full assessment of the resident, document the assessment findings in PCC, notify the physician, DON, and RP of the residents change of condition, complete the change of condition form in PCC, carry out any orders the physician gives ., and follow up with the Don, Physician and RP. The administrator and DON were notified on [DATE] 12:44p.m., that an IJ situation was identified due to the above failure. The administrator was provided the IJ template on [DATE] at 12:43 p.m. The facility's Plan of Removal was accepted on [DATE] 4:47p.m., and included the following interventions: 1.LVN C was suspended on [DATE] and terminated on [DATE]; 2.LVN A was suspended on [DATE] have been removed from duties until ,[DATE] in-service provided by the DON on [DATE]; 3. All licensed nurses will be in-serviced on the facility protocols of completing assessments, documenting, reporting to DON/designee, and physician by [DATE]. 4. A change of condition form will be completed in PCC (e chart) reflecting change in the resident. 5. The DON/ designee will monitor change of conditions daily and follow-up for completion with interventions. Nurses will be in-serviced on notification to the physician, DON, and responsible party. Notification 6. licensed nurses will be in-serviced on facility protocol for notifying physician be [DATE]; 7. MD and DON will be notified of any changes of condition, new admit, and other concerns, as soon as possible. DON/ designee will review the 24-hour report and discuss in morning clinical meeting and change of conditions for follow up. All issues of any of the above will be addressed monthly in QAPI. Quality assurance measures The administrator of the facility held ADHOC QAPI committee meeting on [DATE] at 2p.m. with the MD to discuss POR. Discussion included steps taken to re-educate staff on assessing, documenting, and follow-up; physician notification of change of condition; and CPR-regarding code statues and when to initiate CPR. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 15 staff (DON, Administrator, 1 RN, 5 LVNs, 2 MAs, and 5 CNAs,) they were able to appropriately define full code status and DNR status, identify the location of the resident code status, provided the procedure for a resident found unresponsive with no vital signs that was a full code, provided a procedure for change of condition, accurately assess/ document/ and report a significant change of condition. Chart reviews were completed and reflected code status. Resident care plans included their code status. The crash cart was observed to have a list of all residents' names in alphabetical order with current code statuses. On [DATE] at 4:55p.m., the administrator and DON was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview, and record review the facility failed to ensure adequate supervision was provided to prevent an elopement for 3 of 4 residents reviewed for elopement. (Residents #1, #2, and #3) The facility did not prevent Residents #1, #2, and #3, who were at risk for elopement, from leaving the facility without staff knowledge. The residents were found walking in the middle of the street heading away from the facility in the direction of a major intersection. An Immediate Jeopardy (IJ) situation was determined to have existed on 7/29/19. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who resided on the secure unit at risk for injury, or death. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was 84-years-old with [DIAGNOSES REDACTED]. A start date of 6/3/19 indicated if Resident #1 has exit seeking or wandering behaviors, document in the progress notes every shift. A start date of 7/30/19 indicated Resident #1 may admit to the secured unit. A start date of 7/29/19 indicated Resident #1 was to have a wander guard to her left ankle and to check placement every shift. An elopement assessment dated [DATE] for Resident #1 indicated she was a moderate risk for elopement. An incident report dated 7/29/19 at 7:55 p.m. indicated the DON was called by the medical director who informed her Resident #1 along with 2 other residents were walking down the street towards a major intersection (0.9 miles from facility) and brought back to the facility. A nursing progress note dated 7/29/19 indicated Resident #1's family was notified the resident and 2 other residents eloped from the building, the note indicated they followed some visitors outside. The family was informed the facility was changing the codes to the door and staff would not be giving out the code to the door, and a wander guard would be placed on the resident. An MDS dated [DATE] indicated Resident #1 was severely impaired cognitively. Resident #1 wandered 1-3 days a week, wore a wander alarm less than daily, had an unsteady balance, and was independent with most ADLs. A care plan initiated 6/3/19 and updated on 7/29/19 indicated Resident #1 was an elopement risk/wanderer related to history of exit seeking at a previous facility. The care plan indicated on 7/29/19 Resident #1 eloped from the secured unit, outside the facility, by following behind some visitors. Interventions included .complete wandering evaluation tool . distract resident from wandering . door codes changed .resident will remain on secure unit . and wander guard in place. The elopement assessment dated [DATE] for Resident #1 indicated she was a moderate risk for elopement. A physician progress notes [REDACTED].#1 had a lack of safety awareness and was at risk of elopement from healthcare setting. During an observation and interview on 8/13/19 at 10:06 a.m., Residents #1 and Resident #2 were observed in their rooms sitting on their beds (they are roommates), Resident #3 was also in their room sitting in a chair. Both Resident #1 and #2 indicated they went out for a stroll on the day in question (7/29/19) and indicated Resident #3 did not go with them. Resident #1 said they were cooped up all the time and they needed to blow off some steam by taking a walk, she said they did not do anything wrong. Resident #2 said they walked out of the facility door, she pointed towards the exit door on their hallway. Resident #2 said they did not walk down the road, she said they barely got down the steps before they were brought back to the facility. 2. Physician orders [REDACTED].#2 admitted [DATE] was [AGE] year-old with [DIAGNOSES REDACTED]. An elopement assessment dated [DATE] for Resident #2 indicated she was a moderate risk for elopement. A care plan initiated 6/11/19 and last updated 7/30/19 indicated Resident #2 was an elopement risk/wanderer related to history of wandering; on 7/29/19 Resident #2 eloped from the facility after following family members out the door . Interventions included .complete wandering evaluation tool . distract resident from wandering . door codes changed .provide structed activities. The care plan indicated on 7/30/19 Resident #2 refuses to allow staff to place wander guard on her after several attempts. An MDS dated [DATE] indicated Resident #2 was severely impaired cognitively with inattention and disorganized thinking, she wandered daily. A nursing progress note dated 7/29/19 indicated Resident #2's family was notified the resident eloped from the facility and would be given a wander guard and the doors codes to the secure unit would be changed. An incident report dated 7/29/19 at 7:55 p.m., indicated Resident #2 eloped from the facility, the DON was called by the medical director who indicated Resident #2 along with 2 other residents were walking down the street towards a major intersection (0.9 miles from facility) and brought back to the facility. The form indicated the resident followed some family members going out of the side door. A physician progress notes [REDACTED].#2 had a lack of safety awareness and was at risk of elopement from the healthcare setting. 3. Physician orders [REDACTED].