Every finding on record at Methodist Transitional Care Center-Desoto LLC

Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent complications of enteral feeding for four of six residents (Residents #1, #3, #4, and #5) observed for gastrostomy tube feeding. 1.The facility failed to ensure Residents #1, #3, and #4's G-tube dressings were changed and dated. 2. The facility failed to make sure that formula tubing was sealed with a cap to prevent exposure and contamination during downtime for Resident #1 and #5. Thes failures could place residents at risk of contamination and communicable infectious diseases. Findings included: Resident #1Record review of Resident #1's face sheet dated 12/10/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with primary diagnosis of gastrostomy malfunction (this a feeding tube that malfunctions or was replaced). Her secondary diagnoses were COPD ( a lung disease that blocks airflow and makes it difficult to breathe), type 2 diabetes Mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), unspecified dementia (Brain disease that alters brain function and causes a cognitive decline) and cellulitis of the abdominal wall (infection in the stomach wall which appears as redness on the stomach area). Record review of Resident#1's admission MDS dated [DATE] did not reflect a BIMS score. Record review of Resident#1's discharge MDS dated [DATE] revealed Resident #1 had a feeding tube. The MDS did not indicate how much nutritional calories or fluid were obtained using tube feeding. Record review of Resident #1's physician order summary for December 2025 reflected-GT: Pump give [brand name of diabetic feeding] at 40 cc/hr per g-tube for 20 hours every shift. Ordered 11/18/25-GT: Cleanse peg [other name of g-tube] site with normal saline, pat dry and apply dressing daily or as needed every shift. Ordered 11/18/25. Record review of Resident #1's care plan initiated on 11/24/25 revealed Resident #1 had cellulitis of the abdominal wall. The goal was for Resident #1 to have no complications resulting from the cellulitis through the review date. The interventions were to observe/document/report to MD the following symptoms of Cellulitis: Red, Swollen, tender Skin, reddened area begins to spread, small red spots that appear on the reddened skin, small blisters which may form and burst, swollen lymph glands. Further review of the care plan indicated Resident #1 required tube feeding related to dysphagia (difficulty swallowing). The goal was for Resident #1 to maintain adequate nutritional and hydration status as evidenced by weight stability, no signs and symptoms of malnutrition or dehydration. Interventions included Document/report to MD PRN: aspiration, fever, Shortness of breath, tube dislodged, infection at tube site, self-extubation [pulling g-tube out], tube malfunction, abnormal breath/lung sound, abdominal pain, distention, tenderness, diarrhea, nausea and vomiting. In a phone interview with Resident #1's family on 12/09/25 at 3:40 PM, she stated Resident #1 was currently in the hospital. She said she had gone to the facility to visit Resident # 1, on 11/19/25, 11/20/25, and 11/21/25. She said Resident #1 was not connected to her feeding tube on11/20/25, and 11/21/25, and the tube feeding end was hanging from the IV pole uncapped and dirty. She said the same tube feeding from 11/19 was still hanging on the pole. She stated on 11/20/25, Resident #1's Peg tube dressing had a foul odor coming from it so she removed it and cleaned the site the best she could. Record Review of Resident #1's photos provided by family via email revealed a photo dated 11/19/25 at 5:40 pm of the uncapped feeding tubing with brown substance that was dry on the end of the tube and another photo dated 11/20/25 taken at 12:54 PM, revealed a soiled gauze dressing with brown and red discharge on it. The g-tube dressing was undated. Record review of Resident #1's MAR revealed cleanse peg site with normal saline, pat dry and apply dressing daily or as needed every shift. It was documented as completed on the 6 am-6pm shift on 11/19/25 by LVN D and on 11/20 and 11/21/25 it was documented as completed by LVN E On 12/10/25 at 2:57 PM, an attempt was made to contact LVN D. A message with a return number was left. There has been no return call from the nurse. In a phone interview with LVN E on 12/10/25 at 4:51 PM, she stated she worked the overnight 6pm-6 am shift. She said she changed Resident #1's g-tube dressing change, the new feeding tubing and water and the syringe for g-tube. She said it was done overnight by her and other assigned nurses with patients who had g-tubes. She said when she worked with residents who had g-tubes, she made sure that the feeding was new. She said she also labeled the feeding bag, the syringe and the g-tube dressing. She said the potential risk of not completing these tasks was infection. Resident #3Record Review of Resident #3's face sheet dated 12/10/25 revealed a [AGE] year-old male with an initial admission to the facility of 06/03/21 and readmitted on [DATE] with a primary diagnosis of nontraumatic intracerebral hemorrhage in hemisphere, Subcortical (this is a stroke with brain bleed). His secondary diagnoses included Hemiplegia and hemiparesis cerebrovascular disease affecting left dominant side (this is the after effect of stroke that causes one-sided paralysis and weakness of the face, arm or leg on the left side of his body), and Gastronomy status (presence of a gastronomy in which a tube is placed in surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. The MDS indicated Resident #3 was on a mechanically altered diet (requires change in texture of food or liquids . example given pureed food and thickened liquids). The MDS indicated Resident #3 received 51percent or more of his total calories through his feeding and 501 cc/day or more of fluid intake through his feeding tube. Record review of Resident #3's physician order summary for December 2025 reflected-Cleanse peg site with normal saline, pat dry and apply dressing daily or as needed every shift. Ordered 12/20/22. Record Review of Resident #3's care plan initiated 11/10/22 revealed a focus that Resident #3 required feeding related to dysphagia (difficulty swallowing). The goal was for Resident #3 to maintain adequate nutritional and hydration status as evidenced by weight stability, no signs and symptoms of malnutrition or dehydration. The interventions included providing local care to G-tube site as ordered and monitoring for signs and symptoms of infection. Observation and interview with Resident #3 on 12/10/25 at 09:38 AM, revealed Resident #3 stated that he had a g-tube. He lifted his sheet and revealed a g-tube that was intact. The g-tube dressing was dated 12/08/25. The dressing did not have an odor or drainage. Resident #3 said he did not know how often his g-tube dressing was changed. Interview with LVN C on 12/10/25 at 09:50 AM, revealed she was Resident #3's nurse. She said that she was getting ready to give Resident #3 a shower and that was why his g-tube dressing had not been changed yet. She said Resident #3's g-tube dressing should be changed daily. When LVN C was asked why the dressing was not changed on 12/09/25, She did not know why it was not changed on 12/09/25. She said the risk of not changing dressing was infection. Resident #4Record Review of Resident #4's face sheet dated 12/10/25 revealed an [AGE] year-old male with an initial admission to the facility of 12/09/22 and readmitted on [DATE] with a primary diagnosis of sepsis (this is a life-threatening complication of an infection). His secondary diagnoses included cognitive communication deficit, high blood pressure, and Gastronomy status (presence of a gastronomy in which a tube is placed in surgical opening into the stomach for nutritional support or gastric decompression). Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 01, indicating severe cognitive impairment. The MDS indicated Resident #4 had a feeding tube and received 51percent or more of his total calories through tube feeding and 501 cc/day or more of fluid intake through his feeding tube. Record review of Resident #4's physician order summary for December 2025 reflected- Cleanse peg site with normal saline, pat dry and apply dressing daily or as needed every shift. Ordered 08/26/24. Record Review of Resident #4's care plan initiated 11/04/25 revealed a focus of at risk for infection related to indwelling [inside the body] medical device. The goal was to reduce risk of infection through next review. The interventions included reporting to Medical Doctor any signs and symptoms of infection: fever, redness, drainage, or swelling. Observation and interview with LVN C on 12/10/25 at 10:21 AM, revealed she was Resident #4's nurse. She revealed Resident #4's g-tube area which had a 4 by 4 gauze pad around his g-tube. The gauze was clean and intact. The dressing was undated. LVN C stated the facility did not have the g-tube dressing that had a slit in the middle of it for g-tube dressing changes, therefore, they were using the 4 by 4 gauze pads. She said that the night shift may have changed the g-tube dressing overnight and forgot to date it, however she said she was unsure when dressing was changed. She said the risk of not having a date on the g-tube dressing was not knowing when it was last changed. Resident #5Record Review of Resident #5's face sheet dated 12/10/25 revealed a [AGE] year-old female with an initial admission to the facility of 10/16/22 and readmitted on [DATE] with a primary diagnosis of Alzheimer's Disease (Brain condition that progressively destroys memory and other important mental functions). Her secondary diagnoses included Gastronomy status (presence of a gastronomy in which a tube is placed in surgical opening into the stomach for nutritional support or gastric decompression) polyp [pouches] in the colon, and age-related physical debility [weakness]. Record review of Resident #5's physician order summary for December 2025 reflected-GT: Pump give [brand name of feedings] at 70 cc/hr for 20 hours with pump to flush 90 cc water every 4 hours every shift for nutrition. Ordered 04/30/25.-GT: Change tubing with each closed system administrated every shift. Ordered 07/07/23. Record Review of Resident #5's quarterly MDS dated [DATE] did not reveal a BIMS score. The MDS indicated Resident #5 had a feeding tube and received 51percent or more of her total calories through tube feeding and 501 cc/day or more of fluid intake through her feeding tube. Record Review of Resident #5's care plan initiated on 11/08/22 revealed a focus that Resident #5 required feeding related to dysphagia (difficulty swallowing). The goal was for Resident #5 to maintain adequate nutritional and hydration status as evidenced by weight stability, no signs and symptoms of malnutrition or dehydration. The interventions included providing local site care to G-tube as ordered and monitoring for signs and symptoms of infection Observation on 12/10/25 at 09:51 AM, at 12:00 PM, and at 1:00 PM revealed Resident #5 was non interviewable. She was not connected to her feeding tube, and the tube feeding end was hanging from the IV pole uncapped creating an open system. The feeding was dated 12/09/25 at 4:55 pm. Interview with CNA H on 12/10/25 at 10:53 AM, revealed she was getting ready to give Resident #5 a bed bath. She said that the nurse had disconnected Resident #5 for her down time so that ADLs can be provided. She said that residents are usually off their feeding until 1 PM. She said she did not know if the formula tubing had caps on them because that was not something that she watched for as that was not in her scope. She said she would report to the nurses after ADLs if they needed to be reconnected after ADLs. CNA pulled the cover down to show Resident #5's G-tube was clean and intact. The dressing was clean and dated 12/10/25. In an interview with LVN A on 12/10/25 at 10:29 AM, she stated Resident #5 was hers today. She said that she was disconnected from her feeding until 1 PM when she would be reconnected to her feeding. She said that residents on feeding have orders for a 4-hour downtime for ADL care. She said new bags of Formula feedings are hung overnight by night shift. LVN A said that she had changed Resident #5's g-tube dressing this morning. She said the risk of not following g-tube procedures was infection. In an interview with RN F on 12/10/25 at 1:45 PM, she stated she was the infection control preventionist. She said nurses were responsible for putting orders in for dressing changes and the unit managers monitored that orders were accurate. She said she is supposed to monitor that staff are following the infection control procedures. She said that she was not aware that some residents that had g-tube were not getting g-tube dressing changes and that the dressing was not dated. She said the risk of not changing dressing when it was due was infection. RN F stated that the Formula bags kits came with a clear plastic cap that was used at the end of the feeding to close the line when not in use. She said the expectation was that when not connected to a resident the feeding should be closed with the clear cap to create a closed system and prevent infection. An interview with the DON on 12/10/25 at 1:59 PM revealed that nurses were responsible for completing dressing changes as ordered. She said all nursing was responsible for g-tube dressing changes. She said if not done on night shift it should be done on morning shift before medication administration or before hanging a new bag of Formula. She said the expectation was that G-tubes dressings were changed daily, dated and documented and she expected nurses to look at the MAR and complete the tasks. She said risk of not following proper procedures was potential for infection. Interview with the Administrator on 12/10/25 at 5:09 PM revealed all staff members were expected to follow the infection control protocol as indicated. She expected staff to prevent spread of infection. She said the expectation was that G-tubes dressings were changed daily and documented. She also expected nurses to look at the MAR to see when the dressings were last changed. She said the responsibility was on all nurses and for nurse managers to follow up to make sure infection control was being followed. Review of the Gastrostomy/Jejunostomy Site Care policy, revised 09/2004, reflected Purpose: The purposes of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection .Documentation: the date and time the procedure was performed . Review of the Infection Control policy, revised 09/2007, reflected Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.2.The objectives of our infection control policies and practices are to:1. Prevent, detect, investigate, and control infections in the facility;2. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public3. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard Precautions;4. Maintain records of incidents and corrective actions related to infections;5. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment

