Every finding on record at Medina Valley Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 4 of 6 residents (Resident #3, Resident #4, Resident #41, and Resident #42) who were reviewed for resident assessments. 1. The facility failed to document Resident #4's use of anticonvulsant medication on the quarterly MDS assessment. 2. The facility failed to document Resident #41's use of diuretic medication on the annual MDS assessment.3. The facility failed to document Resident #3's admission to hospice services on the Significant Change Assessment.4. The facility failed to document Resident #42's hospice services on her last quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review Resident #4's admission sheet dated 9/08/2024 with an original date of 3/14/2017 documented an [AGE] year-old female resident with diagnoses including dementia, diabetes mellitus, anxiety, insomnia, cerebral infarction (stroke), hyperlipidemia (high cholesterol), hypertension (high blood pressure) and heart disease. Record review of Resident #4's MDS assessment dated [DATE] documented in section reflected she was rarely/never understood. The assessment recorded the use of antidepressant, anticoagulant, diuretic, and hypoglycemic medications but did not record the use of anticonvulsant medications. Record review of Resident #4's order summary documented an order for the anticonvulsant medication Depakote with an order date of 10/23/2025. Depakote was ordered as Depakote 500 mg, Give 1 tablet by mouth two times a day. Record review of Resident #4's February 2026 MAR documented the resident had been receiving Depakote as prescribed during the 7 day look back period of 02/01/2026 through 02/07/2026. Record review of Resident #4's care plan with an initiation date of 10/24/2025 documented the resident uses an anticonvulsant medication for mood stabilization., with interventions including Administer medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. 2. Record review of Resident #41's admission sheet dated 01/20/2026 with an original date of 3/21/2024 documented an [AGE] year-old male resident with diagnoses including dementia, seizures, hyperlipidemia, hypertension, heart disease, diabetes mellitus, and cerebral infarction. Record review of Resident #41's MDS assessment dated [DATE] documented a BIMS score of 10 indicating moderate cognitive impairment and recorded the use of antibiotic, antiplatelet, and anticonvulsant medication. Further review of the MDS revealed the assessment did not record the use of diuretic medication. Record review of Resident #41's order summary documented an order for the diuretic medication Furosemide. Furosemide was ordered as Furosemide 40 mg, Give 1 tablet by mouth one time a day. Record review of Resident #41's January 2026 MAR documented the resident had been receiving Furosemide as prescribed during during the look back period of 01/18/2026 through 01/24/2026. Record review of Resident #41's care plan with an initiation date of 4/11/2024 documented The resident is on diuretic therapy., with interventions including Administer DIURETIC medications as ordered by physician., and Monitor/document/report PRN adverse reactions to DIURETIC therapy: dizziness, postural hypotension, fatigue, and an increased risk for falls. During an interview with the MDS Coordinator on 02/26/2026 at 1:26 PM, the MDS Coordinator stated it was important for the MDS to be as accurate as possible, because the assessment was a reflection of what nursing staff was doing for a resident and what nursing services and other services a resident was receiving during that time period. During an interview with the DON on 02/26/2026 at 2:08 PM, the DON stated it was important for the MDS to be accurate to have an accurate picture of what was going on with a resident and for reimbursement purposes. The DON further stated her expectation for staff was to go over the MAR and determine what was going on and to code appropriately. During an interview with the Administrator on 02/27/2026 at 3:12 PM, the Administrator stated it was important for the MDS to be accurate, because the assessment needed to reflect what is going on with a resident. The Administrator further stated her expectation for staff was they needed to gather all information accurately from a resident's chart before submission. 3. Record review of Resident #3's admission Record dated 02/26/26 documented an [AGE] year-old female originally admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #3's diagnoses included heart failure, unspecified; acute respiratory failure with hypoxia (inadequate oxygenation of the blood), pressure ulcer of unspecified site (injury to skin and underlying tissue caused by prolonged pressure), peripheral vascular disease (a slow, progressive circulation disorder caused by narrowed, blocked, or spasming blood vessels), and dysphagia (a language disorder caused by brain damage - most commonly from a stroke, tumor, or injury – that impairs the ability to produce, understand, read or write language). Record review of Resident #3's Significant Change MDS dated [DATE] indicated that Hospice care was not received. Resident #3's BIMS score was 8 which indicated severe cognitive impairment. Record review of Resident #3's Care Plan with a revision date of 01/30/26 revealed a focus of The resident has a terminal prognosis related to nonrheumatic aortic valve stenosis (narrowing of the aortic valve due to age related calcium buildup that restricts blood flow). One of the interventions included resident choosing hospice provider. Record review of a document titled Facility Notification of Hospice Admission informed the facility that as of 1/30/26, Resident #3 was being admitted to [Contract Name] Hospice. During an interview on 02/27/26 at 10:00 am, the MDS Coordinator stated that hospice should have been checked on Resident #3's MDS assessment dated [DATE] since that was the reason for the Significant Change Assessment. 4. Record review of the admission Record, dated 2/26/26, reflected Resident #42 was a [AGE] year-old female admitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition in which plaque builds up in the coronary arteries that supply blood to the heart muscle, causing narrowing of the arteries without current chest pain symptoms), neuromuscular dysfunction of bladder (a disorder in which nerve damage or neurological impairment affects the bladder's ability to store or empty urine normally), and anxiety disorder (a mental health condition characterized by excessive worry, nervousness, or fear that can interfere with daily functioning). Record review of Resident #42's quarterly MDS assessment, dated 11/6/25, showed Resident #42's memory was intact for daily decision making. It did not show the resident received hospice services while a resident. Record review of Resident #42's MDS assessment list, dated 2/26/26, revealed the last MDS was completed on 11/6/25 and stated the next quarterly ARD was due 2/6/26, complete by: 2/20/26, and was 6 days overdue. Record review of Resident #42's order summary, dated 2/26/26, revealed an order to admit to hospice on 4/24/25 for diagnosis of combined systolic heart failure. The order start date was 5/29/25 with no end date. During an interview on 2/27/26 at 11:53 a.m. the MDS Coordinator stated she could not say why Resident #42's quarterly MDS was done yet completed. She stated she tried to run a tracker to see whose MDS needs to be completed but it does not always find everyone who is due. The MDS Coordinator stated the MDS was overlooked. The MDS Coordinator stated the assessment assesses the resident's care over the last 90 days to make sure staff has access to information on residents' care needs. The MDS Coordinator stated Resident #42 was admitted on hospice, so it should have been on the admission assessment. The MDS Coordinator stated this was important to include on the MDS because it tells the state she receives hospice services and to ensure they are in the appropriate environment for the care they need. Record review of the facility policy titled Conducting an Accurate Resident Assessment with a copyright date of 2025 noted The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas., and Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 16 residents (Resident #21 and Resident #91) reviewed for infection control: 1. The facility failed to ensure CNA D and CNA E wore a PPE gown during incontinent care for Resident #21 who was on EBP. 2. The facility failed to ensure CNA D did not touch a clean brief with dirty gloves during incontinent care for Resident #21. 3. The facility failed to ensure LVN F cleaned the rubber hub of an insulin pen prior to placing a needle cap on the pen and administering it to Resident #91. 4. The facility failed to ensure LVN F sanitized her hands between glove changes while preparing and administering insulin to Resident #91. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1 & 2. Record review of Resident #21's admission record, dated 2/27/26, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included sepsis due to methicillin susceptible Staphylococcus aureus (a life-threatening systemic infection caused by bacteria entering the bloodstream, specifically a strain of Staphylococcus aureus that can be treated with methicillin-class antibiotics), neuromuscular dysfunction of bladder (a condition in which nerve damage or neurological impairment affects the bladder's ability to store or empty urine normally), and pressure ulcer of sacral region unspecified stage (a pressure injury located over the sacrum, the triangular bone at the base of the spine between the hips, caused by prolonged pressure that restricts blood flow to the skin and underlying tissue). Record review of Resident #21's admission MDS assessment dated [DATE] revealed the resident's cognition was severely impaired for daily decision making. Resident #21 was dependent on staff to roll from left to right and for personal hygiene. Record review of Resident #21's care plan, initiated 2/25/26, revised 2/25/26, revealed the resident was on enhanced barrier precautions related to wound and indwelling foley catheter. Interventions included Proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room. Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs. Staff to DON and DOFF PPE according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room. During an observation on 2/27/26 at 10:35 a.m., CNA D and CNA E provided incontinent care to Resident #21. CNA E cleansed the residents peri area and buttocks area. Resident #21 had a stool and CNA E cleaned it off the resident. With the same gloves she had on to clean the residents stool CNA E grabbed a clean brief and placed it on the resident. CNA E stated she already messed up as she grabbed the clean brief and placed it on the resident. CNA E did not change her gloves between cleaning the resident's stool and touching the clean brief. During the incontinent care and catheter care CNA D and CNA E wore gloves only. CNA D and CNA E did not wear a PPE gown. During an interview on 2/27/26 at 10:45 a.m., CNA D and CNA E were asked if they forgot anything. This surveyor pointed to a sign hanging above the head of the bed on the resident's wall stating she was on EBP, gown and gloves were required for high contact care. CNA D and CNA E stated they were missing gowns and needed them because she had wounds and a catheter. CNA E stated she made a mistake, and used her dirty gloves to put the clean brief on Resident #21. CNA D and CNA E stated they needed gowns to prevent infection. CNA E stated she needed to change her gloves to prevent infection. 3&4. Record review of Resident #91's admission record, dated 2/27/26, revealed an [AGE] year-old female resident, admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus. Record review of Resident #91's admission MDS assessment, dated 12/23/25, revealed her BIMS score was a 12 (moderately impaired cognition for daily decision making). She received insulin. Record review of Resident #91's care plan, initiated 12/19/25, revealed she had diabetes mellitus, and to administer medications as ordered. Record review of Resident #91's physician order summary, dated 2/27/26, revealed an order for insulin lispro, inject per sliding scale with a start date of 12/17/25, and no end date. During an observation on 2/26/26 at 11:23 a.m., LVN F checked Resident #91's blood glucose. LVN F returned to the nursing cart to draw up the insulin. LVN F removed the gloves she wore for the blood glucose check. LVN F then put on another pair of gloves and did not sanitize her hands between the glove change. LVN F then placed a needle cap on the end of the insulin pen and did not clean the rubber stopper before. LVN F then primed the insulin pen and administered it to Resident #91 in her lower abdomen area. During an interview on 2/26/26 at 11:30 a.m., LVN F stated she should have cleaned the insulin pens rubber stopper prior to placing the needle on it because she did not know if something touched it before. LVN F stated she should sanitize her hands between glove changes because you could get stuff on your hands. During an interview on 2/27/26 at 10:51 a.m., the DON stated staff were required to wear a PPE gown while providing incontinent or catheter care to Resident #21 because she had open wounds that needed to be protected. The DON stated staff were also expected to sanitize the rubber stopper of the insulin pen because it needed to be cleaned to prevent infection. The DON stated staff was expected to sanitize or wash their hands between gloves changes or clean hands. Record review of the facility's policy titled Enhanced Barrier Precautions, dated 2024 revealed the policy states, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy further states staff are to make gowns and gloves available for staff use and that PPE is required when performing high-contact resident care activities. The policy identifies high-contact resident care activities to include dressing, bathing, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use . urinary catheters, and wound care . requiring a dressing. The policy further states enhanced barrier precautions should be implemented for residents with a wound or indwelling medical device. Record review of the facility's policy titled Hand Hygiene, dated 2023, revealed the policy states, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy further states staff are to perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene . perform hand hygiene prior to donning gloves, and immediately after removing gloves. The policy further indicates hand hygiene should occur between resident contacts,.after handling contaminated objects,.before preparing or handling medications,.before and after applying and removing personal protective equipment (PPE), including gloves. Record review of the facility's policy titled Perineal Care, dated 2022, revealed the policy states, It is the practice of this facility to provide perineal care to all incontinent residents . to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. The policy further states staff are to perform hand hygiene and put on gloves . apply other personal protective equipment as appropriate. The policy additionally states staff are to cleanse buttocks and anus, front to back . using a separate washcloth or wipes, and to change gloves if soiled and continue with perineal care. The policy further states staff are to remove gloves and discard. Perform hand hygiene.

Based on observation, interview, and record review the facility failed to ensure a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 of 4 resident (Residents #21) reviewed for quality of care. The facility failed to ensure on 2/25/26 LVN A cleansed Resident #21's entire wound bed, did not use wound vac canister tubing that was touching the floor, and sanitized the entire surface area of scissors used to cut wound supplies. These failures could result in the residents with pressure ulcers worsening in size and staging.The findings included: Record review of Resident #21's admission record, dated 2/27/26, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included sepsis due to methicillin susceptible Staphylococcus aureus (a life-threatening systemic infection caused by bacteria entering the bloodstream, specifically a strain of Staphylococcus aureus that can be treated with methicillin-class antibiotics), neuromuscular dysfunction of bladder (a condition in which nerve damage or neurological impairment affects the bladder's ability to store or empty urine normally), and pressure ulcer of sacral region unspecified stage (a pressure injury located over the sacrum, the triangular bone at the base of the spine between the hips, caused by prolonged pressure that restricts blood flow to the skin and underlying tissue). Record review of Resident #21's admission MDS assessment dated [DATE] revealed the resident's cognition was severely impaired for daily decision making. Resident #21 was dependent on staff to roll from left to right and for personal hygiene. The resident had pressure wounds including three stage 3 pressure ulcers (a full-thickness loss of skin in which adipose/fat tissue is visible in the wound bed and granulation tissue and epibole may be present; fascia, muscle, tendon, ligament, cartilage, and bone are not exposed) and one stage 4 pressure ulcer (a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone). Record review of Resident #21's care plan, initiated 2/11/26, revised 2/25/26, revealed a care area for the resident has multiple pressure injuries, allow resident rest periods in between wound dressing changes, resident used wound vac for sacral wound.interventions were to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, and report improvements and declines to the MD. Record review of Resident #21's physician order summary dated 2/25/26 revealed orders for:-Wound Care Location: Sacrum Impairment: Pressure stage 4 every day shift every Mon, Wed, Fri for wound healing. Clean and dry affected area. Apply green foam NPWT dressing (Negative Pressure Wound Therapy, a wound treatment system that applies controlled suction through a sealed dressing connected to a vacuum device to remove drainage, reduce edema, promote blood flow, and support wound healing) to wound bed at -125 mmHg continuous suction (a controlled negative pressure measurement in millimeters of mercury created by a vacuum pump that continuously draws fluid and infectious material from the wound to promote tissue healing). Record review of Resident #21's skin assessment dated [DATE] revealed one wound was a sacrum stage 4 pressure ulcer (a severe pressure injury located over the sacrum, the lower portion of the spine above the buttocks, involving full-thickness skin and tissue loss with exposure of deeper structures such as muscle, tendon, or bone) and measured 10.5 cm x 20 cm x 1 cm. The wound had serosanguineous drainage (a mixture of serous fluid and blood, typically pale red and watery) and the primary dressing was negative pressure wound therapy. Observation on 2/25/26 at 2:56 p.m. revealed LVN A performing wound care to Resident #21's sacral pressure ulcer. At approximately 3:03 PM, LVN A sanitized the tray table, obtained supplies from the treatment cart, and placed wound care supplies on the tray table. LVN A removed the existing foam dressing and tubing from the wound vacuum and discarded the items in the trash. LVN A cleansed portions of the wound bed. However, areas of the wound bed were not cleansed before the new dressing was applied. LVN A then removed tubing from a bag and replaced the canister on the wound vacuum unit. During the process, the tubing dropped and contacted the floor and remained on the floor while LVN A continued performing wound care. LVN A used scissors to cut wound care supplies and wiped the exterior surfaces of the scissors with a disinfectant wipe but, did not open the scissors to clean the inner blades or cutting surfaces. LVN A then placed foam dressing into the wound bed and covered the wound with adhesive dressing. After completion of the dressing application, LVN A picked up the tubing that had been resting on the floor and connected the tubing to the tubing attached to the resident's wound vacuum device. During an interview on 2/25/26 at 3:30 p.m., LVN A stated she typically cleaned the scissors at the beginning of the treatment, after cutting sponges, and before cutting additional supplies. LVN A stated the scissors should be opened because the blades also need to be cleaned and the scissors used were angled. LVN A stated the physician instructs staff to cleanse the wound from the top portion of the wound bed downward and stated she was cleaning the whole wound bed. LVN A stated she did not know the wound vacuum tubing had been on the floor and reported she was unaware it had touched the floor. LVN A stated that if the tubing had been on the floor, it would be contaminated and although that portion of the tubing does not directly connect to the wound it would still be considered dirty. During an interview on 2/26/26 at 4:09 p.m., the Director of Nursing (DON) stated staff were expected to cleanse the entire wound bed when performing wound care. The DON stated staff were expected to clean scissors used for wound care either before and after the procedure and should clean the entire pair of scissors, including the blades. The DON stated the wound vacuum system was a closed system, and she described it as dirty to dirty,. She reported that the tubing touching the floor would not present a risk to the resident because the tubing did not directly connect to the wound. Record review of the facility's policy titled Negative Pressure Wound Therapy,, dated 2025, revealed the policy states, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy further defined negative pressure wound therapy stating, Negative pressure wound therapy is an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or 'peel and stick,' and includes an evacuation tube and a computerized pump that applies the negative pressure .Negative pressure wound therapy will be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing change. Clean technique shall be utilized unless otherwise specified by the physician. The policy additionally stated staff are to Cleanse wound according to physician order .Select foam type or gauze appropriate to the size and characteristics of the wound, and place gently into the wound .Fill the entire wound base and sides, tunnels, and undermined areas. The policy further stated staff are to Apply the tubing to the dressing, Connect tubing assembly to the canister tubing. Make sure canister is fully engaged into the pump .Initiate NPWT at the prescribed settings in accordance with pump/product specifications.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility reviewed for nurse services. The facility failed to have RN coverage for 2 days on 9/01/2025 and 12/26/2025. This failure could place residents at risk of not having staff with advanced care skills available to meet their needs.The findings included: Review of the facility's RN timecards from 8/1/2025 through 2/24/2026, revealed there were no RN hours for Monday 9/1/2025 and Friday 12/26/2025 Review of the facility's census dated 9/01/2025 documented a population of 90 residents. Review of the facility census dated 12/26/2025 documented a population of 90 residents. During an interview with the DON on 02/26/26 at 2:08 PM, the DON stated it was important to have sufficient RN staff at the facility to monitor the LVNs and to be present if there was an issue in the building. During an interview with the Administrator on 02/27/2026 at 3:12 PM, the Administrator stated it was important for there to be sufficient RN staff in the facility to give oversight and to provide direction in the event something should happen. The Administrator stated her expectation was that there be an RN in the facility for 8 consecutive hours a day, 7 days a week. Record review of the facility's policy titled Nursing Services and Sufficient Staff with a copyright date of 2025 noted It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. and Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Residents #71) reviewed for administration. The facility failed to document an incident Resident #71 had with Resident #83 in her electronic medical record. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.Record review of Resident #71's admission record, dated 2/25/26, revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, major depressive disorder, and generalized anxiety disorder. Record review of Resident #71's Quarterly MDS assessment, dated 12/31/25, revealed the resident's BIMS score was 13 (intact cognition). Record review of Resident #71's comprehensive care plan, initiated 10/06/25 and revised 12/16/25, revealed the resident was resistant to care, requesting all medications at once versus taking them throughout the day and then refusing to take them, refusing to take medications at times, refusing to allow a urine analysis to be attained at times, and refusing showers and nail care. Interventions included to allow the resident to make decisions about treatment regime, to provide sense of control, educate and encourage the resident to be compliant with scheduled medications, give clear explanation of all care activities prior to and as they occur during each contact, and provide consistency and care to promote comfort with ADL's, and maintain consistency and timing of ADL, caregivers and routines, as much as possible. Record review of Resident #71's nursing progress notes, revealed no notes about any incidents occurring between 2/21/26-2/22/26. Record review of Resident #71's behavioral health note, dated 2/23/26, revealed a note from the Nurse Practitioner that stated .The patient let me know that she had a blow up this weekend. The patient stated, I'm sure they called you about it. I stated that staff had reported nothing about the patient having a disgruntled episode. This seemed to surprise the patient. The patient described the situation and stated that she called a staff member a racial epithet for African Americans starting with the letter N. I advised the patient that it is very derogatory and harmful as well as toxic to demean her staff members. The patient expressed understanding. The patient stated that she couldn't help it because she was so angry. Record review of Resident #83's progress note labeled Late Entry, dated 02/23/2026 at 10:50 a. m., revealed the resident had a verbal outburst in a public area, and that staff had redirected the resident. The note further documented the nurse practitioner had been notified and medication orders were discussed with the resident's responsible party During an interview on 2/24/26 at 10:08 a.m., Resident #71 said sometime between 2/21/26-2/22/26 Resident #83 hit her with her walker while the two residents were arguing about another male resident. Resident #71 reported RN B intervened, separated the residents, and took her away from the area. Resident #71 stated she did not sustain any bruises or injuries, but she did not like that Resident #83 hit her with the walker. Resident #71 further stated she did not like RN B because RN B called her a liar after she reported that Resident #83 hit her with the walker. During an interview on 2/26/26 at 4:22 p.m., RN B stated he worked Saturday and Sunday at the facility, which were the days he normally works. RN B stated there was an incident involving Resident #71 and Resident #83 and that he was not present for the initial altercation. RN B stated when he arrived, both residents were arguing, and another staff member, LVN C, was attempting to intervene. RN B stated he separated the residents and took Resident #71 to the hallway where she resides. RN B stated Resident #71 was upset and reported she felt Resident #83 had provoked her. RN B stated Resident # 71 never reported to him that Resident #83 hit her. RN B stated while attempting to separate the residents, Resident #71 scratched his hands. RN B stated he notified the Director of Nursing (DON) of the incident. RN B stated because Resident #71 resides on a different hallway than his assigned hallway, he instructed the charge nurse for that hallway, LVN C, to document the incident and notify the resident's family. RN B stated he also checked on Resident #83 after the incident, and she only reported Resident #71 yelled at her. RN B did not provide an exact date of the incident he stated it happened over the weekend between 2/21/26-2/22/26. During an interview on 2/27/26 at 12:21 p.m. LVN C stated she was in a resident room at the time the incident began between Resident #71 and Resident #83 and could hear a verbal back-and-forth between the two residents and heard loud yelling and screaming from Resident #71 directed toward Resident #83. LVN C stated she did not observe a physical altercation and only heard the residents yelling. LVN C stated RN B was the staff member who intervened and separated the residents. LVN C stated she assumed RN B documented the incident because he was the staff member present when the incident occurred. LVN C stated RN B did not ask her to document the incident or notify the resident's family or physician. LVN C stated if she had been the staff member who initially responded to the incident, she would have notified the family and physician and documented the incident. LVN C further stated Resident #71 did not report to her that she had been hit. During an attempted interview on 2/27/26 at 12:40 p.m. Resident #83 was not available for an interview. During an interview on 2/27/26 at 1:58 p.m., the Administrator stated if residents had any aggressive behaviors or altercations, staff were expected to complete skin assessments on the residents involved, notify the physician and the resident representative, and the staff involved should document the incident. The Administrator stated Resident #71 did not like Resident #83 because Resident #83 received attention from male residents. The Administrator stated Resident #71 had not previously reported to her that Resident #83 had hit her. However, since the allegation had been reported, the facility would complete skin assessments, notify the resident's psychiatrist and resident representative, and report the allegation to the state. The Administrator further stated staff should have documented incidents in the progress notes so that any allegations made later can be explained when reviewing the resident's medical record. Record review of the facility's policy titled Documentation in Medical Record, dated 2025, revealed the policy states, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy further states, Licensed staff and interdisciplinary team members shall document assessments, observations, and services provided in the resident's medical record . Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. The policy also states documentation shall be factual, objective, and resident centered . Documentation shall be accurate, relevant, and complete . containing sufficient details about the resident's care and/or responses to care.

