Every finding on record at Marshall Manor Nursing & Rehabilitation Center

Based on observation, interviews, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 3 of 22 resident rooms. (Residents # 56, #95, #103) 1. The facility failed to provide Resident #56 with intact window coverings with no broken/damaged areas. 2. The facility failed to provide Resident #95 with a safe toilet that had an appropriate lid on the tank of the toilet. 3. The facility failed to maintain a leaking air vent affecting Resident #103. These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, embarrassment due to rooms not appearing homelike, and a decrease in quality of life and self-worth. Findings included: 1. Record review of Resident #56's undated face sheet revealed he was an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #56 had diagnoses which included traumatic subdural hemorrhage (a serious condition where blood collects between the brain and its outer covering) and cerebral infarction (the death of brain tissue caused by a blocked blood vessel that cuts off blood flow, oxygen, and nutrients). Record review of Resident # 56's admission MDS assessment dated [DATE] indicated he was unable to make self-understood and understood others. Resident #56 had a BIMS score of 00 indicating severe cognitive impairment. Resident #56 required substantial assistance with toileting, bathing, and dressing lower body. Record review of Resident #56's care plan, revised on 7/17/2026 indicated Resident #56 had self-care performance deficits related to muscle weakness, unsteadiness on feet, lack of coordination, reduced mobility, and muscle wasting. During an observation on 07/27/2026 9:35 a.m., Resident #56's blinds were noted to have 2 slats with large missing gaps to the left bottom edge that let sunlight into the room hitting Resident #56 in the eyes. During an observation on 07/28/2029 at 10:00 a.m., Resident #56's blinds had tissue paper taped over the missing section of the blinds. During an observation on 07/29/2029 at 11:00 a.m., Resident #56's blinds continued to have tissue paper taped over the missing section of blinds. 2. Record review of Resident #103's undated face sheet revealed she was an [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #103 had diagnoses which included type II diabetes (a chronic condition that occurs when the body cannot properly use blood sugar, leading to high blood sugar levels), hypertensive heart and chronic kidney disease with heart failure (a complex, interrelated condition in which long-standing, uncontrolled high pressure damages both the heart and kidneys, leading to heart failure and chronic kidney disease). Record review of Resident # 103's quarterly MDS dated [DATE] indicated she was able to make self-understood and understood others. Resident #103 had a BIMS score of 11 indicating moderate cognitive impairment. Resident #103 required substantial assistance with toileting, bathing, and dressing lower body. The quarterly MDS indicated Resident #103 used a wheelchair. Record review of Resident #103's Care plan, revised on 6/17/2026 indicated Resident #103 had self-care performance deficits related to muscle weakness, unsteadiness on feet, lack of coordination, reduced mobility, and muscle wasting. During an observation and interview on 07/27/2026 at 9:20 a.m., Resident #103 stated her only concern about her stay at the facility was that her air conditioner vent leaked down the wall onto her sheets and it would leave a cold wet spot on her sheets. Several dark wet streaks were noted to be trailing down the wall from the air conditioner vent, and a dirty wet spot was noted to her sheets about mid-calf. She stated it was just not good housekeeping, and it made her uncomfortable to sleep in a cold wet bed. During an observation on 07/27/2026 at 2:10 p.m., revealed Resident #103 was in bed and a dinner plate sized wet spot was noted on her sheets mid-calf. Streaks of water were dripping down the wall onto her sheet from the A/C vent located near the ceiling on the wall parallel to Resident #103's bed. During an interview on 07/28/2026 at 10:12 a.m., CNA A stated many rooms had vents that leaked condensation from the air vent down the wall. She stated most people did not have their bed up against the wall like Resident #103'ss. She stated Resident #103 would let her know the bed was wet when she came in the room and she would get a new sheet when it happened. She stated maintenance knew about the condensation from the vents and he told her there was nothing that could be done to prevent condensation from forming when the air ran constantly because of the heat. Record review of the A wing maintenance log dated July 2026 revealed no requests for new blinds or a leaky air vent and no requests for Resident #56 or Resident #103. During an interview on 07/29/2029 at 11:40 a.m., the Maintenance Supervisor stated he had not been made aware of the missing blinds for Resident #56 nor the dripping A/C condensation for Resident #103. He stated he did walking rounds each day and looked in resident rooms for potential problems. He stated it had not been put on the maintenance request log. During an interview on 7/29/2026 at 12:52 p.m., the DON said she expected the staff to alert the maintenance department when any item is was broken in a room. She stated she was unaware of the broken blinds in Resident #56's room and unaware of Resident #103's leaky air vent. She stated it was important for the residents to feel safe in their home. During an interview on 07/29/2026 at 1:20 p.m., the Administrator stated that maintenance did walking rounds and fixed items in their logs daily. He stated the blinds in Resident #56's room and the leaky air vent in Resident #103's room were not reported to the maintenance man, and he had not noticed them on his rounds. The Administrator stated they were both easy fixes and would be taken care of as soon as possible. He stated having a clean and comfortable environment was essential to the residents' feeling home. 3. Record review of a face sheet dated 07/29/26 indicated Resident #95 was [AGE] years old and was admitted on [DATE] with diagnoses including cerebral infarction (the death of brain tissue caused by a blocked blood vessel that cuts off oxygen and blood flow), major depressive disorder (a serious mental health condition defined by a persistent low mood, loss of interest in activities, and lasting changes in sleep and energy for at least two weeks), and adjustment disorder (a short-term, stress-related condition triggered by a major life change or event). Record review of an admission MDS assessment dated [DATE] indicated Resident #95 was understood and understood others. The MDS indicated a BIMS score of 14 indicating Resident #95 was cognitively intact. The MDS indicated Resident #95 required partial to moderate assistance with toileting hygiene. During an observation on 07/27/26 at 10:27 a.m., Resident #95's toilet was off center. The front of the base of the toilet was pushed to the right. On the tank of the toilet there was a lid that did not fit and was too big for the tank. The lid slightly pushed forward the lid to the toilet seat, and the inside of the tank was visible. During an observation on 07/28/26 at 9:11 a.m., Resident #95's toilet was off center. The front of the base of the toilet was pushed to the right. On the tank of the toilet there was a lid that did not fit and was too big for the tank. The lid slightly pushed forward the lid to the toilet seat, and the inside of the tank was visible. During an observation and interview on 07/29/26 at 9:33 a.m., Resident #95's toilet was off center. The front of the base of the toilet was pushed to the right. On the tank of the toilet there was a lid that did not fit and was too big for the tank. The lid slightly pushed forward the back of the toilet seat, and the inside of the tank was visible. Resident #95 said he would like for his toilet to be fixed. He said the toilet was off center and pushed to the right. He said the top on the tank was not made for that toilet and did not fit well. He said it bothered him getting on and off the toilet because it caused the toilet to rock back and forth. He said he was scared that the lid would fall off and break. He said it made it difficult to sit on the toilet. He said he had reported it to staff all of the time. He said the toilet had been that way for months. Record review of a Maintenance Request Log notebook at the nurse's station indicated maintenance request dated 06/25/26 – 07/29/26. There were no requests for the repair of Resident #95's toilet. During an interview on 07/29/26 at 10:38 a.m., CNA B said she had never noticed problems with Resident 95's toilet. She said he had never reported any issues to her. She said any time maintenance issues were noticed or reported they were supposed to enter the issue into maintenance book at the nurses' station or tell the nurse. She said then maintenance made the repairs. During an interview on 07/29/26 at 10:55 a.m., Housekeeper D said he was responsible for cleaning Resident 95's room. He said he had never noticed the toilet. He said the resident had not complained to him about the toilet. He said if he had noticed he would have reported it to his supervisor and verbally reported it to the Maintenance Supervisor. During an observation and interview on 07/29/2026 at 11:00 a.m., RN E said she had never noticed Resident #95's toilet. She said staff assisted him to the toilet. She said he had never reported the problems with the toilet to her. She said she needed to enter it into the maintenance request book that was kept at the nurse's station. She then wrote the repair request into the maintenance log. She said she thought Resident #95 would have reported the issue. She said it was important for the toilet to be stable at the base because it was a safety risk and increased the risk of accidents. During an interview on 07/29/26 at 12:51 p.m., the Maintenance Supervisor said he had been in Resident #95's room a few times over the last month to repair the filler valve that had kept running in the toilet. He said he had pulled the toilet two weeks ago and did not know it was not stable. He said he could tell the lid to that toilet did not fit the tank. He said Resident #95 had only told him that the toilet had been running but nothing else. He said staff should have noticed the lid. He said staff might have known the toilet was loose if they were helping him get on or off the toilet. He said work request should go into the maintenance log. He said he checked the maintenance logs several times a day. He said he also received work request through an app or verbally by residents. During an interview on 07/29/26 at 1:01 p.m., the DON said she felt like staff should have noticed the toilet in Resident #95's room and a repair request should have been placed in the maintenance book. She said he could have had a fall or be uncomfortable when he went to the restroom or it could have caused him not to go to the restroom and he could have become constipated. During an interview on 07/29/26 at 1:25 p.m., the Administrator said he would have expected staff to have noticed Resident #95's toilet even if he did not say anything to them. He said if he told someone it should have been put in the maintenance repair book. He said the toilet should have been bolted to the floor, or replaced, and the accurate lid placed on the tank. He said it was an opportunity for someone to get hurt. Record review of a facility policy titled Homelike Environment dated February 2021 indicated, .Residents are provided with a safe, clean, and comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation.1. Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.a. clean, sanitary and orderly environment.b. comfortable, yet adequate lighting.c. inviting colors and décor.d. personalized furniture and room arrangements.e. clean bed and bath linens that are in good condition.3. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.a. overhead paging.institutional odors.institutional signage.medication carts.chair and bed.4. Comfortable and adequate lighting is provided.

Based on interview and record review the facility failed to ensure the resident's drug regimen was free from PRN orders for psychotropic drugs and are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days and documents their rationale in the resident's medical record and indicate the duration for the PRN for 1 of 6 residents reviewed for unnecessary psychotropic drugs (Resident #56). 1. The facility failed to ensure Resident #56 did not have a PRN order for lorazepam 0.5 mg (a prescription medication used to treat anxiety disorders-feelings of fear, dread, and uneasiness) after 14 days without an evaluation by the physician for continued treatment with a rationale in the resident's medical record and a duration for the PRN order. This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of Resident #56's undated face sheet revealed he was an [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #56 had diagnoses which included traumatic subdural hemorrhage (a serious condition where blood collects between the brain and its outer covering) and cerebral infarction (the death of brain tissue caused by a blocked blood vessel that cuts off blood flow, oxygen, and nutrients). Record review of Resident # 56's admission MDS assessment dated [DATE] indicated he was unable to make self-understood and understood others. Resident #56 had a BIMS score of 00 indicating severe cognitive impairment. Record review of Resident #56's Order Summary Report, dated 07/02/2026, reflected an order for lorazepam oral tablet 0.5mg, give 1 tablet every 4 hours as needed for anxiety. The start date was 07/02/2026. There was not an end date listed. During an interview on 07/29/2026 at 1:00 p.m., the DON stated Resident #56 was on hospice and he was using his Lorazepam frequently. She stated the Lorazepam order should have had a 14-day end date to be reevaluated and written for an extended period if needed. She stated she was unsure how it was overlooked. She stated it was the responsibility of the ADONs to review orders the day after they are written to ensure the validity of each order. She stated because Resident #56 used the Lorazepam there was no risk of harm to the resident. During an interview on 07/29/2026 at 1:30 p.m., the Administrator stated Resident #56's PRN lorazepam should have had an end date. He stated he did not know the risk of it not having an end date because he is not clinical. Record review of the Facility's policy, Medication and Treatment Orders, last revised July 2024, reflected: .Orders for medications and treatments should be consistent with principles of safe and effective order writing.c. PRN medications such as psychotropic medications ordered for 14 days should have a stop date and then the need to continue be evaluated by the physician to determine a continued need for scheduling the medication ongoing.

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 12 residents (Resident #14) reviewed for respiratory care. The facility failed to change the oxygen tubing and water reservoir for Resident #14. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: Record review of Resident #14's face sheet, dated 3/16/24 revealed a [AGE] year-old female originally admitted on [DATE] and most recently re-admitted on [DATE] with diagnoses that included Chronic Obtrusive Pulmonary Disease (a long-term lung problem that makes it hard to breathe, featuring trouble catching your breath, a daily cough, and wheezing), Shortness of Breath, Nausea. Record review of Resident #14's quarterly MDS assessment, dated 06/2/26, revealed Resident #14 had a BIMS of 12, which indicated mild cognitive impairment. Revealed that Resident #14 could be understood and understood others. The MDS revealed that Resident #14 received oxygen therapy. Record review of an order for Resident #14 dated 6/19/2026 revealed that staff were to change oxygen tubing every night shift every Wednesday. Record review of Resident #14's care plan revealed a problem initiated on 6/2/2025 revealed that Resident #14 required the use of oxygen therapy. The care plan reflected that staff were to change Resident #14's oxygen tubing as per facility policy. During an observation on 7/27/26 at 10:01 a.m. it was observed that Resident #14's oxygen tubing was labeled and dated 7/20. The water reservoir was empty and dated 7/20. During an observation and interview on 7/28/26 at 10:32 a.m. it was observed that Resident #14 oxygen tubing was labeled and dated 7/20. The water reservoir was empty and dated 7/20. Resident #14 said that her nose was getting dry. She said that a nurse should come by and change it for her. She said she would push her call button and ask for a nurse as she was bothered by the dry air she was being provided. During an interview on 7/29/26 at 10:17 a.m. the Director of Nurses said that it was the responsibility of the night nurses to ensure that residents who used oxygen have their tubing replaced and the water reservoir replaced with new water. She said that residents who did not get their tubing and reservoir replaced as ordered were placed at risk of nose bleeds and respiratory infections. During an interview on 7/29/26 at 10:24 a.m. the Administrator said that he expected that nursing staff replace oxygen tubing and their water reservoirs as ordered. He said that residents could be placed at risk of respiratory infections and nose bleeds if their equipment is not properly maintained. Record review of a facility policy titled, Oxygen Administration dated October 2010 revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Periodically re-check water level in humidifying jar. The date and time that the procedure was performed.

Based on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 1 (Resident #71) residents reviewed for medication storage and 1 of 8 of medication carts. 1. The facility failed to ensure the medication cart on Hall C was locked while there were no staff around on 7/28/26. 2. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #71 had in his possession a medication cup with an unknown red liquid in it. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.Findings included: 1. During an observation on 7/28/26 at 12:30 PM of a medication cart on Hall C revealed there were no staff around the cart and the cart was unlocked. The unlocked cart was in the hallway close to the nurse's station with the drawers assessable to anyone came in contact with the cart. The drawers were opened by the surveyor; syringes, insulin and medications given by mouth were present. During an interview on 7/28/26 at 12:38 PM, LVN F stated she was responsible for the cart. She stated the cart was supposed to be locked. She stated the cart was her treatment cart. The nurse stated she let someone use her keys and they must have left the cart unlocked. During an interview on 7/29/26 at 9:22 AM, LVN F stated she let someone used her keys to use the bathroom yesterday. She stated that while the person was using the bathroom, she left her cart unlocked so she could continue working to do blood sugar and gave insulin, but she was called away from her cart and left it unlocked. She stated she had taken the bathroom key off the key ring that goes to the cart. She stated a risk was that anyone could walk up to the cart and get into the cart. During an interview on 7/29/26 at 9:30 AM, ADON K stated the nurse or medication aide utilizing the cart was responsible for ensuring the cart was locked. She stated the risk was a safety issue, and the cart was accessible to anyone that came in contact with the cart. During an interview on 7/29/26 at 1:06 PM, the Director of Nursing stated she expected all the carts to be locked when staff were not attentive to them. She stated the nurse or medication aide was responsible to ensure the carts were locked. She stated the risk was that a resident could get medication off the cart that could be harmful to them. During an interview on 7/29/26 at 1:13 PM, the Administrator stated he expected medication carts to be always locked unless staff were using them. He stated the nurse or medication was responsible for the med cart. He stated the risk was that anyone that went by could get into the cart. 2. Record review of Resident #71's face sheet, dated 10/2/13, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and readmitted most recently on 07/03/25. His diagnoses included Anemia (a common blood condition where your body lacks enough healthy red blood cells or hemoglobin to carry needed oxygen to your organs, leading to fatigue, weakness, and shortness of breath), Constipation (happens when you have fewer than three bowel movements a week, or pass hard, dry and painful stools), Dysphagia (trouble swallowing, including oropharyngeal and esophageal types, often caused by nerve damage, muscle weakness, or physical blockages). Record review of Resident #71's Annual MDS assessment, dated 06/30/26, indicated he had a BIMS score of 14, which indicated intact cognition. The MDS further indicated Resident #71 could be understood and could understand others. Record review of Resident #71's care plan indicated that a problem initiated on 03/16/2026 revealed that Resident #71 had very poor vision and eyesight and staff should provide a safe environment. During an observation on 7/27/26 at 9:28 a.m. revealed Resident #71 had a medication cup with an unknown red liquid in the cup. The cup was sitting on Resident #71's bedside dresser. Resident #71 was not in the room to be interviewed. During an interview on 7/29/26 at 10:13 a.m. the Director of Nurses said that the medication aide or nurse that administered medication was supposed to watch the resident to see if they took their medication. She said that if the resident did not want to take the medication then they could go back later and try to have the resident take the medication. She said that residents of the facility were put at risk because anyone could take the medication that was not stored. She said that whoever was passing medication was responsible to ensure it was taken before leaving the resident unsupervised. During an interview on 7/29/26 at 10:22 a.m. the Administrator said that it was the responsibility of the medication aide or nurse to ensure that residents that were given medications actually take the medication. He said that other residents could be put at risk if they took a medication that did not belong to them. Record review of a facility policy titled, Security of Medication Cart dated April 2007 revealed that the purpose of the policy was, The mediation cart shall be secured during medication passes.4. Medications carts must be securely locked at all times when out of the nurse's view.5. When the medication cart is not being used, it must be locked and parked at the nurse's station or inside the medication room. Record review of a facility policy titled, Administering Medications dated December 2012 revealed that the purpose of the policy was to, Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record space provided for that drug and dose.The individual administering the medication must initial the resident's medication administration record on the appropriate line after giving each medication and before administering the next ones.During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 25 resident personal refrigerators reviewed for food safety (Resident #71). The facility failed to ensure the refrigerator for Resident #71 did not contain [NAME] salami that was spoiled and out of date. This failure could place resident at risk for food borne illnesses. Findings include: Record review of a face sheet dated 07/29/26 indicated Resident #71 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, leading to problems with memory, planning, and judgment), diabetes, and cerebral infarction (the death of brain tissue caused by a blocked blood vessel that cuts off oxygen and blood flow). Record review of the MDS dated [DATE] indicated Resident #71 understood others and was understood. The MDS indicated Resident #71 was cognitively intact with a BIMS score of 14. The MDS indicated Resident #71 required setup or clean up assistance with eating. Record review of a care plan for Resident #71 dated 07/05/26 indicated he had impaired cognitive and impaired decision-making abilities due to history of a stroke with cognitive deficits. During an observation on 7/27/26 at 9:42 a.m. Resident #71 had a package of [NAME] Salami in his personal refrigerator. The expiration date was 05/10/26. The meat was greyish in color around the edges and had a large amount of sour smelling liquid in the container. During an observation and interview on 7/29/26 at 8:26 a.m. Resident #71 had a package of [NAME] Salami in his personal refrigerator. The expiration date was 05/10/26. The meat was greyish in color around the edges and had a large amount of sour smelling liquid in the container. Resident #71 was up in his wheelchair propelling around the room. He said he did not remember the last time staff had cleaned out his refrigerator. He said he did not know the salami was spoiled and he would have eaten it. During an interview on 07/29/26 at 10:38 a.m., CNA B said it was both housekeeping and the CNAs job to clean out residents' personal refrigerators. She said really, only the residents went in their refrigerators. She said they did not go in the residents' refrigerators unless they smelled something. During an interview on 07/29/26 at 10:51 a.m., Housekeeper C said housekeeping was responsible for cleaning out residents' personal refrigerators including expired foods. She said when the room was cleaned the refrigerators should be checked every day. She said she mainly just cleaned offices. She said whoever had been cleaning Resident #71's room should have removed the expired meat. During an interview on 07/29/26 at 11:00 a.m., RN E said housekeeping staff were responsible for removing expired food from resident's refrigerators. She said she had even removed expired food items from residents' refrigerators. She said she would have expected for the salami to have been removed from Resident #71's refrigerator when it expired. She said it was important for expired food items to be removed because they can grow mold, make people sick, and stink. During an interview on 07/29/26 at 1:01 p.m., the DON she said housekeeping was responsible for cleaning out Resident #71's refrigerator. She said he had refused before to let anyone clean his refrigerator. She said the temperatures should be checked daily and expired foods should be checked weekly. She said it was important to keep the residents' refrigerators cleaned out because residents could eat expired food and could get food poisoning. She said it was also important for hygiene. During an interview on 07/29/26 at 1:07 p.m., Resident #71 said he had never refused to have his refrigerator cleaned out. He said he did not want good food thrown out because there were too many starving children in the world, but if the food was expired and not any good, he did want staff to throw it out. During an interview on 07/29/26 at 1:25 p.m., the Administrator said housekeeping had been overseeing cleaning out residents' refrigerators. He said it was the responsibility of all staff to ask the resident if they could look in their refrigerator and get out whatever was expired. He said it was important because if Resident #71 had eaten the salami, it may have made him really sick. Record review of a Food Receiving and Storage facility policy last revised on 07/2014, indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices.Food Services, or other designated staff, will maintain clean food storage areas at all times.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 25 residents (Resident #31) reviewed for infection control practices. 1. The facility failed to ensure CNA G and CNA H donned (to put on) their gowns prior to providing catheter care for Resident #31, who was on enhanced barrier precautions, on 7/29/26. This failure could place residents at risk for cross contamination and the spread of infection.Findings include: Record review of Resident #31's face sheet dated 7/29/26 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included: benign prostate hyperplasia (a non-cancerous enlargement of the prostate gland that commonly affects older men) and infection following a procedure. Record review of Resident #31's MDS assessment, dated 5/6/26, reflected Resident #31 was understood and understood by others. Resident #31's BIMS score was a 13, which indicated cognition was intact. Resident #31 required moderate assistance with ADLs. Resident #31 had an indwelling catheter. Record review of Resident #31's care plan dated 4/29/26 reflected Resident #31 required the use of enhanced barrier precautions Resident #31 had an open wound which increases my risk of developing MDRO (multi drug restraint organism) infection. The interventions: EBP PPE required - Wear a gown and gloves for the following High-Contact. Resident Care Activities: dressing, bathing/showering, transferring (especially when anticipating close body contact), providing hygiene (e.g., brushing teeth, combing hair, shaving), changing linens, changing briefs or assisting with toileting. Device Care or Use (e.g., catheter, feeding tube, central line care), wound care (any skin opening requiring a dressing). Enhanced barrier precautions: Post signs outside of my room that state the required precautions and PPE that list activities that require gown and gloves. Ensure the appropriate PPE is available outside of my room. Provide an alcohol-based hand rub in my room and outside of my room when possible. Place a trash can for PPE disposal inside of my room and near the exit. Provide ongoing training for staff, residents, and visitors. Follow infection prevention practices (e.g. hand hygiene and PPE.) Record review of Resident #31's care plan dated 5/8/26 reflected Resident #31 had a Foley catheter due toobstructive uropathy. Resident #31 cannot void without the foley catheter with history of TURP (transurethral resection of the prostate) with perforated bladder. The interventions: provide foley catheter care every shift. Record review of Resident #31's care plan dated 5/8/26 reflected Resident #31 had a foley catheter due to obstructive uropathy. He cannot void without the foley catheter with a history of TURP (transurethral resection of the prostate) with perforated bladder Record review of Resident #31's order summary, dated 4/28/26reflected Urinary Catheter- Care every shift related to benign prostatic hyperplasia with lower urinary tract symptoms. Record review of Resident #31's order summary reflected enhanced barrier precautions while providing personal care every shift for foley catheter, dated 6/18/26. During an observation on 7/13/26 at 10:07 AM, revealed CNA G and CNA H performed catheter care on Resident #31 and did not don a gown prior to performing catheter care. Resident #31 had an EBP sign on the room door and PPE in cart was outside the door. During an interview on 7/29/26 at 10:12 AM, CNA H stated they were supposed to wear the gowns during the catheter care. She stated each staff member was responsible for ensuring they wear the appropriate PPE. She stated the risk was cross contamination. During an interview on 7/29/26 at 10:14 AM, CNA G stated they should have worn a gown during the catheter care. She stated the staff were responsible for ensuring they wore the appropriate PPE. She stated the risk was cross contamination. During an interview on 7/29/26 at 10:15 AM LVN L stated the staff knew to wear the appropriate PPE with residents on EBP, because they had been educated on that. She stated they were just nervous. She stated the risks were cross contamination and the risk of spreading infections. During an interview on 7/29/2026 at 12:32 PM, ADON K stated she excepted for the staff to wear a gown during catheter care. She stated each staff member and the charge nurse were responsible for ensuring staff followed EBPs. She stated the risk was the spread of infection. During an interview on 7/29/26 at 1:06 PM, the Director of Nursing stated she excepted the staff to wear the appropriate PPE with a resident on EBP. She stated the charge nurse, The DON and herself were responsible for supervising the staff. She stated the risks were infection control and cross contamination. During an interview on 7/29/26 at 1:13 PM, the Administrator stated that he expected all staff to wear the appropriate PPE. He stated anyone responsible for going into the resident's room was responsible for what they need to wear. He stated the risk of not putting on the gown was cross contamination and infection control. Record review of the facility's policy and procedure Enhanced Barrier Precautions (EBP) undated, indicated Purpose: To reduce the transmission of multidrug-resistant organisms (MDROs) and other epidemiologically significant pathogens within the facility through the implementation of Enhanced Barrier Precautions (EBP) in accordance with current infection prevention and control practices. Policy: The facility will implement Enhanced Barrier Precautions for residents as indicated by current clinical guidance and infection prevention recommendations. Enhanced Barrier Precautions are intended to reduce the risk of pathogen transmission during resident care activities while promoting resident quality of life and participation in facility activities. The facility follows current guidance from the Centers for Disease Control and Prevention (CDC) and applicable federal and state regulations regarding infection prevention and control practices. Procedure: 1. Residents may be placed on Enhanced Barrier Precautions based on: The presence of specific multidrug-resistant organisms or other epidemiologically important pathogens, as identified by the Infection Preventionist, medical provider, or clinical team.The presence of wounds, medical devices, or other risk factors associated with increased transmission potential.Recommendations from public health authorities or current infection control guidance.2. Staff shall: Perform hand hygiene before and after resident contact and after contact with the resident's environment. Utilize appropriate personal protective equipment (PPE) during high-contact resident care activities as indicated by facility protocols. Follow standard infection prevention practices at all times. Receive education regarding Enhanced Barrier Precautions and proper PPE use. 3. Residents on Enhanced Barrier Precautions may: Participate in communal dining, therapy, activities, and social interactions when clinically appropriate. Leave their room unless otherwise restricted for a specific infection control reason. 4. Signage and communication regarding Enhanced Barrier Precautions shall be utilized in accordance with facility procedures while maintaining resident privacy and dignity. 5. The Infection Preventionist or designee shall: Monitor implementation and compliance with Enhanced Barrier Precautions. Provide ongoing education and guidance to staff. Review infection prevention practices and update procedures as necessary based on current recommendations. Record review of the facility's policy and procedure Catheter Care, Urinary dated September 2014, indicated Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation:1. Review the resident's care plan to assess for any special needs of the resident.2. Assemble the equipment and supplies as needed.General Guidelines:1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure:6.Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).

Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 6 residents (Resident #42) reviewed for resident call system. The facility failed to ensure Resident #42 had a call light button functioning at bedside. This failure could place residents at risk of a delay in assistance and decreased quality of life, self-worth, and dignity. Findings include: Record review of Resident #42's face sheet, dated 7/28/26, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #42 had diagnoses which included: acute and chronic respiratory, non-pressure chronic ulcer, chronic obstructive pulmonary disease (an ongoing lung condition that limits airflow and makes it hard to breath), pain, chest pain, repeated falls, cerebral infarction (a medical emergency that occurs when a blocked blood vessel stops blood and oxygen), shortness of breath and hemiplegia and hemiparesis following a cerebral infarction (nervous system conditions that affect one side of the body). Record review of Resident #42's comprehensive MDS assessment, dated 7/8/26, reflected Resident #42 was understood and understood by others. Resident #42's BIMS score was 12, which indicated moderate cognition impairment. Resident #42 was dependent on all ADLs. Resident #42 was occasionally incontinent to bowel and bladder. Record review of Resident #42's care plan, dated 7/20/26, reflected the potential to have falls related to my poor balance and posture. Resident #42 also receives multiple medications. The interventions included: encourage to use call light and to ask for assistance as needed. Keep call light and frequently used items in reach. During an observation and interview on 7/27/26 at 11:20 AM, revealed Resident #42 was sitting up in wheelchair watching television. Resident #42 stated he had one complaint; his call light did not work beside his bed. Resident #42's call light was the on floor. Resident #42 stated the call light had not worked since he had been in the room. He stated some of the staff knew the call light did not work. The Surveyor pushed the call light button on the resident's side of bed, and the call light did not work. Resident #42 stated he had no other concerns except for his call light did not work. Resident #42 stated the problem with the call light was when a staff member came into the room and did not know this call light did not work. During an observation and interview on 7/28/26 at 8:44 AM, revealed Resident #42 was lying in bed. Resident #42 stated the facility still had not fixed the call light, and it was not working. Resident #42 stated the staff pulled the other call light from the other side of the room to his side of the bed, so they were aware of the situation. During an observation on 7/28/26 at 10:24 AM revealed Resident #42's call light was not working at bedside. Record review of the maintenance request book on 7/29/26 at 9:15 AM at the nurses' station on Hall D revealed there was not an entry for room D2 (Resident #42) call light was not working. During an interview on 7/29/26 at 9:10 AM, CNA H stated the call light next to Resident #42's bed was not working, but the other call light worked from the other side of the room. She stated she was not sure if anyone had looked at the call light. She stated she knew the call light closest to Resident #42's bed did not work, so she attached the other call light to his bed. She stated she was not sure if the issue had been reported in the maintenance book. She stated the risk would be Resident #42 could not get help if needed it, due to his call light not working. During an interview on 7/29/26 at 9:17 AM, LVN L stated she was not aware of the Resident #42's call light not working close to his bed. She stated he had a call light, but she would put it into the maintenance logbook now. She stated she was responsible for putting in a report to maintenance about replacing a call light. She stated Resident #42 needed the call light accessible to have access to staff, it was necessity. During an interview on 7/29/26 at 9:30 AM, ADON K stated it seemed like there was something wrong with the call light close to Resident #42's bed, but staff used the other call light. She stated whoever discovered the call light was not working was responsible for putting the issue in the maintenance logbook. She stated the risks would be the resident falling, immobility or not having access to staff. During an interview on 7/29/26 at 9:45 AM, the Maintenance Supervisor stated he was not aware of the call light not working until staff contacted him today. He stated the issue was not in the Maintenance logbook prior to today. He stated he replaced the whole wall box for the call light. He stated the risk was if the resident needed to call for help and the light did not work. During an interview on 7/29/26 at 1:06 PM, the Director of Nursing stated she excepted for all the residents to have access to their call light, and they were always functioning properly. She stated the charge nurse, and CNAs should be checking the call lights every shift. She stated the risks were a resident could have a fall, need pain medication and no access to staff. During an interview on 7/29/26 at 1:13 PM, the Administrator stated he expected all residents to have a call light accessible and functioning properly. He stated that anyone who realized the call light was not working should put it in the maintenance logbook and the Maintenance Supervisor should ensure the call light was functioning. He stated the risk was that the resident could not call for help. Record review of the facility's policy and procedure Answering the Call Light dated October 2010, indicated .The purpose of this procedure is to respond to the resident's requests and needs.6. Some residents may not be able to use their call light. Be sure you check these residents frequently.7. Report all defective call lights to the nurse supervisor promptly.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 2 wings reviewed for the environment. The facility did not maintain an effective pest control program to ensure the B Wing was free of roaches and water bugs. This could place residents at risk for an unsanitary environment and a diminished quality of life.Findings include: During an interview and observation on 7/27/26 at 9:37 a.m. it was observed Resident #6's bathroom had a large roach approximately half an inch in size and several, approximately 5 to 8, small roaches on the floor. A large water bug approximately 2 inches long was observed entering a hole in the wall in the bathroom. Resident #6 said that it bothered him that there were bugs in his bathroom and they came into his room as well. He said he did not know if anyone did anything about it, but they had been there for a while. During an observation on 7/27/26 at 9:51 a.m. revealed Resident #29's bathroom several large cockroaches were observed going under the toilet and into loose wall trim in the bathroom. Resident #29 was not in the room to interview. During an interview on an undisclosed date and time with anonymous staff revealed that they knew there was a pest problem in B Wing. They said that they had not seen pest control in that part of the building for a while. She said that there have been a lot of roaches and other bugs in this section of the building for 6 months. During an interview on 7/29/26 at 10:17 a.m. the Director of Nurses said that their contracted pest control service needed to come more often and focus on that part of the building. She said that the risk to residents having pests in their bathroom and rooms was both resident hygiene and the potential for pests to get into their food. During an interview on 7/29/26 at 10:26 a.m. the Administrator said that it was the responsibility of maintenance to ensure that pests were not entering the building via damage to the walls and that pest control services should direct their attention to problem areas in the building. He said that pests could affect residents' health. During an interview on 7/29/26 at 12:54 p.m. the Maintenance Manager said that he saw insects occasionally in B Wing. He said that pest control came out once a month. He said he would focus on those rooms with pests and that section of the building. He said that he could caulk or fix the floor trim so the entry into the bathrooms was sealed. He said he did not put out pesticide and left it to the contracted pest control service to poison. Record review of a facility policy titled, Pest Control dated May 2008 revealed that, Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review, the facility failed to obtain physician orders for the resident's' immediate care for 1 (Resident #1) of 5 residents reviewed for admission physician orders. 1.The facility failed to obtain physician orders for the immediate care of Resident #1's surgical wound and pressure ulcer. These failures could affect residents who were admitted or readmitted to the facility by placing them at risk for not receiving the appropriate care, medication, and treatment services. Findings included: 1.Record review of an undated face sheet revealed Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of gangrene of wound (the death of body tissue caused by a loss of blood supply or a severe bacterial infection), Diabetes type II (a chronic metabolic condition where the body resists insulin or cannot produce enough of it), and osteomyelitis (a serious infection and inflammation of the bone, primarily caused by bacteria or fungi). Record reviews of the electronic health record on 06/24/2026 revealed Resident #1 admitted on [DATE] at 05:15 p.m. It revealed the following:Resident #1 had a recent amputation of all of the toes on his right foot. He had a surgical wound from the amputation.Resident #1 had no orders for wound care for his surgical wound to his right foot after amputation of his toes, from 04/03/2026 to 04/06/2026.Resident #1 had a stage II pressure ulcer to left sacrum noted on his admission assessment 04/03/2026.Resident #1 had no orders for wound care for his stage II pressure ulcer to his sacrum from 04/03/2026 to 04/06/2026. Record review of the MD orders for Resident #1 on 04/06/2026 revealed the following orders:Right Transmetatarsal: Cleanse with NS or Wound Cleanser, Pat dry, apply Betadine damped gauze to incision line then nonadherent dressing, then wrapwith rolled gauze secure with tape, then wrap with ace wrap.Sacrum: Cleanse with Soap and H2O, Pat dry, apply Zinc Ointment 20% to wound bed, then Leave Open to Air. Record review of Resident #1's MAR/TAR for April 2026 indicated Resident #1 did not receive any wound care from 04/03/2026 through 04/06/2026. During an interview on 06/23/2026 at 10:30 a.m., LVN A stated she was the nurse that admitted Resident #1. She stated he came in late on a Friday and all of the department head nurses, including the treatment nurse, were gone for the day. She stated there was more than one admit that evening and she had forgotten to contact the MD regarding the wounds and was off on Saturday and Sunday. She stated the resident not having wound for 2 days could have caused complications with his wounds by causing them to worsen. She stated Resident #1's wounds were evaluated by the treatment nurse and the wounds had not worsened on Monday. LVN A stated the treatment nurse initiated wound care on 04/06/2026. During an interview on 06/24/2026 at 1:00 p.m., the treatment nurse stated it was the job of the admitting nurse to do the initial evaluation of all wounds and call the MD for orders for the wounds if they had not come from the hospital with wounds. She stated the treatment nurse would assess the wounds the next weekday and stage the wounds and review the orders for treatment for each wound. The treatment nurse stated Resident #1 had no wound care orders when she came in on 04/06/2026 to evaluate his wounds. She stated she immediately notified the MD and obtained orders and started wound care for him. During an interview on 06/24/2026 at 11:00 a.m., the DON stated the admission process for new residents was that the admitting nurse completes the admission assessment, enter all MD orders from the hospital discharge information, start the baseline care plan, clarify all orders with the physician and administer the initial dose of medications ordered on their shift and begin treatments for wounds. The DON stated it was the expectation that documentation would include vital signs, a full body assessment to include pain and skin issues that need to be addressed. The DON stated not ensuring initial MD orders are in the EHR for all residents and not ensuring their assessments are completed can cause delay in care for the residents. She stated the department head nurses always check the orders and assessments for completion and accuracy on the first business day after the resident admits. During an interview on 06/24/2026 at 2:15 p.m., the Administrator stated it was the responsibility of the admitting nurse to ensure that the resident had all orders in the EHR and that the pharmacy was aware of the orders and was sending the medication. He stated it was the admitting nurse's responsibility to complete the admission assessment and notify the MD of the arrival of the resident and clarify any orders needed after assessing the resident. He stated she he was unaware this process was not being followed. He stated it was the responsibility of the DON and administrative nurses to ensure the residents have all the orders they need and all assessments are completed correctly. He stated the failure to do so could lead to the residents feeling ignored and unimportant. An undated policy titled 'Admitting a Resident' indicated the following: .6. Assist resident into bed. Observe carefully for any open or draining areas, dressings, rashes, bruises or reddened areas and report these to the charge nurse.7. The licensed nurse interviews resident/family member and initiates the admission Nursing data Collection.The drug regimen review is to be completed.12. The licensed nurse notifies the attending physician of his/her arrival and orders.13. Complete and record resident's height, weight, temperature, blood pressure, pulse and respirations on the admission Nursing Assessment and other daily documentation per policy.

Based on observations, interviews, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 2 of 5 residents reviewed for range of motion. (Resident #38 and Resident #65) 1. The facility failed to provide restorative therapy for limited range of motion for Resident #38 as recommended by occupation therapy on 04/22/25. 2. The facility failed to ensure Resident #65 wore a left upper extremity splint (is a medical device that stabilizes a part of your body and holds it in place) per the facility's range of motion/contracture (is a permanent shortening or stiffening of a muscle, tendon, or joint, leading to a loss of mobility and range of motion) log on 5/5/25, 5/6/25, and 5/7/25. These failures could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 05/07/25 revealed Resident #38 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses including diabetes, benign neoplasm of pituitary gland (a non-cancerous tumor of the pituitary gland), and presence of artificial hip joint. Record review of an Order Summary Report for Resident #38 revealed a physician's order for PT/OT to evaluate and treat with a start date of 03/29/25. Record review of an admission MDS dated [DATE] revealed Resident #38 was understood and understood others. Resident #38 had a BIMS score of 12 which indicated moderate cognitive impairment. The MDS indicated Resident #38 had limited range of motion to the upper extremities on one side and limited range of motion on both sides of the lower extremities. The MDS indicated Resident #38 required set up to partial/moderate assistance with ADL's. Record review of a care plan dated 04/15/25 revealed Resident #38 had the potential to have falls related to poor balance and posture. There was an intervention for PT/OT to screen and evaluate the resident as needed. The care plan revealed Resident #38 had the potential for pain due to chronic pain related to arthritic changes along with a history of bilateral total hip replacements with multiple revisions. Record review of an Occupation Therapy, OT Discharge Summary revealed Resident #38 received occupational therapy services from 03/31/25 to 04/22/25. The discharge summary revealed the discharge reason was, Maximum Potential Achieved. Resident #38 was referred to the restorative nursing program. Record review of a Restorative Training Form revealed Resident #38 was discharged for m OT services on 04/22/25. The form recommended bilateral upper extremity exercise across all joints/planes as tolerated with focus on upper body and lower body dressing task. The form recommended lower extremity exercises of one pound ankle weights across all joints/planes as tolerated with focus on functional transfers. Record review of the documentation for the Restorative Nursing Program from 04/22/25 - 05/06/25 revealed no documentation for Resident #38. During an interview on 05/07/25 at 9:03 a.m., the Director of the Rehabilitation Department said Resident #38 was discharged from therapy on 04/22/2025 because he had reached his max potential. She said he had often refused services and at times only allowed staff to provide limited services. She said he was referred to the restorative program upon his discharge from occupational therapy. She said she was not sure how long that process took for him to be added to the restorative program. She said the DON oversaw the restorative program . During an interview on 05/07/25 at 9:44 a.m., Resident #38 said he just graduated from therapy. He said he did not have any contractures. He said his only issue was pain in his hips. He said he had surgeries on both hips, and he felt like he needed more surgeries on them. He said since he was discharged from therapy the aides were not doing exercises with him. He said he had not refused to participate in exercises. He said his hip pain and limited range of motion in his hips had not gotten any worse since admission. During an interview on 05/07/25 at 9:54 a.m., the DON said she could not find Restorative Training Form recommending Resident #38 to receive restorative services. She said she was unaware he had been referred to the restorative program. She said sometimes therapy put the forms in her box and sometimes slid it under her door. She said she preferred it be slid under her door and discussed at the morning meeting. She said it would only take 5 minutes to initiate restorative services for the resident. She said two weeks without restorative services could cause an increase in weakness, develop contractures, and increase the resident's risk of falling. During an interview on 05/07/25 at 10:12 a.m., the Director of the Rehabilitation Department said when a resident was discharged from therapy they were then immediately discharged to the restorative program. She said they complete the Restorative Training Form and place it in the DON's box so the resident could be added to the Restorative Program. She said she did not know what had happened to the Restorative Training Form for Resident #38. She said it was placed in the DON's box. She said she was not sure how not having restorative services for 2 weeks could negatively affect a resident. During an interview on 05/07/25 at 11:22 a.m., Restorative Aide A said, usually the DON, or the therapy department would tell her the restorative form was on the table in the restorative office for her to add a resident to the restorative program. She said she never got a form for Resident #38. She said she just found out on 05/07/25 that he was supposed to be on the restorative program. She said he would start the program on 05/07/25. During an interview on 05/07/25 at 1:30 p.m., the Administrator said therapy would make a recommendation for restorative therapy to the nursing department. He said therapy would also ask nursing if anyone has had any decline. He said the nursing staff were responsible for admitting a resident to the restorative program. He said the recommendation would go directly to the DON and she would admit the resident to the restorative program. He said he would have expected the process admit Resident #38 to have begun as soon as nursing received the recommendation from the therapy department. He said a resident not receiving recommended restorative therapy, there was always the possibility of decline. 2. Record review of Resident #65's face sheet dated 5/6/25 indicated Resident #65 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #65 had diagnoses including cerebral infarction (occurs when blood flow to the brain is blocked, leading to tissue damage or death), hemiplegia (is a condition characterized by paralysis affecting one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction affecting left non-dominant side, pain, and rheumatoid arthritis (is a form of arthritis that causes pain, swelling, and stiffness in your joints). Record review of Resident #65's quarterly MDS assessment dated [DATE] indicated Resident #65 was understood and had the ability to understand others. Resident #65 had a BIMS score of 14 which indicated intact cognition. Resident #65 had functional limitation in range of motion on one side, on the upper and lower extremities. Resident #65 required setup for eating, partial assistance for oral hygiene, and maximal assistance for toileting and personal hygiene, upper and lower body dressing, and putting on/taking off footwear. Record review of Resident #65's care plan dated 8/24/23, reviewed 4/10/25 indicated Resident #65 required weight bearing support from staff during ADL care due to impaired mobility, very poor vision, hemiplegia, and chronic pain. Intervention included to provide range of motion to extremities daily during routine ADL care as tolerated and as will allow. Record review of Resident #65's Nursing Restorative Plan of Care dated 04/2025 indicated, .date restorative plan written .3/6/25 .approaches/interventions with frequency .perform right lower extremity therapy exercise with 3-pound ankle weights .perform postural control/positioning .DON .4/1/25 . The plan of care did not reflect left upper extremity splint placement. Record review of the facility's ROM/Contracture log dated 2025 indicated, .Resident #65 .contracture location or type .LLE/LUE ROM/TONE .device provided .LUE SPLINT .RNP .Yes . During an interview and observation on 5/5/25 at 10:40 a.m., Resident #65 was lying in bed watching television. Resident #65 said she had contractures in her arm and leg. She said she was currently not on therapy service. She said she should have a hand brace, but it was in her drawer somewhere. She said no one had offered to put the hand brace on. During an observation on 5/6/25 at 9:20 a.m., Resident #65 was lying in bed. Resident #65 did not have splint on her left upper extremity. During an interview on 5/6/25 at 11:00 a.m., the DON said she oversaw the RNP and two employees, RA A and RA H, and implemented the program. She said RA H was responsible for A/B wing and RA A was responsible for C/D wing. She said the RAs primarily did range of motion and CNAs and LVNs applied splints and hand rolls. She said the RAs only did the braces if there was a detailed restorative plan for it. She said the RAs normally visited the residents on the RNP daily, but they were also back up drivers. She said the RAs documented on a flowsheet when they provided treatment. During an observation on 5/6/25 at 11:15 a.m., Resident #65 was sitting up in a Broda chair (a wheelchair with ergonomic tilt and recline functions, designed to reduce pressure points, enhance comfort, and improve posture). Resident #65 did not have a splint on her left upper extremity. During an observation on 5/6/25 at 3:30 p.m., Resident #65 was sitting up in a Broda chair. Resident #65 did not have a splint on her left upper extremity. During an observation on 5/6/25 at 5:00 p.m., Resident #65 was sitting up in a Broda chair. Resident #65 did not have a splint on her left upper extremity. During an observation on 5/7/25 at 8:15 a.m., Resident #65 was lying in bed. Resident #65 did not have a splint on her left upper extremity. During an interview on 5/7/25 at 9:28 p.m., COTA E, with the DOR present, said Resident #65 was currently not on rehab therapy services. She said Resident #65 had been on OT 12/19/24-1/16/25 and PT 2/6/25-3/5/25. She said Resident #65 had been discharged to the restorative program. She said Resident #65 had limited range of motion to her left hand and leg. The DOR said therapy wrote the nursing restorative plan of care and gave it to the RNP. COTA E said Resident #65 should have a hand splint to her left hand. COTA E and the DOR said when Resident #65 was on therapy services, she never refused to wear the hand splint. The DOR said the hand splint was not from rehab therapy, but an outside physician ordered the splint. COTA E said she had shown ADON B how to correctly put Resident #65's hand splint on. The DOR said she did not know who was responsible for putting on Resident #65's hand splint since she was on RNP. COTA E said Resident #65's hand splint was important to decrease the risk of developing a contracture. During an interview on 5/7/25 at 10:38 a.m., RN G said she had been working at the facility since January 2025. She said she worked Monday thru Friday, 7am-3pm shift. She said Resident #65 had limited range of motion in her leg. She said she had never been shown or placed a hand splint on Resident #65. She said she knew Resident #65 was on the RNP. She said if the nurses were responsible for applying a resident's hand splint, it would be on the TAR. She said a hand splint was important for a resident with limited range of motion or contracture to prevent pain or discomfort. During an interview on 5/7/25 at 11:30 a.m., Restorative Aide H said she was responsible for the A hall. She said Resident #65 was one of her residents. She said she tried to see the residents every day for restorative therapy. She said she worked on Resident #65's right side of her body. She said she had placed a hand splint on Resident #65 before, but she did not keep it on. She said she did not know who was responsible for applying Resident #65's hand splint or how long it was supposed to be on. She said Resident #65 had the same range of motion since she started the RNP. She said Resident #65 liked to keep her hand closed. She said she did not put Resident #65's hand splint on at all last week or this week. She said Resident #65's hand splint was important to keep her hand open and from drawing up. She said the hand splint could help Resident #65 eventually use her hand and keep her fingers straight. During an interview on 5/7/25 at 2:40 p.m., ADON B said Resident #65 was not supposed to wear a hand splint. She said the only hand splint she knew about was one the family ordered a couple of months ago. She said Resident #65 had worn a hand splint one time for 30 minutes and asked her to remove it. She said Resident #65 never tried the hand splint again. She said a COTA had never shown her how to place a hand splint on Resident #65. She said she did not receive a copy of the resident's nursing restorative plan of care. She said if there was an order for Resident #65's hand splint then it would be on the TAR. She said if Resident #65's hand splint had been on the TAR, the nurses would have been responsible for applying it. She said the RAs were responsible for applying Resident #65's hand splint since she was on the RNP. She said Resident #65's hand splint was important to prevent further contractures. During an interview on 5/7/25 at 3:05 p.m., the DON said rehab therapy would communicate with the nursing staff to get an order for the duration and skin care of the splint. She said the PTs and/or OTs could write an order for the splint. She said if the hand splint was on Resident #65's nursing restorative program then the RAs were responsible for applying it. She said Resident #65's splint was important to decrease the risk of further contracture and maintain mobility. She said she was responsible for ensuring the RNP was implemented by the RAs. She said she oversaw the RNP by monitoring the staff during restorative therapy and reviewing the plan of care at the end of the month. During an interview on 5/7/25 at 3:40 p.m., the Administrator said he was told the family ordered Resident #65's hand splint. He said the facility was not aware Resident #65's hand splint needed to be applied. He said ADON B said the hand splint the family ordered did not fit Resident #65. He said the RAs were responsible for providing the restorative therapy. He said the DON was responsible for overseeing the restorative therapy program. He said splints prevented a decline of a resident's range of motion. Record review of a Rehabilitative Nursing Care facility policy last revised in July 2013 indicated, .Rehabilitative nursing care is provided for each resident admitted .The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence .Rehabilitative nursing care is performed daily for those residents who require such service .Maintaining good body alignment and proper positioning .Assisting residents with their routine range of motion exercises . 44933

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 19 residents (Resident # 81 and Resident #89) and 1 of 1 Laundry room reviewed for infection control practices. 1.The facility failed to ensure CNA O changed her gloves or sanitized her hands after performing incontinent care and applying a clean brief for Resident #81. She touched a clean brief with her dirty gloves, and she touched the resident's pants with dirty gloves. 2.The facility failed to ensure Resident #89 was placed on contact isolation (implemented to prevent the spread of germs that are transmitted through direct or indirect contact with a person or objects they have touched) after her urinalysis with culture and sensitivity (UA examines urine for physical and chemical characteristics, while C&S identifies any bacterial infection and determines its sensitivity to antibiotics), dated 4/22/25, resulted with Vancomycin Resistant Enterococcus (VRE ) (is a super bug, bacterial infection where the bacteria are resistant to the antibiotic vancomycin). 3.The facility failed to ensure laundry in the facility's laundry room was not stored on the floor or touching the floor on 5/7/25. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1.Record review of Resident #81's face sheet dated 05/07/25 indicated a 94-years-old male initially admitted to the facility on [DATE]. Resident #81 had diagnoses including: heart failure, unspecified (a chronic condition in which the heart doesn't pump blood as well as it should), sepsis, unspecified organism (a life-threatening condition where the body's response to infection leads to widespread inflammation and tissue damage, but the specific infectious agent is not identified), and acute kidney failure, unspecified (a condition in which the kidneys suddenly can't filter waste from the blood). Record review of Resident #81's Order Summary Report dated 5/07/25 indicated an order to ensure foley catheter care every shift with a start date of 4/16/25. Record review of the comprehensive MDS dated [DATE] indicated Resident #81 had clear speech, understood others, and was understood by others. The MDS indicated he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #81 required moderate assistance from staff for oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident #81 had an indwelling catheter (urinary catheter) and was always incontinent of bowel. Record review of the care plan dated 5/01/25 indicated Resident #81 had a foley catheter due to obstructive uropathy. He could not void without the foley catheter, due to obstructive uropathy. Interventions included: assess any complaints of dysuria, pubic or abdominal pain, assess pain level as needed, provide foley catheter care as per facility policy and procedure, use a foley catheter Velcro strap around the thigh to secure the tubing. Record review of a Competency Assessment, Foley Cath Care Checkoff dated 5/02/24 indicated CNA O was proficient in catheter care. Record review of a Competency Assessment, Peri care/Incontinent Care Evaluation dated 5/02/24 indicated CNA O was proficient in incontinent care. Record review of a Competency Assessment, Foley Cath Care Checkoff dated 2/15/25 indicated CNA N was proficient in catheter care. Record review of a Competency Assessment, Peri care/Incontinent Care Evaluation dated 2/15/25 indicated CNA N was proficient in incontinent care. During an observation on 05/06/25 at 2:00 P.M., CNA O performed incontinent care and catheter care assisted by CNA N. CNA O performed incontinent care starting from Resident #81's buttocks. She wiped both buttocks and applied a clean brief without changing her gloves or sanitizing her hands. After performing incontinent care to Resident #81's buttocks she started catheter care. She changed her gloves to before starting catheter care, but she did not wash or sanitize her hands. After CNA O performed catheter care she did not change the dirty brief and she did not change the dirty gloves before pulling up the Resident #81's pants. During an interview on 05/06/25 at 2:12 P.M., CNA N she said CNA O needed to slow down and listen.She said CNA O always worked fast. She said CNA O started with the back of Resident #81 and she was supposed to start with the catheter care first; before she did the behind. She said CNA O changed Resident #81's brief and did not change her gloves or sanitize her hands. She said then CNA O started the catheter care after cleaning the rectum. She said CNA O changed her gloves but did not wash or sanitize before starting catheter care. She said CNA O performed catheter care and did not remove the dirty brief after catheter care was performed. CNA N said CNA O did not remove her dirty gloves before pulling up Resident #81's pants. She said he could get an infection or urinary tract infection (infection in any part of the urinary system) from improper catheter care, improper incontinent care, and improper hand hygiene. She said Resident #81's catheter care did not look good, and he looked like he had redness and a discharge to his catheter site. During an interview on 05/06/25 at 2:29 P.M., CNA O said she knew the catheter was on the wrong side when she performed catheter care, she said it should have been on the right side of Resident #81 instead of the left side. She said she should had started the catheter care first on Resident #81; from the front then worked her way to the back. She said she should have changed her gloves and sanitized her hands before she applied Resident #81's clean brief. She said she had anxiety and gets nervous with people watching her. She said a negative effective of improper catheter care, incontinent care, and improper hand hygiene was e.coli (a rod-shaped bacterium that's commonly found in the intestines) can get into the catheter and it can cause skin breakdown. During an interview on 05/06/25 at 2:36 P.M., LVN Q said she would expect the CNA's to start from the front to back with catheter care. She said she would expect them to start with the head of the penis then from the head of the penis down the tubing with a male resident, that had catheter care. She said then from side one side to the other side wiping down, then to the back side of the resident. She said to clean the back side of the resident last, because there was a harmful bacterium in the rectum that should not be brought to the front to the catheter. She said a negative effect of improper catheter care, improper incontinent care, and improper hand hygiene was infection. During an interview on 05/07/25 at 2:01 P.M., LVN ADON P said she would expect the CNA's to clean from front to back and make sure the resident was free from any bile and ensure that the catheter was secured. She said gloves should be changed properly during the process of incontinent care and catheter care. She said she would have performed catheter care and change gloves and sanitized or washed hands before pulling up Resident #81's pants. She said improper incontinent care, catheter care, and hand hygiene could cause infection and cross contamination. During interview on 05/07/25 at 2:33 P.M., the DON said she expect the CNA's to start from front to back and at the penis away from the resident's body with catheter care for a male. She said then after cleaning the front wash or sanitize your hands, then move to the back, then apply clean gloves. She said she would expect the CNA's to change the brief if they got it dirty while cleaning another part of the body. She said improper incontinent care, catheter care, and hand hygiene made the resident at risk for infection and skin breakdown. During an interview on 05/07/25 at 2:46 P.M., the ADM said the CNA's were trained and they know what they were supposed to do and he expected them to do what they were trained to do. He said improper incontinent care, improper catheter care, and improper hand hygiene has a potential for infection. 2. Record review of Resident #89's face sheet dated 5/6/25 indicated resident #89 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #89 had diagnoses including vascular dementia (is a type of dementia caused by reduced blood flow to the brain, damaging brain tissue and affecting cognitive function), Parkinson's disease (is a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement), and urinary tract infection (is an infection that affects a part of the urinary tract). Record review of Resident #89's significant change in status MDS assessment dated [DATE] indicated Resident #89 was understood and had the ability to understand others. Resident #89's BIMS score was 15 which indicated intact cognition. Resident #89 required moderate assistance for toileting hygiene. Resident #89 had occasional urinary incontinence. Record review of Resident #89's care plan dated 11/25/24, reviewed 4/21/25 indicated Resident #89 had the potential for hydration and fluid maintenance problem. Intervention included obtain labs as directed and ensure the MD notification of lab results. Record Review of Resident #89's hard copy, physician's order dated 4/21/25-5/5/25 did not reflect a contact isolation order. Record review of Resident #89's consolidated physician orders dated 5/6/25 did not reflect a contact isolation order. Record review of Resident #89's Urinalysis with culture and sensitivity dated 4/22/25 indicated, .moderate enterococcus faecium, pseudomonas aeruginosa .the detected enterococcus is Vancomycin Resistant .NP M .4/24/25 . Record review of the facility's Infection Control log dated April 2025 indicated, . [Resident #89] .UTI .Enterococcus .Standard Precaution . During an interview on 5/6/25 at 11:00 a.m., the DON said she did not know Resident #89's UA from 4/22/25 had VRE. She said she had reviewed the results and spoke with NP M about antibiotic treatment. She said residents with VRE were placed on contact isolation the duration of the antibiotic treatment. She said Resident #89 was not placed on contact isolation for the UA results from 4/22/25. She said not placing a resident with VRE on contact isolation could spread the organism to other residents. She said as the ICP, she was responsible for reading the UA and C&S results and initiating isolation precautions. During an interview on 5/7/25 at 2:13 p.m., RN D said residents with VRE in the urine were normally placed on contact isolation. She said NP M had visited the facility on 4/24/25. She said NP M had reviewed and signed Resident #89's, 4/22/25 UA results. She said NP M did not order any new orders. She said residents with VRE were placed on contact isolation to decrease the risk of spreading VRE. She said Resident #89 was placed on contact isolation on 5/6/25 and another UA was ordered. During an interview on 5/7/25 at 3:40 p.m., the Administrator said the DON, who was the ICP, was responsible for reviewing UA results and making sure the residents were placed on the appropriate type of isolation. He said the residents were placed on isolation to prevent the spread of the organism. He said it became an infection control issue when residents were not placed on isolation. During an interview on 5/8/25 at 4:20 p.m., NP M said she could not recall if she noticed Resident #89's C&S results, from 4/22/24, reported VRE in her urine. She said the facility had policies and procedures they should follow when a resident had a resistant organism growing. She said most facilities placed their residents on contact isolation for VRE in the urine. She said the resident was placed on contact isolation for the duration of the antibiotics. She said when a resident with VRE was not placed on isolation, it could spread around the nursing home. 3. During an observation on 5/7/25 at 9:36 a.m., the clean side of the facility's laundry room, had the following items: *One small, white bag with resident labeled socks on the floor. *One small box of socks on the floor. *Three large clear bags of clothing on the floor. *One long sleeve of a shirt touched the floor. The long sleeve shirt was on top of a pile of clothes in a metal hamper on wheels. HSK Supervisor C placed the long sleeve shirt back in the pile of clothing. *One mechanical lift pad hung on a hook, with one of the loops touching the ground. *Two items of clothing fell on the floor from a metal hamper on wheels. HSK Supervisor C placed both items back in the pile of clothing. *Two house coat sleeves touched the floor. The house coats were draped over a metal hamper near the dryer. During an interview on 5/7/25 at 9:50 a.m., the HSK Supervisor said the laundry staff working today was not interviewable. She said the laundry staff did not speak English. She said the bags and boxes of clothing should not be on the floor. She said resident's clothing should not touch floor. She said the clothing in the bags and metal hampers were getting sorted. She said some of the clothing was going to be kept for residents who needed clothes at the facility. She said most of the clothes, in the bags and hampers were going to be donated to a local donation station. She said she had not taken the clothes to the local donation station because she wanted to make sure a resident or family member did not come back to claim anything. She said it was cross contamination for clothes to touch the floor or be on the floor then possibly given to the residents. She said the residents could get an infection from the contaminated clothes or lift pad. She said she was responsible for ensuring staff stored clothing correctly. She said she did rounds in the laundry room about every 2 hours to oversee the staff. During an interview on 5/7/25 at 3:05 p.m., the DON said clothing and lift pads should not touch the floor. She said it was an infection control issue. She said it placed the residents at risk for being exposed to germs. She said the residents could become sick and be exposed to dirt or grime. She said HSK Supervisor C should ensure resident's laundry was stored correctly. She said HSK Supervisor C should have a checking system in place and provided in-services to the laundry staff to ensure infection control was being maintained. During an interview on 5/7/25 at 3:40 p.m., the Administrator said it was an infection control issue for clothing to touch the floor. He said the laundry staff should be ensuring clothing and items in the laundry area were not on the ground or touching the ground. He said HSK Supervisor C should be overseeing the laundry staff. He said the residents would not be clean if they wore clothes that touched the floor. Record review of a facility's Urinary Continence and Incontinence-Assessment and Management policy revised 09/2010, indicated .3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Record review of a facility's Catheter Care, Urinary policy dated 09/2014, indicated . The purpose of this to prevent catheter-associated urinary tract infections . 1. Use standard precautions when handling or manipulating the drainage system .2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.a. do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate . b. be sure the catheter tubing and drainage bag are kept off the floor . c. empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing and prevent contact of the drainage spigot with the nonsterile container . d. empty the collection bag at least every eight (8) hours Record review of a facility's Departmental (Environmental Services)- Laundry and Linen policy revised 1/2014 indicated, .The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts . Record review of a facility's Standard Precautions revised 12/2007 indicated, . Wear gloves when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact (VRE, MRSA, VISA-VRSA, etc.) . Wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing . Record review of https://www.ncbi.nlm.nih.gov/books/NBK513233/ was accessed on 5/12/25 and indicated, . Enterococcus is frequently cited as one of the three most likely etiologies of both uncomplicated and complicated UTI, especially healthcare-associated UTIs . Of these, the vast majority is E. faecalis, though the majority of vancomycin-resistant isolates are E. faecium .Enterococcus can persist on hands for as long as 60 minutes after inoculation and as long as four months on inanimate surfaces . Basic infection control prevention practices such as hand hygiene can help . This includes washing hands with soap and water or using alcohol-based hand rubs before and after patient encounters . Contact precautions such as wearing gowns and gloves also decrease transmission . There are reports that VRE can be transmitted by direct patient contact, touching of contaminated surfaces/equipment or through hand transfer after contact with the affected patient . 44933