Based on interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, to other officials (including to the State Agency) for one (Resident #1) of six residents reviewed for abuse. The Administrator, who is the Abuse Coordinator, failed to immediately report (within 2 hours) an allegation of abuse made by Resident #1 on 11/19/25. The failure could affect 72 residents and could result in undetected abuse and/or decline in feelings of safety and well-being. Findings include: Record review of Resident #1's face sheet dated 12/10/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with primary diagnosis of gastrostomy malfunction (this a feeding tube that malfunctions or was replaced). Her secondary diagnoses included COPD ( a lung disease that blocks airflow and makes it difficult to breathe), type 2 diabetes Mellitus (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), unspecified dementia (Brain disease that alters brain function and causes a cognitive decline) and cellulitis of the abdominal wall (infection in the stomach wall which appears as redness on the stomach area). Record review of Resident#1's admission MDS dated [DATE] and discharge MDS dated [DATE] did not reflect a BIMS score. Record review of Resident #1's hospital record dated 11/17/25 reflected Resident #1's mental status assessment was Alert and Oriented to person [she knew who she was, (name, birthday, age)], Place [she knew where she was], and time [she knew what time it was]. Record review of Resident #1's physician order summary for December 2025 reflected-crush/dissolve medication and give with food or fluid three times a day. Ordered 11/18/25 Record review of facility grievance log dated 11/19/25 revealed Resident #1 had reported to DON that on morning of 11/19/25 on the 6am-6pm shift, the staff member passing medication pinched her mouth together and placed medication in her mouth after she had refused the medication because of the taste. The grievance reflected Resident #1's family was present at the time the allegation was made. The grievance revealed medication aide was placed on suspension pending investigation and life satisfaction surveys for Abuse and Neglect were completed. In a phone interview with Resident #1's family on 12/09/25 at 3:40 PM, she stated Resident #1 was in the hospital. She said on 11/19/25 around 3:00 pm, she arrived to visit Resident #1 at the facility. Resident #1 reported to her that earlier that morning, a Medication Technician (name unknown) grabbed her by her mouth and tried to force her to take medication (medication name unknown). The family stated Resident#1 told the Medication Technician that she did not want the medication because she did not like the taste of it crushed. In an interview with DON on 12/10/25 at 1:59 PM, she stated LVN D reported to her that Resident #1's family wanted to speak with her. DON said that family was upset that Resident #1 had alleged that a Medication Aide had forced Resident #1 to take medication. DON said that she filed the grievance, reported the incident to the abuse coordinator (the Administrator) and called corporate office to report the incident. DON said that they did an internal investigation and determined that the allegations were unfounded. She said she was advised by corporate that it was not a reportable incident because Med Tech had LVN D as a witness during the exchange and the following day, Resident #1's family apologized for her outburst and the cursing she had done the day before. DON said Resident #1's family told her that Resident #1 had dementia and may have been confused. DON stated with that information and confirmation from corporate office, they did not feel they needed to report the incident to State office. In an interview with Medication Technician on 12/10/25 at 2:04 PM, she stated Resident #1 was new to the facility and she had an order to crush her medication before oral administration. She said when she went into Resident #1's room to administer medication, Resident #1 who refused to take the medication stated that she took her pills whole (not crushed). Med Tech said she then left Resident #1 and went to confirm with LVN D. She said together with LVN D, they went to talk to Resident #1 about the physician order to crush medications before administration. Med Tech stated at that point Resident #1 was agreeable to take medication as LVN D walked out of the room. Med Tech said after just taking a small bite of the crushed medication Resident #1 refused saying that she did not like the taste. Med Tech said at that point, she walked out and gave the medications to LVN D and reported that Resident #1 refused her medications. Med Tech stated she did not grab Resident#1's mouth or force her to take the medication. She said when she refused, she went and reported it to the nurse and that was it. She said that she would not force a resident to take medication as that was abuse and a resident had a right to refuse medication. She said that all abuse was reported to the Administrator immediately. Med Tech revealed that LVN D was no longer employed at the facility. On 12/10/25 at 2:57 PM, an attempt was made to contact LVN D. A message with a return number was left. There has been no return call from the nurse. Interview with the Administrator on 12/10/25 at 5:09 PM revealed she was aware of the timeframe for reporting abuse allegations was within two hours. The Administrator stated DON contacted her the same evening Resident #1 made the abuse allegation. She said she consulted with her corporate office, and she was advised not to report the allegation because it did not meet the criteria for reportable incidents. She said moving forward she now knows better to report allegations of abuse. She said when they received grievance they did an internal investigation, safe surveys, in services and witness statements. She said the grievance was resolved. Record review of facility Inservice for Abuse and Neglect led by the administrator reflected it was completed on 11/22/25. 15 staff completed the Inservice. Record review of grievance dated 11/19/25, revealed safe surveys completed by 7 residents. No concerns were noted. Review of the facility's policy titled Abuse and Neglect-Clinical Protocol, revision date April 2007, revealed, The management and staff, with the support of the physicians (as needed), will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on observation, interviews, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #2) reviewed for peripheral intravenous care. The facility failed to ensure physician orders for Resident #2 were followed to change PICC line dressing every 7 days as ordered. This failure could affect residents by placing them at risk of infection. Findings included: Record review of Resident #2's face sheet dated 12/10/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of other mechanical complication of internal fixation device of bone of right lower leg, subsequent encounter (this is an active infection that was caused by the hardware in the right lower leg). Record review of Resident #2's admission MDS dated [DATE] did not indicate Resident #2 had a BIMS score. Record review of Resident #2s Physician order summary for December 2025 reflected -LUE DL PICC IV: Change IV dressing Q TUE days and PRN. Ordered on 12/03/25.-Monitor IV insertion site for s/s of infection/infiltration every shift. Ordered 12/02/25. Record review of Resident #2's care plan initiated on 12/03/25 indicated Resident #2 was on IV antibiotic therapy related to pin site osteomyelitis (bone infection) infection. The goal was for Resident #2's infection to resolve without complications. The interventions were to administer medication as ordered. The care plan also revealed that Resident #2 had a surgical incision related to fracture repair. The goal was for the surgical wound to heal without complications by the review date. Inventions included Monitor for signs of infection (redness, warmth, excessive drainage) and report changes to MD. Observation and interview with Resident #2 on 12/10/25 at 10:00 AM revealed Resident #2 was attached to an IV pole with IV antibiotic being infused. Resident #2 said that she received antibiotics twice a day. Resident #2 extended her left arm and revealed a PICC line with two ports. One of the ports was covered with a green cap and the other port was being used for the infusion. The dressing was coming off on the left outer side. The dressing was dated 11/26/25 with time print 17:55 [5:55PM]. The inner insertion site had a gel covering of PICC line and dressing around the immediate proximity was intact and clean. Resident #2 said she did not know how often the IV dressing is changed. In an interview with LVN A on 12/10/25 at 10:29 AM, she stated this was the first time that she was assigned to work with Resident #2 and she wanted to give at least one antibiotic before changing the IV dressing. She said she noticed that the PICC line needed to be changed but she did not change it until the first antibiotic was completed. She said that she had assessed the PICC line before medication administration to make sure there were no signs and symptoms of infection such as redness, swelling, pain, or any discoloration. She said she knew that all PICC line dressings were changed every Tuesdays or weekly. She said that the risk of not changing IV dressing was infection. In an interview with RN F on 12/10/25 at 1:45 PM, she stated she was the infection control preventionist. She said nurses were responsible for putting orders in for dressing changes and the unit managers monitored that orders are accurate. She said she is supposed to monitor that staff are following the infection control procedures. She said that she was not aware that a resident had a PICC line dressing that was overdue. She said the risk of not changing the dressing when it is due is infection. An interview with the DON on 12/10/25 at 1:59 PM revealed that nurses were responsible for completing dressing changes as ordered weekly on Tuesdays and charge nurse were responsible for monitoring completion of tasks. She said LVN B was supposed to change Resident #2's PICC line dressing yesterday on Tuesday (12/09/25). DON stated LVN B told her that she became busy with admission and discharge and forgot to complete the dressing change. She said that LVN B should have communicated with the oncoming nurse that she had not completed the dressing change. She said she did not know how the IV dressing change was missed between 12/03/25 until 12/10/25 but that on Monday 12/08/25, Resident #2 was gone to an appointment. She said if the IV dressing did not get changed as ordered, then there was potential for infection. In an interview with LVN B on 12/10/25 at 4:00 PM, it was revealed she had been employed to the facility for about four months. She said, honestly it slipped my mind. She said she was very busy on Tuesday with admission and discharge and forgot to change Resident #2's PICC line dressing. She said she also forgot to communicate with on coming nurse about the IV dressing change. She said she needed a better time management strategy. She said she had been trained to assess and change IV dressings. She said that she monitored PICC for signs and symptoms of infection. She said failure to change PICC line dressing put the resident at risk for an infection. In an interview with the Administrator on 12/10/25 at 05:09 PM, she said the expectation was for nursing to follow processes in place to prevent the risk of infection. Record review of facility policy titled Intravenous Therapy: Preventing Catheter-Related Infections revised August 2009 reflected. The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters.1. Sterile transparent, semi-permeable membrane (TSM) dressings are the preferred covering for catheter insertion site. This allows visualization of insertion site.2. Change TSM dressings every 7 days or PRN if wet, dirty, or not intact. This does not require a physician's order.