Based on observations and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for physical environment.The 2 dryers were found to have built up lint on top of the lint screen.This deficient practice could place residents at risk for burns due to a fire hazard. Findings included:During an observation of the laundry room and interview on 02/27/26 at 1:57 pm, the dryers were found to have about 2-3 inches of lint on top of the lint screens. The bottom part of the lint screens appeared to have been swept off with only a small amount of lint staying in the bottom of the dryer. The Housekeeping Supervisor stated that the Maintenance Director usually cleaned the upper part of the lint screen at least once a day since there were wires that might cause issues. The Housekeeping Supervisor stated that the Maintenance Director had been out ill for a few days and the Assistant Maintenance Director had other duties. She stated she did not know if other arrangements were going to be made for cleaning the dryers while the Maintenance Director was out.Record review of the facility's Physical Environment: Electrical Equipment policy dated 2025 stated:The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition.1. The Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment.2. Frequency of inspection and maintenance shall be in accordance with the facility's Electrical Safety policy, current Life Safety code requirement, and manufacturer recommendations.4. Essential equipment shall be cleaned, repaired or replaced as soon as practicable. Examples of essential equipment include, but are not limited to:f. Laundry equipment

Based on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 1 (Resident #42) of 8 residents reviewed for timely assessment, in that: The facility failed to complete Resident #42's quarterly MDS assessment by 2/6/26 This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information. The findings were: Record review of the admission Record, dated 2/26/26, reflected Resident #42 was a [AGE] year-old female admitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition in which plaque builds up in the coronary arteries that supply blood to the heart muscle, causing narrowing of the arteries without current chest pain symptoms), neuromuscular dysfunction of bladder (a disorder in which nerve damage or neurological impairment affects the bladder's ability to store or empty urine normally), and anxiety disorder (a mental health condition characterized by excessive worry, nervousness, or fear that can interfere with daily functioning). Record review of Resident #42's quarterly MDS assessment, dated 11/6/25, showed Resident #42's memory was intact for daily decision making. Record review of Resident #42's MDS assessment list, dated 2/26/26, revealed the last MDS was completed on 11/6/25 and stated the next quarterly ARD was due 2/6/26, complete by: 2/20/26, and was 6 days overdue. During an interview on 2/27/26 at 11:53 a.m., the MDS Coordinator stated she could not say why Resident #42's quarterly MDS was done yet completed. She stated she tried to run a tracker to see whose MDS needs to be completed but it does not always find everyone who is due. The MDS coordinator stated the MDS was overlooked. The MDS coordinator stated the assessment assesses the resident's care over the last 90 days to make sure staff has access to information on residents' care needs. Record review of the facility's policy titled Conducting an Accurate Resident assessment with a copyright date of 2025 noted The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas., and Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure that sanitizing buckets were not near containers of food. 2. The facility failed to discard expired flour. 3. The ice machine had an unknown black substance inside the top of the machine. 4. The dishwasher sanitation log was not completed for several days and had an expired bottle of test strips. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation, during the initial kitchen tour, on [DATE] starting at 09:41 a.m., revealed there were 2 sanitizing buckets next to a tray of uncovered onions dated ,d+[DATE]. There was one container of flour with a discard date of ,d+[DATE] and another bag of flour with discard date of ,d+[DATE]. The dish machine sanitation record log was not filled out for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and the AM shift of ,d+[DATE]. There was a bottle of sanitation test strips with an expiration date of ,d+[DATE]. The ice machine had an unknown black substance at the top of the machine. The ice machine log showed it was last cleaned on [DATE]. During an interview on [DATE] at 4:45 p.m. Dishwasher Aide O stated he was new, but the log should be completed twice daily to show the sanitizer had been tested and was working during both shifts. During an interview on [DATE] at 9:45 p.m. the DS stated they should discard the flour in the container and in the bag because they only keep it for one month. The DS stated maintenance was responsible for cleaning the ice machine. The DS stated she expected staff to fill out the dishwasher logs during the morning and evening shift to make sure the sanitizer levels were adequate. During a joint interview on [DATE] at 4:53 p.m. the MS stated he cleaned the ice machine monthly. The MS stated he was not aware the ice machine had an unknown black substance but confirmed from a picture that it should not be in that condition because he did not know what it was and could be dirty. The DS stated it could contaminate the ice. Record review of the facility's policy titled Ice Machines and Portable Ice Carts, dated 2024, stated It is the policy of this facility to ensure that ice machines/carts are working in proper order, cleaned, and maintained as per Federal, State, local, or facility guidance, according to manufacturer's instructions and current standards practice. Policy Explanation: Ice machines/carts can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning, or maintenance of equipment, or through ice handling equipment. Proper cleaning, maintenance, and infection control in relation to ice machines is important to decrease the risk of illness to residents, staff, and visitors. Compliance Guidelines: 1. Ice machines will be cleaned at a frequency specified by the manufacturer or, if manufacturer specifications are absent, at a frequency necessary to preclude accumulation of soil or mold. 2. The facility will determine the frequency at which the ice machine will be cleaned/ sanitized with documentation to support the cleaning procedures. 3. The maintenance director or other designee is responsible for cleaning and maintaining the ice machine at the facility . 5. The ice machine(s) or carts will be cleaned at any time contamination may have occurred or when visibly soiled . notify the maintenance department for any problems with the ice machine. Record review of the facility's policy titled Date Marking for Food Safety, dated 2024, stated Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .

Based on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #15) of 8 residents reviewed for resident rights. The facility failed to notify Resident #15's provider of her change of condition on [DATE] when she developed dysuria (a painful or uncomfortable feeling when urinating, often described as a burning, stinging, or itching sensation in the urethra or urethral meatus) and visual hallucinations (Seeing things that aren't there, such as flashing lights, animals, or people). This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. The findings included: Record review of the Admission Record, printed [DATE], reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated [DATE], showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on [DATE], revised on [DATE], with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. Record review of Resident #15's Progress Notes on [DATE] at 4:00 p.m. revealed no notes about Resident #15 reporting dysuria or hallucinations in the previous 9 days. Record review of Resident #15's progress notes, revealed a note created [DATE], for effective date [DATE], stated Late entry: On [DATE] The nurse spoke with the resident about how she had been feeling. The resident stated she felt fine she had some burning during urination however, she did not have any other symptoms concerning a UTI she was encouraged to drink water instead of soda's. The resident was not in any distress or having any behavioral concerns nor did she express concerns on moving to another room. The note was written by LVN A and did not mention if the resident's provider was contacted. During an interview on [DATE] at 3:03 p.m. Resident #15 stated she thought she currently had a UTI. Resident #15 stated she felt burning every time she urinated. Resident #15 stated she knew it was a UTI because she had felt this way before when she had a UTI. Resident #15 stated she also mentally did not feel right. Resident #15 stated she told LVN A the day before [DATE] and told him she had thick mucus she was coughing up. Resident #15 stated LVN A had not done anything, but she knew she had told him a few times about the issues she was having. During a follow up interview on [DATE] at 3:05 p.m. Resident #15 stated what she meant by not feeling right mentally was she experienced a relative who came to visit her and hugged her but later realized she was hallucinating because this relative was deceased . Resident #15 stated this happened to her once before when she had a UTI. Resident #15 stated she was still having burning and hallucinations and no staff or providers had followed up with her about the symptoms at that time. During an interview on [DATE] at 9:42 a.m. LVN A stated the facility used the McGeers criteria (a set of guidelines used to identify healthcare-associated infections (HAIs) in long-term care facilities. The criteria are used to retrospectively count infections, and different categories are used for different types of infections, such as urinary tract infections, respiratory tract infections, and skin and soft tissue infections) to see if symptoms needed to be reported to a provider and treated. LVN A stated a resident would have to have 2 symptoms from the McGeers criteria list, such as painful urination, burning, frequency, flank pain, color, smell, before they would treat the symptoms. LVN A stated if he informed the Resident's NP, he would document this in a nursing note. LVN A stated if he did not document it in a note then he did not notify the provider. LVN A stated he thought he reported the resident's symptom of burning during urination to the NP but could not recall. LVN A stated he did add a note on [DATE] where he recalled the resident reported dysuria on [DATE] but he could not recall other details. LVN A stated he was not required to report the new onset symptom of dysuria to the NP because it did not meet criteria, but he was sure he did pass the information on to the NP. LVN A stated it should have also been passed on during shift change and would be noted in the 24 hour report. LVN A stated however there was nothing in his personal notes or the 24 hour report on [DATE] about the symptoms the resident reported to him. LVN A stated he did have a note in his personal notes on [DATE] where he reported to the NP the resident had new symptoms of mucus and the NP ordered a chest x-ray and an antibiotic. LVN A stated the NP was aware Resident #15 reported burning during urination but did not order anything for her. During an interview on [DATE] at 10:41 a.m. the NP stated he did not expect nurses to report every symptom a resident has to the provider. The NP stated he was not sure if they reported to him Resident #15 had burning during urination on [DATE] and he would not have any notes about this symptom being reported to him because one symptom does not trigger treatment for a UTI unless something else happened. The NP stated he had not ordered treatment since [DATE] to address the discomfort Resident #15 was experiencing during urination. The NP stated he was not aware the resident was still reporting dysuria or had reported hallucinations. The NP stated the resident was known to drink sodas often and this would be considered noncompliance but that also did not mean it should be left untreated. The NP stated if a Resident had an untreated UTI, they could go septic (when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death.) if left untreated. The NP stated they would need to collect labs to see if she had any infections but there was no reason for them to do that at the time of the interview on [DATE] at 10:41 a.m The NP stated nursing staff had contacted him on [DATE] about respiratory symptoms Resident #15 had. The NP stated he planned to treat the respiratory symptoms with an antibiotic that could also help with a UTI, but they would still need to do a culture and screen, if it was an infection, to ensure they used the correct antibiotic. During an interview on [DATE] at 3:54 p.m. the DON stated nursing staff is expected to report a change in status to the provider and staff should document they reported symptoms to the provider. The DON stated staff should follow up with a resident when they report symptoms like dysuria and document it. The DON stated the facility charts by exception and dysuria would be considered an exception. The DON stated staff was expected to chart by the end of the day or shift. The DON stated the 24-hour report should have noted the dysuria Resident #15 was experiencing so the next nurse would know about it and monitor the resident. The DON stated she had not personally spoken to Resident #15, dysuria alone was not a symptom of a UTI, she did not think Resident #15 reported mental symptoms, and it was speculation to say the resident had dysuria for the past 10 days. The DON stated the note written by LVN A, entered 10 days after [DATE], stated the resident reported no other symptoms so she was not treated. Record review of the facility's policy titled Notifications of Changes, dated ,d+[DATE], stated The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include .2.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include .or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. a new treatment .

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 Residents (Resident #36) whose records were reviewed for assessments. MDS staff failed to ensure Resident #36's MDS assessment reflected he was hearing impaired and used an amplifier as a hearing aid. This deficient practice could affect any resident and could result in residents not receiving the care and services as needed. The findings were: Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of the significant change MDS,, dated 10/1/24, revealed Resident #36's BIMS score was 11 reflecting moderate cognitive impairment; he had minimal difficulty hearing and did not use a hearing device. Review of progress note dated 11/12/2024 read: Was informed by [Resident #36] that he amplifier we provided had worked well for him, but since the wire got damaged and he is not able to hear from it. Administration is in process to try to get another amplifier. Review of Resident #36's Care Plan, revised on 10/8/24, read: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t dependent Physical Limitations and one of the interventions included Ensure that adaptive equipment that the resident needs is provided and is present and functional. Observation and interview on 11/13/24 at 10:40 AM revealed Resident #36 was lying in bed. He stated he thought he was getting a new amplifier and showed the one he had. He pointed to the the cord and it was noted to be frayed. Interview on 11/15/24 at 5:20 PM with LVN/MDS Coordinator F revealed Resident #36 was hearing impaired and used an amplifier to help him hear. She stated the MDS assessment, dated 10/1/24, did not reflect the use of a hearing device. MDS Coordinator F stated the purpose of an MDS assessment was to identify the needs of the resident and to ensure the resident received services as needed. LVN/MDS Coordinator F was asked for a facility policy for resident assessment on 11/15/24 at 5:30 PM. She did not provide a copy of the facility policy by exit at 8:15 PM.

Based on interview and record review, the facility failed to ensure all PASRR Level I residents with mental illness were provided with a PASRR Level II Evaluation and Assessment for 1 of 2 residents (Resident #55) reviewed for PASRR services. The facility failed to identify Resident#55 as having diagnoses indicative of Mental Illness including MDD on the PASRR screening dated 3/10/23, which would require a PASRR Level II assessment. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized services. The findings include: An interview of Resident #55 was attempted on 11/12/24, the resident was a poor historian. Review of Resident #55's admission sheet, dated 7/8/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Hypertension, Hyperlipidemia, MDD. Review of Resident #55's quarterly MDS assessment, dated 8/12/24, noted the resident BIMS was 8, indicating he had moderate cognitive impairment; mood indicators were present including little interest or pleasure in doing things and feeling down, depressed, or hopeless; and active diagnoses of Dementia, MDD and Anxiety Disorder. Review of Resident #55's order summary, dated November 2024 indicated the resident received antidepressants, an anxiolytic (a medication to treat anxiety), and a mood stabilizer. Review of Resident #55's care plan, updated on 10/1/24 noted the resident uses psychotropic medications r/t MDD. One of the approaches was to monitor and document the occurrence of for target behavior symptoms (Sadness, inappropriate response to verbal communication, violence/aggression towards staff/others. Review of the admission sheet on 11/15/24 at 4:41 PM, noted an original admitted [DATE] with documentation of the diagnosis date of MDD as 04/03/2023. Review of the medical record for Resident #55, showed a negative PASRR assessment, dated 3/10/23. Review of the assessments contained in the electronic health record of Resident #55 showed no follow up PASRR Level I or II conducted after the diagnosis of MDD on 04/03/2023. In an interview with the Administrator on 11/15/24 at 4:49 PM regarding the omission of the PASRR assessment, the Administrator acknowledged that Resident #55 did not have a PASRR performed after his diagnosis of MDD on 04/03/2023. The Administrator stated a follow up PASRR was not performed for the resident after his diagnosis of MDD, because the resident was a VA beneficiary, and VA beneficiaries must receive services through the VA. The Administrator stated a PASRR assessment should be conducted even for residents who might qualify to receive services from the Veteran's Administration. The Administrator stated if the facility performed PASRR assessments for all residents with mental illness, no one could get overlooked and not get the services they need. Review of the facility policy, undated, titled Resident Assessment-Coordination with PASRR Program stated all applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. The policy further stated that a negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later.

Based on interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 1 of 2 residents (Resident #52) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #52 had the mental illness diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) which would qualify Resident #52 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include: Attempted to interview Resident #52 on 11/13/24, resident was a poor historian. Record review of Resident #52's admission sheet, dated 5/26/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a movement disorder of the nervous system), Angina (a condition of insufficient oxygen in the blood causing chest discomfort or shortness of breath), Atrial Fibrillation (abnormal heart rhythm), Chronic Kidney Disease, PTSD, Insomnia, and MDD. Record review of Resident #52's quarterly MDS assessment, dated 10/4/24, noted the resident BIMS was 7, indicating he had severe cognitive impairment; mood indicators were present including little interest or pleasure in doing things and feeling down, depressed, or hopeless; and diagnoses of depression and PTSD. Record review of Resident #52's order summary from November 2024 indicated the resident receives an antidepressant. Record review of Resident #52's care plan, updated on 6/7/24 noted the resident uses and antidepressant r/t Depression. One of the approaches was to monitor and document the change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal. Record review of Resident #52's admission sheet on 11/13/24 at 9:07 AM documented diagnoses including PTSD and MDD. The original date of the admission sheet was noted as 03/27/21. The date of diagnosis for the PTSD was noted as 03/37/21, and the date of diagnosis for the MDD was noted as 03/27/21. Record review on 11/14/24 at 2:56 PM of the assessments in the electronic health record for Resident #52 showed three PASRR Level I assessments were performed on 03/26/21, 08/19/21, and 03/38/22. All three PASRR Level I assessments recorded an answer of 0 (No) in response to the question, Is there evidence or an indicator this is an individual that has a Mental Illness? In an interview with the Administrator on 11/14/24 at 03:16 PM, regarding the error in not identifying Resident #52 with mental illness, the Administrator stated the resident should have had a positive PASRR Level I outcome noted on the assessments and a follow up PASSR Level II performed in accordance with state and federal guidelines. The Administrator stated a PASRR was not performed for the resident, because the resident was a VA beneficiary, and VA beneficiaries must receive services through the VA. Review of the facility policy, undated, titled Resident Assessment-Coordination with PASSR Program stated all applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.

Based on observations, interviews, and record review revealed the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 7 Residents (Resident #36 and Resident #15) whose records were reviewed for Care Plans. 1. Staff failed to ensure Resident #36's Care Plan reflected he was hearing impaired and used an amplifier as a hearing aid. 2. The facility failed to update Resident #15's Care Plan to reflect a history of UTIs with interventions for staff to monitor the resident for possible UTI symptoms. This deficient practice could affect any resident and result in residents not receiving the care and services they needed. 1. Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of significant change MDS, dated [DATE], revealed Resident #36's BIMS was 11 reflecting moderate cognitive impairment; he had minimal difficulty hearing and did not use a hearing device. Review of progress note dated 11/12/2024 read: Was informed by [Resident #36] that he amplifier we provided had worked well for him, but since the wire got damaged and he is not able to hear from it. Administration is in process to try to get another amplifier. Review of Resident #36's Care Plan, revised on 10/8/24, read: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t dependent Physical Limitations and one of the interventions included Ensure that adaptive equipment that the resident needs is provided and is present and functional. Further review revealed the Care Plan did not reflect Resident #36 was hearing impaired and that he used a hearing device. Observation and interview on 11/12/24 at 12:37 PM revealed Resident #36 was lying in bed. He engaged in conversation; was difficult to understand but he made his needs known. Resident #36 stated about two months ago he started having problems hearing. He stated he loved baseball and not able to hear it. Observation and interview on 11/13/24 at 10:40 AM revealed Resident #36 was lying in bed. He stated he thought he was getting a new amplifier and showed the one he had. He pointed to the cord and it was noted to be frayed. Interview on 11/15/24 at 5:20 PM with LVN/MDS Coordinator F revealed Resident #36 was hearing impaired and used an amplifier to help him hear. She stated the Care Plan, dated 10/8/24, did not reflect he was hearing impaired and he used a hearing device. MDS Coordinator F stated the purpose of the Care Plan was to address the needs and services the resident would receive. She stated nursing staff had access to the Care Plan to help them understand the needs of the residents. 2. Record review of the Admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was full intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. Another care area initiated and revised on 9/28/24 stated The resident has bowel & bladder incontinence r/t Impaired mobility, Loss of peritoneal tone with interventions to the resident uses disposable briefs, ensure that call light is in reach and assist resident to bathroom PRN, and Check (q 2hrs ) and as required for incontinence. Clean peri-area with each incontinence episode. Change clothing PRN after incontinence episodes. Record review of Resident #15's hospital discharge paperwork, dated 5/16/24, stated chief complaint was respiratory distress and dx of acute respiratory failure and recent UTI. Record review of Resident #15's hospital discharge paperwork, dated 9/24/24, chief complaint was AMS and dx of UTI with sepsis . During an interview on 11/12/24 at 3:03 p.m. Resident #15 stated she thought she currently had a UTI. Resident #15 stated she felt burning every time she urinated. Resident #15 stated she knew it was a UTI because she had felt this way before when she had a UTI. Resident #15 stated she also mentally did not feel right. Resident #15 stated she told LVN A the day before and told him she had thick mucus she was coughing up. Resident #15 stated LVN A had not done anything, but she knew she had told him a few times about the issues she was having. During an interview on 11/14/24 at 9:42 a.m. LVN A stated the facility used the McGeers criteria (a set of guidelines used to identify healthcare-associated infections (HAIs) in long-term care facilities. The criteria are used to retrospectively count infections, and different categories are used for different types of infections, such as urinary tract infections, respiratory tract infections, and skin and soft tissue infections) to see if symptoms needed to be reported to a provider and treated. LVN A stated a resident would have to have 2 symptoms from the McGeers criteria list, such as painful urination, burning, frequency, flank pain, color, and smell before they would treat the symptoms. Interview on 11/15/24 at 5:21 PM with LVN/MDS Coordinator F stated she was new to the role and was told the care plans were all good and already done. The MDS nurse stated Resident #15's care plan did not need to address monitoring for a UTI because staff knew to provide incontinent care and change her brief when residents were prone to UTIs. The MDS nurse stated the resident was oriented and can report UTI symptoms to staff. The MDS nurse stated care areas and interventions should be specific for each resident regardless of if they were oriented or not. LVN/MDS Coordinator F was asked for a facility policy for resident Care Plans on 11/15/24 at 5:30 PM. She did not provide a copy of the facility policy by exit at 8:15 PM. During an interview on 11/15/24 at 6:06 p.m. the DON stated Resident #15's history of UTI's were addressed on the care plan under the enhanced barrier precautions care area. The DON stated some resident with a history of UTIs had a separate care area on their care plans for staff to monitor for UTI symptoms, but it depended on if the resident had a history of UTIs. The DON stated the resident had a few hospital documents that showed a diagnosis of UTI and a personal history of them. The DON stated many times a residents would go to the hospital for other reasons, and they would also find they had a UTI. 45857

Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident #36) whose records were reviewed for activities of daily living. Nursing staff failed to brush Resident #36's teeth and wash his face for 1 of 4 survey dates, 11/14/24 and nursing staff failed to clip his nails for an undetermined amount of time. This deficient practice could affect residents who required assistance and could result in poor hygiene and feelings of dissatisfaction. The findings were: Review of Resident #36's face sheet, dated 11/15/24, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified sequele of cerebral infarction and Major Depressive disorder, recurrent severe without psychotic symptoms. Review of significant change MDS assessment, dated 10/1/24, revealed Resident #36's BIMS was 11 reflecting moderate cognitive impairment; his range of motion was impaired on one side (upper and lower extremities) and he was dependent for most ADLs including oral hygiene. Review of Resident #36's Care Plan, revised on read: The resident has an ADL self-care performance deficit r/t CVA with left hemiplegia & right femur head osteonecrosis. Interventions included Provide the level of assistance resident requires in ADL care as follows: GROOMING: (TD) [totally dependent] x 1 Staff. Review of Resident #36's progress notes from 11/1/24 to 11/15/24 did not reveal Resident #36 had refused any type of hygiene care. Review of Resident #36's personal hygiene tracking document How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) revealed on 11/15/24 at 8:25 am, not applicable. Observation and interview on 11/13/24 at 10:40 AM revealed Resident #36 was lying in bed. He had left hand contracture. His hair looked uncombed, he had not shaven and overall he looked unkept. Further observation revealed his nails were long; about an inch passed his nail beds . The nail on his right pinkie was about 1 and 1/2 inches beyond the nail bed. Resident #36 stated he was diabetic and the nurses had to cut his nails. He stated he asked but nursing staff had staff not cut them. He stated staff only washed his face if he went out for an appointment which was some time last week. He stated other than that staff had not washed his face in a long time. He stated another thing that really bothered him was that staff did not brush his teeth. He stated when he was receiving hospice services staff brushed his teeth regularly. He stated at times nursing staff would swab his mouth but it was not the same. He stated it was important to him and stated he used to brush his teeth regularly. Interview on 11/14/24 at 2:05 PM with CNA D revealed she was the CNA assigned to work with Resident #36 on this date, 11/14/24. She stated normally she would help Residents wash their face and brush their teeth in the morning as needed. She stated she would also help Residents brush their teeth after meals per their request. CNA D stated on this date, 11/14/25, she did not have time to wash Resident #36's face or help him brush his teeth. She stated he required assistance but she spent most of her time showering Residents who were scheduled to be showered. Further interview revealed CNA D stated she would mark on his hygiene task not applicable if she did not provide a Resident with assistance on her scheduled shift. Observation and interview on 11/14/24 at 03:20 PM with LVN I revealed he had worked at the facility since September 2024 and was a new nurse. He stated nail care for Residents was done on Sundays. He stated he was not sure if it was any different for Residents who had diabetes. LVN I stated he made rounds at the beginning and at the end of his shift. He stated he was familiar with Resident #36, but did not know if he was diabetic. He stated the aides had not said anything to him about Resident #36 needing any specific care. Observation revealed Resident #36 lying in bed. He showed LVN I his nails. Resident #36 told LVN I a nurse had to cut his nails because he was diabetic. His nails were long passed his nail beds and some of them were black under the nails. The LVN I revealed he stated he did not know only nurses could cut a Resident's nails. He stated there was brown gunk underneath his nails. He stated it could become an infection control problem if he touched any open areas on his body. Interview with the DON on 11/14/24 at 04:25 PM revealed the charge nurse on duty would be able to cut a Resident's nails who had diabetes on any date as needed. However, typically speaking the charge nurse scheduled to work on Sundays would cut the Resident's nails. This was the day scheduled for Resident nail care. The DON stated Resident #36 had a history of refusing care and it was documented on his Care Plan. The DON stated she expected staff to document refusal of care in a progress note at the time the Resident refused care unless he refused specific care on a daily basis then it would be documented on the Care Plan. Further interview with the DON revealed the CNAs were responsible for providing daily hygiene care as needed and the nurses were to ensure it was done while making their rounds. Observation and interview on 11/14/24 at 04:45 PM revealed Resident #36 lying in bed. He showed the DON his nails and again stated he had asked nursing staff to cut his nails. Resident #36 was able to re-state he understood the nurses should cut his nails because he was diabetic. The DON asked Resident #36 if he refused nail care at any point. He told her he had not refused. She asked again, you never refused. Resident #36 shook his head and stated no. The DON asked Resident #36 if he would allow the nurse to cut his nails. He agreed and it was noted the DON asked ADON E to cut his nails. Further interview with the DON revealed she stated Resident #36's nails were long and according to the length it did not happen overnight. The DON stated the charge nurse should be monitoring residents care needs and should address it at the time they noted an issue. She stated the ADONs were responsible for overseeing the process and should address any concerns brought up by nursing staff and or by the Resident. Review of facility policy, Activities of Daily Living (ADLs) copyright date 2024, read in relevant part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.

Based on observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #191 and Resident #15) of 2 residents reviewed for catheter care and or incontinent care. 1. The facility failed to ensure CNA L and CNA M did not leave stool on Resident #15 when performing incontinent care. 2. The facility failed to ensure CNA J and CNA K kept Resident #191's urine catheter bag below the level of the bladder during incontinent care. This failure could place residents at risk for urinary tract infections. Findings included: 1. Record review of the Admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillin's, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Section H showed the resident was always incontinent of bladder and bowel. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. During an observation on 11/15/24 at 11:16 a.m. CNA L was observed wiping fecal matter from Resident #15's perineal and gluteal area. The fecal soiling was extensive and had spread to the bedding. While the CNA performed multiple wipes, the final pass left visible fecal residue in Resident #15's gluteal cleft. CNA L then put on a clean brief. During an interview on 11/15/24 at 11:48 a.m. CNA L stated she should have kept wiping the resident until the wipe was clean. CNA L stated she did not pay attention to see if the last wipe was heavily soiled or if the resident still had feces on her. CNA L stated she just discarded the wipe and put on a clean brief. CNA L stated she should keep wiping until the wipe had no feces and the resident was clean to prevent infections. 2. Record review of the Admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted on [DATE] with diagnoses that included malignant neoplasm of unspecified site of left female breast (cancerous breast tumor), other intervertebral disc degeneration, lumbosacral region with discogenic pain and lower extremity pain (pain in the lower back (lumbosacral area) due to a degenerated intervertebral disc (discogenic pain), which then radiates down into the leg, causing pain in the lower extremity), and retention of urine (unable to empty their bladder, either partially or completely). Record review of Resident #191's admission MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section H showed the resident had a urinary catheter and was always incontinent of bowel. Record review of the Resident #191's Care Plan, initiated 11/7/24, showed she had an indwelling foley catheter related to neuromuscular dysfunction of the bladder, with interventions to position catheter bag and tubing below the level of the bladder and off the floor at all times. During an observation on 11/14/24 at 11:41 a.m. CNA J and CNA K were positioning Resident #191 for catheter and incontinent care. CNA J handed the urinary catheter bag to CNA K and raised it above the level of Resident #191's bladder, urine in the tube was observed flowing back toward the resident's bladder. During an interview on 11/14/24 at 11:55 a.m. CNA J and CNA K stated they should keep the catheter bag low on the bed if they need to move it to prevent urine from back flowing and it could cause infection. During an interview on 11/14/24 at 3:23 p.m. the DON stated staff were expected to keep the catheter bag below the level of the residents' bladder so there was no flow back into the bladder, but the facility did only purchase anti flow catheter bags. The DON stated staff should wipe until the resident was clean and there was no visible feces on the resident only. The DON stated a resident could have skin break down if they still had feces on them. Record review of the facility's policy titled Perineal Care, dated 2024, stated It is the practice of this facility to provide perinea! care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown .7. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. a. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males using a separate washcloth or wipes. Thoroughly dry . Record review of the facility's policy titled Catheter Care, dated 2023, stated It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine or provide anti-flowback device .

Based on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two of ten residents (Resident #24 and Resident #41) reviewed for pharmacy services. The facility failed to ensure medication doses noted on the electronic Medication Administration Record (MAR) matched doses recorded on the Controlled Drug Reconciliation Log for Resident #24 and #41. This deficient practice could put residents at risk for pain, anxiety, misappropriation, and drug diversion. Findings include: Review of Resident #24's admission sheet, dated 8/18/24, noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Angina, Hypertension, Hyperlipidemia, and Major Depressive Disorder (MDD). Review of Resident #24's quarterly MDS assessment, dated 8/22/24, noted the resident BIMS was 0, indicating she had severe cognitive impairment. The resident had both mood and behavior indicators noting verbal abuse and refusal of care. Review of Resident #24's order summary from November 2024 indicated the resident received an anxiolytic, an antidepressant, and a mood stabilizer. Review of Resident # 24's care plan, updated on 8/25/24 noted the resident uses Klonopin (Clonazepam) r/t anxiety disorder. One of the approaches was to monitor and document target behavior symptoms ANXIOUS, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. Review of Resident #41's admission sheet, dated 3/8/19, noted the resident was admitted to the facility on [DATE] with diagnoses including Pain in Right Knee, Cerebral Infarction, Major Depressive Disorder, Dementia, Coronary Artery Disease, Hypertension, and Generalized Anxiety Disorder. Review of Resident #41's quarterly MDS assessment, dated 10/22/24, noted the resident BIMS was 9, indicating he had moderate cognitive impairment, and received a scheduled pain medication regimen. Review of Resident #41's order summary from November 2024 indicated the resident received an opioid analgesic (a controlled substance) routinely for pain. Review of Resident #41's care plan, updated on 10/8/24, noted the resident is on pain medication therapy r/t disease process. One of the approaches was to administer ANALGESIC medications as ordered and to review (q2h) for pain medication efficacy. Observation of the medication aide cart for the 300/400 hall and interview with Med Aide B was conducted on 11/14/24 at 9:20 AM . During the review of the cart including a review of the controlled medication reconciliation log, it was observed that Resident #41 had an order for Tylenol #3 (Tylenol with Codeine), to take two tablets by mouth three times a day. Tylenol #3 is an analgesic (medication for pain). It was observed that the administered dose of Tylenol #3 was logged out on the electronic medication administration record, but it was not logged out on the controlled medication reconciliation log. The blister pack of Tylenol #3 showed 22 pills were left in the pack. The controlled medication log sheet for Tylenol #3 showed 24 pills were left. It was observed that Resident #24 had an order for Clonazepam 0.5mg, to take 1/2 tablet by mouth twice a day. Clonazepam is an anxiolytic (medication for anxiety). It was observed that the administered dose of Clonazepam was logged out on the electronic medication administration record, but it was not logged out on the controlled medication reconciliation log. The blister pack of Clonazepam showed 34 doses were left. The controlled medication log showed 35 doses were left. Med Aide B stated a medication error could happen if controlled medications were not documented on the controlled medication log immediately after being administered. Med Aide B stated a resident could experience pain or anxiety if they do not receive their analgesic or anxiolytic medication. Review of the facility policy, undated, titled Controlled Substance Administration and Accountability stated the facility will have safeguards in place to prevent loss, diversion, or accidental exposure. The policy further states that all controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. The policy also states that in all cases, the dose noted on the usage form or entered in the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration.

Based on observation, interview, and record review, the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles for one of ten residents (Resident #55) reviewed for medication labeling and storage. The facility failed to ensure Resident #55's insulin pen was labeled with the date it was opened. This deficient practice could place residents who receive medications at risk of not obtaining the therapeutic level of their prescribed medications. The findings include: Review of Resident #55's admission sheet, dated [DATE], noted the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Hypertension, Hyperlipidemia, and Major Depressive Disorder (MDD). Review of Resident #55's quarterly MDS assessment, dated [DATE], noted the resident BIMS was 8, indicating he had moderate cognitive impairment and a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #55's from [DATE] indicated the resident received a biguanide (insulin response enhancer), insulin glargine, and insulin aspart related to Type 2 Diabetes Mellitus. Review of Resident #55's care plan, updated on [DATE] noted the resident has Diabetes Mellitus with neuropathy. One of the approaches was the resident will receive diabetes medications as ordered by doctor. During an observation of the medication pass on the 200 hall and interview with RN Con [DATE] at 4:30 PM, it was observed that the opened date was not documented on the NovoLog insulin pen for Resident #55. RN C stated the resident could potentially receive expired medication and not get the therapeutic effect of the insulin if the opened date was not recorded on the pen. NovoLog pens expire after 28 days at room temperature. RN C stated without an opened date, it would be unclear when the 28 days had passed. Review of the facility's policy, undated, titled Labeling of Medications and Biologicals stated that all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. The policy further stated that labels for multi-use vials must include the date the vial was initially opened or accessed (needle-punctured); and all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #15 and Resident #191) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to timely document Resident #15's complaints of dysuria (a painful or uncomfortable feeling when urinating, often described as a burning, stinging, or itching sensation in the urethra or urethral meatus) on 11/03/24 and 11/11/24. 2. The facility failed to document a wound care order in active orders, when it was ordered on 11/12/24, and not active until 11/14/24, for wound care treatment for Resident #191 who developed a open reddened area to her gluteal folds after admission. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: Record review of the Admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated. Record review of Resident #15's Progress Notes on 11/12/24 at 4:00 p.m. revealed no notes about Resident #15 reporting dysuria or hallucinations in the previous 9 days. Record review of Resident #15's progress notes, revealed a note created 11/13/24, for effective date 11/04/24, stated Late entry: On 11/03/2024 The nurse spoke with the resident about how she had been feeling. The resident stated she felt fine she had some burning during urination however, she did not have any other symptoms concerning a UTI she was encouraged to drink water instead of soda's. The resident was not in any distress or having any behavioral concerns nor did she express concerns on moving to another room. The note was written by LVN A. During an interview on 11/12/24 at 3:03 p.m. Resident #15 stated she thought she currently had a UTI. Resident #15 stated she felt burning every time she urinated. Resident #15 stated she told LVN A a few times before including on 11/11/24, and told him she had thick mucus she was coughing up. Resident #15 stated LVN A had not done anything, but she knew she had told him a few times about the issues she was having. During a follow up interview on 11/14/24 at 3:05 p.m. Resident #15 stated she was still having burning and hallucinations and no staff or providers had followed up with her about the symptoms at that time. During an interview on 11/14/24 at 9:42 a.m. LVN A stated he did add a note on 11/4/24 for 11/3/24 for the resident's report of burning during urination. This surveyor stated the note showed it was entered on 11/13/24. LVN A said sometimes the medical records system did not save his notes, so he had to enter the note on 11/13/24. LVN A stated if something is not documented then it did not occur. During an interview on 11/15/24 at 3:54 p.m. the DON stated staff should follow up with a resident when they report symptoms like dysuria and document it. The DON stated the facility charts by exception and dysuria would be considered an exception. The DON stated staff was expected to chart by the end of the day or shift. The DON stated the 24-hour report should have noted the dysuria Resident #15 was experiencing so the next nurse would know about it and monitor the resident. The DON stated it was acceptable to chart 10 days later as a late entry. 2. Record review of the Admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted on [DATE] with diagnoses that included malignant neoplasm of unspecified site of left female breast (cancerous breast tumor), other intervertebral disc degeneration, lumbosacral region with discogenic pain and lower extremity pain (pain in the lower back (lumbosacral area) due to a degenerated intervertebral disc (discogenic pain), which then radiates down into the leg, causing pain in the lower extremity), and retention of urine (unable to empty their bladder, either partially or completely). Record review of Resident #191's admission MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section H showed the resident had a urinary catheter and was always incontinent of bowel. Record review of the Resident #191's Care Plan, initiated 11/7/24, showed resident was at risk for pressure injury and to educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, and inform the resident/family/caregivers of any new area of skin breakdown. Record review of Resident #191's active order summary, dated 11/14/24, printed at 8:04 a.m., contained no active orders for wound care. Record review of Resident #191's November 2024 TAR, dated 11/14/24, printed at 8:25 a.m. showed an order for apply collagen and zinc to affected area gluteal folds as needed, as needed apply to affected area as needed, with a start date of 11/12/24, and no end date. There was no documentation for wound care on the 12th, 13th, or 14th of November. Record review of an order audit report, dated 11/14/24, revealed an order for apply collagen and zinc to affected area gluteal folds as needed as needed apply to affected area as needed, it showed the order was created on 11/14/24 at 8:05 a.m. The audit showed the order was discontinued on 11/14/2024 at 2:00 p.m. Record review of Resident #191's November 2024 TAR, dated 11/14/24, printed at 6:09 p.m. showed new orders for -Bilateral Gluteal folds Impairment: Abrasion every day shift for Wound Healing Clean area with wound cleanser, pat dry. Apply collagen powder and zinc to affected areas. Leave open to air. with a start date of 11/15/24 and no end date. -Sacrum Impairment: Preventive Care, red skin every day shift for Preventive Care Clean area with wound cleanser, pat dry. Apply topical Triad cream and cover with Foam dressing. with a start date of 11/15/24 and no end date. During an interview on 11/14/24 at 8:02 a.m. RN N stated they should have an order for zinc paste and she was unsure if they had entered the order, but they had been providing wound care to Resident #191 who had developed an in-house skin issue to her gluteal fold area. During an observation on 11/14/24 at 11:41 a.m. Resident #191 was observed with reddened abrasions to the left and right gluteal fold area during incontinent and catheter care. Staff applied zinc to the area. During an interview on 11/14/24 at 3:45 p.m. the DON stated there was an order for wound care for Resident #191 with a start date of 11/12/24. The DON stated there was no missing documentation in the TAR for this order because it was a PRN order. The DON stated they did not need to provide the wound care daily because it was only as needed and that is why it was not documented. The DON stated the audit report, showed the order was entered on 11/14/24 at 8:05 a.m., was incorrect. Record review of the facility's policy titled Documentation in Medical Record, stated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. I . False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. iii. Subjective information shall be recorded only as relevant, such as the resident's verbalizations, in quotation marks. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care .h. Only document conclusions that can be supported by data and avoid bias, labels, and value judgments .

Based on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 residents (Resident #191) reviewed for hospice services, in that: The facility failed to ensure Resident #191's most recent Physician Certification of Terminal Illness and Hospice Election form were completed and were part of the hospice documents at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of the Admission Record, dated 11/15/24, reflected Resident #191 was a [AGE] year-old female originally admitted on [DATE] with diagnosis that included malignant neoplasm of unspecified site of left female breast (cancerous breast tumor), other intervertebral disc degeneration, lumbosacral region with discogenic pain and lower extremity pain (pain in the lower back (lumbosacral area) due to a degenerated intervertebral disc (discogenic pain), which then radiates down into the leg, causing pain in the lower extremity), and retention of urine (unable to empty their bladder, either partially or completely). Record review of Resident #191's admission MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section O showed she was receiving hospice services while a resident. Record review of the Resident #191's Care Plan, initiated 11/7/24, revised 11/13/24, showed the resident had a terminal prognosis related to malignant neoplasm of the breast and is on hospice services with interventions to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review on 11/14/24 revealed Resident #191's hospice binder and EMR did not have the 3071 Individual election form/cancellation/update and 3074 Physician certification and recertification of the terminal illness form in the records. During an interview on 11/14/24 at 6:47 p.m. the Regional Administrator stated they had reached out to hospice to inquire where the forms were and were told by hospice that they did not need the individual election form because the resident was private pay. During an interview on 11/15/24 at 10:11 a.m. the Director of Clinical Services from the hospice company stated there was confusion previously but they are required to have both forms and they provided them to the facility on [DATE]. The Director stated the hospice company did fill out the forms but did not leave copies with the facility. During an interview on 11/15/24 at 2:42 p.m. the SW stated she was responsible for ensuring the hospice documents were present at the facility and a part of the medical record for Resident #191. The SW stated she was unsure of what documents were needed and referred to the hospice company who told her the documents were not required. The SW stated she did not know what the risk was for the resident if they did not have the proper documents and would need to ask. During an interview on 11/15/24 at 4:15 p.m. the DON stated the hospice binder needed to have the 3071 Individual election form/cancellation/update and 3074 Physician certification and recertification of the terminal illness form when the resident was admitted to hospice. Record review of the facility's policy titled Hospice Services Facility Agreement, dated 2024, stated It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility .5. The facility has a designated (the Assistant Director of Nursing, or specify the member from the interdisciplinary team) to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff. This designee: a. Has a clinical background, b. Functions within their state's scope of practice, and c. Has the ability to assess the resident or have someone that has the skill and capabilities to assess the resident. 6. The designated member of the facility working with hospice representative is responsible for: d. Obtaining the following information from the hospice: i. The most recent hospice plan of care specific to each resident ii. Hospice election form iii. Physician certification and recertification of the terminal illness specific to each resident .