Based on observations, interviews, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 19 residents (Resident #76) reviewed for reasonable accommodations. The facility failed to ensure Resident #76 had a comfortable mattress. This failure could place residents at risk of a diminished quality of life due to an environment that is uncomfortable. Findings included: Record review of Resident #76's face sheet dated 5/7/25 indicated Resident #76 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #76 had diagnoses including cerebral infarction (occurs when blood flow to the brain is blocked, leading to tissue damage or death), pain, insomnia (is a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early, causing daytime impairments), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and hemiplegia (is a condition characterized by paralysis affecting one side of the body) and hemiparesis (is one-sided muscle weakness). Resident #76's face sheet indicated. Record review of Resident #76's quarterly MDS assessment dated [DATE] indicated Resident #76 was understood and had the ability to understand others. Resident #76's BIMS score was 13 which indicated intact cognition. Resident #76 required setup assistance for ADLs. Resident #76 was at risk for developing pressure ulcers/injuries. Record review of Resident #76's care plan dated 9/10/24 indicated Resident #76 was at risk for alternations in skin integrity due to impaired mobility and potential for skin associated skin damage due to occasional incontinence of bowel and bladder. Interventions included provide all preventative skin care and interventions as directed. Record review of a maintenance request dated 5/5/25 at 1:30 p.m. indicated, .RN D . [Resident #76's room] . description of problem .wants a new mattress . if corrected please explain what you did to correct .replaced mattress .completed by Maintenance J .5/5/25 . During an observation and interview on 5/5/25 at 10:31 a.m., Resident #76 was lying in the bed. Resident #76 said his only complaint was he had asked for a new mattress at the beginning of last week and still had not gotten one. He said the mattress was not comfortable and it was thin. He said he could not remember who the person was he told about wanting a new mattress. The state surveyor was unable to fully visualize Resident #76's mattress due to the resident being in the bed. Resident #76's mattress appeared slightly lower towards the middle of the mattress. During an observation and interview on 5/6/26 at 3:35 p.m., LVN K said Resident #76 had complained a few times about his mattress. She said Resident #76 had recently lost weight and may have a hole in the mattress from when he was heavier. She said she had not put a work order in for Resident #76's mattress. She said someone else may have done it. LVN K looked in the maintenance request book at the nursing station. Resident #76 had a maintenance request dated and completed on 5/5/25. During an interview on 5/7/25 at 10:17 a.m., RN D said on 5/5/25 was the first time Resident #76 had mentioned his mattress was uncomfortable. She said she put the mattress change request in the maintenance book on 5/5/25 and it was changed the same day. She said it was the resident's right to be comfortable and it affected the resident's dignity to have a good mattress. She said the residents could become unhappy, lose sleep, and become dissatisfied if they had to sleep on an uncomfortable mattress. During an interview on 5/7/25 at 10:20 a.m., CNA F said Resident #76 had never mentioned his mattress being uncomfortable to her. She said Resident #76 laid in his bed a lot. She said if a resident complained about their mattress, she would put it in the maintenance book. She said then maintenance would swap the mattress out for the resident. She said lying on an uncomfortable mattress could cause the resident's back to hurt or develop bed sores. During an interview on 5/7/25 at 3:01 p.m., Maintenance J said Resident #76's mattress was changed on 5/5/25. He said if staff needed something from maintenance, it was placed in the maintenance request book. He said sometimes staff told him things verbally. He said on 5/5/25 was the first time he was aware Resident #76 wanted a new mattress. He said Resident #76 told him the mattress hurt. He said Resident #76's mattress did have an indentation in it. During an interview on 5/7/25 at 3:05 p.m., the DON said anyone could put a maintenance request in the maintenance book. She said primarily the nurses put the request in the book. She said she expected staff to place the work order in the maintenance book the same day it was found or reported. She said most of the time, maintenance was able to fix the issue the same day or the next day. She said it was important for a resident to have a comfortable mattress to rest well and prevent skin breakdown. She said an uncomfortable mattress could affect the resident's behavior, appetite, and skin integrity. She said she did not know if maintenance performed mattress inspections. During an interview on 5/7/25 at 3:34 p.m., LVN K said she may have verbally told maintenance about Resident #76's request for a new mattress. She said she also may have put a maintenance request in the book, and it was previously pulled. During an interview on 5/7/25 at 3:40 p.m., the Administrator said staff verbally told maintenance about work requests if they were available or placed it in the maintenance book. He said any staff could report a maintenance issue. He said a resident was at risk for sleep deprivation if they had an uncomfortable mattress. He said the facility did not do scheduled mattress inspections. He said the CNAs, residents, or family members reported issues with mattresses. Record review of a facility's Quality of Life- Accommodation of Needs revised 8/2009 indicated, . Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being . The resident's individual needs and preferences shall be accommodated to the extent possible .

Based on observations, interviews, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 5 Residents (Resident #9) whose records were reviewed for skin integrity. The facility failed to ensure Resident #9's pressure-relieving 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 included: Record review of Resident #9's face sheet dated 05/07/25 indicated a 97-years-old female initially admitted to the facility on [DATE]. Resident #9 had diagnoses including pressure ulcer of sacral region stage 2 (stage 2 pressure injuries are opened. The skin breaks open, wear away, or forms an ulcer, which is usually tender ad painful), contracture of muscle, multiple sites, hemiplegia and hemiparesis following a cerebral infarction affecting the right side(weakness of the right side following a stroke), contracture of muscle, left ankle and foot, contracture, right foot, contracture, left foot, muscle weakness (decreased strength in the muscles) and muscle wasting and atrophy, not elsewhere classified (multiple sites multiple muscle groups throughout the body are experiencing a loss of muscle mass and strength). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was usually understood and usually understood others. Resident #9 had a BIMS score of 3 which indicated severe cognitive impairment. Resident #9 required maximal assistance to roll left and right. Resident #9 was dependent to sit to lying, lying to sitting on side of the bed, and chair-to-chair transfer. Resident #9 weighed 136 pounds. Resident #9 was at risk of pressure ulcer/injuries. Resident #9 received pressure ulcer/injury care as skin and ulcer/injury treatment, pressure reducing device for bed, and application of dressing to feet. Record review of Resident #9's care plan dated 01/02/24 indicated a pressure ulcer: actual stage 2 sacrum pressure ulcer, related to decreased mobility, nutritional risk, and friction/shear. Interventions included pressure relieving mattress, pressure-relieving cushion, repositioning every 2 hours, treatments per MD orders, assess wound weekly as per schedule and as needed, incontinent care as needed, notify MD/RP of any changes in status, update MD/RP weekly on wound progress, seen by wound specialist in house weekly, nutritional supplement prostat, vitamins/ minerals multi vitamin, zinc and vitamin C, and treatment collagen. Record review of Resident #9's care plan dated 04/28/25 indicated a pressure ulcer: pressure ulcer, related to decreased sensation, decreased mobility, and incontinence. Interventions included reposition every 2 hours, collagen and dry dressing treatments every Monday, Wednesday, and Friday, assess wound weekly, incontinent care as needed, and notify MD/RP of any changes in status. Record review of a facility's wound report dated 03/26/25-05/01/25 indicated .Resident #9 .facility acquired on 04/28/25 .stage 2 sacrum .improved .0.3x0.4x0.1 centimeters .assessment date 04/30/25 . Record review of Resident #9's physicians order dated 04/28/25 indicated sacrum: cleanse with normal saline or wound cleanser, pat dry, apply collagen to wound bed, then cover with dry dressing, as needed related to pressure ulcer of sacral region, stage 2. Record review of Resident #9's physicians order dated 04/28/25 indicated sacrum: cleanse with normal or wound cleanser, pat dry, apply collagen to wound bed, then cover with dry dressing, every day shift every Mon, Wed and Friday related to pressure ulcer of sacral region, stage 2 . Record review of Resident #9's weight record dated 05/06/25 indicated: *01/06/25 141 pounds *02/06/25 134.8 pounds *03/06/25 136.8 pounds *04/03/25 134.8 pounds During an observation on 05/05/25 at 9:21 a.m., Resident #9 was lying in bed resting. Resident #9 said she had no complaints about the facility. Resident #9's pressure relieving mattress weight setting was 360 pounds. During an observation on 05/05/25 at 3:13 p.m., Resident #9 was lying in her bed asleep. Resident #9's pressure relieving mattress weight setting was 360 pounds. During an observation on 05/06/24 at 9:31 a.m., Resident #9 was lying in her bed resting. Resident #9's pressure relieving mattress weight setting was 360 pounds. During an interview on 05/06/25 at 2:36 p.m., LVN Q said she did not know Resident #9 had a certain setting her bed needed to be set on. She said maintenance was responsible for the bed setting as far as she knew or maybe the treatment people. She said if the bed was not on the right setting that could cause a problem with the resident, such as skin breakdown. During an interview on 05/07/25 at 1:46 p.m., the Treatment Nurse said the charge nurse was responsible for the setting on the beds with the low air loss mattress beds. He said Resident #9 bed should be set according to her weight. He said a negative effect of the wrong setting of the low air loss mattress would be the flow would not circulate correctly if the setting was not set correct. He said too firm would have too much pressure and too soft would cave in on Resident #9. He said with the bed not set to the correct weight it would minimize Resident #9's healing potential. During an interview on 05/07/25 at 2:01 p.m., LVN ADON P said the nurse were responsible for ensuring that the low air loss mattress was on the correct setting. She said the mattress should be set according to the resident's weight. She said if there has too much pressure or too low pressure it could affect the resident and the mattress would be ineffective for the resident. During an interview on 05/07/25 at 2:33 p.m., the DON said the pressure relieving mattress should be set based on resident weight. She the nurses were responsible for making sure the beds were on the correct settings. She said if a mattress was too firm, it could cause skin breakdown or worsen the skin breakdown. During an interview on 05/07/25 at 2:46 p.m., the ADM said the nurses were responsible for ensuring the setting was set correctly for the pressure relieving mattress. He said the settings were normally based on the weight of the resident. He said with bed not on the correct setting could lead to a decline in Resident #9's skin integrity. Record review of a facility's Pressure Ulcer/Injury Risk Assessment policy revised 09/2013, indicated . The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries.the care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Record review of a facility's Support Surface Guidelines policy dated 09/2013, indicated . The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction.any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed . Record review of a facility's Pressure Ulcer Injury Overview policy revised 07/2017, indicated . The purpose of this procedure is to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors, which is derived from the definitions in S483.25(b)(1) Pressure ulcers . Record review of a facility's Prevention of Pressure Ulcer policy revised 07/2017, indicated . The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors.select appropriate support surfaces based the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors .

Based on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 4 residents (Residents #81) reviewed for urinary catheters. The facility failed to ensure Resident #81's indwelling urinary catheter (tube inserted into the bladder to drain urine) was secured by an anchor device (used to secure an indwelling urinary catheter). The facility failed to ensure CNA O performed proper catheter care to Resident #81. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections. Findings included: Record review of Resident #81's face sheet dated 05/07/25 indicated a 94-years-old male initially admitted to the facility on [DATE]. Resident #81 had diagnoses including: heart failure, unspecified (a chronic condition in which the heart doesn't pump blood as well as it should), sepsis, unspecified organism (a life-threatening condition where the body's response to infection leads to widespread inflammation and tissue damage, but the specific infectious agent is not identified), and acute kidney failure, unspecified (a condition in which the kidneys suddenly can't filter waste from the blood). Record review of Resident #81's Order Summary Report dated 5/07/25 indicated an order to ensure foley catheter care every shift with a start date of 4/16/25. Record review of Resident #81's Order Summary Report dated 5/07/25 indicated an order to ensure foley catheter leg strap every shift with a start date of 4/16/25. Record review of the comprehensive MDS dated [DATE] indicated Resident #81 had clear speech, understood others, and was understood by others. The MDS indicated he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #81 required moderate assistance from staff for oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident #81 had an indwelling catheter (urinary catheter) and was always incontinent of bowel. Record review of the care plan dated 5/01/25 indicated Resident #81 had a foley catheter due to obstructive uropathy. He could not void without the foley catheter, due to obstructive uropathy. Interventions included: assess any complaints of dysuria, pubic or abdominal pain, assess pain level as needed, provide foley catheter care as per facility policy and procedure, use a foley catheter Velcro strap around the thigh to secure the tubing. Record review of a Competency Assessment, Foley Cath Care Checkoff dated 5/02/24 indicated CNA O was proficient in catheter care. Record review of a Competency Assessment, Peri care/Incontinent Care Evaluation dated 5/02/24 indicated CNA O was proficient in incontinent care. Record review of a Competency Assessment, Foley Cath Care Checkoff dated 2/15/25 indicated CNA N was proficient in catheter care. Record review of a Competency Assessment, Peri care/Incontinent Care Evaluation dated 2/15/25 indicated CNA N was proficient in incontinent care. During an observation on 05/06/25 at 2:00 P.M., CNA O performed incontinent care and catheter care assisted by CNA N. Resident #81's catheter leg securement device was not secured to the resident's leg. CNA O performed incontinent care starting from Resident #81's buttocks. She wiped both buttocks and applied a clean brief without changing her gloves or sanitizing her hands. After performing incontinent care to Resident #81's buttocks she started catheter care. She changed her gloves to before starting catheter care, but she did not wash or sanitize her hands. After CNA O performed catheter care she did not change the dirty brief and she did not change the dirty gloves before pulling up the Resident #81's pants. During an interview on 05/06/25 at 2:12 P.M., CNA N she said CNA O needed to slow down and listen. She said Resident #81's catheter was just hanging, because it was not secured. She said CNA O always worked fast. She said CNA O started with the back of Resident #81 and she was supposed to start with the catheter care first; before she did the behind. She said CNA O changed Resident #81's brief and did not change her gloves or sanitize her hands. She said then CNA O started the catheter care after cleaning the rectum. She said CNA O changed her gloves but did not wash or sanitize before starting catheter care. She said CNA O performed catheter care and did not remove the dirty brief after catheter care was performed. CNA N said CNA O did not remove her dirty gloves before pulling up Resident #81's pants. She said he could get an infection or urinary tract infection (infection in any part of the urinary system) from improper catheter care, improper incontinent care, and improper hand hygiene. She said Resident #81's catheter care did not look good, and he looked like he had redness and a discharge to his catheter site. During an interview on 05/06/25 at 2:29 P.M., CNA O said she knew the catheter was on the wrong side when she performed catheter care, she said it should have been on the right side of Resident #81 instead of the left side. She said she had notified LVN ADON Q that the resident's catheter securement device needed to be replaced. She said she should had started the catheter care first on Resident #81; from the front then worked her way to the back. She said she should have changed her gloves and sanitized her hands before she applied Resident #81's clean brief. She said she had anxiety and gets nervous with people watching her. She said a negative effective of improper catheter care, incontinent care, and improper hand hygiene was e.coli (a rod-shaped bacterium that's commonly found in the intestines) can get into the catheter and it can cause skin breakdown. During an interview on 05/06/25 at 2:36 P.M., LVN Q said she would expect the CNA's to start from the front to back with catheter care. She said she would expect them to start with the head of the penis then from the head of the penis down the tubing with a male resident, that had catheter care. She said then from side one side to the other side wiping down, then to the back side of the resident. She said to clean the back side of the resident last, because there was a harmful bacterium in the rectum that should not be brought to the front to the catheter. She said all residents with catheters should have a tubing securement device. She said a negative effect of improper catheter care, improper incontinent care, and improper hand hygiene was infection. During an interview on 05/07/25 at 2:01 P.M., LVN ADON P said she would expect the CNA's to clean from front to back and make sure the resident was free from any bile and ensure that the catheter was secured. She said gloves should be changed properly during the process of incontinent care and catheter care. She said she would have performed catheter care and change gloves and sanitized or washed hands before pulling up Resident #81's pants. She said CNA O notified her that Resident #81's catheter securement device was not securing the catheter and she had replaced it. She said improper incontinent care, catheter care, and hand hygiene could cause infection and cross contamination. During interview on 05/07/25 at 2:33 P.M., the DON said she expect the CNA's to start from front to back and at the penis away from the resident's body with catheter care for a male. She said then after cleaning the front wash or sanitize your hands, then move to the back, then apply clean gloves. She said she would expect the CNA's to change the brief if they got it dirty while cleaning another part of the body. She said all residents with catheters should have a securement device in place. She said improper incontinent care, catheter care, and hand hygiene made the resident at risk for infection and skin breakdown. During an interview on 05/07/25 at 2:46 P.M., the ADM said the CNA's were trained and they know what they were supposed to do and he expected them to do what they were trained to do. He said all residents with catheters should have a securement device in place. He said improper incontinent care, improper catheter care, and improper hand hygiene has a potential for infection. Record review of a facility's Urinary Continence and Incontinence-Assessment and Management policy revised 09/2010, indicated .3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.4. Indwelling urinary catheters will be used sparingly, for appropriate indicators only . Record review of a facility's Catheter Care, Urinary policy dated 09/2014, indicated . The purpose of this to prevent catheter-associated urinary tract infections . 1. Use standard precautions when handling or manipulating the drainage system .2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.a. do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate . b. be sure the catheter tubing and drainage bag are kept off the floor . c. empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing and prevent contact of the drainage spigot with the nonsterile container . d. empty the collection bag at least every eight (8) hours

Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities and to ensure the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in response to the pharmacist report for 2 of 5 residents (Resident #42 and Resident #89) reviewed for (MRR) Medication Regimen Review. 1. The facility failed to ensure a proper rationale was given for not following the pharmacy consultant's recommendation to discontinue Resident #42's Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) medication. 2. The facility failed to ensure Resident #89's Medication Regimen Review dated 4/28/25, had a detailed rationale for not implementing the pharmacist's recommendations. These failures could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy. Findings included: 1. Record review of Resident #42's face sheet, dated 05/07/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included vascular dementia (a type of dementia caused by reduced blood flow to the brain, damaging brain tissue, and impairing cognitive function), Parkinsonism (a clinical syndrome characterized by movement-related symptoms like tremors, slow movement, and rigidity), anxiety disorder (mental health conditions characterized by excessive fear and worry that significantly impair daily functioning), and delusional disorder (mental health condition characterized by one or more firmly held, false beliefs that persist for at least one month). Record review of Resident #42's significant change MDS assessment, dated 12/17/24, indicated she was rarely/never understood, and rarely/never was able to understand others. A BIMS assessment was not conducted because the resident was rarely/never understood. Record review of Resident #42's Order Summary Report, dated 05/07/25, indicated this order: *Seroquel oral tablet 25mg (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to Parkinsonism; Delusional Disorders. The start date was 03/26/25. Record review of Resident #42's care plan, indicated a focus dated 03/10/23, I am at risk for the development of complications related to receiving psychotropic medications. Interventions included: *Assess the reason I need the medication and reevaluate as needed. Assess for medication dose adjustment to achieve a minimum effective level of medication and notify my doctor as needed. *Conduct a drug utilization review per facility pharmacy consultant as needed. Record review of Resident #42's Consultant Pharmacist/Physician Communications, dated MRR Date 04/02/25 indicated: .This resident is taking a low dose of Seroquel . .I recommend DC unless therapeutic response outweighs risk/benefit. In such case, please document clear rationale and justification in chart . The Physician/Prescriber Response was marked as DISAGREE, and no rationale was given. The form was signed by RN L and dated 04/09/25. During an interview on 05/07/25 at 02:36 PM, ADON B said she expected the RN that signed the consultant pharmacist communication to write a verbal order or document some sort of rationale for the doctor disagreeing with the recommendation. She said the potential risk was the resident could be on an unnecessary medication. During an interview on 05/07/25 at 02:44 PM, the DON said she expected the nurse that signed the consultant pharmacist communication to write a verbal order or have the doctor sign it. She said the risk was the resident could be on unnecessary medication. During an interview on 05/07/25 at 02:54 PM, the Administrator said he expected the nurse to clarify if it was a verbal order or have the doctor sign the consultant pharmacist recommendation. He said the risk was resident could be on an unnecessary medication or there could be some confusion on what the order was. 2. Record review of Resident #89's face sheet dated 5/6/25 indicated resident #89 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #89 had diagnoses including vascular dementia (is a type of dementia caused by reduced blood flow to the brain, damaging brain tissue, and affecting cognitive function), Parkinson's disease (is a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement), generalized anxiety disorder (is a mental health condition characterized by persistent and excessive worry about various aspects of life, often in a way that is difficult to control), pain, hypertension (high blood pressure), difficulty in walking, and fall on same level. Record review of Resident #89's consolidated physician order dated 5/6/25 indicated: *Ativan Oral Tablet (Lorazepam) (is used to treat anxiety disorders) 0.5mg, give 1 tablet by mouth every 24 hours as needed for anxiety related to generalized anxiety disorder for 14 days. Start date 4/25/25. *Cyclobenzaprine HCL Oral Tablet (is used to help relax certain muscles in your body) 7.5mg, give 1 tablet by mouth every 12 hours as needed for muscle spasms related to muscle spasms. Start date 11/20/24. *Diphenhydramine HCL Oral Tablet (is an antihistamine and sedative) 25mg, give 1 tablet by mouth every 6 hours as needed for itching/allergies. Start date 11/20/24. *Flomax Oral Capsule 0.4.mg (Tamsulosin HCL) (helps relax the muscles in the prostate and the opening of the bladder), give 1 capsule by mouth one time a day related to retention of urine. Start date 11/20/24. *Metoprolol Tartrate Oral Tablet (is a medication that lowers your blood pressure and heart rate) 25mg, give 1 tablet by mouth one time a day related to essential (primary) hypertension. Start date 11/21/24. *Norco Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen) (is a combination medicine taken to help treat pain), give 1 tablet by mouth every 6 hours as needed for pain related to pain. Start date 11/20/24. *Remeron Oral Tablet 30mg (Mitrazapine) (is commonly used to treat depression), give 1 tablet by mouth one time a day at hour of sleep related to depressive episodes. Start date 12/26/24. Record review of Resident #89's significant change in status MDS assessment dated [DATE] indicated Resident #89 was understood and had the ability to understand others. Resident #89 had minimal difficulty hearing, clear speech, and impaired vision with corrective lenses. Resident #89's BIMS score was 15 which indicated intact cognition. Resident #89 had falls since admission/entry or reentry or the prior assessment. Resident #89 had 2 falls with no injury and 1 with minor injury. Resident #89 had received anti-anxiety, antidepressant, and opioids during the last 7 days. Record review of Resident #89's care plan dated 11/15/24, reviewed 4/21/25 indicated Resident #89 had falls second to Parkinson's disease with tremors, poor balance, and posture. Resident #89 received multiple medications, history of hypotension and syncope with poor safety awareness and poor impulse control. Interventions included medication review as needed to assess for side effects and adverse drug reactions and sitter provided to assist with visual checks. Record review of Resident #89's Interim Medication Regimen Review dated 4/28/25 indicated, .Rec. Category: Interim Review - Fall Risk .Consultant Pharmacist .Interim Review requested due to recent falls and increased confusion . [Resident #89] is currently has orders for three medications listed on Beers Criteria (is a list of medications that older adults should potentially avoid or use with caution due to the risk of harm outweighing the benefits), and all three can contribute to increased fall risk and confusion. I consider these three the greatest contributors to falls and confusion .Cyclobenzaprine 7.5mg Q12H PRN .Diphenhydramine 25mg Q6H PRN .Lorazepam 0.5mg BID and 0.5mg PRN once daily .I recommend DC cyclobenzaprine, diphenhydramine, and PRN dose of lorazepam .I also recommend plan to GDR routine lorazepam with plan to DC .Hydrocodone-Acetaminophen and Mirtazapine can also contribute .Both can cause sedation and confusion, and both can contribute to an increased fall risk . I recommend ensuring resident is taking lowest necessary dose of Norco and ensure that all non-pharmacological interventions are attempted and documented . I further recommend a plan to GDR mirtazapine to 15mg within the next month or two with a further plan to DC if tolerated . Finally, tamsulosin, metoprolol, and mirtazapine can all contribute to an increased risk of orthostatic hypotension . I recommend monitoring resident for orthostatic hypotension and counsel resident to sit up and rise from a seated position slowly to reduce risk of orthostatic hypotension (is a drop in blood pressure that occurs when a person stands up after sitting or lying down) . Recommendation Summary .DC Cyclobenzaprine .DC Diphenhydramine .DC PRN Ativan .Next month GDR Ativan to 0.25mg BID .Confirm Norco dosing is lowest effective dose .In July, GDR Mirtazapine to 15mg QHS .Monitor Resident for orthostatic hypotension .'Has a sitter now' .NP M .5/5/25 . During an interview on 5/7/25 at 3:05 p.m., the DON said the ADONs and the DON reviewed the MRRs and contacted the NP/MDs. She said hall B did not have an ADON, so she was responsible for hall B's MRRs. She said she had reviewed Resident #89's MRR from 4/28/25. She said when the NP or the MD reviewed the MRRs and disagreed with the recommendation, the facility expected a reason for not following the recommendations. She said, has a sitter now was not an appropriate response for Resident #89's MRR. She said she did not know NP M had written that response to Resident #89's MRR on 5/5/25. She said Resident #89 had a fall 4/20/25 and the facility provided a sitter as an intervention. She said Resident #89 would have a sitter until she was back to her baseline. She said Resident #89 was experiencing confusion possibly from a UTI (is an infection that affects a part of the urinary tract). She said Resident #89 was receiving treatment for the UTI. She said she reviewed the MRRs a few days after they were completed by the pharmacist and when she knew the NP/MD had rounded at the facility. She said it was important for the MRRs to have rationale or reasons for disagreeing with the recommendations to explain why, know how to better take care of the resident, and know when to notify the NP/MD when something was not working. She said it placed the resident at risk for not receiving the interventions they needed. During an interview on 5/7/25 at 3:40 p.m., the Administrator said the DON reviewed the all the resident's MRRs then gave them to the halls ADONs. He said the facility expected the MRRs to have rationales and staff should follow up. He said he did not know if NP M's response to Resident #89's MRR was an appropriate response to the recommendations. He said he would defer to NP M's response. He said the DON was responsible for overseeing the resident's MRRs. During an interview on 5/8/25 at 4:20 p.m., NP M said she had reviewed Resident #89's MRR a couple days ago. She said she could not recall what Resident #89's MRR recommendations were. She said she spoke with the staff to see what the biggest problems were and reviewed the resident's chart before responding to the pharmacist recommendations. She said Resident #89 had several falls but was also non complaint. She said Resident #89's sitter was a new intervention. She said she felt the new intervention needed to be tried then reevaluated. She said she did not know how long the facility planned to have a sitter with Resident #89. Record review of the facility's policy, Tapering Medications and Gradual Dose Reduction, last revised April 2007, indicated: .1. After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences . 2. All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic medications shall be referred to as gradual dose reduction . 3. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs . 5. The Physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or ensuring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose . 9. When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction; for example, because of a return of clinically significant symptoms . 10. Residents who use antipsychotic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Pertinent behavioral interventions will also be at-tempted. (Behavioral interventions refer to non-pharmacological attempts to influence an individual's behavior, including environmental alterations and staff approaches to care) . 11. Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated . 12. For any individual who is receiving an antipsychotic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if: a. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and b. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . 13. For any individual who is receiving an antipsychotic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered contraindicated, if: a. The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or b. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder . 14. Attempted tapering of sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. Tapering shall be done consistent with the following: a. For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer's recommendations for duration of use, the physician shall attempt to taper the medication at least quarterly unless clinically contraindicated. Clinically contraindicated means: (1) The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; or (2) The resident's target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder . Record review of https://agsjournals.onlinelibrary.[NAME].com/doi/epdf/10.1111/jgs.18372 was accessed on 5/12/25 and indicated, .the Beers Criteria was developed .with the purpose of identifying medications for which potential harm outweighed the expected benefit and that should be avoided in nursing home residents .Table 2 .potentially inappropriate medication use in older adults .Diphenhydramine (oral) .risk for confusion .drugs is associated with an increased risk of falls .Lorazepam .older adults increases sensitivity .increase the risk of cognitive impairment, delirium, falls, fracture .Cyclobenzaprine .adverse effects, sedation and increased risk of fractures . 44933

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the CNA Class Instructor did not walk into the kitchen without a hairnet during lunch service on 05/06/25. This failure could place residents at risk of foodborne illness and food contamination. Findings included: During an observation and interview on 05/06/25 at 11:56AM the CNA Class Instructor walked into the kitchen. She was not wearing a hairnet. The kitchen staff had the food out on the steam table and were plating the food for lunch. When questioned if she was wearing a hairnet she said, I'm just giving this sticky note to her. She pointed to one of the cooks on the serving line. She then handed the note to a dietary staff on the serving line next to the steam table and then walked out of the kitchen. During an interview on 05/07/25 at 01:35 PM, the Dietary Manager said she expected all staff that enter the kitchen to wear a hairnet. She said the risk was that a hair could get in the food and potentially cause a foodborne illness. During an interview on 05/07/25 at 02:54 PM, the Administrator said he expected the staff to wear a hairnet while in the kitchen. He said a hair could fall in the food and potentially cause foodborne illness. Record review of the facility's policy, Food Preparation and Service, last revised July 2014, indicated: .Food service employees shall prepare and serve food in a manner that complies with safe food handling practices . .Food Service/Distribution . .7. Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food . .13. Only Dietary staff are allowed in the kitchen. If for any reason other departments must enter the kitchen staff must wear hair restraints (hair net, hat, beard restraint, etc.) .