Based on interview, observation, and record review the facility failed to ensure the resident had access to a private form of communication. 1) The facility removed the landline telephone from the resident's room.2) The facility refused to provide a telephone to the resident when he requested to use one. This failure could cause psychosocial harm to the residents by not allowing them to communicate with people outside of the facility when desired.During the off-site preparation for the investigation, an interview was conducted with the complainant on 09/25/25 at 6:15 PM. The complainant stated [Family Member] demanded the facility not provide Resident #1 access to a telephone to prevent him from communicating with other members of the family. Complainant further stated Resident #1 had been diagnosed with dementia (an umbrella term for a group of symptoms characterized by a decline in mental ability that impacts daily life, including memory, thinking, and behavior). While interviewing Resident #1 on 09/26/25 at 9:45 AM, Resident #1 was able to communicate in a well articulated manner and appeared to be of sound mind. Resident #1 stated he was in the facility due to being involved in a serious vehicle collision and was in the process of recovering. Resident #1 was able to describe to me how the vehicle collision occurred and recount a correct timeline of the collision and his ensuing hospital stays and medical procedures since being hospitalized . While speaking to Resident #1, complainant and [Family Member] arrived to visit. In person interview conducted with complainant and [Family Member] on 09/26/25 at 10:38 AM. Complainant and [Family Member] stated Resident #1 had been diagnosed with Sun Downers (a set of symptoms-including confusion, anxiety, aggression, and agitation-that typically begin in the late afternoon and evening in individuals with dementia.) 2-3 years ago by his personal Doctor. The complainant further stated she and [Family Member] had Resident #1's personal Doctor complete a CME on 08/29/25. The complainant continued to state she and [Family Member] have Medical POA for Resident #1. [Family Member] stated during the interview, he instructed the facility to remove and deny Resident #1 all forms of communication to prevent him from communicating with other members of the family without their knowledge. Complainant and [Family Member] stated they did not have a court order showing Resident #1 had been ruled incompetent. Complainant provided copies of the CME and Medical POA. During an interview with Resident #1's personal Doctor, on 09/26/25 at 1:40 PM, he stated he has not diagnosed Resident #1 with dementia or Sun Downers and stated those diagnoses were given to Resident #1 by [Family Member]. He further advised he did complete the CME at [Family Member] request and stated he wrote on the CME Resident #1 had not been diagnosed with dementia. Resident #1's personal Doctor continued to state [Family Member] was quite insistent on completing the CME indicating Resident #1 had dementia. Resident #1's personal Doctor continued to state he advised [Family Member] he had not seen Resident #1 in some time and could not diagnosis him with dementia. Resident #1's personal Doctor said he completed the CME to appease [Family Member] and completed the CME in such a manner that indicated if there were any mental deficiency, it would be due to the vehicle accident and not dementia, and most likely be temporary. During an interview with DON on 09/26/25 at 2:05 PM, she stated [Family Member] demanded Resident #1 not have access to a telephone to communicate with other family members. DON stated the facility complied with [Family Member] request and removed the phone from Resident #1's room and denied him access to any other forms of communication. DON further stated the facility does have the ability to provide a form of private communication for the resident but has not done so due to the request of [Family Member]. DON stated there are no medical records, diagnostic records, or diagnosis indicating Resident #1 has dementia. Durning a re-interview of Resident #1 on 09/26/25 at 3:10 PM he stated his personal cell phone was taken from him by [Family Member] shortly after being admitted . Resident #1 further stated he had been allowed to use the phone only once when he first arrived to the facility. Resident #1 continued to state he asks to use a phone several times a day and is denied by staff. Resident #1 said no one will tell him why he can't use the phone. Resident #1 stated he missed speaking to his wife and daughter and has not been able to speak to them since being admitted to the facility. While speaking to Resident #1, Med Aid entered to provide care and stated she was instructed to not provide a phone to Resident #1 if he asked. Med Aid further confirmed Resident #1 had asked for a phone every day he has been in the facility to call his wife. During an interview with the Administrator on 09/26/25 at 3:56 PM, she stated there were no records indicating Resident #1 was unable to make decisions for himself. The Administrator said she had instructed Resident #1 not have access to a form of communication at the request of [Family Member]. The Administrator continued to state [Family Member] and complainant had been very aggressive towards her and facility staff while Resident #1 has been in the facility. The Administrator stated she holds resident rights in the highest priority, but to appease [Family Member] and to deescalate verbal confrontations with [Family Member], she denied Resident #1 access to a phone[VT1] [DG2] . Observation of Resident #1's room on 09/26/25 at 9:45 AM showed no landline telephone was present in the room. Record review of the CME, dated 08/29[sic], provided by complainant and [Family Member] reflected question #3: Evaluation of the Proposed Ward's Mental FunctioningMental Diagnosis: Hallucination ?[sic] Post Op, Meds, [illegible] Dementia unknown. Under question #3 the CME, dated 08/29[sic], further reflects: If the mental diagnosis includes dementia, answer the following: Written in handwriting next to this question is not diagnosed @ time[sic] Record review of Resident #1's admission record, dated 09/02/25 reflected he was his own responsible party. Record review of Resident #1's physical therapy notes, dated 09/03/25-09/06/25; 09/08/25; 09/12/25; 09/13/25; 09/15/25; 09/19/25; 09/20/25; 09/22/25; 09/24/25; and 09/25/25, reflected DO NOT ALLOW PATIENT TO LEAVE WITH [FAMILY MEMBER #2]. DO NOT ALLOW PATIENT TO SIGN ANYTHING GIVEN TO HIM BY [FAMILY MEMBER #2]. PHONE REMOVED FROM THE ROOM PER FAMILY REQUEST. Record review of Resident #1's MDS, dated [DATE], reflected he had a BIMS (A standardized, short test used in long-term care facilities to screen for and track cognitive decline in residents. It assesses a person's orientation, attention, and ability to register and recall information.) score of 13 of 15. [VT3] Record review of document titled Medical Power of Attorney and HIPAA Release Authorization of [Resident #1], undated reflected: This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician. Record review of the facility's Resident Rights policy, dated revised December 2016, reflected: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .e. self-determination;f. communication with and access to people and services, both inside and outside the facility; .cc. access to a telephone, mail and email. Record review of the facility's Telephone Accessibility policy, dated revised April 2007, reflected: Residents may have telephones installed in their rooms or may use cellular phones. The resident or his/her responsible party must pay for such service, including fees and line services.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services.The facility failed to ensure Medication Cart #1 was locked when unattended, in the 300 Hall, on 09/26/25.This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversioFindings included:In an observation and interview on 09/26/25 at 9:28 AM, Medication Cart #1 was observed unlocked and unattended as it set outside room [ROOM NUMBER], across from the nurses' station. There were no staff at the nurses' station. There were no staff in the immediate area. Medication Tech A was observed about 4 rooms down as she passed medication. The DON was observed as she came down the hall and locked the medication cart. The DON stated she was not sure who was responsible for the unlocked medication cart. The DON asked Medication Tech A who last attended the medication cart, and Medication Tech A stated she was the last one that used the unlocked medication cart. The DON told Medication Tech A that all medication carts should be locked when unattended to prevent drug diversion.In an interview on 09/26/25 at 12:02 PM, Medication Tech A stated she was responsible for two medication carts today. She stated she used the medication carts for 300 and 400 halls, and she stated she forgot to lock the other cart when she switched to a different cart. She stated she never left medication carts unlocked and was upset about it. Medication Tech A stated the risk of an unlocked medication cart was a patient could get in it and get stuff. Medication Tech A stated she was trained to always lock the medication carts. In an interview on 09/26/25 at 4:05 PM, the Administrator stated she was informed about the unlocked medication cart that was the responsibility of Medication Tech A. She stated the staff received in-services routinely on medication administration and locked medication. The Administrator stated the risk of an unlocked medication cart was anyone would have access to the medications.A policy on locked medication was requested on 09/26/25 at 11:50 AM and at 3:35 PM but not received.

Based on observation, interview, and record review, the facility failed to provide the Resident Council Group a private space for monthly resident council meetings for the facility's only resident council. 1. The facility failed to ensure resident council meetings were held in a private meeting space. Staff continued to enter the activities room while the resident council meeting was being held. This failure could place residents at risk of not disclosing concerns or issues, which could lead to emotional turmoil and distress. Findings included: Observation of the resident council meeting on 6/25/2025 at 1:30pm revealed five residents located in the facility's activities room for the resident group meeting. The activities room was in an open area with no doors to the room. Five care staff and providers continued to enter the activities room and interrupt the group meeting. In an interview with the AD on 06/25/2025 at 1:37pm she stated resident council meetings were held in the activities room or in the dining room. She stated the conference room is a private area, but the conference room was unavailable because the nurse managers used the conference room as a workspace. In a confidential group interview on 06/25/2025 at 1:50pm revealed resident council meetings were held in the activities room and staff frequently came in and out of the activities room during resident council meetings and used the vending machines. In an interview with the ADM on 06/25/2025 at 3:00pm she stated resident council meetings were held in the activities room or the classroom. She stated if the facility was not conducting orientation during the resident council meeting, the meeting could take place in the classroom. She stated not ensuring resident council meetings were held in a private area could violate the privacy of the residents. Record review of the facility's Resident Rights policy revised 2016 reflected, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #12) of four residents reviewed for pressure ulcers (open wound on the skin caused by prolonged pressure to bony prominences). The facility failed to ensure that Resident #12's negative pressure wound device had settings per physician order on 06/25/2025, and 06/26/2025. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers and infection. Findings included: Record review of Resident #12 Face Sheet dated 06/26/2025 revealed she was a [AGE] year-old female admitted from an acute care hospital for long term care on 03/13/2025. Relevant diagnoses included heart failure (heart unable to pump enough blood to meet the body's needs,) pyelonephritis (kidney infection,) and dementia (group of symptoms affecting memory, thinking, and social abilities.) Record review of Resident #12's Quarterly MDS dated [DATE] revealed she had moderate cognitive impairment with a BIMS score of 11. She was dependent upon staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. She was incontinent of bowel and bladder. She was admitted with a total of two stage IV pressure ulcer/injuries. Record review of Resident #12's Physician Orders revealed Wound Vac continuously at 125 mgm hg to Sacrum . every day shift for wound care . Start date 06/21/2025. In an observation and interview of Resident #12 on 06/25/2025 at 10:25 AM, her negative pressure wound device was turned on and the setting was observed at 150 mmHg . In interview, Resident #12 revealed she was not aware of the physician orders for her device settings nor when it was last changed. In an observation of Resident #12 on 06/26/2025 at 10:45 AM, her negative pressure wound device was turned on and the setting was observed at 150 mmHg. In an interview with Resident #12's nurse for the day, LVN H, on 06/26/2025 at 10:47 AM, she stated she was not certain about Resident #12's negative pressure wound device settings and would defer to Treatment Nurse C for more clarification. In an interview and observation with facility's Treatment Nurse C on 06/26/2025 at 10:50 AM, she stated Resident #12's negative pressure wound device settings should be 125 mmHg, stated it was currently at 150 mmHg, and was observed to reset the device to 125 mmHg. She stated the potential outcome was nothing, as [Resident #12] has a lot of drainage. In an interview with facility's DON on 06/26/2025 at 1:08 PM, she stated her expectations were for all nursing staff at the facility to ensure residents with negative pressure wound devices have the settings set according to physician orders. She stated if the settings were not correct, it was a medication error that could cause harm to the residents at the facility. She stated it was Treatment Nurse C's responsibility to ensure the settings were correct each day. In an interview with Administrator on 06/26/2025 at 3:00 PM, she stated she would defer to her clinical team for wound care expectations. Record review of facility policy, Negative Pressure Wound Therapy, rev. 02/2014, revealed Preparation . 1. Verify that there is order for this procedure .13. Turn on pump: a. Initiate negative pressure setting on the pump as ordered .

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 in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure all foods stored in the refrigerator were covered, labeled, and dated. 2. The facility failed to ensure dented cans were placed in a separate storage area. 3. The facility failed to discard open items in the dry storage that were not sealed. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the refrigerator on 6/24/2025 at 8:02am revealed the following: -1 tray of 13 drinks dated 6/24/2025 not labeled. -1 tray of 8 fruit cups not labeled or dated. Observation of the dry storage on 6/24/2025 at 8:10am revealed the following: -1 5.31 lbs jug of mashed potatoes dated 6/18/2025 was opened and exposed to the air. -1 6.56 lbs can of marinara sauce dated 6/14/2025 was dented on bottom right. In an interview with the DM on 06/25/2025 at 9:44am she stated it was the kitchen aides' responsibility to ensure all food and drinks were labeled, dated, and sealed appropriately. She stated failing to properly label, date, and seal food and drinks could cause residents to be sick, vomit, or have food borne illness. She stated it was all the kitchen staff responsibility to check for dented cans and remove any dented cans. She stated dented cans could cause the residents to become sick. In an interview with DA I on 6/25/2025 at 9:50am he stated it was his responsibility to make sure all food and drinks were labeled, dated, and sealed correctly. He stated food and drinks labeled and dated correctly can prevent expired food and drinks served to residents. He stated expired food or drinks could make residents sick. He stated all kitchen staff were responsible for checking for dented cans and placing dented cans in a separate area. He stated dented cans could make residents sick.