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Residents #15) reviewed for infection control 1. The facility failed to ensure CNA L and CNA M used appropriate hand hygiene between glove changes when providing incontinent care to Resident #15. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of the Admission Record, printed 11/15/24, reflected Resident #15 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing an area of dead brain tissue), extended spectrum beta lactamase (ESBL) resistance ( enzymes that make bacteria resistant to many antibiotics, including penicillins, cephalosporins, and aztreonam), unspecified Escherichia coli [E. Coli] as the cause of disease ( bacteria commonly found in the intestines of humans and animals, and while most strains are harmless, certain types can cause illness), and personal history of urinary tract infections. Record review of Resident #15's quarterly MDS assessment, dated 10/4/24, showed her memory was fully intact for daily decision making. Section I of active diagnoses showed she had a UTI in the last 30 days. Section H showed the resident was always incontinent of bladder and bowel. Record review of the Resident #15's Care Plan showed she was on enhanced barrier precautions related to history of ESBL of the urine, initiated on 9/28/24, revised on 11/12/24, with interventions of staff will educate resident on Enhanced Barrier Precautions, proper signage to be clearly indicated, PPE including gown and gloves available outside or near room, alcohol based handrub available, trash can inside room near exit for discarding PPE prior to exit of the room, Proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that promote opportunities for transfer of MDROs (Multidrug-resistant organisms (MDROs) are microorganisms, primarily bacteria, that are resistant to multiple classes of antibiotics and antifungals.), Staff to DON and DOFF PPE (Donning and doffing are terms that refer to putting on and taking off personal protective equipment (PPE)) according to recommendations, which is before any high contact resident care activities like . dressing, bathing/showering, transferring, providing hygiene, changing linens, toileting or assisting with toileting and remove prior to leaving the room, and Standard precautions to be observed regardless of suspected or confirmed infection or colonization status. These precautions are based on the principal that all blood, body fluids, secretions and excretions may contain transmissible infectious agents. During an observation on 11/15/24 at 11:16 a.m. CNA L and CNA M provided incontinent care to Resident #15. CNA M wiped the resident's peri area, removed her gloves, did not perform hand hygiene, and put on new gloves. CNA M again wiped between Resident #15's thighs, removed her gloves, did not perform hand hygiene, and put on new gloves. CNA L and CNA M rolled the dirty brief up partially, both removed their gloves, did not perform hand hygiene, and put on new gloves. CNA M then wiped Resident #15 buttocks and feces fell on the sheets. CNA M then removed her gloves, did not perform hand hygiene, and put on new gloves. CNA L then wiped Resident #15's right side of her buttocks, removed her gloves, did not perform hand hygiene, and put on new gloves. During an interview on 11/15/24 at 11:40 a.m. CNA L and CNA M stated they had been trained on incontinent care at the facility. CNA L and CNA M stated they were unsure if they needed to perform hand hygiene between every glove change but did make sure to wash their hands when they entered a resident room and before they left a resident room. They stated hand hygiene was necessary to prevent infections. During an interview on 11/15/24 at 3:48 p.m. the DON stated staff should perform hand hygiene between each glove change for infection control to prevent infections. Record review of the facility's policy titled Hand Hygiene, dated 2024, stated All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 11 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was being supervised during the overnight shift resulting in the resident eloping from the facility. The resident was found 2 days later. Resident #1 went 2 days without his medication, was out in the cold, and was sent for ER evaluation when found. This was determined to be an Immediate Jeopardy at Past Non-Compliance from [DATE] until [DATE], due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could have the potential to affect the residents in the facility by placing them at risk for serious injury, serious impairment, or death. The findings included: Review of Resident #1's face sheet dated [DATE] revealed the resident was admitted to the facility on [DATE] and had diagnoses that included unspecified dementia without behavioral disturbance, personal history of Covid-19, mixed [CONDITION(S)] (a genetic disorder in which a person has higher than usual levels of cholesterol, triglycerides and other lipids in the blood), hypertension (high blood pressure) and homelessness unspecified. Review of Resident #1's February 2022 Consolidated Physician Orders revealed, Wander guard (band) placed to RLE (right lower extremities) to alert staff if resident attempts to exit facility unassisted d/t (due to) high risk for wandering' with a start date of [DATE]. Further review of the resident's physician orders, below the resident's demographics, revealed, Special Instructions: WANDER GUARD---RISK FOR ELOPEMENT. Review of a Wandering/Elopement Risk Evaluation dated [DATE] and located in Resident #1's medical record revealed a score of 11, moderate risk for elopement. Further review of the evaluation revealed the resident ambulated independently and was mildly confused. Review of an admission Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 5, severely impaired cognitive status. Review of Resident #1's care plan initiated [DATE] revealed, The resident is an elopement risk/wanderer r/t (related to) disoriented to place, impaired safety awareness. Further review of the care plan revealed a goal for the resident not to leave the facility unattended and interventions that included distracting the resident from wandering by offering diversions, identify pattern of wandering and document wandering behavior. Review of Order for Extension of Emergency Order revealed on [DATE] the court determined there was reasonable cause to believe that abuse or neglect threatened the life of Resident #1 and the resident did not have the capacity to consent to medical services. The order revealed an Attorney ad Litem (an attorney appointed to represent the resident's best interest) was appointed by the court so that Resident #1 would receive the necessary medical and protective services to alleviate any threat to life. Further review of the emergency order revealed a hearing would be held on [DATE] to determine if further orders were needed. Review of an Order for Extension of Emergency Order revealed on [DATE] the court determined to extend the order until [DATE]. Review of Resident #1's progress notes located in the resident's clinical record revealed a social service's note dated [DATE] noting the resident was admitted to the facility by Adult Protective Services (APS) and had an appointed Ad Litem guardian who would be the residents' decision maker. The progress notes also revealed the resident had been homeless for the past 6 months and was sleeping in his car. Review of the facility Incident Investigation Worksheet dated [DATE] and reported to state office revealed on [DATE] Resident #1 could not be located after a search of the facility by staff and the local police department was notified of the missing resident. Further review of the worksheet revealed per online weather search for that area, the high was expected to be 42 degrees Fahrenheit and low was 36 degrees Fahrenheit. In an interview on [DATE] at 2:55 p.m. with the Administrator and Chief Operating Officer (COO) revealed the last time Resident #1 was seen in the facility was on [DATE] at 10:30 p.m. but they did not realize he was missing until the following morning, [DATE], when staff went to serve him his breakfast. The Administrator reported when Resident #1 was admitted to the facility he was diagnosed with Covid-19 and placed on the Covid isolation wing. The Administrator went on to say when the residents' health improved, he was moved in with the regular population. The Administrator reported by that time Resident #1 was ambulating independently without assistive devices, toileting himself, dressing himself and showering with someone standing by if assistance was needed. The Administrator reported staff had gotten comfortable with the resident because he was doing most everything himself and did not check on him regularly throughout the night. The Administrator reported the facility did not have a specific policy for staff to check on each resident every 2 hours and 2-hour checks were determined by each residents' care needs. The Administrator stated staff were not used to caring for a resident that did not require a lot more care. The COO revealed through their investigation and in conversation with the local police and the APS caseworker Resident #1 had eloped from another facility prior to being admitted to this facility. The Administrator and COO denied knowing about the resident's history of elopement, but confirmed the resident was wearing a wander guard band while at the facility. The Administrator reported the wander guard band was placed on the resident when he was first admitted to the facility and an elopement assessment was done. The Administrator reported when they spoke to Resident #1's APS caseworker after his elopement they learned APS was no longer seeking guardianship and the resident was his own responsible party as of [DATE]. The Administrator reported they began training staff on [DATE] on checking all residents throughout all shifts. Record review of the facilities in-services dated [DATE]-[DATE] reflected the following subject areas: Missing Resident/Elopement Procedures, walking rounds prior to shift change, midnight census rounds, environmental rounds each shift to check alarms, rounds on residents identified as Elopement Risks every 2 hours, conduct rounds on all residents every 2 hours and more frequently if needed, documentation, and weekly review of the facility Look at me now book with pictures and information on residents that were at risk for elopement. In a telephone interview on [DATE] at 7:17 p.m. with RN A she confirmed she was Resident #1's charge nurse during the overnight shift from [DATE] to [DATE]. The RN reported she had checked on Resident #1 at the start of her shift between 10:00 and 10:30 p.m. The RN reported the resident was asleep in his bed, and he was facing the window. The RN reported she checked the resident's wander guard band and confirmed it was in place at that time. The RN reported Resident #1 usually slept throughout her shift, and if he did need something, he would turn on his call light. The RN reported she had not checked on Resident #1 again throughout the rest of her shift. The RN reported she should have checked on the resident every 2 hours during her shift, but she did not. The RN stated she had been busy that night, but then noted that was no excuse for not checking on him. In a telephone interview on [DATE] at 11:36 a.m. with the APS caseworker for Resident #1 revealed the resident was first placed in a locked facility in Lytle, Texas for long term stay. The APS worker reported the facility was assisting with applying for Medicaid for the resident to defer the cost for his stay, but the resident did not meet medical necessity, so he was moved to an assisted living facility. The APS worker reported the resident was in the assisted living facility for about 1 day before he eloped. The APS worker stated Resident #1 was found 2 days later, back at the homeless camp where he was previously living in his car and brought to this facility. The APS worker confirmed she was aware this facility was not a secured facility, but that the facility had a wander guard system. The APS worker confirmed the temporary guardianship had expired while Resident #1 was at the facility band the judge did not grant continued guardianship because the judge must have thought he (Resident #1) did not need it. In a telephone interview on [DATE] at 3:53 p.m. with Nurse Aide (NA) B she confirmed she had worked the night shift on [DATE], from 10:00 p.m. to 6:00 a.m. [DATE]. NA B reported she had been on leave from work, that was her first night back to work, and she was not familiar with Resident #1. The NA reported when she began work that evening, RN A stated she had checked on Resident #1, his vital signs were good, he was asleep, and the resident would turn on his call light if he needed anything. NA B stated she had never checked on Resident #1 during her shift because RN A had reported the resident used his call light if he needed anything and she had been busy because it was her first night back. In an interview on [DATE] at 3:56 p.m. with the Administrator revealed Resident #1 was found less than a mile away from the facility under a bridge. The Administrator stated the COO, who went to confirm it was their missing resident, reported Resident #1 stated he left the facility around 10:30 p.m. on [DATE]. The resident was examined by emergency medical personnel and no injuries were reported. The resident was sent to the hospital for further examined. In an interview on [DATE] at 10:05 a.m. with the Administrator and COO revealed the hospital examined Resident #1, determined he did not need to be admitted to the hospital, and discharged the resident to a homeless shelter in San [NAME], Texas. The COO reported the resident stated he did not want to return to the facility, and she presented an Against Medical Advice form the resident had signed after he was located on [DATE]. The Administrator reported she had contacted APS to let them know he discharged from the facility against medical advice and was back in the community. Review of the facility Wanderguard Policy, not dated, revealed, 2 2.2 The wandering patient protocol will be instituted when the safety of a patient is jeopardized by his/her potential absence from the unit or the facility. It was determined this failure placed residents in an Immediate Jeopardy situation which continued from [DATE] to [DATE]. The facility took the following action to correct the non-compliance: Review of the facility Corrective Action Plan, dated [DATE], revealed the facility began periodic elopement drill monthly X 3 months, Wander guard device at the door was checked then quarterly, residents identified as risk for elopement would have the residents picture and identifiable information placed in a binder identified as Look at me Now, Wander guard bracelets check increased to 2 shifts instead of 1, wander guard band expiration date updated on the residents record, doors and alarms check each shift, all nursing staff to conduct rounds every 2 hours or more if needed including residents at risk for wandering, staff educated on how to print mid-night census and conduct census checks to assure all residents are identified in the facility at midnight, conduct elopement assessments upon admission, quarterly, or with any sign in exit seeking/wandering behavior and assure information placed in the Look at Me Now binder and all nursing to review the binder weekly. On [DATE] separate interviews were conducted with Central Supply staff person at 12:46 p.m., LVN G at 12:50 p.m., Speech Language Pathologist at 12:54 p.m., Nurse Aide B at 3:53 p.m. and on [DATE] separate interviews were conducted with LVN H at 12:36 p.m., LVN I at 12:40 p.m., Nurse Aide J at 1:03 p.m., Nurse Aide K at 1:12 p.m., Nurse Aide L at 2:01 p.m., Nurse Aide M at 2:05 p.m., Laundry staff person N at 2:45 p.m., LVN O at 2:58 p.m., Nurse Aide P at 3:21 p.m., and LVN Q at 3:50 p.m. The staff were asked what in-service training the facility administration provided since Resident #1 eloped from the facility and what changes were you doing to prevent any additional residents from elopement: All staff reported they had been instructed to check on each resident every 2 hours, despite the resident's care needs and elopement procedures. Staff also reported they were in-serviced about the Look at Me Now binder, which copies were located at all nurses' station and at the front entrance where staff and visitors checked in, that had pictures of all residents that were an elopement risk. Licensed nursing staff reported they would do walking rounds with the on-coming shift to assure all residents whereabouts was accounted for, the residents that wore a wander guard band nursing staff will test the band during morning and evening shift, and overnight staff would run a midnight census report and had to compare the census report to the residents that were physically in the facility. Interview with the Administrator and the COO on [DATE] at 2:50 p.m. revealed they began in-service training with staff by noon the day the resident was discovered missing. They reported staff were in-serviced on abuse and neglect, elopement procedures and checking on residents. The administrator also reported she met with each shift and did education and training to assure their understanding of checking on all residents, despite care needs. The facility provided a Corrective Action plan which was initiated on [DATE], with target dates no later than [DATE], that explained everything the facility had put in place after Resident #1's elopement. In an interview on [DATE] at 3:21 p.m. with the Maintenance Director he reported he checked the wander guard system daily starting the day Resident #1 was reported missing ([DATE]). The Maintenance Director reported he use to do weekly checks prior to incident, and he would continue daily checks for 14 days, then return to weekly checks. The Maintenance Director provided documentation that confirmed the wander guard system was checked as reported. In an interview on [DATE] at 4:10 p.m. with the Administrator and COO they clarified changes that began after the resident eloped, which included resident wander guard bands would be check on 2 shifts daily instead of just 1, nursing staff would do walking rounds at shift change and overnight staff were now printing an overnight census and comparing it to the residents that were in the facility.

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical status for 1 of 5 residents (#1) whose records were reviewed. RN M did not consult with Resident #1's physician and did not contact Resident #1's representative when the resident had a significant change of condition per facility policy. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. This deficient practice could affect 65 residents and could contribute to a delay in physician intervention and family members having the opportunity to voice their wishes regarding the resident's condition. The findings were: Review of Resident #1's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were 3 family members listed for emergency contact including the RP, second contact and third contact. Review of Resident #1's medical chart revealed a Texas Department of State Health Services Standard Out-of-Hospital Do-Not-Resuscitate Order dated [DATE]. Review of a physician fax request (undated; time not documented) read: Temp 99.1 at 7:15 p.m. administered 1 suppository. Resident also noted with upper lobe congestion. 02 sat at 89%. Administered PRN [MEDICATION NAME] INH Solution. May we have PRN order for APAP 325 mg x2 tabs po or 650 mg suppository to be administered for discomfort of fever? Signed by LVN R. Further review read: [DATE] Addendum: may we order a CXR?? signed by RN M. Review of physician orders [REDACTED].> 93% and [MEDICATION NAME] UD per neb mask Q 4 hrs, PRN SOB/Wheezing. Review of a nurse's note dated [DATE] at 1:50 p.m. revealed Resident #1 was noted with audible congestion, labored breathing. PRN neb tx admin this shift. 02 sat was 80% on 2L, (increased) to 3L. Res did not eat breakfast & had minimal intake for lunch. Call placed to RP to inform 0 answer, LM. Addendum to MD fax requesting CXR. Response pending VS 97XXX[DATE]-,[DATE]. Note: According to Web MD dated [DATE] revealed: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Interview on [DATE] at 8:17 a.m. with RN M revealed she had worked at the facility for about 8 years and had started working on a PRN basis about 1 to 2 days a week. RN M stated an assessment should be conducted and care provided according to physician orders [REDACTED]. She stated the assessing nurse should continue to call the physician and or RP until contact was made depending on the situation. RN M confirmed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. and remembered Resident #1's condition that day. She stated she learned the resident was already having difficulties from the day before. RN M reviewed the nurse's notes dated [DATE] and confirmed she wrote the note at 1:50 p.m. She stated that the note reflected the resident's condition throughout the shift. She stated she provided Resident #1 with a neb treatment and increased the oxygen to 3L. She stated she also faxed the addendum to the PCP on [DATE] requesting for a chest X-Ray. RN M stated she called the physician, but was not sure at what point she called him. She confirmed the nurse's note did not indicate whether she called the physician or not. RN M stated that there was usually a slow response from Resident #1's PCP's office and at times another physician would respond in the PCP's stead. RN M confirmed that she should have sent Resident #1 to the hospital, but believed the ADON told her that the family did not want her going out to the hospital, but commented she was not 110% sure. RN M stated she called the RP and left a message. She stated she knew there was another sister and father that were involved in the resident's care, but understood the RP was the decision maker. RN M stated that given the orders in place for the resident and the direction she received, she believed she provided care necessary within those parameters. However, RN M confirmed that a family member did not directly tell her that they did not want Resident #1 going out to the hospital and as a prudent nurse she should have proceeded to sending the resident out to the hospital. Furthermore, she should have been more persistent in calling the physician and if she did not get a response she should have called the Medical Director. RN M stated she should have also documented the times she called the physician. Interview on [DATE] at 4:04 p.m. with CNA S revealed she worked on [DATE] from 10:00 p.m. to 6:00 a.m. CNA S stated she recalled Resident #1 being very sick with cough and congestion but did not need suctioning. She stated vital signs were not recorded at that time. Interview on [DATE] at 4:18 p.m. with CNA T revealed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. CNA T stated Resident #1 had to sit up in a chair because she was coughing a lot. She also had to sit up in a Geri-chair to eat. CNA T stated Resident #1 had a dry cough that would come and go but more so when eating. She stated Resident #1 needed suctioning only when she could not clear the resident's secretions. Review of SBAR Communication Form dated [DATE] revealed Resident #1 had been observed and evaluated for SOB on [DATE]; treatment for [REDACTED]. Vital signs were BP ,[DATE], pulse 53, RR 30, temp 98.5 and sat were 71%.; on 02 4L. Further evaluation revealed abnormal lung sounds, labored or rapid breathing. Further review revealed that RP requesting to be sent to ER. PCP called and then 911 was called. Resident #1 went out to the hospital at 3:40 p.m. At 4:00 p.m. PCP was notified and he stated would talk with the family. Interview on [DATE] at 4:30 p.m. with LVN E revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She stated she worked PRN and worked the 200 hall. LVN E stated that upon starting her shift, RN M did not provide a status report regarding the gravity of Resident #1's condition. She stated she made rounds about 3:00 p.m. and noted Resident #1 was on 02 via NC which was a change for the resident. Upon further assessment, she noted the resident was gurgling, her sats were at 71%, her RR were 30 and her breathing was labored. LVN E commented Resident #1 did not look good; she was clearly in respiratory distress. LVN E stated she called the PCP but did not hear back from him so she called the RP who was not available and then called the 2nd emergency contact. The family member asked her to send the resident to the hospital. LVN E stated she completed the SBAR and called 911 and Resident #1 left to the hospital via EMS. LVN E stated that she could have called the Medical Director, but again believed she was clearly dealing with an emergency situation and did not want to waste any more time. LVN E stated that upon reviewing the nurse's notes dated [DATE] at 1:50 p.m., she believed Resident #1 should have been sent to the hospital at that time. She stated Resident #1 was already experiencing a change of condition; the resident had congestion and labored breathing, her respirations were 24; the range for normal limits was from about 16 to 20. She commented she did not understand why only a message was left for the RP and she questioned the rationale for asking for a chest X-ray versus sending the resident out to the hospital. LVN E stated Resident #1's PCP returned her call after the resident left for the hospital and was upset because she sent the resident to the hospital. He stated the resident was a DNR. She further stated she had always been instructed to do whatever the family wanted. Review of a telephone order dated [DATE] confirmed Resident #1 was sent out to the hospital. Review of a hospital history and physical dated [DATE] revealed Resident #1 was admitted with the following Diagnoses: [REDACTED]. Further review revealed Resident #1 arrived via EMS and was subsequently intubated. Note: Review of a document, Physician Quality Reporting System dated [DATE] revealed a Code Blue was called at 1627 (4:27 p.m.) due to respiratory arrest. Further review of the history and physical revealed Resident #1was admitted to the ICU for further care, however, after talking to the family care was withdrawn. Hospice was contacted and was admitted for hospice services. Review of a Discharge Summary dated [DATE] revealed the patient had orders to treat septic shock with vasopressors and antibiotics, maintain mechanical ventilation, workup for problems, etc. Hospice/comfort care reviewed with the family. Decision was made by the family to place the patient on hospice for comfort care. She ultimately expired under hospice care. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 11:30 a.m. with Resident #1's family member revealed she expressed great concern about how the resident's change of condition was handled while at the facility. She questioned if staff ever heard back from the physician because she understood staff requested a CXR which was not completed. The family member questioned whether nursing staff handling the situation followed facility protocols and whether they received support from administrative staff. Interview on [DATE] at 3:06 p.m. with the DON revealed she had worked at the facility for about 3 weeks. She stated that for a change of condition nurses were to complete an SBAR, call the physician and RP. If cannot get in touch with the physician then call the on call physician or NP. Depending on the change of condition would send out to the hospital, if an emergency then would call 911 and send out to the hospital. Interview on [DATE] at 5:15 p.m. with the ADON revealed she had worked at the facility for over 1 year. The ADON stated the following steps should be taken when a resident experienced a change of condition: complete the SBAR, notify the physician and RP; notify the DON or supervising nurse and document a nurse's note regarding the status of the resident's condition. The ADON stated that Resident #1 had 3 family members listed on the face sheet that could be contacted in the event of an emergency; the RP, second and third contact. She stated that it was policy to have 3 family members listed who the nurses could contact in the event of an emergency. The ADON stated that in Resident #1's case all 3 individuals listed had equal decision making status. In reviewing the nurse's note dated [DATE], the ADON stated Resident #1 experienced a change of condition; she had increased temperature of 99.1, she received a neb treatment and APAP suppository. The ADON stated she wondered if the resident's condition stabilized because at the end of the note it read the resident was resting. She stated the nurse technically should have documented a follow up note after treatment was provided to determine the effectiveness of the treatment. The ADON noted the nurse faxed the physician, but stated the nurse should have also called the physician or Medical Director. In reviewing the nurse's note there was no indication the nurse called the physician. The ADON stated that having Resident #1's PCP return calls or answer to fax requests timely had been a problem in the past. Upon review of the nurse's note dated [DATE] at 1:50 p.m., the ADON stated that Resident #1 continued with a change of condition, which was based on congestion, labored breathing and decreased sats to 80%. The ADON stated RN M should have completed an SBAR, called the PCP and all contacts listed until she reached a family member to inform them of the resident's status and RN M really should have sent Resident #1 to the hospital due to respiratory distress. Interview on [DATE] at 7:35 a.m. via telephone call with Resident #1's RP revealed she expressed concerns regarding how nursing staff handled the resident's change of condition. She stated her primary concern was that there was a delay in care. She stated that Resident #1 started having problems breathing on [DATE] and LVN R called her and she went to the facility to see Resident #1. The RP stated she understood at some point a chest X-Ray was ordered, but was never completed. She stated that Resident #1 had previously aspirated a couple of times. The RP stated she was waiting to hear back from staff after she visited with Resident #1 on [DATE], but she never received a call from staff. Interview on [DATE] at 12:45 p.m. with the ADON revealed she started reporting to work on Tuesday's and Thursday's at 12:30 p.m. during [DATE]. She stated [DATE] was a Thursday and commented she did not remember anyone telling her about Resident #1's change of condition. Furthermore, there was no reason to believe the family did not want the resident being sent to the hospital. The ADON stated the facility had not recognized there had been a problem, a delay in care, when responding to Resident #1's change of condition. She stated afterwards she remembered the previous DON mentioned to her that the family wanted to review the medical record. However, she did not understand there had been a problem. The ADON stated training had not been provided since Resident #1 had a change of condition and was sent to the hospital. She stated she was the one in charge of providing in-services. The ADON again stated that it had been facility policy to include 3 emergency contact people when possible. She stated RN M was the DON at the facility at one point and was aware of this policy and knew to call the 2nd and 3rd contact listed and she also understood to call the PCP and or Medical Director as needed in the event of an emergency. Interview on [DATE] at 1:45 p.m. via telephone call with the previous DON N revealed she did not remember anyone reporting Resident #1 had a change of condition during [DATE]. She stated there had been a flu epidemic in the facility and there were many residents who had been affected during this time period. The Previous DON N reviewed her calendar and remembered that she left at 1:00 p.m. on [DATE] and did not return to work until [DATE]. She stated she did not remember anything being mentioned regarding Resident #1 upon her return to work. Interview on [DATE] at 4:01 p.m. via telephone call with head nurse P at Resident #1's PCP's office revealed they received a fax from the facility on [DATE] at 8:08 p.m. regarding Resident #1's condition. She stated it was reviewed and electronically and signed by another physician within their group on [DATE] at 4:04 p.m. Head Nurse P stated they did not receive the addendum dated [DATE] requesting a chest X-Ray. Interview on [DATE] at 4:15 p.m. with Resident #1's PCP via telephone call revealed he typically returned nursing staff's calls within 20 minutes unless he was driving then he it took longer. The PCP stated he did not remember having any conversations with nursing staff about Resident #1's condition on [DATE] or on [DATE] earlier in the day. It was not until after she was sent out to the hospital that he talked with the charge nurse on [DATE]. Interview on [DATE] at 5:08 p.m. via telephone call with head nurse P revealed that in reviewing their answering service notes, someone called from the facility on [DATE] at 3:37 p.m. that Resident #1 was going out to the hospital due to SOB; ambulance awaiting. Head nurse P stated there was nothing documented that any other messages were received earlier that day or on [DATE] regarding Resident #1's condition. Interview on [DATE] at 10:22 a.m. via telephone call with the previous DON N confirmed she returned to work on [DATE]. She remembered Resident #1's family member came in to the facility and requested to review the medical record. DON N stated the family member did not express any major concerns that she could remember. DON N stated that Resident #1's PCP was upset because LVN E sent the resident to the hospital because she was a DNR. She stated he seemed insensitive. DON N stated she did not believe Resident #1 had any comfort medications like [MEDICATION NAME] to give her for comfort care. DON N stated that LVN E did what any reasonable and prudent nurse would do and that was to send her out to the hospital so they could provide the level of care the resident needed to alleviate the resident's distress. DON N stated she talked to her nursing staff about residents with DNR orders. She advised them that they still had to provide the care the resident needed even though a resident had a DNR order in place. Review of a policy titled, Change of Condition (undated) read: Policy: To ensure a resident who experiences a change of condition receives intervention. Responsible Disciplines: Licensed Nurses, Procedure: Licensed nurses will fill out the SBAR form any time a change of condition is noted to a resident. The licensed nurse should place a telephone call to the attending physician or nurse practitioner to discuss their findings regarding the change of condition. Any new orders obtained from the physician or nurse practitioner should be transcribed onto a telephone order and carried out. If the change of condition is an urgent matter and the physician has not returned the call in a reasonable amount of time, you should contact the facility medical director and Chief Nursing Officer. The change of condition should be noted on the 24 hour report for follow up. Review of facility policy titled, Abuse and Neglect Prohibition Information (undated) read: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Definition of Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Example would be failure to answer the call light. The DON and nurse consultant were notified that an Immediate Jeopardy was identified on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. and it included the following: Area Requiring Attention: Change of Condition. Corrective Action Taken: All licensed nurses will be educated on what constitutes a significant change of condition & the completion of an SBAR. All licensed nurses will be educated that one the SBAR is complete the nurse needs to place a telephone call to the attending physician and document outcome to include date and time. All licensed nurses will be educated that to note the change of condition on the 24 hour report for follow up with follow up with time frames included. Education will include that the nurses should document in the resident's medical record every shift on the change of condition & the effectiveness of the interventions until it is resolved or until the resident goes out to the hospital. This documentation must include date and time of significant change of condition, notification, and interventions. If the resident is hospitalized , documentation will include mode of transport, information that was communicated to EMS, condition of resident at time of transfer, and date and time of transfer. The person responsible for the completion of these tasks will be the Chief Nursing Officer & Administration. Education with licensed staff to include that if at any time the attending physician cannot be reached within 30 minutes & the significant change of condition is an urgent matter the facility's medical director should be notified for any additional direction. All facility primary care physicians and medical director will be educated regarding this expectation. Education with all licensed nurses will notify the Chief Nursing Officer or designee of any significant change of condition and will document any plan. The person responsible for the completion of these tasks will be the Chief Nursing Officer/Designee. The date all tasks were initiated and due for completion was noted as [DATE] & ongoing. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by: 1. Interviewed licensed nurses/staff, ADON and the DON on in-services provided on [DATE], [DATE], [DATE], and on [DATE] regarding the protocols to follow in the event that a resident experienced a change of condition which warranted notification to physician. The following steps were identified as follows: completing an SBAR, a telephone call to the physician, notification to responsible party (1st, 2nd or 3rd contact), documentation of interventions and effectiveness of them, V.S., communication on the 24 hour report to be passed to each shift. F/U documentation must be made each shift and PRN until resolved or hospitalization occurs; dates and times should be noted. All interviewed nursing staff verbalized the understanding of the facility protocols. 2. Reviewed in-services completed by licensed nursing staff and reviewed the sign in sheets for staff who attended the following training: Change of Condition, Notification to MD and RP with Change of Condition and CNO, Documentation of Interventions and SBAR, Documentation of transfer and resident to hospital dated [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and Nurse Consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a at a scope of widespread and severity at actual harm due to the facility's need to continue monitoring the effectiveness of staff following the change of condition protocols. Review of a facility Form CMS-672 dated [DATE] revealed the census was 65.