#3 admitted [DATE] was [AGE] year-old with [DIAGNOSES REDACTED]. The order indicated Resident #3 was to admit to the secure memory care unit. A start date of 5/7/19 indicated the facility was to document exit seeking or wandering every shift in the progress notes. The elopement assessment dated [DATE] for Resident #3 indicated she was a moderate risk for elopement. An MDS dated [DATE] indicated Resident #3 was severely impaired cognitively, she did not have any wandering behaviors and she did not use a wander/elopement alarm. An incident report dated 7/29/19 at 7:55p.m., indicated the DON was called by the medical director who reported Resident #3 along with 2 other residents were noted walking down the street towards a major intersection (0.9 miles from facility) and brought back to the facility. The residents eloped from the secure unit following behind some visitors. An order dated 7/29/19 indicated Resident #3 was to have a wander guard to her left ankle and placement to be checked every shift. A nursing progress note dated 7/29/19 indicated Resident #3's family was notified the resident got out of the secure unit along with 2 other residents following behind some visitors. The family was informed the door codes were changed and a wander guard would be placed on the resident. A care plan initiated 4/16/19 and last updated 7/29/19 indicated Resident #3 was at risk for elopement related to cognitive decline and impaired safety awareness. The care plan indicated on 7/29/19 Resident #3 eloped out of the secure unit outside after following behind some visitors. Interventions included .assess for fall risk .complete wander evaluation . distract resident from wandering . door codes changed .resident will remain on secure unit . and wander guard applied. The elopement assessment dated [DATE] for Resident #3 indicated she was a moderate risk for elopement. A physician progress notes [REDACTED].#3 was found outside the facility on 7/29/19 and escorted back into the secure unit without incident. The form indicated Resident #3 had a lack of safety awareness and was risk of elopement from the healthcare setting. An order dated 7/30/19 indicated Resident #3 was admitted to the secure unit and exit seeking and wandering documentation were to be documented every shift. A clinical list dated 7/31/19 completed by the medical director indicated she was driving north at about 7:50 p.m. on 7/29/19 and noticed three elderly women walking in the south bound lane headed north. She documented the residents were about 2 driveways north of the facility. The medical director indicated she pulled over and parked and approached the women and recognized them as patients from the memory care unit from the facility where she was the medical director. She indicated the residents all appeared well, and the residents said, they were just out for a walk. The medical director indicated they were able state their names but could not tell her where they came from, she redirected the residents and walked them back to the facility to the memory care unit and staff were notified. The note indicated the DON was notified and the patients were unharmed and in good spirts. During a telephone interview on 8/13/19 at 11:48 a.m., the medical director said between 7:50 p.m. and 8 p.m. she was driving by the facility heading north and noticed three residents walking in the street. She said other cars were traveling on the road. The medical director said she did a U-turn and parked her car. She said the residents had walked past the facility and were headed towards the loop (a major intersection). The medical director said she approached the three ladies and realized they were residents from the secure unit of the facility. She said the residents indicated they were walking. She said she walked them back to the facility and notified the staff and called the DON. During a telephone interview on 8/13/19 at 10:14 a.m., LVN A said on 7/29/19 a family member left the facility at 7:50 p.m. LVN A said the residents had to be out the facility approximately 5 to 8 minutes because she was still counting the medications with MA B when the medial director entered the facility with the residents. She said the medical director told her she found Residents #1, #2, and #3 outside the facility. LVN A said Resident #2 pointed to the side door when she asked her how they got out of the facility, she said Resident #1 said they followed someone out of the door. LVN A said she did not know the residents had left the facility. During an interview on 8/13/19 at 9:52 a.m., MA B said the medical director and Residents #1, #2, and #3 entered the unit around 8:00 p.m., while she and LVN A were at the medication cart. During a telephone interview on 8/13/19 at 11:38 a.m., CNA C said she last saw Residents #1, #2, and #3 around 7:00 p.m. on 7/29/19. She said she had just started her shift. CNA C said no one knew the residents had left the facility until they were brought back. She said she was making rounds and LVN A and MA B were counting medications at the cart when they were brought back to the facility. During an interview on 8/13/19 at 11:52 a.m., MA B said she last saw Resident #1 and # 2 around 7:00 p.m., she said they had medication due at 8:00 p.m. MA B said she last saw Resident #3 between 5:30 p.m. and 6:00 p.m., she said she had medication due at 7:00 p.m. During a telephone interview on 8/13/19 at 2:27 p.m., LVN A said she last saw Residents #1, #2, and #3 around 7:00 p.m. when she was coming on for her shift. During an interview on 8/13/19 at 2:07 p.m., the DON and administrator indicated Resident #1, #2, and #3 were all admitted directly to the secure unit, all the residents had a history of [REDACTED]. A provider investigation report dated 8/2/19 indicated on 7/29/19 at approximately 8:00 p.m., the DON notified the administrator the medical director saw Residents #1, #2, and #3 outside of the facility walking on the street and they were brought back into the facility. A head to toe skin assessment was completed on each resident with no injuries noted. An undated Elopement/wandering process indicated . if you notice a resident with exit seeking behaviors, such as trying to go to or out the door or following people out of the door, you need to consider them as a risk for elopement .complete a wandering assessment on the residents . notify the residents responsible party and the physician of the risk of elopement place a wander guard on the resident . initiate wander guard checks update care plan .Inservice facility staff . The website https://weather.com/weather/monthly/l/USTX0793:1:US, accessed 8/13/19 indicated the temperature for Longview, Texas on 7/29/19 ranged from a high of 93 degrees Fahrenheit to a low of 73 degrees Fahrenheit. The administrator and DON were notified on 08/13/19 at 3:09 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #1, #2, and #3 in an IJ situation on 07/29/19. After Residents #1, #2, and #3 were returned to the facility on [DATE]. The facility implemented the following interventions: *staff were in-serviced on Elopement 7/29/19 *staff were in-serviced on Door code 7/29/19 *staff were in-serviced on Abuse and Neglect 7/29/19 *elopement assessments and care plans were updated on 7/29/19 & 7/30/19 These interventions were completed based on 13 staff (DON, ADON, administrator, 3 LVNS, 1 CMA, 3 CNAs, 2 RNs, and 1 HR) interviewed to ensure theses interventions had been completed. Staff were able to appropriately answer the procedure for abuse and neglect missing resident/elopement. Staff were aware to keep codes to secure unit confidential and to ensure families did not let anyone follow them out of the unit. Chart reviews were completed, and all care plans and elopement assessments were completed.

Based on interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1) The facility did not prevent Resident #1 from leaving the facility without staff knowledge. Resident #1 had a history of [REDACTED].# 1 had requested to leave the facility, 2 days prior, but staff was not made aware and monitoring was not provided. The facility did not implement interventions to prevent Resident #1 from leaving the facility safely. The resident was missing for approximately 24 hours. This failure resulted in an indentification of an Immediate Jeopardy (IJ) situation on 2/5/19. While the IJ was removed on 2/6/19 the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents who resided in the general population at risk for neglect, injury, or death. Findings included: Physician orders [REDACTED].