Based on observation, interview, and record review the facility failed to administered in a manner that enables it to use its resources effectively and efficiently to attain or main the highest practicable psychosocial well-being for 17 residents. 1. The facility failed to ensure calls directed to a centralized staff work area were answered. 2. The facility failed to ensure the centralized staff work area had a portable phone available and the portable phone was properly functionating. This failure could place 17 residents on hall 200 with limited resources or other services necessary to provide for the needs of the residents. The findings included: In a confidential interview onn 6/24/2025 at 8:57am revealed the resident referenced in the complaint was discharged from the facility in January 2025. She stated during resident's time at the facility, there was multiple times, particularly during the early morning hours, she contacted the facility via phone and did not receive a response. She stated when she contacted the facility via phone, the phone rung multiple times and was unable to speak with staff. She stated she attempted to contact the facility to discuss concerns regarding the lack of care the resident was receiving. In an interview with Receptionist J on 6/24/2025 at 9:26am revealed the facility had two receptionists that worked Monday- Friday between 8:00am-8:00pm and their responsibility was answering all calls made to the facility. He stated after 8:00pm, all calls were routed to all nurses' stations and any staff could answer calls. He stated there were portable phones at the nurse's station and the portable phones could receive calls and staff could make outgoing calls. He stated to his knowledge the portable phones were properly functioning. Observation of a telephone call made to the facility by the surveyor on 6/26/2025 at 5:00am revealed staff answering the phone. Observation of a telephone call made to the facility by the surveyor on 6/26/2025 at 6:34am revealed the phone rung continuously and staff did not answer the phone. Observation of a telephone call made to the facility by the surveyor on 6/26/2025 at 6:36am revealed the phone rung continuously and staff did not answer the phone. Observation of the 200 hall nurses' station on 6/26/2025 at 8:48am revealed the portable phone was missing from the phone base. In an interview with ADON A on 6/26/2025 at 8:50am revealed the portable phone was misplaced. She stated the phone has been missing for a while. She stated there was a portable phone at the nurse's station on the 100 hall that was available and functioned properly. Observation of the 100 hall nurses' station on 6/26/2025 at 8:54am revealed a portable phone on the charging base however, the portable phone was not functioning properly due to the phone not being fully charged, and incoming and outgoing calls could not be received or made. Observation of the 300 and 400 hall nurses' station on 6/26/2026 at 9:02am revealed a portable phone on the charging base properly functioning. In an interview with the DON on 6/26/2025 at 11:28am she stated after hours, all incoming calls were routed throughout the facility to all nurses' stations. She stated there were land lines at each nurse's station and a portable phone. She stated the portable phone at 200 hall nurses' station, was misplaced and had been missing for three months. She stated to replace the missing the phone, she would inform the ADM and the ADM would order a new phone. She stated nurses and aides were expected to answer any incoming calls. She stated if staff could not answer an incoming call from the land line or portable phone, the phone would continue to ring, and caller could not leave a message unless the caller knew a direct extension. She stated the caller would have to call back until staff answered the phone. She stated staff was expected to answer the phones after hours. She stated it was important for staff to answer the phones because the caller could be calling regarding the care of a resident and a resident care is always important. In an interview with the ADM on 6/26/2025 at 3:00pm she stated after hours all incoming calls were routed to all nurses' stations. She stated any nurses or aides could answer incoming calls. She stated each nurse's station had a land line and the nurses' stations also had a portable phone. She stated if staff could not answer the land lines or the portable phones the call would continue to ring unless the caller knew an extension. She stated if the caller needed to speak with staff, the caller would have to call back until staff answered the phone. She stated she was informed today, the portable phone at the 200 hall nurses' station was misplaced. She stated it was important for staff to answer incoming calls because the caller could be calling about an emergency and it is important representatives and family to check on their loved ones. Record review of the facility's resident rights policy revised December 2016 reflected Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: F. communication with and access to people and services, both inside and outside the facility.

Based on interviews and record reviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming for 1 of 6 residents (Resident #18) reviewed for quality of care. The facility failed to ensure Resident #18 call lights were answered in a timely manner. This deficient practice could affect Resident #18's feelings of dissatisfaction or poor self-esteem. Findings included: Review of Resident #18 admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included appendicitis (inflammation of the appendix), muscle weakness, abnormalities of gait and mobility (any deviations from a typical walking pattern), lack of coordination, cognitive communication deficit, anemia (not enough red blood cells), type 2 diabetes (body doesn't produce enough insulin), hyperlipidemia (abnormally high levels of fatty substances in the blood), hypertension (the force of blood against your artery walls is consistently too high), paroxysmal atrial fibrillation (episodes of an irregular heartbeat stop on their own), gastro-esophageal reflux disease without esophagitis (esophagus doesn't show signs of inflammation or damage despite the presence of reflux), end stage renal disease (kidneys are functioning at a very low level, requiring dialysis or kidney transplant for survival), chronic kidney disease (kidneys cannot filter blood as well as they should, dependence on renal dialysis (kidneys are no longer able to adequately filter waste and excess fluid from the blood, requiring regular dialysis treatments to sustain life. Record review of Resident #18's quarterly MDS assessment, dated 10/16/24, reflected Resident #18 had a BIMS score of 15, indicating intact cognition. Attempted interview with Resident #18 on 06/26 /25 at 12:35 PM but did not receive a return call. During a confidential interview on 06/23/25 at 2:36 PM, Resident #18 revealed to her that she had a bowel movement the night before and pressed her call light and staff came in and turned the light off and refused to change her until the morning. Interview on 06/27/25 at 6:15 PM, CNA K revealed she had to answer a coworker's call light due to light being on for 15 minutes and felt that was to long for the resident to go without care. CNA K stated that residents have reported that when she was not at work they were hesitant to hit their call light cause they didn't want to bother the staff, because staff will come in and turn off the light and not provide care to the resident, which could lead to issues such as skin breakdown if they were left wet or they could be left in extreme pain if the request was for pain medication. Interview on 06/27/25 at 7:02 PM, CNA L revealed resident have complained that staff turned their call light off and did not provide care and stated that could be bad for residents, because it could have been a serious problem like for example, they fell and had an injury, so best practice is to go answer the call light as soon as you can. Interview on 06/28/25 at 1:39 PM, the DON revealed residents have complained to staff about call light response time, staff has been reeducated that anyone can answer a call light and if that staff member is unable to provide care, to leave the light on and go get the staff member who could assist, because if they turn the light off and the can't find the proper person they would forget and the resident care needs weren't provided. The DON stated that the facility conducted ambassador rounds Monday through Friday and hired an evening shift manager that leaves at 10 PM because she realized that unfortunately when staff was not monitored, they may not do what they were supposed to, so the Administrator and the DON have popped up overnight to ensure staff did their job. Interview on 06/28/25 at 3:01 PM, the ADM revealed that the expectation to answer call lights was as soon as possible, but no longer than 15 minutes and that all staff were able to answer call lights, and if unable to provide service to the resident, leave the call light on, go inform the appropriate staff member so they could go address residents' concerns. Additionally, there was no overnight manger on duty, so the DON and ADM conduct monthly spot checks, where they will come into the facility at random times throughout the night to ensure resident care was provided. The Administrator stated it was important to respond to call lights as it could lead to harm of the resident depending on what the call light was on for. Record review of Grievance/Complaint Report dated 10/21/2024, reflected resident stated that she placed her call light on for assistance related to incontinent episode and staff CNA with blue on came in the room told her that she would return and never returned was reported to the DON and Interpreter for Resident #18. Facility follow-up stated that in-serve on call light answering and providing service in a timely manner to provide care was given. Resolution of grievance/complaint stated patient stated that care needs were provided in the next 72 hours in and timely manner. Record review of the facility's policy Answering the Call Light, revised October 2010, reflected Answer the resident's call light as soon as possible.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #123 and #124) of twenty residents reviewed for Infection Control. 1. The facility failed to ensure MA G sanitized the blood pressure cuff while administering medications and checking vital signs of Residents #123 and #124 on 06/24/2025. 2. The facility failed to ensure MA G performed hand hygiene prior to resident contact and care for Resident #124 on 06/24/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings include: Record review of Resident #123's Face Sheet dated 06/26/2025 revealed he was a [AGE] year-old male admitted from an acute care hospital on [DATE]. Relevant diagnoses included encephalopathy (disease that affects the brain's function or structure,) cerebral infarction (obstruction of flow of blood to the brain resulting in brain cell death) resulting in left side deficits, pneumonia (infection that inflames the air sacs in one or both lungs,) and diabetes mellitus type II (insulin resistance.) Record review of Resident 124's Face Sheet dated 06/26/2025 revealed she was an [AGE] year-old female admitted from a rehabilitation hospital for extended rehabilitative therapy on 06/05/2025. Relevant diagnoses included femur (leg) fracture and diabetes mellitus type II (insulin resistance.) During an observation of MA G with Resident #123 on 06/24/2025 at 8:08 AM, she obtained a blood pressure device from an unattended medication cart in the hallway, performed hand hygiene in resident's sink, and obtained his blood pressure with his left upper arm. MA G failed to sanitize the blood pressure cuff and device prior to use on Resident #123. During an observation of MA G with Resident #124 on 06/24/2025 at 8:38 AM, MA G entered the resident room and obtained Resident #124's blood pressure with her right upper arm. MA G failed to perform hand hygiene prior to resident contact and sanitize the blood pressure cuff and device prior to use on Resident #124. In an interview with MA G on 06/24/2025 at 8:56 AM, she stated did not recall if she performed hand hygiene prior to contact with Resident #124. She stated it was important to complete hand hygiene before and after all resident contact for infection control purposes. MA G stated she obtained the blood pressure cuff and device off the nurse's cart in the hall and assumed it was [sanitized] before use with Resident #123. She later stated she should have sanitized it prior to use with Resident #123 and prior to use with Resident #124. She stated, it should have been done, and it was an infection control issue. MA G stated she has received in-services on the topics and it was her responsibility to ensure these tasks were completed. In an interview with DON on 06/26/2025 at 1:08 PM, she stated she expected her staff to perform hand hygiene between resident care and contact for infection control purposes. Additionally, she stated she expected her staff to sanitize shared use equipment between resident contact and use for infection control purposes. She stated it was ultimately her responsibility to ensure this was completed and provided in-services for review. In an interview with Administrator on 06/26/2025 at 3:00 PM, she stated she expected her staff to perform hand hygiene and sanitize shared use equipment between resident contact and use for infection control purposes. Record review of facility policy, Handwashing/Hand hygiene, rev. 08/2015, revealed This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: . before or after direct contact with residents; i. After contact with a resident's intact skin . Record review of facility policy, Cleaning and Disinfection of Resident-Care Items and Equipment, rev. 07/2014 revealed Resident-care equipment, including reusable items . will be cleaned and disinfected . 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: d. Reusable items are cleaned and disinfected or sterilized between residents . Record review of facility in-service, Cleaning and Disinfecting Resident Care Items, dated 04/09/2025 revealed, Remember to clean and disinfect shared items before, in between, and after use to prevent the spread of infection . MA G was listed as in attendance on the signature list. Record review of facility in-service, Handwashing and Hand Sanitizing, dated 04/25/2025 revealed Handwashing is the first line of defense to control the spread of infection . Hand sanitizing should be performed between each patient contact . MA G was listed as in attendance on the signature list.

