Every finding on record at Mason Creek Transitional Care of Katy

Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured a resident with pressure ulcer received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 (Resident #3) of 4 residents and 10 out of 41 days reviewed for quality of care, WCN A, LVN D, and LVN E did not provide wound care for Resident #1 for his buttocks and foot areas for the following dates: 7/6/25, 7/13/26, 7/18/26, 7/19/26, 7/21/26, 7/22/26, 7/24/26, 7/25/26, 7/27/26 and 8/3/2026.This failure could place residents at risk for unwanted pain, infections, and further decrease in quality of life. Findings: Record review of Resident #1's face sheet dated 08/19/2026, he was an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. Resident #1's medical diagnoses included Parkinson's Disease without dyskinesia (a progressive movement disorder of the nervous system with symptoms like tremors, stiffness, and impaired balance without dyskinesia (involuntary muscle movements)), peripheral vascular disease (a slow progressive disorder of the blood vessels (hollow tubes that carry oxygen to parts of the body), presence of cardiac pacemaker, type 2 diabetes mellitus without complications (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), hypertension (high blood pressure) and polyneuropathy (nerve damage in limbs). Resident #1 was discharged to an acute care hospital on [DATE].Record review of Resident #1's most recent Quarterly MDS assessment dated [DATE], reflected he had a BIMS score of 3, indicating severe cognitive impairment related to thinking and memory. He was totally dependent on staff with ADLs like oral and personal hygiene, dressing, toileting and showering and required maximal assistance with eating. He was always incontinent of bowel and bladder. Resident #1 was coded as having a pressure ulcer/injury and was at risk of developing them and had one unhealed pressure injury and two stage 4 injuries (stage 4 being full thickness tissue loss with exposed bone, tendon or muscle and could include tunneling) and was receiving pressure injury care. Resident #1 was coded as being on an antibiotic at the time.Record review of Resident #1's care plan last captured 08/19/2026, reflected he had the following focus areas related to wound care and skin:-Date initiated 05/01/2024 and last revised 08/06/2026, he was at risk for impaired circulation r/t elevated cholesterol and had pitting edema (fluid buildup) to the RLE and arm with Cxray and IV ABT ordered and interventions including administering medication as ordered and elevating legs when resting as much as possible.-Date initiated 2/4/2026 and last revised 7/6/2026, he was at potential risk for nutritional problem r/t altered texture diet, dementia dx, Parkinson's, DM and had interventions including RD eval and f/t and monitor/record/report to MD PRN s/sx of malnutrition like emaciation, muscle wasting and significant weight loss, and provide assistance with meals as needed.-Date initiated 2/11/2026, resident at risk for pressure injury, ulcer, skin breakdown d/t impaired mobility and self-care deficits, with interventions including call light within reach, encourage fluid intake and assist to keep skin hydrated and notify nurse of any new areas of skin breakdown during bath or daily care.-Date initiated 4/3/2026 and last revised 8/10/26, Resident #1 had open wounds to bilateral heels/foot with tx order added, 4/9/2026 he had stage 4 pressure ulcer to distal (away from the body), plantar (connective tissue supporting the foot arch) foot and DTI to right, proximal (closer to the body), lateral (furthest from the center, therefore the outer edge of the foot) foot, 4/30/2026 he had a stage 3 right proximal lateral foot injury, 7/16/26 right distal, plantar foot resolved, 7/23/2026 DTI, right heel stage 3 acquired 7/9/2026, 7/30/2026 right proximal lateral foot is unstageable, right heel is a stage 4, with interventions including administering treatments as ordered and monitor for effectiveness and monitor dressing to ensure it is intact and adhering and report loose dressing to Treatment nurse.-Date initiated 7/16/2026, Resident #1 had a stage 3 pressure ulcer to bilateral buttock acquired on 6/15/2026, tx order in place with interventions including administering treatments as ordered and monitor for effectiveness. -Date initiated 7/16/2026, Resident #1 had a stage 3 pressure ulcer to right lower leg acquired on 6/4/2026, tx in place, with interventions including administering treatments as ordered and monitor for effectiveness.-Date initiated 8/10/2026, Resident #1 had a DTI to left, posterior lower leg acquired 8/1/2026, tx order added with interventions including administering treatments as ordered and monitor for effectiveness and turn and reposition as tolerated. Record review of Resident #1's Braden score for risk of pressure injuries assessments reflected:-On 07/12/2026 he had a score of 14, indicating moderate risk.-On 07/19/2026 he had a score of 11, indicating high risk .Record review of Resident #1's skin assessments reflected:-06/23/2026 he had a wound to the lower right leg and pressure injury to sacrum with TX in place and tolerating well.Record review of Resident #1's Physician Order Summary:-Barrier cream to open area on the buttocks with a start date of 01/14/2026-Cleanse stage 3 pressure injury to right lateral foot with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift with a start date of 06/30/2026 to 08/10/2026.-Cleanse stage 3 pressure injury to the lower leg with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift with a start date of 06/30/2026 to 08/10/2026.-Cleanse stage 3 pressure injury bilateral buttocks with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift, with a start date of 06/30/2026 to 08/10/2026. -Cleanse stage 3 pressure injury right plantar foot with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift with a start date 06/30/2026 to 08/10/2026.-Left great toe discoloration with 2nd toe dry eschar (piece of dead tissue cast from the skin surface), right foot dorsum dry eschar, cleanse with NS, apply skin/prep Betadine, LOTA one time a day for PAD (peripheral arterial disease), discoloration with a start date of 07/14/2026.-Liquid protein two times a day for weight loss, wound healing 50ml BID with a start date of 7/7/2026 to 8/6/2026 -Liquid protein two times a day for weight loss, wound healing 60ml BID with a start date of 8/6/2026 to 8/10/2026 Record review of Resident #1's progress notes for July and August 2026, reflected there were no notes stating wound care was done for the missing dates of 7/6/25, 7/13/26, 7/18/26, 7/19/26, 7/21/26, 7/22/26, 7/24/26, 7/25/26, 7/27/26 and 8/3/2026.Record review of Resident #1's July and August 2026 MAR/TAR reflected the following:-Cleanse stage 3 pressure injury to right lateral foot with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift. Wound care was not documented as being completed on 7/6/2026 (WCN A), 7/13/2026 (LVN D), 7/18/2026 (LVN D), 7/19/2026 (LVN D), 7/22/2026 (LVN D), 7/24/2026 (LVN E), 7/27/2026 (LVN E) and 8/3/2026 (LVN E).-Cleanse stage 3 pressure injury to the lower leg with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift, it was not documented that Resident #1 received wound care on 7/6/2026 (WCN A), 7/13/2026(LVN D), 7/18/2026(LVN D), 7/19/2026(LVN D), 7/22/2026(LVN D), 7/24/2026(LVN E), 7/27/2026(LVN E). Order date was 06/29/2026 and discontinued date was 08/18/2026.-Cleanse stage 3 pressure injury bilateral buttocks with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift, it was not documented that Resident #1 received wound care on 7/6/2026 (WCN A), 7/13/2026(LVN D), 7/18/2026(LVN D), 7/19/2026(LVN D), 7/22/2026(LVN D), 7/24/2026(LVN E), 7/25/2026(LVN D), 7/27/2026(LVN E) and 8/3/2026(LVN E).-Cleanse stage 3 pressure injury right plantar foot with NS or wound cleanser, pat dry, apply calcium alginate and cover with dry dressing every day shift, it was not documented that Resident #1 received wound care on 7/6/2026 (WCN A), 7/13/2026(LVN D), 7/18/2026(LVN D), 7/19/2026(LVN D), 7/22/2026(LVN D), 7/24/2026(LVN E), 7/27/2026(LVN E). Order date was 06/29/2026 and discontinued date was 08/10/2026.-Left great toe discoloration, it was not documented that Resident #1 received wound care 7/18/2026(LVN D), 7/19/2026(LVN D), 7/22/2026(LVN D), 7/24/2026(LVN E), 7/27/2026(LVN E) and 8/3/2026(LVN E).Resident #1 had no pain when assessed in his MAR July 2026.Record review of Resident #1's physician wound care notes reflected:-7/9/2026, his wounds on his buttocks, right, distal, plantar foot, right proximal, lateral foot and right lower legs were treated. There were no changes to his wound progression.-7/16/2026, his wounds on his buttocks, right proximal, lateral foot, right lower legs and right heel were cleansed and treated. Resident ##1 had poor appetite. His bilateral buttocks were deteriorating, his right, distal, plantar foot was improving, and right, proximal, lateral foot and right lower leg had no change. Resident #1's wounds on the right lower leg and right heel were debrided with family member consent and physician noted that possible debridement on follow-up visits would be done as needed.-07/23/2026, his wounds on his buttocks, right proximal, lateral foot, right lower legs and right heel were treated. The wounds on his buttocks were improving, his right, proximal, lateral foot had no change, his right lower leg was improving and right heel had no change. Resident #1 had an initial exam for left heel pressure ulcer. The physician performed debridement on his right lower leg and right heel.-07/30/2026, his wounds on his buttocks, right proximal, lateral foot, right lower legs, and bilateral heels were treated. Resident #1's wounds on his buttocks were deteriorating, his right lateral foot had no change, his right lower leg was improving, and there were no changes to his bilateral heels. -08/06/2026, his wounds on his buttocks, right proximal, lateral foot, right lower legs, bilateral heels and posterior lower leg were treated. The wounds on his buttocks were improving, his right lateral foot had no change, his right lower leg was deteriorating, the right heel was improving, the left heel was deteriorating. He had further debridement of his right lower leg.Interview on 08/19/2026 with LVN O at 9:33a.m., LVN O said the facility did not have a wound care nurse for two weeks and no one reported to nurses they needed to do the wounds. LVN O said Resident #1 went to see his cardiologist and due to the wounds' severity, the cardiologist sent Resident #1 out to the hospital. LVN O said WCN A did the initial skin assessments and wound care, but was asked to work PRN, stopped doing wound care, and was last at the facility 2-3 weeks ago. LVN O said she did not think Resident #1's wound care was done, even if it was documented, due to him being sent out. Interview with CNA H on 08/19/2026 at 12:52p.m., she said she went with Resident #1 to his cardiology appointment. Resident #1 was observed by CNA H to be bleeding out due to the leg wounds, but CNA H did not remember where the bleeding was from, only it came from Resident #1's feet. The wound care nurse at the office unwrapped, cleaned, and rewrapped Resident #1's wounds, but the bleeding did not stop, and the nurse was concerned with infections, so the office sent Resident #1 to the hospital. CNA H said Resident #1 appeared calm during the entire time but did not think he could feel pain in his legs. CNA H said she remembered WCN A's last day at the facility was 07/31/2026, but did not know if wound care was being done. Interview on 08/19/2026 at 10:24p.m., LVN G said that Resident #1 had skin assessments done during the day per the weekly skin schedule printed out for nursing staff. LVN G said nurses were responsible for assessments, and any staff who saw skin concerns, should report it to the nurse. LVN G said they had a wound care nurse on and off, but when the facility did not have a wound care nurse on site, it was communicated to nurses through a group communication channel that the nurses needed to do wound care for residents. LVN G said nurses should be checking residents' physician orders as well and those things should have also been communicated during shift changes. LVN G said if care was not documented it was not done and not doing wound care could have resulted in skin breakdown or sepsis. LVN G was not aware of when the wound care nurse permanently left. LVN G said Resident #1 had changes in condition in the last few months and declined as his Parkinson's progressed. Staff would turn him every two hours, but he did not want to eat but did take his liquid protein. LVN G said Resident #1 had recurring infections and refused to drink water and had UTIs. Interview with Resident #1's family member on 08/19/2026 at 2:50p.m., he said that staff would give him updates on wounds since Resident #1 was admitted but the frequency of updates would depend on the staff. The family member did not have concerns as he did not really come up to the facility as often as he liked but did not think Resident #1's wounds were that bad based on staff updates. He said staff told him the wounds were not getting better. The family member said Resident #1 was sent to the hospital directly from his cardiology appointment due to concerns about his wound. The family member said Resident #1's wounds were cleaned out at the facility and that the hospital cleaned out the wound there too. The hospital told the family member that his wounds were most likely not going to improve. Resident #1 had open wounds, had resistant bacteria in the wounds, and was not getting circulation due to his comorbidities.Interview with ADON P on 08/19/2026 at 3:11p.m., she said Resident #1 was supposed to get a g-tube inserted at the hospital for poor nutrition, but he went to the hospital for his wounds. Resident #1's wounds were not healing, and ADON P said it was because he was not eating much, and that his diagnoses of peripheral vascular disease and diabetes contributed to that. ADON P said she could not recall when wound care was not provided for Resident #1. Interview with WCN B on 08/20/2026 at 9:36a.m., she said she had the DON and ADON show her how to do wound care and the previous wound care nurse, WCN A, was communicating with her through text messages. WCN B started on 08/17/2026.Interview with LVN D on 08/20/2026 at 9:55a.m., she said WCN A was the wound care nurse, had been gone for 2-3 weeks, and since then, floor nurses did wound care. LVN D said she never did weekly skin assessments and that was the wound care nurse's responsibility. LVN D said she did not do wound care because she was not the one responsible for doing it, and that it was WCN A's job until a few weeks ago. Interview with the DON on 08/20/2026 at 10:01a.m., she said that Resident #1 was declining and had lowered nutritional intake which made it hard for his wounds to heal, and the wounds would fluctuate in healing stages. WCN A was doing wound care consistently before she left a few weeks ago and WCN A documented in wound care log or in resident chart.Attempted interview with LVN E on 08/20/2026 at 10:06a.m., left a voice message. LVN E received a text for a returned call at 10:08a.m. and did not call back as of exit.Interview with WCN A on 08/20/2026 at 10:40a.m., she said she was demoted in July 2026, and stopped doing wound care around 07/15/2026 onward. WCN A said she never trained new staff on wound care nor had she been at the facility since August 2026. WCN A said wound care was documented in the TAR, and her job was also to ensure dressings were changed daily, had the date written on the bandage, and she would round with the wound doctor once a week. WCN A said if wound care was not documented, she would not know if it was done and that staff should not do things without documentation. Observation and interview with Resident #1 and RN T on 08/20/2026, Resident #1 was in the hospital, had his eyes closed and appeared to be resting and in no apparent discomfort. He was connected to IV antibiotics and g-tube. Resident #1 was not interviewable. There were wedges behind the left side of his head and below both feet. RN T said that he was Resident #1's admitting nurse and that Resident #1 came in with a primary diagnosis of wound infection. RN T said that Resident #1 was in excruciating pain at the time and was currently at the hospital for wound care to his leg, sacrum and heels, and for pain management. Resident #1's heels gave him the most pain. Interview with the wound care physician on 08/20/2026 at 1:19p.m., he said Resident #1 was declining overall mostly because he did not want to eat or drink food, even when he was offered assistance, which was why Resident #1's physician recommended he get a feeding tube. The physician denied that Resident #1 ever had uncontrolled bleeding during wound care even during debridement. The physician said Resident #1 would develop new wounds sometimes and his wounds worsened weekly. The physician said when the wound care nurse switched to working PRN, there was no replacement, so floor nurses took or outside wound care nurses would cover dressing changes and wound care. The physician said regarding wound care not being documented, he said it could have been done but that it should have been documented. The physician said the wound could drain into the bandage and cause skin to become macerated (cause to become wet or soaked) and if there were multiple days in a row Resident #1 was not getting dressings changed, it could cause skin breakdown. Interview with the DON on 08/20/2026 at 1:49p.m., the DON said that WCN A was the designated wound care nurse for all of July 2026, and she was let go for not documenting. The DON said the ADONs now were responsible for doing omission audits every morning, and when they noticed any, they would go and verify. The DON said she was responsible for monitoring the ADONs. The DON said since she did not physically witness the dressing changes being done or not, she could not say it was done. If wound care was not done multiple days in a row, the DON said there could have been potential issues. Interview with the Administrator on 08/20/2026 at 2:55p.m., he said his expectation was that care should be thorough, clear and complete, and that there should be correct documentation. Record review of the facility's policy titled Skin and Wound Monitoring and Management last revised December 2025, read in part, The purpose of this policy is that the facility provides care and services to:1.Promote interventions that prevent pressure injury development;2.Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and3.Prevent the development of additional, avoidable pressure injury.5.Treatmenta.Continue preventive measures as appropriate, including but not limited to: Pressure reduction Continence care Mobility Nutrition management Hydration managementb.Re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after 14 days or any time a wound is worsening.Record review of the facility's policy titled Charting and Documentation last revised April 2008, read in part, Policy StatementAll services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.Policy Interpretation and Implementation1.All observations, medications administered, services performed, etc., must be documented in the resident's clinical records.6.Documentation of procedures and treatments shall include care-specific details and shall include at a minimum:a.The date and time the procedure/treatment was provided;b.The name and title of the individual(s) who provided the care;c.The assessment data and/or any unusual findings obtained during the procedure/treatment;d.How the resident tolerated the procedure/treatment;e.Whether the resident refused the procedure/treatment;f.Notification of family, physician or other staff, if indicated;g.The signature and title of the individual documenting.

Based on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices on each resident that are complete and accurately documented for 1 of 5 (CR#1) residents reviewed for clinical records. The facility failed to maintain a complete and accurately documented clinical record for CR#1. This failure could place residents at risk of not getting the care and services to improve their quality of life due to not maintaining complete and accurate clinical records.Record review of CR#1's face sheet dated 5/14/2026 revealed the resident was admitted to the facility on [DATE]. His diagnoses included disorders of kidney and ureter(impair urine production filtration or drainage), muscle spasm (involuntary contraction of the muscles), urinary tract infection (bacterial infection of the urinary system), severe sepsis with septic shock(a severe infection that triggers an extreme immune response where blood to vital organs is reduced), benign prostatic hyperplasia with urinary tract symptoms (a noncancerous enlargement of the prostate gland), and, malignant neoplasm of left kidney and hypothyroidism(a cancerous tumor originating in the left renal tissue). Record review of CR#1 quarterly MDS dated [DATE] revealed he had a BIMS Score 15 indicating he was cognitively aware. He was coded as having a catheter and was incontinent of bowel. Record review of CR #1's physician order dated 1/15/2026 revealed orders:1. Suprapubic catheter care every shift, monitor suprapubic insertion site for signs and symptoms of skin breakdown, pain, discomforts, unusual odor, urine characteristic or secretions and catheter pulling causing tension every shift day and night.2. Secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow. Check placement every shift. Record review of the treatment administration record for CR#1, revealed there were blanks on the following dates: Day shift at 6:00am - 6:00pm4/1/2026, 4/2/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/15/2026, 4/16/2026, and 4/17/2026. Night shift at 6:00pm-6:00am 4/5/2026. Day shift 6:00am - 6:00pm4/1/2026, 4/2/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/15/2026, 4/16/2026, and 4/17/2026. Night shift 6:00pm - 6:00 am.4/5/2026. Record review of CR #1's physician order dated 4/25/2026 revealed Tizanidine HCL oral Tablet 2mg. Give one tablet by mouth two times a day for muscle spasm, rigidity and pain at 8:00am and 8:00pm. Record review of CR #1's physician order dated 1/15/2026 revealed an order for Tylenol Oral Tablet 325 mg (acetaminophen), Give two tablets by mouth every 6 hours as needed for pain. Record review of CR #1's MAR for April 2026 revealed no documentation that Tizanidine oral tablet 2 mg for muscle spasm and pain or Tylenol 325mg for pain to be given as needed. Record review of the MAR for April 2026 revealed the following:There was no documentation that PRN Tylenol was given on 4/25/2026 in the AM. The PRN Tylenol was last documented as given was on 4/24/2026 at 3:59pm by LVN T when CR#1's pain level was 7.There was no documentation that the one-time dose of Tizanidine 2mg was supposedly given on 4/25/2026 in the AM. Record review of nurse's notes dated 4/25/2026 at 5:20AM, written by RN A revealed documentation that Tylenol was not effective, however there was no documentation in the nurse's notes or the MAR that the medication was given. In an interview on 5/13/2026 at 12:05pm LVN T said she was the morning nurse who relieved the night nurse RN A. She said the night nurse told her CR#1 was in pain, and she gave him PRN Tylenol, and it was not effective and she called the NP and he told her to give CR#1 a one-time dose of Tizanidine and she should change the Tizanidine 2mg from once a day to Tizanidine 2mg twice a day for pain. In an interview on 5/13/2026 at 4:42pm with RN A she said CR#1 was groaning and she gave him PRN Tylenol, and it was not effective. She said she called the NP and informed him the Tylenol was not effective and he told her to give him a one-time dose of Tizanidine and then change the order to BID Tizanidine. She said she gave CR#1 the one-time dose of Tizanidine and the resident swallowed it and after he opened his mouth and she did not see any medication in his mouth. She said she documented the medication on the MAR and document in the nurse's notes. In an interview on 5/14/2026 at 9:20 am CR#1 said when he was at Facility J they did not change his suprapubic catheter once a month or clean his suprapubic catheter daily as ordered by his physician. He said regarding him not getting his medications on the day he was sent to the hospital he said he could not recall because he was in a coma. In an interview on 5/14/2026 at 11:13AM NP B said sometime after midnight on 4/25/26 RN A call to say CR#1 was in pain because he was groaning and she gave him Tylenol and it was not effective. He said he told her to give him a one-time dose of Tizanidine 2mg and then change the order to two times a day. In an interview on 5/14/2026 at 1:40pm RN C said there should be no blanks on the MAR. She said in nursing if it was not documented it was not done. She said the nurse should also document the PRN Tylenol and the one-time order of Tizanidine. She said they were going to in-service the staff on blanks on the MAR and documentation. In an interview on 5/14/2026 at 5:10pm with the DON she said there should be no blanks on the MAR. She said they should document on the MAR and nurse's notes if medication was given or the resident refused medication. She said staff will be in-serviced on documentation of orders. Record review of the facility's Policy and Procedures titled Documentation dated 7/2025 read in part.Subject: Charting and DocumentationDefinition of RecordThe resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. It is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under the current law and regulations at the time of admission.Disciplines contributing to the record:1. Medicine2. NursingImportance and Use of The Record:1. To the resident it saves time if needed at a future date.2. To the institution it reflects the quality of care given to the resident.3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care.6. To the nurse, it provides a multidisciplinary record of the physical and mental status of the resident.Rules for ChartingNotes are to be written on long-term residents as determined by the individual nursing service. Daily notes are required when the needs arises.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for two of eight medication carts observed for medication security. -An unlocked and unattended medication cart was observed in a resident hall (Hall 400). -An unlocked medication cart (Hall 300 Nurse's medication cart) was observed near the nurses' station, with the assigned nurse in another room with her back turned.The failure placed the residents at risk of drug diversion by staff, residents, and visitors, overdose, or residents' medications not being available when needed. Findings included:Observation and interview on 03/12/2026 at 08:19 a.m. revealed an unlocked and unattended medication cart in front of a resident's room. The room was the most distant from the nurses' station, located near the hall exit. The doors of the residents' rooms near the medication cart were observed to be closed. There were no staff within sight of the cart. At 08:21 a.m., LVN A exited room [ROOM NUMBER] into the hallway. She said she had been in the room for between 10 and 15 minutes. She said she should have locked the cart. She said any person could have gotten into the cart. In an interview on 03/12/2026 at 10:42 a.m., the DON said the medication cart should be locked if the Nurse or Medication Aide was in a room. She added that if the cart was left unlocked, anyone could get into the contents.Observation and interview on 03/12/2026 at 12:41 p.m. revealed an unlocked medication cart at the nurses' station, near the 300 Hall. The surveyor stood next to the unlocked cart for approximately 30 seconds. A nurse from the other side of the nurses' station approached the cart and locked it. She said it was not her cart. She then went to the dining room and alerted LVN B, who was sitting at a table with her back to the nurses' station. The DON approached the medication cart as did LVN B. The DON said she had provided an in-service that day about locking medication carts. LVN B then said she had seen the surveyor standing by the medication cart. When the surveyor asked LVN B how long he had been standing by the cart, LVN B replied, Five minutes. A long time. The surveyor informed her he had been next to the cart for approximately 30 seconds. Record review of the in-service dated 03/12/2026 revealed the topic Keeping Medication Carts Locked at All Times revealed LVN A and LVN B both attended.The facility's policy Security of Medication Cart (revised April 2007) read, in part, . The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.4. Medication carts must be securely locked at all times when out of the nurse's view.

Based on observation, record review and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. - The facility failed to ensure food was labeled and dated. - The facility failed to ensure that food was off the floor in the dry food area. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation on [DATE] at 08:53 AM, revealed in 1 of 1 walk in refrigerator a metal bowl with clear plastic wrap with a with no date or item description. [NAME] B took the bowl out of the refrigerator. Observation on [DATE] at 08:56 AM, revealed on the floor of 1 of 1 walk in pantry a 24-ounce (oz), less than a 25 precent (%) full bottle of syrup dated ,d+[DATE] between 1 of 3 shelves on the right side of pantry and an 1-oz bag of chips was observed on the floor between the shelves near the wall. [NAME] A removed the syrup and bag of chips from the dry food storage area. Observation on [DATE] at 08:59 AM, revealed 1 of 1 standalone refrigerator had 9-glasses of milk with lids sitting on a tray with no label. In an interview on [DATE] at 08:50 AM, [NAME] A stated that he would oversee the kitchen until the Dietary Manager (DM) came on shift, and she would be on her way. During the initial tour of the kitchen in 1 of 1 walk-in refrigerator, [NAME] A stated he was not aware of what was in the metal bowl. He turned to [NAME] B and asked what was in the bowl. [NAME] A stated he had not seen the syrup on the floor in the dry food storage areas. He stated he does not know how long the syrup could have been there. When asked could it have been there since [DATE]th of this year, he stated it could have, but if he had seen it, he would have gotten it up. He stated he was not aware of how long the bag of chips were on the floor. In an interview on [DATE] at 08:53 AM, [NAME] B stated that the food item in the metal bowl was beef tips she had been marinating from a left-over dinner. When asked what day the beef tips were prepared, [NAME] B stated, the other day. When asked why they were in the refrigerator undated, she stated that she would throw them out. In an interview on [DATE] at 08:56 AM, [NAME] A stated that the milk in the 1 of 1 standalone refrigerator was poured the night before in preparation for the morning meal. He stated that he there was a label on the milk tray. [NAME] A looked but could not find a label. [NAME] A stated there should have been a labeled on the tray so that they knew when the milk was old and should not be served to residents that would make them sick. [NAME] A stated that the label was on a tray in the dish area and he had just changed out the trays after milk had spilled on the tray. In an interview on [DATE] at 12:25 PM, Dietary Manager (DM), stated that the meat in the metal bowl were beef tips, prepared for residents on [DATE]. She stated that food not prepared and not cooked was only to be stored for 3-days and thrown on the 3rd day. She stated that [DATE] was the last day for the food to be stored and it was to have been thrown away. She stated it was her expectation when there was left over meat from a meal that it be thrown away the same day. She stated that [NAME] B told her that the beef tips were saved to serve as an alternative meal if needed, and the date and description of the item was written on the label. She stated that [DATE] was the 3rd day and the day the item would have to be thrown away. She stated that she was not aware of the items on the floor in the dry storage area. She stated that [NAME] A told her that he was in the process of relabeling the milk when the State surveyor entered the kitchen and had not relabeled the milk tray because he toured the kitchen with the surveyor. She stated it was her expectation that no interrupt should deter staff from labeling food items and all food items were to be labeled before storing. She stated it was also her expectation if staff saw food items on the floor that they would immediately throw them away. She stated the importance of labeling food was to ensure that residents were not served outdated or expired food that could make them sick. She stated that importance ensure food items were off the floor were to ensure that residents were not served contaminated and expired food that would make them sick and to ensure not to attract pests. In an interview on [DATE] at 02:14 PM, with the DON and Operations Manager (OM) the OM stated that all food should be labeled to know when the items expired, and to know when it would expose danger to residents. The DON stated failure to label could cause the food not to taste good and make the residents sick. Record review of facility menu dated Saturday, Week 1, revealed that braised beef tips with gravy were served for lunch (,d+[DATE], 2024). Record review of facility in-service dated [DATE] at 01:00 PM, with the dietary department revealed: Staff make sure no chip, or item are on dry storage floor. If there is, please put in the trash immediately. Do not put back on shelf. Record review of facility policy titled Control Policy/Procedure and dated ,d+[DATE], revealed: Section: Dietary Services Subject: Food Storage POLICY: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. PROCEDURES: 2. All foods or food items not requiring refrigeration shall be stored at least six (6) inches above the floor and at least eighteen (18) inches from sprinkler heads, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be kept clean and dry at all times.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed: - A roach was observed on a wall in the kitchen where food was being prepared for residents. These failures could place residents at risk for infections. The findings included: In an observation on 12/10/2024 at 11:39 AM, while [NAME] B was preparing soft mechanical food a semi-large roach crossed the wall in front of her and went behind a food mixer on the counter less than an arm's reach away. In an interview on 12/10/2024 at 11:39 AM, [NAME] B stated that she seen the roach on the wall while preparing food. She stated that she had seen roaches in the kitchen, but not a lot. She stated she last saw a roach about 1.5 months ago. She stated that when she saw pests in the kitchen, she informed the DM who informed maintenance. In an interview on 12/10/2024 at 11:41 AM, the DM stated that she had seen the roach on the wall while [NAME] B was preparing food. She stated that pest control services the kitchen every 2-weeks. She stated that the facility just switched to a new pest control company because the previous company's services were not working. In an interview on 12/10/2024 at 12:25 PM, DM, stated that she kept her kitchen clean, and maintenance was informed of the pest sighting in the kitchen. She stated that importance of reporting pests to maintenance was to keep the kitchen free of rodents and maintain infection control. In an interview on 12/12/2024 at 02:14 PM with the OM he stated they just switched pest control companies and the new company just serviced the kitchen on 12/11/2024. He stated when they learned of a roach siting on 12/10/2024, the FMD called the pest control company, and they came out. He stated there have not been any further pests siting since 12/10/2024 in the kitchen. He stated that all facility staff know to contact the Facility Maintenance Director (FMD) and report pest control issues to him immediately. He stated that residents' health and safety could be impacted if they failed to address pest control issues. In an interview on 12/12/2024 at 02:21 PM, the FMD stated that he had been with the facility for 18-years. He stated that they have a new pest control company servicing their pest needs. He stated that the previous company only laid pest compound on the outside of the facility. He stated the previous pest company told them their chemicals were not safe for indoor use and could harm the residents if they came into contact. He stated he had received reports of roaches, spiders, and tiny sugar ants and knew the company's product was not working. He stated as a result, they switched back to their original company about a month ago and they had not had any pest sightings since. He stated that clinical staff reported pests' issues to him directly or by adding it to a maintenance logbook kept at the nurse's station. He stated he checked the book twice a day, once in the morning and once in the evening. He stated the non-clinical, housekeeping staff sometimes reported issues to him through the facility communication app, whenever they seen any pests in the rooms. He stated whenever sightings were reported, he called the pest company to come out and spray immediately. He stated the facility also had an in-house pest chemical they used to spray. He stated the issues began when residents admitted with their own personal mini refrigerators. He stated that refrigerators are roach magnets. He stated that he had made it procedure that when new admissions admitted with refrigerators, they were to be placed out back for his inspection prior to being placed in the room. He stated that the admission team were aware of the procedure and were in full compliance. He stated he conducted an in-service on pest control at the facility's last all staff meeting, which he could not recall the date or time. He stated not addressing pest issues would be unsafe for the resident's health, and residents would not want pests near them. In an interview on 12/12/2024 at 03:26 PM, LVN H stated she works the 1st shift at the facility since May of 2024. She stated that she had not become aware of any pest control issues in the facility and had she, she would immediately report to FMD. She stated that the facility provided an in-service on pest control about a month ago. In an interview on 12/12/2024 at 03:32 PM, CNA R stated she works full-time, PRN for the facility. She stated that she had seen some roaches in the employee breakroom about 4-weeks ago and immediately reported the issue to the FMD. She stated that she received an in-service 2-weeks ago on pest control. Record review of pest service report dated 11/19/2024 and 12/05/2024, revealed that the facility was serviced for pest control in the interior and exterior areas and finding zero pest activity. Record review of facility in-service dated 12/10/2024 at 01:00 PM, with the dietary department revealed Report all rodent issues to manager, if manager not available report to assistant. Manager will report to maintenance. Recommendations/follow-up: maintenance were notified. Conducted by the DM. Record review of undated facility policy titled: Pest Control Policy/Procedure revealed: Subject: Pest Control. Policy: It is the policy of this facility provide an environment free of pests. Procedures: 1. The facility will have a pest control vendor contract that provides treatment of the environment for pests. 2. The pest control visits will occur at least monthly. 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility's state. 5. Pest control problems will be reported prompt. Tag: S/S= Surveyor Name(s): Immediate Supervisor:

Based on observations, interviews, and record review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 (Residents #66) of 1 Residents reviewed for peripheral intravenous care. The facility failed to ensure Resident #66 had a physician order or care plan for the care and monitoring of her midline. The facility failed to ensure Resident #66's midline dressing was changed every 7 days per facility policy. The failures placed residents at risk of developing an infection. Findings included: Record review of Resident #66's face sheet dated 12/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) dementia, abnormal weight loss, chronic kidney disease, constipation, dysphagia (difficulty or discomfort swallowing), cognitive communication deficit, acute osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and cystitis (inflammation of the bladder). Record review of Resident #66's Admission MDS dated [DATE] revealed she did not have a BIMS score. Resident #66 was not admitted on antibiotics. Record review of Resident #66's physician orders dated 12/2024 revealed on .Piperacillin-Tazobactam in Dex Solution 2-0.25GM/50ML dated 11/27/24 insert midline for IV tx for osteomyelitis dated 11/29/24. Resident #66 did not have physician orders to address the care or monitoring of the midline and bandage change. Record review of Resident #66's care plan dated 11/2024 revealed I am on Piperacillin-Tazobactam in Dex Solution 2-0.25 GM/50ML Use 2.25 gram intravenously every 8 hours for sacral wound osteomyelitis for 6 Weeks via midline. Resident #66's care plan did not address the care or monitoring of the midline and bandage change. Observation on 12/10/24 at 2:55 PM Resident #66's midline dressing change by LVN B revealed the midline site without redness, drainage, or swelling. During the dressing change, the nurse did not clean the site first with alcohol, instead cleaned with betadine first, cleaning the site back and forward, instead of starting at the site moving in a circle away from the site. In an interview on 12/10/24 at 1:42 PM LVN B said after observing the dressing to Resident #66's midline read 11/30. LVN B said the dressing to the resident's midline was outdated. LVN B said he believed the midline dressing was supposed to be changed every 2 weeks, but he would have to confirm with the DON or the ADON. LVN B said it was important to change the resident's midline when it was due to be changed to prevent infection. In an interview on 12/10/24 at 1:50 PM the DON said Resident #66's midline dressing was supposed to be changed every 7 days and PRN for infection control. Interview on 12/11/24 at 3:26PM LVN B said he did not think he did well when changing Resident #66's midline dressing because he did not clean the resident site first with alcohol in a circular motion moving away from the site. LVN B said this was supposed to be done to avoid re-introducing bacteria to the site. LVN B said the site should have been cleaned with alcohol first and then betadine. LVN B said the last time he received an in-service on midline dressing change was about a year ago at another facility. LVN B said the ADON informed him that he had to clean the midline dressing site first with alcohol followed with betadine. In an interview on 12/10/24 at 2:52 PM the MDS Nurse stated the DON initiated the care plans and the MDS Nurse assisted with completion. If a care plan needed to be updated the MDS Nurse would complete the update. Every morning she reviewed the change of conditions and order reports. When the physician orders were changed then she knew to update the care plan. She would not have known to update the care plan without an order change . In an interview on 12/10/24 at 3:29 PM the NP stated she may have put in Resident #66's order incorrectly. She sent an order for the midline insertion. She was going to speak with the DON because it should have been a batch order, the monitoring and care of the midline would show up in the physician orders . In an interview on 12/10/24 at 3:23 PM the DON stated Resident #66's physician order was entered by the NP, but the NP did not notify nursing staff, the DON, or put in standing orders for monitoring. The physician orders for monitoring and care were not in the system so the care plan was not updated. It was important to have physician orders to make sure staff were aware how to care for Resident #66's midline. The midline dressing should be changed every 7 days or if it was visibly soiled. In a continued interview the DON said, the DON and the ADON were responsible to monitor the physician orders and care plans, they had been focused on other issues. The DON and the ADON review new orders and change of condition daily, then the care plan will be updated based on those changes. In an interview on 12/11/24 at 2:33PM the DON said the ADON was also the Wound Care Nurse. The DON said LVN B had only been working at the NF for a few months. The DON said she completed training with LVN B on midline dressing changes with return demonstration. The DON said when cleaning the site of the midline, the nurse was supposed to clean the site with alcohol first to ensure the skin was clean and then clean with betadine/iodine for infection control. Record review of the Nursing facility policy on Midline Dressing Changes/Intravenous Therapy dated 08/30/2024 revealed in part: .The purpose of this procedure is to prevent catheter-related associated with contamination, loosened or soiled catheter-site dressings .Change midline catheter dressing every 7 days, or if it is wet, dirty, not intact, or compromised in any way .use aseptic technique when changing a midline catheter dressing .If using alcohol and iodine packages .use alcohol swabs first. Clean in concentric circles away from the catheter .Repeat the same process with iodine swabs. Do not remove iodine from the skin . Record review of the Nursing facility policy Physician Orders dated 11/13/18 revealed in part: It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedures) only upon written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care 6. Medication, treatment, or related orders are transcribed in the eMAR, eTAR accurately and verified.

Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 18 residents (Residents #66) reviewed for care plans. Resident #66 did not have a care plan in place for the care and monitoring of her midline. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Record review of Resident #66's face sheet dated 12/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) dementia, abnormal weight loss, chronic kidney disease, constipation, dysphagia (difficulty or discomfort swallowing), cognitive communication deficit, acute osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and cystitis (inflammation of the bladder) . Record review of Resident #66's Admission MDS dated [DATE] revealed she did not have a BIMS score. Resident #66 was not admitted on antibiotics. Record review of Resident #66's physician orders dated 12/2024 revealed on .Piperacillin-Tazobactam in Dex Solution 2-0.25GM/50ML dated 11/27/24 insert midline for IV tx for osteomyelitis dated 11/29/24. Resident #66 did not have physician orders to address the care or monitoring of the midline and bandage change. Record review of Resident #66's care plan dated 11/2024 revealed I am on Piperacillin-Tazobactam in Dex Solution 2-0.25 GM/50ML Use 2.25 gram intravenously every 8 hours for sacral wound osteomyelitis for 6 Weeks via midline. Resident #66's care plan did not address the care or monitoring of the midline and bandage change. Observation on 12/10/24 at 1:40PM revealed Resident#66 had a midline to her right arm. The date on the midline dressing read 11/30. In an interview on 12/10/24 at 2:52 PM the MDS Nurse stated the DON initiated the care plans and the MDS Nurse assisted with completion. If a care plan needed to be updated the MDS Nurse would complete the update. Every morning she reviewed the change of conditions and order reports. When the physician orders were changed then she knew to update the care plan. She would not have known to update the care plan without an order change . In an interview on 12/10/24 at 3:29 PM the NP stated she may have put in Resident #66's order incorrectly. She sent an order for the midline insertion. She was going to speak with the DON because it should have been a batch order, the monitoring and care of the midline would show up in the physician orders. In an interview on 12/10/24 at 3:23 PM the DON stated Resident #66's physician order was entered by the NP, but the NP did not notify nursing staff, the DON, or put in standing orders for monitoring. The physician orders for monitoring and care were not in the system so the care plan was not updated. It was important to have physician orders to make sure staff were aware how to care for Resident #66's midline. The midline dressing should be changed every 7 days or if it was visibly soiled. In a continued interview the DON, she said the DON and the ADON were responsible to monitor the physician orders and care plans, they had been focused on other issues. The DON and the ADON review new orders and change of condition daily, then the care plan will be updated based on those changes . Record review of the policy and procedure entitled Comprehensive Person-Centered Care Planning dated revision/review date(s):1.2022; 12.2023 read in part .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . to provide effective and person-centered care that meet professional standards of quality care.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and administering medications for 1 (Resident #78) of 8 residents reviewed for pharmaceutical services. -Medication Aide A failed to administer the correct dosage for Resident #78's transdermal nicotine patch. -Medication Aide A failed to rotate the transdermal nicotine patch on Resident #78's body. This failure placed the resident at risk for skin irritation and not receiving the full intended therapeutic dosage of the medication. Findings: Resident #78 Record review of Resident #78's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the NF on 10/22/24 with the diagnoses that included the following: fatigue, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid or bile {fluid produced by the liver and stored in the gallbladder that helps with digestion} that irritates the food pipe lining, respiratory failure, and hypertension (high blood pressure). Record review of Resident #78's Admission MDS dated [DATE] reflected a BIMS score of 13 indicating that resident cognition was intact. Record review of Resident #78's December 2024 Physician Oder Summary Report reflected the following order: -Dated 11/13/24 Nicotine Patch 24-hour 14mg/24HR apply 1 patch trans-dermally (medication that is absorbed through the skin into the blood stream) one time a day for smoking cessation and remove per schedule. Record review of Resident #78's MAR for the month of December 2024 reflected that the resident was being administered mediations per physician orders. Record review of Resident #78's Comprehensive Care Plan dated 10/23/24 reflected that the resident was being care planned for refusing rotation of the nicotine patch date initiated 12/12/24 that included the following interventions: -Allow to make decisions about treatment regimen, to provide sense of control. -Educate resident/family/caregivers of the possible outcome (s) of not complying with treatment or care. -Encourage resident to comply with rotation of nicotine patch to minimize risk of skin irritation. Observation on 12/10/24 at 9:38AM of Medication Aide A administered the medication nicotine transdermal patch 7mg to Resident #78. Medication Aide A removed the old patch on the resident's left upper arm and placed the new patch on the same area of the resident's left upper shoulder. In an interview on 12/12/24 at 10:30AM Medication Aide A said she made a mistake when administering Resident #78's nicotine patch by not administering the correct dosage. Medication Aide A said she administered to the resident 7mg instead of the ordered dose 14mg. Medication Aide A said it was important to rotate the resident's nicotine patch to avoid the risk of skin irritation. Medication Aide A said the reason she did not rotate the resident's nicotine transdermal patch was because the resident refused for it to be rotated. Medication Aide A said because she did not administer the correct dosage, the medication would not be as effective. Medication Aide A said she made a mistake. Medication Aide A said the 6 rights to use when administering medications were the following: the right patient, right medication, right dosage, right time, right route, and right order. Medication Aide A said the last time the pharmacist was at the facility, it was approximately a week ago, and observed her during medication pass. In an interview on 12/12/24 at 11:40AM the DON said the reason the medication patches should be rotated was to avoid any skin irritation. The DON said she would be conducting a medication in-service with Medication Aide A. Further interview with the DON, she said it was herself and the other ADON's that observed medication passes with the nursing staff and that the pharmacist came to the NF once a month to observe medication pass along with checking the medication carts. The DON said she just learned that Resident #78 was refusing for his nicotine transdermal patch to be rotated. The DON said she would provide a copy of Medication Aide A training and her last medication observation. Record review of Medication Aide A last observation of medication pass signed by the DON on 11/06/24. Interview on 12/12/24 at 2:26PM with Resident #78 said he never refused for his nicotine transdermal patch to be rotated. The resident said he did not have any problems with the staff rotating his patch on his body. Record review of the NF policy on Medication Administration---General Guidelines revised 11/13/18 reflected in part: .Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, the nurse/medication aide will verify the MAR with the order in the medical record .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 residents (Resident #78 and Resident #777) of 8 residents reviewed for infection control. -Mediation Aide A failed to sanitize blood pressure equipment after taking Resident #777's blood pressure. Medication Aide proceeded to take Resident #78's blood pressure. This failure placed the residents at risk for cross contamination, infections, and a decrease in quality of life. Findings: Resident #777 Resident #777 was a [AGE] year-old male admitted to the NF on 11/30/34. Resident #777's diagnoses included the following: hypotension (low blood pressure), dementia (memory loss and judgement), Alzheimer's disease (progressive disease that destroys memory and other mental functions), and hypertension (high blood pressure). Resident #78 Record review of Resident #78's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the NF on 10/22/24 with diagnoses that included the following: fatigue, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid or bile {fluid produced by the liver and stored in the gallbladder that helps with digestion} that irritates the food pipe lining, respiratory failure, and hypertension (high blood pressure). Observation on 12/10/24 during medication pass at 9:15AM of Medication Aide A taking Resident #777's blood pressure that was 122/79 and heart rate was 63. After taking Resident #777's B/P, Medication Aide A took the B/P equipment back to her medication cart without sanitizing the equipment. Observation on 12/10/24 at 9:23AM Medication Aide A went to Resident #78's room and took his B/P with the same B/P equipment with a blood pressure reading of 178/86 and heart rate of 63. When done, Medication Aide A took the B/P equipment back to her medication cart without sanitizing the equipment. In an interview on 12/10/24 at 9:40AM Medication Aide A said she was supposed to sanitize resident care equipment after each use to prevent cross contamination and infection control. Medication Aide A said she forgot to sanitize the blood pressure equipment. In an interview on 12/10/24 at 1:50PM the DON said the staff were supposed to sanitize all resident care equipment to prevent cross contamination and infections. Record review of the NF policy on Infection Control Prevention & Control Program revised 12/2023 revealed in part: .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .Reporting mechanisms for infection control .Effective and disinfecting equipment .

Based on observation, interview, and interview, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 9 residents (CR #1) reviewed for change of condition. The facility failed to notify CR #1's physician or seek medical guidance when he experienced a drop in oxygen saturation during physical therapy just after breakfast on [DATE]. At approximately 3:00 p.m., CR #1 experienced a drastic desaturation (a decrease in oxygen saturation, low blood oxygen concentration) to 53% after a shower and resulted in loss of consciousness, initiation of CPR, and intubation (a medical procedure that involves inserting a flexible tube into the trachea to help maintain an open airway). CR #1 expired on [DATE] on hospice at his home. An IJ was identified on [DATE] at 2:52 p.m The IJ template was provided to the facility on [DATE] at 2:52 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. This failure placed residents who experience a change of condition at risk of worsening of condition and possible death. Findings include: Record review of CR #1's face sheet, dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] from an acute care hospital. He was diagnosed with UTI (an illness in any part of the urinary tract), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), aphasia (a language disorder that affects a person's ability to communicate), acute and chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body [hypoxia] or when there is too much carbon dioxide in your body. It can happen all at once [acute] or come on over time [chronic]), and essential hypertension (a form of hypertension without an identifiable cause). CR #1 was discharged to an acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he was admitted from an acute care hospital on [DATE]. Record review of CR #1's BIMS dated [DATE] at 2:55 p.m. revealed he had a score of 0 (severe cognitive impairment). Record review of CR #1's Functional Abilities Admission assessment dated [DATE] revealed, MDS Reason for Evaluation: Admission/5-Day . Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury - Independent - Resident completed all the activities by themselves, with or without an assistive device, with no assistance from a helper . Prior Device Ise - Manual Wheelchair, [NAME] . Record review of CR #1's care plan dated [DATE] revealed the following care area: * ADL Self Care Performance Deficit. Goal included: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene with modified independence. Interventions included: Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders; Toilet Use: requires assistance; Transfers (Chair /Bed to Chair Transfer, toilet transfers: Requires staff participation with transfers; Bed Mobility: Requires staff participation to reposition and turn in bed; Encourage to participate to the fullest extent possible with each interaction; Bathing (Shower/Bathe Self): Staff will provide the required assistance needed for bathing; Personal Hygiene/Oral care: Staff will provide the required assistance needed for personal hygiene/oral care; Dressing: Requires staff participation to dress; Eating: Staff will provide the required assistance needed for eating as needed. Further review of CR #1's care plan revealed no focus/care area related to his respiratory condition or oxygen requirements/needs. Record review of CR #1's preadmission hospital records dated [DATE] revealed he was admitted to a local acute care hospital on [DATE] for weakness and was diagnosed with complicated UTI (any UTI that is not considered simple, and defined by the presence of underlying conditions rather than the severity of the infection), acute on chronic respiratory failure with hypoxia, acute toxic metabolic encephalopathy (a condition that causes global cerebral dysfunction, resulting in altered consciousness, behavior changes, and seizures), acute diarrhea due to E.coli (diarrhea caused by bacteria), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), pulmonary fibrosis (a condition in which the lungs become scarred over time), acute on chronic congestive heart failure (a type of heart failure that occurs when the heart has difficulty compensating for a loss of function that has developed over time) and history of CVA (a stroke; when blood flow to the brain is suddenly cut off) with global aphasia (a severe form of non-fluent aphasia caused by damage to the left side of the brain). The document read in part, . [CR #1] is a [AGE] year-old male with pulmonary fibrosis who was hospitalized for metabolic encephalopathy and atrial fibrillation with rapid ventricular response due to complicated UTI and infectious diarrhea. Patient improved with supportive measures including antibiotics and rate control. Patient was discharged in stable cardiology and pulmonology for continued evaluation and management as outpatient . Review of Systems . Respiratory: Negative for cough, shortness of breath, and wheezing . Respiratory/Pulmonary Interventions Documentation: . Respiratory Quality/Sounds: Dyspnea (shortness of breath) on exertion, dyspnea laying flat, dyspneic (having difficulty breathing or being unable to breathe without effort), tachypneic (fast breathing) . Respiratory/Pulmonary Interventions: O2 Delivery Method: Nasal cannula; O2 flow rate (L/min): 5 L/min . [DATE] . History of Present Illness . He was on baseline O2 of ,d+[DATE] L/min . Patient was admitted for further evaluation . He developed episode of a-fib and SOB/cough overnight, given breathing treatments and IV metoprolol (a medication used to treat high blood pressure, chest pain, and heart failure) . Currently he is resting in bed, no acute distress. On 6L/min via nasal cannula . Pulmonary and Critical Care Consult Note, [DATE]. Assessment: Chronic hypoxic respiratory failure with home oxygen dependence between 4 to 6 L/min at baseline, 8L with exertion . Pulmonary Progress Note: [DATE] . Patient states his breathing feels comfortable at his baseline oxygen requirement of 5L/min . He has been saturating at 100% . Record review of CR #1's Initial Admission Record dated [DATE] revealed LVN C wrote . Most Recent O2 saturation: 98% ([DATE] at 5:15 p.m.) Method: oxygen via nasal [cannula] . General Skin Condition: Normal - Yes, Pale/Ashen - No, Flushed - No, Cyanotic (bluish or purple discoloration) - No . Pulmonary System. Diagnosis: Does the Resident have a Pulmonary Diagnosis - No . Pulmonary System. Oxygen. Oxygen Use - No . Record review of CR #1's physician's orders for [DATE] revealed: * Check and record O2 Saturation every shift. Order Date: [DATE]. Start Date: [DATE]. * O2 at ,d+[DATE] L/Min Continuous per nasal cannula every shift. Order Date: [DATE]. Start Date: [DATE] Record review of CR #1's MAR for [DATE] (there was no MAR for [DATE]) revealed: * Check and record O2 Saturation every shift. There were no entries for this order. CR #1 was hospitalized . * O2 at ,d+[DATE] L/Min Continuous per nasal cannula every shift. There were no entries for this order. CR #1 was hospitalized . Record review of CR #1's progress notes for [DATE] revealed: On [DATE], LVN D wrote, At 5:15 p.m., patient arrived as a new admit to the facility via wheelchair with belongings . O2: 98% 5L of O2. NP notified of admit and verified orders and lab orders for CBC and BMP. Record review of CR #1's progress notes for [DATE] revealed: * On [DATE] at 1:57 p.m., LVN E wrote, COC for CO2 of 45 (normal range 21.0 - 31.0). Resident has a critical lab of CO2 45, NP informed and awaiting new orders. * On [DATE] at 6:08 p.m., LVN E wrote, Resident had just finished taking a shower when the CNA [CNA B] brought out the resident from the bathroom looking weak but breathing. This nurse told the CNA to take resident back to his room. Later this nurse was called by CNA that resident is not looking good. This nurse did a sternal rub (a painful stimulus used to assess a patient's neurological status and responsiveness) on patient and observed that the patient was still unresponsive and had a weak pulse. This nurse told CNA to call code blue. Patient was then transferred from shower chair to bed. Chest compressions began immediately. Staff members rushed in with crash cart at bedside and placed back board underneath. Another staff called 911, while using the non-rebreather to deliver oxygen. Another staff focused putting in a peripheral IV line for fluid. Blood sugar was checked. O2 sat 58% according to pulse oximetry. Resident started moaning and moving his lower extremities just before 911 ambulance arrived to take over. Resident was later taken to the hospital. * On [DATE] at 11:28 a.m., the DON wrote, IDT met to discuss [CR #1]. During review, it was noted that resident's order for O2 ,d+[DATE]LPM was incorrectly typed and should have been ,d+[DATE]LPM as resident order verified for ,d+[DATE]LPM upon resident admission with NP. Resident admitted ,d+[DATE] at approximately 5:15 from hospital on 5L of O2 [saturating] at 98% with diagnosis of Pulmonary Fibrosis, UTI, Aphasia . On ,d+[DATE], resident participated in physical therapy, speech therapy, and occupational therapy. During therapy session, resident was on 5L of oxygen and oxygen was monitored throughout session and remained between 86% and 95% on 5LPM per NC. Later in the day, around 3:00 p.m. resident was taken for a shower. Resident was taken to the shower with oxygen and remained on oxygen therapy throughout the duration of the shower. Shower CNA [A] stated that during his shower, he had his oxygen on, and was alert throughout the course of his shower. Towards the end, resident began to appear weak. CNA [A] called to CNA [B] to come assist. When CNA [B] was transferring the resident back down to his room, resident began to slump in his chair. CNA [F] assisted with getting resident to the room and called to the nurse for assistance with family at bedside. When the nurse arrived at the room, resident was unresponsive to stimuli, RN [E] called code blue and CPR was initiated. Oxygen was changed from NC to NRB and [O2] sat noted to be at 58%. 911 was called by other staff. When EMS arrived, resident had pulse and was responsive. Record review of CR #1's PT Evaluation and Plan of Treatment completed by the PT and dated [DATE] revealed, . Cardiopulmonary Assessment - At rest: . Oxygen saturation: 98 (on 5 L). Activity: Patient's rated/reported level of exertion = Patient is unable to communicate exertion felt during activity. Oxygen saturation with activity: 86 [%](on 5L) . Record review of CR #1's EMS records dated [DATE] revealed, . Call Received: 3:51 p.m. On Scene 3:59 p.m.Depart Scene: 4:41 p.m. Chief Complaint: Patient is a [AGE] year-old male with complaints of unconscious and respiratory distress. Patient is unconscious, cannot sit up and cannot ambulate with assistance . History: The issue with cardiac arrest began more than 5 minutes ago . Treatment (Plan): Stopped CPR and found spontaneous pulses and irregular respirations . SPO2 (4:06 p.m.: 89%), (4:16 p.m.: 96%) . Record review of CR #1's hospital records dated [DATE] revealed he was transferred from the facility to the ER then ICU of a local acute care hospital on [DATE]. He was intubated and was diagnosed with cardiac arrest (when the heart suddenly stops beating). The document read in part, . Brought in by EMS [from facility]. CPR in progress upon EMS arrival, staff was doing compressions. Patient was moving around and had a pulse but decreased respiratory effort . Physical Exam ([DATE]) General: He is in acute distress. Appearance: He is ill-appearing . Pulmonary: Patient is having assisted ventilation . Neurological: Unresponsive . Observation and interview with CR #1 on [DATE], at 2:45 p.m. revealed he was in the ICU at a local acute care hospital. CR #1 was intubated and opened his eyes to verbal stimuli. CR #1 did not attempt to communicate or make any gestures unless a family member spoke to him. There were multiple family members present at that time. Two family members stated they were present at the facility when CR #1 was admitted to the facility on [DATE]. Both family members stated they informed staff at the facility they would have to increase CR #1's oxygen to 6 - 8 L/min while he was in the shower as they had to do at home. The family members stated the DON told them staff had equipment in the shower to monitor CR #1's oxygen. One family member said CR #1 was able to tell them he remembered being at the facility, but he could not recall what happened in the shower. Another family member who only spoke Spanish (translated by an English speaking family member) stated CR #1 complained about the oxygen in that place and he told her through nodding and gestures that he did not have what he needed. CR #1 did not answer questions at that time. In an interview with the DON on [DATE], at 9:45 a.m., she stated CR #1 was admitted on [DATE] and was sent out on [DATE] when he coded in respiratory/cardiac arrest around 4:00 p.m. She said CR #1's oxygen saturation dropped significantly, and he was non-responsive. She said CR #1 received therapy on [DATE] and then he was taken to the shower. The DON said while CR #1 was going back to his room, he became week and then became unresponsive. She said CR #1 was on continuous oxygen and had it on the whole time he was in the shower. She said she investigated the incident after CR #1 was discharged to the hospital on [DATE]. She said CR #1 never went without his oxygen while he was at the facility. She said he transferred from the hospital on [DATE] on 5 L/min of oxygen. She said she verified with the nurses, CNA's and therapist that CR #1 was always on 5 L/min. The DON said she would have gotten a physician's order for more oxygen, but CR #1 was tolerating 5 L/min during exertion (she did not specify which exerting activities). She stated throughout CR #1's time in therapy, he remained between 86% and 95% oxygen saturation (according to the American Lung Association, dated [DATE], a person with pulmonary fibrosis should maintain an oxygen saturation level above 90% throughout the day and night). She stated that level was good given his diagnosis of pulmonary fibrosis. She stated when CR #1 went into distress, his oxygen saturation level was 58% on a non-rebreather (a medical device that delivers a high concentration of oxygen). She stated she spoke with CR #1's family and she told them all of CR #1's orders from the hospital indicated he should have been on 2 - 4 L/min of oxygen, but up to 5 L/min if in distress. She stated CR #1 could not walk, he was aphasic, but was alert and aware. She said CR #1 remained alert in the shower until staff transferred him back to his room in a wheelchair. In an interview with CNA A on [DATE], at 11:20 a.m., she stated she worked at the facility as a shower aide. She stated she only interacted with CR #1 one time ([DATE]). She said she had never seen CR #1 before he was brought to her in the shower room on [DATE]. She said the assigned CNA brought residents to the shower room and went back to pick them up after their shower to go back to their rooms. She said when CNA B brought CR #1 to the shower room, he was on oxygen via nasal cannula and in a shower chair. She said she tried to communicate with CR #1, but he did not really talk. She said CR #1 may have said some words, but they were in Spanish. She said CR #1 was not breathing heavily or abnormally. She said CR #1 seemed to be weak. She said during the shower, she did all the work, other than raising his arm when she asked him to. She said she was in the shower alone with CR #1 until CNA B came back to get him. She said she only looked at CR #1's portable oxygen tank when he initially arrived at the shower room, and he was on 5 L/min. She said she had to carry the portable tank and she saw 5 L/min and it was full. She said she carried the tank over to where she dried and dressed CR #1. She said the only time she noticed a change in CR #1 was when CNA B looked inside the door after he was dressed. She said she told CNA B that she did not think CR #1 looked too good. She said CR #1's color changed, and he looked pale to her. She said CR #1's breathing was the same (normal) and he was sitting straight up in his chair, not slumped over. She said all CNAs were trained to recognize changes of condition, including respiratory distress. She said the only way she could have known if CR #1's oxygen was on was if she checked the nasal cannula to see if air was coming out because the oxygen did not make sound. She said she did not check CR #1's oxygen after the shower started. In a telephone interview with CR #1's family member on [DATE], at 11:32 a.m., she stated CR #1 was currently in the ICU and the family was asked to place him on hospice (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life). She said when she spoke to the facility's DON after CR #1 was transferred to the hospital, she said maybe the hospital discharged CR #1 before he was ready. She stated CR #1's oxygen never decreased (desaturated) as low as it did on [DATE]. She said CR #1 was almost unresponsive when he returned to his room, and she wanted to know how he got to that point because it never happened before. She said CR #1's oxygen levels were never an issue at the hospital prior to his admission to the facility. She stated the hospital doctor told her that CR #1's oxygen level went too low, and his body shut down and it looked like cardiac arrest. She said CR #1's baseline oxygen requirement was 4 L/min at rest and 6 - 8 L/min with exertion. She said CR #1 had therapy on Friday, [DATE] and the therapist told her they had to increase his oxygen while in therapy. She said she informed the admitting nurse on Thursday, [DATE], and the therapist on Friday, [DATE] they would have to increase CR #1's oxygen to 6 - 8 L/min on exertion, including walking and showers. She said the DON told her CR #1 was on 4 L/min when they took him to the shower. She said another family member was in CR #1's room on [DATE] when staff took him to the shower. She said the other family member said they were in the shower for 30 minutes and when CR #1 returned to his room, he was slumped over and unresponsive. In an interview with the PT on [DATE], at 12:15 p.m., she stated she evaluated CR #1 on [DATE] and she did not know he was transferred to the hospital until [DATE]. She said she went to CR #1's room on [DATE] to evaluate him for physical therapy and occupational therapy right after breakfast. She said when she arrived at his room, he was in bed with oxygen on via nasal cannula. She stated CR #1 was aphasic and was not able to verbalize, but he used gestures and pointed to things to communicate. She stated he did speak in a mix of broken Spanish and English and he was able to follow directions. She said she worked with CR #1 on walking from the bed to the bathroom door, about ,d+[DATE] feet. She said CR #1 did alright, but she noticed he was exhibiting signs of SOB, so she checked his oxygen. She said she could not recall what CR #1's oxygen saturation was. She said she instructed CR #1 to breath properly and deeply. She said CR #1 followed instructions and his oxygen saturation went up without increasing his oxygen. She said she assisted CR #1 back to bed and told him he would start therapy. She said she told his nurse (RN E) CR #1's oxygen saturation decreased when she walked him, so the nurse was aware. She said she wanted to get information about CR #1's baseline, so she called his family member. She said CR #1 was already breathing heavily when he was lying down before therapy because she could see his chest and stomach rise and fall. She said CR #1 was on 5 L/min of oxygen according to his physician's order. She said when she called CR #1's family member after the evaluation, the family member mentioned that at home, he was on 5 L/min. She said she did not increase CR #1's oxygen during the evaluation because she did not have the authority to do that, and he was fine after doing proper breathing exercises. In a telephone interview with CR #1's NP on [DATE], at 12:57 p.m., she stated CR #1 admitted on [DATE] after she had already completed rounds at the facility, so she never met him. She stated she did not recall speaking to anybody regarding his medications, so staff must have verified his physician's orders with the on-call physician. She stated it was hard to say if 1 L/min of oxygen would have made a difference for CR #1. She said with his history of pulmonary fibrosis, usually a higher oxygen level did not guarantee better perfusion of lungs. She said she did receive a report that CR #1's blood pressure was slightly low (she could not recall when she received this report), so she called the DON to go assess and recheck, but his blood pressure was normal at that time. She stated there was nothing different she would have done for CR #1 with no symptoms and the nurses reported no symptoms and no distress. She said she did not receive a report that CR #1's oxygen saturation decreased during physical therapy. She said she was not an expert in that area (respiratory/pulmonary), so she did not know if going to the shower could have caused a change of condition so quickly. She said sometimes, therapy and showers could be a lot for a resident. She said she thought CR #1 was not ready to leave the hospital. In a telephone interview with CNA B [DATE], at 1:30 p.m., she stated [DATE] was the first day she worked with CR #1. She said she met CR #1 when she made her first rounds on [DATE] (she could not recall wheat time it was). She said she was told by the previous shift that CR #1 required extensive assistance and he required oxygen. She said CR #1 did not speak English, but a family member who arrived after breakfast was able to translate. She said CR #1 said he was ready to take a shower, so she went to get a shower chair. She said CR #1 was on an oxygen concentrator in his room, so she got a portable tank and switched him from the concentrator to the tank. She said she told RN E she was going to get CR #1 for a shower because she needed to know what level of oxygen to put him on. She said the nurse said to put him on 5 L/min. She said as she pushed CR #1 down the hall in the shower chair, she had another Spanish staff member to verify that CR #1 could feel the oxygen from his nasal cannula. She said she left CR #1 in the shower room with his oxygen on after she took his gown and brief off. She said CNA A texted to let her know CR #1 was ready. She said CR #1 was fine at first, but as they went down the hall, he looked pale. She said she told RN E and she said to get CR #1 to his room, and she would go assess him. She said once she got to CR #1's room, he passed out. She said in the oxygen room, the full and empty tanks were separated. She said she regularly transported another alert and oriented resident on continuous oxygen (4 L/min) to and from the shower, and she never had problems with oxygen running out. She said when she picked CR #1 up from the shower, CNA A said CR #1 did not look the same. CNA B said CR #1 was not breathing heavily when she picked him up from the shower room, but when he was almost to his room, he started passing out. She said she was trained to change residents from the oxygen concentrator to the portable tanks and vice versa. She said she did not look at the portable oxygen tank when she picked CR #1 up because it should have been full when she put him on. She said CR #1 was in the shower for ,d+[DATE] minutes. In a follow-up interview with the DON on [DATE], at 1:30 p.m., she stated she was present when CR #1 admitted to the facility. She said CR #1 was on 5 L/min of oxygen when he arrived, but she wanted to clarify with his doctor. She said she read the hospital records and CR #1 was on 4 - 5 L/min, so she wanted to talk to the doctor because they typically kept residents no higher than 4 L/min. She said the on-call doctor was contacted to verify CR #1's medications and they gave an order for 5 L/min. She said there was a typo in the electronic MAR for 2 - 4 L/min because the 4 was so close to the 5 on the keyboard. She said CR #1's family members told her at home, CR #1 he was on 8 L/min via nasal cannula. She said she told the family members that was not best route because the nasal cannula could only tolerate up to 6 L/min. She said she told them the facility had to get orders to increase the oxygen from what was on his hospital records. She said the CNAs were trained to switch residents from the concentrator to portable tanks as long as the nurse assessed the resident, and the nurse went in and made sure the resident was on the proper oxygen. She said it was ok for CNA B to switch CR #1 from the concentrator to the tank because the nurse saw the resident and he went to physical therapy as well. She stated she did not contact CR #1's physician about increasing his oxygen administration to ,d+[DATE] L/min during exertion because he tolerated 5 L/min well. In a telephone interview with RN E on [DATE], at 12:09 p.m., she stated she only worked with CR #1 on Friday, [DATE]. She said when she arrived for her shift that morning (6:00 a.m. - 6:00 p.m.) she assessed CR #1 and found that his blood pressure was low. She said she could not recall what his blood pressure was, but she took it twice. She gave CR #1 fluids and when the ADON returned to check the blood pressure again at the NP's request, it was normal. She said later that morning, when physical therapy came, CR #1's oxygen was low, and he was weak. She said the PT told her CR #1 walked back and forth from the door to the bed and then his family member said when he was at home and doing therapy, they increased his oxygen to 7 and 8 L because his oxygen dropped during exertion. She said after lunch, she was on her way to another hall when a CNA called for her. She said a CNA brought CR #1 back from a shower and said he did not look ok. She said she looked at CR #1 and she had a flash-back of what the PT said about his oxygen in therapy. RN E said she looked at CR #1 and he looked ok, so she told the CNA to take CR #1 to his room. She said CR #1 looked weak but had oxygen on. RN E said the activity of the shower may have dropped CR #1's oxygen down. She said she told the CNA she was coming, but on her way back, about one minute later, the CNA came running down the hall and said CR #1 looked worse. She said she went to CR #1's room and he looked different and was unconscious. She said she started to do a sternal rub. She said she told the CNA to call a code blue and she started CPR. She said before they went to the shower, CR #1 was on a small oxygen tank. She said the oxygen was on, but she could not recall what level it was on. RN E initially said CR #1 was on 3 L/min of oxygen. RN E said she could not recall if the tank was full, but she knew it was working. RN E eventually said CR #1 was on 5 L/min of oxygen and when she looked at it, it was fine. She said CR #1 and CNA B were already in front of the shower room when she saw them. She said when CR #1 went unconscious, he was still in the shower chair. She said she checked for a pulse, but it was weak. She said they transferred CR #1 to the bed and started CPR. She said EMS came when he was already awake. She said CR #1 did not look pale to her when he came out of the shower. She said he looked weak, and she thought it was because he was used to increasing his oxygen during showers. She said she did not call CR #1's doctor to ask about increasing his oxygen after his oxygen saturation decreased during therapy, even though she was informed his family said to increase it. She said it was not even an hour after the PT told her that before the shower incident happened. She said she was already waiting on the doctor to respond to her about CR #1's critical CO2 lab result. She said after the PT told her about CR #1's desaturation during therapy, she received CR #1's critical lab and called for the doctor regarding the lab. In an interview with the ADON on [DATE] at 11:30 a.m., she stated she was the one who entered CR #1's orders for oxygen into the MAR. She said after reading the hospital record, she understood CR #1 was tolerating ,d+[DATE] L of oxygen. She said she did not know the order was supposed to be 5 L. She said 5 L was the most a nasal cannula could tolerate. She said she had no interactions with CR #1's family until the code blue. She said she did not know where 6 - 8 L/min of oxygen came from. She said if CR #1's family said he was tolerating 6 - 8 L at home, his NP should have been contacted. She said that was the steps staff should have taken if the family said they wanted CR #1 on something different. She said the staff should have gotten guidance from the NP or doctor and educated CR #1's family that they got orders from medical providers. In an interview with LVN D on [DATE], at 12:05 p.m., she stated she admitted CR #1 to the facility on [DATE]. She said CR #1 was on 5 L, so she left him on 5 L. She said CR #1's family said when he was at home, if he walked or moved around the house, they increased his oxygen 6 L. She said if she was working with him, she would have increased his oxygen in the shower if his family said that. She said she verified CR #1's medications with the NP by text. She said the NP instructed to continue with the admission orders. LVN D said she did not ask the NP about CR #1's oxygen administration and she did not enter his medications in the MAR. She said the nurse who admitted the resident was supposed to enter the medication, but she did not. She said she did not know why she did not enter the medications, she must have forgotten. She said once everything was explained to her, she knew it was her fault (the medication/oxygen error). She said there were no orders for oxygen from the hospital, but when the hospital gave report, it said 5 L. In a telephone interview with CR #1's family member on [DATE] at 9:17 p.m., she stated CR #1 expired on [DATE] while at home on hospice care. Record review of the facility's policy titled Significant Change of Condition, Response revised ,d+[DATE] revealed, It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure. 1. If, at ant time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation. Change in a [TRUNCATED]