#1 admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An order dated 10/2/18 indicated Resident #1 was to have a wander guard for being at risk for elopement. A nursing progress note for Resident #1 dated 10/02/18 indicated a new physician order [REDACTED]. An initial care plan dated 10/12/18 for Resident #1 did not address elopement behaviors. The elopement assessment dated [DATE] for Resident #1 indicated a score of 10 which placed him at moderate risk for elopement. A nursing progress note dated 11/07/18 indicated Resident #1 removed his wander guard. Skilled nurse attempted to replace it and resident began to kick and curse. During an interview on 2/5/19 at 2:00 p.m., LVN C said Resident # 1's wanderguard was replaced until it was discontinued on 12/10/18. An occupational therapy evaluation and plan of treatment certification period of 11/28/18 through 12/26/19 for Resident #1 indicated due to documented physical impairments and associated functional deficits, the patient was at risk for . falls, further decline in function, immobility, increased dependency upon caregivers, limited out-of- the bed activity, pressure sores, decrease in level of mobility, decreased leisure task participation, behavior outbursts, decreased ability to return to prior level assistance, decreased participation with functional tasks, depression, [MEDICAL CONDITIONS] and compromised general health . The assessment identified declines in areas of physical, cognitive, psychosocial skills resulting in activity limitation or participation restrictions. The physical/cognitive/psychological performance showed Resident #1 presented .impairment in balance, dexterity, fine motor coordination, gross motor coordination, mobility, strength, attention, follow though, planning, problems solving, self-modification, self-monitoring, interpersonal habits, interpersonal interactions, interpersonal routines/behavior, use of coping strategies and environment modification strategies resulting in limitations and / or participation restrictions in the areas of communication, community, civic life, domestic life, economic, education, general tasks and demands. Interpersonal interactions and relationships, learning and apply knowledge, mobility, self-care and social life. The resident's clinical decision making is moderate complexity . Resident #1's overall score was 21/48 which indicated he needed substantial to maximal assistance with self-care. An MDS dated [DATE] indicated Resident #1 had severely impaired cognition, inattention, and disorganized thinking. The resident had an unsteady balance with surface to surface transfer and required a use of a wheelchair. Resident #1 had upper and lower extremity impairment to one side. Resident #1 required limited one-person assistance with most ADLs and extensive two-person assistance with personal hygiene and bathing. Resident #1 used wander/elopement alarm daily. A physician order [REDACTED]. A nursing progress note for Resident #1 dated 12/10/18 indicated to discontinue wander guard due to decreased elopement risk. Resident #1 was aware and in agreement. A care plan updated 12/11/18 indicated Resident #1 .wished to be discharged to home, length of stay is undetermined at this time . Approaches included .encourage the resident to discuss feelings and concerns with impending discharge and monitor for and address episodes of anxiety , fear, and distress . establish a pre-discharge plan with the resident/family/caregiver and evaluate progress and revise plan every 92 days . The care plan did not address Resident #1's history of elopement or provide interventions to monitor and prevent further elopement behaviors. A care plan updated 12/11/18 indicated Resident #1 had impaired cognitive function related to recent stroke. a problem of impaired decision making due to dementia. Approaches included .ask yes/ no questions in order to determine the resident's needs . cue, reorient and supervise as needed. and present just one thought, idea, question or command at a time . The care plan did not address Resident #1's history of elopement or provide interventions to monitor and prevent further elopement behaviors. A nursing progress note dated 2/4/19 at 6:41 p.m., indicated Resident #1's ex-wife approached nursing desk stating she was unable to locate the resident. Code pink (code used to alert staff a resident was missing) was called, followed by an immediate search of premises. Resident #1 was not located during the search. An incident report dated 2/4/19 at 6:41 p.m., indicated Resident #1's ex-wife approached nursing station stating she was unable to locate resident at this time. Upon searching the building, Resident #1 was not located. Resident #1 was last seen on 2/4/19 at the 4:30 p.m., smoke break. The local police was notified that Resident #1 was missing. During an interview on 2/5/19 at 4:48 p.m., the administrator said he received a phone call from a man informing him Resident #1 was at his house. He said the man said Resident #1 refused to come back to the facility. During an interview on 2/5/19 at 5:59 p.m., the administrator said at this time he and the police were going to the location that Resident #1 was staying. An unauthorized discharge/release of responsibility (AMA) (against medical advice) form dated 2/5/19 was signed by Resident #1 indicating discharge. The comments section of the form indicated Resident #1 understood what AMA meant and wanted to be discharged . He refused for his vital signs to be taken. During an interview on 2/5/19 at 2:24 p.m., Resident #1's ex-wife said she came to the facility on [DATE] at approximately 6:41 p.m., to see Resident #1 but could not find him. She said she notified the staff and they searched for him. Resident #1's ex-wife said after Resident #1 was determined to be missing the facility told her a woman had visited the resident on Friday (2/1/19) and Saturday (2/2/19) and Resident #1 requested to leave with them. She said she thought Resident #1 had planned this elopement because he was a drug user, sought Meth. During a telephone interview on 2/5/19 at 11:32 a.m., LVN A said the last time she saw Resident #1 was on 2/4/19 at approximately 2:30 p.m., at the nursing station. She said Resident #1 was looking around and seemed to be looking for someone specific. LVN A said she did not know Resident #1 was a risk for elopement. She said she and was not informed to monitor him for elopement. During a telephone interview on 2/5/19 at 11:46 a.m., LVN B said she provided care for Resident #1 on 2/4/19 during the 2 p.m.- 10 p.m. shift. She said she passed Resident #1 ambulating via his wheelchair in the hallway on 2/4/19 between 3 p.m. and 4 p.m. LVN B said she did not know Resident #1 was a risk for elopement. She said she and was not informed to monitor him for elopement. LVN B said it would had made a difference if she had been instructed to monitor Resident # 1 because the resident is not safe because he is not able to speak and if started using drugs again in his condition would be dangerous. During an interview on 2/5/19 at 11:13 a.m., CNA D said on 2/4/19 she worked the 6 a.m. -2 p.m. shift. on the hallway where Resident #1 resided. She said Resident #1 passed her in the hallway during lunch. She said she did not know Resident #1 was a risk for elopement and was not informed to monitor him for elopement. During a telephone interview on 2/05/19 at 2:41 p.m., CNA E said she provided care for Resident #1 on 2/4/19 during the 2 p.m.-10 p.m. shift. He said he last saw Resident #1 around 2 or 2:15 p.m. on 2/4/19. CNA E said he did not know Resident #1 was missing until the nurse called the code for a missing resident on 2/4/19. He said he did not know Resident #1 was a risk for elopement and was not informed to monitor him for elopement. During an interview on 2/5/19 at 1:16 a.m., the DON said she was not aware of Resident #1's request to leave the facility with visitors over the weekend. (2/1/19 and 2/2/19) She said if she had she would have been keened into what was going on with Resident #1. The elopement assessment dated [DATE] for Resident #1 indicated a score of 7 which placed him at moderate risk for elopement. Resident #1 eloped on 2/4/19 prior to the completion of this assessment. His risk for elopement did not change. A care plan updated 2/04/19 indicated Resident #1 was an elopement risk/wanderer related to actual elopement on 2/04/19. The approaches included .assess for fall risk, complete wander assessment, and identify patterns of wandering . During an interview on 2/5/19 at 9:47 a.m., the receptionist said on Friday, 2/1/19, Resident #1 had a female visitor that asked the resident to go outside with her to see her car. She said she had not seen Resident #1's visitor before. The receptionist said she told the visitor she could drive her car up to the front of the building, but Resident #1 could not go out to her car. The receptionist said on