Based on observations, interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #1) of three residents reviewed for discharge planning. The facility failed to implement an effective discharge plan for Resident #1, when FM S reported the resident's home was without electricity. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could place residents at risk of not receiving care, supervision, and services to meet their needs upon discharge. Findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/31/2025. DX included: Acute kidney failure (failing kidney function), unspecified dementia (cognitive decline), abnormalities of the gait, unsteadiness on fee, Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected Resident #1 had no history of wandering, section GG for resident functional abilities were left empty, indicating she was not assessed at discharge on [DATE]. Section N - Medications reflected the resident was not taking any high-risk medications. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. Review of Resident #1's Fall risk Assessment at her time of admission dated 03/12/2025 reflected that she was a moderate risk for falls, scoring a 7, indicating some fall interventions were needed based on Falls r/t confusion. Review of Resident #1's Elopement Risk Assessment at her time of admission dated 03/12/25 reflected Resident #1 was cognitively impaired with poor decision-making skills .no pertinent diagnosis for dementia, resident does not ambulate independently, no vision, hearing, or communication problems, no history of elopement, leaving without needed supervision, or wandering aimlessly. The resident was not at risk of elopement/wandering at this time. Record review of progress note dated 03/28/2025 at 2:48 PM by NP reflected Assessment and Plan: Impaired mobility and gait worsened state since PTA, continue rehabilitation efforts with multidisciplinary approach including PT for gait, OT for self-care skills and transfers. - Pt currently will benefit from continuous 24 hr. care for medication, skin care, education, and reinforcement in therapies along with psychiatric medical care/recommendations for ongoing medical issues. Will need to include family education/training and possible DME assessment -Precautions: Fall, Skin Acute Metabolic Encephalopathy [a brain dysfunction caused by a sudden imbalance in the body's metabolism, leading to changes in brain function, such as confusion, disorientation, or memory loss.] oriented X 3, baseline dementia. Previous records, history, pertinent labs, imaging were reviewed and discussed with pt. The above plan was also discussed with pt at depth who states understanding and agrees. PMR (Physical Medicine and Rehabilitation. It is a medical specialty that focuses on restoring function and improving mobility in patients with musculoskeletal, neurological, and spinal cord injuries) will continue to follow this pt and give recommendations, intermittent management for above noted medical issues purely as role of consulting service per facility, IM/Primary/attending team's request. Record review of Resident #1's progress note dated 3/31/2025 at 9:29 PM, NP reflected suspected progressive dementia - supportive care. Record review of Resident #1's MD orders dated 03/12/2025 reflected the following: Hypoglycemic Protocol: Follow Hypoglycemic Protocol if blood sugar is less than 70 mg/dl (a unit of volume equal to one-tenth of a liter.) Assessment tab when protocol is required every shift -Start Date- 03/12/2025 6:00 PM -DC Date-04/01/2025 3:54 PM 03/12/2025 HS snacks .Monitor resident for abnormal bruising and/or bleeding from nose, gums, blood in urine or stool Q Shift every shift .order dated 03/26/2025 reflected .Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth every 8 hours as needed for Anxiety .Hydroxyzine Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety. Record review of progress note dated 03/31/2025 at 3:57 PM by ADM reflected APS referral completed upon discharge from facility on 3/31/25 at 3:45 PM. Worker Intake ID [number]/Report number [number] to 1800-252-5400. APS referral completed due to concerns from the cousin that patient is returning to an unsafe living environment where the cat has urinated/poop all over her apartment, no food, and maybe no lights available. Record review of Resident #1's Discharge Plan of Care dated 04/04/2025 reflected Resident # 1 was being discharged to home with family, nursing needs: wheelchair .transportation: family transported. Scheduled appointments: f/u with PCP .CM explained care/support to resident caregiver, yes no special instructions for diet .treatment reviewed with resident/caregiver, yes .APS referral made with resident discharge home d/t cognitive decline. This note was added after the resident discharged by CM T as a late entry. During an interview with the ADM on 04/11/2025 at 9:40 AM, revealed Resident #1's was discharged on 03/31/2025 at 3:40 PM. ADM said FM S was aware of the discharge home, and home health had been contacted. ADM said FM S had reservations closer to the discharge date stating she was afraid of Resident #1, Resident #1 can't live with her, the home was not safe due to the electric power being disconnected. ADM stated that she did not contact the apartment manager for information on Resident #1's home environment prior to discharge. ADM told FM S she would have Resident #1 transported to the apartments via Uber (transportation business). ADM said she did not attempt to search for other family prior to discharge. ADM said Resident #1 discharged home on a previous stay, and this was the discharge plan at the time of admission on [DATE]. She denied behaviors of cognitive loss and confusion. She said the resident was capable of returning home to care for herself. She notified APS of the home condition allegations from FM S as an alternate plan for Resident #1 when she left the faciity on [DATE]. During a phone interview with FM S on 04/11/2025 at 10:20 AM said she told the ADM that the home did not have electricity. FM S said she did not agree with the ADM goal to discharge home, because Resident #1 was confused, and no services were set up prior to her return home. FM S told the ADM that she would not be living in the home with Resident #1, and she proceeded to discharge home. FM S said there were additional extended kin for the Resident #1, but they were not contacted nor informed about the discharge planning and return home. FM S said that the facility did not ensure home health services were scheduled prior to discharge. FM S said that Resident #1 did not have a walker or wheelchair when she arrived at the apartment, only personal belongings. During a phone interview with the ADON T on 04/11/2025 at 10:40 PM she stated that Resident #1 was a skilled patient under her supervision. She stated Resident #1 was frequently confused and cognitively impaired. She could ambulate independently throughout the facility, but she would not be able to live alone without supervision due to her dementia. ADON T was aware that Resident #1 was being discharged home with cousin and home health services. During a phone interview with the HCM K on 04/11/2025 at 2:10 PM she stated on 03/31/2025 Resident #1 was transported to the hospital by KR K after observing she was confused, and the apartment was not safe and sanitary for Resident #1 to live. HCM K said Resident #1 after medical hospital assessments, the ER staff determined that due to the level of her memory loss, she should not be left at home alone to care for herself due to cognitive loss. During an interview on 04/11/2025 at 6:40 PM with KR K she stated that she was a family member of Resident #1. KR K reported that FM S have excluded her from the rehabilitation contact, therefore she was not aware that Resident #1 had been discharged on 03/31/2025. On 03/31/2025 (time unknown) KR K said she received call from Resident #1 and her neighbor at 5:00 PM requesting that she pick her up, because her electricity was disconnected. KR K said Resident #1 remained with the neighbors until she arrived at 6:00 PM. KR K could not find the neighbors phone number and name. KR K said she contacted KR C to meet her at the apartment. KR K said she and KR C arrived and went to the third floor and Resident #1 was with the neighbor. She immediately took Resident #1 to her car and asked KR C to remain with her while she checked the apartment. KR K said the apartment had no electricity and there was cat food, feces, and urine on the floor. KR K contacted FM S to find out what happened. KR K said the family member was not responsive. KR K said she and KR C explained to Resident #1 that they had to take her to the hospital for an evaluation until the home environment safety and utilities were connected. KR K said Resident #1 was somewhat confused and could not provide details of the day leading up to her calling. KR K and KR C took Resident #1 to the hospital, and she was admitted . KR K said the hospital placement was temporary and a means for getting assistance with another placement. During an interview with CM T on 04/25/2025 at 1:13 PM revealed she completed the hard copy of the Discharge plan and Resident #1 signed at the bottom that she understood. She was not aware of her confusion; she was directed by the IDT and ADM to discharge the resident home with HHC. CM T stated that the facility does not conduct home visits to assess for safety. CM T said she would not have notified the apartment complex of the discharge or uber transport to the complex on 03/31/20205. CM T stated that it was her understanding that FM S would be present to take custody and care of Resident #1 once the uber arrived. CM T stated that additional task and plans were provided to FM S by the ADM. CM T said she left the PCP name empty because the resident did not know the name and contact information. CM T did not set up the intake of HHC, nor followed up with a call after discharge to ensure patient connection for services. CM T said at discharge the Resident was provided the name and contact number of the HHC agency to call upon arriving home. During an interview with RN G on 04/14/2025 at 1:22 PM revealed she observed the discharge of Resident #1. She assisted with transferring her into the uber with personal belongings. She signed the hard paper copy of the discharge planning on 03/31/2025. RN G said she did not complete the discharge plan of care assessment in the electronic records system. During an interview with the DOR on 04/14/2025 at 1:28 PM revealed rehabilitation staff were involved in the discharge process, and her role would require her to attend the IDT for resident status in therapy and reviewing resident discharge form payment providers (insurance) and schedule date. DOR said once a NOMNC she and her staff will provide family education training and ensure the resident and family were prepared for a discharge home. DOR said additional task and assessment for the resident included notifying all if additional equipment was needed at home such as, DME Durable medical equipment assess. The DOR said the therapy department will provide the social worker with this information to continue with discharge. The DOR said Resident #1 was compliant with therapy, she confused and was observed with impaired cognition. The recommendations were to discharge home with home health services and additional therapy assessments for services in home. During an interview with the DON 04/14/2025 at 2:30 PM she stated that the goal was for Resident #1 to return home, and APS was notified of home environment concerns by the ADM after the resident discharged home. She said the resident wanted to return home. The DON said she did not have any concerns with Resident #1 living alone in her apartment. The DON said home health services were set up for FM S to call and schedule for an assessment. The DON said resident was observed with occasional confusion, however, she lived alone prior to admission to the facility and the goal was for her to return home. The DON said FM S reported to the ADM that Resident #1's home was not safe to live prior to departure. The DON said it was at that time the ADM told FM S that she would make an APS report about the condition of the home. The DON said it was not until later that she was notified that the resident was sent to the hospital. During an interview with APSI on 04/15/2025 at 12:44 PM she stated the facility ADM called in an APS report on 03/31/2025. APSI said the resident should not have been returned home if the electricity was disconnected. APSI said there was a current investigation since Resident #1 entered the hospital. She stated she was working with the hospital staff for placement. She said Resident #1's cognitive loss prevents her from living alone at home. During an interview with the HSW on 04/15/2025 at 4:10 PM she stated that the resident was adjusting and would not be discharged at this time until a suitable placement was found. HSW said Resident #1 should not be left at home alone to care for herself due to cognitive loss. During an interview with hospital HRN on 04/25/2025 at 10:00 AM she stated that Resident #1 was adjusting to the hospital stay. HRN said Resident #1 was still very confused and would not be able to live alone at home at this time. HRN said there was no discharge date being considered at this time, they were continuing to monitor her care. During an interview with CM T on 04/25/2025 at 12:50 PM, she stated that she had not completed the discharging planning form in the electronic records, however she had the information to document on a note in her office. She stated that the discharge planning form should have been completed immediately after the discharge to provide the information provided to the resident. During an interview with LSW on 04/25/2025 at 6:25 PM she stated that discharge planning should be coordinated with all disciplines to ensure safety. She stated that residents without a confirmed RP or POA would remain at the facility until a safe discharge plan was confirmed to ensure, resident's safety. She said cognitively impaired residents should not be sent home to live alone. She stated that CM T was under the social services department, however she was not consulted on Resident #1's discharge 03/31/20 25, because CM T discharged residents that were here for short term skilled services. LSW said she will contact the HHC, DME and other services for aftercare to ensure scheduling of the services and equipment prior to discharging from the facility. She said failing to follow up with services could result in the resident not having the aftercare and needed equipment to function at home. During an interview on 04/26/25 at 12:35 PM with the ADON N she said all care plans should be completed timely and accurately to guide the resident's care needs while at a skilled facility and address the plan of discharge. Failure to complete and document discharge plans in the care plan could lead to goals for aftercare not being met. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The following Plan of Removal was accepted on 04/26/2025 at 1:22 PM for immediate actions to ensure residents were not in jeopardy of harm. The Plan of Removal provided reflected the following: Plan of Removal - F660 submits the following Plan of Removal for the alleged failure to develop an effective discharge planning process. By submitting this plan of removal does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The following plan was implemented to ensure the discharge planning is effective immediately on 4/25/2025 for all upcoming discharges: a. Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided. b. Discharge paperwork will be presented to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. c. A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney. d. Post discharge services such as home health will be set up prior to discharge. e. Physicians and NP's will be notified of discharges to address resident's needs. f. Resident #1 no longer resides at the facility. How were other residents at risk to be affected by this deficient practice identified? 1. All residents discharging from the facility have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to ensure that residents have a safe discharge from the facility and to ensure that this does not happen again? a. An in-service was completed on 4-11-25 with the Administrator by the Regional [NAME] President of Operations that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. b. An in-service was completed on 4-11-25 with the social worker and case manager by the Administrator that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. c. An in-service was completed on 4/11/25 with the IDT team by the administrator regarding the completion of the discharge summary, notifying the Physicians and NP's of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. d. All discharges will be reviewed by the IDT team in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed. e. All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/ or administrator will contact the ombudsmen and seek assistance if needed for guardianship. How will the system be monitored to ensure compliance? a. The DON/Designee will review all discharge orders for upcoming discharges for completion daily for the next week and three times a week for the following 6 weeks. b. The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs daily for the next week and three times a week for the next 6 weeks. c. The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health daily for the next week and three times a week for 6 weeks. Quality Assurance An impromptu (unplanned) Quality Assurance and Performance Improvement review of the removal plan will be completed on 4/25/25 with the Medical Director for agreement with this plan. Monitoring of the POR included: Record review of in-service training report dated 04/11/2025 by RD with ADM time unknown, reflected Appropriate discharge planning include the following steps: Discharge summary completion, communication of discharge orders, confirmation of home health orders information of on discharge transportation, Notification of discharge to RP/POA and resident if cognitive. The ADM signature was observed on page 2 confirming attendance. Record review of facility Inservice titled Discharge Plan of Care Completion UDA's department managers dated 04/2025 time unknown by ADM reflected Please ensure that the discharge plan of care UDA's (User defined assessments) are completed within 48 hours of discharge. Discharge summaries are to be completed within 48 hours of discharge. Ensure that the physician and NP assigned to the resident is notified of the upcoming discharge to address any additional resident needs. The facility will ensure that discharge paperwork will be signed by only cognitively intact residents and/or responsible party on power of attorney. Signatures of staff that participated in the in-service, CM T, LSW, ADON, LVN E, DON, LVN K, and MDS R. the date of the in-service was not dated at the top or bottom of the in-service. Record review of facility Inservice titled discharge date d 04/11/2025 time unknown by ADM, reflected to ensure appropriate discharge planning of residents and to ensure safe discharge time following items have been completed: 1. Family members of RP will be required to pick up residents. 2. We will no longer provide courtesy transportation. 3. RP will sign discharge. 4. Discharge will only be signed by a cognitive party/resident and or family member. Signatures of staff that participated in the in-service, CM T, LSW, MDS D, LVN M, RN H, RN G, LVN S, LVN R, LVN O, LVN A, LVN B. Record review of in-service titled dated April 25, 2025, by ADM for the dual services department/ social services titled discharge planning reflected to ensure residents safely discharge back their prior settings, Family members will be required to provide their own transportation. Family members will be required to sign discharge paperwork. Staff signatures LSW P and CM T. LSW and CM T signature was observed on page 2 confirming attendance. Record review on 04/26/2025 of Residents #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 were reviewed for residents with discharged planning completion from the facility on or after 04/08/2025. The charts indicated appropriate notifications were made and the resident's discharges were safe. Interviews were conducted on 04/26/2025 with ADM, DON, ADON N, MDS R, LSW, CM T, RN G (1st shift), RN H (2nd shift), LVN S (2nd shift), LVN O (2nd shift), LVN L (1st shift), LVN J (1st shift) RN U (1st shift) training on discharge planning for residents included: ensuring the resident's POA/RP were present at discharge to transport from the facility; ensure medications were reviewed POA/RP and assess for understanding and document in electronic system; ensure aftercare providers are notified ( HHC, DME .) prior to discharge; ensure that the POA/RP were educated and comprehend the discharge directions prior to discharge; Notify the POA/RP were notified and educated on the residents care needs, medications, doses, treatments, therapies, symptoms, signs of change, notifying the MD of concerns: provide MD/PCP contact information for a follow up appointment in two weeks; ensure the POA/RP have the pharmacy locations where prescriptions will be sent; ensure the POA/RP have knowledge of the delivery timeframe for DME; ensure that nursing/social services staff follow up with aftercare services and MD/PCP to confirm resident client service status: ensure who and where the resident will be living and if supervision was needed or left alone; ensure cognitively impaired residents are not transported via public transportation; ensure and call assessments, care plan, and MDS are completed prior to discharging the resident, and ensure the NP and MD were notified prior to discharge of date, plan, and time of discharge in order to obtain additional services and approvals for the resident to discharge. The staff said that follow up calls would be conducted to confirm follow up appointments and services for aftercare. Record review of facility policy Titled Transfer or Discharge Documentation Policy Statement dated December 2016 red in part When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a. The basis for the transfer or discharge; Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be documented in the resident's clinical record by the resident's Attending Physician: The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. the receiving facility's service(s) that are available to meet those needs. That an appropriate notice was provided to the resident and/or legal representative The date and time of the transfer or discharge; The new location of the resident; The mode of transportation; A summary of the resident's overall medical, physical, and mental condition. Others as appropriate or as necessary; and Comprehensive care plan goals; and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The Administrator was informed the Immediate Jeopardy was removed on 05/26/2025 at 5:45 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

Based on observation, interview and record review, the facility failed to ensure that when the facility anticipated discharge of one (Residents #1) of three residents reviewed, there was a discharge summary that included a recapitulation of the resident's stay. The closed records for Residents #1 that were reviewed did not contain facility discharge summaries that included a recapitulation of the residents' stay, signature of FM S/RP/POA confirmation of aftercare services for a resident that was impaired cognitively on 03/31/2025. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could result in incorrect, incomplete, or misleading information being recorded regarding discharged residents. Findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/31/2025. DX included: Acute kidney failure (failing kidney function), unspecified dementia (cognitive decline), abnormalities of the gait, unsteadiness on fee, Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected Resident #1 had no history of wandering, section GG for resident functional abilities were left empty, indicating she was not assessed at discharge on [DATE]. Section N - Medications reflected the resident was not taking any high-risk medications. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. Record review of Resident #1's progress note dated 03/28/2025 at 12:49 PM by RN G resident is A&O X 1, with confusion. continue. to require assist with ADL. Record review of progress note dated 03/31/2025 at 8:31 AM by RN G reflected Resident remain in stable condition, respirations even unlabored no distress noted denies pain at this time, on cont. ABT/UTI, no adverse reaction noted, PO fluids offered and encouraged as tolerated, will cont. with care. Record review of Resident #1's Physician discharge summary completed by NP RB dated 03/31/2025 reflected provisional diagnosis: Acute Kidney Failure, unspecified Condition at discharge stable .Discharge Diagnosis: aftercare acute kidney failure unspecified Prognosis: Fair. Disposition: home by uber. [name] home health. DME - NA signed by NP RB . Record review of Resident #1's Discharge summary dated [DATE] completed by CM T reflected. Transportation to discharge location by taxi Home health agency [name], Patient has all needed DME the section for appointment scheduled with .date/time .reason .phone was left blank [Pharmacy name and location], Primary Care Physician name, address, phone .DR unknown to patient. The form was signed by CM T on 03/27/2025 and RN G on 03/31/2025 .Resident #1's signature and dated 03/03/2025. The attending physician name written in print [MD A]. During an interview with the facility CM T on 04/14/2025 at 11:00 AM she stated that Resident #1 was confused at times, but overall, she was able to meet all of her care needs, walk independently, and communicate her needs. CM T said Resident #1 lived alone prior to admitting on 03/12/2025 and was able to care for herself at home. CM T said she did provide HHS referral for the family, and it was provided to FM S on 03/27/2025. CM T said she did not contact the apartment where Resident #1 lived to inquire about the safety and condition of the apartment or if the electricity was working. CM T said she later was told the resident's electricity was disconnected and she was in the hospital. During an interview with RN G on 04/14/2025 at 11:30 AM she stated she escorted Resident #1 up to the front and transferred her in the uber car. RN G said Resident #1 was confused most of the time and needed assistance at times. RN G said Resident #1 was not capable of living at home alone due to her dementia and cognitive decline. During an interview with the ADM on 04/11/2025 at 9:40 AM, revealed Resident #1's was discharged on 03/31/2025 at 3:40 PM. ADM stated that the family member participated in Resident #1's plan of care and discharge planning after the insurance company ended the 21 day rehabilitation stay. She stated that FM S became distant the day before the discharge home. FM S told the ADM she was afraid to transport the resident home in her car. ADM said FM S did not say the reason she was afraid of Resident #1. ADM stated that she scheduled and uber driver to transport the resident to FM S at the apartments. FM S told ADM that the apartment was unsafe for Resident #1 to live in due to the environment floor being covered with cat feces and urine, and the electricity was disconnected for non-payment. The ADM stated that she would notify APS to report unsafe conditions, because the facility does not conduct home visits to determine a safe environment for discharge residents. The ADM stated that she contacted APS and made a report, transferred resident in the uber with personal items, and remained on the phone with FM S while the resident was transported, where she waited. Once the resident arrived at the apartment the call was terminated. ADM said she did not have the contact information (name and number) of the uber driver or number. On 04/01/2025, ADM said she received a call from FM S reporting the resident was transported to the hospital by a friend of the family. FM S said Resident #1 did not return home with any devices for mobility. During an interview with ADON T on 04/11/2025 at 10:15 AM, she stated that Resident #1 was a patient that resided on her hall. She said the resident was confused and had interventions to address her dementia. She said though she could independently ambulate through the facility, the staff had to redirect resident and provide segmented task. She said Resident #1 was discharged to her apartment with the family and home health services on 03/31/25. The ADON W did not know that Resident #1's apartment did not have electricity. The ADON T said Resident #1 should not live alone, due to confusion and cognitive decline with dementia. During a phone interview with FM S on 04/11/2025 at 10:20 AM she said that she did not sign the discharge summary, nor did she agree with the discharge home, due to the unsafe environment concerns (no electricity, pet feces and urine throughout the apartment, and spoiled food.) FM S said she was notified by the ADM on 04/27/2025, that Resident #1's insurance days had ended as of 03/31/2025. FM S said the ADM further stated that the resident could not remain at the facility for long