Based on observation, interview, and interview, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's goals and preferences for 1 of 9 residents (CR #1) reviewed for respiratory care. 1. The facility failed to increase CR #1's oxygen or consult/seek further guidance from CR #1's physician to increase his oxygen to ,d+[DATE] L/min during a shower on [DATE] after his family members informed staff his oxygen requirement increased during exerting activities, including showers. The facility failed to monitor CR #1's oxygen administration/O2 levels while in the shower and ensure CR #1's oxygen was working properly or immediately call for a nurse when CNA A and CNA B noted a change of condition (CR #1's skin color was pale). This resulted in CR #1's drastic desaturation (a decrease in oxygen saturation, low blood oxygen concentration) to 53%. CR #1 lost consciousness and required CPR and intubation (a medical procedure that involves inserting a flexible tube into the trachea to help maintain an open airway). CR #1 expired on [DATE] on hospice at his home. 2. The facility failed to notify CR #1's physician or seek medical guidance when he experienced a drop in oxygen saturation during physical therapy on [DATE]. 3. The facility failed to accurately document CR #1's order for 5 L/min of continuous oxygen on his MAR and instead listed ,d+[DATE] L/min of continuous oxygen. An IJ was identified on [DATE] at 2:52 p.m The IJ template was provided to the facility on [DATE] at 2:52 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents on continuous oxygen at risk of experiencing desaturation, unconsciousness, and death. Findings include: Record review of CR #1's face sheet, dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] from an acute care hospital. He was diagnosed with UTI (an illness in any part of the urinary tract), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), aphasia (a language disorder that affects a person's ability to communicate), acute and chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues in your body [hypoxia] or when there is too much carbon dioxide in your body. It can happen all at once [acute] or come on over time [chronic]), and essential hypertension (a form of hypertension without an identifiable cause). CR #1 was discharged to an acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he was admitted from an acute care hospital on [DATE]. Record review of CR #1's BIMS dated [DATE] at 2:55 p.m. revealed he had a score of 0 (severe cognitive impairment). Record review of CR #1's Functional Abilities Admission assessment dated [DATE] revealed, MDS Reason for Evaluation: Admission/5-Day . Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury - Independent - Resident completed all the activities by themselves, with or without an assistive device, with no assistance from a helper . Prior Device Ise - Manual Wheelchair, [NAME] . Record review of CR #1's care plan dated [DATE] revealed the following care area: * ADL Self Care Performance Deficit. Goal included: Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene with modified independence. Interventions included: Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders; Toilet Use: requires assistance; Transfers (Chair /Bed to Chair Transfer, toilet transfers: Requires staff participation with transfers; Bed Mobility: Requires staff participation to reposition and turn in bed; Encourage to participate to the fullest extent possible with each interaction; Bathing (Shower/Bathe Self): Staff will provide the required assistance needed for bathing; Personal Hygiene/Oral care: Staff will provide the required assistance needed for personal hygiene/oral care; Dressing: Requires staff participation to dress; Eating: Staff will provide the required assistance needed for eating as needed. Further review of CR #1's care plan revealed no focus/care area related to his respiratory condition or oxygen requirements/needs. Record review of CR #1's preadmission hospital records dated [DATE] revealed he was admitted to a local acute care hospital on [DATE] for weakness and was diagnosed with complicated UTI (any UTI that is not considered simple, and defined by the presence of underlying conditions rather than the severity of the infection), acute on chronic respiratory failure with hypoxia, acute toxic metabolic encephalopathy (a condition that causes global cerebral dysfunction, resulting in altered consciousness, behavior changes, and seizures), acute diarrhea due to E.coli (diarrhea caused by bacteria), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), pulmonary fibrosis (a condition in which the lungs become scarred over time), acute on chronic congestive heart failure (a type of heart failure that occurs when the heart has difficulty compensating for a loss of function that has developed over time) and history of CVA (a stroke; when blood flow to the brain is suddenly cut off) with global aphasia (a severe form of non-fluent aphasia caused by damage to the left side of the brain). The document read in part, . [CR #1] is a [AGE] year-old male with pulmonary fibrosis who was hospitalized for metabolic encephalopathy and atrial fibrillation with rapid ventricular response due to complicated UTI and infectious diarrhea. Patient improved with supportive measures including antibiotics and rate control. Patient was discharged in stable cardiology and pulmonology for continued evaluation and management as outpatient . Review of Systems . Respiratory: Negative for cough, shortness of breath, and wheezing . Respiratory/Pulmonary Interventions Documentation: . Respiratory Quality/Sounds: Dyspnea (shortness of breath) on exertion, dyspnea laying flat, dyspneic (having difficulty breathing or being unable to breathe without effort), tachypneic (fast breathing) . Respiratory/Pulmonary Interventions: O2 Delivery Method: Nasal cannula; O2 flow rate (L/min): 5 L/min . [DATE] . History of Present Illness . He was on baseline O2 of ,d+[DATE] L/min . Patient was admitted for further evaluation . He developed episode of a-fib and SOB/cough overnight, given breathing treatments and IV metoprolol (a medication used to treat high blood pressure, chest pain, and heart failure) . Currently he is resting in bed, no acute distress. On 6L/min via nasal cannula . Pulmonary and Critical Care Consult Note, [DATE]. Assessment: Chronic hypoxic respiratory failure with home oxygen dependence between 4 to 6 L/min at baseline, 8L with exertion . Pulmonary Progress Note: [DATE] . Patient states his breathing feels comfortable at his baseline oxygen requirement of 5L/min . He has been saturating at 100% . Record review of CR #1's Initial Admission Record dated [DATE] revealed LVN C wrote . Most Recent O2 saturation: 98% ([DATE] at 5:15 p.m.) Method: oxygen via nasal [cannula] . General Skin Condition: Normal - Yes, Pale/Ashen - No, Flushed - No, Cyanotic (bluish or purple discoloration) - No . Pulmonary System. Diagnosis: Does the Resident have a Pulmonary Diagnosis - No . Pulmonary System. Oxygen. Oxygen Use - No . Record review of CR #1's physician's orders for [DATE] revealed: * Check and record O2 Saturation every shift. Order Date: [DATE]. Start Date: [DATE]. * O2 at ,d+[DATE] L/Min Continuous per nasal cannula every shift. Order Date: [DATE]. Start Date: [DATE] Record review of CR #1's MAR for [DATE] (there was no MAR for [DATE]) revealed: * Check and record O2 Saturation every shift. There were no entries for this order. CR #1 was hospitalized . * O2 at ,d+[DATE] L/Min Continuous per nasal cannula every shift. There were no entries for this order. CR #1 was hospitalized . Record review of CR #1's progress notes for [DATE] revealed: On [DATE], LVN D wrote, At 5:15 p.m., patient arrived as a new admit to the facility via wheelchair with belongings . O2: 98% 5L of O2. NP notified of admit and verified orders and lab orders for CBC and BMP. Record review of CR #1's progress notes for [DATE] revealed: * On [DATE] at 1:57 p.m., LVN E wrote, COC for CO2 of 45 (normal range 21.0 - 31.0). Resident has a critical lab of CO2 45, NP informed and awaiting new orders. * On [DATE] at 6:08 p.m., LVN E wrote, Resident had just finished taking a shower when the CNA [CNA B] brought out the resident from the bathroom looking weak but breathing. This nurse told the CNA to take resident back to his room. Later this nurse was called by CNA that resident is not looking good. This nurse did a sternal rub (a painful stimulus used to assess a patient's neurological status and responsiveness) on patient and observed that the patient was still unresponsive and had a weak pulse. This nurse told CNA to call code blue. Patient was then transferred from shower chair to bed. Chest compressions began immediately. Staff members rushed in with crash cart at bedside and placed back board underneath. Another staff called 911, while using the non-rebreather to deliver oxygen. Another staff focused putting in a peripheral IV line for fluid. Blood sugar was checked. O2 sat 58% according to pulse oximetry. Resident started moaning and moving his lower extremities just before 911 ambulance arrived to take over. Resident was later taken to the hospital. * On [DATE] at 11:28 a.m., the DON wrote, IDT met to discuss [CR #1]. During review, it was noted that resident's order for O2 ,d+[DATE]LPM was incorrectly typed and should have been ,d+[DATE]LPM as resident order verified for ,d+[DATE]LPM upon resident admission with NP. Resident admitted ,d+[DATE] at approximately 5:15 from hospital on 5L of O2 [saturating] at 98% with diagnosis of Pulmonary Fibrosis, UTI, Aphasia . On ,d+[DATE], resident participated in physical therapy, speech therapy, and occupational therapy. During therapy session, resident was on 5L of oxygen and oxygen was monitored throughout session and remained between 86% and 95% on 5LPM per NC. Later in the day, around 3:00 p.m. resident was taken for a shower. Resident was taken to the shower with oxygen and remained on oxygen therapy throughout the duration of the shower. Shower CNA [A] stated that during his shower, he had his oxygen on, and was alert throughout the course of his shower. Towards the end, resident began to appear weak. CNA [A] called to CNA [B] to come assist. When CNA [B] was transferring the resident back down to his room, resident began to slump in his chair. CNA [F] assisted with getting resident to the room and called to the nurse for assistance with family at bedside. When the nurse arrived at the room, resident was unresponsive to stimuli, RN [E] called code blue and CPR was initiated. Oxygen was changed from NC to NRB and [O2] sat noted to be at 58%. 911 was called by other staff. When EMS arrived, resident had pulse and was responsive. Record review of CR #1's PT Evaluation and Plan of Treatment completed by the PT and dated [DATE] revealed, . Cardiopulmonary Assessment - At rest: . Oxygen saturation: 98 (on 5 L). Activity: Patient's rated/reported level of exertion = Patient is unable to communicate exertion felt during activity. Oxygen saturation with activity: 86 [%](on 5L) . Record review of CR #1's EMS records dated [DATE] revealed, . Call Received: 3:51 p.m. On Scene 3:59 p.m.Depart Scene: 4:41 p.m. Chief Complaint: Patient is a [AGE] year-old male with complaints of unconscious and respiratory distress. Patient is unconscious, cannot sit up and cannot ambulate with assistance . History: The issue with cardiac arrest began more than 5 minutes ago . Treatment (Plan): Stopped CPR and found spontaneous pulses and irregular respirations . SPO2 (4:06 p.m.: 89%), (4:16 p.m.: 96%) . Record review of CR #1's hospital records dated [DATE] revealed he was transferred from the facility to the ER then ICU of a local acute care hospital on [DATE]. He was intubated and was diagnosed with cardiac arrest (when the heart suddenly stops beating). The document read in part, . Brought in by EMS [from facility]. CPR in progress upon EMS arrival, staff was doing compressions. Patient was moving around and had a pulse but decreased respiratory effort . Physical Exam ([DATE]) General: He is in acute distress. Appearance: He is ill-appearing . Pulmonary: Patient is having assisted ventilation . Neurological: Unresponsive . Observation and interview with CR #1 on [DATE], at 2:45 p.m. revealed he was in the ICU at a local acute care hospital. CR #1 was intubated and opened his eyes to verbal stimuli. CR #1 did not attempt to communicate or make any gestures unless a family member spoke to him. There were multiple family members present at that time. Two family members stated they were present at the facility when CR #1 was admitted to the facility on [DATE]. Both family members stated they informed staff at the facility they would have to increase CR #1's oxygen to 6 - 8 L/min while he was in the shower as they had to do at home. The family members stated the DON told them staff had equipment in the shower to monitor CR #1's oxygen. One family member said CR #1 was able to tell them he remembered being at the facility, but he could not recall what happened in the shower. Another family member who only spoke Spanish (translated by an English speaking family member) stated CR #1 complained about the oxygen in that place and he told her through nodding and gestures that he did not have what he needed. CR #1 did not answer questions at that time. In an interview with the DON on [DATE], at 9:45 a.m., she stated CR #1 was admitted on [DATE] and was sent out on [DATE] when he coded in respiratory/cardiac arrest around 4:00 p.m. She said CR #1's oxygen saturation dropped significantly, and he was non-responsive. She said CR #1 received therapy on [DATE] and then he was taken to the shower. The DON said while CR #1 was going back to his room, he became week and then became unresponsive. She said CR #1 was on continuous oxygen and had it on the whole time he was in the shower. She said she investigated the incident after CR #1 was discharged to the hospital on [DATE]. She said CR #1 never went without his oxygen while he was at the facility. She said he transferred from the hospital on [DATE] on 5 L/min of oxygen. She said she verified with the nurses, CNA's and therapist that CR #1 was always on 5 L/min. The DON said she would have gotten a physician's order for more oxygen, but CR #1 was tolerating 5 L/min during exertion (she did not specify which exerting activities). She stated throughout CR #1's time in therapy, he remained between 86% and 95% oxygen saturation (according to the American Lung Association, dated [DATE], a person with pulmonary fibrosis should maintain an oxygen saturation level above 90% throughout the day and night). She stated that level was good given his diagnosis of pulmonary fibrosis. She stated when CR #1 went into distress, his oxygen saturation level was 58% on a non-rebreather (a medical device that delivers a high concentration of oxygen). She stated she spoke with CR #1's family and she told them all of CR #1's orders from the hospital indicated he should have been on 2 - 4 L/min of oxygen, but up to 5 L/min if in distress. She stated CR #1 could not walk, he was aphasic, but was alert and aware. She said CR #1 remained alert in the shower until staff transferred him back to his room in a wheelchair. In an interview with the ADON on [DATE], at 10:55 a.m., she stated she had never seen CR #1 until [DATE], when the code blue (used to indicate that a patient requires resuscitation or is in need of immediate medical attention) was called. She said she got involved because she heard the code blue. She said when she went to CR #1's room, she assisted other staff with moving him from the shower chair to his bed and then she provided chest compressions during CPR. She said they initiated CPR in CR #1's bed with a back board. She said CR #1 had a weak pulse and responded well to chest compressions. She said CR #1 began to make noises and then she assessed his pupils. She said CR #1 blinked hard and then started moving his legs before EMS arrived. She said CR #1 had a nasal cannula and was on a portable oxygen tank until staff traded out for the ambu bag (a manual resuscitator or self-inflating bag) to administer breaths. She stated the portable oxygen tanks had a gauge on it which indicated how much oxygen it contained. She said all the portable oxygen tanks went up to 5 L/min. She stated she never sat and watched a portable oxygen tank as it administered oxygen, so she could not say how long a small portable oxygen tank (like the one used in the shower with CR #1) would last on 5 L/min. She stated the tank did not make a sound if it was going empty. She said staff charged (filled the tanks with oxygen) the portable tanks regularly and they would not have put CR #1 on a used (one that was not full) tank. She said normal protocol would be for the CNA or nurse to go get a portable tank. She said a CNA would tell a nurse when a resident was about to take a shower and the CNA would ask the nurse to swap the resident from the oxygen concentrator (the resident would have been on an oxygen concentrator inside their room) to a portable tank. She said the nurse would check to make sure the portable tank was full. In an interview with CNA A on [DATE], at 11:20 a.m., she stated she worked at the facility as a shower aide. She stated she only interacted with CR #1 one time ([DATE]). She said she had never seen CR #1 before he was brought to her in the shower room on [DATE]. She said the assigned CNA brought residents to the shower room and went back to pick them up after their shower to go back to their rooms. She said when CNA B brought CR #1 to the shower room, he was on oxygen via nasal cannula and in a shower chair. She said she tried to communicate with CR #1, but he did not really talk. She said CR #1 may have said some words, but they were in Spanish. She said CR #1 was not breathing heavily or abnormally. She said CR #1 seemed to be weak. She said during the shower, she did all the work, other than raising his arm when she asked him to. She said she was in the shower alone with CR #1 until CNA B came back to get him. She said she only looked at CR #1's portable oxygen tank when he initially arrived at the shower room, and he was on 5 L/min. She said she had to carry the portable tank and she saw 5 L/min and it was full. She said she carried the tank over to where she dried and dressed CR #1. She said the only time she noticed a change in CR #1 was when CNA B looked inside the door after he was dressed. She said she told CNA B that she did not think CR #1 looked too good. She said CR #1's color changed, and he looked pale to her. She said CR #1's breathing was the same (normal) and he was sitting straight up in his chair, not slumped over. She said all CNAs were trained to recognize changes of condition, including respiratory distress. She said the only way she could have known if CR #1's oxygen was on was if she checked the nasal cannula to see if air was coming out because the oxygen did not make sound. She said she did not check CR #1's oxygen after the shower started. In a telephone interview with CR #1's family member on [DATE], at 11:32 a.m., she stated CR #1 was currently in the ICU and the family was asked to place him on hospice (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life). She said when she spoke to the facility's DON after CR #1 was transferred to the hospital, she said maybe the hospital discharged CR #1 before he was ready. She stated CR #1's oxygen never decreased (desaturated) as low as it did on [DATE]. She said CR #1 was almost unresponsive when he returned to his room, and she wanted to know how he got to that point because it never happened before. She said CR #1's oxygen levels were never an issue at the hospital prior to his admission to the facility. She stated the hospital doctor told her that CR #1's oxygen level went too low, and his body shut down and it looked like cardiac arrest. She said CR #1's baseline oxygen requirement was 4 L/min at rest and 6 - 8 L/min with exertion. She said CR #1 had therapy on Friday, [DATE] and the therapist told her they had to increase his oxygen while in therapy. She said she informed the admitting nurse on Thursday, [DATE], and the therapist on Friday, [DATE] they would have to increase CR #1's oxygen to 6 - 8 L/min on exertion, including walking and showers. She said the DON told her CR #1 was on 4 L/min when they took him to the shower. She said another family member was in CR #1's room on [DATE] when staff took him to the shower. She said the other family member said they were in the shower for 30 minutes and when CR #1 returned to his room, he was slumped over and unresponsive. In an interview with the PT on [DATE], at 12:15 p.m., she stated she evaluated CR #1 on [DATE] and she did not know he was transferred to the hospital until [DATE]. She said she went to CR #1's room on [DATE] to evaluate him for physical therapy and occupational therapy right after breakfast. She said when she arrived at his room, he was in bed with oxygen on via nasal cannula. She stated CR #1 was aphasic and was not able to verbalize, but he used gestures and pointed to things to communicate. She stated he did speak in a mix of broken Spanish and English and he was able to follow directions. She said she worked with CR #1 on walking from the bed to the bathroom door, about ,d+[DATE] feet. She said CR #1 did alright, but she noticed he was exhibiting signs of SOB, so she checked his oxygen. She said she could not recall what CR #1's oxygen saturation was. She said she instructed CR #1 to breath properly and deeply. She said CR #1 followed instructions and his oxygen saturation went up without increasing his oxygen. She said she assisted CR #1 back to bed and told him he would start therapy. She said she told his nurse (RN E) CR #1's oxygen saturation decreased when she walked him, so the nurse was aware. She said she wanted to get information about CR #1's baseline, so she called his family member. She said CR #1 was already breathing heavily when he was lying down before therapy because she could see his chest and stomach rise and fall. She said CR #1 was on 5 L/min of oxygen according to his physician's order. She said when she called CR #1's family member after the evaluation, the family member mentioned that at home, he was on 5 L/min. She said she did not increase CR #1's oxygen during the evaluation because she did not have the authority to do that, and he was fine after doing proper breathing exercises. In a telephone interview with CR #1's NP on [DATE], at 12:57 p.m., she stated CR #1 admitted on [DATE] after she had already completed rounds at the facility, so she never met him. She stated she did not recall speaking to anybody regarding his medications, so staff must have verified his physician's orders with the on-call physician. She stated it was hard to say if 1 L/min of oxygen would have made a difference for CR #1. She said with his history of pulmonary fibrosis, usually a higher oxygen level did not guarantee better perfusion of lungs. She said she did receive a report that CR #1's blood pressure was slightly low (she could not recall when she received this report), so she called the DON to go assess and recheck, but his blood pressure was normal at that time. She stated there was nothing different she would have done for CR #1 with no symptoms and the nurses reported no symptoms and no distress. She said she did not receive a report that CR #1's oxygen saturation decreased during physical therapy. She said she was not an expert in that area (respiratory/pulmonary), so she did not know if going to the shower could have caused a change of condition so quickly. She said sometimes, therapy and showers could be a lot for a resident. She said she thought CR #1 was not ready to leave the hospital. In a telephone interview with CNA B [DATE], at 1:30 p.m., she stated [DATE] was the first day she worked with CR #1. She said she met CR #1 when she made her first rounds on [DATE] (she could not recall wheat time it was). She said she was told by the previous shift that CR #1 required extensive assistance and he required oxygen. She said CR #1 did not speak English, but a family member who arrived after breakfast was able to translate. She said CR #1 said he was ready to take a shower, so she went to get a shower chair. She said CR #1 was on an oxygen concentrator in his room, so she got a portable tank and switched him from the concentrator to the tank. She said she told RN E she was going to get CR #1 for a shower because she needed to know what level of oxygen to put him on. She said the nurse said to put him on 5 L/min. She said as she pushed CR #1 down the hall in the shower chair, she had another Spanish staff member to verify that CR #1 could feel the oxygen from his nasal cannula. She said she left CR #1 in the shower room with his oxygen on after she took his gown and brief off. She said CNA A texted to let her know CR #1 was ready. She said CR #1 was fine at first, but as they went down the hall, he looked pale. She said she told RN E and she said to get CR #1 to his room, and she would go assess him. She said once she got to CR #1's room, he passed out. She said in the oxygen room, the full and empty tanks were separated. She said she regularly transported another alert and oriented resident on continuous oxygen (4 L/min) to and from the shower, and she never had problems with oxygen running out. She said when she picked CR #1 up from the shower, CNA A said CR #1 did not look the same. CNA B said CR #1 was not breathing heavily when she picked him up from the shower room, but when he was almost to his room, he started passing out. She said she was trained to change residents from the oxygen concentrator to the portable tanks and vice versa. She said she did not look at the portable oxygen tank when she picked CR #1 up because it should have been full when she put him on. She said CR #1 was in the shower for ,d+[DATE] minutes. In a follow-up interview with the DON on [DATE], at 1:30 p.m., she stated she was present when CR #1 admitted to the facility. She said CR #1 was on 5 L/min of oxygen when he arrived, but she wanted to clarify with his doctor. She said she read the hospital records and CR #1 was on 4 - 5 L/min, so she wanted to talk to the doctor because they typically kept residents no higher than 4 L/min. She said the on-call doctor was contacted to verify CR #1's medications and they gave an order for 5 L/min. She said there was a typo in the electronic MAR for 2 - 4 L/min because the 4 was so close to the 5 on the keyboard. She said CR #1's family members told her at home, CR #1 he was on 8 L/min via nasal cannula. She said she told the family members that was not best route because the nasal cannula could only tolerate up to 6 L/min. She said she told them the facility had to get orders to increase the oxygen from what was on his hospital records. She said the CNAs were trained to switch residents from the concentrator to portable tanks as long as the nurse assessed the resident, and the nurse went in and made sure the resident was on the proper oxygen. She said it was ok for CNA B to switch CR #1 from the concentrator to the tank because the nurse saw the resident and he went to physical therapy as well. She stated she did not contact CR #1's physician about increasing his oxygen administration to ,d+[DATE] L/min during exertion because he tolerated 5 L/min well. In an interview with multiple hospital nurse managers and one hospital physician on [DATE], at 10:00 a.m., one nurse stated CR #1 had six hospital stays and three ER visits in 2024. The nurse stated CR #1 arrived at the hospital on [DATE] in cardiac arrest but it was hard to say whether his blood pressure dropped first and caused his oxygen to drop, or if his respiratory distress caused his blood pressure to drop. Another nurse stated CR #1's cardiac arrest was due to his respiratory desaturation. The physician stated CR #1's condition deteriorated over time, and he had become more and more short of breath. He said CR #1's chronic lung disease and the probability that he did not have enough air could have led to a quick desaturation. He stated 8 L of oxygen may not have made a difference, but in the shower, CR #1 would have required a little bit more oxygen. He said since it was an acute event, he did not know if 8 L of oxygen would have made a difference. He said CR #1 was diagnosed with aspiration pneumonia (a type of lung infection due to a relatively large amount of material from the stomach or mouth entering the lungs) and his prognosis was poor. In a telephone interview with RN E on [DATE], at 12:09 p.m., she stated she only worked with CR #1 on Friday, [DATE]. She said when she arrived for her shift that morning (6:00 a.m. - 6:00 p.m.) she assessed CR #1 and found that his blood pressure was low. She said she could not recall what his blood pressure was, but she took it twice. She gave CR #1 fluids and when the ADON returned to check the blood pressure again at the NP's request, it was normal. She said later that morning, when physical therapy came, CR #1's oxygen was low, and he was weak. She said the PT told her CR #1 walked back and forth from the door to the bed and then his family member said when he was at home and doing therapy, they increased his oxygen to 7 and 8 L because his oxygen dropped during exertion. She said after lunch, she was on her way to another hall when a CNA called for her. She said a CNA brought CR #1 back from a shower and said he did not look ok. She said she looked at CR #1 and she had a flash-back of what the PT said about his oxygen in therapy. RN E said she looked at CR #1 and he looked ok, so she told the CNA to take CR #1 to his room. She said CR #1 looked weak but had oxygen on. RN E said the activity of the shower may have dropped CR #1's oxygen down. She said she told the CNA she was coming, but on her way back, about one minute later, the CNA came running down the hall and said CR #1 looked worse. She said she went to CR #1's room and he looked different and was unconscious. She said she started to do a sternal rub. She said she told the CNA to call a code blue and she started CPR. She said before they went to the shower, CR #1 was on a small oxygen tank. She said the oxygen was on, but she could not recall what level it was on. RN E initially said CR #1 was on 3 L/min of oxygen. RN E said she could not recall if the tank was full, but she knew it was working. RN E eventually said CR #1 was on 5 L/min of oxygen and when she looked at it, it was fine. She said CR #1 and CNA B were already in front of the shower room when she saw them. She said when CR #1 went unconscious, [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #1) reviewed for resident abuse. The facility failed to prevent Resident #1 from being physically abused by LVN B on 12/05/23. The noncompliance was identified as past noncompliance (PNC) IJ. The noncompliance began on 12/05/23 and ended on 12/12/23. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. Findings included: Record review of Resident #1's face sheet dated 09/25/24 revealed an [AGE] year-old female admitted to the facility initially on 11/09/21 and readmitted [DATE]. Resident #1 had diagnoses which included Major depressive disorder (mental health condition that cause loss of interest in activities that once brought joy), dementia (impair ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness). Record review of Resident #1's quarterly MDS assessment, dated 09/09/2024, revealed a BIMS score of 02 out of 15, which indicated the resident's cognition was severely impaired. Further review of Resident #2's MDS revealed the resident needed extensive assistance with ADL care. Record review of Resident #1's undated care plan initiated 11/09/21 revealed: Resident #1 had impaired cognitive function or impaired thought processes related to Dx of Dementia. An intervention included: Communication: Identify yourself at each interaction, face when speaking and make eye contact, use simple, directive sentences, provide with necessary cues- stop and return if agitated. Observation and interview on 09/24/24 at 11:20 a.m., Resident #1 was in bed, and she was dressed in her street clothes. Resident #1 was not able to say if the staff was abusive to her. Resident #1 was a poor historian. During an interview on 09/24/24 at 1:40 a.m., ADON A said there was an issue on 12/04/23 with LVN B when Resident #1 bumped into LVN B while she stood by the medication cart in front of the nursing station. ADON A said LVN B turned around and pushed Resident #1's wheelchair away and leaned forward in front of Resident #1 while she talked to Resident #1 aggressively, but there was no audio. ADON A said LVN B slapped Resident #1's hand away when Resident #1 raised her hand. ADON A said there was no reason for LVN B to physically abuse Resident #1. During an interview on 09/24/24 between 10:47 a.m. and 5:54 p.m., (2 LVN, 1 CNA, 1 MA, 1 shower teach) from day shift were interviewed on the facility in service on abuse/neglect. All staff interviewed were able to verbalize understanding of abuse/neglect in-services received. During an interview on 09/25/24 at 11:35 a.m., the DON said while she was making rounds on 12/05/23, a resident told her she heard loud noise last night (12/05/23). The DON said she reviewed the facility camera and saw LVN B standing in front of the medication cart by the nursing station when Resident#1 bumped into LVNA B. The DON said LVN B shoved Resident #1's wheelchair back forcefully, leaned forward to Resident #1, and pointed to Resident#1's face, but she could not hear what she said because the camera had no audio. The DON said LVN B's demeanor was intimidating, and it made her the DON sick. The DON said the video of the incident was not available to be reviewed when surveyors entered. The DON said she immediately reported it to HHSC. The DON said she called LVN B at home and told LVN B she could not return to the facility because of the incident, and LVN B was terminated after the facility investigation, which indicated LVN B abused Resident #1. During an interview on 09/25/24 at 11:43 a.m., the DON said they had QAPI about the incident, in-service with the staff on abuse/neglect, they did safe survey with residents, and the DON would train new staff upon hire on abuse/neglect. During an interview on 09/24/24 between 12:7 a.m. and 3:25 p.m., (3 LVN, and 1 CNA) from day shift were interviewed on the facility in service on abuse/neglect. All staff interviewed were able to verbalize understanding of abuse/neglect in-services received. Record review of the provider investigation report dated 12/05/23 revealed LVN B written statement reflected, I would never treat my patients in such a way. I was doing my job at the nurse's cart when the resident approached me demanding coffee. I told her that the kitchen was closed for the day, and she continued to try and roll past me. When she did, she ran into my foot and by reaction, I moved her continued to try and roll past me. When she did, she ran into my foot and by reaction, I moved her chair away to prevent injury to myself. I then attempted to redirect the resident by getting eye level with her and gestured to her, the kitchen is closed. She then attempted to hit me, so I attempted to block her from injuring me . the facility investigation reflected the incident happened on 12/5/23, and abuse was substantiated . Director of Nursing viewed security footage from around 7pm the night prior and noted an interaction between Resident #1 and LVN B. Footage revealed that Resident #1 was in her wheelchair rolling slowly towards the dining room. She stopped shortly next to LVN B at her nursing cart, at the nurse's station. Resident#1 then proceeded to propel herself slowly bumping LVN B's foot. In response, LVN B forcefully pushed Resident #1's wheelchair backwards and proceeded to point her finger at Resident #1. Verbal interaction took place between Resident #1 and LVN B. Resident #1 appeared to start yelling at the nurse and in return LVN B leaned forward into Resident#1's face. Resident #1 swung her hand toward the nurse and LVN B batted Resident #1 hand away. After review of footage, LVN B was suspended immediately pending investigation. The interventions during investigation were physician notified, responsible party notified, sheriff's department notified, safe surveys, abuse and neglect in services LVN suspended and terminated . Record review of the facility report of progress to the CQI Committee dated 12/12/23 reflected in part . PROBLEM Nurse became physically aggressive and intimidating to resident. CAUSAL FACTORS nurse startled by being bumped into by resident wheelchair. Nurse reaction to dementia resident behavior INTERVENTION(S) a. On-going education for abuse and neglect, b. Re-educate facility staff on handing. residents with behaviors and dementia, c. DON/Designee to review all new hire background checks, d. Medical Director Notified, e. Safe Surveys f. RP notified, g. Police notified, h. Discuss on-going education and background checks in monthly QAPI. i. ensure Relias trainings are completed before new hires start training and are completely annually by all staff. Record review of LVN B employee file reflected the following: DOH: 03/27/2020. Criminal background checks completed 03/26/2020. DADS check completed 03/27/2020. EMR: 11/07/2023. Record review of the facility policy on abuse dated 11/2017, revision 12/2023 reflected in part .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations . Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -The facility failed to dispose of expired food items and keep Scoops stored outside of food bins. These failures could place residents at risk of food borne illness and diseases. Findings include: Observation of the facility's kitchen and interview on [DATE] between 8:30 am and 8:40 am with the Food Service Manager revealed the following: Sliced American Cheese in a plastic container dated [DATE] stored in the refrigerator. Sliced Swiss Cheese in a plastic container dated [DATE] stored in the refrigerator. Cheese Parmigiana in a plastic container dated [DATE] stored in the refrigerator. Scoops for bulk food were left in the sugar and flour bins stored in the storeroom. Interview with the Dietary Food Service Manager on [DATE] at 8:35 AM, stated that the plastic containers with cheese should have been used or discarded prior to the used by date. The Scoops for bulk food should be stored in the storeroom, it was not to be stored in the food bin. Interview with the Food Service Manager on [DATE] at 9:00 AM, she stated she was responsible for training staff on labeling and storage requirements, ensuring dietary requirements were met. She further stated she would in- service the dietary staff on refrigerated storage, practices to maintain safe refrigerated storage, labeling, dating, and monitoring refrigerated food. Record review of facility's Policy Food Safety Requirements dated ,d+[DATE]; Policy: Food will be stored in area that is clean, dry, and free from contaminants. Policy read in part. Leftover foods will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Record review of 2017 Federal Food Code revealed that leftover food is used or discarded within 7 days. Scoops must be provided for bulk foods such as sugar, flour, and spices. Scoops are not to be stored in food or ice containers. Scoops are washed and sanitized on a regular basis.

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #60) reviewed for incontinent care. - The facility failed to ensure CNA M completely cleaned Resident #1 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #60's face sheet, dated 11/10/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #60 had diagnoses which included Morbid (severe)obesity (weight is more than 80 to 100 pounds above ideal body weight), hypertension (a condition in which the blood vessels have persistently raised pressure), and diaper dermatitis (a form of irritated skin ). Record review of Resident #60's quarterly MDS assessment, dated 09/22/2023, reflected a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident #60's functional status reflected she required extensive assistance with one staff for ADL care. Resident #60 was incontinent of bladder and bowel. Record review of Resident #60's care plan, revision date 10/19/23, reflected: Resident #60 had bladder/bowel incontinence related to impaired mobility, loss of peritoneal tone, and overactive bladder which placed her at risk for skin breakdown and infection. Interventions: Incontinent: check as required for incontinence. Wash, rinse, and dry perineum. Monitor for signs and symptoms of UTI, pain burning, foul and smelling urine. During an observation of incontinent care provided by CNA M for Resident #60 on 11/07/07/23 at 10:32 a.m., revealed, CNA M did not wash or sanitize her hands before she donned double gloves and placed the clean incontinent brief and a packet of wipes on Resident 60's bed. CNA M assisted Resident #60 to her right side, facing the window. CNA M removed the dirty incontinent brief, which was saturated with urine from front to back. CNA M took wipes from the wipe packet with the same dirty gloves and used the same gloves from beginning to end. She did not separate Resident #60's labia to clean it. CNA M did not clean under Resident #60's abdominal folds close to the peri area. CNA M also did not clean Resident #60's right buttocks, and she wiped the resident three times with the same wipe before she took another clean wipe. During an interview on 11/07/23 at 12:18 p.m., CNA M said she did not separate or clean Resident #60's labia and did not clean under her abdominal folds when she provided incontinent care. CNA M said if she did not clean the labia properly, Resident #60 could get an infection and rashes. CNA M said if she did not clean Resident#60's abdominal folds , her skin could break down. CNA M said she should have wiped the resident once with one wipe instead of multiple times (three or four). During an interview on 11/08/23 at 2:20 p.m., the DON said her expectation for CNA M was to knock on the door, introduce herself, and explain to Resident #60 she would provide incontinent care. The DON said CNA M should either sanitize her hands or wash her hands, disinfect the bedside, and set up her supplies for incontinent care. The DON said CNA M should have separated Resident #60's labia and abdominal folds and cleaned the areas to avoid build-up, skin breakdown, and infection. During an interview on 11/09/23 at 1:31 p.m., ADON said CNA M should separate Resident # 60's labia and clean each side with one wipe to prevent Resident #60 from getting infection and skin breakdown. ADON said CNA M should have used a wipe one time. ADON said CNA M should have lifted the abdominal folds by the peri area, cleaned it, got in-between creeks and crannies, and cleaned them. Record review of the undated facility policy on perineal care read in part . protocol . clean perineum, eliminate odor, prevent infection and irritation . Record review of the facility perineal requirements November 2023 read in part . procedure : female: separate labia wash urethral area first . rationale: washes pathogens from the meatus . perform hand hygiene . apply clean gloves . Record review of CNA M revealed she signed perineal care training dated November 2023.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #60) reviewed for ADL care. 1. The facility failed to ensure Resident #60 was provided incontinent care in a timely manner . 2. The facility failed to ensure Resident #60 was provided grooming (dry skin) causing her skin to be dry and flaky. These failures could place residents at risk for discomfort, and dignity issues. Findings included: 1. Record review of Resident #60's face sheet, dated 11/10/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #60 had diagnoses which included Morbid (severe) obesity (weight is more than 80 to 100 pounds above ideal body weight), hypertension (a condition in which the blood vessels have persistently raised pressure), and diaper dermatitis (a form of irritated skin). Record review of Resident #60's quarterly MDS assessment, dated 09/22/2023, reflected a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Resident # 60's functional status reflected she required extensive assistance with one staff for ADL care. Resident #60 was incontinent of bladder and bowel. Record review of Resident #60's care plan, revision date 10/19/23, reflected: Resident #60 had bladder/bowel incontinence related to impaired mobility, loss of peritoneal tone, and overactive bladder which placed her at risk for skin breakdown and infection. Interventions: Incontinent: check as required for incontinence. Wash, rinse, and dry perineum. Monitor for signs and symptoms of UTI , pain burning, foul and smelling urine . During an interview on 11/07/23 at 10:05 a.m., Resident # 60 said she wanted to be changed when CNA M came in this morning and changed her roommate, and she told her she had to wait. Resident # 60 said she was changed by the night shift aide around 4:30 a.m . During an observation on 11/07/23 at 10:32 a.m., Resident # 60's incontinent brief change provided by CNA M reflected brief was saturated from front to back. The inside of the incontinent brief was brown, and the wet indicator was faded entirely. During an interview on 11/07/ 23 at 12:14 p.m., CNA M said she was Resident #60's aide and came to work at 6:00 a.m. CNA M said she had not provided incontinent care for Resident #60 since she arrived this morning because the night shift changed Resident #60, and she was not getting her out of bed this morning. CNA M said the aides usually changed residents who were left in bed after breakfast. She stated she had not gotten to Resident #60 to change her incontinent brief until 10:30 a.m. because she was busy. CNA M said Resident # 60's incontinent brief was wet with urine from front to back, and the wet indicator lines faded out. CNA M said if she did not change Resident # 60 timely, she could develop rashes and wounds. CNA M said she was supposed to make rounds every two hours for incontinent care and change the resident if the resident was wet. CNA M said the charge nurse monitored the aides by marking random rounds, and the ADON monitored the charge nurses. She said she had an in-service on rounding and incontinent care. During an interview on 11/08/23 at 1:39 p.m., the DON said CNA M should make rounds every two hours, check on residents, and provide incontinent care for residents who needed care. The DON said it was not the facility protocol to change only the residents who were getting up in the morning. CNA M had to change the residents she would be getting up first and then use her discretion on whom CNA M would change next. The DON said Resident #60 could have skin irritation if left in a wet brief. The DON said the charge nurse monitored the aides to make sure they were providing care to the residents. The DON said the ADON monitored the nurses, and the ADON should have the answer to how she monitored the nurses for care. During an interview on 11/09/23 at 1:27 p.m., ADON said CNA M should make rounds every two hours and as needed to provide incontinent care for Resident #60. ADON said it was unacceptable not to change Resident # 60 because she was not being assisted out of bed that morning. ADON said Resident #60 could sustain skin breakdown, skin irritation, skin infection, and UTI. ADON said when the wet indicator faded out, and the brief was saturated, it meant Resident #60 had not been changed for some time. ADON said the charge nurse monitored the aides by making random rounds, and ADON LT said she monitored the charge nurses by making random rounds and asked the residents if they were changed . 2. During an observation on 11/07/23 at 10:45 a.m., revealed Resident #60's skin from her knees down to her feet were dry and flaky, and there was a substantial amount of flaked dry skin on Resident #60's mattress. During an interview on 11/07/23 at 11:00 a.m., CNA P said she saw Resident #60's mattress had a lot of dry skin. CNA P said Resident #60's aide should have applied lotion on Resident #60's skin on shower days and any time Resident # 60's skin was dry. She stated that it was to prevent it from flaking off, such as the dry flaked skin on Resident #60's mattress. CNA P said Resident #60's skin could break down if dry skin was not prevented or treated . During an interview on 11/07/23 at 11:04 a.m., Resident #60 said the nurses should apply lotion on her skin after showering on Tuesday, Thursday, and Saturday. She stated lotion should be applied when her skin was dry on the days she did not shower, but sometimes the nurse did not apply any cream on her . During an interview on 11/07/23 at 12:16 p.m., CNA M said Resident #60's skin was dry and flakey from her knees down to her feet, and there was a lot of flaked skin on Resident #60's mattress. CNA M said Resident #60 was showered on Tuesday, Thursday, and Saturday, and the aide who showered Resident # 60 should have applied lotion on her . CNA M said if Resident #60's skin continued to fall off, she could have a skin tear or a wound. CNA M said the nurse made random rounds to monitor the aides. CNA M said she had not applied any lotion on Resident #60's legs before now , but she would apply cream later. CNA M said she had skills checked off on shower. During an interview on 11/08/23 at 2:49 p.m., the DON said she would talk to Resident #60's provider about applying lotion on Resident #60's skin. The DON said Resident #60 could have skin break down if her skin continued to flake off. During an interview on 11/09/23 at 1:51 p.m., ADON said Resident #60 should get a shower at least three times a week, and the aide who showered Resident #60 should apply lotion on her skin on her shower days and as needed. ADON said the aides should often lotion Resident #60's legs to prevent dry skin flakes. ADON said Resident #60's skin could develop wound and infection if the skin opened. Record review of the facility policy on bath, and shower, revised 05/2007, read in part . this facility policy to promote cleanliness, stimulate circulation and assist in relaxation . procedures: dependent residents: #6. Apply lotion