Based on interview and record review the facility failed to ensure that each resident was free from neglect for 1 of 5 resident's (#1) whose records were reviewed for neglect. On [DATE] at 1:50 p.m. RN M failed to consult with Resident #1's PCP or Medical Director; she failed to send Resident #1 to the hospital after identifying an emergency situation and then failed to let the on-coming nurse (LVN E) know the severity of Resident #1's condition. ON [DATE] at 3:40 p.m. LVN E sent Resident #1 out to the hospital, however, waited until she called the physician and a family member. This all resulted in the delay of medical care. Subsequently, Resident #1 suffered respiratory arrest and ultimately expired while at the hospital. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 65 residents and could contribute to a delay in care and ultimately a decline in physical health. The findings were: Review of Resident #1's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were 3 family members listed for emergency contact including the RP, second contact and third contact. Review of Resident #1's medical chart revealed a Texas Department of State Health Services Standard Out-of-Hospital Do-Not-Resuscitate Order dated [DATE]. Review of a physician fax request (undated; time not documented) read: Temp 99.1 at 7:15 p.m. administered 1 suppository. Resident also noted with upper lobe congestion. 02 sat at 89%. Administered PRN [MEDICATION NAME] INH Solution. May we have PRN order for APAP 325 mg x2 tabs po or 650 mg suppository to be administered for discomfort of fever? Signed by LVN R. Further review read: [DATE] Addendum: may we order a CXR?? signed by RN M. Review of physician orders [REDACTED].> 93% and [MEDICATION NAME] UD per neb mask Q 4 hrs, PRN SOB/Wheezing. Review of a nurse's note dated [DATE] at 1:50 p.m. revealed Resident #1 was noted with audible congestion, labored breathing. PRN neb tx admin this shift. 02 sat was 80% on 2L, (increased) to 3L. Res did not eat breakfast & had minimal intake for lunch. Call placed to RP to inform 0 answer, LM. Addendum to MD fax requesting CXR. Response pending VS 97XXX[DATE]-,[DATE]. Note: According to Web MD dated [DATE] revealed: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Interview on [DATE] at 8:17 a.m. with RN M revealed she had worked at the facility for about 8 years and had started working on a PRN basis about 1 to 2 days a week. RN M stated an assessment should be conducted and care provided according to physician orders [REDACTED]. She stated the assessing nurse should continue to call the physician and or RP until contact was made depending on the situation. RN M confirmed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. and remembered Resident #1's condition that day. She stated she learned the resident was already having difficulties from the day before. RN M reviewed the nurse's notes dated [DATE] and confirmed she wrote the note at 1:50 p.m. She stated that the note reflected the resident's condition throughout the shift. She stated she provided Resident #1 with a neb treatment and increased the oxygen to 3L. She stated she also faxed the addendum to the PCP on [DATE] requesting for a chest X-Ray. RN M stated she called the physician, but was not sure at what point she called him. She confirmed the nurse's note did not indicate whether she called the physician or not. RN M stated that there was usually a slow response from Resident #1's PCP's office and at times another physician would respond in the PCP's stead. RN M confirmed that she should have sent Resident #1 to the hospital, but believed the ADON told her that the family did not want her going out to the hospital, but commented she was not 110% sure. RN M stated she called the RP and left a message. She stated she knew there was another sister and father that were involved in the resident's care, but understood the RP was the decision maker. RN M stated that given the orders in place for the resident and the direction she received, she believed she provided care necessary within those parameters. However, RN M confirmed that a family member did not directly tell her that they did not want Resident #1 going out to the hospital and as a prudent nurse she should have proceeded to sending the resident out to the hospital. Furthermore, she should have been more persistent in calling the physician and if she did not get a response she should have called the Medical Director. RN M stated she should have also documented the times she called the physician. Interview on [DATE] at 4:04 p.m. with CNA S revealed she worked on [DATE] from 10:00 p.m. to 6:00 a.m. CNA S stated she recalled Resident #1 being very sick with cough and congestion but did not need suctioning. She stated vital signs were not recorded at that time. Interview on [DATE] at 4:18 p.m. with CNA T revealed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. CNA T stated Resident #1 had to sit up in a chair because she was coughing a lot. She also had to sit up in a Geri-chair to eat. CNA T stated Resident #1 had a dry cough that would come and go but more so when eating. She stated Resident #1 needed suctioning only when she could not clear the resident's secretions. Review of SBAR Communication Form dated [DATE] revealed Resident #1 had been observed and evaluated for SOB on [DATE]; treatment for [REDACTED]. Vital signs were BP ,[DATE], pulse 53, RR 30, temp 98.5 and sat were 71%.; on 02 4L. Further evaluation revealed abnormal lung sounds, labored or rapid breathing. Further review revealed that RP requesting to be sent to ER. PCP called and then 911 was called. Resident #1 went out to the hospital at 3:40 p.m. At 4:00 p.m. PCP was notified and he stated would talk with the family. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 4:30 p.m. with LVN E revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She stated she worked PRN and worked the 200 hall. LVN E stated that upon starting her shift, RN M did not provide a status report regarding the gravity of Resident #1's condition. She stated she made rounds about 3:00 p.m. and noted Resident #1 was on 02 via NC which was a change for the resident. Upon further assessment, she noted the resident was gurgling, her sats were at 71%, her RR were 30 and her breathing was labored. LVN E commented Resident #1 did not look good; she was clearly in respiratory distress. LVN E stated she called the PCP but did not hear back from him so she called the RP who was not available and then called the 2nd emergency contact. The family member asked her to send the resident to the hospital. LVN E stated she completed the SBAR and called 911 and Resident #1 left to the hospital via EMS. LVN E stated that she could have called the Medical Director, but again believed she was clearly dealing with an emergency situation and did not want to waste any more time. LVN E stated that upon reviewing the nurse's notes dated [DATE] at 1:50 p.m., she believed Resident #1 should have been sent to the hospital at that time. She stated Resident #1 was already experiencing a change of condition; the resident had congestion and labored breathing, her respirations were 24; the range for normal limits was from about 16 to 20. She commented she did not understand why only a message was left for the RP and she questioned the rationale for asking for a chest X-ray versus sending the resident out to the hospital. LVN E stated Resident #1's PCP returned her call after the resident left for the hospital and was upset because she sent the resident to the hospital. He stated the resident was a DNR. She further stated she had always been instructed to do whatever the family wanted. Review of a telephone order dated [DATE] confirmed Resident #1 was sent out to the hospital. Review of a hospital history and physical dated [DATE] revealed Resident #1 was admitted with the following Diagnoses: [REDACTED]. Further review revealed Resident #1 arrived via EMS and was subsequently intubated. Note: Review of a document, Physician Quality Reporting System dated [DATE] revealed a Code Blue was called at 1627 (4:27 p.m.) due to respiratory arrest. Further review of the history and physical revealed Resident #1was admitted to the ICU for further care, however, after talking to the family care was withdrawn. Hospice was contacted and was admitted for hospice services. Review of a Discharge Summary dated [DATE] revealed the patient had orders to treat septic shock with vasopressors and antibiotics, maintain mechanical ventilation, workup for problems, etc. Hospice/comfort care reviewed with the family. Decision was made by the family to place the patient on hospice for comfort care. She ultimately expired under hospice care. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 11:30 a.m. with Resident #1's family member revealed she expressed great concern about how the resident's change of condition was handled while at the facility. She questioned if staff ever heard back from the physician because she understood staff requested a CXR which was not completed. The family member questioned whether nursing staff handling the situation followed facility protocols and whether they received support from administrative staff. Interview on [DATE] at 3:06 p.m. with the DON revealed she had worked at the facility for about 3 weeks. She stated that for a change of condition nurses were to complete an SBAR, call the physician and RP. If cannot get in touch with the physician then call the on call physician or NP. Depending on the change of condition would send out to the hospital, if an emergency then would call 911 and send out to the hospital. Interview on [DATE] at 5:15 p.m. with the ADON revealed she had worked at the facility for over 1 year. The ADON stated the following steps should be taken when a resident experienced a change of condition: complete the SBAR, notify the physician and RP; notify the DON or supervising nurse and document a nurse's note regarding the status of the resident's condition. The ADON stated that Resident #1 had 3 family members listed on the face sheet that could be contacted in the event of an emergency; the RP, second and third contact. She stated that it was policy to have 3 family members listed who the nurses could contact in the event of an emergency. The ADON stated that in Resident #1's case all 3 individuals listed had equal decision making status. In reviewing the nurse's note dated [DATE], the ADON stated Resident #1 experienced a change of condition; she had increased temperature of 99.1, she received a neb treatment and APAP suppository. The ADON stated she wondered if the resident's condition stabilized because at the end of the note it read the resident was resting. She stated the nurse technically should have documented a follow up note after treatment was provided to determine the effectiveness of the treatment. The ADON noted the nurse faxed the physician, but stated the nurse should have also called the physician or Medical Director. In reviewing the nurse's note there was no indication the nurse called the physician. The ADON stated that having Resident #1's PCP return calls or answer to fax requests timely had been a problem in the past. Upon review of the nurse's note dated [DATE] at 1:50 p.m., the ADON stated that Resident #1 continued with a change of condition, which was based on congestion, labored breathing and decreased sats to 80%. The ADON stated RN M should have completed an SBAR, called the PCP and all contacts listed until she reached a family member to inform them of the resident's status and RN M really should have sent Resident #1 to the hospital due to respiratory distress. Interview on [DATE] at 7:35 a.m. via telephone call with Resident #1's RP revealed she expressed concerns regarding how nursing staff handled the resident's change of condition. She stated her primary concern was that there was a delay in care. She stated that Resident #1 started having problems breathing on [DATE] and LVN R called her and she went to the facility to see Resident #1. The RP stated she understood at some point a chest X-Ray was ordered, but was never completed. She stated that Resident #1 had previously aspirated a couple of times. The RP stated she was waiting to hear back from staff after she visited with Resident #1 on [DATE], but she never received a call from staff. Interview on [DATE] at 12:45 p.m. with the ADON revealed she started reporting to work on Tuesday's and Thursday's at 12:30 p.m. during [DATE]. She stated [DATE] was a Thursday and commented she did not remember anyone telling her about Resident #1's change of condition. Furthermore, there was no reason to believe the family did not want the resident being sent to the hospital. The ADON stated the facility had not recognized there had been a problem, a delay in care, when responding to Resident #1's change of condition. She stated afterwards she remembered the previous DON mentioned to her that the family wanted to review the medical record. However, she did not understand there had been a problem. The ADON stated training had not been provided since Resident #1 had a change of condition and was sent to the hospital. She stated she was the one in charge of providing in-services. The ADON again stated that it had been facility policy to include 3 emergency contact people when possible. She stated RN M was the DON at the facility at one point and was aware of this policy and knew to call the 2nd and 3rd contact listed and she also understood to call the PCP and or Medical Director as needed in the event of an emergency. Interview on [DATE] at 1:45 p.m. via telephone call with the previous DON N revealed she did not remember anyone reporting Resident #1 had a change of condition during [DATE]. She stated there had been a flu epidemic in the facility and there were many residents who had been affected during this time period. The Previous DON N reviewed her calendar and remembered that she left at 1:00 p.m. on [DATE] and did not return to work until [DATE]. She stated she did not remember anything being mentioned regarding Resident #1 upon her return to work. Interview on [DATE] at 4:01 p.m. via telephone call with head nurse P at Resident #1's PCP's office revealed they received a fax from the facility on [DATE] at 8:08 p.m. regarding Resident #1's condition. She stated it was reviewed and electronically and signed by another physician within their group on [DATE] at 4:04 p.m. Head Nurse P stated they did not receive the addendum dated [DATE] requesting a chest X-Ray. Interview on [DATE] at 4:15 p.m. with Resident #1's PCP via telephone call revealed he typically returned nursing staff's calls within 20 minutes unless he was driving then he it took longer. The PCP stated he did not remember having any conversations with nursing staff about Resident #1's condition on [DATE] or on [DATE] earlier in the day. It was not until after she was sent out to the hospital that he talked with the charge nurse on [DATE]. Interview on [DATE] at 5:08 p.m. via telephone call with head nurse P revealed that in reviewing their answering service notes, someone called from the facility on [DATE] at 3:37 p.m. that Resident #1 was going out to the hospital due to SOB; ambulance awaiting. Head nurse P stated there was nothing documented that any other messages were received earlier that day or on [DATE] regarding Resident #1's condition. Interview on [DATE] at 10:22 a.m. via telephone call with the previous DON N confirmed she returned to work on [DATE]. She remembered Resident #1's family member came in to the facility and requested to review the medical record. DON N stated the family member did not express any major concerns that she could remember. DON N stated that Resident #1's PCP was upset because LVN E sent the resident to the hospital because she was a DNR. She stated he seemed insensitive. DON N stated she did not believe Resident #1 had any comfort medications like [MEDICATION NAME] to give her for comfort care. DON N stated that LVN E did what any reasonable and prudent nurse would do and that was to send her out to the hospital so they could provide the level of care the resident needed to alleviate the resident's distress. DON N stated she talked to her nursing staff about residents with DNR orders. She advised them that they still had to provide the care the resident needed even though a resident had a DNR order in place. Review of a policy titled, Change of Condition (undated) read: Policy: To ensure a resident who experiences a change of condition receives intervention. Responsible Disciplines: Licensed Nurses, Procedure: Licensed nurses will fill out the SBAR form any time a change of condition is noted to a resident. The licensed nurse should place a telephone call to the attending physician or nurse practitioner to discuss their findings regarding the change of condition. Any new orders obtained from the physician or nurse practitioner should be transcribed onto a telephone order and carried out. If the change of condition is an urgent matter and the physician has not returned the call in a reasonable amount of time, you should contact the facility medical director and Chief Nursing Officer. The change of condition should be noted on the 24 hour report for follow up. Review of facility policy titled, Abuse and Neglect Prohibition Information (undated) read: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Definition of Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Example would be failure to answer the call light. The DON and nurse consultant were notified that an Immediate Jeopardy was identified on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. and it included the following: Area Requiring Attention: Change of Condition. Corrective Action Taken: All licensed nurses will be educated on what constitutes a significant change of condition & the completion of an SBAR. All licensed nurses will be educated that one the SBAR is complete the nurse needs to place a telephone call to the attending physician and document outcome to include date and time. All licensed nurses will be educated that to note the change of condition on the 24 hour report for follow up with follow up with time frames included. Education will include that the nurses should document in the resident's medical record every shift on the change of condition & the effectiveness of the interventions until it is resolved or until the resident goes out to the hospital. This documentation must include date and time of significant change of condition, notification, and interventions. If the resident is hospitalized , documentation will include mode of transport, information that was communicated to EMS, condition of resident at time of transfer, and date and time of transfer. The person responsible for the completion of these tasks will be the Chief Nursing Officer & Administration. Education with licensed staff to include that if at any time the attending physician cannot be reached within 30 minutes & the significant change of condition is an urgent matter the facility's medical director should be notified for any additional direction. All facility primary care physicians and medical director will be educated regarding this expectation. Education with all licensed nurses will notify the Chief Nursing Officer or designee of any significant change of condition and will document any plan. The person responsible for the completion of these tasks will be the Chief Nursing Officer/Designee. The date all tasks were initiated and due for completion was noted as [DATE] & ongoing. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by: 1. Interviewed licensed nurses/staff, ADON and the DON on in-services provided on [DATE], [DATE], [DATE], and on [DATE] regarding the protocols to follow in the event that a resident experienced a change of condition which warranted notification to physician. The following steps were identified as follows: completing an SBAR, a telephone call to the physician, notification to responsible party (1st, 2nd or 3rd contact), documentation of interventions and effectiveness of them, V.S., communication on the 24 hour report to be passed to each shift. F/U documentation must be made each shift and PRN until resolved or hospitalization occurs; dates and times should be noted. All interviewed nursing staff verbalized the understanding of the facility protocols. 2. Reviewed in-services completed by licensed nursing staff and reviewed the sign in sheets for staff who attended the following training: Change of Condition, Notification to MD and RP with Change of Condition and CNO, Documentation of Interventions and SBAR, Documentation of transfer and resident to hospital dated [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and Nurse Consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to continue monitoring the effectiveness of staff following the change of condition protocols. Review of a facility Form CMS-672 dated [DATE] revealed the census was 65.