Based on interviews, and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 5 residents reviewed antibiotic use. (Resident #31) The facility failed to ensure Resident #31 did not receive Cephalexin (is a cephalosporin antibiotic used to treat a variety of bacterial infections) for prophylactic antibiotic use. The facility failed to ensure Resident #31's Cephalexin, ordered prophylactically, was discontinued after he was started on Cefdinir (is a cephalosporin antibiotic used to treat a variety of bacterial infections) for an active UTI. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #31's face sheet dated 5/5/25 indicated Resident #31 was an [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #31 had diagnoses including urinary tract infection (is an infection in any part of the urinary system, including the bladder, urethra, kidneys, or ureters), neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should), and retention of urine (is when your bladder doesn't empty completely or at all). Record review of Resident #31's significant change in status MDS assessment dated [DATE] indicated Resident #31 was understood and had the ability to understand others. Resident #31 had a BIMS score of 10 which indicated moderate cognitive impairment. Resident #31 required substantial/maximal assistance for toileting hygiene. Resident #31 had an indwelling catheter (is a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) and frequent bowel incontinence. Resident #31 had received an antibiotic during the last 7 days. Record review of Resident #31's care plan dated 2/12/25 indicated Resident #31 had recurrent urinary tract infections. Intervention included assess causative factors that may have led to the development of the UTI. If identified, help develop additional approaches and interventions to prevent the reoccurrence. Record review of Resident #31's consolidated physician order dated 5/5/25 indicated Cephalexin Oral Capsule 250mg, give 1 capsule by mouth one time a day related to encounter for prophylactic measures. Start date 3/13/25. Record review of Resident #31's Telephone Orders dated 5/5/25 indicated Cefdinir 300mg 1 capsule by mouth two times a day for 10 days related to UTI. Record review of Resident #31's culture and sensitivity (is a laboratory procedure used to identify bacteria or fungi causing an infection and determine which antibiotics (or antifungals) are effective in treating it) results dated 5/2/25 indicated low pathogen detection of pseudomonas aeruginosa (is a germ that can cause infections). Pseudomonas aeruginosa may develop resistance during prolonged therapy with all antimicrobial agents. During an interview on 5/7/25 at 2:13 p.m., RN D said Resident #31 was currently on an antibiotic for a pseudomonas UTI. She said Resident #31 had a history of UTIs. She said Resident #31 used to have an indwelling catheter. She said Resident #31 had seen a urologist (is a medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the urinary tract and the reproductive system) who discontinued the indwelling catheter in March 2025. She said Resident #31 refused to see the urologist after that appointment. She said she felt after Resident #31's last UTI, he would benefit from a prophylactic antibiotic. She said she spoke with NP M about a prophylactic antibiotic for Resident #31 and convinced her to order Cephalexin. She said Resident #31 started having behaviors earlier in the week and urinalysis with culture and sensitivity was collected and sent on 5/2/25. She said she spoke with NP M about Resident #31's, 5/2/25 lab results and she ordered Cefdinir. She said NP M did not order Resident #31's Cephalexin to be discontinued. She said the day after (5/6/25) she received the order for Resident #31's Cefdinir, she thought about him being on two antibiotics. She said she probably should have informed NP M of Resident #31 being on two antibiotics. She said the DON was over the antibiotic stewardship program. During an interview on 5/7/25 at 3:05 p.m., the DON said she was the ICP. She said the facility's antibiotic stewardship program did not recommend the use of prophylactic antibiotics. She said she was not aware Resident #31 was on Cephalexin as a prophylactic antibiotic. She said Resident #31 Cephalexin should have been discontinued when he was prescribed Cefdinir on 5/5/25. She said a resident could experience C.diff (is a bacterial infection that can cause serious digestive problems, particularly diarrhea and colitis) and GI issues being on two antibiotics. She said a resident being on a prophylactic antibiotic placed them at risk for a MDRO (is an infection caused by a germ (usually bacteria) that has become resistant to multiple antibiotics). She said as the DON and ICP, she provided in-services to staff on discouraging the use of prophylactic antibiotics. She said she monitored antibiotic use by reviewing the infection sheets the nursing staff completed that informed her who had an infection and what antibiotic was ordered. During an interview on 5/7/25 at 3:40 p.m., the Administrator said he could not speak on the use of prophylactic antibiotics use. He said the DON, who was the ICP, oversaw the antibiotic stewardship program. He said he expected the ordered antibiotic to treat the organism growing. He said proper antibiotic treatment affected the overall care and well-being of the residents. During an interview on 5/7/25 at 4:20 p.m., NP M said she was not a fan of prophylactic antibiotics. She said Resident #31 had a complicated medical history. She said Resident #31 had previously been seen by a urologist then refused to return. She said she had ordered a new urologist consult on 5/1/25. She said she did not recall Resident #31 being on Cephalexin for prophylactic antibiotic use. She said she wished the staff had reminded her Resident #31 was on Cephalexin when Cefdinir was ordered. She said prophylactic antibiotics did not work and risked the resident becoming resistant to antibiotics. She said a resident should only be prescribed two types of antibiotics when treating different type of organisms or infections. She said if a resident was on two types of antibiotics, their lab work needed to be monitored. She said a resident being on two types of antibiotics placed them at risk for yeast infection and C.diff, and could affect their kidneys. Record review of a facility's Antibiotic Stewardship policy revised 12/2016 indicated, . Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program . The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents . Record review of a facility's Antibiotic Stewardship policy revised 12/2016 indicated, . 3. Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending) .

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 did not experience physical abuse by Resident #2 on 4/5/25. The noncompliance was identified as PNC. The noncompliance began on 4/5/25 and ended on 4/6/25. The facility had corrected the noncompliance before the investigation began on 4/15/25. This failure could place residents at risk for emotional distress and further abuse. Findings included: 1. Record review of Resident #1's face sheet dated 4/15/25 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including metabolic encephalopathy (is a change in how your brain works due to an underlying condition), altered mental status, and legal blindness. Record review of Resident #1's admission MDS assessment dated [DATE] indicated Resident #1 was rarely/never understood and rarely/never had the ability to understand others. Resident #1 had a BIMS score of 00 which indicated severe cognitive impairment. Record review of Resident #1's care plan dated 3/18/25 indicated: *Resident #1 had impaired vision due to macular degeneration (an eye disease that causes vision loss). Intervention included attempt to provide a safe and obstacle free environment. *Resident #1 had impaired cognitive and decision-making abilities. Intervention included monitor facial expressions and body language for signs and symptoms of distress. Record review of Resident #1's nurses note by LVN B, dated 4/5/25 indicated, . [CNA A] reported that [Resident #2] kicked [Resident #1] on her left leg just below the knee .may have x-ray .no signs/symptoms of pain noted at this time . Record review of Resident #1's Incident/Accident Report by LVN B, dated 4/5/25 indicated, . [Resident #1] was in hall talking to . [Resident #2] was trying to tell [Resident #1] what to do . [CNA A] said '[Resident #2] just kicked [Resident #1]' .assessed [Resident #1] .no apparent injury . Record review of Resident #1's Left tibia and fibula (are the two bones that form your lower leg), 2 view x-ray results dated 4/6/25 indicated, .no evidence of acute fracture or dislocation of the tibia or fibula . Record review of Resident #1's social service progress notes by the Social Service Designee (SSD), dated 4/7/25 indicated, .Spoke with [Responsible Party of Resident #1] and offered [local provider] referral related to incident that happened over the weekend between [Resident #1] and [Resident #2] .[RP of Resident #1] did not think [Resident #1] needs a referral at this time . [RP of Resident #1] said they visited with [Resident #1] over the weekend and [Resident #1] didn't remember anything about the incident .I [SSD] also spoke with [Resident #1] and she was in a pleasant mood and did not remember incident . During an interview and observation on 4/15/25 at 3:45 p.m., Resident #1 said no one had kicked her that she could remember. Resident #1 had disorganized thoughts and appeared confused about the questions asked. Resident #1 appeared without distress or pain. 2. Record review of Resident #2's face sheet dated 4/15/25 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses including moderate intellectual disability (is defined as observable developmental delays, which may be accompanied by physical impairments), generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities), and mood affective disorder (is a mental health condition that primarily affects your emotional state). Resident #2 had been discharged on [DATE] to psychiatric hospital. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and had the ability to understand others. Resident #2 had clear speech, moderate difficulty hearing, and moderately impaired vision with correctives lenses. Resident #2 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #2 had not displayed behaviors during the assessment period. Resident #2 had no functional limitation in range of motion and did not use a mobility device. Resident #2 required setup for oral hygiene, dressing, and putting on/taking off footwear, supervision for toileting and personal hygiene, and moderate assistance for shower/bathe self. Record review of Resident #2's care plan with target date of 6/15/25 indicated: *Resident #2 had specific preferences, wants, needs, and likes. Interventions included Resident #2 talked loud and times and many need reminders to lower voice and to honor others personal space. Resident #2 did not like to be told what to do and had tendency to become defensive and say, You are not my momma you can't tell me what to do. Approach [Resident #2] with a calm friendly tone to prevent upsetting. Resident #2 could become argumentative with the staff at times when they were only trying to help. *Resident #2 had exhibited behavior symptoms. Resident #2 had poor impulse control, intellectual disabilities with episodes of poor social judgement and reasoning skills. Resident #2 had episodes of invading others personal space. Resident #2 had episodes of agitation and yelling. Resident #2 had difficulty regulating emotions and behaviors. Resident #2 had episodes of making fun of others and calling them ugly names and thinking they were talking about me or telling me what to do. Intervention included calmly redirect when exhibiting an inappropriate behavior. Record review of Resident #2's nurse's notes dated 4/5/25 by LVN B, indicated, . [CNA A] said [Resident #2] kicked [Resident #1] just below her left knee . [Resident #2] apologized . Record review of Resident #2's Incident/Accident Report dated 4/5/25 by LVN B, indicated, .4/5/25 .1:45pm .hallway near nursing station .normal resident's condition before incident/accident . [Resident #1] and another resident talking while in their wheelchairs . [Resident #2] was telling [Resident #1] what to do . [Resident #1] ignored [Resident #2] .when I [LVN B] was not looking [CNA A] said '[Resident #2] kick [Resident #1]' .assessed [Resident #1] .no signs/symptoms of an injury noted .no apparent injury .awake, alert, and oriented to person, place or time . Record review of CNA A's witness statement dated 4/5/25 indicated, .I [CNA A] was down the hall and I [CNA A] saw [Resident #2] kicked [Resident #1] on her left leg below her kneecap . Record review of MA D statement dated 4/5/25 indicated, .I [MA D] didn't see the incident when it happened, but after they asked [Resident #2] why she did it, [Resident #2] went and apologized to [Resident #1] and said 'I [Resident #2] am sorry for kicking you' . Record review of the facility's Provider Investigation Summary and Findings dated 4/10/25 indicated, .at around 1:45pm on Saturday April 5th on the C wing hallway .[CNA A] was coming out of a resident's room when she looked down the hall and observed [Resident #2], as she was standing kick [Resident #1], in her left shin as she was sitting in her wheelchair . [CNA A] called out to [Resident #2] and who then went down the hall to her room . [Resident #2] did not voice any complaints of pain but was upset . Charge nurse did an assessment of [Resident #1] and determined she may have a mark on her left shin but wasn't sure if it was varicose veins or bruising . [Resident #2] could not verbalize why she did what she did but was apologetic . [Resident #2] was moved off the wing that [Resident #1] resides on and a sitter was placed with her til she was transferred to [local behavioral center] .what happened preceding the incident is unknown as the why [Resident #2] did what she did . [Resident #2] did not deny it and there is an eyewitness . During an interview on 4/15/25 at 10:00 a.m., the DON said Resident #2 was still at an inpatient behavioral hospital. Unable to interview Resident #2. During an interview on 4/15/25 at 1:43 p.m., MA D said Resident #2 had behaviors and was hard to redirect at times. She said Resident #2 was bossy and had a history of hitting other residents. She said Resident #2 got loud when staff tried to redirect her and refused to follow directions. She said sometimes if staff left Resident #2 alone or explained to her why something needed to be done, she was more agreeable. She said in the past, Resident #2 told her when she had done something wrong. She said sometimes Resident #2 would tell her the reason she did something was because she got mad. She said Resident #2 said she did not think about the action before she did it. She said Resident #2 was normally apologetic. She said she did not witness the incident on 4/5/25 but was Resident #2's sitter on 4/6/25 and 4/7/25. She said Resident #2 was still on the C wing when she was her sitter. She said she asked Resident #2 about the incident. She said Resident #2 told her; Resident #1 pushed her against the wall so she kicked her. She said Resident #2 was stressing about the incident and told her she would not do it again. She said this incident was the first incident between Resident #1 and Resident #2. She said Resident #2 wandered the halls and visited other residents. She said Resident #2 knew hitting people was wrong but could not control herself. During an interview on 4/15/25 at 2:52 p.m., CNA A said before she went into another resident's room on 4/5/25, she saw Resident #1 and another resident sitting at the nursing station holding hands. She said as she was coming out of the resident's room, she saw Resident #2 walk up to Resident #1. She said Resident #2 kicked Resident #1 on her left leg near the knee. She said she did not see Resident #1 do anything to Resident #2. She said after the incident, Resident #2 ran away to the lobby area. She said she hollered out for LVN B and him came to the nursing station. She said she asked Resident #2 why she kicked Resident #1. She said Resident #2 just said she was sorry and apologized to Resident #1. She said Resident #2 did not mention if Resident #1 did something to her first. She said Resident #2 picked on everybody especially those who could not defend themselves. She said this incident was the second time she had heard Resident #2 hitting another resident. She said Resident #2 had behaviors at times but was easy to redirect. She said Resident #2 was ambulatory and walked around the facility. She said Resident #2 was placed on 1:1 monitoring until she was transferred to a behavioral hospital. She said immediately after the incident on 4/5/25, Resident #1 kept saying, she kicked me. She said Resident #2 understood she kicked Resident #1. She said Resident #2 kicked her with intention. She said Resident #2 pulled her leg back like when you ball up your fist before you hit someone. She said Resident #2 apologized to Resident #1 and told her we're friends now. She said Resident #1 eventually had a bruise on her leg. She said Resident #1 had not mentioned the incident since it happened on 4/5/25. She said no residents had reported to her being afraid of Resident #2. During an interview on 4/15/25 at 3:07 p.m., LVN B said the incident between Resident #1 and Resident #2 happened on 4/5/25. He said before he left the nursing station on 4/5/25, he overheard Resident #2 trying to tell Resident #1 what to do. He said Resident #1 was trying to console another resident. He said CNA A reported to him that Resident #2 had kicked Resident #1. He said the residents were immediately separated. He said Resident #2 was placed on 1:1 monitoring and family, medical doctor, and the DON were notified. He said a bruise was not noted on Resident #1 over the weekend. He said he had initially thought a dark arear on her left leg was a bruise but it was varicose veins. He said Resident #2 was bossy and liked to argue with everyone. He said Resident #2 wandered the halls and went to different floors. He said Resident #2 was usually easy redirect. He said Resident #2 apologized so it was not like she did not know what she was doing. He said he did not know if Resident #2 intent was to hurt Resident #1. He said Resident #1 did not appear upset after the incident. During an interview on 4/15/25 at 3:58 p.m., the DON said Resident #2 had a similar incident in January 2025. She said Resident #2 hit a male resident. She said after the incident in January 2025, Resident #2 had a sitter with 1:1 monitoring, psych consult, and medication changes. She said when the 1:1 monitoring was discontinued, Resident #2 was placed on every 15 minutes visual checks. She said after the incident on 4/5/25, she had a sitter until she was transferred out on 4/7/25. She said Resident #2 did not have any behavioral changes leading up to the incident on 4/5/25. She said Resident #2 wandered and visited residents and staff everywhere. She said Resident #2 was moved from C wing to A wing. She said Resident #1 did not develop a bruise after the incident. She said the darkened area on Resident #1's leg was a varicose vein. She said the facility ordered the x-ray to error on the cautionary side. She said Resident #2, said she knew what she had done was wrong and should not had done it. She said Resident #2 said she would not do it anymore. She said according to the facility's abuse policy, Resident #2 physically abused Resident #1. She said the facility tried to prevent resident to resident altercations by noticing behavior changes, notifying the physician of behavior changes, and getting psych consults. She said depending on the resident's behaviors, the resident could be placed on every 15-minute checks or 1:1 monitoring. She said the family was also involved to see if they noticed any changes and what worked to help with the behaviors. She said when a resident was abused, they could become fearful, anxious, sleeping problems, depressed, or scared all the time. During an interview on 4/15/25 at 4:44 p.m., the corporate administrator said from what he knew of the incident on 4/5/25, Resident #2 had kicked Resident #1. He said Resident #2 was transferred to a behavioral hospital and her room changed to another floor. He said Resident #2 had an intellectual disability and was childlike. He said he felt Resident #2's actions were not intentional but impulsive. He said Resident #2's actions on 4/5/25 was not willful intent so he did not consider it abuse. Record review of a facility's Abuse Prevention Program revised on 12/2016 indicated, .our resident have the right to be free from abuse, neglect .this includes but is not limited to .physical abuse .protect our residents from abuse by anyone including, but not necessarily limited to .other residents . The facility took the following actions to correct the non-compliance: Record review of Resident #1 and Resident #2's Incident/Accident Report dated 4/5/25 indicated the family members/responsible parties, nurse practitioner, and/or medical doctor had been notified on the incident. Record review of safe survey interview form dated 4/5/25 indicated 5 residents who resided on C hall with Resident #2 were interviewed. All 5 residents indicated no one had been hurtful, physically, or verbally, did not have any problems with another resident in the facility, felt safe and free from any harm or abuse, and felt they were free to voice a complaint with fear of retaliation. Record review of Resident #2's visual every 15-minute check dated 4/6/25 and 4/7/25 were completed. Record review of Resident #2's nurse's notes dated 4/7/25 at 1:05 a.m., indicated urinalysis (is a medical test that analyzes a urine sample to assess kidney function, identify potential infections, and detect other health issues) was collected via in and out catheter. Record review of Resident #2's nurse's notes dated 4/7/25 at 1:00 p.m., indicated Resident #2 was transferred to room A20-A. Record review of Resident #2's nurse's notes dated 4/7/25 at 5:00 p.m., indicated Resident left the facility via facility transportation to go to a behavioral hospital. Record review of a local behavioral hospital referral dated 4/7/25 indicated Resident #2 needed evaluation for inpatient treatment. Record review of the PIR dated 4/10/25 indicated the facility had reported the incident within the regulated timeframe. The PIR reflected a thorough investigation had been conducted with witness/involved person statements obtained and the resident was protected during the investigation. Record review of a facility's resident roster dated 4/15/25 indicated Resident #2 was out of the facility and would return to room A20-A. Record review of Resident #2's urinalysis results dated 4/7/25, reviewed on 4/15/25, did not reflected a urinary tract infection that could have contributed to Resident #2's behavior. Record review of a facility conducted in-service, Abuse, Neglect, and Exploitation; Resident to Resident abuse dated 4/6/25, was conducted by the DON indicated, fifty-six staff members across all shifts had been in-serviced. Interviews of sampled resident during the investigation on 4/15/25 reflected no residents complained of resident abuse/neglect. The sampled residents verified they did not fear any residents and knew who to report abuse/neglect allegation to. Interviews of sampled staff members during the investigation on 4/15/25 reflected they had been in-serviced on abuse/neglect and resident to resident altercation on 4/6/25. The sampled staff members, across all shifts indicated they were not aware of any abuse/neglect in the facility and knew to immediately report alleged abuse/neglect allegations to the DON and Assistant Administrator (Abuse Coordinator). Record review of facility incident/accident reports for the past three (3) months revealed no concerns in the area(s) of Resident Abuse (Resident to Resident Altercation), Resident Neglect. Appropriate facility responses and investigations were done as necessary. Incident report for Resident-to-Resident altercation was addressed with appropriate facility response and investigation. Resident #2 was placed with sitter and 15-minute visual checks. Resident #2 was transferred to a local behavioral hospital. Resident #1 was assessed for injuries and x-ray obtained for precautionary measures. Resident #1 responsible party was offered a psych consult which was declined. Resident #1 and Resident #2 no longer resided on the same floor. Record review of facility complaints for the past three (3) months revealed no concerns in the area(s) of Resident Abuse or Resident Neglect. The monthly grievance logs did not reflect any complaints related to Resident #2. The noncompliance was identified as PNC. The noncompliance began on 4/5/25 and ended on 4/6/25. The facility had corrected the noncompliance before the investigation began on 4/15/25.

ased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 19 residents reviewed for care plans. (Resident# 13, Resident #47, Resident #73) 1. The facility failed to develop a care plan for Resident #13 and Resident #47's use of a transfer bar. 2. The facility failed to implement Resident #73's care plan intervention to wear a seizure safety helmet while out of bed on 04/09/24. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of a face sheet printed 04/09/24 indicated Resident #13 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including fracture of shaft of left fibula (a long bone in the lower extremity that is positioned on the lateral side of the tibia), fracture of lower end tibia (the shinbone; the larger of the two bones in the lower leg), acquired absence of right leg below knee, muscle weakness, and history of falling. Record review of an annual MDS assessment dated [DATE] indicated Resident #13 was understood and understood others. The MDS indicated Resident #13 had minimal difficulty hearing, clear speech, and moderately impaired vision with corrective lenses. The MDS indicated Resident #13 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #13 required moderate assistance for toilet hygiene, shower/bathe self, dressing, and personal hygiene and independent for oral hygiene. The MDS indicated Resident #13 required substantial assistance for rolling left and right and sitting to lying, and moderate assistance for lying to sitting on side of bed. Record review of a care plan dated 05/12/23, revised on 02/05/24, indicated Resident #13 required weight bearing support from staff during ADL care due to right and left below the knee amputation, impaired mobility, and legal blindness. An intervention included encouraging the resident to increase participation in all aspects of ADLs. There was no care plan or intervention for the use of transfer bar. During an observation and interview on 04/08/24 at 11:02 a.m., Resident #13 was sitting up in bed with a transfer bar on both sides of her bed. Resident #13 said she was able to turn side to side with assistance using the rails. During an observation on 04/10/24 at 12:00 p.m., Resident #13 was sitting in her wheelchair at the bedside. Resident #13 had a transfer bar on both sides of her bed. 2. Record review of a face sheet printed on 04/10/24 indicated Resident #47 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including metabolic encephalopathy ( a problem in the brain caused by a chemical imbalance in the blood), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), history and repeated falls, displaced intertrochanteric fracture of left femur (is a type of hip fracture or broken hip), and muscle weakness. Record review of a significant change of status MDS assessment dated [DATE] indicated Resident #47 was rarely/never understood and rarely/never understood others. The MDS indicated Resident #47 had minimal hearing difficulty, clear speech, and adequate vision. The MDS indicated Resident #47 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #47 required maximal assistance for putting on footwear and personal hygiene, moderate assistance for eating, oral and toilet hygiene, dressing, and showering or bathing herself. The MDS indicated Resident #47 required moderate assistance for rolling left and right, sitting to lying, and lying to sitting on side of bed. Record review of a care plan dated 04/05/24 indicated Resident #47 needed assistance with all aspects of ADL care. Resident #47 had vascular dementia (brain damage caused by multiple strokes) with malnutrition requiring feeding tube placement (soft, flexible plastic tubes through which liquid nutrition travels through your gastrointestinal (GI) tract). Intervention included required weight bearing assistance with transfer. No care plan or intervention for use of transfer bar. During an observation on 04/08/24 at 10:24 a.m., Resident #47 was lying down in bed with a transfer bar on the right side of the bed. Resident #47 did not react or respond to greeting. During an observation on 04/09/24 at 07:50 a.m., Resident #47 was lying down in bed asleep with a transfer bar on the right side of the bed. 3. Record review of a face sheet printed 04/09/24 indicated Resident #73 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), autistic disorder (problems with social communication and interaction, and restricted or repetitive behaviors or interests), epilepsy (ia brain condition that causes recurring seizures), intellectual disability (limits to a person's ability to learn at an expected level and function in daily life) and attention deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness). Record review of Resident #73's consolidated physician order dated 04/08/24 indicated may have seizure helmet in place while out of bed for preventative measure and seizure precautions. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #73 was sometimes understood and sometimes had the ability to understand others. The MDS indicated Resident #73 had adequate hearing, unclear speech, and adequate vision. The MDS indicated Resident #73 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #73 had short-and-long term memory problem and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #73 was dependent for shower/bathe self, substantial assistance for eating and oral hygiene, and partial assistance for toileting hygiene, body dressing, putting on/off footwear, and personal hygiene. Record review of a care plan dated 07/05/23, revised on 04/02/24, indicated Resident #73 had a seizure which placed her at risk to have injuries during the episode. Resident #73 had the potential to have more seizures. An intervention included that the resident may have seizure safety helmet in place while out of bed for preventative measures/seizure precautions. During an observation on 04/09/24 at 7:50 a.m., Resident #73 was in her wheelchair on the hall A community room. Resident #73 was leaning sideways in her wheelchair with no seizure safety helmet in place. During an observation on 04/09/24 at 11:02 a.m., Resident #73 was in her wheelchair in the community room. She was then pushed into her room with no seizure safety helmet in place. During an interview on 04/10/24 at 1:52 p.m., CNA F said she worked prn, on all the halls. She said she had worked at the facility off and on for 6-7 years. CNA F said Resident #73 had seizures and was supposed to wear the seizure helmet when out of the bed. She said she felt liked Resident #73 should wear the helmet in bed too. She said honestly, Resident #73 should have the seizure helmet on all the time. She said the seizure helmet was in case she had a seizure. She stated it protected Resident #73's head. She said if Resident #73 did not wear her seizure helmet, she could hurt herself during a seizure. She said Resident #47 no longer followed commands, so she did not use the bar on the bed anymore. During an interview on 04/10/24 at 2:30 p.m., LVN G said Resident #73 was supposed to have on the seizure helmet when she was out of the bed. She said she felt like Resident #73 should have the helmet on all the time for seizure precaution. She said if Resident #73 did not have the seizure helmet on during an active seizure, she could injury her head. She said it was the CNAs and LVNs, but primarily the LVN's responsibility to ensure Resident #73 had the seizure helmet on when she was out of the bed. She said she did notice later in the afternoon on 04/09/24, Resident #73 was out of the bed without her helmet on. She said Resident #13 and Resident #47 had mobility rails. She said she knew if the rails were not to help with transferring, then it was considered a restraint. She said the facility did not have an assessment for transfer bars. She said the transfer bars should be care planned so it was clear what the rails were for. She said Resident #47 used the bar to transfer but after her recent hospital admission she had declined. She said Resident #13 used her transfer bar to transfer herself. During an interview on 04/10/24 at 3:37 p.m., the ADON D said Resident #73 should have had her seizure helmet on when out of the bed. She said the CNA should put the helmet on when they got her out of the bed. She said the LVNs should have made sure the CNAs placed the helmet on when she was out of the bed. She said it was important to follow the care plan intervention to keep the resident safe. She said Resident #13 and Resident #47 had mobility bars on their bed. She said Resident #13 and Resident #47 should have had a care plan problem for the mobility bars. She said nursing staff should have informed the MDS coordinator that the residents had mobility bars on their beds. She said it was important to have a care plan for the bars to know it was for mobility not a restraint. During an interview on 04/10/24 at 3:40 p.m., the DON said the mobility bars were usually care planned. She said the mobility bars were needed to help resident to turn. She said Resident #47 had good and bad days and assisted with turning on some days. She said Resident #47 still used the mobility bars when she was more alert. She said because the mobility bars were not care planned, staff, especially new staff, may not have known why they were needed and if the resident was safe to use them. She said Resident #73 was supposed to have the seizure helmet when she was out of the bed. She said the helmet was for seizure precaution intervention on the care plan. She said Resident #73 not wearing the seizure helmet when she fell on the floor during a seizure risked a head injury, contusion, and subdural hematoma. She said the CNAs and LVNs should have ensured Resident #73 had the seizure helmet on but ultimately it was the LVNs responsibility. During an interview on 04/10/24 at 4:00 p.m., the ADM said he expected staff to follow the resident's care plans. He said Resident #73 not wearing her seizure helmet placed her at risk for injury. He said all staff were responsible to ensure Resident #73 had the helmet on when out of bed. He said the mobility bars should have been care planned. He said the charge nurse and MDS coordinator were responsible for developing care plans with interventions. He said it was important to follow or develop a care plan because it was the resident's plan of care and set the tone of how care was going to be provided. Record review of a facility Care Plans, Comprehensive Person-Centered policy revised 12/16 indicated .a comprehensive, person centered care plan .meet the resident's physical, psychosocial and functional needs is developed and implemented .the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive .care plan for each resident .the comprehensive, person-centered care plan will .describe the services that are to be furnished .incorporate identified problem areas .aid in preventing or reducing decline in the resident's functional status .reflect currently recognized standards of practice for problems areas and conditions .the IDT must review and update the care plan .

ased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 20 residents (Resident #32, Resident #19, Resident #47, Resident #62, and Resident # 73) reviewed for quality of care. 1. The facility failed to keep Resident #32's smoking materials locked up at the nurse's station. Resident #32's cigarette and lighter was on his bedside table in his room. 2. The facility failed to ensure Resident #19, Resident #47, Resident #62, and Resident #73 did not have objects on top of their overhead light fixtures. These failures could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #32's Admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Polymyositis (an uncommon inflammatory disease that causes muscle weakness affecting both sides of your body), Hypokalemia (a lower-than-normal potassium level in your bloodstream), and Bacteremia (viable bacteria in the blood). Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 which indicated he was cognitively intact. The MDS also revealed, Resident #32, required substantial assistance with transfer and ADLs. Record review of Resident #32's Care Plan revealed a problem initiated on 2/1/2024 for smoking. It stated Resident # 32 would be compliant with facility policies regarding smoking. Resident # 32 was care planned for leaving his smoking materials at the nurse's station and that he was unable to keep smoking materials in his bedroom. During an observation on 04/08/24 at 3:43 p.m., Resident #32 bedside table had a pack of cigarettes that was open. A cigarette lighter was observed inside the pack of cigarettes. Resident #32 was not in the room during the observation. Resident #32's roommate said that the cigarettes belonged to Resident #32. During an interview on 04/08/24 at 3:48 p.m., CNA A said she was supposed to lock up resident's smoking materials when they were finished smoking. She said Resident #32 had just finished smoking. She said his package of cigarettes and the lighter were in Resident #32's room. She said facility policy required residents to leave their smoking materials at the nurse's station. During an interview on 04/09/24 at 10:06 a.m., Resident #32 said he smoked cigarettes. He said he had left earlier to go to the doctor. He said he left his cigarettes in the room. He said sometimes he would go to the nurse's station to get cigarettes and sometimes he had them in his room. During an interview on 04/09/24 at 11:00 a.m., The DON said she expected all residents to follow the facility's smoking policy and leave their smoking materials in the nurse's office. She said that facility staff should follow facility policies and ensure that residents did not have their smoking materials in their rooms. She said a risk of residents having their smoking materials in their room was that they could start a fire or harm themselves or others. During an interview on 04/09/24 at 11:15 a.m., The Administrator said he expected all residents follow the facility smoking policy which is to leave their smoking materials in the nurse's office. He said that facility staff should follow facility policy and ensure that resident's do not have their smoking materials in their rooms. He said that residents can be placed at risk for fire if a resident kept their smoking materials in their room. 2. During an observation on 04/08/24 at 9:38 a.m., Resident #73 was sitting up in her bed. Above Resident #73's bed, on the overhead light fixture was a stuffed animal. The overhead light fixture was on. Resident #62 was also sitting up in her bed. Above Resident #62's bed, on the overhead light fixture was a clear picture frame. The overhead light fixture was on. During an observation on 04/08/24 at 10:24 a.m., Resident #47 was lying down in her bed. Above Resident #47's bed, on the overhead light fixture, was a stuffed animal and picture frame. During an observation on 04/08/24 at 10:48 a.m., Resident #19 was sitting up in her bed. In Resident #19's room, the privacy curtain was draped over the on, overhead light fixture near the bedroom door. During an observation 04/08/24 at 12:43 p.m., Resident #73 was sitting up in her bed. Above Resident #73's bed, on the overhead light fixture, was a stuffed animal. The overhead light fixture was on. Resident #62 was also sitting up in her bed. Above Resident #62's bed, on the overhead light fixture was a clear picture frame. The overhead light fixture was on. During an observation on 04/09/24 at 7:50 a.m., Resident #47 was lying down in her bed. Above Resident #47's bed, on the overhead light fixture, was a stuffed animal and picture frame. During an interview on 04/10/24 at 1:52 p.m., CNA F said she worked prn, on all the halls. She said she had worked at the facility off and on for 6-7 years. She said she preferred things not be on the overhead light because pictures could fall. She said stuff animals on the overhead lights could be a fire hazard. She said sometimes family members visited and put things on the overhead light. She said having items on the overhead light could hurt the resident. During an interview on 04/10/24 at 2:30 p.m., LVN G said having items on the overhead lights was a safety hazard. She said she preferred items not be on the overhead lights. She said privacy curtains should not be draped on the overhead light either. She said she tried to keep Resident #73's stuff animals in her bed not on the overhead light. She said picture frames on the overhead lights could fall and hit a resident on the head. She said family did put things on the overhead light and she had to call family to let them know she took it down. During an interview on 04/10/24 at 3:27 p.m., ADON D said items should not be on the overhead light. She said things such as privacy curtains and stuffed animals could become flammable sitting on the overhead light. She said it was the unit managers and maintenance responsible to make sure items were not on the overhead light. During an interview on 04/10/24 at 3:40 p.m., the DON said stuffed animals, picture frames, and privacy curtains were not allowed on the overhead light. She said items on the overhead lights were a fire and safety hazards. She said picture frames could fall and cause injuries. She said all staff members were responsible to ensure items were not stored on top of the overhead light. She said staff members needed to be educated to take things off the overhead lights and family members not to place things on it. During an interview on 04/10/24 at 4:00 p.m., the ADM said items were not supposed to be stored on the overhead lights. He said items stored on the overhead light was a fire hazard. He said all staff were responsible to make sure things were not stored on top of the overhead lights. Record review of a facility policy revised on July 2017 entitled [Facility] Smoking Policy revealed, Provide maximum safety to all residents at all times. It is the intent of the facility to provide an environment to allow those residents who wish to smoke the opportunity to do so in a safe environment, with optimal safety themselves, other residents, volunteers, visitors, staff members and non-smokers . Residents will be informed of the written smoking policy prior or at the time of admission . Smoking materials will be kept in a designated area accessible to staff. Safe smokers will request these items from their nurse or staff member. At no time will residents be allowed to keep any smoking materials in their room. Record review of a facility's Fire Safety and Prevention policy revised on 05/11 indicated .all personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard .fire prevention is the responsibility of all personnel, residents, visitors, and the general public . 44933