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 11-07-23 at 9:00 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the top lid was wide open. Interview on 11-07-23 at 9:05 am, with the Food Service Manager, she stated that the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of facility's, undated, policy and procedure Dispose of Garbage and Refuse reflected all garbage will be disposed of daily and as needed throughout the day. Procedure:. all dumpster lids and doors shall be closed or sealed at all times. Trash will be deposited into containers outside the premises.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice for one of one resident (CR#1) received treatment and care in accordance with the professional standards of practice reviewed for falls in that: The facility did not immediately transfer CR#1 to the hospital after an unwitnessed fall with head injury and mild bleeding to the head. This failure placed all resident at risk of falls for not receiving timely care and treatment to improve their quality of life. Findings Included: CR#1 Record review of CR#!#1's admission face sheet dated 1/18/2023 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident diagnoses included type two diabetes (high blood sugar), chronic obstructive pulmonary disease (A chronic inflammatory disease that makes breathing difficult), hypertension (high blood pressure), anemia (insufficient health red blood cells), vascular dementia without behavior (memory loss), history of falling, hyperlipidemia (high levels of fat particles in the blood), recurrent depressive disorder (mood disorder), insomnia, occlusion and stenosis of unspecified carotid artery, unspecified sequelae of nontraumatic subarachnoid hemorrhage (a blood vessel bulging blood vessel that burst in the brain) and hypokalemia (low potassium). In an interview with unidentified Family Member on 12/29/2022 at 9:00 am revealed that CR#1 had a fall, and the doctor gave orders for her to be sent to the hospital and she was not sent out until almost two hours later. Record review of the nurse's notes dated 12/06/2022 at 6:21pm documented that CR#1 was found on the floor and was bleeding from her head with a little bit of hematoma noted with mild blood. Further record review indicated and Aassessment was done by the nurse. Notified NP, received order to send CR#1 to the hospital for CT of head. Record review of NP D notes dated 12/06/2022 at 6:33pm documented Patient with unwitnessed fall with head injury. Order given to be sent to the hospital for evaluation. Record review of nurse's notes dated 12/6/2023 written at 7:53 pm, documented that Family wants to call nonemergency because EMS took about one hour and a half to come through. Paramedics showed up at 7:57pm to pick up resident. In an interview on 01/18/2023 at 2:00 pm the DON said 911 was not called because it was a nonemergency situation. She said the resident's vitals were stable and she was in no acute distress. She said they did neuro check every 15 minutes and the resident was monitored and there were no changes in CR#1's condition. Record review of the physician's order dated 10/12/2021 revealed CR#1 had an order for Aspirin 81 mg once a day and on 10/23/2020 an order for Plavix 75 mg once a day. Record review of the medication administration record dated 12/2022 revealed Plavix and Aspirin were given as ordered from 12/1/2022 to 12/6/2022. In an interview on 1/18/2023 at 2:30pm CNA B said she was not the CNA who found CR#1 on the resident floor. She said she did not know it if the resident was assessed prior to transferring her to the bed as she was not in the room. She said the nurse called her to assist her to lift the resident off the floor to the bed. She said the resident was on the floor and was complaining of back and side pain. She said she assisted the nurse to put the resident in bed and she notice the bleeding to the head. She said the resident was in pain and she did not know if the resident was medicated as she was not in the room. In an interview on 1/18/2023 at 4:01pm with LVN A she said she was not the nurse who assessed CR#1 when she fell . She said she was the oncoming nurse, and she did the documentation in the CR#1's file based on what she was told by LVN C . She said that it should be a 911 because it was a fall with head injury however it also depends on how stable the resident was. She said the NP did not give an order for a 911 call. In an interview on 1/18/2023 at 4:46pm LVN C said she was called to CR#1's room because she was on the floor. She said the resident was yelling and was notcomplaining of pain . CR#1 was assisted to bed. She said the resident may have hit her head when she fell . She said an order for the resident to be sent to the hospital was given, but it was not given as a 911 call, so they called the non-emergency transport. She said she did neuro checks and monitored the resident, and the resident was stable. Observation and interview with CR#1 on 1/24/2023 at 9:15am revealed the resident was in bed, she was well groomed with no offensive odor. The resident was alert and oriented with some confusion. In an interview at that time with CR#1 she said she could not remember what happened. Record review of hospital admission notes dated 12/06/2022 written at 9:02am revealed documentation of a fall at the nursing home when she was reaching down to pick up an objective. Examination: CT scan confirms a pelvic fracture and a scalp laceration that was repaired. Further record review revealed no intercranial hemorrhage or skull fracture. Record review of the facility's Policy and Procedures on Emergency Procedures dated 05/2007 read in part . Policy: It is the policy of this facility to provide appropriate and expedient care in emergency situations i.ei.e.: falls, or physical conditions. Any changes in physical condition or behavior warrant the following nursing observations and measures: Procedures: Initial Assessment Objective symptoms: bleeding and swelling Nursing Clinicals: 1. Head injuries- Try to determine force of blow to head, observed for presence or absence of swelling, bleeding and report to physician for further instructions. 2. Lacerations - apply pressure to stop bleeding, evaluate size of area and report to physician. Record review of the facility's Policy and Procedures on Emergency Procedures dated 05/2007 read in part . Policy: It is the policy of this facility is to ensure each resident receives quality care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.

Based on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 1 (Resident #2) of 12 residents reviewed for professional standards. The facility failed to follow Resident #2s physician's order for Resident #2 about the use of [NAME] hose. This failure could place residents at risk of not receiving the care and services ordered by the physician and a decline in health status. Findings Included: Resident #2 Record review of Resident#2's face sheet revealed he was admitted to the facility on [DATE] with diagnoses; protein calorie malnutrition, dementia encephalopathy, glaucoma, history of falls, TIA, (transient ischemic attack), hypertension (high blood pressure) insomnia (lack sleep) nondisplaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture. Record review of Resident #2's nurses progress notes on 11/28/22 revealed resident had unwitnessed fall in bathroom, resident states he lost his balance during transfer from walker to toilet. X-ray completed 11/28/22 and 12/1/22 with no acute fracture or dislocation. Sustained R hip discoloration/hematoma. 12/6/22 resident sent to hospital for hematoma evacuation and found to have pelvic fracture. Record review of Resident #2's admission assessment MDS dated [DATE] revealed the resident had short- and long-term memory problems, modified independence, required limited assistance of one-person for transfer, bed mobility, dressing, toilet use and personal hygiene. The resident required supervision, bathing, and used wheelchair for mobility. BIMS score of 4, which indicated the resident was moderately cognitively impaired. Record review of Resident#2's care plan dated 11/03/22 revealed he had severe impaired vision and at risk for further decline in vision and eye infection related to medical condition diagnosis Glaucoma and difficulty falling asleep, feeling tired/little energy taking medication for insomnia. Goal was the resident will not have any injury during the next 90 days. Intervention included: ability to perform ADLS, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, turned vision or hazy vision. Record review of Physician orders dated 12/09/2022 indicated apply [NAME] hose to bilateral lower extremities (BLE) every shift for to prevent DVT (Deep venous thrombosis). Record review of TAR (Treatment Administration Record) for 10/12/ 2022 through January 24, 2023, with initialed ( apply [NAME] hose to BLE every shift for to prevent DVT s/p fracture fall) as given day and night shift and there was no documentation of resident refusal of [NAME] hose. Observation on 01/18/2023 at 9:00 AM revealed Resident #2 in a wheelchair in his room. He had non-slip socks on. Observation on 1/18/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:30 PM Resident #2 had non- slip socks on. Checked Resident #2 dressers for [NAME] hose and no [NAME] hose found Interview with Resident #2 on 1/18/23 at 11:00 AM, regarding any special sock he used, he had no special socks to wear and he showed the surveyor his nonslip slippers. Observation and interview on 01/20/2023 at 10:30 AM, 2:00 PM, 3:00 PM revealed Resident #2 was in a wheelchair in his room. He had non-slip socks. Observation on 1/20/23 at 4:00 PM, 5:30 PM, lying in bed, Resident #2 had non- slip socks on. Interview with C.NA C on 1/20/23 at 3:05 PM regarding Resident #2's [NAME] hose, she said she was not aware of [NAME] hose order. Interview with Physical Therapist D on 1/20/23 at 3:10 PM regarding Resident #2's wearing [NAME] hose, she said she was not aware of [NAME] hose order and has not seen Resident #2 wearing any [NAME]-hose. Interview with LVN B on 1/20/23 at 3:30 PM regarding Resident #2's [NAME] hose, she said she was not aware of [NAME] hose order, she said Resident #2 had nonslip socks on. Observation and interview on 01/24/2023 at 10:00 AM revealed Resident #2 in a wheelchair in his room with non-slip socks on. Observation on 1/24/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:40 PM lying in bed, Resident #2 had non-slip socks on. Resident #2 said he had the non slip socks and had more in his dresser draw. Interview with ADON LVN on1/24/23 at 11:40 AM regarding the physician's order for Resident #2 's [NAME] hose, resident wearing non-slip sock and noted hose in Resident #2's dresser draw. ADON, LVN said resident #2 refused the use of [NAME] hose and it might be in the laundry. ADON LVN said she was going to look into it. At 12:20 PM ADON, LVN, brought back TAR (Treatment Administration Record) for the month of December 2022 and January 2023 with signed initials for day and night of Resident #2 using (Apply [NAME] hose every to BLE every shift for to prevent DVT s/p fracture fall). ADON LVN,on 1/24/23 at 1:24 PM said she had in-services with facility staffs on documenting/notifying NP/MD when resident refuse orders/treatments. In an interview on 1/24/2023 at 2:10 PM the DON stated her expectations were to ensure the orders were followed as ordered by the physician and care plan. DON said her MDS nurses were very good, and they just missed the care plan. [NAME] hose was updated on the care plan prior to exit. Record review of facility policy Pharmacy Services/Nursing Services orders undated indicated: It is the policy of this facility that drug shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedure) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 12 residents (Resident #2) reviewed for order and care plans. The facility failed to follow physician orders about use of [NAME] hose and initial a care plan for Resident #2's use of [NAME] hose. This failure placed residents at risk for not receiving care according to their individually assessed needs. Findings included: Record review of Resident#2's face sheet revealed he was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, dementia encephalopathy (brain disease or malfunction), glaucoma, (Cause of vison and blindness damaging optic nerve) history of falls, TI , (transient ischemic attack), hypertension, ( high blood pressure) insomnia ( lack of sleep) nondisplaced fracture of anterior wall of right acetabulum, initial encounter for closed fracture. Record review of Resident #2's admission assessment MDS dated [DATE] revealed the resident had short- and long-term memory problems, modified independence, required limited assistance of one-person for transfer, bed mobility, dressing, toilet use and personal hygiene. The resident required supervision, bathing, and used wheelchair for mobility. The resident had a BIMS score of 4, which indicated the resident was moderately cognitively impaired. Record review of Resident#2's care plan dated 11/03/22 revealed he had severe impaired vision and at risk for further decline in vision and eye infection related to medical condition diagnosis Glaucoma and difficulty falling asleep, feeling tired/little energy taking medication for insomnia. Goal was the resident will not have any injury during the next 90 days. Intervention included: ability to perform ADLS, decline in mobility, Sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, turned vision or hazy vision. Record review of Resident #2's nurses progress notes dated 11/28/22 revealed resident had unwitnessed fall in bathroom, resident states he lost his balance during transfer from walker to toilet. X-rays completed 11/28/22 and 12/1/22 with no acute fracture or dislocation. Sustained R hip discoloration/hematoma. 12/6/22 resident sent to hospital for hematoma evacuation and found to have pelvic fracture. Record review of Physician orders dated 12/09/2022 indicated apply [NAME] hose to bilateral lower extremities (BLE) every shift for to prevent DVT (Deep venous thrombosis). Record review of TAR (Treatment Administration Record) for 10/12/ 2022 through January 24, 2023, with initialed ( apply [NAME] hose to BLE every shift for to prevent DVT s/p fracture fall) as given day and night shift and there was no documentation of resident refusal of [NAME] hose. Observation on 01/18/2023 at 9:00 AM revealed Resident #2 was in a wheelchair in his room. He had on non-slip socks. Further observation on 1/18/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:30 PM Resident #2 had on non-slip socks on. Checked Resident #2 dressers for [NAME] hose and there were no [NAME] hose found. Interview with Resident #2 on 1/18/23 at 11:00 AM, regarding any special sock he used, he had no special socks to wear and he showed the surveyor his non-slip slippers. Resident #2 only knew the non-slip sock he was wearing, he did not know about [NAME] hose. Observation and interviews conducted on 01/20/2023 at 10:30 AM, 2:00 PM, 3:00 PM revealed Resident #2 was in a wheelchair in his room. He had non-slip socks. Observation on 1/20/23 at 4:00 PM, 5:30 PM, lying in bed, Resident #2 had non- slip socks on. Interview with CNA C on 1/20/23 at 3:05 PM she said she was not aware of Resident #2's [NAME] hose order. Interview with Physical Therapist D on 1/20/23 at 3:10 PM she said she was not aware of [NAME] hose order and has not seen Resident #2 wearing any [NAME]-hose. Interview with LVN B on 1/20/23 at 3:30 PM she said she was not aware of the [NAME] hose order, she said Resident #2 had nonslip socks on. Observation and interview on 01/24/2023 at 10:00 AM revealed Resident #2 in a wheelchair in his room with non-slip socks on. Observation on 1/24/23 at 11:00 AM, 2:00 PM, 3:00 PM, 4:30 PM, and 5:40 PM lying in bed, Resident #2 had non- slip socks on. In an interview at that time with Resident #2 said he have the no slip socks and had more non-slip draw in his dresser draw. Interview with ADON LVN, on 1/24/23 at 11:40 AM the ADON LVN said the [NAME] hose would be in the laundry room and Resident #2 always refused [NAME] hose and she was not sure why the nurses did not document when resident refused, and the doctor/NP should be notified. ADON LVN S said she was going to check it, she then returned with TAR (Treatment Administration Record) for December 2022 and January 24, 2023, with initial on the apply [NAME] hose to BLE every shift for to prevent DVT s/p fracture fall) as given day and night shift and there was no documentation of resident refusal of [NAME] hose. In an interview with the ADON on 1/24/23 at 1:24 PM she said had in-services with facility staff on documenting/notifying NP/MD when residents refused orders. Interview with MDS coordinator, LVN A on 1/24/23 at 12:48 PM, regarding not care planning Resident #2's [NAME] hose ordered on 12/09/22, she said she was going to check Resident #2's care plan. Interview on 1/24/23 at 1:13 PM the MDS coordinator, LVN A said she checked Resident #2's care plan and the [NAME] hose was not updated in Resident #2 care plan and she will be updating it now. Record review of care plan dated 1/24/23 at 1:24 PM documented 12/9/22- I have an order for [NAME] hose, I do refuse to wear them. In an interview on 1/24/2023 at 2:10 PM the DON stated her expectations were to ensure the orders were followed as ordered by the physician and care plan. The DON said her MDS nurses were very good, and they just missed the care plan about [NAME] hose. Facility policy on care plan process requested on 1/24/23 at 3:00 PM for the DON, it was not provided till exit. Record review of facility policy Pharmacy Services/Nursing Services orders undated indicated: .implement orders in addition to medication orders (treatment, procedure) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for one of one kitchen food service safety in that: -The facility stored unlabeled food in the refrigerator and the freezer. This failure had the potential to place residents that eat from the kitchen at risk of foodborne illness. Findings included: Observation and interview on 09/07/22 at 9:07 a.m., revealed 1 bag of unlabeled lettuce in the walk-in refrigerator;1 unlabeled bag of frozen waffles, and 1 unlabeled bag of fried chicken. The Lead Kitchen Aid Manager stated the bags should be labeled. He stated food needs to be labeled so that residents were not served food that had gone beyond the expiration date and that it was safe for the residents. In an interview with the Director of Food Services Supervisor on 09/08/2022 at 12:30 p.m., she stated that the policy for storing food is when foods are placed in the fridge they are placed in bag and labeled with the prep date and the used by date. The Director of Food Services Supervisor was asked why labeling was important and she stated labeling was important to ensure that spoiled food was not served to residents. In an interview with the DON on 09/08/2022 at 1:52 p.m., the DON stated that the facility used the Texas Food Establishment Rules or TFER as their food storage and labeling policy. Record Review of Inservice training of Labeling and Dating of Products dated 06/21/2021 reflected in part: .If you open a package, make sure it put into a sealed bag or container and a label with an opened date and use by date Record review of In-service training on Label and dating, rotating product conducted on 06/12/2021 read in part: . When you open a new box of product and you do not use it all, an OPEN DATE needs to go on the box and product is to be put back in the same place you got it from A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. A record review of the FDA food code and the code that is relevant to the failure. https://www.fda.gov/media/ 2/download

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to prevent development and worsening of pressure injuries to 3 of 8 residents (Resident #1 Resident #2, and Resident #3) reviewed for pressure ulcers. - The facility failed to assess and monitor Resident #1's skin condition, resulting in the progression of a wound on his left ischium (the lower back part of the hip bone area) from a MASD to a Stage III pressure wound -The facility failed to assess and monitor Resident #2 and Resident #3's skin to prevent the development of pressure ulcers. -The facility failed to ensure the Weekly Wound Report and Weekly Skin assessments were consistently completed and/or updated to identify and track the progression of new wounds on Resident #1, Resident #2, and Resident #3. -The facility failed to ensure CNAs communicated skin issues to the charge nurses. Shower sheets were not completed when skin issues were identified during showers or bed baths for Residents #1, Resident #2, and Resident #3. These failures could affect residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization . Findings include; Resident #1 Record review of Resident #1's face sheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Comprehensive MDS dated [DATE] read in part, Is this resident at risk of developing pressure ulcers/injuries? Yes was documented. Does this resident have one or more unhealed pressure ulcers/injuries? 0 was documented which indicated no. Further record review of Resident #1's Comprehensive MDS dated [DATE] revealed, no documentation indicating the resident had any current unhealed pressure ulcer/injuries, venous and/or arterial ulcers. Other Ulcers, Wounds and Skin Problems None of the above were present was checked. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 10/29/20 revealed, a score of 15' indicating Low Risk. Record review of Resident #1's care plan (undated) read in part, Focus: I have a stage 3 pressure ulcer to sacrum. (Resident refuses to get out of bed, refused bathing, repositioning). Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: .Administer treatments as ordered and monitor for effectiveness, Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD Daily body checks, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Further record review of Resident #1's care plan (undated) read in part, .Interventions .Left ischium: Cleanse stage 3 pressure injury with ns/wc pat dry. Apply Collagen to wound bed with alginate cover with dry protective dressing daily and prn .Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size and stage .Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. Record review of the facility's Pressure Ulcer and Non-Pressure Ulcer report for the months of August and September 2020 revealed, Resident #1 was not on the report. Record review of the facility's Pressure Ulcer and Non-Pressure Ulcer report for the month of October 2020 on Resident #1 revealed, documentation of a left ischium stage 3 pressure ulcer measuring 3.6cm x 1.7cm x 0.1cm on week 4, there were no measurements for weeks 1 and 2. A Braden scale score of 17 was documented. There was no documentation of a MASD and/or sacral wound. The sections for How Acquired, Onset Date, Date of Last Braden were all left blank. Record review of Resident #1's Physician orders [REDACTED]. Apply Collagen to wound bed, cover with dry protective dressing daily and prn. Every day shift for Wound Healing. Record review of Resident #1's Physician orders [REDACTED]. Apply Collagen to wound bed, with alginate cover with dry protective dressing daily and prn. Every day shift for Wound Healing. Record review of Resident #1 Skin Weekly Pressure Ulcer review dated 10/27/20 revealed, documentation of a FA St III left ischium pressure ulcer measuring 3.6cm x 1.7cm x 0.1cm, with moderate serous exudate and an onset date of 10/27/20. Further record review of Resident #1 Skin Weekly Pressure Ulcer review dated 10/27/20 read in part, Left ischium started out as MASD which worsened to a stage 3 pressure injury due to residents' noncompliance . Interview and observation on 10/29/20 at 12:13pm of Resident #1 revealed, the resident sitting up in bed, watching TV. When asked if he had a wound, he stated yes. The resident did not want to answer any further questions. Resident #2 Record review of Resident #2's face sheet revealed, an [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] read in part, Is this resident at risk of developing pressure ulcers/injuries? 1 = Yes was documented. Does this resident have one or more unhealed pressure ulcers/injuries? 0 was documented which indicated no. There was no documentation indicating the resident had any current unhealed pressure ulcer/injuries, venous and/or arterial ulcers. Other Ulcers, Wounds and Skin Problems None of the above were present was checked. Record review of Resident #2's Care Plan read in part, Focus: I have a Coccyx wound: Cleanse Unstageable wound with ns/wc pat dry. Paint wound bed with [MEDICATION NAME], leave open to air daily and prn. Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: .Assess/record/monitor wound healing. Monitor length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD .Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx of infection, wound size and stage . Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care .Weekly head to toe skin at risk assessment. Record review of the facility's Pressure Ulcer and Non-Pressure Ulcer report for the month of August 2020 on Resident #2 revealed, documentation of an in house MASD gluteal wound identified on 7/31/20 measuring 1.5cm x 0.5cm x 0.1cm on Week 1 and measuring 0.9cm x 0.3cm x 0.1cm on Week 2. On Week 3 resolved was documented. There was no further documentation of subsequent wounds on Resident #2. Record review of the facility's Pressure Ulcer and Non-Pressure Ulcer report for the month of September 2020 revealed, Resident #2 was not on the report. Record review of Resident #2's Braden Scale for Predicting Pressure Sore Risk dated 10/07/20 revealed, a score of 17 documented indicating, Low Risk. Record review of the facility's Pressure Ulcer and Non-Pressure Ulcer report for the month of October 2020 on Resident #2 revealed, documentation of an unstageable sacral pressure ulcer measuring 7.0cm x 5.0cm and an unstageable coccyx pressure ulcer measuring 1.9cm x 3.1cm x0.1cm for Weeks 3 and 4. Both PUs had a documented onset date of 10/25/20. A Braden scale score of 17 was documented. How Acquired and measurements for Week 1 and Week 2 were left blank. Record review of Resident #2's Skin Pressure Ulcer Weekly review dated 10/27/20 revealed, a FA sacral pressure ulcer with an onset date of 10/25/20 measuring 3.1cm x 2.9cm x 0.1cm with a black/brown (Eschar) wound bed. It further revealed, a FA coccyx pressure ulcer with an onset date of 10/25/20 measuring 1.9cm x 3.1cm x 0.1cm with black/brown (eschar). Further record review of Resident #1 Skin Weekly Pressure Ulcer reviews revealed, there was only one assessment completed on 10/27/20. The next Skin Weekly Pressure Ulcer review was documented as incomplete on 8/30/17. There were no further Skin Weekly Pressure Ulcers assessments to review. Record review of Resident #2's Physician orders [REDACTED]. Paint wound bed with [MEDICATION NAME], leave open to air daily and prn. Every day shift for Wound Healing. Further record review of Resident #2's Physician orders [REDACTED]. Paint wound bed with [MEDICATION NAME], leave open to air daily and prn. As needed for Wound Healing. Resident #3 Record review of Resident #3's face sheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS dated [DATE] read in part, Is this resident at risk of developing pressure ulcers/injuries? 1= Yes was documented. Does this resident have one or more unhealed pressure ulcers/injuries? 0 was documented which indicated no. There was no documentation indicating the resident had any current unhealed pressure ulcer/injuries, venous and/or arterial ulcers. Other Ulcers, Wounds and Skin Problems None of the above were present was checked. Record review of Resident #3's Care plan read in part, Focus: I have a stage 2 to right heel; Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date; Interventions: .Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD.Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care . Further record review of Resident #3's Care plan read in part, Focus: I have a DTI lateral leg; Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date; Interventions: .Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD.Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care . Record review of Resident #3's Braden Scale for Predicting Pressure Sore Risk dated 09/28/20 revealed, a score of 13 documented indicating, Moderate Risk. Record review of the facility's Pressure Ulcer and Non-Pressure Ulcer report for the month of October 2020 on Resident #3 revealed, documentation of a right heel DTI measuring 4.5cm x 3.5cm and a right lateral ankle DTI measuring 2.0cm x 1.0cm on Weeks 3 and 4. Both wounds had a documented onset date of 10/23/20. A 13 Braden Score was documented. How Acquired was left blank. Weeks 1 and 2 had no measurements documented. Record review of Resident #3's Skin Weekly Pressure Ulcer review dated 10/23/20 revealed, a FA St II Right Heel PU measuring 4.5cm x 3.5cm with an onset date of 10/23/20. Further record review of Resident #3's Skin Weekly Pressure Ulcer Review revealed, wound #2 a sacral DTI measuring 2.0cm x 1.0cm with scant exudate. Exudate type was not documented. Onset date of 10/23/20 was documented. Further record review of Resident #3's Skin Weekly Pressure Ulcer reviews revealed there was only one Weekly PU review completed for the month of October 2020. Record review of Resident #3's Physician orders [REDACTED]. Apply skin prep and leave open to air daily and prn. As needed for Wound Healing. Further record review of Resident #3's Physician orders [REDACTED]. Apply skin prep and leave open to air daily and prn. As needed for Wound Healing. Observation on 10/29/20 at 12:17pm of Resident #3 revealed, the resident lying in bed on a scoop mattress, asleep, clean, the bed was low to the floor with fall matt to side of bed. The resident was not interviewable due to cognitive impairment. Interview on 10/29/20 at 1:19pm with the DON, she stated they hired a new treatment nurse two weeks ago stating the previous one was fired. She said they realized the previous wound nurse was not completing reports or weekly assessments further stating they completed a QIT meeting and skin sweeps of all residents once they were aware of the problem. Interview on 10/29/20 at 1:42pm with the DON and Clinical Resource nurse, when asked if the weekly PU reports were being completed, the DON stated it was hit or miss if the reports were being done and if they were completed in October. She said some assessments were there and some were not. She said the treatment nurse went on vacation and while she was on vacation an audit was completed and they noticed missing documentation, some skin issues as well as some inconsistencies in the skin assessments. She stated because of this, they had a QIT meeting and completed skin sweeps on the entire building. Further interview on 10/29/20 at 1:42pm with the DON and Clinical Resource nurse, when asked who was responsible for completing the weekly wound reports, the Clinical Resource nurse stated the treatment nurse is responsible for completing the weekly PU and non-PU reports. When asked if the September wound notes/log tracker assessments were completed for the month of September, she stated some reports were missing in the month of September further stating September was the one all over the place when the audit was done about two weeks ago. The DON said there would be missing notes for the month of September as well, further stating August looked good. The Clinical resource nurse stated they completed an audit 90 days ago, and when the redid the audit they noticed some missing documentation. The DON said the treatment nurse is also responsible for completing the weekly skin and Braden assessments, wound monitoring, completing treatments, and setting up the weekly skin and Braden schedules. Further interview on 10/29/20 at 1:42pm with the DON, when asked if wound care was being completed by the previous treatment nurse as ordered, the DON stated she was always busy and it would look like she was doing wound care because they spot checked the dates on the dressings being changed. She said the times they counseled the treatment nurse she would say, I'm getting it done. She said she did ask for a documentation day, and they said they could get someone else to come in to help her, further stating they tried to accommodate that need and had a nurse assist with documentation for eight hours. The DON stated that did not seem to help because when they did their next audit, documentation was not being done, further stating they had no choice but to terminate the treatment nurse. The DON said the current Wound Nurse comes with five years of wound care experience. Further interview on 10/29/20 at 1:42pm with the DON, when asked what was currently being done to prevent wounds from developing and/or deteriorating, she stated they were completing weekly rounds with the wound nurse, further stating the DON and Clinical Resource nurse were rounding before the new treatment nurse was brought in and the ADONs were doing wounds at bedside. She said they did a skin sweep on the entire building, and the treatment nurse was rounding every week with the Wound MD. Further interview on 10/29/20 at 1:42pm with the DON, she said she received wound reports and sent the report to the Clinical Resource nurse to audit, and she was completing weekly audits to ensure non-PU and PU UDA assessments were being done and completed accurately. The DON further stated she saw the wound tracker submitted by Treatment nurse weekly to ensure wounds were being measured correctly and a documentation report was being run daily to see if treatments that were not being documented on the TAR show up on the report, stating these reports were being run every morning. She said she can see if the treatment was done by running the missed documentation report. She said the new Wound MD will see everything identified from the building skin sweep stating he will see all those patients which will allow them to get a good start and the appropriate treatments for all wounds identified. Further interview on 10/29/20 at 1:42pm with the DON, when the investigator asked the DON if the Weekly skin assessments could not be reviewed on Resident #1, #2 and #3 because they were not being completed, she said yes, that was the reason, stating they weren't being consistently completed. Interview on 10/29/20 at 1:44pm with the DON, she said that they realized that skin assessments were not being completed, stating they implemented a plan in which they would have more accurate documentation. She further stated the CNA's should document whatever they identify on a resident when they are providing routine care, a bed bath or shower, stating redness, bruising, or open areas. She said the Charge nurse would sign off on the sheet and further evaluate the residents skin to determine the care and treatment needed. Shower Sheets Record review of Resident #1's Skin Evaluation PRN/Weekly for dates of 10/20/20, 10/13/20, 10/6/20, 9/29/20, 9/22/20, 9/15/20, 9/8/20, and 9/1/20 revealed, no documentation a pressure ulcer wound and/or MASD. Record review of Resident #1's Skin Observation - Shower Sheets revealed the following: -10/1/20 revealed, Skin Tear-Yes was circled on the sheet. Further record review of the Skin Observation - Shower Sheet revealed, the sheet was not signed by the Charge nurse indicating the sheet was reviewed. -10/03/20 revealed, Red Areas-Yes was circled on the sheet. Further record review of the Skin Observation - Shower Sheet revealed, the sheet was not signed by the Charge nurse indicating the sheet was reviewed. -10/06/20 revealed, Bruises, Red Areas, and Open Areas-Yes were circled on the sheet. Further record review of the Skin Observation - Shower Sheet revealed, the sheet was not signed by the Charge nurse indicating the sheet was reviewed. -10/27/20 revealed, Red Areas, and Open Areas-Yes were circled on the sheet. Further record review of the Skin Observation - Shower Sheet revealed, the sheet was not signed by the Charge nurse indicating the sheet was reviewed. Further record review of Resident #1's Skin Observation - Shower Sheets dated 10/08/20, 10/12/20, 10/10/20, 10/13/20, 10/15/20, 10/17/20, 10/20/20, 10/22/20, 10/24/20 revealed, Red Areas-Yes was circled on the sheets. Further record review of the Skin Observation - Shower Sheets revealed, the sheets were not signed by the Charge nurse to indicate the sheets were reviewed. Record review of Resident #2's Skin Observation - Shower Sheets dated 10/01/20, 10/03/20, 10/06/20, 10/08/20, 10/10/20, 10/13/20, 10/15/20, 10/17/20, 10/20/20, 10/22/20, 10/24/20, and 10/27/20 revealed, no documentation indicating old and/or new wounds, bruises, rash, cuts, PU, or other open areas were present on the resident. Record review of Resident #2's Skin Observation - Shower Sheets dated 10/01/20, 10/03/20, 10/06/20, 10/08/20, 10/10/20, 10/13, 10/15/20, 10/17/20, 10/20/20, 10/22/20, 10/24/20, and 10/27/20 revealed, the sheets were not signed by the Charge nurse to indicate the sheets were reviewed. Record review of Resident #3's Skin Observation - Shower Sheets dated 9/02/20, 9/04/20, 9/07/20, 9/11/20, 9/14/20, 9/16/20, 9/18/20, 9/19/20, 9/25/20, 9/28/20, 9/30/20, 10/02/20, 10/05/20, 10/07/20, 10/09/20, 10/12/20, 10/14/20, 10/16/200, and 10/19/20 revealed, no signatures of the CNAs who completed the shower or bath, and no signature of the Charge nurse to indicate the sheets were reviewed. Further Record review of Resident #3's Skin Observation - Shower Sheets dated 9/21/20 and 9/23/20 revealed, the form was not completed and was not signed by the CNAs who completed the shower or bath or signed by the Charge nurse to indicate the sheets were reviewed. Record review of Resident #3's Skin Observation - Shower Sheets dated 10/23/20, 10/26/20, and 10/28/20 revealed, Red Areas-Yes was checked. Further record review of the Skin - Observation Shower Sheets revealed, no signatures of the CNA who completed the bath or shower and no signature of the Charge nurse to indicate the sheets were reviewed. Further Record review of Resident #3's Skin Observation - Shower Sheets dated 10/23/20, 10/26/20, and 10/28/20 revealed, Red Areas-Yes checked. Further record review of the Skin - Observation Shower Sheets revealed, no signatures of the CNAs who completed the bath or shower and no signature of the Charge nurse to indicate the sheets were reviewed. Interview on 10/29/20 at 3:23pm with MA #1, when asked what the policy on is communicating skin issues observed during showers, she stated she would tell the charge nurse she was working on floor with and let the treatment nurse know. When asked where you document your findings, she stated we document on the shower sheets and in the kiosk, when asked what would be documented, she said she would document, what I saw, where I saw it, color, drainage, if it was an open wound. When asked if this was a new policy, she stated she has always done that. Interview on 10/29/20 at 3:29pm with Restorative Aide A, when asked what the policy on communicating skin issues observed during showers, she said we have a shower sheet and fill that out and report it to our nurse, and we have a wound care nurse we give the shower sheets to. When asked what is documented, she said there is a picture of the body front and back and you put where you found the wound or area that has an open sore, red area, or skin tear and you can circle that. She said generally if we are doing routine care on a hall we can grab a shower sheet and mark it at that time. When asked if this is a new policy, she stated we've always done them, stating, I can't tell you how long ago, but we always had the shower sheets. She said the shower tech also completes them too. Interview on 10/29/20 at 3:35pm with CNA #1, when asked what the policy on communicating skin issues observed during showers or routine care, he stated we just had an in-service, stating even if it's not a shower day and we notice a bruise or something we fill out a shower sheet and give it to the charge or the wound nurse, further stating the shower tech also completes it. When asked if this policy has always been in place, he said it is not new. When asked what is documented on the shower sheets, he stated we document any redness, bruising, stating there is a whole body and you circle the area and write bruise or redness and there is a legend on the side. Interview on 10/29/20 at 3:42pm with the Lead CNA, when asked what the policy is on communicating skin issues observed when completing showers or routine care, she said you tell the charge nurse before you get the resident up, you notify the shower aide and there is a sheet you fill out with the body parts and on what side the skin issue is observed. She said the shower aide will complete this if he/she is giving the shower, further stating If the CNA is giving the shower, the CNA is responsible for completing the shower sheet. When asked what is documented on the shower sheet, she said if the wound is on the left hip, you put on the left hip or whichever part of the body system it was on. When asked if this is a new policy, she stated this has always been a policy. Interview on 10/29/20 at 6:30pm during exit conference with the DON, when informed the shower sheets are incomplete and most are not signed by the CNA and/or charge nurse she said she was going to in-service the CNA's again. Record review of the facility's Policy/Procedure - Nursing revised 2/2020 read in part, Subject: Skin Management System Policy: It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures taken to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. Further record review of the facility's Policy/Procedure - Nursing revised 2/2020 read in part, .Procedures: .4. Residents will have ongoing head to toe assessments done weekly, incorporated into the LN Weekly Summary review by the licensed nursing staff. 5. A report of all wounds and their progress will be updated by the treatment nurse weekly .