Based on interview and record review the facility failed to implement written policies and procedures to prohibit neglect for 1 of 5 resident's (#1) whose records were reviewed for neglect. On [DATE] at 1:50 p.m. RN M failed to consult with Resident #1's PCP or Medical Director; she failed to send Resident #1 to the hospital after identifying an emergency situation and then failed to let the on-coming nurse (LVN E) know the severity of Resident #1's condition. ON [DATE] at 3:40 p.m. LVN E sent Resident #1 out to the hospital, however, waited until she called the physician and a family member. This all resulted in the delay of medical care. Subsequently, Resident #1 suffered respiratory arrest and ultimately expired while at the hospital. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 65 residents and could contribute to a delay in care and ultimately a decline in physical health. The findings were: Review of facility policy titled, Abuse and Neglect Prohibitation Information (undated) read: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Definition of Neglect is the failure to provide goods and servides necessary to avoid physical harm, mental anguish, or mental illness. Example would be failure to answer the call light. Review of a policy titled, Change of Condition (undated) read: Policy: To ensure a resident who experiences a change of condition receives intervention. Responsible Disciplines: Licensed Nurses, Procedure: Licensed nurses will fill out the SBAR form any time a change of condition is noted to a resident. The licensed nurse should place a telephone call to the attending physician or nurse practitioner to discuss their findings regarding the change of condition. Any new orders obtained from the physician or nurse practitioner should be transcribed onto a telephone order and carried out. If the change of condition is an urgent matter and the physician has not returned the call in a reasonable amount of time, you should contact the facility medical director and Chief Nursing Officer. The change of condition should be noted on the 24 hour report for follow up. Review of Resident #1's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were 3 family members listed for emergency contact including the RP, second contact and third contact. Review of Resident #1's medical chart revealed a Texas Department of State Health Services Standard Out-of-Hospital Do-Not-Resuscitate Order dated [DATE]. Review of a physician fax request (undated; time not documented) read: Temp 99.1 at 7:15 p.m. administered 1 suppository. Resident also noted with upper lobe congestion. 02 sat at 89%. Administered PRN [MEDICATION NAME] INH Solution. May we have PRN order for APAP 325 mg x2 tabs po or 650 mg suppository to be administered for discomfort of fever? Signed by LVN R. Further review read: [DATE] Addendum: may we order a CXR?? signed by RN M. Review of physician orders [REDACTED].> 93% and [MEDICATION NAME] UD per neb mask Q 4 hrs, PRN SOB/Wheezing. Review of a nurse's note dated [DATE] at 1:50 p.m. revealed Resident #1 was noted with audible congestion, labored breathing. PRN neb tx admin this shift. 02 sat was 80% on 2L, (increased) to 3L. Res did not eat breakfast & had minimal intake for lunch. Call placed to RP to inform 0 answer, LM. Addendum to MD fax requesting CXR. Response pending VS 97XXX[DATE]-,[DATE]. Note: According to Web MD dated [DATE] revealed: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Interview on [DATE] at 8:17 a.m. with RN M revealed she had worked at the facility for about 8 years and had started working on a PRN basis about 1 to 2 days a week. RN M stated an assessment should be conducted and care provided according to physician orders [REDACTED]. She stated the assessing nurse should continue to call the physician and or RP until contact was made depending on the situation. RN M confirmed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. and remembered Resident #1's condition that day. She stated she learned the resident was already having difficulties from the day before. RN M reviewed the nurse's notes dated [DATE] and confirmed she wrote the note at 1:50 p.m. She stated that the note reflected the resident's condition throughout the shift. She stated she provided Resident #1 with a neb treatment and increased the oxygen to 3L. She stated she also faxed the addendum to the PCP on [DATE] requesting for a chest X-Ray. RN M stated she called the physician, but was not sure at what point she called him. She confirmed the nurse's note did not indicate whether she called the physician or not. RN M stated that there was usually a slow response from Resident #1's PCP's office and at times another physician would respond in the PCP's stead. RN M confirmed that she should have sent Resident #1 to the hospital, but believed the ADON told her that the family did not want her going out to the hospital, but commented she was not 110% sure. RN M stated she called the RP and left a message. She stated she knew there was another sister and father that were involved in the resident's care, but understood the RP was the decision maker. RN M stated that given the orders in place for the resident and the direction she received, she believed she provided care necessary within those parameters. However, RN M confirmed that a family member did not directly tell her that they did not want Resident #1 going out to the hospital and as a prudent nurse she should have proceeded to sending the resident out to the hospital. Furthermore, she should have been more persistent in calling the physician and if she did not get a response she should have called the Medical Director. RN M stated she should have also documented the times she called the physician. Interview on [DATE] at 4:04 p.m. with CNA S revealed she worked on [DATE] from 10:00 p.m. to 6:00 a.m. CNA S stated she recalled Resident #1 being very sick with cough and congestion but did not need suctioning. She stated vital signs were not recorded at that time. Interview on [DATE] at 4:18 p.m. with CNA T revealed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. CNA T stated Resident #1 had to sit up in a chair because she was coughing a lot. She also had to sit up in a Geri-chair to eat. CNA T stated Resident #1 had a dry cough that would come and go but more so when eating. She stated Resident #1 needed suctioning only when she could not clear the resident's secretions. Review of SBAR Communication Form dated [DATE] revealed Resident #1 had been observed and evaluated for SOB on [DATE]; treatment for [REDACTED]. Vital signs were BP ,[DATE], pulse 53, RR 30, temp 98.5 and sat were 71%.; on 02 4L. Further evaluation revealed abnormal lung sounds, labored or rapid breathing. Further review revealed that RP requesting to be sent to ER. PCP called and then 911 was called. Resident #1 went out to the hospital at 3:40 p.m. At 4:00 p.m. PCP was notified and he stated would talk with the family. Interview on [DATE] at 4:30 p.m. with LVN E revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She stated she worked PRN and worked the 200 hall. LVN E stated that upon starting her shift, RN M did not provide a status report regarding the gravity of Resident #1's condition. She stated she made rounds about 3:00 p.m. and noted Resident #1 was on 02 via NC which was a change for the resident. Upon further assessment, she noted the resident was gurgling, her sats were at 71%, her RR were 30 and her breathing was labored. LVN E commented Resident #1 did not look good; she was clearly in respiratory distress. LVN E stated she called the PCP but did not hear back from him so she called the RP who was not available and then called the 2nd emergency contact. The family member asked her to send the resident to the hospital. LVN E stated she completed the SBAR and called 911 and Resident #1 left to the hospital via EMS. LVN E stated that she could have called the Medical Director, but again believed she was clearly dealing with an emergency situation and did not want to waste any more time. LVN E stated that upon reviewing the nurse's notes dated [DATE] at 1:50 p.m., she believed Resident #1 should have been sent to the hospital at that time. She stated Resident #1 was already experiencing a change of condition; the resident had congestion and labored breathing, her respirations were 24; the range for normal limits was from about 16 to 20. She commented she did not understand why only a message was left for the RP and she questioned the rationale for asking for a chest X-ray versus sending the resident out to the hospital. LVN E stated Resident #1's PCP returned her call after the resident left for the hospital and was upset because she sent the resident to the hospital. He stated the resident was a DNR. She further stated she had always been instructed to do whatever the family wanted. Review of a telephone order dated [DATE] confirmed Resident #1 was sent out to the hospital. Review of a hospital history and physical dated [DATE] revealed Resident #1 was admitted with the following Diagnoses: [REDACTED]. Further review revealed Resident #1 arrived via EMS and was subsequently intubated. Note: Review of a document, Physician Quality Reporting System dated [DATE] revealed a Code Blue was called at 1627 (4:27 p.m.) due to respiratory arrest. Further review of the history and physical revealed Resident #1was admitted to the ICU for further care, however, after talking to the family care was withdrawn. Hospice was contacted and was admitted for hospice services. Review of a Discharge Summary dated [DATE] revealed the patient had orders to treat septic shock with vasopressors and antibiotics, maintain mechanical ventilation, workup for problems, etc. Hospice/comfort care reviewed with the family. Decision was made by the family to place the patient on hospice for comfort care. She ultimately expired under hospice care. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 11:30 a.m. with Resident #1's family member revealed she expressed great concern about how the resident's change of condition was handled while at the facility. She questioned if staff ever heard back from the physician because she understood staff requested a CXR which was not completed. The family member questioned whether nursing staff handling the situation followed facility protocols and whether they received support from administrative staff. Interview on [DATE] at 3:06 p.m. with the DON revealed she had worked at the facility for about 3 weeks. She stated that for a change of condition nurses were to complete an SBAR, call the physician and RP. If cannot get in touch with the physician then call the on call physician or NP. Depending on the change of condition would send out to the hospital, if an emergency then would call 911 and send out to the hospital. Interview on [DATE] at 5:15 p.m. with the ADON revealed she had worked at the facility for over 1 year. The ADON stated the following steps should be taken when a resident experienced a change of condition: complete the SBAR, notify the physician and RP; notify the DON or supervising nurse and document a nurse's note regarding the status of the resident's condition. The ADON stated that Resident #1 had 3 family members listed on the face sheet that could be contacted in the event of an emergency; the RP, second and third contact. She stated that it was policy to have 3 family members listed who the nurses could contact in the event of an emergency. The ADON stated that in Resident #1's case all 3 individuals listed had equal decision making status. In reviewing the nurse's note dated [DATE], the ADON stated Resident #1 experienced a change of condition; she had increased temperature of 99.1, she received a neb treatment and APAP suppository. The ADON stated she wondered if the resident's condition stabilized because at the end of the note it read the resident was resting. She stated the nurse technically should have documented a follow up note after treatment was provided to determine the effectiveness of the treatment. The ADON noted the nurse faxed the physician, but stated the nurse should have also called the physician or Medical Director. In reviewing the nurse's note there was no indication the nurse called the physician. The ADON stated that having Resident #1's PCP return calls or answer to fax requests timely had been a problem in the past. Upon review of the nurse's note dated [DATE] at 1:50 p.m., the ADON stated that Resident #1 continued with a change of condition, which was based on congestion, labored breathing and decreased sats to 80%. The ADON stated RN M should have completed an SBAR, called the PCP and all contacts listed until she reached a family member to inform them of the resident's status and RN M really should have sent Resident #1 to the hospital due to respiratory distress. Interview on [DATE] at 7:35 a.m. via telephone call with Resident #1's RP revealed she expressed concerns regarding how nursing staff handled the resident's change of condition. She stated her primary concern was that there was a delay in care. She stated that Resident #1 started having problems breathing on [DATE] and LVN R called her and she went to the facility to see Resident #1. The RP stated she understood at some point a chest X-Ray was ordered, but was never completed. She stated that Resident #1 had previously aspirated a couple of times. The RP stated she was waiting to hear back from staff after she visited with Resident #1 on [DATE], but she never received a call from staff. Interview on [DATE] at 12:45 p.m. with the ADON revealed she started reporting to work on Tuesday's and Thursday's at 12:30 p.m. during [DATE]. She stated [DATE] was a Thursday and commented she did not remember anyone telling her about Resident #1's change of condition. Furthermore, there was no reason to believe the family did not want the resident being sent to the hospital. The ADON stated the facility had not recognized there had been a problem, a delay in care, when responding to Resident #1's change of condition. She stated afterwards she remembered the previous DON mentioned to her that the family wanted to review the medical record. However, she did not understand there had been a problem. The ADON stated training had not been provided since Resident #1 had a change of condition and was sent to the hospital. She stated she was the one in charge of providing in-services. The ADON again stated that it had been facility policy to include 3 emergency contact people when possible. She stated RN M was the DON at the facility at one point and was aware of this policy and knew to call the 2nd and 3rd contact listed and she also understood to call the PCP and or Medical Director as needed in the event of an emergency. Interview on [DATE] at 1:45 p.m. via telephone call with the previous DON N revealed she did not remember anyone reporting Resident #1 had a change of condition during [DATE]. She stated there had been a flu epidemic in the facility and there were many residents who had been affected during this time period. The Previous DON N reviewed her calendar and remembered that she left at 1:00 p.m. on [DATE] and did not return to work until [DATE]. She stated she did not remember anything being mentioned regarding Resident #1 upon her return to work. Interview on [DATE] at 4:01 p.m. via telephone call with head nurse P at Resident #1's PCP's office revealed they received a fax from the facility on [DATE] at 8:08 p.m. regarding Resident #1's condition. She stated it was reviewed and electronically and signed by another physician within their group on [DATE] at 4:04 p.m. Head Nurse P stated they did not receive the addendum dated [DATE] requesting a chest X-Ray. Interview on [DATE] at 4:15 p.m. with Resident #1's PCP via telephone call revealed he typically returned nursing staff's calls within 20 minutes unless he was driving then he it took longer. The PCP stated he did not remember having any conversations with nursing staff about Resident #1's condition on [DATE] or on [DATE] earlier in the day. It was not until after she was sent out to the hospital that he talked with the charge nurse on [DATE]. Interview on [DATE] at 5:08 p.m. via telephone call with head nurse P revealed that in reviewing their answering service notes, someone called from the facility on [DATE] at 3:37 p.m. that Resident #1 was going out to the hospital due to SOB; ambulance awaiting. Head nurse P stated there was nothing documented that any other messages were received earlier that day or on [DATE] regarding Resident #1's condition. Interview on [DATE] at 10:22 a.m. via telephone call with the previous DON N confirmed she returned to work on [DATE]. She remembered Resident #1's family member came in to the facility and requested to review the medical record. DON N stated the family member did not express any major concerns that she could remember. DON N stated that Resident #1's PCP was upset because LVN E sent the resident to the hospital because she was a DNR. She stated he seemed insensitive. DON N stated she did not believe Resident #1 had any comfort medications like [MEDICATION NAME] to give her for comfort care. DON N stated that LVN E did what any reasonable and prudent nurse would do and that was to send her out to the hospital so they could provide the level of care the resident needed to alleviate the resident's distress. DON N stated she talked to her nursing staff about residents with DNR orders. She advised them that they still had to provide the care the resident needed even though a resident had a DNR order in place. The DON and nurse consultant were notified that an Immediate Jeopardy was identified on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. and it included the following: Area Requiring Attention: Change of Condition. Corrective Action Taken: All licensed nurses will be educated on what constitutes a significant change of condition & the completion of an SBAR. All licensed nurses will be educated that one the SBAR is complete the nurse needs to place a telephone call to the attending physician and document outcome to include date and time. All licensed nurses will be educated that to note the change of condition on the 24 hour report for follow up with follow up with time frames included. Education will include that the nurses should document in the resident's medical record every shift on the change of condition & the effectiveness of the interventions until it is resolved or until the resident goes out to the hospital. This documentation must include date and time of significant change of condition, notification, and interventions. If the resident is hospitalized , documentation will include mode of transport, information that was communicated to EMS, condition of resident at time of transfer, and date and time of transfer. The person responsible for the completion of these tasks will be the Chief Nursing Officer & Administration. Education with licensed staff to include that if at any time the attending physician cannot be reached within 30 minutes & the significant change of condition is an urgent matter the facility's medical director should be notified for any additional direction. All facility primary care physicians and medical director will be educated regarding this expectation. Education with all licensed nurses will notify the Chief Nursing Officer or designee of any significant change of condition and will document any plan. The person responsible for the completion of these tasks will be the Chief Nursing Officer/Designee. The date all tasks were initiated and due for completion was noted as [DATE] & ongoing. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by: 1. Interviewed licensed nurses/staff, ADON and the DON on in-services provided on [DATE], [DATE], [DATE], and on [DATE] regarding the protocols to follow in the event that a resident experienced a change of condition which warranted notification to physician. The following steps were identified as follows: completing an SBAR, a telephone call to the physician, notification to responsible party (1st, 2nd or 3rd contact), documentation of interventions and effectiveness of them, V.S., communication on the 24 hour report to be passed to each shift. F/U documentation must be made each shift and PRN until resolved or hospitalization occurs; dates and times should be noted. All interviewed nursing staff verbalized the understanding of the facility protocols. 2. Reviewed in-services completed by licensed nursing staff and reviewed the sign in sheets for staff who attended the following training: Change of Condition, Notification to MD and RP with Change of Condition and CNO, Documentation of Interventions and SBAR, Documentation of transfer and resident to hospital dated [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and Nurse Consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to continue monitoring the effectiveness of staff following the change of condition protocols. Review of a facility Form CMS-672 dated [DATE] revealed the census was 65.