Based on interview, observation, and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents reviewed for abuse. (Resident #6) The facility failed to immediately remove Resident #6 from the situation when her private sitter was physically and verbally abusing her. This failure could place residents at risk for physical abuse, mental abuse, and emotional abuse, and harm. This was determined to be past non compliance due to the facility having implemented actions that corrected the non compliance prior to the beginning of the survey. Findings included: Record review of Resident #6's face sheet indicated she was a [AGE] year old female who admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's MDS assessment dated [DATE] indicated she had short and long-term memory problems. She had severely impaired decision-making skills, continuous inattention, and continuous disorganized thinking. She had no recorded behaviors for that specific look back period. She was totally dependent on one staff member for locomotion and required the extensive assist of one staff member for transfers, and bed mobility. Record review of Resident #6's care plan, dated 6/21/22, indicated she experienced anxiety and may experience anxious behaviors and/or have panic attacks, agitation and aggression. Interventions included staff were to allow her to verbalize her feelings and were to eliminate causative factors that triggered her anxiety. Staff were to remain calm if she became agitated and were to provide her with a calm and safe environment. Staff were also supposed to redirect her when she began grabbing, pushing, hitting, kicking or yelling. Record review of Resident #2's Medication Review Report dated, 4/29/22, indicated she had wound care orders for skin tears to her left arm and right hand. The order date for both skin tears was 4/13/22, with a start date of 4/14/22. Record review of Resident #6's care plan, dated 6/21/22, indicated she experienced anxiety and may experience anxious behaviors and/or have panic attacks, agitation and aggression. Record review of an Incident Report dated 4/27/22 indicated at 2:30 p.m. Resident #6 became irate and combative during activities, and she sustained a skin tear to her left hand and right arm. Record review of a Weekly Skin Assessment form dated 4/27/22 indicated the resident had a skin tear to her left dorsal (back) hand and her right forearm. No measurements for the wounds were noted. Record review of a nurse's note dated 4/27/22 at 2:30 p.m. indicated LVN A was notified of the resident becoming irate in activities. A skin tear to the resident's hand and forearm were found and cleansed with wound cleanser and steri-strips were applied. Record review of a witness statement by the Activity Director dated 4/27/22 indicated the resident was attending [NAME] bingo and started to get out of her chair while yelling she wanted to go. The resident began yelling at her sitter and the sitter began repeating what the resident said. The resident became upset by this and attempted to slap the sitter. The resident again tried to get out of her chair and the private sitter was forcing the resident to sit down. The resident received a skin tear to her left hand while she fought the private sitter to let her up. The resident then attempted to bite out of anger. The private sitter told the resident to shut up while the resident acted out. He said by this time, he got the administrator involved. Record review of Resident #8's witness statement, dated 4/27/22, indicated he was sitting at the table with Resident #6 and her private sitter during activities. He said Resident #6 started hitting and trying to bite her private sitter. He said Resident #6 was also trying to stand up and her sitter was trying to keep her in her seat. He said the sitter took Resident #6's hand, put it in her own mouth, and made her bite herself. Record review of an Unusual Occurrence Incident Report Attachment form dated 4/27/22, filled out by the private sitter, indicated Resident #6 became very upset and started scratching and hitting the private sitter. The resident then began trying to bite the private sitter, so the sitter put the resident's hand in her own mouth and made her bite herself. No further documentation was provided by the sitter. Record review of the Administrator's investigation dated 4/29/22 indicated Resident #6, and her private sitter, were participating in activities on 4/27/22. At around 2:45 p.m., activity staff witnessed the resident becoming agitated and saying, I want to go home! over and over. The resident's private sitter began mocking the resident and caused the resident to become more agitated. The resident then became combative and started swinging at the private sitter, striking her in the face. The activity staff witnessed the private sitter grab the resident's hand, put it to her own mouth, and the resident bit her own hand, causing a laceration. Shortly after this incident, the administrator was notified and arrived at the activity room, but the situation had already de-escalated. The resident was removed from the activity room and taken to the nurse's station. The private sitter was asked to leave the facility. A head-to-toe skin assessment was performed by the resident's nurse and treatment was provided to her skin tears. Police were called, the family was notified and declined pressing charges, but did request the private sitter no longer sit with the resident. The private sitter's company was notified of the abuse and the company provided a new sitter in the same day. During an observation and interview with Resident #6 on 8/1/22 at 1:00 p.m., she was up in her wheelchair. Her eyes were closed, and she would not respond to questions or to her name. The private sitter in the room with her said the resident did frequently act that way and did not like to be disturbed. During an interview on 8/1/22 at 2:30 p.m., LVN A said she was the nurse on duty the day Resident #6 was involved in the altercation with her private sitter. LVN A stated she did not remember anything from that day. During an interview on 8/1/22 at 3:00 p.m., the Activity Director said he saw Resident #6 swatting at the private sitter and then saw the resident was bleeding. He said he texted the Administrator and said he needed him to come to the activity room. He said the resident was trying to get up from her wheelchair and the sitter was trying to physically sit her back down. He said he also believed the sitter was kicking the resident under the table. He said his assistant also noticed the behaviors, but neither of them removed the resident from the situation. He said he texted the Administrator and the Administrator came quickly. He said the resident would say things like, I don't want you!, to the private sitter and the private sitter would say, I don't want to be with you either!. He said the sitter tried to deny any of the events happened even with witnesses in the room with her. He said the private sitter did not usually behave that way and she had been very involved in activities and helpful to the residents. During an interview on 8/1/22 at 3:28 p.m., the Administrator said the sitter admitted to what she did to the resident. He said he spoke to the Activity Director right after the incident occurred. He said he told the Activity Director he knew what to do in events like that and what the facility policy said. He said the Activity Director texted him and said something like we have a situation in the dining room, but the text didn't go into specifics. He said he felt like sometimes the Activity Director wasn't sure what to do and he told the Activity Director that he know what their policy said about abuse, so therefore he should have removed the resident from the situation. He said he did counsel the Activity Director and did an abuse and neglect in-service. It was determined these failures resulted in Resident #6 being harmed on 4/27/22. Facility took the following actions to correct the non-compliance : Record review of the facility's Provider Investigation Report indicated in-services were conducted on 4/27/22 with all staff regarding abuse and neglect, managing combative residents, and immediately notifying the charge nurse of behaviors. Police were called, the family was notified and declined pressing charges, but did request the private sitter no longer sit with the resident. The private sitter's company was notified of the abuse and the company provided a new sitter in the same day. During interviews with 3 CNAs and 3 LVNs on the day shift, all employees indicated they would remove a resident from the abusive situation. The 3 CNA's said they would notify their charge nurse and the 3 LVN's said they would notify the administrator, who was the abuse coordinator. Record review of the facility's Abuse Prevention and Prohibition Policies, dated 6/1/21, indicated: .C. PREVENTION .Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property and intervene as appropriate .

Based on interview and record review, the facility failed to ensure the physician was consulted for a significant change in physical status and need to alter treatment for 2 of 29 residents reviewed for physician notification. (Resident #55 and #8) The facility did not notify Resident #55's physician when she developed a stage 3 pressure injury on [DATE]. The physician was not notified when the pressure injury worsened to an unstageable on [DATE] and developed signs and symptoms of infection on [DATE]. Resident #55 was transferred to the hospital where she was diagnosed with [REDACTED]. The facility did not immediately notify Resident #55's physician on [DATE] when she developed a critically low FSBS of less than 20. The physician was not notified for over 2 hours. Resident #55 was transferred to the hospital and admitted to the ICU in critical condition. An Immediate Jeopardy situation was identified [DATE]. While the Immediate Jeopardy, was removed on [DATE] at 4:51 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy - The facility did not notify the physician when Resident #8 had a hypoglycemic episode (blood sugar of less than 60). This failure could place residents at risk for not receiving appropriate care from the physician or interventions to prevent injury or death. Findings included: Pressure Injury 1. Physician orders dated [DATE] for Resident #55 indicated to cleanse lower buttocks with wound cleanser, pat dry, apply hydrogel gauze to wound bed, cover with bordered foam dressing, and change daily. A Skin-Acute Care Plan dated [DATE] indicated Resident #55 had a pressure injury of the sacrum, related to decreased mobility, incontinence and right [MEDICAL CONDITION] (partial weakness on one side of the body). An addendum added [DATE] indicated in the next 30 days the wound would remain infection free and decrease in size. The Pressure Ulcer/Wound Weekly Log completed by the DON dated [DATE] indicated Resident #55 had the following pressure injuries: *#1 -upper sacrum-facility acquired stage 3- identified [DATE], measured 1.2 cm x 0.8 cm x 0.1 cm. *#2 -lower sacrum-facility acquired stage 3- identified on [DATE], measured 1.8 cm x 0.6 cm x 0.1 cm. A monthly nursing summary note dated [DATE] indicated Resident #55 had two stage 3 pressure injuries and was receiving pressure injury care. The notes did not address if the physician/NP were notified of the newly identified pressure injuries. There were no other nursing notes for the month of (MONTH) 2019 in the medical record. A treatment record dated [DATE]-[DATE] indicated Resident #55 had 2 pressure injuries: #1 upper buttocks-daily treatment from [DATE]- [DATE] - cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The treatment sheet indicated the treatment was discontinued on [DATE]. #2 - lower buttocks-daily treatment from [DATE] through [DATE]- cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. Physician orders dated [DATE] for Resident #55 indicated to discontinue hydrogel to Resident #55's upper buttocks, area resolved. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] stage 3- measured 1.4 cm x 0.6 cm x 0.1 cm. No drainage noted. Wound bed pink with surrounding tissue/wound edges pink in color. *[DATE] stage 3-measured 1.8 cm x 1.0 cm x 0.2 cm. No odor. Wound bed pink/red with surrounding tissue/wound edges pink in color. There were no nursing notes dated [DATE] for Resident #55 indicating the physician/NP were notified of the pressure injury #2 increasing in size. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, was usually understood, and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting and personal hygiene. Resident #55 had one unhealed stage 3 pressure injury that was present on readmission/reentry. She had a pressure reducing device for her bed and was receiving pressure injury care including the application of non-surgical dressings. A care plan initiated on [DATE] indicated Resident #55 was at risk for alterations in skin integrity and she had a history of [REDACTED]. The care plan indicated efforts would be in place to minimize her risk for developing a pressure injury. Interventions included assess skin weekly and as needed, offload pressure points and reposition every 2 hours, and notify the physician of any skin problems. During an interview on [DATE] at 7:00 p.m., the administrator said Resident #55 had not been out of the building to the hospital or other since her admission. She said there was an old scar over the resident's sacral area and the resident had a history of [REDACTED]. The most recent NP progress note for Resident #55 was dated [DATE]. There were no physician progress notes [REDACTED]. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: *#2, lower buttocks-treatment from [DATE] through [DATE]- continue to cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 1.9 cm x 1.1 cm, (not able to measure depth); minimal serosanguinous drainage, no odor, 25% of the wound bed was covered with brown tissue. A nursing note dated [DATE] at 1:40 pm., completed by the DON indicated Resident #55 had greater than 25% of the wound bed located at 3 to 5 o'clock covered with light brown to tan tissue. The DON indicated the wound treatment was changed to apply Santyl to the wound bed and [MEDICATION NAME] applied to the peri wound. The nursing notes for [DATE] did not indicate Resident #55's physician/NP was notified of the pressure injury worsening in size and appearance. An unsigned physician order dated [DATE] indicated to discontinue hydrogel to Resident #55's buttocks, and to start the following: cleanse buttocks with wound cleanser, apply Santyl to wound bed, cover with bordered foam dressing, and change dressing daily and as needed for dislodgement. The Weekly Pressure Ulcer record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 2.1 cm x 1.3 cm (unable to measure depth)-area larger in size-no odor was present with a scant amount of serosanguinous drainage noted. A nursing note dated [DATE] at 11:15 a.m., completed by the DON indicated Resident #55's pressure injury had increased in size, and there was dry skin around the wound that had peeled and dropped off. The note indicated there were no signs and symptoms of infection. The treatment to the area changed to Santyl with calcium alginate and [MEDICATION NAME] to the peri-wound. The nursing note did not indicate Resident #55's physician or NP was notified of the pressure injury worsening. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2, lower buttocks-treatment from [DATE] through [DATE]-cleanse with wound cleanser, pat dry, apply Santyl to wound bed and cover with foam dressing, change every day and as need for dislodgement. A nursing note dated [DATE] at 8:05 a.m. completed by the DON indicated she was called to the nursing station by LVN B to look at Resident #55's sacral pressure injury which had developed an odor with increased brown tissue in the wound bed. The note indicated the DON asked LVN B to contact the NP to obtain antibiotic orders and request changing the dressing from daily to two times a day. The note indicated at 11:45 a.m. the DON informed the NP and the NP refused to order an antibiotic and agreed to the dressing change two times a day. In addition, a new order for a wound culture and sensitivity of the sacral pressure injury was noted. An unsigned physician order dated [DATE] for Resident #55 indicated to obtain a wound culture and to discontinue the Santyl treatment. New order to cleanse area to sacrum with wound cleanser, pat dry, apply Santyl and calcium alginate to the wound bed, apply [MEDICATION NAME] to peri-wound, and cover with bordered foam dressing two times a day, and as need for dislodgement. During an interview on [DATE] at 9:28 a.m., the NP said she was first notified on [DATE] of Resident #55's pressure injury. She said before that date, she had not received a phone call or facsimile transmission describing the pressure injury, location, or stage. She said that would be the normal procedure. She said physician orders for wound care treatments were sent to her, but she did not really read them, unless it was an order for [REDACTED]. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2 - Sacrum-treatment from [DATE] through [DATE]-cleanse area to sacrum with wound cleanser, pat dry, apply Santyl to wound bed and cover with calcium alginate. Apply [MEDICATION NAME] to peri-wound and cover with large bordered foam dressing two times a day and as needed for dislodgement. A nursing note dated [DATE] at 9:20 a.m., completed by the DON indicated she was notified the NP was making rounds and the NP refused to order a requested laboratory value for a complete blood count (CBC) and refused to change the treatment to the pressure injury of the sacrum until the wound culture and sensitivity laboratory results came back. The note did not indicate if the physician was notified. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] unstageable-measured 3.5 cm x 3.0 cm (unable to measure depth)- area larger in size-an odor was present with small amount of serosanguinous wound drainage. The wound bed contained light brown to brown tissue that was detached from the wound edges, the surrounding skin color was light red, wound edges were defined. The note indicated a culture and sensitivity was performed on [DATE]. During an interview on [DATE] at 3:32 p.m., the administrator said the Weekly Pressure Ulcer Record for Resident #55 completed by the DON dated [DATE] was not accurate. She said the wound culture and sensitivity was not done on [DATE] as documented, she said it was done on [DATE]. She said she did not know if the DON assessed the resident's sacral pressure injury on [DATE] because Resident #55 was sent to the hospital that morning. A nursing note dated [DATE] at 10:18 a.m. indicated the DON spoke with Resident #55 family representative and informed her of Resident #55's change of condition, FSBS of 22 and was transferred to the emergency room for a low glucose reading. The note did not indicate the physician was notified. An emergency room Nursing Documentation dated [DATE] indicated upon arrival at 9:03 a.m., Resident #55 was unresponsive with a FSBS of 29. The note indicated the resident had a decubitus (pressure injury) located on her coccyx area (sacral area) and covered with dressing. The resident had [MEDICAL CONDITION] screening that was positive with an unknown origin of infection. At 12:13 p.m. Resident #55 was admitted to the ICU in critical condition. An ICU nursing note dated [DATE] at 8.:36 p.m. indicated Resident #55 initial white blood cell count was 55.0, reference range (3XXX,[DATE].1) TH/mm3. The resident's chest x-ray was negative for pneumonia and her urinalysis negative for possible infection. The note indicated the resident had a large sacral pressure injury measuring 8.0 cm x 6.4 cm x 1.2 cm with a large amount of necrotic (dead) tissue. Resident #55 remained non-verbal, was not following commands, and was not tracking with her eyes. A hospital physician's short stay summary note dated [DATE] indicated Resident #55 had a large open decubitus on her sacral area with foul smelling purulent drainage. The physician determined Resident #55 needed to be transferred to a higher level of care after an examination of the sacral pressure injury showed it was infected and required urgent debridement. A physician discharge summary dated [DATE] indicated Resident #55's admission [DIAGNOSES REDACTED]. Possibly infected necrotic decubitus ulcer to the sacrum. 2.[MEDICAL CONDITION] 3. Urinary tract infection. 4 [DIAGNOSES REDACTED] .Discharge Diagnoses: [REDACTED]. 2. Escherichia coli urinary tract infection 3.[MEDICAL CONDITION] . The hospital course indicated Resident #55 initially had shortness of breath, altered mental status, and infected decubitus ulcer, was transferred from another hospital for evaluation of the infected decubitus ulcer and possible surgical debridement. Upon arrival Resident #55 had abnormal heart rate of 121, respirations of 30 and abnormal white blood count of 55.2. Surgical debridement was deferred due to functional status [MEDICAL CONDITION]. Resident #55 had positive wound culture that grew Proteus (Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans) and [MEDICATION NAME] (a gram-positive bacterium that can cause a variety of nosocomial infections) , her kidney function worsened, and she eventually died on [DATE]. The discharge [DIAGNOSES REDACTED]. Escherichia coli (bacteria found in the environment, foods, and intestines of people and animals) urinary tract infection. [MEDICAL CONDITION] . A laboratory report dated [DATE] for Resident #55 indicated a wound culture of a wound/abscess identified as a sacral wound was collected on [DATE] at 10:30 a.m. The laboratory result indicated moderate growth of proteus mirabilis and moderate growth of Escherichia coli-the two organisms were sensitive to all antibiotics listed except [MEDICATION NAME]. During an interview on [DATE] at 9:24 a.m., LVN B said on [DATE] she notified the NP of Resident #55's sacral pressure injury draining and having an odor via telephone. LVN B said the NP ordered a wound culture and sensitivity and declined ordering an antibiotic until the wound culture results came back. She said she (LVN B) and the DON provided wound care for Resident #55 on [DATE] and the wound bed was covered with soft stringy brown eschar (dead tissue) in the center and the wound was draining. She said the wound dressing changes were increased to two times a day. LVN B said on [DATE] and [DATE] the pressure injury continued to have an odor. She said the NP was making rounds on [DATE] and the DON discussed using a new treatment of [REDACTED]. She said she usually just sent the orders to the NP by facsimile for wound care orders that the DON would tell her to write. She said she did not notify Resident #55's primary care physician or the NP of the sacral pressure injury measurements or how the pressure injury declined, she would just send in the treatment orders. LVN B said [DATE] was the first time she called the NP about Resident #55's pressure injury. During an interview on [DATE] at 9:28 a.m., the NP said on [DATE] she was told Resident #55's sacral pressure injury looked wet and was asked if a culture could be performed and she approved. She said there was no mention about the increasing size of the pressure injury, that the wound had an odor, if the resident had a temperature, or other signs and symptoms that would indicate further action. The NP said while she was in the facility on [DATE], LVN B came to her and showed her a picture of the resident's pressure injury. She said she went to examine Resident #55 but did not turn her over and visually inspect the sacral pressure injury nor did she notice any odors. She said at that time she believed she had the preliminary report back from the culture but no sensitivity. She said LVN B did not report any change in vital signs i.e., temperature, low blood pressure, or increased heart rate and did not indicate the wound had worsened. She said she did not order an antibiotic. She said she suggested a wound care physician look at the resident's pressure injury and the DON indicated they treat their own pressure injuries in-house. The NP said she did not document her visit in Resident #55's medical record on [DATE] because it was not a scheduled visit. She said when she reviewed the record she could not find any progress notes indicating Resident #55 was seen since (MONTH) 2019. During an interview on [DATE] at 10:03 a.m., the medical director said there were wound protocols in place for the attending physician. She said she preferred residents see a wound care specialist if a pressure injury was a stage 3 or stage 4. She said she was not contacted or consulted for wound care orders or a review of Resident #55's sacral pressure injury. She said she reviewed Resident #55's pressure injury sheets with the NP after Resident #55 was sent to the hospital and believed obtaining a CBC would have given them more information to work with on what other interventions could have been implemented. The medical director said elderly residents do not respond to infection the same ways a healthy adult would. She said the elderly residents did not always mount a temperature in response to an infection and it could be sub-normal with FSBS dropping into a low range due to the infection. The medical director said when a resident's pressure injury developed slough (a type of necrotic tissue, it is often white, yellow or grey in color) and drainage, treatment should have included debridement. She said if chemical debridement (example - Santyl) was not effective, then surgical debridement would be needed. She said Resident #55's sacral pressure injury could have benefited in healing from a dressing impregnated with silver applied to pressure injury because of its [MEDICATION NAME] properties which helps treat/prevent infection. She said if an antibiotic had been initiated when Resident #55's pressure injury began to decline as in when it developed slough, drainage, and odor they might have been able to slow the infectious process and [MEDICAL CONDITION]. She said the facility staff were supposed to notify the physician of a resident's change in condition, either by facsimile or telephone. She said if the staff could not contact the attending physician, they should call her or the NP who worked under them. A Pressure Ulcer Treatment Policy dated ,[DATE] indicated: .Residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection and reduce the likelihood of new pressure ulcers developing .1. Contact physician for treatment orders .6. Use effective wound cleansing and debridement methods to minimize pressure ulcer colonization and enhance wound healing .19. Use [MEDICATION NAME], mechanical, enzymatic and/or autolytic debridement techniques to remove devitalized tissue .23. Refer to wound center as Needed . Practice Guidelines for Physician Notification of Change of Condition dated ,[DATE] indicated: .Nursing staff have been in serviced on the Physician notification of change of condition practice guideline. Immediate Notification-the physician should be informed at the time the event occurs either directly or by cell. Non-Immediate Notification-the physician should be informed of the problem or event during office hours and generally no later than the next regular office day. If a non-immediate event occurs on a weekend or holiday, good nursing judgment shall determine if the notification could wait until the next office day or should be made during the weekend or holiday.Resident-The resident receives prompt medical intervention .1. Nursing personnel identify those residents with a change of condition which requires an immediate notification of the physician and those which require a non-immediate notification .Management-1. The subject of notifying physician of resident change of condition is part of every new nurse orientation .3. A designated 'on call' or alternate physician is identified in each resident's medical record. 4. At any time the RN supervising nurse determines the change in condition jeopardizes the resident's wellbeing and the physician does not return the call promptly the RN supervisor will call 911, but will continue to attempt to notify the physician of change of condition .Pressure Ulcer-Immediate notification required for Stage I, II, III, or IV receiving no prior treatment protocol available to cover condition. Any signs of infection of ulcer-Non-immediate Any need for change in treatment unless ulcer is showing signs of infection. The National Pressure Ulcer Advisory Panel website accessed [DATE] indicated the following: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. 2. Physician orders dated [DATE] indicated Resident #55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated a FSBS should be performed two times a week on Tuesday and Thursday. The order did not include glucose parameters for physician notification. A care plan initiated [DATE] indicated Resident #55 had potential for fluctuations in her blood glucose level related to diabetes. Interventions included FSBS as ordered and as needed per nursing judgement and to notify the physician as needed. The care plan indicated to follow facility policy and procedures for care of residents with hypo/[MEDICAL CONDITION]. Standing orders from Unit C signed [DATE] by the primary care physician for Resident #55 indicated: .If glucometer blood sugar is < 60 give ,[DATE] cc of sweetened orange juice or other sweetened drink (if patient is conscious). Re-check blood sugar in 30 minutes and notify Physician by phone if FSBS still less than 60 administer [MEDICATION NAME] 1mg/ml. If [DIAGNOSES REDACTED] persists send to ER and notify MD. If FSBS <60 more than 3 times, fax to Physician for medication adjustment . A Diabetic Record for (MONTH) 2019 indicated Resident #55's FSBS reading for [DATE] at 6:30 a.m. had a 'Lo' reading. The Assure Platinum Blood Glucose Monitoring System user instruction manual provided by the administrator indicated: .: If your blood glucose is below 20 mg/dL, you will receive a Lo. Repeat the test with a new test strip. If this message shows again, contact your healthcare professional immediately! A nursing note dated [DATE] at 6:30 a.m., completed by LVN C indicated Resident #55's FSBS result was 'Lo'. The resident was moaning and pushing the medication LVN C attempted to administer out of her mouth with her tongue. LVN C gave Resident #55 apple juice with sugar and the resident held the juice in her mouth for a few seconds before she swallowed it. The note indicated LVN C notified the oncoming shift of the 'Lo' glucose reading; however, it did not indicate she notified the physician. During an interview on [DATE] at 7:10 a.m., LVN C said Resident #55 had a 'Lo' FSBS reading on [DATE] when she checked it around 6:30 a.m. to 6:40 a.m. LVN C said Resident #55 was grunting and moaning. She said she rechecked the FSBS with a new test strip after she got the initial result of 'Lo' and the second test result was also 'Lo'. LVN C said she put a few drops of apple juice mixed with sugar in Resident #55's mouth and got some cupcake icing and rubbed on Resident #55's gums. She said Resident #55's FSBS continued to have a 'Lo' reading. She said a result of 'Lo' indicated the blood sugar was below 60 and the typical treatment was to give juice with sugar. She said she then left the room and gave report to LVN B, whose shift began at 7:00 a.m. LVN C said she did not notify the attending physician and did not know the 'Lo' reading indicated a blood sugar level of less than 20. LVN C said a blood sugar of less than 40 should be treated with [MEDICATION NAME] injection, the physician should be notified, and if the blood sugar did not come up in 3 or 4 minutes the nurse should call for emergency transport. LVN C said she was not aware of any standing orders to give [MEDICATION NAME] 1mg intramuscular and did not recall any training on the Assure Platinum glucometer. A nursing note dated [DATE] at 7:15 a.m. completed by LVN B indicated Resident #55 had a FSBS result of 'Lo' and the resident continued to moan. LVN B attempted to give the resident icing and orange juice. The note indicated LVN B would recheck the FSBS. The note indicated LVN B did not notify the physician. At 7:45 a.m. LVN B rechecked the FSBS and the result remained 'Lo'. A new order was noted to give [MEDICATION NAME] 1mg now. At 8:00 a.m. the [MEDICATION NAME] injection was administered. The note indicated Resident #55's face was flushed, and she had sputum in her mouth. LVN B indicated she would recheck the resident's FSBS at 8:30 a.m. Resident #55's FSBS was checked and the result was 22. The NP was notified, and orders were received to send the resident to the hospital for an assessment and evaluation. At 8:45 a.m. Resident #55 left the facility in an ambulance. During an interview on [DATE] at 5:03 p.m., LVN B said on [DATE] at 7:00 a.m. she took report from LVN C who informed her Resident #55's FSBS reading was 'Lo' and she (LVN C) had given apple juice with sugar and repeated the FSBS with another 'Lo' result. LVN B said around 7:15 a.m. she checked Resident #55's blood sugar and obtained a 'Lo' result. LVN B said she administered cake icing and orange juice at that time. LVN B said Resident #55 had her eyes open and was moaning but did not talk to her. She said she returned about 30 minutes later to recheck Resident #55's blood sugar. She said when she rechecked the FSBS and got another 'Lo' result, she administered [MEDICATION NAME] 1mg. LVN B said after she administered the [MEDICATION NAME] and the resident's FSBS was 22 she notified the DON. LVN B said she was instructed to call the NP who gave orders to send Resident #55 to the emergency room . LVN B said she was not aware a 'Lo' reading indicated a blood sugar less than 20 and thought the protocol indicated if the resident could swallow to continue giving juice or some form of sugar by mouth. She said she was not in-serviced on the Assure Platinum glucose monitor concerning the 'Lo' readings. A SNF/NF Hospital Transfer Form dated [DATE] at 8:30 a.m. was initiated by LVN B for Resident #55. The form indicated the purpose of the hospital transfer was [DIAGNOSES REDACTED]. The emergency room (ER) nursing note dated [DATE] indicated Resident #55 arrived at the emergency room at 9:03 a.m. with [DIAGNOSES REDACTED]. The note indicated the resident's presenting complaint: EMS states blood sugar was 29 and unable to get an O2 saturation level and the resident was placed on continuous positive airway pressure ([MEDICAL CONDITION]) to support respirations. The note indicated the nurse was unable to complete a screening due to the resident being unresponsive. The ER physician documentation note dated [DATE] at 9:03 a.m. indicated Resident #55 arrived in the emergency department (ED). The resident presented to the ED with shortness of breath since this morning. The note indicated EMS states on arrival to the nursing facility the resident had a D-Stick (glucose reading) of 22 and was given [MEDICATION NAME] with slight improvement to 29. EMS was unable to obtain an oxygen saturation (O2 saturation). The resident was positive for [DIAGNOSES REDACTED]. At 9:10 a.m. the resident was administered D50W 50ml ([MEDICATION NAME] 50% in water) pushed through an intravenous port and again at 10:40 a.m. The resident was transferred to ICU at 1:22 p.m. The ICU physician notes dated [DATE] indicated at 4:08 p.m. the physician indicated Resident #55 was presented to the hospital with decreased level of activity and shortness of breath. The physician recommended the resident be sent to another hospital for a higher level of care. During an interview on [DATE] at 9:28 a.m., the NP said she was not notified of Resident #55's 'Lo' FSBS on [DATE]. She said she was informed Resident #55 had a decreased level of consciousness and she ordered to send the resident to the ER. She said she did not order [MEDICATION NAME] and the facility usually just wrote orders without consulting her and sent them for her signature. The NP said if she had been notified of the 'Lo' result on Resident #55's FSBS, she would have told them to give her something and send her out. She said she would not expect anyone with an FSBS result below 20 to be conscious enough to tolerate anything liquid by mouth. She said the facility should have notified someone of the Lo result. During an interview on [DATE] at 10:01 a.m., the medical director said a resident whose blood sugar was below 20 would require emergent action. She said the nurse should have given [MEDICATION NAME], notified the attending physician and notified EMS. She said there was a protocol in place to treat [DIAGNOSES REDACTED], she said a nurse must use critical thinking and know what to do when the glucose was critically low. She said she would not expect a resident with a blood sugar less than 20 to be fully conscious, and liquids by mouth would be contraindicated due to the risk of aspiration. She said 2 hours was too long to go before notifying a primary care physician of a critical low blood sugar. During an interview on [DATE] at 11:01 a.m., the DON said LVN B should have recognized that a 'Lo' reading on the glucometer indicated a glucose level of less than 20 which was a critical level. She said the nurse should have notified the physician for any value less than 60. The DON said for a critical level, the nurse should have administered [MEDICATION NAME] 1 mg intramuscular (IM), (TRUNCATED)