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (CR #1) reviewed for quality of care. The facility failed to provide CR #1 with side rails to assist with repositioning and incontinent care as requested and consented by the resident and as recommended by the IDT team resulting in CR#1 falling out of bed during incontinent care. The facility failed to adequately assess and monitor CR#1 following a fall and failed to immediately send CR #1 out to the hospital when she complained of pain all over. CR #1 was diagnosed with [REDACTED]. These failures affected one former resident who died from injuries sustained from the fall and placed all other facility residents at risk of poor quality of care. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE]. She returned to the facility from her most recent hospital stay on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #1's bed rail safety assessment dated [DATE] revealed bed rails were recommended, and consent was received from CR #1 and her family member. The justification read To assist in reposition self while in bed and assist staff members during incontinent care. Record review of CR #1's significant change in status MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderately impaired cognition. Further review revealed she required extensive assistance of one person for dressing, toileting, and personal hygiene. She was 5'1 and weighed 225 pounds and had no recorded falls. Record review of CR #1's care plan revised on [DATE] revealed she had an ADL self-care performance deficit and required assistance of staff for ADLs. Interventions included mobility bars to aide in easy turning and repositioning while in bed. Further review revealed she was at risk of falls and the goal was she would not sustain serious injury through the review date. The care plan revealed CR #1 used ¼ side rails as an enabler. The goal was I will be able to assist staff with turning and repositioning and or able to reposition self. During an interview on [DATE] at 11:39 am, when asked if CR #1 had mobility bars or side rails the DON said My knowledge is it's mobility bars. Every resident in my building has an order for [REDACTED]. Most of the time they would prefer mobility bars. Observation on [DATE] at 2:20 pm revealed CR #1's room located on the COVID wing. The bed to the far right was an air mattress with side rails at the head of the bed. The siderail on the left was down, the siderail on the right was up. When asked to demonstrate how to use the side rails the Administrator was unable to lift or lower either. 3 unidentified CNAs working the wing were asked to operate the side rails and were unable to lower or lift the side rails. When asked if side rails were supposed to be lowered while CR #1 was in bed an unidentified CNA said, No that would be considered a restraint. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's incident report dated [DATE] at 6:08 am revealed LVN A was summoned to her room where she was observed on her back in a sitting position. CNA said CR #1 rolled out of bed while giving care. A head to toe assessment was done and CR #1 complained of pain to the left knee. CR #1 was provided [MEDICATION NAME] and neuro checks were initiated. CR #1 was put back in bed and the RP, NP, and DON were notified. The RP requested CR #1 be sent out for evaluation. EMS was called and were on the way. Further review revealed there was no swelling noted, vitals were within normal limits, and range of motion was at baseline. The resident description indicated Res said I rolled out of bed. The incident report was incomplete and did not have the following information: level of pain, level of consciousness, mental status, injuries reported post incident, predisposing environmental factors, predisposing situation factors, and witnesses. During an interview on [DATE] at 2:55 pm, LVN A said on ,[DATE] sometime before 6 am CNA T screamed for him to come to CR #1's room. He said he went to the room and found her on the floor to the right of her bed near the window with her sweat pants up to her knees. He said he was not sure if she was supposed to have a fall mat, but she was not lying on top of one when observed. He said he did a head to toe assessment and checked her vitals but did not notice anything unusual. He said CR #1 complained of pain in her leg. He said he asked CR #1 to rate the pain, but she did not provide a number. When asked if she hit her head he said, She was complaining about the leg really not the head. He said with the assistance of CNA T they got CR #1 back in bed. He then provided her [MEDICATION NAME] 7.5 mg for the pain and called the NP, RP, and family. He said the physician said to follow up with family and see if they wanted CR #1 sent out. He said he called CR #1's RP who did want her sent out to the hospital, so he called EMS to schedule the transport. When asked why EMS was called instead of 911 he said because CR #1 was not in distress. He said he started neuros and informed the oncoming nurse, RN B, of the incident. He said he left around 6:30 am and CR #1 was sleeping. When asked why some of the areas on the incident report were incomplete he said they must've been missed because of the urgency. During an interview on [DATE] at 8:20 am, CR #1's family member said when CR #1 returned from the hospital she was readmitted to the COVID hall. She said the siderails she had in her previous room were not moved to the new room. She said CR #1 requested the rails multiple times because she felt more comfortable with them, but the ones she had wouldn't come down. She said on [DATE] she was called at 5:30 am by LVN A and informed CR #1 had a fall from her bed while getting changed. She was transferred to the emergency room where it was discovered she had two broken legs and a broken ankle. She said CR #1 was currently in the ICU with a brain bleed and was not expected to survive. During a telephone interview on [DATE] at 12:50 pm, CNA T said on [DATE] she worked in the COVID unit from 10 pm - 6 am. She said around 4:45 am the nurse asked her to get CR #1 ready for her [MEDICAL TREATMENT] appointment. She said CR #1's brief needed to be changed, and as she was turning her to change her CR #1 rolled off the bed and hit her right hip on the ground. When asked if CR #1 hit her head she said, I didn't notice that. When asked if CR #1 was using the side rails during care CNA T said the side rails wouldn't come down that day. She said before performing care she tried to adjust the side rails, but It was bad and couldn't come down. She said that was not the first time it happened and continued care anyways. CNA T said she screamed for LVN A who came to the room immediately. She said CR #1 complained of pain everywhere and kept yelling pain repeatedly. She said LVN A took CR #1's vitals, they put her back in the bed, and LVN A provided pain medication. She said CR #1 was more calm after receiving the medication. She said LVN A was the only person she spoke with regarding the incident and he asked her to write a statement before she left, which she completed and gave to LVN A before leaving. She said CR #1 was not sent out to the hospital on her shift. During an interview on [DATE] at 1:56 pm when asked about CR #1's fall on [DATE] the Administrator said LVN A told him CNA T was getting her dressed when she slid out of the bed. A copy of the investigation was requested from the Administrator. He said the DON, who was not in the building that day, was responsible for fall investigations and he did not have a written investigation. When asked if there was a signed witness statement from CNA T, he said he did not have one. When asked about the consent CR #1's side rails he said she had them on the bed in her regular room and the bed in the COVID room. During an interview on [DATE] at 11:39 am, the DON said on ,[DATE] around 5 am LVN A called her and informed her CR #1 had a fall. She said LVN A told her CNA T was performing care and rolled CR #1 who fell on the floor on top of her floor mat. She said LVN A said he did a head to toe assessment and observed no apparent injuries but did complain of knee pain. She said she got to the facility around 6 am and described CR #1 as Definitely having pain. When asked what CR #1's pain level was she said between 4 - 5. She said the non-emergent line was called initially, but they were taking a while, so 911 was eventually called. Record review of CR #1's neurological assessment dated [DATE] revealed it was initiated at 5 am by LVN A. RN B documented and signed off that the neuro checks were completed from 6:30 am to 5:45 pm. HOSP was written on top of the already documented assessment indicating the resident was sent out to the hospital. During an interview on [DATE] at 11:39 am a copy of the neuro check was shown to the DON. When asked why vitals were recorded up until 5:45 pm she said I don't know where these came from. She wasn't here. You would have to interview the morning charge nurse. Record review of CR #1's nursing note dated [DATE] revealed she was sent out to the hospital for evaluation following her fall. Her vitals were recorded as: Temperature - 98 degrees Fahrenheit. Respirations - 18. Pulse - 76. Blood pressure - ,[DATE]. The note was signed by RN B. A telephone call and voice message was left for RN B on [DATE] at 12:20 pm. The phone call was not returned. Record review of CR #1's SBAR evaluation dated [DATE] revealed CR #1 had a fall that morning. The vital signs recorded on the assessment were not current vitals. They were recorded as: Temperature - 98 degrees Fahrenheit from [DATE] at 5:39 pm. Respirations - 18 from [DATE] at 5:39 pm. Pulse - 75 from [DATE] at 5:39 pm. Blood pressure - ,[DATE] at 5:39 pm. Oxygen saturation - 97% from [DATE] at 5:39 pm. Further review revealed there was suspected serious injury with pain to the left and right knee. The pain was recorded as acute pain and rated as a ,[DATE]. She was also noted to have complaints of back pain. The assessment was initiated and signed by the DON. Record review of CR #1's fall evaluation dated [DATE] revealed she was high risk for falls. The evaluation was signed by the DON. Record review of CR #1's pain management review dated [DATE] revealed CR #1 had a throbbing pain in her knees and rated it a ,[DATE]. The following sections were not filled out How does your pain affect your everyday life, what makes your pain worse, what non-drug approaches make your pain better, what medications have relieved your pain in the past, and over the last 3 months or since your admission here, how well has your pain been managed. The assessment was initiated and signed by the DON. Record review of CR #1's fall committee IDT meeting note dated [DATE] revealed the DON was notified of a witnessed fall from the bed. There were no noted injuries and vitals were within normal limits. CR #1 was assisted back into bed and the NP and RP were notified. The NP ordered CR #1 be sent out. The conclusion was that CR #1's air mattress would be changed. The note was signed by the DON. During an interview on [DATE] at 1:58 pm the ADON said following a fall the nurse witnessing the incident should complete a head to toe assessment, SBAR, and fall evaluation. She said vitals on the SBAR should be from the time of the incident. During an interview on [DATE] at 2:55 pm, LVN A said he left around 6:30 am and CR #1 was sleeping. When asked if he completed any assessments in the system he said no. He said I should have done an SBAR. I did everything else though. When asked to define everything else he said he did the incident report, neuro checks, and notified the proper entities. When asked why some of the areas on the incident report were incomplete he said they must've been missed because of the urgency. During an interview on [DATE] at 11:39 am, the DON said she was responsible for all post fall investigations. When asked when investigations are reported to the Administrator as incidences needing to be reported to HHSC she said if it were a fall happened with a resident who had a low BIMS score. She said following a fall the involved nurse should do a head to toe assessment, initiate neuro checks, and complete the fall, pain, and SBAR assessments completely. She said the nurse should also contact NP, RP, and DON. When asked why she completed the fall, pain, and SBAR assessments and not LVN A she said LVN A initiated the assessments, but she closed them out. When informed all three assessments indicated they were initiated and completed by her she said whenever she updated an assessment being that she was the DON it updated to say it was initiated by her. She said, I took a verbal counseling for that because I didn't know I couldn't close them out for him. When informed that LVN A said he did not initiate any assessments she said, Yes he did. She said she made sure everything was filled out on the assessments and closed them out. She said she noticed LVN A did not update the vitals on the SBAR but recorded them on the neuro checks. When asked if that was acceptable she said no which is why she spoke with him. Record review of LVN A's time adjustment request form dated [DATE] revealed he clocked in at 6 pm and clocked out at 6:20 am. Record review of the pain, fall, and SBAR assessments dated [DATE] revealed they were initiated after 6:20 am when LVN A was already off. During an interview on [DATE] at 1:10 pm, the DON was informed LVN A clocked out before the assessments were initiated and she said, Those are COVID time sheets. She said staff on the COVID wing don't manually clock in, they hand write their time and it could be inaccurate. Record review of CR #1's emergency department note dated [DATE] revealed she arrived to the hospital at 8:18 am. The note read Per EMS patient (pt.) was found on the floor. Pt complained of pain all over body. hypotensive but obeys commands. The physical exam revealed she was in acute distress and her pain was noted to be a constant aching. A contusion was noted on her right upper femur. Her vitals from 8:30 am were recorded as: Temperature - 96 degrees Fahrenheit . Respirations - 18 . Pulse - 71 . Blood pressure - ,[DATE]. Oxygen saturation - 100%. Further review of hospital record above revealed a written noted at 8:47 am that read [AGE] year-old female brought in from nursing home after being found on the ground next to the bed, last seen yesterday night, patient states that she had her [MEDICAL TREATMENT] this morning which is not true. She is oriented to self and president (SIC) but not day. Complaining of pain all over. A note was written at 2:09 pm revealed Ct head shows: A number of small subdural collections are identified at the anterior right frontal lobe. The thickest near the midline measures 7 mm in thickness. There is no midline shift. The last note written prior to CR #1's transfer to a different hospital revealed Third transfusion on going, last blood pressure was ,[DATE], respiratory status has been unchanged. She has only stabilized for the last 30 minutes, I still think she needs very close monitoring especially ICU and would best served at the trauma center as a suspect that is likely the cause of the patient. Record review of CR #1's x-rays dated [DATE] revealed she had a [MEDICATION NAME] comminuted [MEDICAL CONDITION] left femur with anterior displacement distally. She also had an acute fracture plane located 6 cm distally in the left femur. Record review of CR #1's death certificate dated [DATE] revealed she died on [DATE]. Her death was ruled an accident due to a fall from the bed at the facility. The immediate cause was listed as [MEDICATION NAME] trauma of head with subdural hematoma and [MEDICATION NAME] trauma of torso. Extremities with fractures was listed as the underlying condition. During a follow-up interview on [DATE] at 3:10 pm CR #1's family member said she passed away on ,[DATE] and just received the death certificate. She said the cause of death was listed as [MEDICATION NAME] trauma of head with subdural hematoma, [MEDICATION NAME] trauma of torso, and fractures to extremities. Record review of the facility ADL, Services to carry out policy (Revised ,[DATE]) revealed in part, .it is the policy of the facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities . 2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: good nutrition, grooming, personal hygiene, oral hygiene . Record review of the facility's policy on, Quality of Care, revised on ,[DATE], revealed it read in part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .

Based on observation, interview and record review, the facility failed promptly notify the ordering physician or nurse practitioner laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [REDACTED].#1) reviewed for laboratory services, in that: Resident #1's abnormally high ammonia lab results were not reported to her physician for intervention resulting in the resident 's physician discontinuing the resident's 's medication to treat high ammonia level ([MEDICATION NAME]). Resident #1 had chest pains and an altered mental status and was transferred to the hospital 13 days after her lab results were completed and had not been reported to her physician. She was diagnosed with [REDACTED]. These failures could affect any residents with ordered labs and place them at risk of delayed treatment/intervention and decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview of Mental Status score of 12 indicating her cognition was moderately impaired. Record review of Resident #1's undated care plan revealed she had a [DIAGNOSES REDACTED]. Further review of the care plan revealed she was not compliant with her care and refused to take her [MEDICATION NAME] for liver [MEDICAL CONDITION] because she had not taken it at home. Her interventions included: allow to make decisions about treatment regimen, to provide sense of control and give clear explanation of all care activities prior to and as they occur during each contact. Record review of Resident #1's NP notes dated 1/15/2020 revealed in part, .Nurse requested to evaluate patient. She reports, patient has been refusing her [MEDICATION NAME]. Patient is on [MEDICATION NAME] 30 mL 3 times a day for Hyperammonemia ( a metabolic disturbance characterized by an excess of ammonia in the blood) . Nurse reports patient only took once during day shift. No aggression or Altered mental status reported . Further review of the note revealed in part, .Non-compliance/Dementia - discuss with patient complication of not taking [MEDICATION NAME]. Patient agrees to take the medicine. Continue supportive care. Monitor Hyperammonemia - continue [MEDICATION NAME] 30mL 3 times a day. Will order ammonia level . Record review of Resident #1's NP notes dated 1/18/2020 revealed in part, .Non-compliance/Dementia - Continue supportive care. Monitor Hyperammonemia/hepatic [MEDICAL CONDITION] - continue [MEDICATION NAME] 30mL 3 times a day. Will order ammonia level . Record review of Resident #1's NP notes dated 1/20/2020 revealed in part, .Hyperammonemia/hepatic [MEDICAL CONDITION] - continue [MEDICATION NAME] 30mL 3 times a day. Ammonia level pending . Record review of Resident #1's requisition form dated 1/21/2020 at 6:45PM revealed the facility requested the ammonia lab to be completed by the lab company. Interview on 2/20/2020 at 3:00PM, NP said she gave a verbal order to complete an ammonia lab for Resident #1. Record review of Resident #1's nurses notes dated 1/21/2020 at 5:33PM revealed, [MEDICATION NAME] Solution 10 GM/15ML, Give 30 ml by mouth three times a day for high ammonia level for 14 Days. Nurse Notified. Patient stated did not want it. Record review of Resident #1's ammonia lab results collected on 1/22/2020 and approved on [DATE]20 revealed a high level of 108 umol/L with a reference range of 16-53. Record review of Resident #1's NP notes dated [DATE]20 revealed in part, .Nursing calls and reports, patient is still refusing her [MEDICATION NAME]. She said she's having severe diarrhea. Pt is on [MEDICATION NAME] 30mL 3 times a day for Hyperammonemia and hepatic [MEDICAL CONDITION]. She has history of non-compliance. Patient is high risk for worsening hyperammonemia, dehydration, and rehospitalization . Further review of the NP note revealed in part, .Uncontrolled Hyperammonemia/hepatic [MEDICAL CONDITION] - Ammonia level pending. Discuss with nurse to count how many times of diarrhea. Push fluids as tolerated. For now, continue [MEDICATION NAME] 30 mL 3 times a day. Consider decreasing frequency depends on ammonia level. Monitor Non-compliance/Dementia/labile mood - Talk to the patient and encourage to take [MEDICATION NAME] to prevent rehospitalization , discuss and educate [MEDICATION NAME] expected side effects; she reports, I don't care if I go back to the hospital. I don't care if I die!. Consulted in house Psychologist, Psychiatrist. Continue supportive care. Monitor . Record review of Resident #1's NP notes dated 1/24/2020 revealed in part, .Follow up needed for Uncontrolled Hyperammonemia/hepatic [MEDICAL CONDITION] - current management with [MEDICATION NAME] 30ml 3 times a day. High risk for worsening hyperammonemia. Follow up needed for Dementia with Non-compliance, wax/wane (increase/decrease) - not on medication management for dementia. Patient reports, I took my medicine . Further review of the NP note revealed in part, .Uncontrolled Hyperammonemia/hepatic [MEDICAL CONDITION] - Ammonia level pending, nurse to follow up. Continue [MEDICATION NAME] 30 mL 3 times a day. Consider decreasing frequency depends on ammonia level. Monitor. High risk for rehospitalization . Record review of Resident #1's January 2020 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The medication was administered at all times on 1/15/2020 and 1/16/2020. Further review of the MAR indicated [REDACTED]. On [DATE]20 - 1/25/2020, Resident #1 refused the medication for all administration times except for 4PM dose. On [DATE]20, Resident #1 refused all doses except for 8AM dose and on 1/28/2020 refused all doses except for 4PM dose. Resident #1 refused a total of 30 doses of her [MEDICATION NAME]. Record review of Resident #1's nurses notes dated 2/1/2020 at 4:28PM revealed [MEDICATION NAME] [MED] Tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain 0 - 7 was administered for resident crying and stated she just didn't feel well. Record review of Resident #1's nurses notes dated 2/1/2020 at 6:00PM revealed [MEDICATION NAME] [MED] Tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain 0 - 7. PRN Administration was: Effective. Resident stated she felt much better. Record review of Resident #1's nurses notes dated 2/2/2020 at 6:30PM revealed [MEDICATION NAME] [MED] Tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain 0 - 7 was administered because resident was crying in bed. Record review of Resident #1's nurses notes dated 2/3/2020 at 12:31AM revealed [MEDICATION NAME] Administration was effective. Record review of Resident #1's nurses notes dated 2/3/2020 at 1:00AM revealed [MEDICATION NAME] [MED] Tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain 0 - 7 was given for general pain. Record review of Resident #1's nurses notes dated 2/3/2020 at 2:05AM revealed [MEDICATION NAME] administration was effective. Record review of Resident #1 January 2020 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of Resident #1's nurses notes dated 2/3/2020 at 6:42AM revealed, On rounding noted resident sitting on floor mat, caregiver just left patient room in 5 min after incontinence care. Head to toe assessment completed no apparent injury noted. Patient denies pain, able to move all extremities. Patient educated on calling for assistance with transfer and reoriented to call light. Neuro checks initiated, no deficits noted. Vital signs as follows: P 89, R 18, T 98.2, BP 142/82, O2 sat 95% nasal cannula on 2 L/Min oxygen. RP Aware at time of fall, states he was sleeping at time of fall. DON notified. NP notified. No new orders at this time. Record review of Resident #1 February 2020 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Reviewed notes above show documented reasons for medication administration (stating she doesn't feel well, crying in bed, and general pain). Record review of Resident #1's nurses notes revealed no documentation of facility receiving ammonia lab results or notifying physician from 1/22/2020 - 2/4/2020. Also, no nurses note indicating Resident #1 was transferred to the hospital on [DATE]. Record review of Resident #1's NP note dated 2/4/2020 revealed in part, .DON at patient's bedside calls and reports, patient is having chest pain and O2 sat is [AGE]% on 5L NC. Patient has OOH-DNR and wishes to go to hospital. Patient's family member is currently at bedside and patient as well in the facility . Further review of the note revealed in part, .New onset Chest pain/[MEDICAL CONDITION] - order to call 911, give Nitro tab 0.4mg SL x1 dose, transfer to hospital to evaluate and treat . Record review of Resident #1's hospital discharge summary revealed she was admitted to the hospital on [DATE] for altered mental status and chest pain. The hospital reviewed her medication list from the facility and found the resident was not receiving [MEDICATION NAME] as prescribed from her previous hospital discharge. The summary noted that Resident #1 family noticed she had more confusion lately and were concerned her ammonia level may be higher and she may have a UTI. Resident #1 labs showed she had a positive UA and an elevated ammonia level. The hospital treated Resident #1 with [MEDICATION NAME] and IV antibiotics and she responded well to the treatment. Resident #1's ammonia level was noted to be 157 umol/L upon admission to the hospital. Record review of Resident #1's nurses notes dated 2/8/2020 12:00AM revealed in part, .A [AGE] year-old Female readmitted from Hospital at 8:30PM. Patient was brought to the facility by a private car accompanied by her family member. Patient was readmitted under the care of her Doctor with admitting [DIAGNOSES REDACTED]. Patient has a history of Muscle weakness and Unspecified [MEDICAL CONDITION] OF LIVER. Patient alert and oriented x 3. Patient is able to make needs known. Patient is incontinent of Bowel and continent of Bladder and Bowel. Skin dry and warm to touch. Patient has some skin discoloration to BUE, BLE. No signs of distress noted at this time. Patient denies pain at this time. Lung sounds clear on auscultation and bowel sounds present to all four quadrants . Observation and interview on 2/20/2020 at 4:00PM, Resident #1 was lying in bed covered with a blanket. Resident said she was feeling good and was hoping to go home soon. Resident said she remembered being in the hospital on [DATE] but could not recall what led up to her being sent to the hospital. She said, I was in pretty bad shape. Resident #1 said she knew her family had some concerns about her hospitalization and felt the facility had missed something that could have avoided her being hospitalized . Resident #1 said she's been much better since her return to the facility from the hospital and said whatever the hospital did worked. Resident said she could be stubborn but denied currently refusing any medications. Interview on [DATE] at 1:00PM, Resident #1's family friend said, Resident #1 was transferred to the hospital and when her and Resident #1's family member arrived at the hospital to check on her, she was confused and disoriented. The family friend said Resident #1's hospital records showed she had an elevated ammonia level and was concerned because the hospital informed them that Resident #1 was not receiving [MEDICATION NAME] per the facility's medication sheet, which was used to treat the resident's high ammonia level. The family friend said the resident was known to have an issue with her ammonia levels and was concerned the facility was not monitoring this and that Resident #1 was not receiving her medications. Interview on [DATE] at 3:15PM, Resident #1's NP said she was never provided or reviewed the ammonia lab that was completed on 1/22/2020 for Resident #1. The NP said she did not see the results until after Resident #1 returned to the facility from the hospital. The NP also said if she would have seen the results she would have continued the resident on [MEDICATION NAME] and counseled with her about the importance of taking it. She also said she would have ordered for the lab to be redone again after that and if the levels increased or the resident began to show symptoms she would have transferred the resident to the hospital. The NP was asked why the [MEDICATION NAME] was only ordered for 14 days and stopped and she said she did not recall ordering it that way and did not know the order had ended. Interview on [DATE] at 3:18PM, ADON #1 said she was not aware Resident #1's NP had not received the ammonia lab completed on 1/22/2020. She said the facility now has a new lab process where the lab results are sent directly to their electronic records from the lab company and they started the new process at the beginning of February. ADON #1 said the old lab process was to put lab request in a requisition book and the lab company would come every day except for Sundays to review the book and collect requested labs. She said the company would then fax over the lab results and it was the nurses at the facility to retrieve the fax and notify the physician of the results. ADON #1 said the nursing staff are required to follow up with the lab company if they have not received lab results in a day . ADON #1 said they were unable to locate the ammonia lab that was done on 1/22/2020 and was not sure if they had received the lab or not from the lab company. Record review of the facility's laboratory testing policy (Revised 01/2020) revealed in part, .It is the policy of this facility to obtain laboratory and radiology services when ordered by a physician, PA, NP, or clinical nurse specialist and to notify the ordering entity of test results . Further review of the policy revealed in part, .2. Results of laboratory, radiological and diagnostic test outside the clinical reference ranges shall be reported to the residents attending physician, PA, NP or clinical nurse specialist or as specified in the order. Any non - critical labs are reported and recorded to electronic record and will be reviewed by the resident attending physician, PA, NP . 3. Notification of the test results will be documented in the resident clinical record .

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 7 residents (CR #1) reviewed for quality of care. The facility failed to identify CR #1 had a change in condition of yeast growing in his abdominal folds and groin area. The facility failed to identify and treat CR #1's abscess that had formed under his scrotum before discharging him home resulting in his hospitalization a day after he was discharge from the facility. These failures could affect all facility residents who may experience changes in their condition. Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged home on[DATE] at 3:03PM. Further review of the face sheet revealed [DIAGNOSES REDACTED]. Record review of CR #1's admission MDS dated [DATE] revealed a BI[CONDITION] score of 14 indicating he was cognitively intact. Further review of the MDS revealed CR #1 required extensive assistance with his ADL's including transfers, dressing, toilet use, personal hygiene, and was totally dependent on staff for bathing. MDS revealed CR #1 had no skin issues. Record review of CR #1's undated care plan revealed he had the potential for impairment to skin integrity related to decrease mobility, incontinence, and [DIAGNOSES REDACTED]. Use lotion on dry skin. Obtain blood work such as CBC with Differential, Blood Cultures and culture and sensitivity of any open wounds as ordered by the physician. Provide pressure relieving/reducing mattress to protect the skin while in bed. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp surface. Further review of CR #1's undated care plan revealed he had a yeast infection to abdominal fold related to sweat/moisture. [MEDICATION NAME] cream ordered. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Do not use harsh detergent, soaps, fragrances, or other irritating substances. Treatment as ordered. Interview on [DATE] at 1:00PM, CR #1's family friend said she came in to check on CR #1 on 2/4/2020 and noticed his scrotum was exposed on the side of his brief. She said she undid CR #1's brief to rearrange his private area into the brief and when she did there was a horrible sour smell that came out and she observed the resident was red all over and had white stuff caked in the folds of his skin. The family friend said she was upset at what she saw and went to tell the nurse (RN #1) and the nurse came in to check the resident. She said the nurse told her it looked like a rash. She asked the nurse if they had been putting cream on him and the nurse said they had not because he did not have an order to apply cream. She said the nurse left the room and then later came back with some cream and was going to apply it to the resident without cleaning him first and had to ask her to clean the resident first before she applied the cream. The family friend said the resident was discharged home on the evening of 2/10/2020 and CR #1 had a bowel movement on the toilet at home where she assisted with wiping him and noticed blood but thought it was maybe from his anal area . She said it was not until the next morning she got to really look the resident over and noticed the rash had worsened and he had developed an abscess under his scrotum that was leaking blood and puss. She said she took CR #1 to the doctor that same days after noticing the abscess and the Doctor looked the resident over and immediately had him transferred to the hospital. She said the hospital diagnosed the resident with an infection and he remained in the hospital for three days to receive IV antibiotics. The family friend said she was upset they would send the resident home in the condition he was in and had not identified the development of the abscess. The family friend said she spoke with CR #1's CNA (CNA #1) and she reported she had noticed the reddened area and told the nurse (RN #1) but the nurse told her he did not have an order for [REDACTED].>Record review of CR #1's hospital records dated 2/15/2020 revealed in part, .He was discharged yesterday from this hospital after a 3-day hospitalization for scrotal abscess. Patient was sent back home and then he woke up early this morning with more shortness of breath than usual . Further review of the records revealed in part, .presents back after a recent specialization with 3 days of scrotal abscess . Patient was to continue antibiotics for his scrotal abscess in which basically did well . Discharge [DIAGNOSES REDACTED]. Record review of CR#1's pictures provided by CR #1's family friend revealed pictures taken on 2/4/20 at 4:55PM and 2/11/20 at 9:50AM per the google drive file provided. Pictures taken on 2/4/20 showed CR #1's scrotum area that was bright red in color all over and on the inside of his thighs. The picture showed resident had developed several little red bumps in his abdominal folds and around the inside of his thighs. The resident's inner thigh area was dried and chaffed. There was also a larger closed red bump at the bottom of the resident scrotum. Also shown in the pictures taken on 2/4/20 revealed the residents skin folds had white caked up substance in between them and the skin surrounding was reddened. Pictures provided that were dated 2/11/20 revealed the resident's scrotum and inner thigh area were a dark deep red all over. Resident had an open wound at the bottom of his scrotum that was leaking blood and puss. Resident brief that was laid under him had blood stains on it from drainage from the open wound. Interview on [DATE] at 5:41PM, RN #1 said CR #1's visitor came to her and told her about CR #1 having redness in his groin area. She said she went and assessed the resident and found he had a rash in his groin and abdominal folds. She said no one had previously brought it to her attention before the visitor mentioned it to her. She agreed that the visitor was upset about the rash and demanded she put some cream on the resident. RN #1 said she called CR #1's NP who ordered [MEDICATION NAME] cream and she went and applied it on the resident. RN #1 said over the next few days before the resident was discharged home she felt his rash had improved. RN #1 said she had not noticed an abscess forming on the resident scrotum and said she did not observe any open areas on the resident before he left. Record review of CR #1's physician orders [REDACTED]. Review of CR #1's February 2020 MAR indicated [REDACTED]. The resident was discharged home and expected to complete the treatment at home. Record review of CR #1 skin assessment sheets dated [DATE] and 1/31/20 revealed resident skin was intact, no skin issues. Record review of CR #1's daily skilled note dated 2/4/20 at 1:47pm revealed in part, .Overall skin description is: skin intact. There are No active symptoms effecting the Integumentary system observed. Skin condition is Not a new onset . Further review of the note revealed in part, .Patient on status [REDACTED]. Heart rate is [AGE]. Denied pain. Patient is resting in bed at this time without any signs of distress noted . Continues on skilled nursing services. ADLs care provided by staff . Record review of CR #1's change in condition note dated 2/4/20 at 6:06PM revealed resident had, other change in condition rash in the groin area and abdominal fold. Note completed by RN #1. Record review of CR #1's SBAR Communication form dated 2/4/20 revealed resident had rash in abdominal area and abdominal fold. The appearance noted, patient has multiple areas of red rashes. Further review of the SBAR revealed the NP was notified and ordered [MEDICATION NAME] Cream to be applied in the affected areas four times a day for 14 days. SBAR completed by RN #1. Record review of CR #1's NP note dated 2/4/2020 revealed in part, .Nurse reports, patient has new onset BLE redness and abdominal folds redness . Skin: Abdominal skin fold/both groin [CONDITION], warm and dry to touch, frail, general bruising . Further review of the NP note revealed in part, .[MEDICAL CONDITION] [CONDITION] - order [MEDICATION NAME] cream QID x14days and PRN to abdominal folds and other affected skin folds . Record review of CR #1's nurses notes from 2/5/2020 - 2/10/2020 revealed resident was checked frequently throughout the shift and assisted with his ADLs. Further review revealed he had redness to his groin area, inner thighs, and abdominal folds that were ongoing treatment with [MEDICATION NAME] ream and was noted to be improving. Record review of CR #1's weekly skin evaluation dated [DATE]20 revealed he had ongoing treatment for [REDACTED]. Redness is improving. Record review of CR #1's NP discharge summary dated [DATE]20 revealed in part, .Skin: Warm and dry to touch, frail, general bruising, [MEDICAL CONDITION] [CONDITION] to abdominal folds, groins . Further review of the summary revealed in part, .[MEDICAL CONDITION] [CONDITION] - continue [MEDICATION NAME] cream QID x14days and PRN to abdominal folds and other affected skin folds . Record review of CR #1's discharge summary dated 2/10/2020 revealed CR #1 was discharged home with no skin treatments or concerns. Record review of CR #1's clinical record revealed no mention of an abscess forming or opened. Interview on [DATE] at 3:18PM, ADON #1 said she was unaware of CR #1 developing a rash, [MEDICAL CONDITION] [CONDITION], or an abscess. ADON said aides should have notified the charge nurse when skin issue was identified, and the charge nurse would consult the resident's physician. Phone interview was attempted with CNA #1 on [DATE] at 5:20PM but received no answer or call back. Record review of the facility's Skin Management System policy (Revised 03/2015: 01/2020) revealed in part, . 4. Residents will have ongoing head to toe assessment done, incorporated in to the weekly summary review by the licensed nursing staff. 5. A report of all wounds and their progress will be updated by the treatment nurse . Record review of the facility ADL, Services to carry out policy (Revised 01/2020) revealed in part, .it is the policy of the facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities . 2. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: good nutrition, grooming, personal hygiene, oral hygiene .