Based on interview and record review the facility failed to ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality for 1 of 5 residents (#1) whose records were reviewed. On [DATE] at 1:50 p.m. RN M failed to consult with Resident #1's PCP or Medical Director; she failed to send Resident #1 to the hospital after identifying an emergency situation and then failed to let the on-coming nurse (LVN E) know the severity of Resident #1's condition. ON [DATE] at 3:40 p.m. LVN E sent Resident #1 out to the hospital, however, waited until she called the physician and a family member. This all resulted in the delay of medical care. Subsequently, Resident #1 suffered respiratory arrest and ultimately expired while at the hospital. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 65 residents and could contribute to a delay in care and ultimately a decline in physical health. The findings were: 1. According Texas Board of Nursing, 15.4 In the interest of fulfilling its mission to protect the health, safety, and welfare of the people of Texas through the regulation of nurses, the Board of Nursing (BON), through the Nursing Practice Act and Board Rules, emphasizes the nurse ' s responsibility and duty to the client/patient to provide safe, effective nursing care. Specifically, the following portions of the Board Rules and supporting documents underscore the duty and responsibilities of the LVN and/or the RN to the client/patient: · The Standards of Nursing Practice differentiate the roles of the LVN and the RN in accepting nursing care assignments, assuring a safe environment for patients, and obtaining instruction and supervision as needed (22 TAC § 217.11); and · Each nurse must be able to support how his/her clinical judgments and nursing actions were aligned with the NPA and Board Rules. The Board recommends nurses use the Six-Step Decision-Making Model for Determining Nursing Scope of Practice when trying to determine if a given task is within the individual nurse ' s abilities. Congruence with standards adopted by national nursing specialty organizations may further serve to enhance and support the nurse ' s decision to perform a particular task. The nurse, by virtue of a rigorous process of education and examination leading to either LVN or RN licensure, is accountable to the Board to assure that nursing care meets standards of safety and effectiveness. 2. According to the Texas Board of Nursing, Texas Administrative Code, TITLE 22 EXAMINING BOARDS PART 11,TEXAS BOARD OF NURSING, CHAPTER 217, LICENSURE, PEER ASSISTANCE AND PRACTICE, RULE §217.11, Standards of Nursing Practice, The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing [DIAGNOSES REDACTED]. (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client's responses to nursing interventions; (B) Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute are environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions. Review of Resident #1's medical chart revealed a Texas Department of State Health Services Standard Out-of-Hopsital Do-Not-Resuscitate Order dated [DATE]. Review of the most recent CP updated on [DATE] revealed that Resident #1 was not capable of understanding and exercising her rights and being informed of her health status. It was noted she was non-verbal, so her RP must make all decisions on her behalf. One of the approaches was for staff to ensure her needs were met in a timely manner with her dignity intact since Resident #1 could not voice her needs. Further review revealed that Resident #1's RP and MD would be notified of changes in cognitive ability and due to being non-verbal staff should monitor for non-verbal signs and symptoms of distress during ADL's/personal care. In addition, it was noted that Resident #1 had a swallowing problem and was at risk for aspiration and upper respiratory infections and she required the use of oxygen at 4L PRN via NC PRN SOB. One of the approaches was to monitor oxygen saturation PRN-notify MD/RP of abnormalities. Review of a physician fax request (undated; time not documented) read: Temp 99.1 at 7:15 p.m. administered 1 suppository. Resident also noted with upper lobe congestion. 02 sat at 89%. Administered PRN [MEDICATION NAME] INH Solution. May we have PRN order for APAP 325 mg x2 tabs po or 650 mg suppository to be administered for discomfort of fever? Signed by LVN R. Further review read: [DATE] Addendum: may we order a CXR?? signed by RN M. Review of physician orders [REDACTED].> 93% and [MEDICATION NAME] UD per neb mask Q 4 hrs, PRN SOB/Wheezing. Review of a nurse's note dated [DATE] at 1:50 p.m. revealed Resident #1 was noted with audible congestion, labored breathing. PRN neb tx admin this shift. 02 sat was 80% on 2L, (increased) to 3L. Res did not eat breakfast & had minimal intake for lunch. Call placed to RP to inform 0 answer, LM. Addendum to MD fax requesting CXR. Response pending VS 97XXX[DATE]-,[DATE]. Note: According to Web MD dated [DATE] revealed: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Interview on [DATE] at 8:17 a.m. with RN M revealed she had worked at the facility for about 8 years and had started working on a PRN basis about 1 to 2 days a week. RN M stated an assessment should be conducted and care provided according to physician orders [REDACTED]. She stated the assessing nurse should continue to call the physician and or RP until contact was made depending on the situation. RN M confirmed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. and remembered Resident #1's condition that day. She stated she learned the resident was already having difficulties from the day before. RN M reviewed the nurse's notes dated [DATE] and confirmed she wrote the note at 1:50 p.m. She stated that the note reflected the resident's condition throughout the shift. She stated she provided Resident #1 with a neb treatment and increased the oxygen to 3L. She stated she also faxed the addendum to the PCP on [DATE] requesting for a chest X-Ray. RN M stated she called the physician, but was not sure at what point she called him. She confirmed the nurse's note did not indicate whether she called the physician or not. RN M stated that there was usually a slow response from Resident #1's PCP's office and at times another physician would respond in the PCP's stead. RN M confirmed that she should have sent Resident #1 to the hospital, but believed the ADON told her that the family did not want her going out to the hospital, but commented she was not 110% sure. RN M stated she called the RP and left a message. She stated she knew there was another sister and father that were involved in the resident's care, but understood the RP was the decision maker. RN M stated that given the orders in place for the resident and the direction she received, she believed she provided care necessary within those parameters. However, RN M confirmed that a family member did not directly tell her that they did not want Resident #1 going out to the hospital and as a prudent nurse she should have proceeded to sending the resident out to the hospital. Furthermore, she should have been more persistent in calling the physician and if she did not get a response she should have called the Medical Director. RN M stated she should have also documented the times she called the physician. Interview on [DATE] at 4:04 p.m. with CNA S revealed she worked on [DATE] from 10:00 p.m. to 6:00 a.m. CNA S stated she recalled Resident #1 being very sick with cough and congestion but did not need suctioning. She stated vital signs were not recorded at that time. Interview on [DATE] at 4:18 p.m. with CNA T revealed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. CNA T stated Resident #1 had to sit up in a chair because she was coughing a lot. She also had to sit up in a Geri-chair to eat. CNA T stated Resident #1 had a dry cough that would come and go but more so when eating. She stated Resident #1 needed suctioning only when she could not clear the resident's secretions. Review of SBAR Communication Form dated [DATE] revealed Resident #1 had been observed and evaluated for SOB on [DATE]; treatment for [REDACTED]. Vital signs were BP ,[DATE], pulse 53, RR 30, temp 98.5 and sat were 71%.; on 02 4L. Further evaluation revealed abnormal lung sounds, labored or rapid breathing. Further review revealed that RP requesting to be sent to ER. PCP called and then 911 was called. Resident #1 went out to the hospital at 3:40 p.m. At 4:00 p.m. PCP was notified and he stated would talk with the family. Interview on [DATE] at 4:30 p.m. with LVN E revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She stated she worked PRN and worked the 200 hall. LVN E stated that upon starting her shift, RN M did not provide a status report regarding the gravity of Resident #1's condition. She stated she made rounds about 3:00 p.m. and noted Resident #1 was on 02 via NC which was a change for the resident. Upon further assessment, she noted the resident was gurgling, her sats were at 71%, her RR were 30 and her breathing was labored. LVN E commented Resident #1 did not look good; she was clearly in respiratory distress. LVN E stated she called the PCP but did not hear back from him so she called the RP who was not available and then called the 2nd emergency contact. The family member asked her to send the resident to the hospital. LVN E stated she completed the SBAR and called 911 and Resident #1 left to the hospital via EMS. LVN E stated that she could have called the Medical Director, but again believed she was clearly dealing with an emergency situation and did not want to waste any more time. LVN E stated that upon reviewing the nurse's notes dated [DATE] at 1:50 p.m., she believed Resident #1 should have been sent to the hospital at that time. She stated Resident #1 was already experiencing a change of condition; the resident had congestion and labored breathing, her respirations were 24; the range for normal limits was from about 16 to 20. She commented she did not understand why only a message was left for the RP and she questioned the rationale for asking for a chest X-ray versus sending the resident out to the hospital. LVN E stated Resident #1's PCP returned her call after the resident left for the hospital and was upset because she sent the resident to the hospital. He stated the resident was a DNR. She further stated she had always been instructed to do whatever the family wanted. Review of a telephone order dated [DATE] confirmed Resident #1 was sent out to the hospital. Review of a hospital history and physical dated [DATE] revealed Resident #1 was admitted with the following Diagnoses: [REDACTED]. Further review revealed Resident #1 arrived via EMS and was subsequently intubated. Note: Review of a document, Physician Quality Reporting System dated [DATE] revealed a Code Blue was called at 1627 (4:27 p.m.) due to respiratory arrest. Further review of the history and physical revealed Resident #1was admitted to the ICU for further care, however, after talking to the family care was withdrawn. Hospice was contacted and was admitted for hospice services. Review of a Discharge Summary dated [DATE] revealed the patient had orders to treat septic shock with vasopressors and antibiotics, maintain mechanical ventilation, workup for problems, etc. Hospice/comfort care reviewed with the family. Decision was made by the family to place the patient on hospice for comfort care. She ultimately expired under hospice care. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 11:30 a.m. with Resident #1's family member revealed she expressed great concern about how the resident's change of condition was handled while at the facility. She questioned if staff ever heard back from the physician because she understood staff requested a CXR which was not completed. The family member questioned whether nursing staff handling the situation followed facility protocols and whether they received support from administrative staff. Interview on [DATE] at 3:06 p.m. with the DON revealed she had worked at the facility for about 3 weeks. She stated that for a change of condition nurses were to complete an SBAR, call the physician and RP. If cannot get in touch with the physician then call the on call physician or NP. Depending on the change of condition would send out to the hospital, if an emergency then would call 911 and send out to the hospital. Interview on [DATE] at 5:15 p.m. with the ADON revealed she had worked at the facility for over 1 year. The ADON stated the following steps should be taken when a resident experienced a change of condition: complete the SBAR, notify the physician and RP; notify the DON or supervising nurse and document a nurse's note regarding the status of the resident's condition. The ADON stated that Resident #1 had 3 family members listed on the face sheet that could be contacted in the event of an emergency; the RP, second and third contact. She stated that it was policy to have 3 family members listed who the nurses could contact in the event of an emergency. The ADON stated that in Resident #1's case all 3 individuals listed had equal decision making status. In reviewing the nurse's note dated [DATE], the ADON stated Resident #1 experienced a change of condition; she had increased temperature of 99.1, she received a neb treatment and APAP suppository. The ADON stated she wondered if the resident's condition stabilized because at the end of the note it read the resident was resting. She stated the nurse technically should have documented a follow up note after treatment was provided to determine the effectiveness of the treatment. The ADON noted the nurse faxed the physician, but stated the nurse should have also called the physician or Medical Director. In reviewing the nurse's note there was no indication the nurse called the physician. The ADON stated that having Resident #1's PCP return calls or answer to fax requests timely had been a problem in the past. Upon review of the nurse's note dated [DATE] at 1:50 p.m., the ADON stated that Resident #1 continued with a change of condition, which was based on congestion, labored breathing and decreased sats to 80%. The ADON stated RN M should have completed an SBAR, called the PCP and all contacts listed until she reached a family member to inform them of the resident's status and RN M really should have sent Resident #1 to the hospital due to respiratory distress. Interview on [DATE] at 7:35 a.m. via telephone call with Resident #1's RP revealed she expressed concerns regarding how nursing staff handled the resident's change of condition. She stated her primary concern was that there was a delay in care. She stated that Resident #1 started having problems breathing on [DATE] and LVN R called her and she went to the facility to see Resident #1. The RP stated she understood at some point a chest X-Ray was ordered, but was never completed. She stated that Resident #1 had previously aspirated a couple of times. The RP stated she was waiting to hear back from staff after she visited with Resident #1 on [DATE], but she never received a call from staff. Interview on [DATE] at 12:45 p.m. with the ADON revealed she started reporting to work on Tuesday's and Thursday's at 12:30 p.m. during [DATE]. She stated [DATE] was a Thursday and commented she did not remember anyone telling her about Resident #1's change of condition. Furthermore, there was no reason to believe the family did not want the resident being sent to the hospital. The ADON stated the facility had not recognized there had been a problem, a delay in care, when responding to Resident #1's change of condition. She stated afterwards she remembered the previous DON mentioned to her that the family wanted to review the medical record. However, she did not understand there had been a problem. The ADON stated training had not been provided since Resident #1 had a change of condition and was sent to the hospital. She stated she was the one in charge of providing in-services. The ADON again stated that it had been facility policy to include 3 emergency contact people when possible. She stated RN M was the DON at the facility at one point and was aware of this policy and knew to call the 2nd and 3rd contact listed and she also understood to call the PCP and or Medical Director as needed in the event of an emergency. Interview on [DATE] at 1:45 p.m. via telephone call with the previous DON N revealed she did not remember anyone reporting Resident #1 had a change of condition during [DATE]. She stated there had been a flu epidemic in the facility and there were many residents who had been affected during this time period. The Previous DON N reviewed her calendar and remembered that she left at 1:00 p.m. on [DATE] and did not return to work until [DATE]. She stated she did not remember anything being mentioned regarding Resident #1 upon her return to work. Interview on [DATE] at 4:01 p.m. via telephone call with head nurse P at Resident #1's PCP's office revealed they received a fax from the facility on [DATE] at 8:08 p.m. regarding Resident #1's condition. She stated it was reviewed and electronically and signed by another physician within their group on [DATE] at 4:04 p.m. Head Nurse P stated they did not receive the addendum dated [DATE] requesting a chest X-Ray. Interview on [DATE] at 4:15 p.m. with Resident #1's PCP via telephone call revealed he typically returned nursing staff's calls within 20 minutes unless he was driving then he it took longer. The PCP stated he did not remember having any conversations with nursing staff about Resident #1's condition on [DATE] or on [DATE] earlier in the day. It was not until after she was sent out to the hospital that he talked with the charge nurse on [DATE]. Interview on [DATE] at 5:08 p.m. via telephone call with head nurse P revealed that in reviewing their answering service notes, someone called from the facility on [DATE] at 3:37 p.m. that Resident #1 was going out to the hospital due to SOB; ambulance awaiting. Head nurse P stated there was nothing documented that any other messages were received earlier that day or on [DATE] regarding Resident #1's condition. Interview on [DATE] at 10:22 a.m. via telephone call with the previous DON N confirmed she returned to work on [DATE]. She remembered Resident #1's family member came in to the facility and requested to review the medical record. DON N stated the family member did not express any major concerns that she could remember. DON N stated that Resident #1's PCP was upset because LVN E sent the resident to the hospital because she was a DNR. She stated he seemed insensitive. DON N stated she did not believe Resident #1 had any comfort medications like [MEDICATION NAME] to give her for comfort care. DON N stated that LVN E did what any reasonable and prudent nurse would do and that was to send her out to the hospital so they could provide the level of care the resident needed to alleviate the resident's distress. DON N stated she talked to her nursing staff about residents with DNR orders. She advised them that they still had to provide the care the resident needed even though a resident had a DNR order in place. Review of a policy titled, Change of Condition (undated) read: Policy: To ensure a resident who experiences a change of condition receives intervention. Responsible Disciplines: Licensed Nurses, Procedure: Licensed nurses will fill out the SBAR form any time a change of condition is noted to a resident. The licensed nurse should place a telephone call to the attending physician or nurse practitioner to discuss their findings regarding the change of condition. Any new orders obtained from the physician or nurse practitioner should be transcribed onto a telephone order and carried out. If the change of condition is an urgent matter and the physician has not returned the call in a reasonable amount of time, you should contact the facility medical director and Chief Nursing Officer. The change of condition should be noted on the 24 hour report for follow up. The DON and nurse consultant were notified that an Immediate Jeopardy was identified on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. and it included the following: Area Requiring Attention: Change of Condition. Corrective Action Taken: All licensed nurses will be educated on what constitutes a significant change of condition & the completion of an SBAR. All licensed nurses will be educated that one the SBAR is complete the nurse needs to place a telephone call to the attending physician and document outcome to include date and time. All licensed nurses will be educated that to note the change of condition on the 24 hour report for follow up with follow up with time frames included. Education will include that the nurses should document in the resident's medical record every shift on the change of condition & the effectiveness of the interventions until it is resolved or until the resident goes out to the hospital. This documentation must include date and time of significant change of condition, notification, and interventions. If the resident is hospitalized , documentation will include mode of transport, information that was communicated to EMS, condition of resident at time of transfer, and date and time of transfer. The person responsible for the completion of these tasks will be the Chief Nursing Officer & Administration. Education with licensed staff to include that if at any time the attending physician cannot be reached within 30 minutes & the significant change of condition is an urgent matter the facility's medical director should be notified for any additional direction. All facility primary care physicians and medical director will be educated regarding this expectation. Education with all licensed nurses will notify the Chief Nursing Officer or designee of any significant change of condition and will document any plan. The person responsible for the completion of these tasks will be the Chief Nursing Officer/Designee. The date all tasks were initiated and due for completion was noted as [DATE] & ongoing. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by: 1. Interviewed licensed nurses/staff, ADON and the DON on in-services provided on [DATE], [DATE], [DATE], and on [DATE] regarding the protocols to follow in the event that a resident experienced a change of condition which warranted notification to physician. The following steps were identified as follows: completing an SBAR, a telephone call to the physician, notification to responsible party (1st, 2nd or 3rd contact), documentation of interventions and effectiveness of them, V.S., communication on the 24 hour report to be passed to each shift. F/U documentation must be made each shift and PRN until resolved or hospitalization occurs; dates and times should be noted. All interviewed nursing staff verbalized the understanding of the facility protocols. 2. Reviewed in-services completed by licensed nursing staff and reviewed the sign in sheets for staff who attended the following training: Change of Condition, Notification to MD and RP with Change of Condition and CNO, Documentation of Interventions and SBAR, Documentation of transfer and resident to hospital dated [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and Nurse Consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to continue monitoring the effectiveness of staff following the change of condition protocols. Review of a facility Form CMS-672 dated [DATE] revealed the census was 65.

Based on interview and record review the facility failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical well-being consistent with the resident's comprehensive assessment and plan of care for 1 of 5 resident's (#1) whose records were reviewed. On [DATE] at 1:50 p.m. RN M failed to consult with Resident #1's PCP or Medical Director; she failed to send Resident #1 to the hospital after identifying an emergency situation and then failed to let the on-coming nurse (LVN E) know the severity of Resident #1's condition. ON [DATE] at 3:40 p.m. LVN E sent Resident #1 out to the hospital, however, waited until she called the physician and a family member. This all resulted in the delay of medical care. Subsequently, Resident #1 suffered respiratory arrest and ultimately expired while at the hospital. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 65 residents and could contribute to a delay in care and ultimately a decline in physical health. The findings were: Review of Resident #1's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were 3 family members listed for emergency contact including the RP, second contact and third contact. Review of Resident #1's medical chart revealed a Texas Department of State Health Services Standard Out-of-Hopsital Do-Not-Resuscitate Order dated [DATE]. Review of the most recent quarterly MDS dated [DATE] revealed that Resident #1 had severe cognitive impairment; she had no speech; was totally dependent on staff for all ADL's; she had a history of [REDACTED]. Review of the most recent CP updated on [DATE] revealed that Resident #1 was not capable of understanding and exercising her rights and being informed of her health status. It was noted she was non-verbal, so her RP must make all decisions on her behalf. One of the approaches was for staff to ensure her needs were met in a timely manner with her dignity intact since Resident #1 could not voice her needs. Further review revealed that Resident #1's RP and MD would be notified of changes in cognitive ability and due to being non-verbal staff should monitor for non-verbal signs and symptoms of distress during ADL's/personal care. In addition, it was noted that Resident #1 had a swallowing problem and was at risk for aspiration and upper respiratory infections and she required the use of oxygen at 4L PRN via NC PRN SOB. One of the approaches was to monitor oxygen saturation PRN-notify MD/RP of abnormalities. Review of a physician fax request (undated; time not documented) read: Temp 99.1 at 7:15 p.m. administered 1 suppository. Resident also noted with upper lobe congestion. 02 sat at 89%. Administered PRN [MEDICATION NAME] INH Solution. May we have PRN order for APAP 325 mg x2 tabs po or 650 mg suppository to be administered for discomfort of fever? Signed by LVN R. Further review read: [DATE] Addendum: may we order a CXR?? signed by RN M. Review of physician orders [REDACTED].> 93% and [MEDICATION NAME] UD per neb mask Q 4 hrs, PRN SOB/Wheezing. Review of a nurse's note dated [DATE] at 1:50 p.m. revealed Resident #1 was noted with audible congestion, labored breathing. PRN neb tx admin this shift. 02 sat was 80% on 2L, (increased) to 3L. Res did not eat breakfast & had minimal intake for lunch. Call placed to RP to inform 0 answer, LM. Addendum to MD fax requesting CXR. Response pending VS 97XXX[DATE]-,[DATE]. Note: According to Web MD dated [DATE] revealed: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Interview on [DATE] at 8:17 a.m. with RN M revealed she had worked at the facility for about 8 years and had started working on a PRN basis about 1 to 2 days a week. RN M stated an assessment should be conducted and care provided according to physician orders [REDACTED]. She stated the assessing nurse should continue to call the physician and or RP until contact was made depending on the situation. RN M confirmed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. and remembered Resident #1's condition that day. She stated she learned the resident was already having difficulties from the day before. RN M reviewed the nurse's notes dated [DATE] and confirmed she wrote the note at 1:50 p.m. She stated that the note reflected the resident's condition throughout the shift. She stated she provided Resident #1 with a neb treatment and increased the oxygen to 3L. She stated she also faxed the addendum to the PCP on [DATE] requesting for a chest X-Ray. RN M stated she called the physician, but was not sure at what point she called him. She confirmed the nurse's note did not indicate whether she called the physician or not. RN M stated that there was usually a slow response from Resident #1's PCP's office and at times another physician would respond in the PCP's stead. RN M confirmed that she should have sent Resident #1 to the hospital, but believed the ADON told her that the family did not want her going out to the hospital, but commented she was not 110% sure. RN M stated she called the RP and left a message. She stated she knew there was another sister and father that were involved in the resident's care, but understood the RP was the decision maker. RN M stated that given the orders in place for the resident and the direction she received, she believed she provided care necessary within those parameters. However, RN M confirmed that a family member did not directly tell her that they did not want Resident #1 going out to the hospital and as a prudent nurse she should have proceeded to sending the resident out to the hospital. Furthermore, she should have been more persistent in calling the physician and if she did not get a response she should have called the Medical Director. RN M stated she should have also documented the times she called the physician. Interview on [DATE] at 4:04 p.m. with CNA S revealed she worked on [DATE] from 10:00 p.m. to 6:00 a.m. CNA S stated she recalled Resident #1 being very sick with cough and congestion but did not need suctioning. She stated vital signs were not recorded at that time. Interview on [DATE] at 4:18 p.m. with CNA T revealed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. CNA T stated Resident #1 had to sit up in a chair because she was coughing a lot. She also had to sit up in a Geri-chair to eat. CNA T stated Resident #1 had a dry cough that would come and go but more so when eating. She stated Resident #1 needed suctioning only when she could not clear the resident's secretions. Review of SBAR Communication Form dated [DATE] revealed Resident #1 had been observed and evaluated for SOB on [DATE]; treatment for [REDACTED]. Vital signs were BP ,[DATE], pulse 53, RR 30, temp 98.5 and sat were 71%.; on 02 4L. Further evaluation revealed abnormal lung sounds, labored or rapid breathing. Further review revealed that RP requesting to be sent to ER. PCP called and then 911 was called. Resident #1 went out to the hospital at 3:40 p.m. At 4:00 p.m. PCP was notified and he stated would talk with the family. Interview on [DATE] at 4:30 p.m. with LVN E revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She stated she worked PRN and worked the 200 hall. LVN E stated that upon starting her shift, RN M did not provide a status report regarding the gravity of Resident #1's condition. She stated she made rounds about 3:00 p.m. and noted Resident #1 was on 02 via NC which was a change for the resident. Upon further assessment, she noted the resident was gurgling, her sats were at 71%, her RR were 30 and her breathing was labored. LVN E commented Resident #1 did not look good; she was clearly in respiratory distress. LVN E stated she called the PCP but did not hear back from him so she called the RP who was not available and then called the 2nd emergency contact. The family member asked her to send the resident to the hospital. LVN E stated she completed the SBAR and called 911 and Resident #1 left to the hospital via EMS. LVN E stated that she could have called the Medical Director, but again believed she was clearly dealing with an emergency situation and did not want to waste any more time. LVN E stated that upon reviewing the nurse's notes dated [DATE] at 1:50 p.m., she believed Resident #1 should have been sent to the hospital at that time. She stated Resident #1 was already experiencing a change of condition; the resident had congestion and labored breathing, her respirations were 24; the range for normal limits was from about 16 to 20. She commented she did not understand why only a message was left for the RP and she questioned the rationale for asking for a chest X-ray versus sending the resident out to the hospital. LVN E stated Resident #1's PCP returned her call after the resident left for the hospital and was upset because she sent the resident to the hospital. He stated the resident was a DNR. She further stated she had always been instructed to do whatever the family wanted. Review of a telephone order dated [DATE] confirmed Resident #1 was sent out to the hospital. Review of a hospital history and physical dated [DATE] revealed Resident #1 was admitted with the following Diagnoses: [REDACTED]. Further review revealed Resident #1 arrived via EMS and was subsequently intubated. Note: Review of a document, Physician Quality Reporting System dated [DATE] revealed a Code Blue was called at 1627 (4:27 p.m.) due to respiratory arrest. Further review of the history and physical revealed Resident #1was admitted to the ICU for further care, however, after talking to the family care was withdrawn. Hospice was contacted and was admitted for hospice services. Review of a Discharge Summary dated [DATE] revealed the patient had orders to treat septic shock with vasopressors and antibiotics, maintain mechanical ventilation, workup for problems, etc. Hospice/comfort care reviewed with the family. Decision was made by the family to place the patient on hospice for comfort care. She ultimately expired under hospice care. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 11:30 a.m. with Resident #1's family member revealed she expressed great concern about how the resident's change of condition was handled while at the facility. She questioned if staff ever heard back from the physician because she understood staff requested a CXR which was not completed. The family member questioned whether nursing staff handling the situation followed facility protocols and whether they received support from administrative staff. Interview on [DATE] at 3:06 p.m. with the DON revealed she had worked at the facility for about 3 weeks. She stated that for a change of condition nurses were to complete an SBAR, call the physician and RP. If cannot get in touch with the physician then call the on call physician or NP. Depending on the change of condition would send out to the hospital, if an emergency then would call 911 and send out to the hospital. Interview on [DATE] at 5:15 p.m. with the ADON revealed she had worked at the facility for over 1 year. The ADON stated the following steps should be taken when a resident experienced a change of condition: complete the SBAR, notify the physician and RP; notify the DON or supervising nurse and document a nurse's note regarding the status of the resident's condition. The ADON stated that Resident #1 had 3 family members listed on the face sheet that could be contacted in the event of an emergency; the RP, second and third contact. She stated that it was policy to have 3 family members listed who the nurses could contact in the event of an emergency. The ADON stated that in Resident #1's case all 3 individuals listed had equal decision making status. In reviewing the nurse's note dated [DATE], the ADON stated Resident #1 experienced a change of condition; she had increased temperature of 99.1, she received a neb treatment and APAP suppository. The ADON stated she wondered if the resident's condition stabilized because at the end of the note it read the resident was resting. She stated the nurse technically should have documented a follow up note after treatment was provided to determine the effectiveness of the treatment. The ADON noted the nurse faxed the physician, but stated the nurse should have also called the physician or Medical Director. In reviewing the nurse's note there was no indication the nurse called the physician. The ADON stated that having Resident #1's PCP return calls or answer to fax requests timely had been a problem in the past. Upon review of the nurse's note dated [DATE] at 1:50 p.m., the ADON stated that Resident #1 continued with a change of condition, which was based on congestion, labored breathing and decreased sats to 80%. The ADON stated RN M should have completed an SBAR, called the PCP and all contacts listed until she reached a family member to inform them of the resident's status and RN M really should have sent Resident #1 to the hospital due to respiratory distress. Interview on [DATE] at 7:35 a.m. via telephone call with Resident #1's RP revealed she expressed concerns regarding how nursing staff handled the resident's change of condition. She stated her primary concern was that there was a delay in care. She stated that Resident #1 started having problems breathing on [DATE] and LVN R called her and she went to the facility to see Resident #1. The RP stated she understood at some point a chest X-Ray was ordered, but was never completed. She stated that Resident #1 had previously aspirated a couple of times. The RP stated she was waiting to hear back from staff after she visited with Resident #1 on [DATE], but she never received a call from staff. Interview on [DATE] at 12:45 p.m. with the ADON revealed she started reporting to work on Tuesday's and Thursday's at 12:30 p.m. during [DATE]. She stated [DATE] was a Thursday and commented she did not remember anyone telling her about Resident #1's change of condition. Furthermore, there was no reason to believe the family did not want the resident being sent to the hospital. The ADON stated the facility had not recognized there had been a problem, a delay in care, when responding to Resident #1's change of condition. She stated afterwards she remembered the previous DON mentioned to her that the family wanted to review the medical record. However, she did not understand there had been a problem. The ADON stated training had not been provided since Resident #1 had a change of condition and was sent to the hospital. She stated she was the one in charge of providing in-services. The ADON again stated that it had been facility policy to include 3 emergency contact people when possible. She stated RN M was the DON at the facility at one point and was aware of this policy and knew to call the 2nd and 3rd contact listed and she also understood to call the PCP and or Medical Director as needed in the event of an emergency. Interview on [DATE] at 1:45 p.m. via telephone call with the previous DON N revealed she did not remember anyone reporting Resident #1 had a change of condition during [DATE]. She stated there had been a flu epidemic in the facility and there were many residents who had been affected during this time period. The Previous DON N reviewed her calendar and remembered that she left at 1:00 p.m. on [DATE] and did not return to work until [DATE]. She stated she did not remember anything being mentioned regarding Resident #1 upon her return to work. Interview on [DATE] at 4:01 p.m. via telephone call with head nurse P at Resident #1's PCP's office revealed they received a fax from the facility on [DATE] at 8:08 p.m. regarding Resident #1's condition. She stated it was reviewed and electronically and signed by another physician within their group on [DATE] at 4:04 p.m. Head Nurse P stated they did not receive the addendum dated [DATE] requesting a chest X-Ray. Interview on [DATE] at 4:15 p.m. with Resident #1's PCP via telephone call revealed he typically returned nursing staff's calls within 20 minutes unless he was driving then he it took longer. The PCP stated he did not remember having any conversations with nursing staff about Resident #1's condition on [DATE] or on [DATE] earlier in the day. It was not until after she was sent out to the hospital that he talked with the charge nurse on [DATE]. Interview on [DATE] at 5:08 p.m. via telephone call with head nurse P revealed that in reviewing their answering service notes, someone called from the facility on [DATE] at 3:37 p.m. that Resident #1 was going out to the hospital due to SOB; ambulance awaiting. Head nurse P stated there was nothing documented that any other messages were received earlier that day or on [DATE] regarding Resident #1's condition. Interview on [DATE] at 10:22 a.m. via telephone call with the previous DON N confirmed she returned to work on [DATE]. She remembered Resident #1's family member came in to the facility and requested to review the medical record. DON N stated the family member did not express any major concerns that she could remember. DON N stated that Resident #1's PCP was upset because LVN E sent the resident to the hospital because she was a DNR. She stated he seemed insensitive. DON N stated she did not believe Resident #1 had any comfort medications like [MEDICATION NAME] to give her for comfort care. DON N stated that LVN E did what any reasonable and prudent nurse would do and that was to send her out to the hospital so they could provide the level of care the resident needed to alleviate the resident's distress. DON N stated she talked to her nursing staff about residents with DNR orders. She advised them that they still had to provide the care the resident needed even though a resident had a DNR order in place. Review of a policy titled, Change of Condition (undated) read: Policy: To ensure a resident who experiences a change of condition receives intervention. Responsible Disciplines: Licensed Nurses, Procedure: Licensed nurses will fill out the SBAR form any time a change of condition is noted to a resident. The licensed nurse should place a telephone call to the attending physician or nurse practitioner to discuss their findings regarding the change of condition. Any new orders obtained from the physician or nurse practitioner should be transcribed onto a telephone order and carried out. If the change of condition is an urgent matter and the physician has not returned the call in a reasonable amount of time, you should contact the facility medical director and Chief Nursing Officer. The change of condition should be noted on the 24 hour report for follow up. The DON and nurse consultant were notified that an Immediate Jeopardy was identified on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. and it included the following: Area Requiring Attention: Change of Condition. Corrective Action Taken: All licensed nurses will be educated on what constitutes a significant change of condition & the completion of an SBAR. All licensed nurses will be educated that one the SBAR is complete the nurse needs to place a telephone call to the attending physician and document outcome to include date and time. All licensed nurses will be educated that to note the change of condition on the 24 hour report for follow up with follow up with time frames included. Education will include that the nurses should document in the resident's medical record every shift on the change of condition & the effectiveness of the interventions until it is resolved or until the resident goes out to the hospital. This documentation must include date and time of significant change of condition, notification, and interventions. If the resident is hospitalized , documentation will include mode of transport, information that was communicated to EMS, condition of resident at time of transfer, and date and time of transfer. The person responsible for the completion of these tasks will be the Chief Nursing Officer & Administration. Education with licensed staff to include that if at any time the attending physician cannot be reached within 30 minutes & the significant change of condition is an urgent matter the facility's medical director should be notified for any additional direction. All facility primary care physicians and medical director will be educated regarding this expectation. Education with all licensed nurses will notify the Chief Nursing Officer or designee of any significant change of condition and will document any plan. The person responsible for the completion of these tasks will be the Chief Nursing Officer/Designee. The date all tasks were initiated and due for completion was noted as [DATE] & ongoing. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by: 1. Interviewed licensed nurses/staff, ADON and the DON on in-services provided on [DATE], [DATE], [DATE], and on [DATE] regarding the protocols to follow in the event that a resident experienced a change of condition which warranted notification to physician. The following steps were identified as follows: completing an SBAR, a telephone call to the physician, notification to responsible party (1st, 2nd or 3rd contact), documentation of interventions and effectiveness of them, V.S., communication on the 24 hour report to be passed to each shift. F/U documentation must be made each shift and PRN until resolved or hospitalization occurs; dates and times should be noted. All interviewed nursing staff verbalized the understanding of the facility protocols. 2. Reviewed in-services completed by licensed nursing staff and reviewed the sign in sheets for staff who attended the following training: Change of Condition, Notification to MD and RP with Change of Condition and CNO, Documentation of Interventions and SBAR, Documentation of transfer and resident to hospital dated [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and Nurse Consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to continue monitoring the effectiveness of staff following the change of condition protocols. Review of a facility Form CMS-672 dated [DATE] revealed the census was 65.