Based on interview and record review, the facility failed to ensure the necessary treatment and services, consistent with professional standards of practice and based on a comprehensive assessment to promote healing and prevent infection of pressure injuries was provided for 1 of 7 residents reviewed for pressure injuries. (Resident #55) The facility did not consult and/or notify the physician when Resident #55 developed 2 facility acquired stage 3 pressure injuries on her buttocks. The facility did not follow the physician wound care protocol for consulting the wound care center for the pressure injuries. The facility did not accurately assess the pressure injuries. The facility did not consult or notify the physician/NP when one of the pressure injuries on her sacral area worsened in size and appearance. The resident's sacral wound worsened with increased drainage and odor from an infection in the wound. She was not provided appropriate treatment to [MEDICAL CONDITION] of the wound. Resident #55 was transferred to the hospital and later died [MEDICAL CONDITION]. The DON provided treatment orders to the LVN for Resident #55's pressure injuries. An Immediate Jeopardy situation was identified [DATE] due to the above failures related to Resident #55. While the Immediate Jeopardy was lifted on [DATE] at 4:51 p.m., the facility remained out of compliance at 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 with pressure injuries at risk for development of new pressure injuries and worsening of existing pressure injuries, development of infections,[MEDICAL CONDITION], and/or death. Findings included: Physician orders dated [DATE] indicated Resident #55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #55 had moderately impaired cognition, unclear speech, was usually understood, and usually understood others. She was dependent on one staff for bed mobility, toileting, and hygiene. Resident #55 was incontinent of bowel and bladder and did not have a pressure injury. A Wound Care Protocol Orders signed [DATE] by Resident #55's attending physician indicated: .3. Stage III/IV or Full Thickness Pressure Ulcer .A. Culture wound if (1) S/s of infection, (2)[MEDICAL CONDITION], (3) bone/joint involvement .C. Wound Center to manage care or evaluate and recommend care. D. Wound Center to be consulted if any wound is not progressing positively. Physician orders dated [DATE] for Resident #55 indicated to cleanse lower buttocks with wound cleanser, pat dry, apply hydrogel gauze to wound bed, cover with bordered foam dressing, and change daily. A Skin-Acute Care Plan dated [DATE] indicated Resident #55 had a pressure injury of the sacrum, related to decreased mobility, incontinence and right [MEDICAL CONDITION] (partial weakness on one side of the body). An addendum added [DATE] indicated in the next 30 days the wound would remain infection free and decrease in size. The nursing notes for Resident #55 did not address a pressure injury identified on [DATE]. A Wound/Pressure Report dated [DATE] completed by the DON indicated Resident #55 developed a pressure injury on [DATE] on her lower sacrum (midline buttocks #2). The pressure injury was described as follows: -Stage 3 measuring 1.8 cm x 0.6cm x 0.1 cm with a red/pink wound bed and small amount of serosanguinous drainage. The open area to the lower sacrum was noted with no signs of infection and treatment was initiated with hydrogel. The Pressure Ulcer/Wound Weekly Log completed by the DON dated [DATE] indicated Resident #55 had the following pressure injuries: *#1 -upper sacrum-facility acquired stage 2- identified [DATE], measured 1.2 cm x 0.8 cm x 0.1 cm. No drainage or odor. No other description of the wound was noted. *#2 -lower sacrum-facility acquired- stage 2- identified on [DATE], measured 1.8 cm x 0.6 cm x 0.1 cm. No drainage or odor. No other description of the wound was noted. A monthly nursing summary note dated [DATE] indicated Resident #55 had two stage 3 pressure injuries and was receiving pressure injury care. The notes did not address if the physician/NP were notified of the newly identified pressure injuries. There were no other notes for the month of (MONTH) in the medical record. A treatment record dated [DATE]-[DATE] indicated Resident #55 had 2 pressure injuries: #1 upper buttocks-daily treatment from [DATE]- [DATE] - cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The treatment sheet indicated the treatment was discontinued on [DATE]. #2 - lower buttocks-daily treatment from [DATE] through [DATE]- cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The Pressure Ulcer/Wound Weekly Log completed by the DON dated [DATE] indicated Resident #55 had the following pressure injuries: #1 -upper sacrum-facility acquired stage 3- identified [DATE], measured 1.0 cm x 0.4 cm x .01 cm. No drainage or odor. No other description of the wound was noted. #2 -upper sacrum-facility acquired- stage 3- identified on [DATE], measured 1.4 cm x 0.7 cm x 0.1 cm. No other description of the wound was noted. Physician orders dated [DATE] for Resident #55 indicated to discontinue hydrogel to Resident #55's upper buttocks, area resolved. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] stage 3- measured 1.4 cm x 0.6 cm x 0.1 cm. No drainage noted. Wound bed pink with surrounding tissue/wound edges pink in color. *[DATE] stage 3-measured 1.8 cm x 1.0 cm x 0.2 cm. No odor. Wound bed pink/red with surrounding tissue/wound edges pink in color. There were no nursing notes dated [DATE] for Resident #55 indicating the physician/NP were notified of the pressure injury #2 increasing in size. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, was usually understood, and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting and personal hygiene. Resident #55 had one unhealed stage 3 pressure injury that was present on readmission/reentry. She had a pressure reducing device for her bed and was receiving pressure injury care including the application of non-surgical dressings. A care plan initiated on [DATE] indicated Resident #55 was at risk for alterations in skin integrity and she had a history of [REDACTED]. The care plan indicated efforts would be in place to minimize her risk for developing a pressure injury. Interventions included assess skin weekly and as needed, offload pressure points and reposition every 2 hours, and notify the physician of any skin problems. During an interview on [DATE] at 7:00 p.m., the administrator said Resident #55 had not been out of the building to the hospital or other since her admission. She said there was an old scar over the resident's sacral area and the resident had a history of [REDACTED]. The most recent NP progress note for Resident #55 was dated [DATE]. There were no physician progress notes [REDACTED]. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: *#2, lower buttocks-treatment from [DATE] through [DATE]- continue to cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. During an interview on [DATE] at 6:33 a.m., CNA H said she provided care for Resident #55 when she came back to work after Resident #55's birthday on [DATE]. She said she noted a foul odor coming from the wound on her sacral area. She said the wound was covered with a dressing. She said when she provided incontinent care she wiped a greenish colored substance from around the wound dressing edges that was seeping out from under the dressing. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 1.9 cm x 1.1 cm, (not able to measure depth); minimal serosanguinous drainage, no odor, 25% of the wound bed was covered with brown tissue. A nursing note dated [DATE] at 1:40 pm., completed by the DON indicated Resident #55 had greater than 25% of the wound bed located at 3 to 5 o'clock covered with light brown to tan tissue. The DON indicated the wound treatment was changed to apply Santyl to the wound bed and [MEDICATION NAME] applied to the peri wound. The nursing notes for [DATE] did not indicate Resident #55's physician/NP was notified of the pressure injury worsening in size and appearance. An unsigned physician order dated [DATE] indicated to discontinue hydrogel to Resident #55's buttocks, and to start the following: cleanse buttocks with wound cleanser, apply Santyl to wound bed, cover with bordered foam dressing, and change dressing daily and as needed for dislodgement. During an interview on [DATE] at 9:28 a.m., the NP said she was first notified on [DATE] of Resident #55's pressure injury. She said before that date, she had not received a phone call or facsimile transmission describing the pressure injury, location, or stage. She said that would be the normal procedure. She said physician orders for wound care treatments were sent to her, but she did not really read them, unless it was an order for [REDACTED]. The Weekly Pressure Ulcer record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 2.1 cm x 1.3 cm (unable to measure depth)-area larger in size-no odor was present with a scant amount of serosanguinous drainage noted. A nursing note dated [DATE] at 11:15 a.m., completed by the DON indicated Resident #55's pressure injury had increased in size, and there was dry skin around the wound that had peeled and dropped off. The note indicated there were no signs and symptoms of infection. The treatment to the area changed to Santyl with calcium alginate and [MEDICATION NAME] to the peri-wound. The nursing note did not indicate Resident #55's physician or NP was notified of the pressure injury worsening. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: *#2, lower buttocks-treatment from [DATE] through [DATE]-cleanse with wound cleanser, pat dry, apply Santyl to wound bed and cover with foam dressing, change every day and as need for dislodgement. A nursing note dated [DATE] at 8:05 a.m. completed by the DON indicated she was called to the nursing station by LVN B to look at Resident #55's sacral pressure injury which had developed an odor with increased brown tissue in the wound bed. The note indicated the DON asked LVN B to contact the NP to obtain antibiotic orders and request changing the dressing from daily to two times a day. The note indicated at 11:45 a.m. the DON informed the NP and the NP refused to order an antibiotic and agreed to the dressing change two times a day. In addition, a new order for a wound culture and sensitivity of the sacral pressure injury was noted. An unsigned physician order dated [DATE] for Resident #55 indicated to obtain a wound culture and to discontinue the Santyl treatment. New order to cleanse area to sacrum with wound cleanser, pat dry, apply Santyl and calcium alginate to the wound bed, apply [MEDICATION NAME] to peri-wound, and cover with bordered foam dressing two times a day, and as need for dislodgement. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: *#2 - Sacrum-treatment from [DATE] through [DATE]-cleanse area to sacrum with wound cleanser, pat dry, apply Santyl to wound bed and cover with calcium alginate. Apply [MEDICATION NAME] to peri-wound and cover with large bordered foam dressing two times a day and as needed for dislodgement. A nursing note dated [DATE] at 9:20 a.m., completed by the DON indicated she was notified the NP was making rounds and the NP refused to order a requested laboratory value for a complete blood count (CBC) and refused to change the treatment to the pressure injury of the sacrum until the wound culture and sensitivity laboratory results came back. The note did not indicate if the physician was notified. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] unstageable-measured 3.5 cm x 3.0 cm (unable to measure depth)- area larger in size-an odor was present with small amount of serosanguinous wound drainage. The wound bed contained light brown to brown tissue that was detached from the wound edges, the surrounding skin color was light red, wound edges were defined. The note indicated a culture and sensitivity was performed on [DATE]. During an interview on [DATE] at 3:32 p.m., the administrator said the Weekly Pressure Ulcer Record for Resident #55 completed by the DON dated [DATE] was not accurate. She said the wound culture and sensitivity was not done on [DATE] as documented, she said it was done on [DATE]. She said she did not know if the DON assessed the resident's sacral pressure injury on [DATE] because Resident #55 was sent to the hospital that morning. A nursing note dated [DATE] at 10:18 a.m. indicated the DON spoke with Resident #55 family representative and informed her of Resident #55's change of condition, FSBS of 22 and was transferred to the emergency room for a low glucose reading. The note did not indicate the physician was notified. An emergency room Nursing Documentation dated [DATE] indicated upon arrival at 9:03 a.m., Resident #55 was unresponsive with a FSBS of 29. The note indicated the resident had a decubitus (pressure injury) located on her coccyx area (sacral area) and covered with dressing. The resident had [MEDICAL CONDITION] screening that was positive with an unknown origin of infection. At 12:13 p.m. Resident #55 was admitted to the ICU in critical condition. An ICU nursing note dated [DATE] at 8.:36 p.m. indicated Resident #55 initial white blood cell count was 55.0, reference range (3XXX,[DATE].1) TH/mm3. The resident's chest x-ray was negative for pneumonia and her urinalysis negative for possible infection. The note indicated the resident had a large sacral pressure injury measuring 8.0 cm x 6.4 cm x 1.2 cm with a large amount of necrotic tissue. Resident #55 remained non-verbal, was not following commands, and was not tracking with her eyes. A hospital physician's short stay summary note dated [DATE] indicated Resident #55 had a large open decubitus on her sacral area with foul smelling purulent drainage. The physician determined Resident #55 needed to be transferred to a higher level of care after an examination of the sacral pressure injury showed it was infected and required urgent debridement. A physician discharge summary dated [DATE] indicated Resident #55's admission [DIAGNOSES REDACTED]. Possibly infected necrotic decubitus ulcer to the sacrum. 2.[MEDICAL CONDITION] 3. Urinary tract infection. 4 [DIAGNOSES REDACTED] .Discharge Diagnoses: [REDACTED]. 2. Escherichia coli urinary tract infection 3.[MEDICAL CONDITION] . The hospital course indicated Resident #55 initially had shortness of breath, altered mental status, and infected decubitus ulcer, was transferred from another hospital for evaluation of the infected decubitus ulcer and possible surgical debridement. Upon arrival Resident #55 had abnormal heart rate of 121, respirations of 30 and abnormal white blood count of 55.2. Surgical debridement was deferred due to functional status [MEDICAL CONDITION]. Resident #55 had positive wound culture that grew Proteus (Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans) and [MEDICATION NAME] (a gram-positive bacterium that can cause a variety of nosocomial infections) , her kidney function worsened, and she eventually died on [DATE]. The discharge [DIAGNOSES REDACTED]. Escherichia coli (bacteria found in the environment, foods, and intestines of people and animals) urinary tract infection. [MEDICAL CONDITION] . A laboratory report dated [DATE] for Resident #55 indicated a wound culture of a wound/abscess identified as a sacral wound was collected on [DATE] at 10:30 a.m. The laboratory result indicated moderate growth of proteus mirabilis (a Gram-negative, facultatively anaerobic, rod-shaped bacterium causes 90% of all Proteus infections in humans) and moderate growth of Escherichia coli-the two organisms were sensitive to all antibiotics listed except [MEDICATION NAME]. During an interview on [DATE] at 9:24 a.m., LVN B said on [DATE] she notified the NP of Resident #55's sacral pressure injury draining and having an odor via telephone. LVN B said the NP ordered a wound culture and sensitivity and declined ordering an antibiotic until the wound culture results came back. She said she (LVN B) and the DON provided wound care for Resident #55 on [DATE] and the wound bed was covered with soft stringy brown eschar in the center and the wound was draining. She said the wound dressing changes were increased to two times a day. LVN B said on [DATE] and [DATE] the pressure injury continued to have an odor. She said the NP was making rounds on [DATE] and the DON discussed using a new treatment of [REDACTED]. She said she usually just sent the orders to the NP by facsimile for wound care orders that the DON would tell her to write. She said she did not notify Resident #55's primary care physician or the NP of the sacral pressure injury measurements or how the pressure injury declined, she would just send in the treatment orders. LVN B said [DATE] was the first time she called the NP about Resident #55's pressure injury. During an interview on [DATE] at 9:28 a.m., the NP said she was first notified on [DATE] of Resident #55's pressure injury. She said before that date, she had not received a phone call or facsimile transmission describing the pressure injury, location, or stage. She said that would be the normal procedure. She said physician orders for wound care treatments were sent to her, but she did not really read them, unless it was an order for [REDACTED]. She said on [DATE] she was told Resident #55's sacral pressure injury looked wet and was asked if a culture could be performed and she approved. She said there was no mention about the increasing size of the pressure injury, that the wound had an odor, if the resident had a temperature, or other signs and symptoms that would indicate further action. The NP said while she was in the facility on [DATE], LVN B came to her and showed her a picture of the resident's pressure injury. She said she went to examine Resident #55 but did not turn her over and visually inspect the sacral pressure injury nor did she notice any odors. She said at that time she believed she had the preliminary report back from the culture but no sensitivity. She said LVN B did not report any change in vital signs i.e., temperature, low blood pressure, or increased heart rate and did not indicate the wound had worsened. She said she did not order an antibiotic. She said she suggested a wound care physician look at the resident's pressure injury and the DON indicated they treat their own pressure injuries in-house. The NP said she did not document her visit in Resident #55's medical record on [DATE] because it was not a scheduled visit. She said when she reviewed the record she could not find any progress notes indicating Resident #55 was seen since (MONTH) 2019. During an interview on [DATE] at 10:03 a.m., the medical director said there were wound protocols in place for the attending physician. She said she preferred residents see a wound care specialist if a pressure injury was a stage 3 or stage 4. She said she was not contacted or consulted for wound care orders or a review of Resident #55's sacral pressure injury. She said she reviewed Resident #55's pressure injury sheets with the NP after Resident #55 was sent to the hospital and believed obtaining a CBC would have given them more information to work with on what other interventions could have been implemented. The medical director said elderly residents do not respond to infection the same ways a healthy adult would. She said the elderly residents did not always mount a temperature in response to an infection and it could be sub-normal with FSBS dropping into a low range due to the infection. The medical director said when a resident's pressure injury developed slough (a type of necrotic tissue, it is often white, yellow or grey in color) and drainage, treatment should have included debridement. She said if chemical debridement (example - Santyl) was not effective, then surgical debridement would be needed. She said Resident #55's sacral pressure injury could have benefited in healing from a dressing impregnated with silver applied to pressure injury because of its [MEDICATION NAME] properties which helps treat/prevent infection. She said if an antibiotic had been initiated when Resident #55's pressure injury began to decline as in when it developed slough, drainage, and odor they might have been able to slow the infectious process and [MEDICAL CONDITION]. She said the facility staff were supposed to notify the physician of a resident's change in condition, either by facsimile or telephone. She said if the staff could not contact the attending physician, they should call her or the NP who worked under them. A Pressure Ulcer Treatment Policy dated ,[DATE] indicated: .Residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection and reduce the likelihood of new pressure ulcers developing .1. Contact physician for treatment orders .6. Use effective wound cleansing and debridement methods to minimize pressure ulcer colonization and enhance wound healing .19. Use [MEDICATION NAME], mechanical, enzymatic and/or autolytic debridement techniques to remove devitalized tissue .23. Refer to wound center as Needed . Practice Guidelines for Physician Notification of Change of Condition dated ,[DATE] indicated: .Nursing staff have been in serviced on the Physician notification of change of condition practice guideline. Immediate Notification-the physician should be informed at the time the event occurs either directly or by cell. Non-Immediate Notification-the physician should be informed of the problem or event during office hours and generally no later than the next regular office day. If a non-immediate event occurs on a weekend or holiday, good nursing judgment shall determine if the notification could wait until the next office day or should be made during the weekend or holiday.Resident-The resident receives prompt medical intervention .1. Nursing personnel identify those residents with a change of condition which requires an immediate notification of the physician and those which require a non-immediate notification .Management-1. The subject of notifying physician of resident change of condition is part of every new nurse orientation .3. A designated 'on call' or alternate physician is identified in each resident's medical record. 4. At any time the RN supervising nurse determines the change in condition jeopardizes the resident's wellbeing and the physician does not return the call promptly the RN supervisor will call 911, but will continue to attempt to notify the physician of change of condition .Pressure Ulcer-Immediate notification required for Stage I, II, III, or IV receiving no prior treatment protocol available to cover condition. Any signs of infection of ulcer-Non-immediate Any need for change in treatment unless ulcer is showing signs of infection. The National Pressure Ulcer Advisory Panel website accessed [DATE] indicated the following: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The Texas Board of Nursing-Registered Nurse Scope of Practice website accessed [DATE] indicated: The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RNs). Professional nursing means the performance of an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical [DIAGNOSES REDACTED]. Professional nursing involves: A. the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes; B. the maintenance of health or prevention of illness; C. the administration of a medication or treatment as ordered by a physician, podiatrist, or dentist; D. the supervision or teaching of nursing; E. the administration, supervision, and evaluation of nursing practices, policies, and procedures; F. the requesting, receiving, signing for, and distribution of prescription drug samples to patients at practices at which an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157; G. the performance of an act delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059; and H. the development of the nursing care plan. The RN takes responsibility and accepts accountability for [MEDICATION NAME] within the legal scope of practice and is prepared to work in all health care settings, and may engage in independent nursing practice without supervision by another health care provider. The RN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws; rules and regulations; and policies, procedures and guidelines of the employing health care institution or practice setting. The RN is responsible for providing safe, [MEDICATION NAME], and comprehensive nursing care to patients and their families with complex healthcare needs. The administrator, corporate nurse, and the DON were informed on [DATE] at 5:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The template was given to the IJ template was given to the facility on [DATE] at 5:54 p.m. The facility's Plan of Removal was accepted on [DATE] at 2:41 p.m. and included: *100 percent audit of all resident's skin assessments have been completed to ensure all wounds or abnormal skin findings have been reported to physician and family as of [DATE]. AMT RN Wound care nurse will ensure all wounds are staged correctly. Physician and families will be notified of current wound report on [DATE]. All wounds Stage 3, stage 4 or unstageable will be referred to the wound clinic. To be completed by the DON and the AMT RN on [DATE]. *All licensed and registered nurse will be in serviced on [DATE] on the physician notification on changes in condition including wounds. AMT RN will conduct an in-service directly on accurate staging and identifying infected wounds, to be completed on [DATE]. *All Licensed and Registered nurses will be tested on identifying wound infections [MEDICAL CONDITION] on [DATE] or before working next scheduled shift. To be completed by the DON and the administrator. On [DATE] at 4:51 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to lift the Immediate Jeopardy by: *9 nurses were interviewed from different shifts on the recognition of signs and symptoms of infected pressure injury, staging pressure injury, monitoring and follow up for response to treatment interventions and immediate notification of physician when pressure injury changes are identified. The nurses were able to verbalize the correct answers. On [DATE] at 4:51 p.m., the administrator and corporate nurse were informed the Immediate Jeopardy was lifted: however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

Based on observation, interview and record review the facility failed to ensure that a physician supervised the medical care of residents for 1 of 26 residents reviewed for physician orders. (Resident #55) The facility did not ensure a physician supervised Resident #55's medical care. Resident #55 was seen by the attending physician at least every 60 days. Resident #55 had not been seen by her attending physician or designee since [DATE]. Resident #55's developed a stage 3 pressure injury on [DATE] that worsened to an infected unstageable pressure injury. The physician did not evaluate the pressure injury for 42 days from onset nor when the pressure injury worsened and developed a foul odor, slough, and drainage. Resident #55 was transferred to the hospital where she was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was lifted on [DATE] at 4:51 p.m., the facility remained out of compliance at a pattern of 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 at risk of not receiving appropriate and adequate medical care and interventions to prevent harm or death. Findings included: Physician orders dated [DATE] indicated Resident #55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent physician visit progress note for Resident #55 was dated [DATE]. Physician orders dated [DATE] for Resident #55 indicated cleanse lower buttocks with wound cleanser, pat dry, apply hydrogel gauze to wound bed, cover with bordered foam dressing, and change daily. The Pressure Ulcer/Wound Weekly Log completed by the DON dated [DATE] indicated Resident #55 had the following pressure injuries: *Pressure injury #1 -upper sacrum-facility acquired stage 3- identified [DATE], measured 1.2 cm x 0.8 cm x 0.1 cm. *Pressure injury #2 -lower sacrum-facility acquired stage 3- identified on [DATE], measured 1.8 cm x 0.6 cm x 0.1 cm. A monthly nursing summary note dated [DATE] indicated Resident #55 had two stage 3 pressure injuries and was receiving pressure injury care. The notes did not address if the physician/NP were notified of the newly identified pressure injuries. A treatment record dated [DATE]-[DATE] indicated Resident #55 had 2 pressure injuries: #1 upper buttocks-daily treatment from [DATE]- [DATE] - cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The treatment sheet indicated the treatment was discontinued on [DATE]. #2 - lower buttocks-daily treatment from [DATE] through [DATE]- cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. Physician orders dated [DATE] for Resident #55 indicated to discontinue hydrogel to Resident #55's upper buttocks, area resolved. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] stage 3- measured 1.4 cm x 0.6 cm x 0.1 cm. No drainage noted. Wound bed pink with surrounding tissue/wound edges pink in color. *[DATE] stage 3-measured 1.8 cm x 1.0 cm x 0.2 cm. No odor. Wound bed pink/red with surrounding tissue/wound edges pink in color. There were no nursing notes dated [DATE] for Resident #55 indicating the physician/NP were notified of the pressure injury #2 increasing in size. Physician orders dated [DATE] for Resident #55 indicated to discontinue hydrogel to Resident #55's upper buttocks, area resolved. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, was usually understood and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting and personal hygiene. Resident #55 had one unhealed stage 3 pressure injury, a pressure reducing device for her bed and was receiving pressure injury care including the application of non-surgical dressings. A care plan initiated on [DATE] indicated Resident #55 was at risk for alterations in skin integrity and she had a history of [REDACTED]. Interventions included to assess skin weekly and as needed, offload pressure points and reposition every 2 hours, and notify the physician of any skin problems. The clinical record from [DATE] through [DATE] for Resident #55 indicated the last visit made was by a NP on [DATE]. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] stage 3- measured 1.4 cm x 0.6 cm x 0.1 cm. No drainage noted. Wound bed pink with surrounding tissue/wound edges pink in color. *[DATE] stage 3-measured 1.8 cm x 1.0 cm x 0.2 cm. No odor. Wound bed pink/red with surrounding tissue/wound edges pink in color. There were no nursing notes dated [DATE] for Resident #55 indicating the physician/NP were notified of the pressure injury #2 increasing in size. A nursing note dated [DATE] at 1:40 pm., completed by the DON indicated Resident #55 had greater than 25% of the wound bed located at 3 to 5 o'clock covered with light brown to tan tissue. The DON indicated the wound treatment was changed to apply Santyl to the wound bed and [MEDICATION NAME] applied to the peri wound. The nursing notes for [DATE] did not indicate Resident #55's physician/NP was notified of the pressure injury worsening in size and appearance. An unsigned physician order dated [DATE] indicated to discontinue hydrogel to Resident #55's buttocks, and to start the following: cleanse buttocks with wound cleanser, apply Santyl to wound bed, cover with bordered foam dressing, and change dressing daily and as needed for dislodgement. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2, lower buttocks-treatment from [DATE] through [DATE]- continue to cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 1.9 cm x 1.1 cm, (not able to measure depth); minimal serosanguinous drainage, no odor, 25% of the wound bed was covered with brown tissue. The Weekly Pressure Ulcer record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 2.1 cm x 1.3 cm (unable to measure depth)-area larger in size-no odor was present with a scant amount of serosanguinous drainage noted. A nursing note dated [DATE] at 11:15 a.m., completed by the DON indicated Resident #55's pressure injury had increased in size, and there was dry skin around the wound that had peeled and dropped off. The note indicated there were no signs and symptoms of infection. The treatment to the area changed to Santyl with calcium alginate and [MEDICATION NAME] to the peri-wound. The nursing note did not indicate Resident #55's physician or NP was notified of the pressure injury worsening. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2, lower buttocks-treatment from [DATE] through [DATE]-cleanse with wound cleanser, pat dry, apply Santyl to wound bed and cover with foam dressing, change every day and as need for dislodgement. A nursing note dated [DATE] at 8:05 a.m. completed by the DON indicated she was called to the nursing station by LVN B to look at Resident #55's sacral pressure injury which had developed an odor with increased brown tissue in the wound bed. The note indicated the DON asked LVN B to contact the NP to obtain antibiotic orders and request changing the dressing from daily to two times a day. The note indicated at 11:45 a.m. the DON informed the NP and the NP refused to order an antibiotic and agreed to the dressing change two times a day. In addition, a new order for a wound culture and sensitivity of the sacral pressure injury was noted. An unsigned physician order dated [DATE] for Resident #55 indicated to obtain a wound culture and to discontinue the Santyl treatment. New order to cleanse area to sacrum with wound cleanser, pat dry, apply Santyl and calcium alginate to the wound bed, apply [MEDICATION NAME] to peri-wound, and cover with bordered foam dressing two times a day, and as need for dislodgement. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2 - Sacrum-treatment from [DATE] through [DATE]-cleanse area to sacrum with wound cleanser, pat dry, apply Santyl to wound bed and cover with calcium alginate. Apply [MEDICATION NAME] to peri-wound and cover with large bordered foam dressing two times a day and as needed for dislodgement. A nursing note dated [DATE] at 9:20 a.m., completed by the DON indicated she was notified the NP was making rounds and the NP refused to order a requested laboratory value for a complete blood count (CBC) and refused to change the treatment to the pressure injury of the sacrum until the wound culture and sensitivity laboratory results came back. The note did not indicate if the physician was notified. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] unstageable-measured 3.5 cm x 3.0 cm (unable to measure depth)- area larger in size-an odor was present with small amount of serosanguinous wound drainage. The wound bed contained light brown to brown tissue that was detached from the wound edges, the surrounding skin color was light red, wound edges were defined. The note indicated a culture and sensitivity was performed on [DATE]. During an interview on [DATE] at 3:32 p.m., the administrator said the Weekly Pressure Ulcer Record for Resident #55 completed by the DON dated [DATE] was not accurate. She said the wound culture and sensitivity was not done on [DATE] as documented, she said it was done on [DATE]. She said she did not know if the DON assessed the resident's sacral pressure injury on [DATE] because Resident #55 was sent to the hospital that morning. A nursing note dated [DATE] at 10:18 a.m. indicated the DON spoke with Resident #55 family representative and informed her of Resident #55's change of condition, FSBS of 22 and was transferred to the emergency room for a low glucose reading. The note did not indicate the physician was notified. An emergency room Nursing Documentation dated [DATE] indicated upon arrival at 9:03 a.m., Resident #55 was unresponsive with a FSBS of 29. The note indicated the resident had a decubitus (pressure injury) located on her coccyx area (sacral area) was covered with a dressing. The resident had [MEDICAL CONDITION] screening that was positive with an unknown origin of infection. At 12:13 p.m. Resident #55 was admitted to the ICU in critical condition. An ICU nursing note dated [DATE] at 8.:36 p.m. indicated Resident #55 initial white blood cell count was 55.0, reference range (3XXX,[DATE].1) TH/mm3. The resident's chest x-ray was negative for pneumonia and her urinalysis negative for possible infection. The note indicated the resident had a large sacral pressure injury measuring 8.0 cm x 6.4 cm x 1.2 cm with a large amount of necrotic tissue. Resident #55 remained non-verbal, was not following commands, and was not tracking with her eyes. A hospital physician's short stay summary note dated [DATE] indicated Resident #55 had a large open decubitus on her sacral area with foul smelling purulent drainage. The physician determined Resident #55 needed to be transferred to a higher level of care after an examination of the sacral pressure injury showed it was infected and required urgent debridement. A physician discharge summary dated [DATE] indicated Resident #55's admission [DIAGNOSES REDACTED]. Possibly infected necrotic decubitus ulcer to the sacrum. 2.[MEDICAL CONDITION] 3. Urinary tract infection. 4 [DIAGNOSES REDACTED] .Discharge Diagnoses: [REDACTED]. 2. Escherichia coli urinary tract infection 3.[MEDICAL CONDITION] . The hospital course indicated Resident #55 initially had shortness of breath, altered mental status, and infected decubitus ulcer, was transferred from another hospital for evaluation of the infected decubitus ulcer and possible surgical debridement. Upon arrival Resident #55 had abnormal heart rate of 121, respirations of 30 and abnormal white blood count of 55.2. Surgical debridement was deferred due to functional status [MEDICAL CONDITION]. Resident #55 had positive wound culture that grew Proteus and [MEDICATION NAME], her kidney function worsened, and she eventually died on [DATE]. The discharge [DIAGNOSES REDACTED]. Escherichia coli urinary tract infection. [MEDICAL CONDITION] . A laboratory report dated [DATE] for Resident #55 indicated a wound culture of a wound/abscess identified as a sacral wound was collected on [DATE] at 10:30 a.m. The laboratory result indicated moderate growth of proteus mirabilis and moderate growth of Escherichia coli-the two organisms were sensitive to all antibiotics listed except [MEDICATION NAME]. A Wound Care Protocol Orders signed [DATE] by Resident #55's attending physician indicated: .3. Stage III/IV or Full Thickness Pressure Ulcer .A. Culture wound if (1) S/s of infection, (2)[MEDICAL CONDITION], (3) bone/joint involvement .C. Wound Center to manage care or evaluate and recommend care. D. Wound Center to be consulted if any wound is not progressing positively. During an interview on [DATE] at 9:24 a.m., LVN B said on [DATE] she notified the NP of Resident #55's sacral pressure injury draining and having an odor via telephone. LVN B said the NP ordered a wound culture and sensitivity and declined ordering an antibiotic until the wound culture results came back. She said she (LVN B) and the DON provided wound care for Resident #55 on [DATE] and the wound bed was covered with soft stringy brown eschar in the center and the wound was draining. She said the wound dressing changes were increased to two times a day. LVN B said on [DATE] and [DATE] the pressure injury continued to have an odor. She said the NP was making rounds on [DATE] and the DON discussed using a new treatment of [REDACTED]. She said she usually just sent the orders to the NP by facsimile for wound care orders that the DON would tell her to write. She said she did not notify Resident #55's primary care physician or the NP of the sacral pressure injury measurements or how the pressure injury declined, she would just send in the treatment orders. LVN B said [DATE] was the first time she called the NP about Resident #55's pressure injury. During an interview on [DATE] at 9:28 a.m., the NP said she was first notified on [DATE] of Resident #55's pressure injury. She said before that date, she had not received a phone call or facsimile transmission describing the pressure injury, location, or stage. She said that would be the normal procedure. She said physician orders for wound care treatments were sent to her, but she did not really read them, unless it was an order for [REDACTED]. She said on [DATE] she was told Resident #55's sacral pressure injury looked wet and was asked if a culture could be performed and she approved. She said there was no mention about the increasing size of the pressure injury, that the wound had an odor, if the resident had a temperature, or other signs and symptoms that would indicate further action. The NP said while she was in the facility on [DATE], LVN B came to her and showed her a picture of the resident's pressure injury. She said she went to examine Resident #55 but did not turn her over and visually inspect the sacral pressure injury nor did she notice any odors. She said at that time she believed she had the preliminary report back from the culture but no sensitivity. She said LVN B did not report any change in vital signs i.e., temperature, low blood pressure, or increased heart rate and did not indicate the wound had worsened. She said she did not order an antibiotic. She said she suggested a wound care physician look at the resident's pressure injury and the DON indicated they treat their own pressure injuries in-house. The NP said she did not document her visit in Resident #55's medical record on [DATE] because it was not a scheduled visit. She said when she reviewed the record she could not find any progress notes indicating Resident #55 was seen since (MONTH) 2019 by a physician. During an interview on [DATE] at 10:03 a.m., the medical director said there were wound protocols in place for the attending physician. She said she preferred residents see a wound care specialist if a pressure injury was a stage 3 or stage 4. She said she was not contacted or consulted for wound care orders or a review of Resident #55's sacral pressure injury. She said she reviewed Resident #55's pressure injury sheets with the NP after Resident #55 was sent to the hospital and believed obtaining a CBC would have given them more information to work with on what other interventions could have been implemented. The medical director said elderly residents do not respond to infection the same ways a healthy adult would. She said the elderly residents did not always mount a temperature in response to an infection and it could be sub-normal with FSBS dropping into a low range due to the infection. The medical director said when a resident's pressure injury developed slough (a type of necrotic tissue, it is often white, yellow or grey in color) and drainage, treatment should have included debridement. She said if chemical debridement (example - Santyl) was not effective, then surgical debridement would be needed. She said Resident #55's sacral pressure injury could have benefited in healing from a dressing impregnated with silver applied to pressure injury because of its [MEDICATION NAME] properties which helps treat/prevent infection. She said if an antibiotic had been initiated when Resident #55's pressure injury began to decline as in when it developed slough, drainage, and odor they might have been able to slow the infectious process and [MEDICAL CONDITION]. She said the facility staff were supposed to notify the physician of a resident's change in condition, either by facsimile or telephone. She said if the staff could not contact the attending physician, they should call her or the NP who worked under them. A Pressure Ulcer Treatment Policy dated ,[DATE] indicated: .Residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection and reduce the likelihood of new pressure ulcers developing .1. Contact physician for treatment orders .6. Use effective wound cleansing and debridement methods to minimize pressure ulcer colonization and enhance wound healing .19. Use [MEDICATION NAME], mechanical, enzymatic and/or autolytic debridement techniques to remove devitalized tissue .23. Refer to wound center as Needed . During an interview on [DATE] at 9:28 p.m., the NP said staff were writing orders that they thought were appropriate without proper notification of the primary care physician or herself. The NP said she had not seen Resident #55 since [DATE]. She said on [DATE] when she assessed the resident she did not document the visit because it was not a scheduled visit. During an interview on [DATE] at 2:08 p.m., Resident #55's physician said he had not been notified of Resident #55's pressure injury on her sacrum. He indicated he could not provide any further information and it sounded like a quality of care issue. During an interview on [DATE] at 8:31 a.m., the medical director said Resident #55's primary care physician could not give an answer for why he had not assessed her over the past 6 months. During an interview on [DATE] at 8:28 a.m., the DON said the physician should see their residents every 60 days. She said letters were sent out to the physicians as reminders. She said a NP was hired earlier that year to see all of Resident #55's primary care physician residents and she did not know why Resident #55 was not seen. During an interview on [DATE] at 1:16 p.m., the DON said she was aware there was a problem with physician visits in (MONTH) 2019. She said audits were performed to track, trend, and notify the physicians who were not seeing their residents. The DON said the medical director was supposed to follow-up on this and call physicians who were not performing their visits. She said she believed they did a follow-up in (MONTH) on the frequency of the physician visits but could not provide the audits or tracking and trending. During an interview on [DATE] at 1:27 p.m., the administrator said a review of the QA minutes for (MONTH) 24, 2019 that covered issues discussed in (MONTH) through March, did not indicate they discussed physician services or issues with physician services or physician visits. The administrator said the only time she knew physicians were contacted was this month. The administrator, corporate nurse, and DON was informed on [DATE] at 5:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The template was given to the IJ template was given to the facility on [DATE] at 5:54 p.m. The facility's Plan of Removal was accepted on [DATE] at 2:41 p.m. and included: *100 percent audit of all resident's skin assessments have been completed to ensure all wounds or abnormal skin findings have been reported to physician and family as of [DATE]. The AMT RN wound care nurse will ensure all wounds are staged correctly. Physician and families will be notified of current wound report on [DATE]. All wounds Stage 3, stage 4 or unstageable will be referred to the wound clinic. To be completed by the DON and the AMT RN on [DATE]. *100 percent audit of all resident's charts completed to ensure all residents have been evaluated by a physician in the last 30 days. All residents that were not current will be evaluated by the medical director on [DATE]. All physicians with current residents were notified on [DATE] of current guidelines and the importance of visit compliance. Completed by the administrator. On [DATE] at 4:51 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to lift the Immediate Jeopardy by: *During an observation on [DATE] at 9:00 a.m., multiple physicians were making rounds on the residents. The medical director was making rounds to assure all residents who had delinquent visits were evaluated. On [DATE] at 4:51 p.m., the administrator and corporate nurse were informed the Immediate Jeopardy was lifted: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