Saturday 2/2/19 the visitor returned with her husband and they wanted to take Resident #1 home with them. She said Resident #1 had really wanted to leave the facility with his visitors. The receptionist said she told the visitors they could not take Resident #1 home with them. The receptionist said the administrator told Resident #1 and his visitors Resident #1's son was his responsible party and he was the one who had to make the decision of discharge. The receptionist said the visitors said they would come back on Monday, 2/4/18, and speak to the social worker about discharge for Resident #1. During an interview on 2/5/19 at 3:06 p.m., the administrator said Saturday, 2/2/19, he asked the nurses if they had seen Resident #1's visitors before and was told no. He said he and the receptionist monitored the front doors of the building to make sure Resident #1 did not leave. The administrator said on Sunday, 2/3/19, he watched Resident #1 to make sure he did not leave. The administrator said he did not tell the floor staff to monitor Resident #1 and did not say why he did not instruct them to monitor Resident #1. During an interview on 2/5/19 at 3:45 p.m., the administrator said Resident #1 was his own responsible party and had no power of attorney. During an interview on 2/5/19 at 9:29 p.m., the DON said Resident #1 could have left against medical advice, but we wanted to make sure the resident was safe. The DON said they had never seen those people that visited Resident #1 during the past weekend. (2/1/19 and 2/2/19) She said I don't think the resident is in danger, just think he may be back hooked on drugs. During an interview on 2/5/19 at 1:45 p.m., the social worker said Resident #1's discharge plan was not finalized. She said Resident #1's ex-wife said he could not come home with her but would help him get an apartment. The social worker said Resident #1 had not left the facility before, but on admission his ex-wife said he had left from his previous residence. She said Resident #1's elopement risk was based on his social history, prior to admission. The social worker said I believe the resident understood what was going on, I think he decided this was too taxing on him and left the facility. During an interview on 2/5/19 at 2:00 p.m., LVN C said Resident #1 had a wander guard when he admitted because he had been exit seeking. She said Resident #1 kept cutting off the wander guard. LVN C said the wander guard was removed due to no behavior of exit seeking. She said the Resident #1 never eloped from the facility before. During an interview on 2/5/19 at 1:22 p.m., the OT assistant said Resident #1 could transfer from chair to chair, but the transfer was spastic and unsafe. She said Resident #1 needed to wear a brace on the right knee, because his knee would buckle. The OT assistant said Resident #1 needed the assistance of at least 1 person maybe 2 when he walked. The OT assistant said when Resident #1 walked, it took one person to support him, but required two people for safety. She said Resident #1 was not safe because he can't communicate well, unable to balance, and will not be able to protect himself; which left him very vulnerable. The OT assistant said it was possible for Resident #1 to make it to the road side, but he would have been unsafe in the road, he would've got hit. She said Resident #1's ex-wife mentioned he had bad friends in the community and she did not want them to know where he was due to his drug addiction and she had fears about those friends. During an interview on 2/5/19 at 1:20 p.m., the DON said they did not have an elopement policy. At https://weather.com/weather/monthly/l/USTX0793:1:US, accessed 2/11/19 indicated the temperature for Longview, Texas on 2/4/19 ranged from a high of 80 degrees Fahrenheit to a low of 62 degrees Fahrenheit. On 2/5/18 the temperature ranged from a high of79 degrees Fahrenheit to a low of 64 degrees Fahrenheit. The administrator was notified on 02/05/19 at 4:21 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's plan of removal was accepted on 2/6/19 at 6:29 p.m , and included: .all staff educated by the DON to report to the facility administrator or DON any resident encounters where the resident verbalizes the desire to leave the facility so immediate action can be taken for resident safety. All staff educated by the DON regarding the abuse and neglect policy. The regional clinical specialist educated the DON and Administrator on implementing elopement prevention interventions for residents considered at risk for elopement thorough verbalization or wandering assessment. All staff educated by the DON on what exit seeking behaviors are and how to identify them. The education included mention of the residents who may be nonverbal or choose not to verbalize their desire to elope, so monitoring for exit seeking behaviors is key to identify those at risk. The social worker and the administrator interviewed residents to identify anyone who verbalized the desire to leave. The DON and ADON initiated Wander assessments had been completed for all residents in the facility to identify residents at risk for elopement. The DON, ADON, and MDS nursed reviewed and updated care plans to identify high risk for elopement. Residents identified at risk for elopement will have wander guards put in place. DON initiated elopement drills for all three shifts; the DON or designee will review the process to identify missed opportunities and areas for improvement. Administrator will complete a quality assurance meeting with facility medical director and IDT to review the incident and the action plan implemented. Residents that are considered at risk for elopement either through verbalization or exit seeking behaviors, facility administration or licensed nurse will immediate complete Inservice for staff to alert them of the resident and the risk. The risk for elopement will also be put in the 24-hour report to continue the notification of risk. The Reginal clinical consultant and the DON will develop and follow the process for residents identified at risk for elopement. The DON is to ensure education will continue until 100% of the staff is educated; employees on will have their education completed upon arrival before the start of the next scheduled shift to work . On 2/6/19, the investigator confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During interviews on 2/6/19 from 8:39 a.m. to 3:10 p.m., 18 nursing staff and 1 housekeeper said they received training on the elopement process to include what exit seeking behaviors were and how to identify them. They said they were instructed to report to the facility administrator or DON if any resident verbalized or had non-verbal behaviors that desire to leave the facility so immediate action could be taken for resident safety. The care plans for 15 residents indicated interventions were in place to ensure the resident's safety. On 2/6/19 at 3:17 p.m., the administrator and corporate nurse were informed the IJ was removed; however, the facility remained out of compliance at isolated, no actual harm with potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure 1 of 8 residents reviewed for neglect (Resident #1) was free from neglect. The facility did not ensure Resident #1 received the physician ordered diet. Resident #1 had orders for a pureed diet, and ate a peanut butter sandwich. Resident #1 choked on the sandwich which likely contributed to his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 38 residents receiving mechanically altered diets, including pureed diets, at risk for harm or death. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], and transferred to a local hospital on [DATE]. His [DIAGNOSES REDACTED]. His physician orders [REDACTED]. An incomplete Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was sometimes understood and was severely impaired cognitively. The MDS indicated Resident #1 was easily agitated, continually slapped himself in his face, and was at significant risk for physical injury. This MDS did not contain information regarding Resident #1's dietary restrictions for dysphagia. An undated care plan indicated Resident #1 was at nutritional risk related to dysphagia. Interventions included providing a pureed diet as ordered and evaluating for proper consistency of diet. The care plan indicated Resident #1 exhibited behaviors of hitting himself. The care plan did not address Resident #1's behaviors of grabbing other resident's food or personal items. The Admission (MDS) data set [DATE] indicated Resident #1 had severely impaired cognition, sometimes understood, and was restless. The Admission Data Set indicated Resident #1 had swallowing problems and a history of dysphagia. A psychological assessment dated [DATE] indicated Resident #1 was essentially non-verbal, but agitated and attempted to leave the facility. Resident #1 responded to being offered preferred items to eat or drink. It was recommended that Resident #1 be monitored at all times. A Nutritional assessment dated [DATE] indicated Resident #1 required a dysphagia puree diet. A physician progress notes [REDACTED].