Based on interview, and record review, the facility failed to ensure nurse competency in skills and techniques necessary to care for resident who sustained fall with bleeding laceration to forehead for one of one nurse ( LVN #1) reviewed for nursing services , in that : LVN #1 inaccurately assessed Resident #1's laceration to her forehead after an unwitnessed fall. LVN #1inaccirately informed the NP that Resident #1 sustained a skin tear instead of a laceration . Resident #1's laceration bleed for approximately 14 hours before LVN#1 consulted her physician for further interventions and treatment. Resident #1 required staples to close her laceration and stop bleeding after her transfer to ER and was life-flighted to a second local hospital after being diagnosed with [REDACTED].>These failures affected one resident who had delayed intervention to stop her bleeding and placed her at risk of complication and decline in health. Findings include: Incident # 6/TX 240 Incident # 7/TX 357 Incident # 2/TX 514 Resident #1 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. She was diagnosed with [REDACTED]. Record review of Resident #1's MDS (Minimum Data Set), dated 1/23/19 revealed her BIMS (Brief Interview for Mental Status) score was 99, indicating the resident was unable to complete the interview. Record review of Resident #1's care plan, updated, 4/19/19 revealed she had impaired cognition, required extensive staff assistance with toilet use, bathing, personal hygiene, dressing, transferring, and wheelchair mobility. The care plan also indicated the resident had a history of [REDACTED]. Record review of Resident #1's progress notes dated 4/14/19 revealed LVN #1 documented at 6:26 p.m. Resident #1 was observed crawling out of her room with a bleeding forehead. She was assessed and noted to have a fresh skin tear to her left lower forehead. The skin tear was cleaned, and gauze was taped to her forehead. The resident kept taking the gauze off. The resident's NP #1 (Nurse Practitioner) was notified on 4/14/19 at 3:00 p.m. and advised LVN #1 to apply a cold compress and wrap the skin tear with Xeroform and gauze. Neuro-checks were initiated. Record review of Resident #1's progress notes dated 4/15/19 at 12:52 a.m., LVN #1 documented that Resident #1 continued to take off the dressing to the skin tear. Staff continued to direct and reinforce the dressing to avoid more bleeding. Record review of Resident #1's progress notes revealed on 4/15/19 at 5:08 a.m., LVN #1 wrote that the resident continued to remove the dressing to the skin tear making it bleed. The resident's NP was contacted and advised LVN #1 to send Resident #1 out to a local emergency room . Record review of Resident #1's hospital records retrieved from a local hospital revealed Resident #1 arrived there via ambulance on 4/15/19 at 6:45 a.m. She had a laceration above her left eye with continuous bleeding and left eye swelling and bruising. Further review of the hospital record revealed [AGE] year-old female presents to ER (emergency room ) post fall. Fall happened yesterday. Takes no anticoagulation drugs. History of dementia thus poor historian. Arrived with GCS (Glasgow Coma Scale) of 14 (indicating a mild head injury). CT (computed tomography) brain shows an acute subdural hematoma. Patient had a facial laceration which was bleeding profusely. Facial laceration closed with staples. Arranged for transfer of patient to higher level of care facility. Spoke with life flight . Life flight left at 9:30 a.m . Record review of radiology findings from Resident #1's CT scan without contrast completed on 4/15/19 at 8:15 a.m. at the local hospital revealed acute subdural hemorrhage (a collection of blood outside the brain) along the right cerebral hemisphere ( one of a pair of large lobes in the forebrain of vertebrates) measured 1.3 cm in thickness and results in 2 mm right-to-left bowing/shift of the septum pellucidum ( a structure that separates the two lobes of the brain) midline of the brain, Record review of hematology results from the hospital record dated 4/15/19 revealed hematocrit (The ratio of the volume of red blood cells to the total volume of blood): 26.8% (Low 4/15/19). Hemoglobin (A red protein responsible for transporting oxygen in the blood of vertebrates): 9.1 g/dL (Low 4/15/19) Record review of Resident #1's physician progress notes [REDACTED].#1's NP #1 wrote in part, .Visit Type: .Called yesterday evening to report patient fall with bleeding skin tear, presumed to extremity; orders for xeroform and pressure dressing; Called again at 5:30 this a.m. to report skin tear continues to bleed. Nurse clarified that wound is on Left forehead, not arm. Orders to send to hospital for evaluation; Notified attending MD. Discussed with DON and ADON; Multiple calls throughout day to follow clinical progression . In an interview with a random family member on 4/16/19 at 12:45 p.m., she stated she was present on Sunday 4/14/19 when Resident # 1 across the hall fell . Random family member said she went over there when she heard the commotion. She saw the nurse put a towel on the resident's head. Resident #1 was bleeding and screaming. There was blood all over. Random family member kept telling the nurse to call the doctor. Random family member said she knew Resident #1 went to the hospital on Monday morning, but she was not there at that time. In an interview with the facility's DON on 4/25/19 at 9:30 a.m., she stated she was very surprised when she saw Resident #1 after she returned from the hospital on [DATE]. She did not know how serious the resident's injury was until she observed her with staples. She said LVN #1 described the laceration as a small skin tear and he had since been reprimanded. The DON said LVN #1 called her on 4/15/19 at 5 a.m. and said the skin tear was bleeding really bad because Resident #1 kept pulling on the dressing. The DON said it was really bleeding because it was a deep laceration and she realized that once the resident returned from the hospital. Observation and attempted interview of Resident #1 on 4/25/18, at 9:50 a.m. revealed she was wheelchair bound and sat slightly reclined. She had an inch long small laceration above her left eye that was closed with three staples. She also had a dark purple bruise under her left eye. She was sitting in an activity but kept her eyes closed despite calling her name several times. Resident #1 was not able to respond to asked question about she care . In a telephone interview with LVN #1 on 4/25/19 at 11:15 a.m., he stated he normally worked the 6 p.m. to 6 a.m. shift. On 4/14/19, he had to come in at 2:00 p.m. Resident #1 was in bed during the change of shift rounds. Several minutes later, around 2:45 p.m. or 3:00 p.m., he was in the room next door to Resident #1 and heard a noise. He went into the room and found her on the floor with a skin tear to her head that was bleeding. He called CNA #2 for assistance and he assessed the resident. He contacted NP #1 (nurse practitioner) who told him to apply ice and a dressing to stop the bleeding. Resident #1's vitals remained stable throughout the day and night during regular neuro-checks. The resident kept pulling the dressing off which made it bleed. He said the bleeding stopped but starred again when the resident became anxious and picked on it . He called NP #1 again at 4:00 a.m. and he was ordered to send the resident out to the hospital. The ambulance arrived around 5 something in the morning. The skin tear was close to the left eye but there was no bruising or swelling at that time. He said he had been counseled about not recognizing the laceration. He said a laceration was a skin tear, but it is just a deeper cut. He was initially able to clean and stop the blood flow. Now, he knows to clean the blood and do a measurement of the cut. In a telephone interview with CNA #2 on 4/25/19 at 11:45 a.m., she stated she always worked the 2 p.m. to 10 p.m. shift. She said on 4/14/19, she was called to Resident #1's room by the nurse after she fell . The resident was on the floor and she helped to get her back in bed. They tried to clean the wound and put a bandage on it, but the resident would not stay calm and was refusing. She left the resident for a while, but she was not sleeping or staying calm. The more she struggled, the more the wound bled. The nurse called NP #1 at first and she said not to send her out. CNA #2 stayed with her a while then went to help other residents. When she returned, blood was dripping from her head and was soaked all over her hair and everywhere. The bleeding had stopped at first, but she was not calm, and the nurse begged her to stay calm. Resident #1 kept crying, Help me, help me! They tried to wrap her head, but the blood kept coming out. She and LVN #1 would go to her, then another room, then back to her over and over. The nurse said he had given her something to help her sleep. kept having to change the dressing because blood kept soaking through. She observed the nurse change the dressing three times, but CNA #2 left after that at 10 p.m. She checked on her before she left, and the resident was calm with her eyes open. The wound had stopped bleeding. When she came back to work, the nurse told her Resident #1 had bled all through the night. In an interview with Resident #1's NP #1 on 4/25/19 at 2:30 p.m., she stated when the nurse initially ( 4/14/19 at 3:00pm) contacted her about the wound, she did not know if the nurse said it was on her head or not because in her mind, NP #1 thought it was on her arm. She did not know if she heard wrong or just assumed the wound was on the arm. She could not say the nurse did not say the wound was on her forehead, but she could not recall. She gave orders for xeroform and curlex dressing. The nurse called her again at 5:30 a.m. or 6:00 a.m. and said the resident kept taking off the dressing and it continued to bleed. The nurse still said it was a skin tear that kept bleeding and that there was blood all over the bed. She told the nurse to send her out. It was not until the resident returned to the facility with three staples that she found out it was more serious than she thought. She then knew it was a laceration. NP #1 said she told the nurse to call her back if the initial treatment did not work. He should have called her a little sooner. She would have told him to send the resident out for a laceration that would not stop bleeding. In a later interview and observation with Resident #1 on 4/26/19 at 2:30 p.m., she was observed in her wheelchair with a chair alarm in place. Resident #1 stated she had recently fallen because she was doing something she was not supposed to be doing. She said she was moving stuff around in her room. She also stated she did not bleed or have blood from her face, she did not have any wounds or cuts on her face, and she did not recall going out to the hospital. Record review of the staff records revealed LVN #1 was hired by the facility on 1/28/16. All background checks and mandatory trainings were completed timely and were appropriate. LVN #1 received a Counsel/Disciplinary Notice on 4/22/19 for resident sustained [REDACTED].#1 to be a small skin tera on 4/14/19. There was incorrect description of the incident chatted in resident's record. Record review of facility' policy on nursing service revised on 11/2017, revealed , It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities . Policy did not address competency of nursing skills.

Based on observation , interview and record review, the facility failed to ensure residents received treatment and care that are resident centered , in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 16 residents (Resident #1) reviewed for quality of care, in that; LVN #1 inaccurately assessed Resident #1's laceration and initially described it to her physician as a skin tear. LVN #1 observed Resident #1's laceration bleed for approximately 14 hours before consulting her physician and sending her out for further evaluation and treatment. Resident #1 required staples to close her laceration and stop bleeding after her transfer to ER and was life-flighted to a second local hospital after being diagnosed with [REDACTED]. This failure affected one resident and placed her at risk of experiencing serious pain, and deterioration and decline in health. Findings include: Incident # 6/TX 240 Incident # 7/TX 357 Incident # 2/TX 514 Resident #1 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. She was diagnosed with [REDACTED]. Record review of Resident #1's MDS (Minimum Data Set), dated 1/23/19 revealed her BIMS (Brief Interview for Mental Status) score was 99, indicating the resident was unable to complete the interview. Record review of Resident #1's care plan, updated, 4/19/19 revealed she had impaired cognition, required extensive staff assistance with toilet use, bathing, personal hygiene, dressing, transferring, and wheelchair mobility. The care plan also indicated the resident had a history of [REDACTED]. Record review of Resident #1's progress notes dated 4/14/19 revealed LVN #1 documented at 6:26 p.m. Resident #1 was observed crawling out of her room with a bleeding forehead. She was assessed and noted to have a fresh skin tear to her left lower forehead. The skin tear was cleaned, and gauze was taped to her forehead. The resident kept taking the gauze off. The resident's NP #1 (Nurse Practitioner) was notified on 4/14/19 at 3:00 p.m. and advised LVN #1 to apply a cold compress and wrap the skin tear with Xeroform and gauze. Neuro-checks were initiated. Record review of Resident #1's progress notes dated 4/15/19 at 12:52 a.m., LVN #1 documented that Resident #1 continued to take off the dressing to the skin tear. Staff continued to direct and reinforce the dressing to avoid more bleeding. Record review of Resident #1's progress notes revealed on 4/15/19 at 5:08 a.m., LVN #1 wrote that the resident continued to remove the dressing to the skin tear making it bleed. The resident's NP was contacted and advised LVN #1 to send Resident #1 out to a local emergency room . Record review of Resident #1's hospital records retrieved from a local hospital revealed Resident #1 arrived there via ambulance on 4/15/19 at 6:45 a.m. She had a laceration above her left eye with continuous bleeding and left eye swelling and bruising. Further review of the hospital record revealed [AGE] year-old female presents to ER (emergency room ) post fall. Fall happened yesterday. Takes no anticoagulation drugs. History of dementia thus poor historian. Arrived with GCS (Glasgow Coma Scale) of 14 (indicating a mild head injury). CT (computed tomography) brain shows an acute subdural hematoma. Patient had a facial laceration which was bleeding profusely. Facial laceration closed with staples. Arranged for transfer of patient to higher level of care facility. Spoke with life flight . Life flight left at 9:30 a.m . Record review of radiology findings from Resident #1's CT scan without contrast completed on 4/15/19 at 8:15 a.m. at the local hospital revealed acute subdural hemorrhage (a collection of blood outside the brain) along the right cerebral hemisphere ( one of a pair of large lobes in the forebrain of vertebrates) measured 1.3 cm in thickness and results in 2 mm right-to-left bowing/shift of the septum pellucidum ( a structure that separates the two lobes of the brain) midline of the brain, Record review of hematology results from the hospital record dated 4/15/19 revealed hematocrit (The ratio of the volume of red blood cells to the total volume of blood): 26.8% (Low 4/15/19). Hemoglobin (A red protein responsible for transporting oxygen in the blood of vertebrates): 9.1 g/dL (Low 4/15/19) Record review of Resident #1's physician progress notes [REDACTED].#1's NP #1 wrote in part, .Visit Type: .Called yesterday evening to report patient fall with bleeding skin tear, presumed to extremity; orders for xeroform and pressure dressing; Called again at 5:30 this a.m. to report skin tear continues to bleed. Nurse clarified that wound is on Left forehead, not arm. Orders to send to hospital for evaluation; Notified attending MD. Discussed with DON and ADON; Multiple calls throughout day to follow clinical progression . In an interview with a random family member on 4/16/19 at 12:45 p.m., she stated she was present on Sunday 4/14/19 when Resident # 1 across the hall fell . Random family member said she went over there when she heard the commotion. She saw the nurse put a towel on the resident's head. Resident #1 was bleeding and screaming. There was blood all over. Random family member kept telling the nurse to call the doctor. Random family member said she knew Resident #1 went to the hospital on Monday morning, but she was not there at that time. In an interview with the facility's DON on 4/25/19 at 9:30 a.m., she stated she was very surprised when she saw Resident #1 after she returned from the hospital on [DATE]. She did not know how serious the resident's injury was until she observed her with staples. She said LVN #1 described the laceration as a small skin tear and he had since been reprimanded. The DON said LVN #1 called her on 4/15/19 at 5 a.m. and said the skin tear was bleeding really bad because Resident #1 kept pulling on the dressing. The DON said it was really bleeding because it was a deep laceration and she realized that once the resident returned from the hospital. Observation and attempted interview of Resident #1 on 4/25/18, at 9:50 a.m. revealed she was wheelchair bound and sat slightly reclined. She had an inch long small laceration above her left eye that was closed with three staples. She also had a dark purple bruise under her left eye. She was sitting in an activity but kept her eyes closed despite calling her name several times. Resident #1 was not able to respond to asked question about she care . In a telephone interview with LVN #1 on 4/25/19 at 11:15 a.m., he stated he normally worked the 6 p.m. to 6 a.m. shift. On 4/14/19, he had to come in at 2:00 p.m. Resident #1 was in bed during the change of shift rounds. Several minutes later, around 2:45 p.m. or 3:00 p.m., he was in the room next door to Resident #1 and heard a noise. He went into the room and found her on the floor with a skin tear to her head that was bleeding. He called CNA #2 for assistance and he assessed the resident. He contacted NP #1 (nurse practitioner) who told him to apply ice and a dressing to stop the bleeding. Resident #1's vitals remained stable throughout the day and night during regular neuro-checks. The resident kept pulling the dressing off which made it bleed. He said the bleeding stopped but starred again when the resident became anxious and picked on it . He called NP #1 again at 4:00 a.m. and he was ordered to send the resident out to the hospital. The ambulance arrived around 5 something in the morning. The skin tear was close to the left eye but there was no bruising or swelling at that time. He said he had been counseled about not recognizing the laceration. He said a laceration was a skin tear, but it is just a deeper cut. He was initially able to clean and stop the blood flow. Now, he knows to clean the blood and do a measurement of the cut. In a telephone interview with CNA #2 on 4/25/19 at 11:45 a.m., she stated she always worked the 2 p.m. to 10 p.m. shift. She said on 4/14/19, she was called to Resident #1's room by the nurse after she fell . The resident was on the floor and she helped to get her back in bed. They tried to clean the wound and put a bandage on it, but the resident would not stay calm and was refusing. She left the resident for a while, but she was not sleeping or staying calm. The more she struggled, the more the wound bled. The nurse called NP #1 at first and she said not to send her out. CNA #2 stayed with her a while then went to help other residents. When she returned, blood was dripping from her head and was soaked all over her hair and everywhere. The bleeding had stopped at first, but she was not calm, and the nurse begged her to stay calm. Resident #1 kept crying, Help me, help me! They tried to wrap her head, but the blood kept coming out. She and LVN #1 would go to her, then another room, then back to her over and over. The nurse said he had given her something to help her sleep. kept having to change the dressing because blood kept soaking through. She observed the nurse change the dressing three times, but CNA #2 left after that at 10 p.m. She checked on her before she left, and the resident was calm with her eyes open. The wound had stopped bleeding. When she came back to work, the nurse told her Resident #1 had bled all through the night. In an interview with Resident #1's NP #1 on 4/25/19 at 2:30 p.m., she stated when the nurse initially ( 4/14/19 at 3:00pm) contacted her about the wound, she did not know if the nurse said it was on her head or not because in her mind, NP #1 thought it was on her arm. She did not know if she heard wrong or just assumed the wound was on the arm. She could not say the nurse did not say the wound was on her forehead, but she could not recall. She gave orders for xeroform and curlex dressing. The nurse called her again at 5:30 a.m. or 6:00 a.m. and said the resident kept taking off the dressing and it continued to bleed. The nurse still said it was a skin tear that kept bleeding and that there was blood all over the bed. She told the nurse to send her out. It was not until the resident returned to the facility with three staples that she found out it was more serious than she thought. She then knew it was a laceration. NP #1 said she told the nurse to call her back if the initial treatment did not work. He should have called her a little sooner. She would have told him to send the resident out for a laceration that would not stop bleeding. In a later interview and observation with Resident #1 on 4/26/19 at 2:30 p.m., she was observed in her wheelchair with a chair alarm in place. Resident #1 stated she had recently fallen because she was doing something she was not supposed to be doing. She said she was moving stuff around in her room. She also stated she did not bleed or have blood from her face, she did not have any wounds or cuts on her face, and she did not recall going out to the hospital. Record review of the facility's policy on, Quality of Care, revised on 11/2017, revealed it read in part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .

Based on observation, interview and record review, the facility failed to immediately inform the resident representative and consult with the physician when a resident experienced a change of condition and a need to alter treatment significantly was required for 2 of 16 residents (Resident #1 and CR#2) reviewed for notification of changes, in that: Resident #1's physician was not promptly consulted when a laceration on her forehead continued to bleed profusely throughout the night after she experienced a fall with head injury . Resident #1 was transferred to a local hospital 14 hours later and Resident #1 required staples to close her laceration . She was then life-flighted to a second local hospital after being diagnosed with [REDACTED]. CR #2's responsible party was not informed of identified left knee swelling pain. These failures affected one resident and one former resident who experienced delay in treatment and placed at risk of decline in health . Findings include: Incident # 6/TX 240 Incident # 7/TX 357 Resident #1 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. She was diagnosed with [REDACTED]. Record review of Resident #1's MDS (Minimum Data Set), dated 1/23/19 revealed her BIMS (Brief Interview for Mental Status) score was 99, indicating the resident was unable to complete the interview. Record review of Resident #1's care plan, updated, 4/19/19 revealed she had impaired cognition, required extensive staff assistance with toilet use, bathing, personal hygiene, dressing, transferring, and wheelchair mobility. The care plan also indicated the resident had a history of [REDACTED]. Record review of Resident #1's progress notes dated 4/14/19 revealed LVN #1 documented at 6:26 p.m. Resident #1 was observed crawling out of her room with a bleeding forehead. She was assessed and noted to have a fresh skin tear to her left lower forehead. The skin tear was cleaned, and gauze was taped to her forehead. The resident kept taking the gauze off. The resident's NP #1 (Nurse Practitioner) was notified on 4/14/19 at 3:00 p.m. and advised LVN #1 to apply a cold compress and wrap the skin tear with Xeroform and gauze. Neuro-checks were initiated. Record review of Resident #1's progress notes dated 4/15/19 at 12:52 a.m., LVN #1 documented that Resident #1 continued to take off the dressing to the skin tear. Staff continued to direct and reinforce the dressing to avoid more bleeding. Record review of Resident #1's progress notes revealed on 4/15/19 at 5:08 a.m., LVN #1 wrote that the resident continued to remove the dressing to the skin tear making it bleed. The resident's NP was contacted and advised LVN #1 to send Resident #1 out to a local emergency room . Record review of Resident #1's hospital records retrieved from a local hospital revealed Resident #1 arrived there via ambulance on 4/15/19 at 6:45 a.m. She had a laceration above her left eye with continuous bleeding and left eye swelling and bruising. Further review of the hospital record revealed [AGE] year-old female presents to ER (emergency room ) post fall. Fall happened yesterday. Takes no anticoagulation drugs. History of dementia thus poor historian. Arrived with GCS (Glasgow Coma Scale) of 14 (indicating a mild head injury). CT (computed tomography) brain shows an acute subdural hematoma. Patient had a facial laceration which was bleeding profusely. Facial laceration closed with staples. Arranged for transfer of patient to higher level of care facility. Spoke with life flight . Life flight left at 9:30 a.m . Record review of radiology findings from Resident #1's CT scan without contrast completed on 4/15/19 at 8:15 a.m. at the local hospital revealed acute subdural hemorrhage (a collection of blood outside the brain) along the right cerebral hemisphere ( one of a pair of large lobes in the forebrain of vertebrates) measured 1.3 cm in thickness and results in 2 mm right-to-left bowing/shift of the septum pellucidum ( a structure that separates the two lobes of the brain) midline of the brain, Record review of hematology results from the hospital record dated 4/15/19 revealed hematocrit (The ratio of the volume of red blood cells to the total volume of blood): 26.8% (Low 4/15/19). Hemoglobin (A red protein responsible for transporting oxygen in the blood of vertebrates): 9.1 g/dL (Low 4/15/19) Record review of Resident #1's physician progress notes [REDACTED].#1's NP #1 wrote in part, .Visit Type: .Called yesterday evening to report patient fall with bleeding skin tear, presumed to extremity; orders for xeroform and pressure dressing; Called again at 5:30 this a.m. to report skin tear continues to bleed. Nurse clarified that wound is on Left forehead, not arm. Orders to send to hospital for evaluation; Notified attending MD. Discussed with DON and ADON; Multiple calls throughout day to follow clinical progression . In an interview with a random family member on 4/16/19 at 12:45 p.m., she stated she was present on Sunday 4/14/19 when Resident # 1 across the hall fell . Random family member said she went over there when she heard the commotion. She saw the nurse put a towel on the resident's head. Resident #1 was bleeding and screaming. There was blood all over. Random family member kept telling the nurse to call the doctor. Random family member said she knew Resident #1 went to the hospital on Monday morning, but she was not there at that time. In an interview with the facility's DON on 4/25/19 at 9:30 a.m., she stated she was very surprised when she saw Resident #1 after she returned from the hospital on [DATE]. She did not know how serious the resident's injury was until she observed her with staples. She said LVN #1 described the laceration as a small skin tear and he had since been reprimanded. The DON said LVN #1 called her on 4/15/19 at 5 a.m. and said the skin tear was bleeding really bad because Resident #1 kept pulling on the dressing. The DON said it was really bleeding because it was a deep laceration and she realized that once the resident returned from the hospital. Observation and attempted interview of Resident #1 on 4/25/18, at 9:50 a.m. revealed she was wheelchair bound and sat slightly reclined. She had an inch long small laceration above her left eye that was closed with three staples. She also had a dark purple bruise under her left eye. She was sitting in an activity but kept her eyes closed despite calling her name several times. Resident #1 was not able to respond to asked question about she care . In a telephone interview with LVN #1 on 4/25/19 at 11:15 a.m., he stated he normally worked the 6 p.m. to 6 a.m. shift. On 4/14/19, he had to come in at 2:00 p.m. Resident #1 was in bed during the change of shift rounds. Several minutes later, around 2:45 p.m. or 3:00 p.m., he was in the room next door to Resident #1 and heard a noise. He went into the room and found her on the floor with a skin tear to her head that was bleeding. He called CNA #2 for assistance and he assessed the resident. He contacted NP #1 (nurse practitioner) who told him to apply ice and a dressing to stop the bleeding. Resident #1's vitals remained stable throughout the day and night during regular neuro-checks. The resident kept pulling the dressing off which made it bleed. He said the bleeding stopped but starred again when the resident became anxious and picked on it . He called NP #1 again at 4:00 a.m. and he was ordered to send the resident out to the hospital. The ambulance arrived around 5 something in the morning. The skin tear was close to the left eye but there was no bruising or swelling at that time. He said he had been counseled about not recognizing the laceration. He said a laceration was a skin tear, but it is just a deeper cut. He was initially able to clean and stop the blood flow. Now, he knows to clean the blood and do a measurement of the cut. In a telephone interview with CNA #2 on 4/25/19 at 11:45 a.m., she stated she always worked the 2 p.m. to 10 p.m. shift. She said on 4/14/19, she was called to Resident #1's room by the nurse after she fell . The resident was on the floor and she helped to get her back in bed. They tried to clean the wound and put a bandage on it, but the resident would not stay calm and was refusing. She left the resident for a while, but she was not sleeping or staying calm. The more she struggled, the more the wound bled. The nurse called NP #1 at first and she said not to send her out. CNA #2 stayed with her a while then went to help other residents. When she returned, blood was dripping from her head and was soaked all over her hair and everywhere. The bleeding had stopped at first, but she was not calm, and the nurse begged her to stay calm. Resident #1 kept crying, Help me, help me! They tried to wrap her head, but the blood kept coming out. She and LVN #1 would go to her, then another room, then back to her over and over. The nurse said he had given her something to help her sleep. kept having to change the dressing because blood kept soaking through. She observed the nurse change the dressing three times, but CNA #2 left after that at 10 p.m. She checked on her before she left, and the resident was calm with her eyes open. The wound had stopped bleeding. When she came back to work, the nurse told her Resident #1 had bled all through the night. In an interview with Resident #1's NP #1 on 4/25/19 at 2:30 p.m., she stated when the nurse initially ( 4/14/19 at 3:00pm) contacted her about the wound, she did not know if the nurse said it was on her head or not because in her mind, NP #1 thought it was on her arm. She did not know if she heard wrong or just assumed the wound was on the arm. She could not say the nurse did not say the wound was on her forehead, but she could not recall. She gave orders for xeroform and curlex dressing. The nurse called her again at 5:30 a.m. or 6:00 a.m. and said the resident kept taking off the dressing and it continued to bleed. The nurse still said it was a skin tear that kept bleeding and that there was blood all over the bed. She told the nurse to send her out. It was not until the resident returned to the facility with three staples that she found out it was more serious than she thought. She then knew it was a laceration. NP #1 said she told the nurse to call her back if the initial treatment did not work. He should have called her a little sooner. She would have told him to send the resident out for a laceration that would not stop bleeding. In a later interview and observation with Resident #1 on 4/26/19 at 2:30 p.m., she was observed in her wheelchair with a chair alarm in place. Resident #1 stated she had recently fallen because she was doing something she was not supposed to be doing. She said she was moving stuff around in her room. She also stated she did not bleed or have blood from her face, she did not have any wounds or cuts on her face, and she did not recall going out to the hospital. CR #2 Record review of CR #2's face-sheet revealed an [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's care-plan dated 4/8/19 revealed: Focus: I am at risk for impaired cognitive function/Dementia or impaired thought processes related to Dementia. I have ADL self-care performance deficit related to prior history of [MEDICAL CONDITION]. Interventions: bathing: total dependence with one-person physical assist. Bed mobility: extensive assistance with two-person physical assist. Dressing: extensive assist with one-person physical assist. Personal hygiene: extensive assist with one-person physical assist. Toilet use: extensive assist with one-person physical assist. Transfer: dependent on two staff for all transfers using mechanical lift. Record review of CR #2's Discharge MDS dated [DATE] revealed Resident's cognitive skills for daily decision making was modified. The MDS revealed CR #2 required extensive assist for bed mobility, dressing, and personal hygiene and was totally dependent on staff for transfers, toilet use, and bathing. Interview with CNA #7 on 4/25/19 at 9:47 AM, she stated on 4/11/19, she went to CR #2's room to assist CNA # 8 with transferring CR #2 to the wheel-chair. CNA #7 stated when she entered the room, CNA #8 pointed out that CR #2's knee was swollen, and that she made the nurse aware of it. CNA #7 stated she and CNA #8 proceeded to transfer CR #2 to the wheel-chair, and during the transfer, the resident made facial grimaces. CNA #7 stated she asked the resident if she still wanted to get her hair done, the resident stated yes, and was taken to the beauty shop. Interview with CNA #8 on 4/25/19 at 9:54 AM, CNA #8 stated on 4/11/19, she worked the 6am - 2 PM shift, at the beginning of her shift, she went to CR #2's room to get the resident up, upon removing the sheets from CR #2, she saw that the resident's knee was swollen. CNA #8 explained that she immediately called LVN #5, the LVN went to CR #2's room, saw the resident's knee, and left to call the doctor. CNA #8 further stated CR #2 did not complain of any pain, she wanted to get up and go to the beauty shop. Interview with NP #2 on 4/25/19 at 2:51 PM, she stated on 4/11/19 between 8:30am and 9:00am, the nurse asked her to look at CR #2's knee because it was swollen. NP #2 explained that she found CR #2 around lunch time and looked at the knee and saw that it was swollen. NP #2 stated she tried to move the resident's knee, and the resident said ouch, so she proceeded to order x-rays. NP #2 further explained she ordered regular x-ray instead of stat x-ray because the resident was not presenting severe pain, and she did not suspect a fracture because when she asked the resident if she fell , and the resident stated no recent falls. NP #2 further stated she did not call CR #2's Responsible party (RP) right away because she did not know what she was dealing with. NP #2 stated she called CR #2's RP early in the morning the following day. Interview with NP #1 on 4/25/19 at 2:54 PM, she stated on 4/11/19, around 10:51 PM she was notified of CR #2's x-ray results, and she called the Resident's family member /RP once she received the results to inform them of what was going on. NP #1 further stated she did not know if the facility nurse called the family. Interview with LVN #5 on 4/25/19 at 3:23 PM, she stated on 4/11/19 she was on the hall passing medications when a CNA informed her that CR #2's knee was swollen. LVN stated she proceeded to go to CR #2's room and saw that the knee was very swollen. LVN #5 stated NP #2 was in the facility, and she informed her of the swollen knee. The NP saw the resident and ordered an x-ray, and it was called in. LVN # 5 said the resident was asked if she fell , and she said no. Resident did not complain of any pain, she wanted to go to the beautician, and was given something for pain because of how swollen he knee was. LVN #5 further stated she wrote on a piece of paper to remind herself to call CR #2's family, but that she forgot. The following day, the ADON called her and asked if she called the resident's family, and she told her that she forgot. Record review of CR #2's MAR indicated [REDACTED].Left knee x-ray DX: swelling, pain. Order date: 4/11/19 at 12:33PM . Record review of X-ray company's Exam completion log dated 4/25/19 revealed: Exam was called in at 3:47 PM as a routine exam Exam was completed at 8:42PM Report was faxed to facility at 9:48 PM The order states Left knee x-ray: DX: swelling, pain Record review of CR #2's radiology interpretation dated 4/11/19 revealed in part .Findings: There is a nondisplaced [MEDICAL CONDITION] femur. Joint spaces are aligned. There are no bony [MEDICAL CONDITION]. Diffuse osteopenia is demonstrated. Soft tissue swelling is noted. Impression: Acute [MEDICAL CONDITION] femur . Record review of CR #2's progress note dated 4/11/19 at 7:31 PM revealed in part . Resident noted with a swollen left knee. NP #2 in the facility, notified of the swelling, assessed the resident and a new order for x-ray given. X-Ray company called for the X-Ray. No distress/discomfort noted during shift. Author: LVN #5 . Record review of CR #2's progress note dated 4/11/19 at 10:22 PM patient 's x-ray results received from X-ray company. Findings: There is a nondisplaced [MEDICAL CONDITION] femur. Joint spaces are aligned. There are no bony [MEDICAL CONDITION]. Diffuse osteopenia is demonstrated. Soft tissue swelling is noted to left leg. Spoke with NP. Order given to send resident out for evaluation per family member . Patient given prn medication for pain. No further distress or complaints voiced at this time. Will continue to monitor. Vitals stable. Author: LVN #6 . On 4/25/19 at 11:18 AM, Surveyor attempted to conduct a phone interview with LVN #6, LVN did not answer the phone, call was not returned. Record review of CR #2's progress note dated 4/11/19 at 11:45 PM, Patient left via stretcher accompanied by two paramedics to hospital. Patient in stable condition and is smiling. No signs or symptoms of distress. Report given to emergency room nurse. Family member is at hospital waiting for CR#2 . Author: LVN #6 . Record review of CR #2's hospital records dated 4/12/19 revealed in part .Radiology report: Findings: The anteroposterior oblique and lateral views of the left knee demonstrate marked bony demineralization with acute fracture crossing the distal femoral metaphysis . Further review revealed .Impression: 1. Impacted fracture at the distal femoral metaphysis has appearance suggestive of acute insufficiency fracture . Record review of LVN #5' Counseling/Disciplinary Notice dated 4/13/19 revealed: Type of action being taken written warning Date of hire: 10/13/15 Date of notice: 4/13/19 Reason why counseling/disciplinary action is necessary: Family was not notified of a change of condition for a resident that happened on 4/11/19. Employee's comments: I was notified by the CNA about the incident and I put down on a piece of paper what to follow up with including notifying the family but completely forgot due to working. Record review of the facility's policy, Notification, Physician or Responsible Party, revised 8/2017, revealed it read in part, It is the policy of this facility to promptly notify the resident, his/her attending physician, and/or family/responsible party of changes in the resident's condition and/or status .1. The nurse supervisor will notify the resident's attending physician when: .B. There is a significant change in the resident's physical, mental, or psychosocial status C. There is a need to alter the resident's treatment significantly D. The resident repeatedly refuses treatment or medications .F. Deemed necessary or appropriate in the best interest of the resident . Record review of facility's policy titled Change of Condition (revised 05/2017) revealed in part .Procedures: 3. Licensed nurse will inform family of change of condition and document notification .