Based on interview and record review, the facility failed to ensure physician visits were provided at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for 1 of 26 residents reviewed for physician visits. (Resident #55) The facility did not make sure Resident #55 was seen by the attending physician at least every 60 days. Resident #55 had not been seen by her attending physician or designee since [DATE]. Resident #55's developed a stage 3 pressure injury on [DATE] that worsened to an infected unstageable pressure injury. The physician did not evaluate the pressure injury for 42 days from onset nor when the pressure injury worsened and developed a foul odor, slough, and drainage. Resident #55 was transferred to the hospital where she was diagnosed with [REDACTED]. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was lifted on [DATE] at 4:51 p.m., the facility remained out of compliance at a pattern of 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 at risk of not receiving appropriate and adequate medical care and interventions to prevent harm or death. Findings included: Physician orders dated [DATE] indicated Resident #55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent physician visit progress note for Resident #55 was dated [DATE]. Physician orders dated [DATE] for Resident #55 indicated cleanse lower buttocks with wound cleanser, pat dry, apply hydrogel gauze to wound bed, cover with bordered foam dressing, and change daily. The Pressure Ulcer/Wound Weekly Log completed by the DON dated [DATE] indicated Resident #55 had the following pressure injuries: *Pressure injury #1 -upper sacrum-facility acquired stage 3- identified [DATE], measured 1.2 cm x 0.8 cm x 0.1 cm. *Pressure injury #2 -lower sacrum-facility acquired stage 3- identified on [DATE], measured 1.8 cm x 0.6 cm x 0.1 cm. A monthly nursing summary note dated [DATE] indicated Resident #55 had two stage 3 pressure injuries and was receiving pressure injury care. The notes did not address if the physician/NP were notified of the newly identified pressure injuries. A treatment record dated [DATE]-[DATE] indicated Resident #55 had 2 pressure injuries: #1 upper buttocks-daily treatment from [DATE]- [DATE] - cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The treatment sheet indicated the treatment was discontinued on [DATE]. #2 - lower buttocks-daily treatment from [DATE] through [DATE]- cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. Physician orders dated [DATE] for Resident #55 indicated to discontinue hydrogel to Resident #55's upper buttocks, area resolved. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] stage 3- measured 1.4 cm x 0.6 cm x 0.1 cm. No drainage noted. Wound bed pink with surrounding tissue/wound edges pink in color. *[DATE] stage 3-measured 1.8 cm x 1.0 cm x 0.2 cm. No odor. Wound bed pink/red with surrounding tissue/wound edges pink in color. There were no nursing notes dated [DATE] for Resident #55 indicating the physician/NP were notified of the pressure injury #2 increasing in size. Physician orders dated [DATE] for Resident #55 indicated to discontinue hydrogel to Resident #55's upper buttocks, area resolved. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, was usually understood and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting and personal hygiene. Resident #55 had one unhealed stage 3 pressure injury, a pressure reducing device for her bed and was receiving pressure injury care including the application of non-surgical dressings. A care plan initiated on [DATE] indicated Resident #55 was at risk for alterations in skin integrity and she had a history of [REDACTED]. Interventions included to assess skin weekly and as needed, offload pressure points and reposition every 2 hours, and notify the physician of any skin problems. The clinical record from [DATE] through [DATE] for Resident #55 indicated the last visit made was by a NP on [DATE]. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] stage 3- measured 1.4 cm x 0.6 cm x 0.1 cm. No drainage noted. Wound bed pink with surrounding tissue/wound edges pink in color. *[DATE] stage 3-measured 1.8 cm x 1.0 cm x 0.2 cm. No odor. Wound bed pink/red with surrounding tissue/wound edges pink in color. There were no nursing notes dated [DATE] for Resident #55 indicating the physician/NP were notified of the pressure injury #2 increasing in size. A nursing note dated [DATE] at 1:40 pm., completed by the DON indicated Resident #55 had greater than 25% of the wound bed located at 3 to 5 o'clock covered with light brown to tan tissue. The DON indicated the wound treatment was changed to apply Santyl to the wound bed and [MEDICATION NAME] applied to the peri wound. The nursing notes for [DATE] did not indicate Resident #55's physician/NP was notified of the pressure injury worsening in size and appearance. An unsigned physician order dated [DATE] indicated to discontinue hydrogel to Resident #55's buttocks, and to start the following: cleanse buttocks with wound cleanser, apply Santyl to wound bed, cover with bordered foam dressing, and change dressing daily and as needed for dislodgement. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2, lower buttocks-treatment from [DATE] through [DATE]- continue to cleanse with wound cleanser, pat dry, and apply hydrogel gauze to wound bed, cover with bordered foam dressing every day. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 1.9 cm x 1.1 cm, (not able to measure depth); minimal serosanguinous drainage, no odor, 25% of the wound bed was covered with brown tissue. The Weekly Pressure Ulcer record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] -unstageable-measured 2.1 cm x 1.3 cm (unable to measure depth)-area larger in size-no odor was present with a scant amount of serosanguinous drainage noted. A nursing note dated [DATE] at 11:15 a.m., completed by the DON indicated Resident #55's pressure injury had increased in size, and there was dry skin around the wound that had peeled and dropped off. The note indicated there were no signs and symptoms of infection. The treatment to the area changed to Santyl with calcium alginate and [MEDICATION NAME] to the peri-wound. The nursing note did not indicate Resident #55's physician or NP was notified of the pressure injury worsening. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2, lower buttocks-treatment from [DATE] through [DATE]-cleanse with wound cleanser, pat dry, apply Santyl to wound bed and cover with foam dressing, change every day and as need for dislodgement. A nursing note dated [DATE] at 8:05 a.m. completed by the DON indicated she was called to the nursing station by LVN B to look at Resident #55's sacral pressure injury which had developed an odor with increased brown tissue in the wound bed. The note indicated the DON asked LVN B to contact the NP to obtain antibiotic orders and request changing the dressing from daily to two times a day. The note indicated at 11:45 a.m. the DON informed the NP and the NP refused to order an antibiotic and agreed to the dressing change two times a day. In addition, a new order for a wound culture and sensitivity of the sacral pressure injury was noted. An unsigned physician order dated [DATE] for Resident #55 indicated to obtain a wound culture and to discontinue the Santyl treatment. New order to cleanse area to sacrum with wound cleanser, pat dry, apply Santyl and calcium alginate to the wound bed, apply [MEDICATION NAME] to peri-wound, and cover with bordered foam dressing two times a day, and as need for dislodgement. A treatment record dated (MONTH) 2019 indicated Resident #55 had 1 pressure injury: #2 - Sacrum-treatment from [DATE] through [DATE]-cleanse area to sacrum with wound cleanser, pat dry, apply Santyl to wound bed and cover with calcium alginate. Apply [MEDICATION NAME] to peri-wound and cover with large bordered foam dressing two times a day and as needed for dislodgement. A nursing note dated [DATE] at 9:20 a.m., completed by the DON indicated she was notified the NP was making rounds and the NP refused to order a requested laboratory value for a complete blood count (CBC) and refused to change the treatment to the pressure injury of the sacrum until the wound culture and sensitivity laboratory results came back. The note did not indicate if the physician was notified. The Weekly Pressure Ulcer Record completed by the DON indicated the following assessments for Pressure injury #2, the sacral pressure injury, for Resident #55: *[DATE] unstageable-measured 3.5 cm x 3.0 cm (unable to measure depth)- area larger in size-an odor was present with small amount of serosanguinous wound drainage. The wound bed contained light brown to brown tissue that was detached from the wound edges, the surrounding skin color was light red, wound edges were defined. The note indicated a culture and sensitivity was performed on [DATE]. During an interview on [DATE] at 3:32 p.m., the administrator said the Weekly Pressure Ulcer Record for Resident #55 completed by the DON dated [DATE] was not accurate. She said the wound culture and sensitivity was not done on [DATE] as documented, she said it was done on [DATE]. She said she did not know if the DON assessed the resident's sacral pressure injury on [DATE] because Resident #55 was sent to the hospital that morning. A nursing note dated [DATE] at 10:18 a.m. indicated the DON spoke with Resident #55 family representative and informed her of Resident #55's change of condition, FSBS of 22 and was transferred to the emergency room for a low glucose reading. The note did not indicate the physician was notified. An emergency room Nursing Documentation dated [DATE] indicated upon arrival at 9:03 a.m., Resident #55 was unresponsive with a FSBS of 29. The note indicated the resident had a decubitus (pressure injury) located on her coccyx area (sacral area) was covered with a dressing. The resident had [MEDICAL CONDITION] screening that was positive with an unknown origin of infection. At 12:13 p.m. Resident #55 was admitted to the ICU in critical condition. An ICU nursing note dated [DATE] at 8.:36 p.m. indicated Resident #55 initial white blood cell count was 55.0, reference range (3XXX,[DATE].1) TH/mm3. The resident's chest x-ray was negative for pneumonia and her urinalysis negative for possible infection. The note indicated the resident had a large sacral pressure injury measuring 8.0 cm x 6.4 cm x 1.2 cm with a large amount of necrotic tissue. Resident #55 remained non-verbal, was not following commands, and was not tracking with her eyes. A hospital physician's short stay summary note dated [DATE] indicated Resident #55 had a large open decubitus on her sacral area with foul smelling purulent drainage. The physician determined Resident #55 needed to be transferred to a higher level of care after an examination of the sacral pressure injury showed it was infected and required urgent debridement. A physician discharge summary dated [DATE] indicated Resident #55's admission [DIAGNOSES REDACTED]. Possibly infected necrotic decubitus ulcer to the sacrum. 2.[MEDICAL CONDITION] 3. Urinary tract infection. 4 [DIAGNOSES REDACTED] .Discharge Diagnoses: [REDACTED]. 2. Escherichia coli urinary tract infection 3.[MEDICAL CONDITION] . The hospital course indicated Resident #55 initially had shortness of breath, altered mental status, and infected decubitus ulcer, was transferred from another hospital for evaluation of the infected decubitus ulcer and possible surgical debridement. Upon arrival Resident #55 had abnormal heart rate of 121, respirations of 30 and abnormal white blood count of 55.2. Surgical debridement was deferred due to functional status [MEDICAL CONDITION]. Resident #55 had positive wound culture that grew Proteus and [MEDICATION NAME], her kidney function worsened, and she eventually died on [DATE]. The discharge [DIAGNOSES REDACTED]. Escherichia coli urinary tract infection. [MEDICAL CONDITION] . A laboratory report dated [DATE] for Resident #55 indicated a wound culture of a wound/abscess identified as a sacral wound was collected on [DATE] at 10:30 a.m. The laboratory result indicated moderate growth of proteus mirabilis and moderate growth of Escherichia coli-the two organisms were sensitive to all antibiotics listed except [MEDICATION NAME]. A Wound Care Protocol Orders signed [DATE] by Resident #55's attending physician indicated: .3. Stage III/IV or Full Thickness Pressure Ulcer .A. Culture wound if (1) S/s of infection, (2)[MEDICAL CONDITION], (3) bone/joint involvement .C. Wound Center to manage care or evaluate and recommend care. D. Wound Center to be consulted if any wound is not progressing positively. During an interview on [DATE] at 9:24 a.m., LVN B said on [DATE] she notified the NP of Resident #55's sacral pressure injury draining and having an odor via telephone. LVN B said the NP ordered a wound culture and sensitivity and declined ordering an antibiotic until the wound culture results came back. She said she (LVN B) and the DON provided wound care for Resident #55 on [DATE] and the wound bed was covered with soft stringy brown eschar in the center and the wound was draining. She said the wound dressing changes were increased to two times a day. LVN B said on [DATE] and [DATE] the pressure injury continued to have an odor. She said the NP was making rounds on [DATE] and the DON discussed using a new treatment of [REDACTED]. She said she usually just sent the orders to the NP by facsimile for wound care orders that the DON would tell her to write. She said she did not notify Resident #55's primary care physician or the NP of the sacral pressure injury measurements or how the pressure injury declined, she would just send in the treatment orders. LVN B said [DATE] was the first time she called the NP about Resident #55's pressure injury. During an interview on [DATE] at 9:28 a.m., the NP said she was first notified on [DATE] of Resident #55's pressure injury. She said before that date, she had not received a phone call or facsimile transmission describing the pressure injury, location, or stage. She said that would be the normal procedure. She said physician orders for wound care treatments were sent to her, but she did not really read them, unless it was an order for [REDACTED]. She said on [DATE] she was told Resident #55's sacral pressure injury looked wet and was asked if a culture could be performed and she approved. She said there was no mention about the increasing size of the pressure injury, that the wound had an odor, if the resident had a temperature, or other signs and symptoms that would indicate further action. The NP said while she was in the facility on [DATE], LVN B came to her and showed her a picture of the resident's pressure injury. She said she went to examine Resident #55 but did not turn her over and visually inspect the sacral pressure injury nor did she notice any odors. She said at that time she believed she had the preliminary report back from the culture but no sensitivity. She said LVN B did not report any change in vital signs i.e., temperature, low blood pressure, or increased heart rate and did not indicate the wound had worsened. She said she did not order an antibiotic. She said she suggested a wound care physician look at the resident's pressure injury and the DON indicated they treat their own pressure injuries in-house. The NP said she did not document her visit in Resident #55's medical record on [DATE] because it was not a scheduled visit. She said when she reviewed the record she could not find any progress notes indicating Resident #55 was seen since (MONTH) 2019 by a physician. During an interview on [DATE] at 10:03 a.m., the medical director said there were wound protocols in place for the attending physician. She said she preferred residents see a wound care specialist if a pressure injury was a stage 3 or stage 4. She said she was not contacted or consulted for wound care orders or a review of Resident #55's sacral pressure injury. She said she reviewed Resident #55's pressure injury sheets with the NP after Resident #55 was sent to the hospital and believed obtaining a CBC would have given them more information to work with on what other interventions could have been implemented. The medical director said elderly residents do not respond to infection the same ways a healthy adult would. She said the elderly residents did not always mount a temperature in response to an infection and it could be sub-normal with FSBS dropping into a low range due to the infection. The medical director said when a resident's pressure injury developed slough (a type of necrotic tissue, it is often white, yellow or grey in color) and drainage, treatment should have included debridement. She said if chemical debridement (example - Santyl) was not effective, then surgical debridement would be needed. She said Resident #55's sacral pressure injury could have benefited in healing from a dressing impregnated with silver applied to pressure injury because of its [MEDICATION NAME] properties which helps treat/prevent infection. She said if an antibiotic had been initiated when Resident #55's pressure injury began to decline as in when it developed slough, drainage, and odor they might have been able to slow the infectious process and [MEDICAL CONDITION]. She said the facility staff were supposed to notify the physician of a resident's change in condition, either by facsimile or telephone. She said if the staff could not contact the attending physician, they should call her or the NP who worked under them. A Pressure Ulcer Treatment Policy dated ,[DATE] indicated: .Residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection and reduce the likelihood of new pressure ulcers developing .1. Contact physician for treatment orders .6. Use effective wound cleansing and debridement methods to minimize pressure ulcer colonization and enhance wound healing .19. Use [MEDICATION NAME], mechanical, enzymatic and/or autolytic debridement techniques to remove devitalized tissue .23. Refer to wound center as Needed . During an interview on [DATE] at 9:28 p.m., the NP said staff were writing orders that they thought were appropriate without proper notification of the primary care physician or herself. The NP said she had not seen Resident #55 since [DATE]. She said on [DATE] when she assessed the resident she did not document the visit because it was not a scheduled visit. During an interview on [DATE] at 2:08 p.m., Resident #55's physician said he had not been notified of Resident #55's pressure injury on her sacrum. He indicated he could not provide any further information and it sounded like a quality of care issue. During an interview on [DATE] at 8:31 a.m., the medical director said Resident #55's primary care physician could not give an answer for why he had not assessed her over the past 6 months. During an interview on [DATE] at 8:28 a.m., the DON said the physician should see their residents every 60 days. She said letters were sent out to the physicians as reminders. She said a NP was hired earlier that year to see all of Resident #55's primary care physician residents and she did not know why Resident #55 was not seen. During an interview on [DATE] at 1:16 p.m., the DON said she was aware there was a problem with physician visits in (MONTH) 2019. She said audits were performed to track, trend, and notify the physicians who were not seeing their residents. The DON said the medical director was supposed to follow-up on this and call physicians who were not performing their visits. She said she believed they did a follow-up in (MONTH) on the frequency of the physician visits but could not provide the audits or tracking and trending. During an interview on [DATE] at 1:27 p.m., the administrator said a review of the QA minutes for (MONTH) 24, 2019 that covered issues discussed in (MONTH) through March, did not indicate they discussed physician services or issues with physician services or physician visits. The administrator said the only time she knew physicians were contacted was this month. The administrator, corporate nurse, and DON was informed on [DATE] at 5:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The template was given to the IJ template was given to the facility on [DATE] at 5:54 p.m. The facility's Plan of Removal was accepted on [DATE] at 2:41 p.m. and included: *100 percent audit of all resident's skin assessments have been completed to ensure all wounds or abnormal skin findings have been reported to physician and family as of [DATE]. The AMT RN wound care nurse will ensure all wounds are staged correctly. Physician and families will be notified of current wound report on [DATE]. All wounds Stage 3, stage 4 or unstageable will be referred to the wound clinic. To be completed by the DON and the AMT RN on [DATE]. *100 percent audit of all resident's charts completed to ensure all residents have been evaluated by a physician in the last 30 days. All residents that were not current will be evaluated by the medical director on [DATE]. All physicians with current residents were notified on [DATE] of current guidelines and the importance of visit compliance. Completed by the administrator. On [DATE] at 4:51 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to lift the Immediate Jeopardy by: *During an observation on [DATE] at 9:00 a.m., multiple physicians were making rounds on the residents. The medical director was making rounds to assure all residents who had delinquent visits were evaluated. On [DATE] at 4:51 p.m., the administrator and corporate nurse were informed the Immediate Jeopardy was lifted: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

Based on interview and record reviews the facility failed to ensure that the quality assessment and assurance committee (QAA) developed and implemented appropriate plans of actions to correct and identify potential deficiencies of care for 1 of 24 residents reviewed for care and services. (Resident #55) 1. The QA Committee did not identify or address issues with physician services in which the attending physicians were not making routine trips to the facility for resident assessments and care. 2 The QA Committee did not identify or address the facility's failure to notify Resident #55's physician of the development and change in the resident's condition, with a pressure wound, which lead to [MEDICAL CONDITION] and to the resident's death. 3. The QA Committee did not identify or address the facility's failure to identify issues with identifying and treating Resident #55's critically low blood sugar which lead to the resident's hospitalization These failures could place residents who experience medical emergencies and changes of condition at risk for not receiving appropriate care and services to prevent harm and inappropriate care and services. Findings included: During an interview on 08/02/19 at 12:57 p.m., the administrator said the facility met quarterly for the QA Committee meetings. She said the facility should have been aware of issues with the physician services. The administrator said the physicians had not been making visits as required to the facility to see their residents. She said the QA committee should have been aware nursing services had not notified Resident #**'s physician about the development and worsening of her pressure sore. The administrator also said the facility should have been aware the nursing staff were not aware what to do with critically low blood sugars. During an interview on 08/02/19 at 1:16 p.m., the DON said she felt the staff that attended the QA meetings knew about the issues regarding physician issues in (MONTH) of 2019. The DON said the facility did audits to track and trend the physicians' visits were completed and the physicians were notified about what was required regarding visits and checks to their residents. She said the medical director for the facility spoke with the physicians and a follow-up was conducted in the (MONTH) 2019 QA meeting. Minutes for the QA Meeting dated 01/30/19 at 7:30 a.m. did not contain any information regarding physician services, physician notification, or addressing critically low blood sugars. Minutes for the QA Meeting dated (MONTH) 24, 2019 at 7:30 a.m. that covered for the months of (MONTH) through (MONTH) did not address physician services, physician notification or critically low blood sugars During an interview on 08/02/19 at 1:27 p.m., DON said the first time the QA Committee discussed physician services the QA Committee had not documented in the minutes. During an interview on 08/02/19 at 1:27 p.m., the administrator said the only time she knew of the facility contacting the physicians was in (MONTH) of 2019, within the last week.