#1 had dysphagia and required aspiration precautions. During an interview on [DATE] at 3:31 p.m., CNA C said on [DATE] she was working on the secure unit. She said between 8:45 p.m. and 8:55 p.m., she saw Resident #1 sitting in a chair with a bed side table in front of him, by the nursing station of Hall 100. She said they spoke to each other and then she went into the secure unit. She said approximately ,[DATE] minutes later, she came out of the secure unit and Resident #1 was lying across the bedside table, his eyes and mouth were open, and his lips were blue. She said she began screaming at the 2 nurses sitting behind the nursing station that Resident #1 was blue. She said she pulled Resident #1 from the chair and began performing the [MEDICATION NAME] maneuver. She said a piece of bread that smelled like peanut butter came out of his mouth. She said the nurses began CPR and EMS arrived. She said the nurses were seated behind the nursing station and they could not have seen Resident #1 where he was seated. She said the snack tray that included peanut butter sandwiches were delivered to the nursing station around 7:30 p.m. to 8:00 p.m. on [DATE]. During an interview on [DATE] at 12:16 p.m., CNA D, said he saw Resident #1 sitting near the nursing station on Hall 100 between 8:35 p.m. to 8:50 p.m. He said he and CNA E went into another resident's room to perform care. He said about 5 minutes later, he heard commotion at the nursing station. He said he and CNA E went to the nursing station and saw CNA C performing the [MEDICATION NAME] maneuver on Resident #1. He said he saw a peanut butter sandwich in his mouth. He said CPR was started on Resident #1 and EMS arrived. He said after the incident, RN A told him that she gave Resident #1 a sandwich and asked CNA D not to tell anybody. He said he did not tell administration about what RN A told him until [DATE]. He said the snack tray was on the nursing station around 8:00 p.m. on [DATE], and peanut butter sandwiches were on the tray. During an interview on [DATE] at 12:22 p.m., CNA E said she saw Resident #1 sitting by the Hall 100 nursing station with a bedside table in front of him on [DATE] at approximately 8:45 p.m. She said CNA D and she were making rounds and ,[DATE] minutes later she heard hollering at the nursing station. She said she saw CNA C performing the [MEDICATION NAME] maneuver on Resident #1, and saw part of a peanut butter sandwich come out of Resident #1's mouth. She said Resident #1's lips were blue. She said peanut butter sandwiches were on the snack tray at the nursing station. She said after the incident, RN A told her that she gave Resident #1 a sandwich and asked her not to tell anybody. She said she did not report the information to administration until [DATE]. During an interview on [DATE] at 1:14 p.m., RN A said on [DATE] at approximately 8:45 p.m., she sat Resident #1 down in his chair by the nursing station and put the bedside table in front of him. She said she went behind the nursing station with LVN B and they both began charting. She said maybe 2 minutes later, CNA C came out of the secure unit and began yelling that Resident #1 was lying on the bedside table and was blue. She said Resident #1 was blue and CNA C began the [MEDICATION NAME] maneuver. She said LVN B went to get the crash cart and she called 911. She said she did not give him a sandwich, but she believed he ate a sandwich. She said the snack tray had peanut butter sandwiches on it and Resident #1 had a history of [REDACTED]. She said earlier in the shift, Resident #1 was drinking from the water pitcher on the medication cart. She said Resident #1 was admitted to this facility from a group home because the staff there was unable to provide the one to one supervision that he needed. During an interview on [DATE] at 9:39 a.m., LVN B said Resident #1 was sitting by the nursing station while she and RN A were behind the nursing station charting. She said CNA C came out the secure unit and began yelling that Resident #1 was blue. She said she went to get the crash cart and when she came back, Resident #1 had food in his mouth. She said the snack tray was sitting on the nursing station and there were peanut butter sandwiches on the tray. She said she caught Resident #1 going into the kitchen trying to get something to eat the night before. She said Resident #1 was impulsive and tried to grab whatever he could. She said he did not like the pureed diet and wanted what other residents were eating. During an interview on [DATE] at 2:22 p.m., Resident #2 said he saw Resident #1 sitting near the nursing station on Hall 100 on the evening of [DATE]. He said Resident #1 was eating a sandwich. An EMS report dated [DATE] indicated Resident #1 was choking and had [MEDICAL CONDITION]. The report indicated Resident #1's [MEDICAL CONDITION] was due to respiratory/asphyxia. Resident #1 was transferred to a local ER. Hospital records dated [DATE] indicated Resident #1 was choking on food preceding his [MEDICAL CONDITION]. EMS reported suctioning ,[DATE] mL of gastric content from Resident #1. Resident #1 was intubated and he did not have eye response, verbal response, or motor response. The hospital records indicated his [DIAGNOSES REDACTED]. Resident #1 was admitted to the ICU with concern for organ failure and [MEDICAL CONDITIONS]. During an interview on [DATE] at 2:28 p.m., Resident #2 said Resident #1's family came to the facility to pick up Resident #1's belongings. Resident #2 said Resident #1's family said Resident #1 died in the hospital on [DATE]. During an interview on [DATE] at 2:36 p.m., LVN F said Resident #1 had impulsive behaviors and would grab anything he could in his reach. During an interview on [DATE] at 4:16 p.m., the DON said the snack tray included peanut butter sandwiches and were delivered the nursing stations around 7:30 p.m. to 8:00 p.m. She said snacks were not locked up. She said Resident #1 was ambulatory and would grab anything he could reach. During an interview on [DATE] at 3:28 p.m., the administrator said Resident #1 was not on one to one supervision. The facility's Abuse/Neglect Policy dated [DATE] defined neglect as, .the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness . The administrator was notified on [DATE] at 12:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 3:41 p.m. and included: Corrective Action and Identification: o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding CPR/[MEDICATION NAME] maneuver to include signs/symptoms of choking. Staff will be re-educated prior to starting their next shift. o On [DATE] the Director of Nursing or designee will review all resident diet orders and will update all Kardex and care plans accordingly to ensure all residents will receive correct diet. o On [DATE], residents' care plans were updated by the Director of Nursing and designees in the medical record. o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding use of the Kardex to communicate a Resident's specific diet. Staff will be re-educated prior to starting their next shift. o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding snack pass procedure to include delivery to nursing who will store in med room until passed to residents or discarded. Staff will be re-educated prior to starting their next shift. o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding how to deal with residents with behaviors and cognitive deficits. Staff will be re-educated prior to starting their next shift. o On [DATE], an Interdisciplinary Team meeting (IDT) was held. Residents with non-compliance behaviors were reviewed for changes needed to care plan. The IDT's recommendations were discussed with the Medical Director and attending physicians. o On [DATE], the responsible parties of the residents who had recommendations from the IDT meeting were contacted by the Social Worker or designee. (sic) On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 4 LVNs, 1 MAs, 4 CNAs, 1 dietary worker, 1 dietitian, and 1 staffing coordinator were interviewed and said they were in-serviced about abuse/neglect, that snack trays were to be kept locked in the medication room until passed out, and how to locate residents' ordered diets. On [DATE] at 3:18 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 38 residents had mechanically altered diets.