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of ten residents (Resident #4) reviewed for pain management, in that; Resident #4 experienced pain after a fall on 11/2/18 and the pain was not addressed or reported to Physician until 11/5/18. On 11/5/18, X-ray was ordered which confirmed fractures of the pubic bones Resident #4 sustained a second fall on 11/9/18 with increased pain which was not adequately addressed or reported to the Physician until 11/12/18. Resident #4's X-ray confirmed Lumbar fracture following the second fall. These failures affected one resident who was placed at risk for further decline in mental or physical functioning and diminished quality of life. Findings include: Intake # 6 Resident #4 Record review of Resident #4's face sheet revealed an [AGE] year-old female resident admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview on Mental Status (BIMS) score of 3 indicating the resident was severely impaired. The MDS revealed the resident ambulated independently. She did not receive scheduled pain medication, as needed pain medication (PRN), or non-medication interventions for pain. The pain assessment revealed resident had no presence of pain and no history of falls. Record review of Resident #4's pain management review form dated 10/23/18 and 11/2/18, revealed there was no observed issues of pain. Record review of Resident #4's Care Plan revised on 11/12/18 revealed the resident was at risk for falls due to poor balance, poor safety awareness, dementia, muscle weakness. She cannot remember to ask for assistance with transfers, ambulation due to dementia. Interventions listed include to anticipate and meet needs, put call light in reach, put bed in low position, follow facility fall protocol, keep needed items within reach, ensure a safe clutter free environment. Record review of Resident #4's Care Plan revised on11/13/18 revealed resident had an actual fall with no injuries, slid from chair in the dining room. Resident had a fall on 9/22/18, she stated she slipped to the floor while getting out of bed, had discoloration to the eye. On 10/23/18 resident found on floor with no injury. On 11/2/18 resident found on floor in room, no injuries. On 11/9/18 resident found on floor, no injury. On 11/12/18 cervical, [MEDICATION NAME] and lumbar spine x-rays were ordered due to pain after fall. Intervention listed to have bed in low position, bedside commode, chair alarm, check for UTI, check range of motion, continue interventions on the at-risk plan, continue therapy, diathermy in therapy for low back pain, encourage rest at night, monitor/document/report to MD for signs or symptoms of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, and neuro checks. Review of Resident #4's Care plan focus area initiated on 9/14/18 and revised on 11/12/18 revealed resident had complaints of hip pain with bilateral hip/pelvis X-rays and right femur X-ray due to right hip pain with decreased mobility. Refuses offers of pain medication. On 11/10/18, [MEDICATION NAME] Tablet 600MG for 7 days was started. Interventions listed to administer [MEDICATION NAME] medication as per orders, encourage to take pain medications to alleviate pain, and X-rays as ordered. Record review of Resident #4's Physician orders [REDACTED]. Record review of Resident #4's (MONTH) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED] 11/3/18 at 9:52AM for pain level of 5, medication was listed effectiveness was unknown. 11/4/18 at 4:56AM for pain level of 3, medication was listed as effective. 11/5/18 at 9:16AM for pain level of 3, medication was listed as effective. Record review of Resident #4's (MONTH) MAR indicated [REDACTED] 11/2/18 rated a pain level of 0 on all shifts. 11/3/18 rated a pain level of 0 on all shifts. 11/4/18 rated a pain level of 0 on all shifts. 11/5/18 rated a pain level of 0 on all shifts. Observation and interview on 11/13/18 at 12:25PM, Resident #4 was in the dining hall with other residents waiting for lunch trays. Resident #4 was sitting in a wheel chair and did not make movements to get up or propel herself. Resident#4 said she was doing okay. The resident appeared confused .When asked about food at the facility, she stated, I don't know what to do and was not aware food was served at the facility. Record review of incident report dated 11/2/18 at 1:20am revealed the resident was observed on the floor in her room in a sitting position leaning against the bed. Head to toe assessment was done with no apparent injuries noted. PRN Tylenol 650 MG was given, neuro vital signs initiated, and resident was stable. During the assessment the resident denied banging her head and resident was assisted back to bed and made comfortable. Family and Physician notified at 1:37AM. Further review of incident report revealed follow up notes on the report revealed on 11/5/18, the resident complained of pain and imaging was ordered to check for any concerns. Subacute right superior and inferior pubic rami fractures were found and suggested they were due to recent fall on 11/2/18. Reported to HHSC as a major injury and resident was sent to emergency room (ER) for continued evaluation and treatment. LVN #3 completed the incident report. Record review of Resident #4's progress notes dated 11/2/18 at 1:40am revealed LVN #3 was summoned to residents' room and observed her sitting on the floor. Head to toe assessment done with no apparent injury, placed call to family and Medical Director (MD) aware and nurse practitioner (NP) book was noted. Interview on 11/13/18 at 2:58PM, LVN #3 said he was the nurse who worked with Resident #4 on the night of 11/2/18 when she fell . He said the resident was found on the floor around 1:00AM on 11/2/18. He assessed the resident and she had no injuries and did not complain of pain. He said he gave the resident her PRN Tylenol as a precaution. Record review of Resident #4's progress notes revealed: On 11/3/18 at 9:52AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. On 11/3/18 at 11:07AM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration effectiveness was unknown. On 11/4/18 at 4:56AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain.1 tablet was given for lower back pain. On 11/4/18 at 6:08AM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was effective. Follow up pain scale was 0. On 11/5/18 at 9:16AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of back pain. On 11/5/18 at 11:18AM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was somewhat effective. Follow up pain scale was 1. On 11/5/18 at 12:24PM, New order: lumbar and bilateral femur x-ray. Taken this shift as resident continues to complain of back pain but refusing to swallow pain meds. Awaiting results. Resident resting in bed at this time. Will continue to monitor. On 11/5/18 at 1:18PM, x-ray results: subacute right superior/inferior pubic rami fractures. NP made aware awaiting results. On 11/5/18 at 1:28PM, new order: please refer to Orthopedic doctor for evaluation. On 11/6/18 at 8:00AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of back pain. On 11/6/18 at 2:50PM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration effectiveness was unknown. Follow up pain scale was 2. On 11/8/18 at 5:20PM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. On 11/8/18 at 6:38PM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was effective. Follow up pain scale was 0. Record review of Incident report dated 11/9/18 at 11:14PM revealed Resident #4 was in bed eating her dinner, a CNA called to notify nurse the resident was on the floor. Resident #4 said she was trying to go to the bathroom. Resident's vital signs were taken, and extremities were well assessed and moveable. The resident was able to walk back to bed. Resident was put on neuro checks. At the time of the incident , the resident had a pain level of 4. Incident report notes revealed [MEDICATION NAME] 650MG was administered for lower back pain. Report listed no injuries were found. Further review of the reports revealed no one was listed as being notified of the incident. Report was completed by LVN #4. Interview on 11/13/18 at 3:25PM, LVN #4 said Resident #4 was complaining of back pain around dinner time on 11/9/18. She said she gave the resident some PRN Tylenol, rubbed her back with some bio freeze and then set up her up in bed with her dinner tray. She left the room and later someone was passing down the hallway and saw the resident on the floor and told her. She said she assessed the resident and there was a paramedic who happened to be there admitting someone who helped her assist the resident to the bed after she was assessed. The resident did complain of pain after the fall but LVN #4 said the resident was in pain before she fell so she felt it was the same pain, and not pain from the fall. LVN #4 said she did notify the Nurse Practitioner (NP) the same day after the fall through text message. She said there was no response from the NP, so she figured there was no new orders. LVN #4 added she spoke to the NP earlier in the day before the fall due to Resident #4's pain medication being ineffective, and the resident continued to complain of pain after the PRN Tylenol was administered. LVN #4 said the NP ordered scheduled [MEDICATION NAME] 600MG for 3 times a day to address the resident's pain before she had the second fall. LVN #4 said Resident #4 had a history of [REDACTED]. Record review of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED] 11/10/18 at 11:51AM for pain level of 3, medication was listed as effective. 11/11/18 at 2:36PM for pain level of 2, medication was spit out by the resident. Record review of Resident #4's (MONTH) MAR indicated [REDACTED] 11/9/18 rated a pain level of 1 on the night shift. 11/10/18 rated a pain level of 3 on the morning shift. 11/11/18 rated a pain level of 2 on the morning shift. 11/12/18 rated a pain level of 2 on the morning shift. Record review of Resident #4's Physicians orders revealed an order dated 11/9/18 for [MEDICATION NAME] Tablet 600MG to be given by mouth every 8 hours for pain for 7 days starting on 11/10/18. Record review of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED] 11/10/18 at 6:00AM, 2:00PM, and 10:00PM 11/11/18 at 6:00AM, 2:00PM, and 10:00PM 11/12/18 at 6:00AM, 2:00PM, and 10:00PM Record review of Resident #4's progress notes revealed in part: On 11/10/18 at 11:51AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of increased pain in the back pain. On 11/10/18 at 12:55PM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was effective, resident was sleeping. Follow up pain scale was 1. On 11/10/18 at 1:36PM, status for post fall on floor, day 1/3. Resident #4 was alert and oriented with no change in locomotion. 1 PRN was given for complaint of pain in back. Medication was spit out, but reproach was effective. No apparent injury noted from previous incident. Will continue to monitor. On 11/11/18 at 2:36PM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of increased pain in the back pain. Medication was refused. Record review of Resident #4's clinical record revealed a Communication Form and Progress Note for RNs/LPN/LVN dated 11/5/18 revealed the resident had decreased mobility and the resident had worsened chronic pain. Pain intensity was listed at a 4. The review area noted on 11/5/18 at 3:00PM the physician recommended to send resident to the ER for evaluation. Record review of Resident #4's X-ray results from 11/5/18 revealed in part, Lumbar 2V - 3V: Diffuse spondylosis osteopenia facet arthritis. No fracture or acute bone abnormality. Impression: No acute bone abnormality. Further review of the X-ray results revealed in part, Right Femur 2V: There are subacute right superior and inferior pubic rami fractures, not seen on the previous exam on 9/13/18. Impression: Subacute right superior and inferior pubic rami fractures. Record review of Resident #4's hospital dated 11/5/18 revealed reason for visit was hip pain or injury. Hospital discharge summary revealed base on the [DIAGNOSES REDACTED]. Record review of Resident #4's X-ray results from 11/12/18 revealed in part, Lumbar 2V - 3V: There is a [MEDICAL CONDITION] body of L1 which is of indeterminate age. [MEDICAL CONDITION] changes manifested by endplate osteophytes are noted. Generalized osteopenia is noted. Impression: [MEDICAL CONDITION] body of L1 which is chronic. Interview on 11/13/18 at 2:00PM, the DON said the resident did not complain of pain until 11/4/18 after her first fall on 11/2/18. She said the NP came in on the following Monday (11/5/18) to examine her. The DON said she had already ordered the X-ray before the NP came in to assess the resident and they received the results when she arrived. It was advised for the resident to be sent to an Orthopedic doctor for the injury. The resident was not able to be seen by the Orthopedic Doctor until 11/7/18 and the resident was refusing to take her pain medication. The DON said she suggested they send the resident to the hospital to manage her pain since she was refusing to take medication for pain. The resident was sent out to the hospital and the hospital sent the resident right back to the facility. She did not feel the resident presented any new concerns for pain and said the resident had a history of [REDACTED]. The DON said she was informed of the second fall and though she could not find the documentation she felt the nurse (LVN #4) did inform the NP of the second fall on 11/9/18. The DON said the resident did not present any signs of new injury or increased pain after the second fall. Interview on 11/13/18 at 2:20PM, PT #1 said Resident #4 did not receive any form of therapy on 11/3/18, 11/4/18, 11/10/18, or 11/11/18. Interview on 11/13/18 at 5:30PM, LVN #2 said she often worked with Resident #4 and said she had worked with the resident on 11/10/18 and 11/11/18. She said Resident #4 had increased issues with pain since her first fall. She said the resident does not say she is in pain due to her cognition was impaired but will grimace when she moves or has a hard time moving like she did before the fall on 11/2/18. LVN #2 described the resident as always being busy and wandered . LVN#2 said since the resident had the fall, the resident will say she was okay and then made faces as if she was in pain when moved. She reported the resident was not moving around as much since the falls. She also reported the resident was in pain on 11/10/18 and 11/11/18. LVN #2 said she did not personally tell the Nurse Practitioner about the resident's pain but said she knew the NP was aware of the pain. Interview on 11/14/18 at 8:00AM and said she was informed of Resident #4's fall on 11/2/18. The staff reported no complaints of pain or apparent injury. She was not aware resident had issues with pain until she came to the facility on [DATE] and assessed the resident. During her assessment ,the resident appeared to be experiencing some pain, therefore X-ray was ordered. NP confirmed the resident was sent out to the hospital to manage pain due to the resident refusing to take pain medication and the X-ray results confirmed the resident had a fracture. The NP said she was contacted on 11/9/18 about the resident having continued pain and the PRN Tylenol being ineffective. She said she ordered the scheduled [MEDICATION NAME] to address the resident's pain. She was not informed until 11/10/18 about the resident's second fall on 11/9/18. The staff reported no injuries and did not mention any continued issues with pain. NP said she did not discover the resident had increased pain until the following Monday (11/12/18) when she came in to assess the resident and during her examination, the resident was experiencing pain but could not verify where the pain was coming from. After her assessment, she ordered another X-ray to check for further injury from the second fall. Record review of Resident #4's NP progress notes from 11/5/18 revealed resident had a fall on 11/2/18 and initially there was no pain or injury reported until 11/4/18 when the resident began to complain of pain. The NP evaluated the resident on 11/5/18 as requested by nursing staff and the resident was found to have lower back and thigh pain, unsure which leg. It was noted the resident was on pain management with PRN Tylenol. The progress note revealed lumbar spine X-ray and bilateral femur X-rays was ordered and to continue PRN Tylenol. Further review of Resident #4's NP progress notes from 11/6/18 revealed X-rays were obtained for evaluation for right superior and inferior pubic rami fractures. An orthopedic consult was ordered. Resident was sent out yesterday per DON's request (11/5/18) and she was sent back with no new orders. The resident was to continue PRN Tylenol and to be non-weight bearing until the orthopedic appointment on 11/7/18. Record review of Resident #4's NP progress notes from 11/8/18 revealed Resident #4 was seen by an orthopedic doctor and orders were to continue with conservative management, ordered physical therapy , occupational therapy evaluation and treatment, ordered skilled nursing, and to continue PRN Tylenol. Record review of Resident #4's NP Progress notes from 11/12/18 revealed on 11/9/18 the nurse reported continued back pain after Tylenol was given and bio freeze applied. Additional orders were given for [MEDICATION NAME] 600MG every 8 hours for 7 days which had helped per staff. Nurse reported Resident #4 sustained a fall over the weekend as well. It was noted the resident was unable to describe exactly where pain was coming from and it was unsure if back pain is exacerbated from first fall or subsequent fall as patient is poor historian. An order was placed for cervical, thoracis and lumbar spine X-rays for evaluation. Record review of the facility's Pain Management policy revised on 2010 revealed in part, the resident will be assessed for pain upon development of new symptoms of acute or chronic pain that has not been previously assessed. Complete the pain risk assessment as needed .Consult physician for additional intervention if pain is not relieved by currently ordered treatment , modalities and comfort measures.

Based on observation, interview, and record review, the facility failed to immediately consult with the physician when there was a change in condition for 1 of 10 residents (Resident #4) reviewed for notification of changes, in that; Resident #4's physician was not timely consulted after Resident #4 experienced pain following her fall on 11/2/18. Resident #4 was found to have sustained acute pubic bone fractures. Resident #4's physician was not timely consulted after Resident #4 experienced a fall on 11/9/18, Resident #4's Physician was also not notified of her continued pain throughout that weekend after the fall. Resident #4 was found to have sustained lumber fractures. These failures affected one resident who sustained fractures and was placed at increasing risk of pain which was not adequately addressed. Findings include: Intake # 6 Resident #4 Record review of Resident #4's face sheet revealed an [AGE] year-old female resident admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview on Mental Status (BIMS) score of 3 indicating the resident was severely impaired. The MDS revealed the resident ambulated independently. She did not receive scheduled pain medication, as needed pain medication (PRN), or non-medication interventions for pain. The pain assessment revealed resident had no presence of pain and no history of falls. Record review of Resident #4's pain management review form dated 10/23/18 and 11/2/18, revealed there was no observed issues of pain. Record review of Resident #4's Care Plan revised on 11/12/18 revealed the resident was at risk for falls due to poor balance, poor safety awareness, dementia, muscle weakness. She cannot remember to ask for assistance with transfers, ambulation due to dementia. Interventions listed include to anticipate and meet needs, put call light in reach, put bed in low position, follow facility fall protocol, keep needed items within reach, ensure a safe clutter free environment. Record review of Resident #4's Care Plan revised on11/13/18 revealed resident had an actual fall with no injuries, slid from chair in the dining room. Resident had a fall on 9/22/18, she stated she slipped to the floor while getting out of bed, had discoloration to the eye. On 10/23/18 resident found on floor with no injury. On 11/2/18 resident found on floor in room, no injuries. On 11/9/18 resident found on floor, no injury. On 11/12/18 cervical, [MEDICATION NAME] and lumbar spine x-rays were ordered due to pain after fall. Intervention listed to have bed in low position, bedside commode, chair alarm, check for UTI, check range of motion, continue interventions on the at-risk plan, continue therapy, diathermy in therapy for low back pain, encourage rest at night, monitor/document/report to MD for signs or symptoms of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, and neuro checks. Review of Resident #4's Care plan focus area initiated on 9/14/18 and revised on 11/12/18 revealed resident had complaints of hip pain with bilateral hip/pelvis X-rays and right femur X-ray due to right hip pain with decreased mobility. Refuses offers of pain medication. On 11/10/18, [MEDICATION NAME] Tablet 600MG for 7 days was started. Interventions listed to administer [MEDICATION NAME] medication as per orders, encourage to take pain medications to alleviate pain, and X-rays as ordered. Observation and interview on 11/13/18 at 12:25PM, Resident #4 was in the dining hall with other residents waiting for lunch trays. Resident #4 was sitting in a wheel chair and did not make movements to get up or propel herself. Resident#4 said she was doing okay. The resident appeared confused .When asked about food at the facility, she stated, I don't know what to do and was not aware food was served at the facility. Record review of incident report dated 11/2/18 at 1:20am revealed the resident was observed on the floor in her room in a sitting position leaning against the bed. Head to toe assessment was done with no apparent injuries noted. PRN Tylenol 650 MG was given, neuro vital signs initiated, and resident was stable. During the assessment the resident denied banging her head and resident was assisted back to bed and made comfortable. Family and Physician notified at 1:37AM. Further review of incident report revealed follow up notes on the report revealed on 11/5/18, the resident complained of pain and imaging was ordered to check for any concerns. Subacute right superior and inferior pubic rami fractures were found and suggested they were due to recent fall on 11/2/18. Reported to HHSC as a major injury and resident was sent to emergency room (ER) for continued evaluation and treatment. LVN #3 completed the incident report. Record review of Resident #4's progress notes dated 11/2/18 at 1:40am revealed LVN #3 was summoned to residents' room and observed her sitting on the floor. Head to toe assessment done with no apparent injury, placed call to family and Medical Director (MD) aware and nurse practitioner (NP) book was noted. Interview on 11/13/18 at 2:58PM, LVN #3 said he was the nurse who worked with Resident #4 on the night of 11/2/18 when she fell . He said the resident was found on the floor around 1:00AM on 11/2/18. He assessed the resident and she had no injuries and did not complain of pain. He said he gave the resident her PRN Tylenol as a precaution. Record review of Resident #4's Physician orders [REDACTED]. Record review of Resident #4's (MONTH) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED] 11/3/18 at 9:52AM for pain level of 5, medication was listed effectiveness was unknown. 11/4/18 at 4:56AM for pain level of 3, medication was listed as effective. 11/5/18 at 9:16AM for pain level of 3, medication was listed as effective. Record review of Resident #4's (MONTH) MAR indicated [REDACTED] 11/2/18 rated a pain level of 0 on all shifts. 11/3/18 rated a pain level of 0 on all shifts. 11/4/18 rated a pain level of 0 on all shifts. 11/5/18 rated a pain level of 0 on all shifts. Record review of Resident #4's progress notes revealed: On 11/3/18 at 9:52AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. On 11/3/18 at 11:07AM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration effectiveness was unknown. On 11/4/18 at 4:56AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain.1 tablet was given for lower back pain. On 11/4/18 at 6:08AM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was effective. Follow up pain scale was 0. On 11/5/18 at 9:16AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of back pain. On 11/5/18 at 11:18AM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was somewhat effective. Follow up pain scale was 1. On 11/5/18 at 12:24PM, New order: lumbar and bilateral femur x-ray. Taken this shift as resident continues to complain of back pain but refusing to swallow pain meds. Awaiting results. Resident resting in bed at this time. Will continue to monitor. On 11/5/18 at 1:18PM, x-ray results: subacute right superior/inferior pubic rami fractures. NP made aware awaiting results. On 11/5/18 at 1:28PM, new order: please refer to Orthopedic doctor for evaluation. On 11/6/18 at 8:00AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of back pain. On 11/6/18 at 2:50PM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration effectiveness was unknown. Follow up pain scale was 2. On 11/8/18 at 5:20PM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. On 11/8/18 at 6:38PM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was effective. Follow up pain scale was 0. Record review of Incident report dated 11/9/18 at 11:14PM revealed Resident #4 was in bed eating her dinner, a CNA called to notify nurse the resident was on the floor. Resident #4 said she was trying to go to the bathroom. Resident's vital signs were taken, and extremities were well assessed and moveable. The resident was able to walk back to bed. Resident was put on neuro checks. At the time of the incident , the resident had a pain level of 4. Incident report notes revealed [MEDICATION NAME] 650MG was administered for lower back pain. Report listed no injuries were found. Further review of the reports revealed no one was listed as being notified of the incident. Report was completed by LVN #4. Interview on 11/13/18 at 3:25PM, LVN #4 said Resident #4 was complaining of back pain around dinner time on 11/9/18. She said she gave the resident some PRN Tylenol, rubbed her back with some bio freeze and then set up her up in bed with her dinner tray. She left the room and later someone was passing down the hallway and saw the resident on the floor and told her. She said she assessed the resident and there was a paramedic who happened to be there admitting someone who helped her assist the resident to the bed after she was assessed. The resident did complain of pain after the fall but LVN #4 said the resident was in pain before she fell so she felt it was the same pain, and not pain from the fall. LVN #4 said she did notify the Nurse Practitioner (NP) the same day after the fall through text message. She said there was no response from the NP, so she figured there was no new orders. LVN #4 added she spoke to the NP earlier in the day before the fall due to Resident #4's pain medication being ineffective, and the resident continued to complain of pain after the PRN Tylenol was administered. LVN #4 said the NP ordered scheduled [MEDICATION NAME] 600MG for 3 times a day to address the resident's pain before she had the second fall. LVN #4 said Resident #4 had a history of [REDACTED]. Record review of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED] 11/10/18 at 11:51AM for pain level of 3, medication was listed as effective. 11/11/18 at 2:36PM for pain level of 2, medication was spit out by the resident. Record review of Resident #4's (MONTH) MAR indicated [REDACTED] 11/9/18 rated a pain level of 1 on the night shift. 11/10/18 rated a pain level of 3 on the morning shift. 11/11/18 rated a pain level of 2 on the morning shift. 11/12/18 rated a pain level of 2 on the morning shift. Record review of Resident #4's Physicians orders revealed an order dated 11/9/18 for [MEDICATION NAME] Tablet 600MG to be given by mouth every 8 hours for pain for 7 days starting on 11/10/18. Record review of Resident #4's (MONTH) (YEAR) MAR indicated [REDACTED] 11/10/18 at 6:00AM, 2:00PM, and 10:00PM 11/11/18 at 6:00AM, 2:00PM, and 10:00PM 11/12/18 at 6:00AM, 2:00PM, and 10:00PM Record review of Resident #4's progress notes revealed in part: On 11/10/18 at 11:51AM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of increased pain in the back pain. On 11/10/18 at 12:55PM, Resident #4's Tylenol Tablet by mouth every 6 hours as needed for pain PRN administration was effective, resident was sleeping. Follow up pain scale was 1. On 11/10/18 at 1:36PM, status for post fall on floor, day 1/3. Resident #4 was alert and oriented with no change in locomotion. 1 PRN was given for complaint of pain in back. Medication was spit out, but reproach was effective. No apparent injury noted from previous incident. Will continue to monitor. On 11/11/18 at 2:36PM, Resident #4 was given Tylenol Tablet 650MG by mouth every 6 hours as needed for pain. Administered for complaints of increased pain in the back pain. Medication was refused. Record review of Resident #4's clinical record revealed a Communication Form and Progress Note for RNs/LPN/LVN dated 11/5/18 revealed the resident had decreased mobility and the resident had worsened chronic pain. Pain intensity was listed at a 4. The review area noted on 11/5/18 at 3:00PM the physician recommended to send resident to the ER for evaluation. Record review of Resident #4's X-ray results from 11/5/18 revealed in part, Lumbar 2V - 3V: Diffuse spondylosis osteopenia facet arthritis. No fracture or acute bone abnormality. Impression: No acute bone abnormality. Further review of the X-ray results revealed in part, Right Femur 2V: There are subacute right superior and inferior pubic rami fractures, not seen on the previous exam on 9/13/18. Impression: Subacute right superior and inferior pubic rami fractures. Record review of Resident #4's hospital dated 11/5/18 revealed reason for visit was hip pain or injury. Hospital discharge summary revealed base on the [DIAGNOSES REDACTED]. Record review of Resident #4's X-ray results from 11/12/18 revealed in part, Lumbar 2V - 3V: There is a [MEDICAL CONDITION] body of L1 which is of indeterminate age. [MEDICAL CONDITION] changes manifested by endplate osteophytes are noted. Generalized osteopenia is noted. Impression: [MEDICAL CONDITION] body of L1 which is chronic. Interview on 11/13/18 at 2:00PM, the DON said the resident did not complain of pain until 11/4/18 after her first fall on 11/2/18. She said the NP came in on the following Monday (11/5/18) to examine her. The DON said she had already ordered the X-ray before the NP came in to assess the resident and they received the results when she arrived. It was advised for the resident to be sent to an Orthopedic doctor for the injury. The resident was not able to be seen by the Orthopedic Doctor until 11/7/18 and the resident was refusing to take her pain medication. The DON said she suggested they send the resident to the hospital to manage her pain since she was refusing to take medication for pain. The resident was sent out to the hospital and the hospital sent the resident right back to the facility. She did not feel the resident presented any new concerns for pain and said the resident had a history of [REDACTED]. The DON said she was informed of the second fall and though she could not find the documentation she felt the nurse (LVN #4) did inform the NP of the second fall on 11/9/18. The DON said the resident did not present any signs of new injury or increased pain after the second fall. Interview on 11/13/18 at 2:20PM, PT #1 said Resident #4 did not receive any form of therapy on 11/3/18, 11/4/18, 11/10/18, or 11/11/18. Interview on 11/13/18 at 5:30PM, LVN #2 said she often worked with Resident #4 and said she had worked with the resident on 11/10/18 and 11/11/18. She said Resident #4 had increased issues with pain since her first fall. She said the resident does not say she is in pain due to her cognition was impaired but will grimace when she moves or has a hard time moving like she did before the fall on 11/2/18. LVN #2 described the resident as always being busy and wandered . LVN#2 said since the resident had the fall, the resident will say she was okay and then made faces as if she was in pain when moved. She reported the resident was not moving around as much since the falls. She also reported the resident was in pain on 11/10/18 and 11/11/18. LVN #2 said she did not personally tell the Nurse Practitioner about the resident's pain but said she knew the NP was aware of the pain. Interview on 11/14/18 at 8:00AM and said she was informed of Resident #4's fall on 11/2/18. The staff reported no complaints of pain or apparent injury. She was not aware resident had issues with pain until she came to the facility on [DATE] and assessed the resident. During her assessment ,the resident appeared to be experiencing some pain, therefore X-ray was ordered. NP confirmed the resident was sent out to the hospital to manage pain due to the resident refusing to take pain medication and the X-ray results confirmed the resident had a fracture. The NP said she was contacted on 11/9/18 about the resident having continued pain and the PRN Tylenol being ineffective. She said she ordered the scheduled [MEDICATION NAME] to address the resident's pain. She was not informed until 11/10/18 about the resident's second fall on 11/9/18. The staff reported no injuries and did not mention any continued issues with pain. NP said she did not discover the resident had increased pain until the following Monday (11/12/18) when she came in to assess the resident and during her examination, the resident was experiencing pain but could not verify where the pain was coming from. After her assessment, she ordered another X-ray to check for further injury from the second fall. Record review of Resident #4's NP progress notes from 11/5/18 revealed resident had a fall on 11/2/18 and initially there was no pain or injury reported until 11/4/18 when the resident began to complain of pain. The NP evaluated the resident on 11/5/18 as requested by nursing staff and the resident was found to have lower back and thigh pain, unsure which leg. It was noted the resident was on pain management with PRN Tylenol. The progress note revealed lumbar spine X-ray and bilateral femur X-rays was ordered and to continue PRN Tylenol. Further review of Resident #4's NP progress notes from 11/6/18 revealed X-rays were obtained for evaluation for right superior and inferior pubic rami fractures. An orthopedic consult was ordered. Resident was sent out yesterday per DON's request (11/5/18) and she was sent back with no new orders. The resident was to continue PRN Tylenol and to be non-weight bearing until the orthopedic appointment on 11/7/18. Record review of Resident #4's NP progress notes from 11/8/18 revealed Resident #4 was seen by an orthopedic doctor and orders were to continue with conservative management, ordered physical therapy , occupational therapy evaluation and treatment, ordered skilled nursing, and to continue PRN Tylenol. Record review of Resident #4's NP Progress notes from 11/12/18 revealed on 11/9/18 the nurse reported continued back pain after Tylenol was given and bio freeze applied. Additional orders were given for [MEDICATION NAME] 600MG every 8 hours for 7 days which had helped per staff. Nurse reported Resident #4 sustained a fall over the weekend as well. It was noted the resident was unable to describe exactly where pain was coming from and it was unsure if back pain is exacerbated from first fall or subsequent fall as patient is poor historian. An order was placed for cervical, thoracis and lumbar spine X-rays for evaluation. Record review of facility's fall prevention policy revised 2007 revealed significant information obtained as a result of post fall assessment should be reported to the resident's physician and family and documented in the medical records. Record review of the facility's Pain Management policy revised on 2010 revealed in part, Consult physician for additional intervention if pain is not relieved by currently ordered treatment , modalities and comfort measures.

Based on observation, interview and record review, the facility failed to consult with the resident's physician when a change in condition occurred for one of 22 residents (CR #1) reviewed for physician notification. CR #1's blood glucose levels were elevated for three days (08/20/16, 08/21/16 and 08/22/16) and the physician was not consulted. The facility failed to obtain parameters for reporting CR #1's blood glucose levels to the physician when she was admitted . CR #1 was admitted to the hospital on [DATE] for a scheduled surgical procedure, which was canceled due to a critical blood glucose level, causing CR #1 to be admitted to ICU. An immediate Jeopardy (IJ) was identified on 08/25/16, beginning on 08/20/16 and ending on 08/22/16 when CR #1 went to the hospital. While the IJ was removed on 08/22/16 when CR #1 went to the hospital and the facility began implementing activities to correct the deficient practice. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern, because the facility was continuing to monitor the effectiveness of their plan of removal. This failure to consult with the physician affected one resident who required acute care treatment at a hospital due to untreated elevated blood glucose levels, and placed 28 other residents with diabetes at risk of harm from deterioration of health due to their physician not being consulted. Findings include: Intake # 1 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's admission [DIAGNOSES REDACTED]. Record review of CR #1's MDS assessment dated [DATE], revealed the resident was moderately cognitively impaired. She required extensive assistance for transfer and dressing, limited assistance for mobility, and was completely dependent for hygiene. Record review of CR #1's care plan with Focus read in part Has Diabetes Mellitus and date initiated 8/16/16 read in part: Diabetes medication (insulin) as ordered by doctor. Monitor/document for side effects and effectiveness. Fasting serum glucose as ordered by doctor. The care plan did not include any parameters for reporting blood glucose levels to the physician. Record review of the CR #1's physician's orders [REDACTED]. Further record review revealed additional insulin coverage-Humalog Solution 100 Unit/ml, inject 5 unit subcutaneously with meals for DM. Dosages for Humalog were scheduled for 7:00 a.m., 12:00 p.m., and 5:00 p.m. Record review of the Hospital Record for CR #1 dated 8/22/16 revealed CR #1 was admitted to the hospital on [DATE] for elective replacement or repair of a [MEDICAL TREATMENT] catheter. CR #1 had a glucose level of greater that 800 on arrival (NPO so no insulin) so CR #1 was admitted to ICU for [REDACTED]. Interview on 8/24/16 at 8:50 a.m., the hospital ICU Charge Nurse stated CR #1 had been admitted to the ICU for a critical blood glucose level and was currently receiving an IV insulin drip. This Nurse further stated there were no plans to discharge CR #1 from the hospital at that time. Observation and interview on 8/24/16 at 9:00 a.m. during a visit to the hospital ICU revealed CR #1 resting in bed and receiving an IV insulin drip to regulate her blood glucose levels. CR #1 stated the morning of 8/22/16 she was transferred to the hospital for placement of a [MEDICAL TREATMENT] shunt. She said the nurse at the facility checked her blood glucose and it was high, but she could not recall the number. She further stated she refused to take insulin and was given no insulin prior to being transferred to the hospital. Upon arrival at the hospital a nurse rechecked her blood glucose and it was high. She said that was why she had to have the insulin drip. CR #1 stated her blood sugars were up and down at the facility gave her insulin as she required. Record review of the CR #1's MAR indicated [REDACTED]. There was no documentation on the MAR for 6:00 a.m. on 8/22/16. Further review revealed her blood glucose levels were documented as follows by LVN #5: 8/20/16: 299 mm/dL at 7:00 a.m. 396 mm/dL at 12:00 p.m. 398 mm/dL at 5:00 p.m. 8/21/16: 516 mm/dL at 7:00 a.m. 596mm/dL at 12:00 p.m. 482mm/dL at 5:00 p.m. There was no documentation of blood glucose levels or refusal of insulin on 8/22/16 by LVN #16. Record review of the American Diabetes Association website www.diabetes.org/living-with-diabetes read in part .The American Diabetes Association suggests the following targets for most nonpregnant adults with diabetes. More or less stringent glycemic goals may be appropriate for each individual. Before a meal (preprandial plasma glucose): 80-130 mg/dl. 1-2 hours after beginning of the meal (Postprandial plasma glucose): Less than 180 mg/dl. Record review of Nurse's Progress Notes for CR #1 dated 8/20/16 signed by LVN #5 revealed no mention of the resident's elevated blood glucose levels or notification of her physician. Record review of Nurse's Progress Notes for CR #1 dated 8/21/16 signed by LVN #5 revealed no mention of the resident's elevated blood glucose levels or notification of physician. Numerous calls were made to LVN #5 with messages left on 8/24/16, 8/25/16, 8/26/16, and 8/27/16. No return call was received so an interview could not be done. Record review of Nurse's Progress Notes for CR #1 dated 8/22/16 at 6:14 a.m. signed by LVN #16 read as follows: Insulin [MEDICATION NAME] Solution 100Unit/ml Inject 20 Unit subcutaneously in the morning for DM. Administer before breakfast. BS-256, patient not administered insulin due to procedure and patient not eating breakfast. Record review of Nurse's Progress Notes for CR #1 on 8/22/16 at 9:13 a.m. signed by LVN #16 read as follows: Received a call from hospital where procedure for fistula is to take place. Requesting information on blood sugar, states patient's blood sugar is over 500. I stated blood sugar reading of 256 this morning at 6:14 a.m. Patient had not eaten anything prior to procedure or overnight. Patient worried blood sugar may drop too low if she had coverage, as it had in the past. Hospital stated would like Nurse Practitioner to call her (hospital nurse) and give insulin coverage (medication). NP notified, will follow up. Record review of Nurse's Progress Notes for CR #1 on 8/22/16 at 9:13 a.m. signed by LVN #16 read as follows: 9:30 am: Addendum: follow up-when administering blood sugar check, patient results was 256. Patient stated I am worried I may become hypoglycemic, I had that happen before when I was in the hospital and I had not eaten. I was found on the bed unconscious. Therefore patient refused insulin coverage prior to doctor appointment. NP notified. There was no documentation of when the NP was notified and what was ordered. Interview on 8/25/16 at 10:20 a.m. LVN #16 stated she checked CR #1's blood glucose level at 6:14 a.m., just before the resident was leaving for her procedure at the hospital at 6:15 a.m. CR #1 stated she had not eaten and would not take insulin. LVN #16 further stated she immediately notified the NP of the resident's refusal and transferred CR #1 to the Hospital. LVN #16 said she instructed the resident that [MEDICATION NAME] was a long acting insulin and her blood sugar was high so she needed the insulin, but CR #1 continued to refuse the insulin. Interview on 8/25/16 at 10:50 a.m. the DON stated she had reviewed CR #1's clinical records on 08/22/16 and noted the elevated blood glucose levels on 8/20/16, 8/21/16, and 8/22/16 along with the resident's refusal of insulin dosage on 8/22/16. The DON further stated the elevated blood glucose levels and the refusal of insulin on 8/22/16 before transfer to the hospital were reported to the physician and the Medical Director during an informal QA committee by phone. The DON, Administrator, Medical Director and CR #1's physician were present during this QA committee meeting. A formal QA committee meeting was set up for 8/23/16, but standard survey was started on that date so it was postponed until 8/25/16. She stated the formal QA committee meeting was completed on 8/25/16. The DON further stated she counseled LVN #5 and LVN #16 on 8/22/16 for failure to report CR #1's elevated blood glucose levels. She further stated they audited all resident's charts on 08/22/16 and it was determined that all other Residents on SS insulin had parameters of when to notify the physician so this was an isolated event. All other residents on SS insulin had physicians notified when their blood glucose levels were outside normal parameters. Interview on 8/25/16 at 4:40 p.m., the DON explained there was a problem with communicating with physicians when elevated blood glucose levels had been noted. CR #1 had elevated blood glucose levels on 8/20/16 and 8/21/16 and an elevated blood glucose level with resident refusal of insulin dosage on 8/22/16. This problem was identified the morning of 8/22/16 when the DON received a call from the hospital concerning CR #1's elevated blood glucose level. She further stated an informal QA committee meeting was held by phone with the medical director and Administrator on 08/22/16 and a formal QA committee meeting was scheduled for 8/23/16. She stated the formal QA committee meeting was postponed until 8/25/16 due to standard survey beginning on 8/23/16. She stated at the QA committee meetings held on 8/22/16 and 8/25/16 they addressed the development of parameters for blood glucose levels to be reported to the physician when they were below 60 or above 250 and the Interact Change of Condition Tool was implemented. She further stated on 08/22/16, both nurses (LVN #5 and LVN #16) involved in this incident were immediately in-serviced on reporting blood glucose levels. An audit of all diabetic resident charts was conducted on 08/22/16 and they determined this was an isolated event. All other residents on SS insulin had parameters for when to notify the physician. The DON stated all remaining nursing staff were in-serviced by 08/25/16. Interview on 8/25/16 at 4:40 p.m., the Administrator stated the problem was brought to her attention on 8/22/16 by the DON. The Administrator stated she participated in the QA committee meetings held on 8/22/16 and 8/25/16. She stated a QA committee meeting was originally scheduled for 8/23/16, but standard survey began that day so they postponed the meeting until 8/25/16. During these QA committee meetings, she, the DON, and the Medical Director established new parameters for reporting blood glucose levels along with a Change of Condition Tool. She stated in-services were held with all nursing staff, beginning 8/22/16 and completed on 8/25/16. Policies were also established for new blood glucose parameters to be reported to the physicians and the Change of Condition Tool. Record review of the facility's policy entitled Change of Condition Reporting revised 05/2007 read in part .It is the policy of this facility that all changes in resident condition will be communicated to the physician .All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening .The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted .Document resident change of condition and response in nursing progress notes on 24-Hour Report (24 Hour Report Form) and update resident Care Plan, as indicated .All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response .The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabled . On 08/25/16 it was determined that these failures placed CR #1 in an immediately Jeopardy (IJ) situation from 08/20/16 through 08/22/16. The IJ was removed on 08/25/16. The facility implemented the following plan to remove the IJ on 08/25/16: Plan of Removal: 1. The DON and Administrator identified a system problem in the notification of physician's when diabetic residents had elevated blood sugars and presented the problem to the QA committee on 08/22/16 and again on 08/25/16. Parameters were obtained from the Medical Director for abnormal finger stick blood sugars and the Interact Change of Condition Tool was introduced. Policies and procedures were developed concerning the Interact and the notification of physicians for abnormal blood sugars. 2. Audits of the records of all diabetic resident charts were conducted on 08/22/16 where it was determined this was an isolated event. All other residents on SS insulin had parameters for when to notify the physician. 3. In-services for LVN #5 and LVN #16 were conducted on 08/22/16 which included when to notify the physician for residents with abnormal blood sugars. All remaining nursing staff were in-serviced on 08/25/16 on diabetic management including parameters and notification of attending physician and responsible party for values outside of ordered parameters. 4. All nurses were in-serviced on 08/25/16 on the use of the Interact Change of Condition Tool for any change of condition, including sending an alert to the DON for further review and insuring the attending physician and responsible party were notified. 5. The ADON will monitor daily blood sugar values through auditing of documentation. All results will be brought to the DON and Administrator daily for review and any further concerns will be discussed at a QA meeting. Monitoring by surveyor revealed: Interviews on 8/25/16 with nursing staff members from all shifts (6 a.m.-2 p.m., 2 p.m.-10 p.m., and 10 p.m.-6 a.m.) revealed they had all been in-serviced on the new parameters for reporting blood glucose levels to the physician. All staff interviewed verbalized that all blood glucose levels less than 60 or greater than 250 must be reported to the physician. All staff knew how to use the new Interact Change of Condition Tool that had been implemented. Record Review of the In-Service Training Report dated 8/25/16 revealed: Topic: Management of the Diabetic Patient Contents: If no sliding scale ordered: Notification of physician and family for FSBS <60 or >250. If sliding scale ordered: Follow sliding scale instructions for physician notification. Nursing Staff including LVNs and RNs (16) were present at this in-service. Record review of an additional six diabetic residents revealed all had parameters for blood glucose levels of when to notify the physician. All laboratory result records were initialed as the physician being notified. All glucose levels were below the levels of when a physician was to be notified and all were recorded as ordered by the physician and proper amounts of insulin were administered. Interviews with 11 nursing staff over two shifts and calls made to the third shift nursing staff concerning effectiveness with recent training's revealed all staff were very knowledgeable concerning when to call the attending physician and able to recall new parameters for reporting blood glucose levels. All knew how to use the new Interact Change of Condition Tool. Interview on 8/25/16 at 4:00 p.m. the DON stated all staff had been in-serviced on the new Interact Change of Condition Tool and notifying the physician when blood glucose levels were less than 60 and greater than 250. She stated the ADONS would monitor daily blood sugar values through auditing of documentation. All results would be brought to the DON and Administrator daily for review and any further concerns would be discussed at a QA committee meeting. After monitoring the implementation of the plan, it was determined the IJ was removed for CR #1 on 08/22/16 when she went to the hospital, and the facility began implementing activities to correct the deficient practice. While the IJ was removed on 08/22/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plan to ensure residents' physicians were promptly consulted following an elevated blood glucose level. The DON reported there were 28 residents with diabetes in the facility.