Based on interview and record review the facility failed to ensure that the medical care of each resident was supervised by a physician for 1 of 5 residents (#1) whose records were reviewed for physician services. The Interim ADM did not ensure PCP O responded to staff's communication. Resident #1's PCP O did not respond in a reasonable amount of time per facility policy when RN M and LVN E notified him of the resident's change of condition; she was ultimately sent out to the hospital in respiratory distress. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. The IJ was removed on [DATE]. The facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to complete in-service training and to evaluate the effectiveness of their corrective systems. These deficient practices could affect 65 residents and could contribute to a delay in care and ultimately a decline in physical health. The findings were: Review of Resident #1's medical face sheet dated [DATE] revealed she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed there were 3 family members listed for emergency contact including the RP, second contact and third contact. Review of Resident #1's medical chart revealed a Texas Department of State Health Services Standard Out-of-Hospital Do-Not-Resuscitate Order dated [DATE]. Review of a physician fax request (undated; time not documented) read: Temp 99.1 at 7:15 p.m. administered 1 suppository. Resident also noted with upper lobe congestion. 02 sat at 89%. Administered PRN [MEDICATION NAME] INH Solution. May we have PRN order for APAP 325 mg x2 tabs po or 650 mg suppository to be administered for discomfort of fever? Signed by LVN R. Further review read: [DATE] Addendum: may we order a CXR?? signed by RN M. Review of physician orders [REDACTED].> 93% and [MEDICATION NAME] UD per neb mask Q 4 hrs, PRN SOB/Wheezing. Review of a nurse's note dated [DATE] at 1:50 p.m. revealed Resident #1 was noted with audible congestion, labored breathing. PRN neb tx admin this shift. 02 sat was 80% on 2L, (increased) to 3L. Res did not eat breakfast & had minimal intake for lunch. Call placed to RP to inform 0 answer, LM. Addendum to MD fax requesting CXR. Response pending VS 97XXX[DATE]-,[DATE]. Note: According to Web MD dated [DATE] revealed: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. Interview on [DATE] at 8:17 a.m. with RN M revealed she had worked at the facility for about 8 years and had started working on a PRN basis about 1 to 2 days a week. RN M stated an assessment should be conducted and care provided according to physician orders [REDACTED]. She stated the assessing nurse should continue to call the physician and or RP until contact was made depending on the situation. RN M confirmed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. and remembered Resident #1's condition that day. She stated she learned the resident was already having difficulties from the day before. RN M reviewed the nurse's notes dated [DATE] and confirmed she wrote the note at 1:50 p.m. She stated that the note reflected the resident's condition throughout the shift. She stated she provided Resident #1 with a neb treatment and increased the oxygen to 3L. She stated she also faxed the addendum to the PCP on [DATE] requesting for a chest X-Ray. RN M stated she called the physician, but was not sure at what point she called him. She confirmed the nurse's note did not indicate whether she called the physician or not. RN M stated that there was usually a slow response from Resident #1's PCP's office and at times another physician would respond in the PCP's stead. RN M confirmed that she should have sent Resident #1 to the hospital, but believed the ADON told her that the family did not want her going out to the hospital, but commented she was not 110% sure. RN M stated she called the RP and left a message. She stated she knew there was another sister and father that were involved in the resident's care, but understood the RP was the decision maker. RN M stated that given the orders in place for the resident and the direction she received, she believed she provided care necessary within those parameters. However, RN M confirmed that a family member did not directly tell her that they did not want Resident #1 going out to the hospital and as a prudent nurse she should have proceeded to sending the resident out to the hospital. Furthermore, she should have been more persistent in calling the physician and if she did not get a response she should have called the Medical Director. RN M stated she should have also documented the times she called the physician. Interview on [DATE] at 4:04 p.m. with CNA S revealed she worked on [DATE] from 10:00 p.m. to 6:00 a.m. CNA S stated she recalled Resident #1 being very sick with cough and congestion but did not need suctioning. She stated vital signs were not recorded at that time. Interview on [DATE] at 4:18 p.m. with CNA T revealed she worked on [DATE] from 6:00 a.m. to 2:00 p.m. CNA T stated Resident #1 had to sit up in a chair because she was coughing a lot. She also had to sit up in a Geri-chair to eat. CNA T stated Resident #1 had a dry cough that would come and go but more so when eating. She stated Resident #1 needed suctioning only when she could not clear the resident's secretions. Review of SBAR Communication Form dated [DATE] revealed Resident #1 had been observed and evaluated for SOB on [DATE]; treatment for [REDACTED]. Vital signs were BP ,[DATE], pulse 53, RR 30, temp 98.5 and sat were 71%.; on 02 4L. Further evaluation revealed abnormal lung sounds, labored or rapid breathing. Further review revealed that RP requesting to be sent to ER. PCP called and then 911 was called. Resident #1 went out to the hospital at 3:40 p.m. At 4:00 p.m. PCP was notified and he stated would talk with the family. Interview on [DATE] at 4:30 p.m. with LVN E revealed she worked on [DATE] from 2:00 p.m. to 10:00 p.m. She stated she worked PRN and worked the 200 hall. LVN E stated that upon starting her shift, RN M did not provide a status report regarding the gravity of Resident #1's condition. She stated she made rounds about 3:00 p.m. and noted Resident #1 was on 02 via NC which was a change for the resident. Upon further assessment, she noted the resident was gurgling, her sats were at 71%, her RR were 30 and her breathing was labored. LVN E commented Resident #1 did not look good; she was clearly in respiratory distress. LVN E stated she called the PCP but did not hear back from him so she called the RP who was not available and then called the 2nd emergency contact. The family member asked her to send the resident to the hospital. LVN E stated she completed the SBAR and called 911 and Resident #1 left to the hospital via EMS. LVN E stated that she could have called the Medical Director, but again believed she was clearly dealing with an emergency situation and did not want to waste any more time. LVN E stated that upon reviewing the nurse's notes dated [DATE] at 1:50 p.m., she believed Resident #1 should have been sent to the hospital at that time. She stated Resident #1 was already experiencing a change of condition; the resident had congestion and labored breathing, her respirations were 24; the range for normal limits was from about 16 to 20. She commented she did not understand why only a message was left for the RP and she questioned the rationale for asking for a chest X-ray versus sending the resident out to the hospital. LVN E stated Resident #1's PCP returned her call after the resident left for the hospital and was upset because she sent the resident to the hospital. He stated the resident was a DNR. She further stated she had always been instructed to do whatever the family wanted. Review of a telephone order dated [DATE] confirmed Resident #1 was sent out to the hospital. Review of a hospital history and physical dated [DATE] revealed Resident #1 was admitted with the following Diagnoses: [REDACTED]. Further review revealed Resident #1 arrived via EMS and was subsequently intubated. Note: Review of a document, Physician Quality Reporting System dated [DATE] revealed a Code Blue was called at 1627 (4:27 p.m.) due to respiratory arrest. Further review of the history and physical revealed Resident #1was admitted to the ICU for further care, however, after talking to the family care was withdrawn. Hospice was contacted and was admitted for hospice services. Review of a Discharge Summary dated [DATE] revealed the patient had orders to treat septic shock with vasopressors and antibiotics, maintain mechanical ventilation, workup for problems, etc. Hospice/comfort care reviewed with the family. Decision was made by the family to place the patient on hospice for comfort care. She ultimately expired under hospice care. Review of facility staff roster (undated) revealed the Interim ADM's date of hire was [DATE] and the DON's date of hire was [DATE]. Interview on [DATE] at 11:30 a.m. with Resident #1's family member revealed she expressed great concern about how the resident's change of condition was handled while at the facility. She questioned if staff ever heard back from the physician because she understood staff requested a CXR which was not completed. The family member questioned whether nursing staff handling the situation followed facility protocols and whether they received support from administrative staff. Interview on [DATE] at 3:06 p.m. with the DON revealed she had worked at the facility for about 3 weeks. She stated that for a change of condition nurses were to complete an SBAR, call the physician and RP. If cannot get in touch with the physician then call the on call physician or NP. Depending on the change of condition would send out to the hospital, if an emergency then would call 911 and send out to the hospital. Interview on [DATE] at 5:15 p.m. with the ADON revealed she had worked at the facility for over 1 year. The ADON stated the following steps should be taken when a resident experienced a change of condition: complete the SBAR, notify the physician and RP; notify the DON or supervising nurse and document a nurse's note regarding the status of the resident's condition. The ADON stated that Resident #1 had 3 family members listed on the face sheet that could be contacted in the event of an emergency; the RP, second and third contact. She stated that it was policy to have 3 family members listed who the nurses could contact in the event of an emergency. The ADON stated that in Resident #1's case all 3 individuals listed had equal decision making status. In reviewing the nurse's note dated [DATE], the ADON stated Resident #1 experienced a change of condition; she had increased temperature of 99.1, she received a neb treatment and APAP suppository. The ADON stated she wondered if the resident's condition stabilized because at the end of the note it read the resident was resting. She stated the nurse technically should have documented a follow up note after treatment was provided to determine the effectiveness of the treatment. The ADON noted the nurse faxed the physician, but stated the nurse should have also called the physician or Medical Director. In reviewing the nurse's note there was no indication the nurse called the physician. The ADON stated that having Resident #1's PCP return calls or answer to fax requests timely had been a problem in the past. Upon review of the nurse's note dated [DATE] at 1:50 p.m., the ADON stated that Resident #1 continued with a change of condition, which was based on congestion, labored breathing and decreased sats to 80%. The ADON stated RN M should have completed an SBAR, called the PCP and all contacts listed until she reached a family member to inform them of the resident's status and RN M really should have sent Resident #1 to the hospital due to respiratory distress. Interview on [DATE] at 7:35 a.m. via telephone call with Resident #1's RP revealed she expressed concerns regarding how nursing staff handled the resident's change of condition. She stated her primary concern was that there was a delay in care. She stated that Resident #1 started having problems breathing on [DATE] and LVN R called her and she went to the facility to see Resident #1. The RP stated she understood at some point a chest X-Ray was ordered, but was never completed. She stated that Resident #1 had previously aspirated a couple of times. The RP stated she was waiting to hear back from staff after she visited with Resident #1 on [DATE], but she never received a call from staff. Interview on [DATE] at 12:45 p.m. with the ADON revealed she started reporting to work on Tuesday's and Thursday's at 12:30 p.m. during [DATE]. She stated [DATE] was a Thursday and commented she did not remember anyone telling her about Resident #1's change of condition. Furthermore, there was no reason to believe the family did not want the resident being sent to the hospital. The ADON stated the facility had not recognized there had been a problem, a delay in care, when responding to Resident #1's change of condition. She stated afterwards she remembered the previous DON mentioned to her that the family wanted to review the medical record. However, she did not understand there had been a problem. The ADON stated training had not been provided since Resident #1 had a change of condition and was sent to the hospital. She stated she was the one in charge of providing in-services. The ADON again stated that it had been facility policy to include 3 emergency contact people when possible. She stated RN M was the DON at the facility at one point and was aware of this policy and knew to call the 2nd and 3rd contact listed and she also understood to call the PCP and or Medical Director as needed in the event of an emergency. Interview on [DATE] at 1:45 p.m. via telephone call with the previous DON N revealed she did not remember anyone reporting Resident #1 had a change of condition during [DATE]. She stated there had been a flu epidemic in the facility and there were many residents who had been affected during this time period. The Previous DON N reviewed her calendar and remembered that she left at 1:00 p.m. on [DATE] and did not return to work until [DATE]. She stated she did not remember anything being mentioned regarding Resident #1 upon her return to work. Interview on [DATE] at 3:48 p.m. with the Interim ADM revealed staff had made him aware that there had been a problem communicating with Resident #1's PCP O. He stated that it was brought up during a morning meeting last week, but he had not talked to PCP O and had not developed a plan to address the issue. Interview on [DATE] at 4:01 p.m. via telephone call with head nurse P at Resident #1's PCP's office revealed they received a fax from the facility on [DATE] at 8:08 p.m. regarding Resident #1's condition. She stated it was reviewed and electronically and signed by another physician within their group on [DATE] at 4:04 p.m. Head Nurse P stated they did not receive the addendum dated [DATE] requesting a chest X-Ray. Interview on [DATE] at 4:15 p.m. with Resident #1's PCP via telephone call revealed he typically returned nursing staff's calls within 20 minutes unless he was driving then he it took longer. The PCP stated he did not remember having any conversations with nursing staff about Resident #1's condition on [DATE] or on [DATE] earlier in the day. It was not until after she was sent out to the hospital that he talked with the charge nurse on [DATE]. Interview on [DATE] at 5:08 p.m. via telephone call with head nurse P revealed that in reviewing their answering service notes, someone called from the facility on [DATE] at 3:37 p.m. that Resident #1 was going out to the hospital due to SOB; ambulance awaiting. Head nurse P stated there was nothing documented that any other messages were received earlier that day or on [DATE] regarding Resident #1's condition. Interview on [DATE] at 10:22 a.m. via telephone call with the previous DON N confirmed she returned to work on [DATE]. She remembered Resident #1's family member came in to the facility and requested to review the medical record. DON N stated the family member did not express any major concerns that she could remember. DON N stated that Resident #1's PCP was upset because LVN E sent the resident to the hospital because she was a DNR. She stated he seemed insensitive. DON N stated she did not believe Resident #1 had any comfort medications like [MEDICATION NAME] to give her for comfort care. DON N stated that LVN E did what any reasonable and prudent nurse would do and that was to send her out to the hospital so they could provide the level of care the resident needed to alleviate the resident's distress. DON N stated she talked to her nursing staff about residents with DNR orders. She advised them that they still had to provide the care the resident needed even though a resident had a DNR order in place. Review of a policy titled, Change of Condition (undated) read: Policy: To ensure a resident who experiences a change of condition receives intervention. Responsible Disciplines: Licensed Nurses, Procedure: Licensed nurses will fill out the SBAR form any time a change of condition is noted to a resident. The licensed nurse should place a telephone call to the attending physician or nurse practitioner to discuss their findings regarding the change of condition. Any new orders obtained from the physician or nurse practitioner should be transcribed onto a telephone order and carried out. If the change of condition is an urgent matter and the physician has not returned the call in a reasonable amount of time, you should contact the facility medical director and Chief Nursing Officer. The change of condition should be noted on the 24 hour report for follow up. The DON and nurse consultant were notified that an Immediate Jeopardy was identified on [DATE] at 2:12 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:00 p.m. and it included the following: Area Requiring Attention: Change of Condition. Corrective Action Taken: All licensed nurses will be educated on what constitutes a significant change of condition & the completion of an SBAR. All licensed nurses will be educated that one the SBAR is complete the nurse needs to place a telephone call to the attending physician and document outcome to include date and time. All licensed nurses will be educated that to note the change of condition on the 24 hour report for follow up with follow up with time frames included. Education will include that the nurses should document in the resident's medical record every shift on the change of condition & the effectiveness of the interventions until it is resolved or until the resident goes out to the hospital. This documentation must include date and time of significant change of condition, notification, and interventions. If the resident is hospitalized , documentation will include mode of transport, information that was communicated to EMS, condition of resident at time of transfer, and date and time of transfer. The person responsible for the completion of these tasks will be the Chief Nursing Officer & Administration. Education with licensed staff to include that if at any time the attending physician cannot be reached within 30 minutes & the significant change of condition is an urgent matter the facility's medical director should be notified for any additional direction. All facility primary care physicians and medical director will be educated regarding this expectation. Education with all licensed nurses will notify the Chief Nursing Officer or designee of any significant change of condition and will document any plan. The person responsible for the completion of these tasks will be the Chief Nursing Officer/Designee. The date all tasks were initiated and due for completion was noted as [DATE] & ongoing. On [DATE] the Surveyor confirmed the plan of removal had been sufficiently implemented to remove the Immediate Jeopardy by: 1. Interviewed licensed nurses/staff, ADON and the DON on in-services provided on [DATE], [DATE], [DATE], and on [DATE] regarding the protocols to follow in the event that a resident experienced a change of condition which warranted notification to physician. The following steps were identified as follows: completing an SBAR, a telephone call to the physician, notification to responsible party (1st, 2nd or 3rd contact), documentation of interventions and effectiveness of them, V.S., communication on the 24 hour report to be passed to each shift. F/U documentation must be made each shift and PRN until resolved or hospitalization occurs; dates and times should be noted. All interviewed nursing staff verbalized the understanding of the facility protocols. 2. Reviewed in-services completed by licensed nursing staff and reviewed the sign in sheets for staff who attended the following training: Change of Condition, Notification to MD and RP with Change of Condition and CNO, Documentation of Interventions and SBAR, Documentation of transfer and resident to hospital dated [DATE], [DATE], [DATE] and on [DATE]. On [DATE] at approximately 5:00 p.m. the DON and Nurse Consultant were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of widespread and severity at actual harm due to the facility's need to continue monitoring the effectiveness of staff following the change of condition protocols. Review of a facility Form CMS-672 dated [DATE] revealed the census was 65.