Based on interview and record review, the facility failed to ensure the right to be free from neglect was provided for 1 of 34 residents reviewed for neglect. (Resident #55) The facility did not immediately provide emergency medical services for Resident #55 when she had a critically low FSBS result of less than 20 (Normal 60-100). Resident #55's FSBS remained at a critical level for 2 hours before being transferred to the emergency room . The nurses were not aware of the physician's standing orders for treating FSBS. The facility did not provide training to the nurses regarding the meaning of the glucometer's Lo (blood glucose is below 20 mg/dL) readings. Upon arrival to the emergency room , Resident #55 was non-responsive, and her blood sugar remained critically low. She was admitted to ICU. An Immediate Jeopardy situation was identified 7/31/19 due to the above failures related to Resident #55. While the Immediate Jeopardy was lifted on 8/1/19 at 4:51 p.m., the facility remained out of compliance at a pattern of 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 at risk for neglect and not being provided care they needed to prevent harm or death. Findings included: Physician orders [REDACTED].#55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated a FSBS would be performed two times a week on Tuesday and Thursday. The order did not include glucose parameters for physician notification. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, and was usually understood and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting, and personal hygiene. A care plan initiated 6/25/19 indicated Resident #55 had potential for fluctuations in her blood glucose level related to diabetes. Interventions included FSBS as ordered and as needed per nursing judgement and to notify the physician as needed. The care plan indicated to follow facility policy and procedures for care of residents with hypo/[MEDICAL CONDITION]. Standing orders from Unit C signed 2/3/12 by the primary care physician for Resident #55 indicated: .If glucometer blood sugar is < 60 give 120-180 cc of sweetened orange juice or other sweetened drink (if patient is conscious). Re-check blood sugar in 30 minutes and notify Physician by phone if FSBS still less than 60 administer [MEDICATION NAME] 1mg/ml. If [DIAGNOSES REDACTED] persists send to ER and notify MD. If FSBS <60 more than 3 times, fax to Physician for medication adjustment . A Diabetic Record for (MONTH) 2019 indicated Resident #55's FSBS reading for 7/18/19 at 6:30 had a 'Lo' reading. The Assure Platinum Blood Glucose Monitoring System user instruction manual provided by the administrator indicated: .: If your blood glucose is below 20 mg/dL, you will receive a Lo. Repeat the test with a new test strip. If this message shows again, contact your healthcare professional immediately! A nursing note dated 7/18/19 at 6:30 a.m., completed by LVN C indicated Resident #55's FSBS result was 'Lo'. The resident was moaning and pushing the medication LVN C attempted to administer out of her mouth with her tongue. LVN C gave Resident #55 apple juice with sugar and the resident held the juice in her mouth for a few seconds before she swallowed it. The note indicated LVN C notified the oncoming shift of the 'Lo' glucose reading; however, it did not indicate she notified the physician. During an interview on 7/31/19 at 7:10 a.m., LVN C said Resident #55 had a 'Lo' FSBS reading on 7/18/19 when she checked it around 6:30 a.m. to 6:40 a.m. LVN C said Resident #55 was grunting and moaning. She said she rechecked the FSBS with a new test strip after she got the initial result of 'Lo' and the second test result was also 'Lo'. LVN C said she put a few drops of apple juice mixed with sugar in Resident #55's mouth and got some cupcake icing and rubbed on Resident 55's gums. She said Resident #55's FSBS continued to have a 'Lo' reading. She said a result of 'Lo' indicated the blood sugar was below 60 and the typical treatment was to give juice with sugar. She said she then left the room and gave report to LVN B, whose shift began at 7:00 a.m. LVN C said she did not notify the attending physician and did not know the 'Lo' reading indicated a blood sugar level of less than 20. LVN C said a blood sugar of less than 40 should be treated with [MEDICATION NAME] injection, the physician should be notified, and if the blood sugar did not come up in 3 or 4 minutes the nurse should call for emergency transport. LVN C said she was not aware of any standing orders to give [MEDICATION NAME] 1mg intramuscular and did not recall any training on the Assure Platinum glucometer. A nursing note dated 7/18/19 at 7:15 a.m. completed by LVN B indicated Resident #55 had a FSBS result of 'Lo' and the resident continued to moan. LVN B attempted to give the resident icing and orange juice. The note indicated LVN B would recheck the FSBS. The note indicated LVN B did not notify the physician. At 7:45 a.m. LVN B rechecked the FSBS and the result remained 'Lo'. A new order was noted to give [MEDICATION NAME] 1mg now. At 8:00 a.m. the [MEDICATION NAME] injection was administered. The note indicated Resident #55's face was flushed, and she had sputum in her mouth. LVN B indicated she would recheck the resident's FSBS at 8:30 a.m. Resident #55's FSBS was checked and the result was 22. The nurse practitioner was notified, and orders were received to send the resident to the hospital for an assessment and evaluation. At 8:45 a.m. Resident #55 left the facility in an ambulance. During an interview on 8/2/19 at 5:03 p.m., LVN B said on 7/18/19 at 7:00 a.m. she took report from LVN C who informed her Resident #55's FSBS reading was 'Lo' and she (LVN C) had given apple juice with sugar and repeated the FSBS with another 'Lo' result. LVN B said around 7:15 a.m. she checked Resident #55's blood sugar and obtained a 'Lo' result. LVN B said she administered cake icing and orange juice at that time. LVN B said Resident #55 had her eyes open and was moaning but did not talk to her. She said she returned about 30 minutes later to recheck Resident #55's blood sugar. She said when she rechecked the FSBS and got another 'Lo' result, she administered [MEDICATION NAME] 1mg. LVN B said after she administered the [MEDICATION NAME] and the resident's FSBS was 22 she notified the DON. LVN B said she was instructed to call the NP who gave orders to send Resident #55 to the emergency room . LVN B said she was not aware a 'Lo' reading indicated a blood sugar less than 20 and thought the protocol indicated if the resident could swallow to continue giving juice or some form of sugar by mouth. She said she was not in-serviced on the Assure Platinum glucose monitor concerning the 'Lo' readings. A SNF/NF Hospital Transfer Form dated 7/18/19 at 8:30 a.m. was initiated by LVN B for Resident #55. The form indicated the purpose of the hospital transfer was [DIAGNOSES REDACTED]. The emergency room (ER) nursing note dated 7/18/19 indicated Resident #55 arrived at the emergency room at 9:03 a.m. with [DIAGNOSES REDACTED]. The note indicated the resident's presenting complaint: EMS states blood sugar was 29 and unable to get an O2 saturation level and the resident was placed on continuous positive airway pressure ([MEDICAL CONDITION]) to support respirations. The note indicated the nurse was unable to complete a screening due to the resident being unresponsive. The ER physician documentation note dated 7/18/19 at 9:03 a.m. indicated Resident #55 arrived in the emergency department (ED). The resident presented to the ED with shortness of breath since this morning. The note indicated EMS states on arrival to the nursing facility the resident had a D-Stick (glucose reading) of 22 and was given [MEDICATION NAME] with slight improvement to 29. EMS was unable to obtain an oxygen saturation (O2 saturation). The resident was positive for [DIAGNOSES REDACTED]. At 9:10 a.m. the resident was administered D50W 50ml ([MEDICATION NAME] 50% in water) pushed through an intravenous port and again at 10:40 a.m. The resident was transferred to ICU at 1:22 p.m. The ICU physician notes dated 7/18/19 indicated at 4:08 p.m. the physician indicated Resident #55 was presented to the hospital with decreased level of activity and shortness of breath. The physician recommended the resident be sent to another hospital for a higher level of care. During an interview on 7/31/19 at 9:28 p.m., the NP said she was not notified of Resident #55's 'Lo' FSBS on 7/18/19. She said she was informed Resident #55 had a decreased level of consciousness and she ordered to send the resident to the ER. She said she did not order [MEDICATION NAME] and the facility usually just wrote orders without consulting her and sent them for her signature. The NP said if she had she been notified of the 'Lo' result on Resident #55's FSBS, she would have told them to give her something and send her out. She said she would not expect anyone with an FSBS result below 20 to be conscious enough to tolerate anything liquid by mouth. She said the facility should have notified someone of the Lo result. During an interview on 7/31/19 at 10:01 a.m., the medical director said a resident whose blood sugar was below 20 would require emergent action. She said the nurse should have given [MEDICATION NAME], notified the attending physician and notified EMS. She said there was a protocol in place to treat [DIAGNOSES REDACTED], she said a nurse must use critical thinking and know what to do when the glucose was critically low. She said she would not expect a resident with a blood sugar less than 20 to be fully conscious, and liquids by mouth would be contraindicated due to the risk of aspiration. She said 2 hours was too long to go before notifying a primary care physician of a critical low blood sugar. During an interview on 7/31/19 at 11:01 a.m., the DON said LVN B should have recognized that a 'Lo' reading on the glucometer indicated a glucose level of less than 20 which was a critical level. She said the nurse should have notified the physician for any value less than 60. The DON said for a critical level, the nurse should have administered [MEDICATION NAME] 1 mg intramuscular (IM), notified the physician, and called EMS to transfer the resident to the hospital. The DON said the nurse should have followed the standing orders provided by the primary care physician. The DON said nurses were reviewed for competency on hire and annually thereafter. A Job Competency Testing dated 2/11/15 indicated LVN B was trained on medical equipment that included a glucometer. The competency check did not indicate LVN B was trained on the Assure Platinum Glucometer or hi and lo readings. A Job Competency Testing dated 7/25/19 indicated LVN B was trained on medical equipment that included a glucometer, fingersticks, and reading Hi and Lo readings. A Job Competency Testing dated 7/26/19 indicated LVN C was trained on medical equipment that included a glucometer. The competency check did not indicate LVN C was trained on the Assure Platinum Glucometer or hi and lo readings. A Job Competency Testing dated 7/25/19 indicated LVN C was trained on medical equipment that included a glucometer, fingersticks, and reading Hi and Lo readings. During an interview on 7/31/19 at 10:03 a.m., the administrator said she was sure the staff had been in-serviced on FSBS and should follow the standing orders. She said all staff should be aware of the standing orders because they have been in place for a while now. The administrator said the protocols for low and high FSBS were in the medication administration book on each unit. [DIAGNOSES REDACTED] (Insulin Shock) policy dated 3/2000 did not include procedures to follow in cases of critically low FSBS results or hypoglycemic crisis. An Abuse Prevention and Prohibition Polices dated 6/2019 indicated: .The resident has the right to be free of .neglect .Neglect the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Residents, representatives and staff will be able to report concerns, incidents and grievances without fear of retribution. Facility supervisors will immediately correct and intervene in reported or identified situations in which .neglect .of resident is at risk for occurring . The administrator, corporate nurse, and the DON were informed on 7/31/18 at 5:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was given to the facility on [DATE] at 5:54 p.m. The facility's Plan of Removal was accepted on 8/1/19 at 2:41 p.m. and included: *All licensed and registered nurses will be in serviced on 8/1/19 on the physician notification on changes in condition including glucose readings and vital signs outside of normal parameters. Nurses will be in serviced on facility glucometers and that a reading of Lo is below 20. The facility has educated that a FSBS of Lo or below 20 is a critical value and should be treated as a medical emergency by calling emergency services. To be completed by the DON on 8/1/19. *100 Percent of all Diabetic residents that require FSBS have been audited to ensure no other residents were affected with FSBS less than 60 without appropriate interventions and follow up notification to physician. *The nurse that failed to notify the physician for two hours of critically low FSBS has been terminated. Done on 7/31/19 by the administrator. *All Licensed and Registered nurses will be tested on [DIAGNOSES REDACTED] and identifying signs and symptoms. To be Completed by the DON and the administrator on 8/1/19. On 8/1/19 at 4:51 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to lift the Immediate Jeopardy by: *The facility training included in-services 8/1/19 on recognizing the symptoms of hypo/[MEDICAL CONDITION], physician notification, Assure Platinum glucose levels and manufacturers guidelines. *9 nurses were interviewed from different shifts on the recognition of signs and symptoms of hypo/[MEDICAL CONDITION], recognition of values of 'Lo' readings on the glucometer and when to notify the physician. The nurses were able to verbalize the correct procedures. *5 residents who required FSBS checks records were reviewed records. No concerns about 'Lo' readings were noted. On 8/1/19 at 4:51 p.m., the administrator and corporate nurse were informed the Immediate Jeopardy was lifted: however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

Based on interview and record review, the facility failed to implement written policies and proceduces to prevent neglect of residents for 1 of 34 residents reviewed for neglect. (Resident #55) The facility did not implement their written policy and procedures to prevent neglect when they failed to recognize a medical emergency, and immediately transfer Resident #55 to the emergency room when she had a critically low FSBS result of less than 20. Resident #55's FSBS remained at a critical level for 2 hours before being transferred to the emergency room . The nurses were not aware of the physician's standing orders for treating FSBS and were not aware of the meaning of the glucometer's Lo readings. Upon arrival to the emergency room , Resident #55 was non-responsive, and her blood sugar remained critically low. She was admitted to ICU. An Immediate Jeopardy situation was identified 7/31/19 due to the above failures related to Resident #55. While the Immediate Jeopardy was lifted on 8/1/19 at 4:51 p.m., the facility remained out of compliance at a pattern of 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 at risk for neglect and not being provided care they needed to prevent harm or death. Findings included: An Abuse Prevention and Prohibition Polices dated 6/2019 indicated: .The resident has the right to be free of .neglect .Neglect the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .Residents, representatives and staff will be able to report concerns, incidents and grievances without fear of retribution. Facility supervisors will immediately correct and intervene in reported or identified situations in which .neglect .of resident is at risk for occurring . Physician orders [REDACTED].#55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated a FSBS would be performed two times a week on Tuesday and Thursday. The order did not include glucose parameters for physician notification. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, and was usually understood and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting, and personal hygiene. A care plan initiated 6/25/19 indicated Resident #55 had potential for fluctuations in her blood glucose level related to diabetes. Interventions included FSBS as ordered and as needed per nursing judgement and to notify the physician as needed. The care plan indicated to follow facility policy and procedures for care of residents with hypo/[MEDICAL CONDITION]. Standing orders from Unit C signed 2/3/12 by the primary care physician for Resident #55 indicated: .If glucometer blood sugar is < 60 give 120-180 cc of sweetened orange juice or other sweetened drink (if patient is conscious). Re-check blood sugar in 30 minutes and notify Physician by phone if FSBS still less than 60 administer [MEDICATION NAME] 1mg/ml. If [DIAGNOSES REDACTED] persists send to ER and notify MD. If FSBS <60 more than 3 times, fax to Physician for medication adjustment . A Diabetic Record for (MONTH) 2019 indicated Resident #55's FSBS reading for 7/18/19 at 6:30 had a 'Lo' reading. The Assure Platinum Blood Glucose Monitoring System user instruction manual provided by the administrator indicated: .: If your blood glucose is below 20 mg/dL, you will receive a Lo. Repeat the test with a new test strip. If this message shows again, contact your healthcare professional immediately! A nursing note dated 7/18/19 at 6:30 a.m., completed by LVN C indicated Resident #55's FSBS result was 'Lo'. The resident was moaning and pushing the medication LVN C attempted to administer out of her mouth with her tongue. LVN C gave Resident #55 apple juice with sugar and the resident held the juice in her mouth for a few seconds before she swallowed it. The note indicated LVN C notified the oncoming shift of the 'Lo' glucose reading; however, it did not indicate she notified the physician. During an interview on 7/31/19 at 7:10 a.m., LVN C said Resident #55 had a 'Lo' FSBS reading on 7/18/19 when she checked it around 6:30 a.m. to 6:40 a.m. LVN C said Resident #55 was grunting and moaning. She said she rechecked the FSBS with a new test strip after she got the initial result of 'Lo' and the second test result was also 'Lo'. LVN C said she put a few drops of apple juice mixed with sugar in Resident #55's mouth and got some cupcake icing and rubbed on Resident 55's gums. She said Resident #55's FSBS continued to have a 'Lo' reading. She said a result of 'Lo' indicated the blood sugar was below 60 and the typical treatment was to give juice with sugar. She said she then left the room and gave report to LVN B, whose shift began at 7:00 a.m. LVN C said she did not notify the attending physician and did not know the 'Lo' reading indicated a blood sugar level of less than 20. LVN C said a blood sugar of less than 40 should be treated with [MEDICATION NAME] injection, the physician should be notified, and if the blood sugar did not come up in 3 or 4 minutes the nurse should call for emergency transport. LVN C said she was not aware of any standing orders to give [MEDICATION NAME] 1mg intramuscular and did not recall any training on the Assure Platinum glucometer. A nursing note dated 7/18/19 at 7:15 a.m. completed by LVN B indicated Resident #55 had a FSBS result of 'Lo' and the resident continued to moan. LVN B attempted to give the resident icing and orange juice. The note indicated LVN B would recheck the FSBS. The note indicated LVN B did not notify the physician. At 7:45 a.m. LVN B rechecked the FSBS and the result remained 'Lo'. A new order was noted to give [MEDICATION NAME] 1mg now. At 8:00 a.m. the [MEDICATION NAME] injection was administered. The note indicated Resident #55's face was flushed, and she had sputum in her mouth. LVN B indicated she would recheck the resident's FSBS at 8:30 a.m. Resident #55's FSBS was checked and the result was 22. The nurse practitioner was notified, and orders were received to send the resident to the hospital for an assessment and evaluation. At 8:45 a.m. Resident #55 left the facility in an ambulance. During an interview on 8/2/19 at 5:03 p.m., LVN B said on 7/18/19 at 7:00 a.m. she took report from LVN C who informed her Resident #55's FSBS reading was 'Lo' and she (LVN C) had given apple juice with sugar and repeated the FSBS with another 'Lo' result. LVN B said around 7:15 a.m. she checked Resident #55's blood sugar and obtained a 'Lo' result. LVN B said she administered cake icing and orange juice at that time. LVN B said Resident #55 had her eyes open and was moaning but did not talk to her. She said she returned about 30 minutes later to recheck Resident #55's blood sugar. She said when she rechecked the FSBS and got another 'Lo' result, she administered [MEDICATION NAME] 1mg. LVN B said after she administered the [MEDICATION NAME] and the resident's FSBS was 22 she notified the DON. LVN B said she was instructed to call the NP who gave orders to send Resident #55 to the emergency room . LVN B said she was not aware a 'Lo' reading indicated a blood sugar less than 20 and thought the protocol indicated if the resident could swallow to continue giving juice or some form of sugar by mouth. She said she was not in-serviced on the Assure Platinum glucose monitor concerning the 'Lo' readings. A SNF/NF Hospital Transfer Form dated 7/18/19 at 8:30 a.m. was initiated by LVN B for Resident #55. The form indicated the purpose of the hospital transfer was [DIAGNOSES REDACTED]. The emergency room (ER) nursing note dated 7/18/19 indicated Resident #55 arrived at the emergency room at 9:03 a.m. with [DIAGNOSES REDACTED]. The note indicated the resident's presenting complaint: EMS states blood sugar was 29 and unable to get an O2 saturation level and the resident was placed on continuous positive airway pressure ([MEDICAL CONDITION]) to support respirations. The note indicated the nurse was unable to complete a screening due to the resident being unresponsive. The ER physician documentation note dated 7/18/19 at 9:03 a.m. indicated Resident #55 arrived in the emergency department (ED). The resident presented to the ED with shortness of breath since this morning. The note indicated EMS states on arrival to the nursing facility the resident had a D-Stick (glucose reading) of 22 and was given [MEDICATION NAME] with slight improvement to 29. EMS was unable to obtain an oxygen saturation (O2 saturation). The resident was positive for [DIAGNOSES REDACTED]. At 9:10 a.m. the resident was administered D50W 50ml ([MEDICATION NAME] 50% in water) pushed through an intravenous port and again at 10:40 a.m. The resident was transferred to ICU at 1:22 p.m. The ICU physician notes dated 7/18/19 indicated at 4:08 p.m. the physician indicated Resident #55 was presented to the hospital with decreased level of activity and shortness of breath. The physician recommended the resident be sent to another hospital for a higher level of care. During an interview on 7/31/19 at 9:28 p.m., the NP said she was not notified of Resident #55's 'Lo' FSBS on 7/18/19. She said she was informed Resident #55 had a decreased level of consciousness and she ordered to send the resident to the ER. She said she did not order [MEDICATION NAME] and the facility usually just wrote orders without consulting her and sent them for her signature. The NP said if she had she been notified of the 'Lo' result on Resident #55's FSBS, she would have told them to give her something and send her out. She said she would not expect anyone with an FSBS result below 20 to be conscious enough to tolerate anything liquid by mouth. She said the facility should have notified someone of the Lo result. During an interview on 7/31/19 at 10:01 a.m., the medical director said a resident whose blood sugar was below 20 would require emergent action. She said the nurse should have given [MEDICATION NAME], notified the attending physician and notified EMS. She said there was a protocol in place to treat [DIAGNOSES REDACTED], she said a nurse must use critical thinking and know what to do when the glucose was critically low. She said she would not expect a resident with a blood sugar less than 20 to be fully conscious, and liquids by mouth would be contraindicated due to the risk of aspiration. She said 2 hours was too long to go before notifying a primary care physician of a critical low blood sugar. During an interview on 7/31/19 at 11:01 a.m., the DON said LVN B should have recognized that a 'Lo' reading on the glucometer indicated a glucose level of less than 20 which was a critical level. She said the nurse should have notified the physician for any value less than 60. The DON said for a critical level, the nurse should have administered [MEDICATION NAME] 1 mg intramuscular (IM), notified the physician, and called EMS to transfer the resident to the hospital. The DON said the nurse should have followed the standing orders provided by the primary care physician. During an interview on 7/31/19 at 10:03 a.m., the administrator said she was sure the staff had been in-serviced on FSBS and should follow the standing orders. She said all staff should be aware of the standing orders because they have been in place for a while now. The administrator said the protocols for low and high FSBS were in the medication administration book on each unit. [DIAGNOSES REDACTED] (Insulin Shock) policy dated 3/2000 did not include procedures to follow in cases of critically low FSBS results or hypoglycemic crisis. The administrator, corporate nurse, and the DON were informed on 7/31/18 at 5:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was given to the facility on [DATE] at 5:54 p.m. The facility's Plan of Removal was accepted on 8/1/19 at 2:41 p.m. and included: *All licensed and registered nurses will be in serviced on 8/1/19 on the physician notification on changes in condition including glucose readings and vital signs outside of normal parameters. Nurses will be in serviced on facility glucometers and that a reading of Lo is below 20. The facility has educated that a FSBS of Lo or below 20 is a critical value and should be treated as a medical emergency by calling emergency services. To be completed by the DON on 8/1/19. *100 Percent of all Diabetic residents that require FSBS have been audited to ensure no other residents were affected with FSBS less than 60 without appropriate interventions and follow up notification to physician. *The nurse that failed to notify the physician for two hours of critically low FSBS has been terminated. Done on 7/31/19 by the administrator. *All Licensed and Registered nurses will be tested on [DIAGNOSES REDACTED] and identifying signs and symptoms. To be completed by the DON and the administrator on 8/1/19. On 8/1/19 at 4:51 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to lift the Immediate Jeopardy by: *The facility training included in-services 8/1/19 on recognizing the symptoms of hypo/[MEDICAL CONDITION], physician notification, Assure Platinum glucose levels and manufacturers guidelines. *9 nurses were interviewed from different shifts on the recognition of signs and symptoms of hypo/[MEDICAL CONDITION], recognition of values of 'Lo' readings on the glucometer and when to notify the physician. The nurses were able to verbalize the correct procedures. *5 residents who required FSBS checks records were reviewed records. No concerns about 'Lo' readings were noted. On 8/1/19 at 4:51 p.m., the administrator and corporate nurse were informed the Immediate Jeopardy was lifted: however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

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 #55) The facility did not recognize a medical emergency, notify the physician, and immediately transfer Resident #55 to the emergency room when she had a critically low FSBS result of less than 20 and was not responsive. Resident #55's FSBS remained at a critical level for 2 hours before the nurse notified the physician and called EMS to transfer the resident to the emergency room . Upon arrival to the emergency room , Resident #55 was non-responsive, and her blood sugar remained critically low. She was admitted to ICU and then transferred to another hospital for a higher level of care where she later died . An Immediate Jeopardy (IJ) situation was identified on [DATE] due to the above failures related to Resident #55. While the IJ was lifted on [DATE] at 4:51 p.m., the facility remained out of compliance at a pattern of 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 with abnormal blood sugar levels at risk of harm or death. Findings included: Physician orders [REDACTED].#55 admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders indicated a FSBS would be performed two times a week on Tuesday and Thursday. The order did not include glucose parameters for physician notification. A significant change MDS dated [DATE] indicated Resident #55 had severe cognitive deficit, unclear speech, and was usually understood and usually understood others. She was incontinent of bowel and bladder and required full staff performance of one for bed mobility, toileting, and personal hygiene. A care plan initiated [DATE] indicated Resident #55 had potential for fluctuations in her blood glucose level related to diabetes. Interventions included FSBS as ordered and as needed per nursing judgement and to notify the physician as needed. The care plan indicated to follow facility policy and procedures for care of residents with hypo/[MEDICAL CONDITION]. Standing orders from Unit C signed [DATE] by the primary care physician for Resident #55 indicated: .If glucometer blood sugar is < 60 give ,[DATE] cc of sweetened orange juice or other sweetened drink (if patient is conscious). Re-check blood sugar in 30 minutes and notify Physician by phone if FSBS still less than 60 administer [MEDICATION NAME] 1mg/ml. If [DIAGNOSES REDACTED] persists send to ER and notify MD. If FSBS <60 more than 3 times, fax to Physician for medication adjustment . A Diabetic Record for (MONTH) 2019 indicated Resident #55's FSBS reading for [DATE] at 6:30 a.m. had a 'Lo' reading. The Assure Platinum Blood Glucose Monitoring System user instruction manual provided by the administrator indicated: .: If your blood glucose is below 20 mg/dL, you will receive a Lo. Repeat the test with a new test strip. If this message shows again, contact your healthcare professional immediately! A nursing note dated [DATE] at 6:30 a.m., by LVN C indicated Resident #55's FSBS result was 'Lo'. The resident was moaning and pushing the medication LVN C attempted to administer out of her mouth with her tongue. LVN C gave Resident #55 apple juice with sugar and the resident held the juice in her mouth for a few seconds before she swallowed it. The note indicated LVN C notified the oncoming shift of the 'Lo' glucose reading; however, it did not indicate she notified the physician. During an interview on [DATE] at 7:10 a.m., LVN C said Resident #55 had a 'Lo' FSBS reading on [DATE] when she checked it around 6:30 a.m. to 6:40 a.m. LVN C said Resident #55 was grunting and moaning. She said she rechecked the FSBS with a new test strip after she got the initial result of 'Lo' and the second test result was also 'Lo'. LVN C said she put a few drops of apple juice mixed with sugar in Resident #55's mouth and got some cupcake icing and rubbed on Resident 55's gums. She said Resident #55's FSBS continued to have a 'Lo' reading. She said a result of 'Lo' indicated the blood sugar was below 60 and the typical treatment was to give juice with sugar. She said she then left the room and gave report to LVN B, whose shift began at 7:00 a.m. LVN C said she did not notify the attending physician and did not know the 'Lo' reading indicated a blood sugar level of less than 20. LVN C said a blood sugar of less than 40 should be treated with [MEDICATION NAME] injection, the physician should be notified, and if the blood sugar did not come up in 3 or 4 minutes the nurse should call for emergency transport. LVN C said she was not aware of any standing orders to give [MEDICATION NAME] 1mg intramuscular and did not recall any training on the Assure Platinum glucometer. A nursing note dated [DATE] at 7:15 a.m. completed by LVN B indicated Resident #55 had a FSBS result of 'Lo' and the resident continued to moan. LVN B attempted to give the resident icing and orange juice. The note indicated LVN B would recheck the FSBS. The note indicated LVN B did not notify the physician. At 7:45 a.m. LVN B rechecked the FSBS and the result remained 'Lo'. A new order was noted to give [MEDICATION NAME] 1mg now. At 8:00 a.m. the [MEDICATION NAME] injection was administered. The note indicated Resident #55's face was flushed, and she had sputum in her mouth. LVN B indicated she would recheck the resident's FSBS at 8:30 a.m. Resident #55's FSBS was checked and the result was 22. The nurse practitioner was notified, and orders were received to send the resident to the hospital for an assessment and evaluation. At 8:45 a.m. Resident #55 left the facility in an ambulance. During an interview on [DATE] at 5:03 p.m., LVN B said on [DATE] at 7:00 a.m. she took report from LVN C who informed her Resident #55's FSBS reading was 'Lo' and she (LVN C) had given apple juice with sugar and repeated the FSBS with another 'Lo' result. LVN B said around 7:15 a.m. she checked Resident #55's blood sugar and obtained a 'Lo' result. LVN B said she administered cake icing and orange juice at that time. LVN B said Resident #55 had her eyes open and was moaning but did not talk to her. She said she returned about 30 minutes later to recheck Resident #55's blood sugar. She said when she rechecked the FSBS and got another 'Lo' result, she administered [MEDICATION NAME] 1mg. LVN B said after she administered the [MEDICATION NAME] and the resident's FSBS was 22 she notified the DON. LVN B said she was instructed to call the NP who gave orders to send Resident #55 to the emergency room . LVN B said she was not aware a 'Lo' reading indicated a blood sugar less than 20 and thought the protocol indicated if the resident could swallow to continue giving juice or some form of sugar by mouth. She said she was not in-serviced on the Assure Platinum glucose monitor concerning the 'Lo' readings. A SNF/NF Hospital Transfer Form dated [DATE] at 8:30 a.m. was initiated by LVN B for Resident #55. The form indicated the purpose of the hospital transfer was [DIAGNOSES REDACTED]. The ER nursing note dated [DATE] indicated Resident #55 arrived at the emergency room at 9:03 a.m. with [DIAGNOSES REDACTED]. The note indicated the resident's presenting complaint: EMS states blood sugar was 29 and unable to get an O2 saturation level and the resident was placed on continuous positive airway pressure ([MEDICAL CONDITION]) to support respirations. The note indicated the nurse was unable to complete a screening due to the resident being unresponsive. The ER physician documentation note dated [DATE] at 9:03 a.m. indicated Resident #55 arrived in the emergency department (ED). The resident presented to the ED with shortness of breath since this morning. The note indicated EMS states on arrival to the nursing facility the resident had a D-Stick (glucose reading) of 22 and was given [MEDICATION NAME] with slight improvement to 29. EMS was unable to obtain an oxygen saturation (O2 saturation). The resident was positive for [DIAGNOSES REDACTED]. At 9:10 a.m. the resident was administered D50W 50ml ([MEDICATION NAME] 50% in water) pushed through an intravenous port and again at 10:40 a.m. The resident was transferred to ICU at 1:22 p.m. The ICU physician notes dated [DATE] indicated at 4:08 p.m. the physician indicated Resident #55 was presented to the hospital with decreased level of activity and shortness of breath. The physician recommended the resident be sent to another hospital for a higher level of care. During an interview on [DATE] at 9:28 a.m., the NP said she was not notified of Resident #55's 'Lo' FSBS on [DATE]. She said she was informed Resident #55 had a decreased level of consciousness and she ordered to send the resident to the ER. She said she did not order [MEDICATION NAME] and the facility usually just wrote orders without consulting her and sent them for her signature. The NP said if she had she been notified of the 'Lo' result on Resident #55's FSBS, she would have told them to give her something and send her out. She said she would not expect anyone with an FSBS result below 20 to be conscious enough to tolerate anything liquid by mouth. She said the facility should have notified someone of the Lo result. During an interview on [DATE] at 10:01 a.m., the medical director said a resident whose blood sugar was below 20 would require emergent action. She said the nurse should have given [MEDICATION NAME], notified the attending physician and notified EMS. She said there was a protocol in place to treat [DIAGNOSES REDACTED], she said a nurse must use critical thinking and know what to do when the glucose was critically low. She said she would not expect a resident with a blood sugar less than 20 to be fully conscious, and liquids by mouth would be contraindicated due to the risk of aspiration. She said 2 hours was too long to go before notifying a primary care physician of a critical low blood sugar. During an interview on [DATE] at 11:01 a.m., the DON said LVN B should have recognized that a 'Lo' reading on the glucometer indicated a glucose level of less than 20 which was a critical level. She said the nurse should have notified the physician for any value less than 60. The DON said for a critical level, the nurse should have administered [MEDICATION NAME] 1 mg intramuscular (IM), notified the physician, and called EMS to transfer the resident to the hospital. The DON said the nurse should have followed the standing orders provided by the primary care physician. During an interview on [DATE] at 10:03 a.m., the administrator said she was sure the staff had been in-serviced on FSBS and should follow the standing orders. She said all staff should be aware of the standing orders because they have been in place for a while now. The administrator said the protocols for low and high FSBS were in the medication administration book on each unit. [DIAGNOSES REDACTED] (Insulin Shock) policy dated ,[DATE] did not include procedures to follow in cases of critically low FSBS results or hypoglycemic crisis. The administrator, corporate nurse, and the DON were informed on [DATE] at 5:35 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was given to the facility on [DATE] at 5:55 p.m. The facility's Plan of Removal was accepted on [DATE] at 2:41 p.m. and included: *All licensed and registered nurses will be in serviced on [DATE] on the physician notification on changes in condition including glucose readings and vital signs outside of normal parameters. Nurses will be in serviced on facility glucometers and that a reading of Lo is below 20. The facility has educated that a FSBS of Lo or below 20 is a critical value and should be treated as a medical emergency by calling emergency services. To be completed by the DON on [DATE]. *100 Percent of all Diabetic residents that require FSBS have been audited to ensure no other residents were affected with FSBS less than 60 without appropriate interventions and follow up notification to physician. *The nurse that failed to notify the physician for two hours of critically low FSBS has been terminated. Done on [DATE] by the administrator. *All Licensed and Registered nurses will be tested on [DIAGNOSES REDACTED] and identifying signs and symptoms. To be completed by the DON and the administrator on [DATE]. On [DATE] at 4:51 p.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to lift the Immediate Jeopardy by: *The facility training included in-services [DATE] on recognizing the symptoms of hypo/[MEDICAL CONDITION], physician notification, Assure Platinum glucose levels and manufacturers guidelines. *9 nurses were interviewed from different shifts on the recognition of signs and symptoms of hypo/[MEDICAL CONDITION], recognition of values of 'Lo' readings on the glucometer and when to notify the physician. The nurses were able to verbalize the correct procedures. *5 other residents receiving FSBS were reviewed by surveyors. On [DATE] at 4:51 p.m., the administrator and corporate nurse were informed the Immediate Jeopardy was lifted: however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.