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit neglect for 1 of 8 residents reviewed for neglect. (Resident #1) The facility did not ensure Resident #1 received the physician ordered diet. Resident #1 had orders for a pureed diet, and ate a peanut butter sandwich. Resident #1 choked on the sandwich which likely contributed to his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 38 residents receiving mechanically altered diets, including pureed diets, at risk for harm or death. Findings included: The facility's Abuse/Neglect Policy dated [DATE] defined neglect as .the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness . Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], and transferred to a local hospital on [DATE]. His [DIAGNOSES REDACTED]. His physician orders [REDACTED]. An incomplete Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was sometimes understood and was severely impaired cognitively. The MDS indicated Resident #1 was easily agitated, continually slapped himself in his face, and was at significant risk for physical injury. This MDS did not contain information regarding Resident #1's dietary restrictions for dysphagia. An undated care plan indicated Resident #1 was at nutritional risk related to dysphagia. Interventions included providing a pureed diet as ordered and evaluating for proper consistency of diet. The care plan indicated Resident #1 exhibited behaviors of hitting himself. The care plan did not address Resident #1's behaviors of grabbing other resident's food or personal items. The Admission (MDS) data set [DATE] indicated Resident #1 had severely impaired cognition, sometimes understood, and was restless. The Admission Data Set indicated Resident #1 had swallowing problems and a history of dysphagia. A psychological assessment dated [DATE] indicated Resident #1 was essentially non-verbal, but agitated and attempted to leave the facility. Resident #1 responded to being offered preferred items to eat or drink. It was recommended that Resident #1 be monitored at all times. A Nutritional assessment dated [DATE] indicated Resident #1 required a dysphagia puree diet. A physician progress notes [REDACTED].#1 had dysphagia and required aspiration precautions. During an interview on [DATE] at 3:31 p.m., CNA C said on [DATE] she was working on the secure unit. She said between 8:45 p.m. and 8:55 p.m., she saw Resident #1 sitting in a chair with a bed side table in front of him, by the nursing station of Hall 100. She said they spoke to each other and then she went into the secure unit. She said approximately ,[DATE] minutes later, she came out of the secure unit and Resident #1 was lying across the bedside table, his eyes and mouth were open, and his lips were blue. She said she began screaming at the 2 nurses sitting behind the nursing station that Resident #1 was blue. She said she pulled Resident #1 from the chair and began performing the [MEDICATION NAME] maneuver. She said a piece of bread that smelled like peanut butter came out of his mouth. She said the nurses began CPR and EMS arrived. She said the nurses were seated behind the nursing station and they could not have seen Resident #1 where he was seated. She said the snack tray that included peanut butter sandwiches were delivered to the nursing station around 7:30 p.m. to 8:00 p.m. on [DATE]. During an interview on [DATE] at 12:16 p.m., CNA D, said he saw Resident #1 sitting near the nursing station on Hall 100 between 8:35 p.m. to 8:50 p.m. He said he and CNA E went into another resident's room to perform care. He said about 5 minutes later, he heard commotion at the nursing station. He said he and CNA E went to the nursing station and saw CNA C performing the [MEDICATION NAME] maneuver on Resident #1. He said he saw a peanut butter sandwich in his mouth. He said CPR was started on Resident #1 and EMS arrived. He said after the incident, RN A told him that she gave Resident #1 a sandwich and asked CNA D not to tell anybody. He said he did not tell administration about what RN A told him until [DATE]. He said the snack tray was on the nursing station around 8:00 p.m. on [DATE], and peanut butter sandwiches were on the tray. During an interview on [DATE] at 12:22 p.m., CNA E said she saw Resident #1 sitting by the Hall 100 nursing station with a bedside table in front of him on [DATE] at approximately 8:45 p.m. She said CNA D and she were making rounds and ,[DATE] minutes later she heard hollering at the nursing station. She said she saw CNA C performing the [MEDICATION NAME] maneuver on Resident #1, and saw part of a peanut butter sandwich come out of Resident #1's mouth. She said Resident #1's lips were blue. She said peanut butter sandwiches were on the snack tray at the nursing station. She said after the incident, RN A told her that she gave Resident #1 a sandwich and asked her not to tell anybody. She said she did not report the information to administration until [DATE]. During an interview on [DATE] at 1:14 p.m., RN A said on [DATE] at approximately 8:45 p.m., she sat Resident #1 down in his chair by the nursing station and put the bedside table in front of him. She said she went behind the nursing station with LVN B and they both began charting. She said maybe 2 minutes later, CNA C came out of the secure unit and began yelling that Resident #1 was lying on the bedside table and was blue. She said Resident #1 was blue and CNA C began the [MEDICATION NAME] maneuver. She said LVN B went to get the crash cart and she called 911. She said she did not give him a sandwich, but she believed he ate a sandwich. She said the snack tray had peanut butter sandwiches on it and Resident #1 had a history of [REDACTED]. She said earlier in the shift, Resident #1 was drinking from the water pitcher on the medication cart. She said Resident #1 was admitted to this facility from a group home because the staff there was unable to provide the one to one supervision that he needed. During an interview on [DATE] at 9:39 a.m., LVN B said Resident #1 was sitting by the nursing station while she and RN A were behind the nursing station charting. She said CNA C came out the secure unit and began yelling that Resident #1 was blue. She said she went to get the crash cart and when she came back, Resident #1 had food in his mouth. She said the snack tray was sitting on the nursing station and there were peanut butter sandwiches on the tray. She said she caught Resident #1 going into the kitchen trying to get something to eat the night before. She said Resident #1 was impulsive and tried to grab whatever he could. She said he did not like the pureed diet and wanted what other residents were eating. During an interview on [DATE] at 2:22 p.m., Resident #2 said he saw Resident #1 sitting near the nursing station on Hall 100 on the evening of [DATE]. He said Resident #1 was eating a sandwich. An EMS report dated [DATE] indicated Resident #1 was choking and had [MEDICAL CONDITION]. The report indicated Resident #1's [MEDICAL CONDITION] was due to respiratory/asphyxia. Resident #1 was transferred to a local ER. Hospital records dated [DATE] indicated Resident #1 was choking on food preceding his [MEDICAL CONDITION]. EMS reported suctioning ,[DATE] mL of gastric content from Resident #1. Resident #1 was intubated and he did not have eye response, verbal response, or motor response. The hospital records indicated his [DIAGNOSES REDACTED]. Resident #1 was admitted to the ICU with concern for organ failure and [MEDICAL CONDITIONS]. During an interview on [DATE] at 2:28 p.m., Resident #2 said Resident #1's family came to the facility to pick up Resident #1's belongings. Resident #2 said Resident #1's family said Resident #1 died in the hospital on [DATE]. During an interview on [DATE] at 2:36 p.m., LVN F said Resident #1 had impulsive behaviors and would grab anything he could in his reach. During an