Based on observation, interview and record review, the facility failed to provide the necessary care and services, in accordance with the comprehensive assessment and plan of care, to attain the highest practicable mental and physical well-being for one of 22 residents (CR #1) reviewed for quality of care. CR #1's blood glucose levels were elevated for three days (08/20/16, 08/21/16 and 08/22/16) and the physician was not consulted. The facility failed to obtain parameters for reporting CR #1's blood glucose levels to the physician when she was admitted . CR #1 was admitted to the hospital on [DATE] for a scheduled surgical procedure, which was canceled due to a critical blood glucose level, causing CR #1 to be admitted to ICU. An immediate Jeopardy (IJ) was identified on 08/25/16, beginning on 08/20/16 and ending on 08/22/16 when CR #1 went to the hospital. While the IJ was removed on 08/22/16 when CR #1 went to the hospital and the facility began implementing activities to correct the deficient practice. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern, because the facility was continuing to monitor the effectiveness of their plan of removal. This failure to consult with the physician affected one resident who required acute care treatment at a hospital due to untreated elevated blood glucose levels, and placed 28 other residents with diabetes at risk of harm from deterioration of health due to their physician not being consulted. Findings include: Intake # 1 CR#1 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. The resident's admission [DIAGNOSES REDACTED]. Record review of CR #1's MDS assessment dated [DATE], revealed the resident was moderately cognitively impaired. She required extensive assistance for transfer and dressing, limited assistance for mobility, and was completely dependent for hygiene. Record review of CR #1's care plan with Focus read in part Has Diabetes Mellitus and date initiated 8/16/16 read in part: Diabetes medication (insulin) as ordered by doctor. Monitor/document for side effects and effectiveness. Fasting serum glucose as ordered by doctor. The care plan did not include any parameters for reporting blood glucose levels to the physician. Record review of the CR #1's physician's orders [REDACTED]. Further record review revealed additional insulin coverage-Humalog Solution 100 Unit/ml, inject 5 unit subcutaneously with meals for DM. Dosages for Humalog were scheduled for 7:00 a.m., 12:00 p.m., and 5:00 p.m. Record review of the Hospital Record for CR #1 dated 8/22/16 revealed CR #1 was admitted to the hospital on [DATE] for elective replacement or repair of a [MEDICAL TREATMENT] catheter. CR #1 had a glucose level of greater that 800 on arrival (NPO so no insulin) so CR #1 was admitted to ICU for [REDACTED]. Interview on 8/24/16 at 8:50 a.m., the hospital ICU Charge Nurse stated CR #1 had been admitted to the ICU for a critical blood glucose level and was currently receiving an IV insulin drip. This Nurse further stated there were no plans to discharge CR #1 from the hospital at that time. Observation and interview on 8/24/16 at 9:00 a.m. during a visit to the hospital ICU revealed CR #1 resting in bed and receiving an IV insulin drip to regulate her blood glucose levels. CR #1 stated the morning of 8/22/16 she was transferred to the hospital for placement of a [MEDICAL TREATMENT] shunt. She said the nurse at the facility checked her blood glucose and it was high, but she could not recall the number. She further stated she refused to take insulin and was given no insulin prior to being transferred to the hospital. Upon arrival at the hospital a nurse rechecked her blood glucose and it was high. She said that was why she had to have the insulin drip. CR #1 stated her blood sugars were up and down at the facility gave her insulin as she required. Record review of the CR #1's MAR indicated [REDACTED]. There was no documentation on the MAR for 6:00 a.m. on 8/22/16. Further review revealed her blood glucose levels were documented as follows by LVN #5: 8/20/16: 299 mm/dL at 7:00 a.m. 396 mm/dL at 12:00 p.m. 398 mm/dL at 5:00 p.m. 8/21/16: 516 mm/dL at 7:00 a.m. 596mm/dL at 12:00 p.m. 482mm/dL at 5:00 p.m. There was no documentation of blood glucose levels or refusal of insulin on 8/22/16 by LVN #16. Record review of the American Diabetes Association website www.diabetes.org/living-with-diabetes read in part .The American Diabetes Association suggests the following targets for most nonpregnant adults with diabetes. More or less stringent glycemic goals may be appropriate for each individual. Before a meal (preprandial plasma glucose): 80-130 mg/dl. 1-2 hours after beginning of the meal (Postprandial plasma glucose): Less than 180 mg/dl. Record review of Nurse's Progress Notes for CR #1 dated 8/20/16 signed by LVN #5 revealed no mention of the resident's elevated blood glucose levels or notification of her physician. Record review of Nurse's Progress Notes for CR #1 dated 8/21/16 signed by LVN #5 revealed no mention of the resident's elevated blood glucose levels or notification of physician. Numerous calls were made to LVN #5 with messages left on 8/24/16, 8/25/16, 8/26/16, and 8/27/16. No return call was received so an interview could not be done. Record review of Nurse's Progress Notes for CR #1 dated 8/22/16 at 6:14 a.m. signed by LVN #16 read as follows: Insulin [MEDICATION NAME] Solution 100Unit/ml Inject 20 Unit subcutaneously in the morning for DM. Administer before breakfast. BS-256, patient not administered insulin due to procedure and patient not eating breakfast. Record review of Nurse's Progress Notes for CR #1 on 8/22/16 at 9:13 a.m. signed by LVN #16 read as follows: Received a call from hospital where procedure for fistula is to take place. Requesting information on blood sugar, states patient's blood sugar is over 500. I stated blood sugar reading of 256 this morning at 6:14 a.m. Patient had not eaten anything prior to procedure or overnight. Patient worried blood sugar may drop too low if she had coverage, as it had in the past. Hospital stated would like Nurse Practitioner to call her (hospital nurse) and give insulin coverage (medication). NP notified, will follow up. Record review of Nurse's Progress Notes for CR #1 on 8/22/16 at 9:13 a.m. signed by LVN #16 read as follows: 9:30 am: Addendum: follow up-when administering blood sugar check, patient results was 256. Patient stated I am worried I may become hypoglycemic, I had that happen before when I was in the hospital and I had not eaten. I was found on the bed unconscious. Therefore patient refused insulin coverage prior to doctor appointment. NP notified. There was no documentation of when the NP was notified and what was ordered. Interview on 8/25/16 at 10:20 a.m. LVN #16 stated she checked CR #1's blood glucose level at 6:14 a.m., just before the resident was leaving for her procedure at the hospital at 6:15 a.m. CR #1 stated she had not eaten and would not take insulin. LVN #16 further stated she immediately notified the NP of the resident's refusal and transferred CR #1 to the Hospital. LVN #16 said she instructed the resident that [MEDICATION NAME] was a long acting insulin and her blood sugar was high so she needed the insulin, but CR #1 continued to refuse the insulin. Interview on 8/25/16 at 10:50 a.m. the DON stated she had reviewed CR #1's clinical records on 08/22/16 and noted the elevated blood glucose levels on 8/20/16, 8/21/16, and 8/22/16 along with the resident's refusal of insulin dosage on 8/22/16. The DON further stated the elevated blood glucose levels and the refusal of insulin on 8/22/16 before transfer to the hospital were reported to the physician and the Medical Director during an informal QA committee by phone. The DON, Administrator, Medical Director and CR #1's physician were present during this QA committee meeting. A formal QA committee meeting was set up for 8/23/16, but standard survey was started on that date so it was postponed until 8/25/16. She stated the formal QA committee meeting was completed on 8/25/16. The DON further stated she counseled LVN #5 and LVN #16 on 8/22/16 for failure to report CR #1's elevated blood glucose levels. She further stated they audited all resident's charts on 08/22/16 and it was determined that all other Residents on SS insulin had parameters of when to notify the physician so this was an isolated event. All other residents on SS insulin had physicians notified when their blood glucose levels were outside normal parameters. Interview on 8/25/16 at 4:40 p.m., the DON explained there was a problem with communicating with physicians when elevated blood glucose levels had been noted. CR #1 had elevated blood glucose levels on 8/20/16 and 8/21/16 and an elevated blood glucose level with resident refusal of insulin dosage on 8/22/16. This problem was identified the morning of 8/22/16 when the DON received a call from the hospital concerning CR #1's elevated blood glucose level. She further stated an informal QA committee meeting was held by phone with the medical director and Administrator on 08/22/16 and a formal QA committee meeting was scheduled for 8/23/16. She stated the formal QA committee meeting was postponed until 8/25/16 due to standard survey beginning on 8/23/16. She stated at the QA committee meetings held on 8/22/16 and 8/25/16 they addressed the development of parameters for blood glucose levels to be reported to the physician when they were below 60 or above 250 and the Interact Change of Condition Tool was implemented. She further stated on 08/22/16, both nurses (LVN #5 and LVN #16) involved in this incident were immediately in-serviced on reporting blood glucose levels. An audit of all diabetic resident charts was conducted on 08/22/16 and they determined this was an isolated event. All other residents on SS insulin had parameters for when to notify the physician. The DON stated all remaining nursing staff were in-serviced by 08/25/16. Interview on 8/25/16 at 4:40 p.m., the Administrator stated the problem was brought to her attention on 8/22/16 by the DON. The Administrator stated she participated in the QA committee meetings held on 8/22/16 and 8/25/16. She stated a QA committee meeting was originally scheduled for 8/23/16, but standard survey began that day so they postponed the meeting until 8/25/16. During these QA committee meetings, she, the DON, and the Medical Director established new parameters for reporting blood glucose levels along with a Change of Condition Tool. She stated in-services were held with all nursing staff, beginning 8/22/16 and completed on 8/25/16. Policies were also established for new blood glucose parameters to be reported to the physicians and the Change of Condition Tool. Record review of the facility's policy entitled Change of Condition Reporting revised 05/2007 read in part .It is the policy of this facility that all changes in resident condition will be communicated to the physician .All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening .The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted .Document resident change of condition and response in nursing progress notes on 24-Hour Report (24 Hour Report Form) and update resident Care Plan, as indicated .All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response .The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabled . On 08/25/16 it was determined that these failures placed CR #1 in an immediately Jeopardy (IJ) situation from 08/20/16 through 08/22/16. The IJ was removed on 08/25/16. The facility implemented the following plan to remove the IJ on 08/25/16: Plan of Removal: 1. The DON and Administrator identified a system problem in the notification of physician's when diabetic residents had elevated blood sugars and presented the problem to the QA committee on 08/22/16 and again on 08/25/16. Parameters were obtained from the Medical Director for abnormal finger stick blood sugars and the Interact Change of Condition Tool was introduced. Policies and procedures were developed concerning the Interact and the notification of physicians for abnormal blood sugars. 2. Audits of the records of all diabetic resident charts were conducted on 08/22/16 where it was determined this was an isolated event. All other residents on SS insulin had parameters for when to notify the physician. 3. In-services for LVN #5 and LVN #16 were conducted on 08/22/16 which included when to notify the physician for residents with abnormal blood sugars. All remaining nursing staff were in-serviced on 08/25/16 on diabetic management including parameters and notification of attending physician and responsible party for values outside of ordered parameters. 4. All nurses were in-serviced on 08/25/16 on the use of the Interact Change of Condition Tool for any change of condition, including sending an alert to the DON for further review and insuring the attending physician and responsible party were notified. 5. The ADON will monitor daily blood sugar values through auditing of documentation. All results will be brought to the DON and Administrator daily for review and any further concerns will be discussed at a QA meeting. Monitoring by surveyor revealed: Interviews on 8/25/16 with nursing staff members from all shifts (6 a.m.-2 p.m., 2 p.m.-10 p.m., and 10 p.m.-6 a.m.) revealed they had all been in-serviced on the new parameters for reporting blood glucose levels to the physician. All staff interviewed verbalized that all blood glucose levels less than 60 or greater than 250 must be reported to the physician. All staff knew how to use the new Interact Change of Condition Tool that had been implemented. Record Review of the In-Service Training Report dated 8/25/16 revealed: Topic: Management of the Diabetic Patient Contents: If no sliding scale ordered: Notification of physician and family for FSBS <60 or >250. If sliding scale ordered: Follow sliding scale instructions for physician notification. Nursing Staff including LVNs and RNs (16) were present at this in-service. Record review of an additional six diabetic residents revealed all had parameters for blood glucose levels of when to notify the physician. All laboratory result records were initialed as the physician being notified. All glucose levels were below the levels of when a physician was to be notified and all were recorded as ordered by the physician and proper amounts of insulin were administered. Interviews with 11 nursing staff over two shifts and calls made to the third shift nursing staff concerning effectiveness with recent training's revealed all staff were very knowledgeable concerning when to call the attending physician and able to recall new parameters for reporting blood glucose levels. All knew how to use the new Interact Change of Condition Tool. Interview on 8/25/16 at 4:00 p.m. the DON stated all staff had been in-serviced on the new Interact Change of Condition Tool and notifying the physician when blood glucose levels were less than 60 and greater than 250. She stated the ADONS would monitor daily blood sugar values through auditing of documentation. All results would be brought to the DON and Administrator daily for review and any further concerns would be discussed at a QA committee meeting. After monitoring the implementation of the plan, it was determined the IJ was removed for CR #1 on 08/22/16 when she went to the hospital, and the facility began implementing activities to correct the deficient practice. While the IJ was removed on 08/22/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plan to ensure residents' physicians were promptly consulted following an elevated blood glucose level. The DON reported there were 28 residents with diabetes in the facility.

Based on observation, interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 4 residents (Resident #95) reviewed for care provided. Resident # 95 was not routinely assessed for pain; she was not provided alternate measure/consult to ensure effective pain control when she complained of increase pain despite current pain management regimen. This failure affected 1 resident and placed 52 residents on pain management at increased risk of not receiving adequate assessments, medical care and services, hopelessness and fear which could have a negative impact on their health and wellbeing. Findings include: Record review of Resident #95 ' s admission information revealed she was an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 95 ' s care plan conference form dated June 2014 revealed a concern from Resident #95 ' s family member as to why her mother ' s call lights were not answered at night. Record review of Resident #95 ' s MDS dated 7/11/14 revealed the resident ' s Brief Interview of Mental Status (BIMS) was a 15 which indicated she was cognitively intact. The MDS further revealed the resident had frequent pain and on a scale of 0 to 10 with 10 be the most severe pain the resident had rated her pain as a 5. The MDS revealed the resident was on scheduled pain medication. Record review of Resident #95 ' s MAR for August 2014 revealed no scheduled pain medication. Pain medication was the same as stated below. Observation and interview on 9/2/14 at 9:40 A.M., during initial tour revealed the resident in bed. She was alert, awake and oriented to person, time and place. She had both lower extremities amputated. Resident # 95 complained of being in a lot of pain. She complained of her mattress hurting her back and being uncomfortable. Resident # 95 reported she made staff aware of the need for a new mattress but the mattress had not been changed yet. Resident #95 stated " I ' m in a lot of pain, it hurts so bad " . She said her buttocks and lower back were hurting. Resident stated staff did not always answer her call light when she was in pain. She explained her roommate tried to get her help but staff would not come in to help her. She said it was worse at night. Record review of Resident #95 ' s September 2014 ' s MAR indicated [REDACTED] [MEDICATION NAME] tablet 5.325 mg, give one tablet by mouth every 6 hours as needed for pain, use for break through pain. Medication was ordered 8/19/14. Medication was documented as administered daily 9/1 and was administered twice on 9/2/14. [MEDICATION NAME] tablet 5.325 mg, give two tablet by mouth every 4 hours as needed for pain. Medication was ordered 8/19/14. Medication was documented as administered daily on 9/1, 9/2 and 9/3/14. Record review of Resident #95 ' s monthly consolidated physician order [REDACTED]. Record review of Resident #95 ' s care plan dated 9/3/14 revealed the resident was on pain medication therapy (initiated 9/3/14). Goal was the resident would be free of any discomfort or adverse side effects from pain medication through the review date. Approach included; review for pain medication efficacy, assess whether pain intensity acceptable to resident, on treatment regimen or change in regimen required: controlled adequate by the therapeutic regimen, but continue to monitor closely, therapeutic regimen followed but pain control not adequate ...initiated 9/4/14. Record review of Resident #95 ' s controlled drug record for medication [MEDICATION NAME] 5/325 mg revealed mediation was received on 7/30/14 in amount of 120 tablets. Resident requested and received medication almost daily with the average of 4 tablets daily. Amount left on 9/3/14 at 10:00P.M., was 10 tablets. Observation and interview on 9/3/14 at 6:00 P.M., revealed Resident # 95 in bed in her room crying in pain. She said her pain was about 9 in scale of 0-10. Observation and interview on 9/4/14 at 7:58 A.M., revealed Resident # 95 in bed crying. She complained of pain to her buttocks, legs and tightness in her chest. At this same time the charge nurse came into the room and offered [MEDICATION NAME] to the resident that had been ordered for chest pain. Further observation revealed the resident was very anxious and had some agitation. Observation revealed Resident # 95's face was flushed and puffy. She reported she had a horrible night. Interview on 9/4/14 at 7:58 A.M., following the observation revealed the resident said she was in pain all night (9/3/2014) but the night nurse did not come into her room and did not give her pain medication. Resident # 95 was crying and asked " why is she so mean to me. " When asked why she believed the night nurse was mean to her, she stated whenever LVN #1 worked, she would not answer her call light for help. Resident # 95 said last night when she put her call light on, the aides came in to see what she wanted. The aide went and told the nurse that she wanted pain medication because she was in pain and also needed the water in her oxygen concentrator changed because the water was backing up into her nostrils. Resident # 95 said LVN # 1 changed the oxygen concentrator about 5:00 A.M., this morning. She said she stayed up all night in pain. Resident # 96 who was Resident # 95 ' s roommate also reported she tried to yell out to get some help for the roommate but no one answered. Resident # 95 further said it was a common practice here at night. Resident # 95 said she did not want LVN # 1 to work with her again. Record review of Resident #95 ' s nurse notes for 9/3/2014 revealed the resident was medicated on at 4:08 P.M. The medication was documented as being effective at 4:56 P.M. Further review of Resident #95 ' s nurse notes revealed on 9/3/14 at 9:12 P.M., Resident # 95 was given two tablets of [MEDICATION NAME] 5/325 mg by mouth. The order read she could have this medication every 4 hours as needed for pain. Record review for Resident #95 on 9/4/14 at 3:25 A.M., the computer generated post pain medication assessment was answered by LVN # 1. LVN #1 documented the pain medication offered at 9:12 P.M., was effective. Interview on 9/4/14 at 8:40 A.M., the DON said she was not aware of the resident being in pain. She said she was in the facility early this morning had not heard anything concerning Resident #95's pain. She said Resident # 95 should be medicated if she was in pain. The DON said the facility protocol was to assess residents for pain prior to pain medication was administerd and after for the effectiveness of the pain medication. She further said pain assessments were completed quarterly and annually and on admission but the assessments were not completed routinely or every shift. The DON agreed residents on pain management should be assessed at frequent intervals to ensure effective pain management and control. The DON said she was not aware of any other alternative measure for Resident #95 ' s pain management besides the medication. Interview on 9/4/14 at 9:00 A.M., LVN # 1 said Resident # 95 did not complain of pain through the night (9/3/2014) . She said the resident was alert and oriented and able to make her needs known. She said Resident #95 would call 911 when in pain sometimes. LVN # 1 said she went into her room to change her oxygen concentrator when the resident reported it was backing up water into her nostrils. LVN # 1 said the resident also complained of not being able to hear with her right ear but did not complain of pain. LVN # 1 said she did not assess the resident for pain throughout her shift because Resident #95 was able to make her pain known. LVN # 1 explained her documentation of the pain assessment on the nurse ' s notes was computer generated. She stated she only selected the pain medication was effective because she was not aware of any pain complaint from Resident #95. Record review of Resident # 95 ' s record did not reveal any referral or consult order for a pain management specialist. Record review of the resident ' s records did not reveal alternative pain management measures (diversion activities, relaxation therapy, massage therapy, etc) had been attempted on Resident # 95. Interview on 9/4/14 at 2:15 P.M., the Administrator said the facility was addressing the resident ' s pain and staff were working with the resident ' s doctor who said the resident was not on scheduled pain medication because it lowered her blood pressure. The Administrator said the resident had not been refered to a pain specialist yet. The Administrator said more documentation would be submitted for review. Record review of facility additional documentation from Resident # 95 ' s physician dated 9/8/14 received after exit revealed " Resident #95 was not on regular scheduled pain medication and instead uses her pain medications on as needed basis. This is because: she is allergic to [MEDICATION NAME], experiences hypertension specially after [MEDICAL TREATMENT] if she gets a dose of anything stronger than 5/325 mg. Her pain is difficult to assess. Her gastroparaesis and nausea are worsened by pain medication, her mental status and blood pressure are adversely affected by [MEDICATION NAME] and she is hospice eligible but declines hospice. The physician's note further read: because of her [MEDICAL TREATMENT] and waxing and waning nature of her hydration status, regularly scheduled narcotics would be very difficult to manage and are generally avoided. Also , it is difficult to assess her complaint of pain: she has moderate dementia and all of her pain seems to be 9 out of 10 or 10 out of 10. Because of severity and complexity of her medical problems, it is very difficult to figure out which pain she is having. On the other hand, Resident ( #95) has intermittent pains from her gout, [MEDICAL CONDITION], phantom limb pain and arthritis, this why we chose as needed regimen for her pain. " Record review of facility ' s policy on pain management dated December 2005 revealed " all facility staff has a commitment to provide patients with a quick response to reports of pain and will encourage patients to participate in their pain management. The patients pain status is monitored for improvement by obtaining parameters for pain management, using the pain scale, reassessing ineffective pain management, considering a pain specialist consultation. Documentation of pain competed using the nurses ' progress notes " . The Facility's CMS 672 form dated 9/2/14 listed 53 residents were on pain management.

Based on observation, interview and record review the facility failed to ensure 1 of 7 residents ( Resident #57) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Resident #57 ' s pain was not effectively controlled when the resident was discharged from Hospice services. There was an eight day delay in the facility receiving the pain medication the resident had routinely been receiving. This failure affected 1 resident whose pain was uncontrolled for eight days,and placed 53 residents on pain management at risk of not receiving adequate assessments, medical care and services, which could have a negative impact on their health and wellbeing. Findings include: Resident # 57 Record review of Resident # 57 ' s face sheet revealed a [AGE] year old female with an admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #57's phsyician's orders revealed the resident was admitted to Hospice services on 11/06/2012. Record review of Resident # 57 ' s care plan dated 5/10/13 revealed the resident had acute/chronic pain related to Arthritis. Goal was the resident would verbalize adequate relief of pain or the ability to cope with incompletely relieved pain. Approaches listed included: nursing would anticipate the resident ' s needs for pain relief and respond immediately to any complaint of pain , and re-evaluate effectiveness. Nursing staff would monitor and record pain characteristic, location, onset, frequency and severity etc. Record review of Resident # 57 ' s MDS dated [DATE] revealed the resident was moderately impaired for cognition, had limitations on both sides of her upper and lower extremities, received scheduled pain medications, and as needed pain medication. Record review of Resident # 57 ' s record revealed she was discharged from Hospice on 9/7/13 due to end of coverage. Observation on 9/16/13 at 10:12 A.M., revealed Resident #57 in bed. She was able to make her needs known. The Resident had contractures on both sides of her upper and lower extremities. The resident was very hard of hearing. Interviewer had to shout into her "good" ear. The resident stated she had limited vision. The resident verbalized " I am in so much pain and would rather die than feel this way " . She explained she was so unhappy because she was discharged from Hospice and the staff at the facility could not get her pain medication orders from the facility physician. She stated the physician for Hospice had used [MEDICATION NAME] to help control her pain. She stated she had been without her pain medication for some days now. The resident said she was given some pain medications by the weekend staff but it did not help because she had been without the [MEDICATION NAME] for such a long time. She said she would like to have some of her regular pain medication. Further interview on 9/17/13 at 1:00 P.M., Resident # 57 said she would not get out of bed because she was in so much pain. She stated she did not want to worsen her pain by getting up. Record review of Resident # 57 ' s MAR indicated [REDACTED] * [MEDICATION NAME] tablet 10/325 mg., give two tablets by mouth every 4 hours as needed for pain. "Give until [MEDICATION NAME] is available." Start date 9/11/13 and discontinued date was 9 /13/13. None was documented as being given. * Tylenol suppository 650 mg rectal every 6 hours for pain/fever. Start date was 11/06/12. None were documented as being administered. * [MEDICATION NAME] 10 mg. by mouth every 8 hours, start date was 12/28/12. Further record review of Resident #57 ' s MAR indicated [REDACTED]. Start date 9/13/13. [MEDICATION NAME] tablet 325 mg. take two tablets every 6 hours as needed for pain related to Arthritis. Start date was 6/26/13. Medication was documented as being administered on 09/16/13 only. Record review of Resident #57 ' s Nurses MAR indicated [REDACTED]=No pain 1-2=Mild pain 3-4=Moderate pain 5-6=Severe 7-8=Very severe and 9-10=Worst. Continued review revealed there was a mark in the space for each day where staff had assessed the pain but there was no documented number identifying the severity level of the resident ' s pain. Record review of Resident #57 ' s nurses notes revealed staff had attempted to reach the physician from 9/7/13 to 9/14/13 when the [MEDICATION NAME] became available in the facility. Interview on 9/18/13 at 1:21 P.M., LVN # 19 said she made a several attempts to contact Resident # 57 ' s physician. She said she called the office several times with no return calls. She said she documented in the progress notes for on-coming staff to follow up. She said the resident was in a lot of pain and was also having withdrawal symptoms. Interview on 9/18/13 at 3: 21 P.M., ADON # 2 said the resident was discharged from Hospice on 9/07/2013, and there was a delay in getting her facility physician to send in the required Triplicate form for the [MEDICATION NAME]. She explained it took some time and when the physician wrote the order, he had the wrong date which resulted in a rejection of the triplicate by the pharmacy. She said staff had to wait on the physician to sign another form. The whole process took some time and the [MEDICATION NAME] did not get delivered to the facility until 9/14/2013. ADON # 2 explained the resident was provided another type of pain medication, [MEDICATION NAME], which she did not want because according to her, it did not work for her and she had been on [MEDICATION NAME] for a long time. She explained the medications were available over the weekend and was offered to Resident # 57. ADON #2 said she could not explained why it took the physician such a long time to send the order. Staff were instructed to contact the facility ' s medical director when this occurs. Record review of the facility policy on pain management dated December 2005 revealed " ...all facility staff have a commitment to provide patients with a quick response to reports of pain and will encourage patient to participate in their pain management. A. The patient ' s pain status is monitored for improvement by: obtaining parameter for pain management, using the pain scale, reassessing ineffective pain management, considering a pain specialist consultation. B. Documentation of pain is completed using the nurse ' s progress notes. C. File all documentation if the patient ' s clinical record " . Facility CMS form 672 dated 9/19/13 listed 54 Residents on pain management.

Based on observation, interview and record review the facility failed to ensure that 1 of 8 sampled residents (#1) was free from neglect when the facility did not intervene and prevent a contractor from transporting the resident in a wheelchair, which resulted in the resident receiving serious injuries. This failure affected Resident # 1 by causing pain, a fractured neck, nose, and finger, a dislocated shoulder and sutures to the head. The failure placed 81 residents at risk of injuries by the facility allowing contractors to transport residents. Findings include: Intake # 1 Record review of the Admission Face Sheet revealed Resident # 1 was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Interview during tour on 5/24/11 at 10:50 a.m. LVN # 1 stated Resident # 1 recently fell out of her wheelchair and broke her neck, nose and finger and dislocated her left shoulder. She stated the mitt was placed on her hand to prevent her from taking the neck collar off. Observation on 5/24/11 at 10:55 a.m. of Resident # 1 revealed she was in bed covered, with the head of the bed slightly elevated. A neck brace was in place and a sling was on her left arm. She yelled out several times with no response from staff and grimaced when spoken to. She had a mitt on her left hand. Interview at this same date and time Resident # 1 stated she was in pain and repeated " pain " several times. She moaned and closed her eyes. Record review of the Initial Care Plan dated 4/21/11 revealed Resident # 1 was at risk for falls, pain, pressure ulcers, dehydration, required assistance toileting, and required ADL and ambulation assistance by one staff member. Review of the Care Plan dated 5/5/11 revealed Resident # 1 required assistance of one staff member with transfer and locomotion by wheelchair, to perform bathing, eating, dressing, oral care, turning, repositioning, and incontinent care. Review of the CNA Kardex for Resident # 1 revealed she required staff to assist her with meals, was in a wheelchair and required staff to push her. It revealed the resident was at risk for falls and had a bed alarm, Review of Nurse ' s Progress notes dated 5/10/11 at 1:30 p.m. revealed the resident fell from the wheelchair while being transported to the beauty parlor. The resident was kept in stable position until EMT arrived and a neck brace was applied. Resident was transferred to the hospital. Review of an undated handwritten statement, written and signed by the Beautician and attached to the Nurse ' s Progress note dated 5/10/11, revealed the following: " I (Beautician) was taking (Resident # 1) to the Beauty Shop to cut her hair, when I was taking her, all of the sudden she feld(sic) to the floor in the Hall of the entrance to the 300 section. This happen(sic) Tuesday " . Review of Nurse ' s Progress notes dated 5/15/11 revealed Resident #1 was readmitted to the facility from the hospital on [DATE]. Patient had [DIAGNOSES REDACTED]. Patient had multiple bruises to her face, arms, shoulder and around both eyes. Patient was to wear a Miami-J C-collar at all times. The note revealed the resident was totally dependent on one person to assist with ADL ' s, eating and toileting and on two persons to assist with transfers. In an interview on 5/24/11 at 4:00 p.m. LVN # 2 stated on 5/10/11 she was standing near the nurse ' s station with her back facing Hall 300. She said she heard a " loud thump " and turned and saw Resident # 1 on the floor face down by the hydration cart. She said the Beautician was standing over her. She said the resident was bleeding profusely from her nose and was on her left side. She said the resident did not self-propel her chair and required assistance from 1 staff member with transportation. LVN # 2 stated only staff was to provide transportation assistance for a resident in a wheelchair. She said staff had been instructed in orientation and other trainings that when a resident must be pushed in a wheelchair, staff must use the leg rests to prevent the resident ' s feet from getting underneath the chair and there being an accident like the one that had occurred. She stated in orientation, staff were told outside caregivers, private sitters, family members and volunteers were not to provide any ADL care to the residents, including transporting them in their wheelchairs. LVN # 2 stated she had previously observed the Beautician transporting residents in their wheelchairs and had intervened. She had told the Beautician that staff were the only ones that were to push the resident's in their wheelchairs. She said knew of other staff that had also told her. LVN # 2 said after the incident the nurses were discussing what happened and she was told the resident ' s son had spoken with the Beautician that same day before the incident occurred. The son had told the Beautician to be careful with his mom and not to push her so fast. She did not know if the facility reported the incident to the state office. Record Review of the facility Beauty Shop Contract - 2010 dated 7/19/10 revealed " the Provider shall be an independent contractor and not a facility employee " . It further read, " The parties agree that Provider is to provide only Cosmetology services under the terms and conditions of the agreements ." In an interview on 5/24/11 at 5:35 p.m. LVN # 3 stated when a resident was unable to self-propel the wheelchair leg rests should be used for safety precautions. She said the DON just recently emphasized this with them again in an in-service. She said only staff should assist residents. In an interview on 5/24/11 at 5:37 p.m. RN # 1 stated when a resident was unable to self-propel the wheelchair leg rests should be used for safety precautions. She said only staff should assist residents. In an interview on 5/24/11 at 4:30 p.m. LVN # 5 stated when she came out of the MDS room she saw LVN # 2 standing at the end of the hall over the resident. LVN # 5 said that the resident ' s son told her he had spoken with the Beautician twice and asked her not to be in such a rush, to be careful with his mom, and not to push her so fast. He said he had previously seen facility staff transporting his mom without her leg rests and had spoken with nursing staff. In an interview on 5/24/11 at 4:50 p.m. the DON stated Resident # 1 was to have leg rests on the wheelchair when being transported and if she did not the act would be classified as negligent and should be reported to the state. She stated she was unable to find it documented that the resident required leg rests in the care plan or kardex. In an interview on 5/24/11 at 5:20 p.m. the DON stated that leg rests should be used for residents who do not self-propel and stated she had given the staff an in-service on this information after the incident with Resident # 1. She said only staff should assist residents. Requests were made several times to the DON on 5/24/11 for the incident/accident report and the In-House investigation of the incident but the DON failed to present these prior to exit. Review of the facility ' s Admission Packet revealed the following Resident Rights: ? The facility must implement procedures that protect you from abuse, neglect or mistreatment, and misappropriation of your property. ? In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. ? All alleged violations must be thoroughly investigated and the results reported. Review of the facility ' s Appendix A (Abuse) not dated in the section marked Prevention revealed the facility was " ...responsible for ensuring that situations in which abuse, neglect and/or misappropriation of resident property are most likely to occur are identified, corrected and that proper interventions are initiated to preclude occurrence or recurrence ... " Facility roster revealed census of 82.