interview on [DATE] at 4:16 p.m., the DON said the snack tray included peanut butter sandwiches and were delivered the nursing stations around 7:30 p.m. to 8:00 p.m. She said snacks were not locked up. She said Resident #1 was ambulatory and would grab anything he could reach. During an interview on [DATE] at 3:28 p.m., the administrator said Resident #1 was not on one to one supervision. The administrator was notified on [DATE] at 12:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 3:41 p.m. and included: Corrective Action and Identification: o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding CPR/[MEDICATION NAME] maneuver to include signs/symptoms of choking. Staff will be re-educated prior to starting their next shift. o On [DATE] the Director of Nursing or designee will review all resident diet orders and will update all Kardex and care plans accordingly to ensure all residents will receive correct diet. o On [DATE], residents' care plans were updated by the Director of Nursing and designees in the medical record. o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding use of the Kardex to communicate a Resident's specific diet. Staff will be re-educated prior to starting their next shift. o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding snack pass procedure to include delivery to nursing who will store in med room until passed to residents or discarded. Staff will be re-educated prior to starting their next shift. o On [DATE], the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding how to deal with residents with behaviors and cognitive deficits. Staff will be re-educated prior to starting their next shift. o On [DATE], an Interdisciplinary Team meeting (IDT) was held. Residents with non-compliance behaviors were reviewed for changes needed to care plan. The IDT's recommendations were discussed with the Medical Director and attending physicians. o On [DATE], the responsible parties of the residents who had recommendations from the IDT meeting were contacted by the Social Worker or designee. (sic) On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 4 LVNs, 1 MAs, 4 CNAs, 1 dietary worker, 1 dietitian, and 1 staffing coordinator were interviewed and said they were in-serviced about abuse/neglect, that snack trays were to be kept locked in the medication room until passed out, and how to locate residents' ordered diets. On [DATE] at 3:18 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 38 residents had mechanically altered diets.

Based on observation, interview, and record review, the facility failed to ensure residents received food prepared in a form designed to meet individual needs for 1 of 8 residents reviewed for dietary intake. (Resident #1) The facility did not ensure Resident #1 received the physician ordered diet. Resident #1 had orders for a pureed diet, and ate a peanut butter sandwich. Resident #1 choked on the sandwich which likely contributed to his death. An Immediate Jeopardy situation was identified on 12/28/16. The Immediate Jeopardy was removed on 12/29/16; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 38 residents receiving mechanically altered diets, including pureed diets, at risk for harm or death. Findings included: The facility's Abuse/Neglect Policy dated 11/28/16 defined neglect as .the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness . Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], and transferred to a local hospital on [DATE]. His [DIAGNOSES REDACTED]. His physician orders [REDACTED]. An incomplete Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was sometimes understood and was severely impaired cognitively. The MDS indicated Resident #1 was easily agitated, continually slapped himself in his face, and was at significant risk for physical injury. This MDS did not contain information regarding Resident #1's dietary restrictions for dysphagia. An undated care plan indicated Resident #1 was at nutritional risk related to dysphagia. Interventions included providing a pureed diet as ordered and evaluating for proper consistency of diet. The care plan indicated Resident #1 exhibited behaviors of hitting himself. The care plan did not address Resident #1's behaviors of grabbing other resident's food or personal items. The Admission (MDS) data set [DATE] indicated Resident #1 had severely impaired cognition, sometimes understood, and was restless. The Admission Data Set indicated Resident #1 had swallowing problems and a history of dysphagia. A psychological assessment dated [DATE] indicated Resident #1 was essentially non-verbal, but agitated and attempted to leave the facility. Resident #1 responded to being offered preferred items to eat or drink. It was recommended that Resident #1 be monitored at all times. A Nutritional assessment dated [DATE] indicated Resident #1 required a dysphagia puree diet. A physician progress notes [REDACTED].#1 had dysphagia and required aspiration precautions. During an interview on 12/27/16 at 3:31 p.m., CNA C said on 12/24/16 she was working on the secure unit. She said between 8:45 p.m. and 8:55 p.m., she saw Resident #1 sitting in a chair with a bed side table in front of him, by the nursing station of Hall 100. She said they spoke to each other and then she went into the secure unit. She said approximately 5-10 minutes later, she came out of the secure unit and Resident #1 was lying across the bedside table, his eyes and mouth were open, and his lips were blue. She said she began screaming at the 2 nurses sitting behind the nursing station that Resident #1 was blue. She said she pulled Resident #1 from the chair and began performing the [MEDICATION NAME] maneuver. She said a piece of bread that smelled like peanut butter came out of his mouth. She said the nurses began CPR and EMS arrived. She said the nurses were seated behind the nursing station and they could not have seen Resident #1 where he was seated. She said the snack tray that included peanut butter sandwiches were delivered to the nursing station around 7:30 p.m. to 8:00 p.m. on 12/24/16. During an interview on 12/28/16 at 12:16 p.m., CNA D, said he saw Resident #1 sitting near the nursing station on Hall 100 between 8:35 p.m. to 8:50 p.m. He said he and CNA E went into another resident's room to perform care. He said about 5 minutes later, he heard commotion at the nursing station. He said he and CNA E went to the nursing station and saw CNA C performing the [MEDICATION NAME] maneuver on Resident #1. He said he saw a peanut butter sandwich in his mouth. He said CPR was started on Resident #1 and EMS arrived. He said after the incident, RN A told him that she gave Resident #1 a sandwich and asked CNA D not to tell anybody. He said he did not tell administration about what RN A told him until 12/27/16. He said the snack tray was on the nursing station around 8:00 p.m. on 12/24/16, and peanut butter sandwiches were on the tray. During an interview on 12/28/16 at 12:22 p.m., CNA E said she saw Resident #1 sitting by the Hall 100 nursing station with a bedside table in front of him on 12/24/16 at approximately 8:45 p.m. She said CNA D and she were making rounds and 5-10 minutes later she heard hollering at the nursing station. She said she saw CNA C performing the [MEDICATION NAME] maneuver on Resident #1, and saw part of a peanut butter sandwich come out of Resident #1's mouth. She said Resident #1's lips were blue. She said peanut butter sandwiches were on the snack tray at the nursing station. She said after the incident, RN A told her that she gave Resident #1 a sandwich and asked her not to tell anybody. She said she did not report the information to administration until 12/27/16. During an interview on 12/28/16 at 1:14 p.m., RN A said on 12/24/16 at approximately 8:45 p.m., she sat Resident #1 down in his chair by the nursing station and put the bedside table in front of him. She said she went behind the nursing station with LVN B and they both began charting. She said maybe 2 minutes later, CNA C came out of the secure unit and began yelling that Resident #1 was lying on the bedside table and was blue. She said Resident #1 was blue and CNA C began the [MEDICATION NAME] maneuver. She said LVN B went to get the crash cart and she called 911. She said she did not give him a sandwich, but she believed he ate a sandwich. She said the snack tray had peanut butter sandwiches on it and Resident #1 had a history of [REDACTED]. She said earlier in the shift, Resident #1 was drinking from the water pitcher on the medication cart. She said Resident #1 was admitted to this facility from a group home because the staff there was unable to provide the one to one supervision that he needed. During an interview on 12/28/16 at 9:39 a.m., LVN B said Resident #1 was sitting by the nursing station while she and RN A were behind the nursing station charting. She said CNA C came out the secure unit and began yelling that Resident #1 was blue. She said she went to get the crash cart and when she came back, Resident #1 had food in his mouth. She said the snack tray was sitting on the nursing station and there were peanut butter sandwiches on the tray. She said she caught Resident #1 going into the kitchen trying to get something to eat the night before. She said Resident #1 was impulsive and tried to grab whatever he could. She said he did not like the pureed diet and wanted what other residents were eating. During an interview on 12/28/16 at 2:22 p.m., Resident #2 said he saw Resident #1 sitting near the nursing station on Hall 100 on the evening of 12/24/16. He said Resident #1 was eating a sandwich. An EMS report dated 12/24/16 indicated Resident #1 was choking and had [MEDICAL CONDITION]. The report indicated Resident #1's [MEDICAL CONDITION] was due to respiratory/asphyxia. Resident #1 was transferred to a local ER. Hospital records dated 12/24/16 indicated Resident #1 was choking on food preceding his [MEDICAL CONDITION]. EMS reported suctioning 50-100 mL of gastric content from Resident #1. Resident #1 was intubated and he did not have eye response, verbal response, or motor response. The hospital records indicated his [DIAGNOSES REDACTED]. Resident #1 was admitted to the ICU with concern for organ failure and [MEDICAL CONDITIONS]. During an interview on 12/29/16 at 2:28 p.m., Resident #2 said Resident #1's family came to the facility to pick up Resident #1's belongings. Resident #2 said Resident #1's family said Resident #1 died in the hospital on [DATE]. During an interview on 12/27/16 at 2:36 p.m., LVN F said Resident #1 had impulsive behaviors and would grab anything he could in his reach. During an interview on 12/28/16 at 4:16 p.m., the DON said the snack tray included peanut butter sandwiches and were delivered the nursing stations around 7:30 p.m. to 8:00 p.m. She said snacks were not locked up. She said Resident #1 was ambulatory and would grab anything he could reach. During an interview on 12/28/16 at 3:28 p.m., the administrator said Resident #1 was not on one to one supervision. The administrator was notified on 12/28/16 at 12:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 12/28/16 at 3:41 p.m. and included: Corrective Action and Identification: o On December 28, 2016, the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding CPR/[MEDICATION NAME] maneuver to include signs/symptoms of choking. Staff will be re-educated prior to starting their next shift. o On December 28, 2016 the Director of Nursing or designee will review all resident diet orders and will update all Kardex and care plans accordingly to ensure all residents will receive correct diet. o On December 28, 2016, residents' care plans were updated by the Director of Nursing and designees in the medical record. o On December 28, 2016, the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding use of the Kardex to communicate a Resident's specific diet. Staff will be re-educated prior to starting their next shift. o On December 28, 2016, the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding snack pass procedure to include delivery to nursing who will store in med room until passed to residents or discarded. Staff will be re-educated prior to starting their next shift. o On December 28, 2016, the Nurse Practice Educator or designee began conducting an in-service with direct care staff regarding how to deal with residents with behaviors and cognitive deficits. Staff will be re-educated prior to starting their next shift. o On December 28, 2016, an Interdisciplinary Team meeting (IDT) was held. Residents with non-compliance behaviors were reviewed for changes needed to care plan. The IDT's recommendations were discussed with the Medical Director and attending physicians. o On December 28, 2016, the responsible parties of the residents who had recommendations from the IDT meeting were contacted by the Social Worker or designee. (sic) On 12/29/16 the surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: Two RNs, 4 LVNs, 1 MAs, 4 CNAs, 1 dietary worker, 1 dietitian, and 1 staffing coordinator were interviewed and said they were in-serviced about abuse/neglect, that snack trays were to be kept locked in the medication room until passed out, and how to locate residents' ordered diets. On 12/29/16 at 3:18 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 12/27/16 indicated 38 residents had mechanically altered diets.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance was provided to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident #4) Resident #4 sustained a fractured arm during a transfer by CNA B and a family member. The facility did not ensure Resident #4 was transferred using a mechanical lift. This failure may have contibuted to Resident #4's fractured arm. This failure could place 12 residents who were dependent on staff for assistance with transfers at risk for injuries. Findings included: Consolidated physician orders [REDACTED].#4 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. The orders did not indicate how to transfer Resident #4. The most recent MDS dated [DATE] indicated Resident #4 was able to make her needs known and understood others. Resident #4 was extensive to totally dependent on staff for assistance with ADLs. Resident #4 had range of motion limitations to both upper and lower extremities. The most recent care plan dated 6/11/15 indicated Resident #4 was to be transferred with a mechanical lift and required total to extensive assistance with ADLs. During an interview on 6/29/15 at 8:22 a.m., Resident #4 said on 6/16/15 around 9:00 p.m., the power went out and CNA B and a family member placed their arms under each of her arms and lifted her out of the bed to an electric wheelchair. Resident #4 said she heard a snap in her left arm during the transfer and her arm began to hurt. Resident #4 said CNA B did not use a gait belt. During an interview on 6/29/15 at 12:15 p.m., CNA B said on 6/16/15 on the 2-10 p.m. shift, the power went out and Resident #4's air mattress deflated. CNA B said she attempted to place a Hoyer lift pad under Resident #4, but was unsuccessful. CNA B said Resident #4 wanted to get in her electric wheelchair. CNA B said the resident said her family member could help transfer her. CNA B said she and Resident #4's family member placed their arms under Resident #4's arms and lifted her off of the bed to the electric wheel chair. CNA B said she did not use a gait belt for the transfer. CNA B said Resident #4 was non-weight bearing. CNA B said she had not received training for the Hoyer or gait belt transfer. During an interview on 6/29/15 at 12:37 p.m., LVN A said she was the charge nurse caring for Resident #4 on 6/16/15. LVN A said Resident #4's air mattress deflated on 6/16/15 when the power went out and the emergency plugs threw a breaker. LVN A said she offered to transport Resident #4 to another area of the facility where the emergency plugs were working, but Resident #4 did not want to go. LVN A said Resident #4 requested to get in her electric wheel chair and Resident #4's family member volunteered to assist CNA B. LVN A said Resident #4 was to be transfered by a Hoyer lift, but CNA B was unable to get a Hoyer pad under the resident, so they transferred her with two people without a gait belt. A radiology report dated 6/16/15 from a local hospital indicated Resident #4 had a fracture of the left arm. During an interview on 6/29/15 at 1:05 p.m., the ADON said Resident #4 was non-weight bearing. The ADON said CNA B performed an incorrect transfer, and a gait belt should have been used. The ADON said Resident #4 was a Hoyer transfer. During an interview on 6/29/15 at 2:25 p.m., the administrator said gait belts were available on 6/16/15, but CNA B failed to use one. The administrator said CNA B performed an incorrect transfer on Resident #4. The CMS 672 dated 6/29/15 indicated 12 residents were dependent for transfers.