term, due to not having an ID. FM S told the ADM that she (FM S) would not pick the resident up from the facility, and Resident #1's home was not safe, because she would be living alone, the electric power was disconnected, and cat feces and urine covered the apartment floor. FM S said ADM agreed to pay for an Uber to transport Resident #1 home. The ADM agreed to remain on the phone with FM S until the resident arrived at the apartment complex. The ADM did not provide any additional information about the uber driver or his car. FM S said she was not aware of how discharge worked; and was not the POA for Resident #1. FM S said once Resident #1 arrived, she instructed the [NAME] to bring the resident to her apartment and allow entrance into her apartment, because FM S lost her key. FM S remained downstairs in her car observing [NAME] and Resident #1 entering the apartment. FM S said [NAME] told her that Resident #1 was confused and asked the whereabouts of the restroom as she did not recognize her apartment. FM S left Resident #1 upstairs in her apartment alone, while waiting for law enforcement to arrive. FM S stated the ADM instructed her to call 911 for law enforcement to come out and assess the apartment for safety once Resident #1 arrived at the apartment. FM S said she remained downstairs until she received a call from KR K that she had picked up Resident #1 and transported her to the hospital, because the Resident's electricity was turned off. FM S said she did not attend any care plan meeting for Resident #1 while she a patient and the ADM and nursing staff were told many times. FM S said she did not sign any forms, nor did she agree to the resident returning home. During an interview with [NAME] T on 04/11/2025 at 1:00 PM she stated that on 03/31/2025 she observed Resident #1 entering the apartment office and sitting in the lobby. [NAME] said Resident #1 was observed confused, stating she had just returned from work by Uber. Resident #1 then asked to renew her lease. [NAME] told Resident #1 that her lease was current, and no action was needed at this time. [NAME] called FM S to report that Resident #1 was in the office confused. [NAME] said FM S asked her to bring Resident #1 to her apartment and unlock the door. [NAME] said she and Resident #1 arrived at the apartment and she unlocked the door and allowed her to enter. [NAME] said Resident #1 appeared confused when the door opened and asked for the location of the restroom. [NAME] departed the apartment and observed FM S downstairs in her car. The [NAME] said that Resident #1 did not have a walker or wheelchair when she arrived at the apartment, only personal belongings in plastic bags. The [NAME] did notify FM S of Resident #1's confusion while entering the apartment. During an interview with the Resident #1 on 04/14/2025 at 9:45 AM she stated she was brought to the hospital by KR K and KR C after she called for help. Resident #1 said her electricity was disconnected when she returned from a hospital. Resident #1 said after departing the hospital, she took an uber to her apartment to check on her cat, then to the hospital. Resident #1 was very confused and could not recall the events of discharge, home, then to hospital. Resident #1 said she does not trust anyone due to them reporting she was confused and could not return home. Resident #1 was observed in the hospital bed dressed in 2 hospital gowns, hair groomed, body and environment clean. During an interview with ADON T on 4/25/2024 at 12:35 PM, she said that she initiated the discharge planning after Resident #1 was discharged . ADON N said the task was observed in the electronic record system as needing to be completed, so she completed the nursing portion of the form. She stated that the facility policy did not specify the timeline for completing the discharge planning. She stated that the discharge planning form has not been completed for it to be locked as completed. She stated that CM/SW needed to complete the pharmacy section and close out the form. During an interview with CM T on 04/25/2025 at 12:50 PM, she stated that FM S did not come to the facility for the discharge summary, so the information was provided by phone. CM T said that Resident #1 was asked to sign the discharge summary and the information about HHC, medication, and MD were provided, and she stated that she understood. The CM T stated that the ADM and DON contacted FM S to set up transportation home for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 04/25/2025 at 5:57 PM. The ADM and DON was notified and provided an IJ template, and a POR (Plan of Removal) was requested. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The Plan of Removal was accepted on 04/26/2025 at 1:22 PM for immediate actions to ensure residents were not in jeopardy of harm and reflected the following: Plan of Removal - F 661 Methodist Transitional Care Center submits the following Plan of Removal for the alleged failure to complete a discharge summary. By submitting this plan of removal does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The identified Resident no longer resides in the facility. How were other residents at risk to be affected by this deficient practice identified? 2. All residents discharging from the facility have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to ensure that residents have a safe discharge from the facility and to ensure that this does not happen again? 1. An audit was initiated on 4/14/25 ongoing to ensure that the discharge plan of care/summary was completed, Discharge Summary completed and reviewed with an appropriate family representative, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed. 2. An in-service was completed with the Administrator regarding discharge planning by the Regional [NAME] President of Operations on 4/11/25. 3. An in-service was completed with the social worker and case manager regarding discharge planning by the Administrator on 4/11/25. 4. An in-service was completed with the IDT team regarding the completion of the discharge summaries, notifying the Physicians and NP's of discharges to address resident's needs, providing discharge paperwork to the power of attorney or appropriate family representative, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge by the Administrator on 4/11/25. 5. The Corporate Clinical Service Director reviewed facility policy on 04/11/2025 regarding completing the discharge summary and no revisions were deemed necessary. 6. All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/ or administrator will contact the ombudsmen and seek assistance if needed for guardianship. How will the system be monitored to ensure compliance? d. The DON/Designee will review all discharge orders for upcoming discharges for completion daily for the next week and three times a week for the following 6 weeks. e. The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs daily for the next week and three times a week for the next 6 weeks. f. The Administrator/Designee will audit all discharges for discharge summaries, Discharge Summary completed and reviewed with an appropriate family representative when applicable, discharge location, means of transportation, and confirmation of home health daily for the next week and three times a week for 6 weeks. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the removal plan will be completed on 4/25/25 with the Medical Director for agreement with this plan. The facility took the following actions to correct the non-compliance: Monitoring of the POR included: Record review of facility Inservice dated 04/11/2025 time unknown by ADM reflected Discharge Summary LSW/CM T must ensure that discharge planning completed for all residents, discharge summary must be completed for home health orders, DME orders were completed. To ensure Residents safely discharge back to their prior settings family members well be required to provide their own transportation. Record review of facility Inservice by DON on 04/25/2025 with the nursing department titled Discharge/Discharge Planning, dated 4/25/2025, reflected when discharging a resident, education is performed [with] resident and RP/POA on all medications. Discharge summary [with] home health if needed and DME. Resident will be asked to follow up [with] PCP within 14 days. Signatures of staff that participated in the in-service, CM T, LSW, MDS D, LVN M, RN H, RN G, LVN S, LVN R, LVN O, LVN A, LVN B. Record review on 04/26/2025 of Residents #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 were reviewed for residents who discharged planning completion from the facility on or after 04/08/2025. The charts indicated appropriate notifications were made and the resident's discharges were safe. Interviews were conducted on 04/26/2025 with ADM, DON, ADON N, MDS R, LSW, CM T, RN G (1st shift), RN H (2nd shift), LVN S (2nd shift), LVN O (2nd shift), LVN L (1st shift), LVN J (1st shift) RN U (1st shift) training on completing discharge summaries thoroughly and ensure all information was documented. Ensure a meeting with the IDT prior and discharge summary to ensure all needed information, cognition, and ability to safely transfer to after care service with the necessary equipment. Ensure comprehension of the services and notifications for assessments once they are discharged . The Social Services and Nursing Services will assign a staff to conduct a follow call to providers for the resident status of services. The POA/RP and MD signatures documented on the form confirming that they were in agreement with the discharge summary, knowledge of the discharge summary of events, needed services, and referrals and aftercare. The staff will ensure that all information was completed when residents were discharged . Notify the ADM of residents that are unable to discharge home safely due to cognition, supervision, or limited abilities safely discharge home. Record review of facility policy Titled Discharging the Resident December 2016 read in part The purpose of this procedure is to provide guidelines for the discharge process Discharging the resident to home or another long-term care facility: Who will be providing the resident's care (i.e., nurses, assistants, therapists, etc.). That his or her family and visitors will be informed of the discharge and where the resident will be living .Transport the resident to the pick-up area. Assist the resident into the automobile. Assist the family in loading the president's personal effects. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions. The Administrator was informed the Immediate Jeopardy was removed on 05/26/2025 at 5:45 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident reviewed for one (Resident #1) of four residents reviewed for Administration. The ADM and DON failed to ensure residents discharged home were provided the appropriate supervision and care before returning home. The ADM directed staff to discharge Resident #1 home without knowing she was diagnosed with dementia, confusion, altered mental status, and no POA. The IDT failed to notify the NP/MD of Resident #1's discharge home alone without services. The ADM, DON, and CM T returned Resident #1 to an unsafe home environment without investigating and following up prior to sending her home in an Uber (ride share). An Immediate Jeopardy (IJ) situation was identified on 05/08/2025 at 11:00 AM after an administrative review determined that the noncompliance would be elevated to an IJ. The ADM was provided an IJ template and told that the current POR (Plan of Removal) that was accepted on 04/26/2025 at 1:22 PM was sufficient. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure placed residents at risk of not receiving the appropriate care and services to maintain their highest practicable well-being and at risk of a diminished quality of life and supervision for safety. The findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. DX reflected unspecified dementia (cognitive decline), Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). The face sheet did not list a POA or RP, only emergency contact #1 (FM S) and the name and phone number of FM J. Record review of Resident #1's entry MDS assessment, dated 03/12/2025 reflected entry date of 03/12/2025 from the hospital to a skilled nursing facility. Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected Resident #1 had no history of wandering; section GG for resident functional abilities was left empty, indicating she was not assessed at discharge on 03/31/2025. Section N - Medications reflected the resident was not taking any high-risk medications. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. Record review of Resident #1's MD orders dated 03/12/2025 reflected the following: Hypoglycemic Protocol: Follow Hypoglycemic Protocol if blood sugar is less than 70 mg/dl (a unit of volume equal to one-tenth of a liter.) Assessment tab when protocol is required every shift -Start Date- 03/12/2025 6:00 PM -DC Date-04/01/2025 3:54 PM 03/12/2025 HS snacks .Monitor resident for abnormal bruising and/or bleeding from nose, gums, blood in urine or stool Q Shift every shift .order dated 03/26/2025 reflected .Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth every 8 hours as needed for Anxiety .Hydroxyzine Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety. Record review of Resident #1's progress note dated 03/28/2025 at 12:49 PM by RN G resident is A &O x 1 (alert and oriented times) indicating that she knew her name but not where they are, what time it is or what is happening, with confusion. cont. to require assist with ADL. Record review of Resident #1's progress note dated 03/28/2025 at 2:48 PM by the NP reflected Assessment and Plan: Impaired mobility and gait worsened state since PTA, continue rehabilitation efforts with multidisciplinary approach including PT for gait, OT for self-care skills and transfers. - Pt currently will benefit from continuous 24 hr care for medication, skin care, education, and reinforcement in therapies along with psychiatric medical care/recommendations for ongoing medical issues. Record review of Resident #1's progress note dated 3/31/2025 at 9:29 PM, by the NP reflected suspected progressive dementia - supportive care. Record review of Resident #1's insurance dated 03/30/2025 titled Medicare coverage of current skilled nursing services will end on 03/30/2025. Verbal notification given patient or RP on 03/27/2025. Additional information reason unable to sign cognitive impairment NOMNC given to [FM] via telephone the beneficiary's last day of coverage 03/30/2025 and the date when the beneficiary liability is expected to begin 03/31/2025 informed [FM] that appeal must be done as soon as possible, but no later than 12:00 noon of the day before the last covered day [FM] plans to take member to home on 03/31/2025. Record review of Resident #1's Physician discharge summary completed by NP RB dated 03/31/2025 reflected provisional diagnosis: Acute Kidney Failure, unspecified Condition at discharge stable .Discharge Diagnosis: aftercare acute kidney failure unspecified Prognosis: Fair. Disposition: home by uber. [name] home health. DME - NA signed by NP RB. Record review of Resident #1's ADON N Discharge Plan of Care dated 04/04/2025 reflected Resident # 1 was being discharged to home with family, nursing needs: wheelchair .transportation: family transported. Scheduled appointments: f/u with PCP .CM explained care/support to resident caregiver, yes no special instructions for diet .treatment reviewed with resident/caregiver, yes .APS referral made with resident discharge home d/t cognitive decline. This note was added after the resident discharged by CM T as a late entry. During an interview with Resident #1 on 04/25/2025 at 10:00 AM at the hospital revealed she was interviewable, confused and could not recall daily routines, where she lived, nor her discharge home details. She had lost her ID card, purse, and cell phone. She couldn't recall the last time she used the items. During a phone interview with FM S on 04/11/2025 at 10:20 AM revealed that she did not attend any meetings as an RP during Resident #1's stays at the facility. FM S told the ADM that the home did not have electricity and that Resident #1 would be living in the home alone. FM S said that the facility did not ensure home health services were scheduled prior to discharging Resident #1 home alone. FM S said she did not agree with the ADM goal to discharge Resident #1 home, because Resident #1 was confused, and no services were set up prior to her return home. FM S said the ADM proceeded to discharge Resident #1 home despite her concerns. FM S said there were additional kinship relations of FM J (RK K and RK C), however, they were not contacted nor informed about the discharge planning and return home. FM S said that Resident #1 did not have a walker or wheelchair when she arrived at the apartment, only personal belongings. FM S said she was waiting in her car at Resident #1's apartment when the driver left her at the apartment complex. FM S asked the [NAME] to bring Resident #1 to her apartment and allow entrance, because she did not have a key. FM S said once [NAME] escorted Resident #1 in her apartment and departed in a golf cart. During an interview with the ADM on 04/11/2025 at 9:40 AM, revealed Resident #1's was discharged on [DATE] at 3:40 PM. ADM said FM S was aware of the discharge home, and home health had been contacted. ADM said it was the RP's responsibility to call HHS and schedule a visit to the home for an assessment. ADM said FM S had reservations closer to the discharge date stating she was afraid of Resident #1, Resident #1 can't live with her, the home was not safe due to the electric power being disconnected. ADM stated that she did not contact the apartment manager for information on Resident #1's home environment prior to discharge. ADM told FM S she would have Resident #1 transported to the apartments via Uber (transportation business). ADM said she did not attempt to search for other family prior to discharge. ADM said Resident #1 discharged home on a previous stay, and this was the discharge plan at the time of admission on 03/12/2025. She denied behaviors of cognitive loss and confusion. She said the resident was capable of returning home to care for herself. She notified APS of the home condition allegations from FM S as an alternate plan for Resident #1 when she left the faciity on [DATE]. During an interview on 04/11/2025 at 6:40 PM with KR K she stated that she was not related to Resident #1. KR K reported that FM S have excluded her from the rehabilitation contact, therefore she was not aware that Resident #1 had been discharged on [DATE]. On 03/31/2025 (time unknown) KR K said Resident #1 was somewhat confused at times. KR K said resident lived alone and was discharged home from the facility in 12/2024. KR K said the facility staff did not contact her during Resident #1's stays 03/12/2025. KR K said the hospital placement was temporary and a means for getting assistance with another placement. During an interview with the facility CM T on 04/14/2025 at 11:00 AM she stated that Resident #1 was sent home after a NOMNC discharge for insurance payment ending. The ADM directed CM T to complete the discharge summary on 03/27/2025 (see record review for discharge plan). CM T and ADM called FM S to transport Resident #1 home; however, FM S refused and did not want to be responsible for the care of Resident #1. CM T said the ADM notified the FM that Resident #1 would be discharged home today via paid public transportation, because FM S agreed to the discharge home in the NOMNC via phone. FM S told the ADM that the resident would be living alone, the apartment electric power was disconnected, the apartment was soiled with cat feces and urine, and the environment was not safe for the resident to live. CM T stated that she had notified the HHS of the resident discharge home and the need for an assessment of after care services. During an interview with the DON on 04/14/2025 at 2:30 PM revealed Resident #1's FM agreed to the courtesy transport, and she would be waiting at the complex for Resident #1, then called and stated the home was not safe and sanitary for Resident #1 to live in due to the utilities not working. DON said the FM told the ADM that the home was not safe prior to sending her home via uber. The DON and the ADM were notified after the discharge that the FM was not present to receive the resident at the home location. the ADM and DON stated that the resident payment insurance days had ended, and the FM knew the plan to discharge the resident home at the time of admission. The DON said the resident did not have an identifying information to pursue Medicaid or an additional placement at the time of the discharge. The ADM told the FM she would contact APS to for a report regarding the unsafe home environment. During a phone interview with NP on 04/25/2025 at 10:45 AM she stated that Resident #1's confusion and cognition was progressive, and she required supervision if discharged home. During an interview with the DON on 04/26/2025 at 5:05 PM she stated that in the future residents would no longer be transported via courtesy transportation at the expense of the facility. The DON said she would ensure the MD was included in the discharge planning in the IDT meeting, seek additional clinical guidance from members prior to discharge to ensure resident safety. The DON said she would report all concerns involving RP and POA's to the ADM. During a second interview with the ADM 04/25/25 at 5:25 PM she stated that changes to the facility discharge included no courtesy transports from the facility for discharged residents. She would notify the ombudsman and leadership of a resident's changes in condition, the need for a responsible representative and additional resources before sending an impaired cognitive resident home to live alone. The ADM said that the ADM, DON, ADON, CM, SW, MD, MDS, and DOR was a part of the IDT. During an interview with LSW on 04/25/2025 at 6:25 PM she stated that discharge planning should be coordinated with all disciplines to ensure safety. She stated that residents without a confirmed RP or POA would remain at the facility until a safe discharge plan was confirmed to ensure, resident's safety. She said cognitively impaired residents should not be sent home to live alone. She stated that CM T was under the social services department, however she was not consulted on Resident #1's discharge 03/31/2025, because CM T discharged residents that were here for short term skilled services. LSW said she will contact the HHC, DME and other services for aftercare to ensure scheduling of the services and equipment prior to discharging from the facility. She said failing to follow up with services could result in the resident not having the aftercare and needed equipment to function at home. During an interview on 05/06/2025 at 2:42 PM with KR K revealed the hospital was discharging the resident home, since the family did not want a referral for services in a nursing home. She will consult with them to request more time before discharging the resident home. During an interview on 05/12025 at 840 AM with KR K she stated Resident # 1 was discharged home. She stated that the apartment has been cleaned, and she and KR C are visiting daily until HHS or other aftercare services were provided. KR K said the barrier to placement and services were limited insurance benefits. An Immediate Jeopardy (IJ) situation was identified on 05/08/2025 at 11:00 AM after an administrative review determined that the noncompliance would be elevated to an IJ. The ADM was provided an IJ template and told that the current POR (Plan of Removal) that was accepted on 04/26/2025 at 1:22 PM was sufficient. While the IJ was removed on 04/26/2025 at 5:45 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The following Plan of Removal was accepted on 04/26/2025 at 1:22 PM for immediate actions to ensure residents were not in jeopardy of harm. The POR reflected the following: The Plan of Removal reflected the following: Plan of Removal - F 835 submits the following Plan of Removal for the alleged failure to develop an effective discharge planning process. By submitting this plan of removal covered the non-compliance. does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? 1. The following plan was implemented to ensure the discharge planning is effective immediately on 4/25/2025 for all upcoming discharges: a. Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided. b. Discharge paperwork will be presented to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. c. A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney. d. Post discharge services such as home health will be set up prior to discharge. e. Physicians and NP's will be notified of discharges to address resident's needs. f. Resident #1 no longer resides at the facility was at the hospital How were other residents at risk to be affected by this deficient practice identified? 1. All residents discharging from the facility have the potential to be affected by this alleged deficient practice. What does the facility need to change immediately to ensure that residents have a safe discharge from the facility and to ensure that this does not happen again? a. An in-service was completed on 4-11-25 with the Administrator by the Regional [NAME] President of Operations that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. b. An in-service was completed on 04/11/2025 with the Social Worker and Case Manager by the Administrator that detailed the entire discharge planning process including the completion of discharge summaries, contacting RP/POA/'s, confirmation of transportation, and home health set up confirmation. c. An in-service was completed on 4/11/25 with the IDT by the Administrator regarding the completion of the discharge summary, notifying the Physicians and NP's of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge. d. All discharges will be reviewed by the IDT in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed. e. All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/ or administrator will contact the ombudsmen and seek assistance if needed for guardianship. How will the system be monitored to ensure compliance? a. The DON/Designee will review all discharge orders for upcoming discharges for completion daily for the next week and three times a week for the following 6 weeks. b. The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs daily for the next week and three times a week for the next 6 weeks. c. The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health daily for the next week and three times a week for 6 weeks. Quality Assurance An impromptu (unplanned) Quality Assurance and Performance Improvement review of the removal plan will be completed on 4/25/25 with the Medical Director for agreement with this plan. Monitoring of the POR included: Record review of in-service training report dated 04/11/2025 by the RD with the ADM, time unknown, reflected Appropriate discharge planning include the following steps: Discharge summary completion, communication of discharge orders, confirmation of home health orders information of on discharge transportation, Notification of discharge to RP/POA and resident if cognitive. The ADM's signature was observed on page 2 confirming attendance. Record review of a facility in-service titled discharge date d 04/11/2025, time unknown, by the ADM, reflected to ensure appropriate discharge planning of residents and to ensure safe discharge time following items have been completed: 1. Family members of RP will be required to pick up residents. 2. We will no longer provide courtesy transportation. 3. RP will sign discharge. 4. Discharge will only be signed by a cognitive party/resident and or family member. Signatures of staff that participated in the in-service revealed CM T, LSW, MDS D, LVN M, RN H, RN G, LVN S, LVN R, LVN O, LVN A, LVN B. Record review of facility Inservice titled Discharge Plan of Care Completion UDA's department managers dated 04/2025 time unknown by ADM reflected Please ensure that the discharge plan of care UDA's (User defined assessments) are completed within 48 hours of discharge. Discharge summaries are to be completed within 48 hours of discharge. Ensure that the physician and NP assigned to the resident is notified of the upcoming discharge to address any additional resident needs. The facility will ensure that discharge paperwork will be signed by only cognitively intact residents and/or responsible party on power of attorney. Signatures of staff that participated in the in-service, CM T, LSW, ADON, LVN E, DON, LVN K, and MDS R. the date of the in-service was not dated at the top or bottom of the in-service. Record review of in-service titled dated April 25, 2025, by ADM for the dual services department/ social services titled discharge planning reflected to ensure residents safely discharge back their prior settings, Family members will be required to provide their own transportation. Family members will be required to sign discharge paperwork. Staff signatures LSW P and CM T. LSW and CM T signature was observed on page 2 confirming attendance. Record review on 04/26/2025 of Residents #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 were reviewed for residents with discharged planning completion from the facility on or after 04/08/2025. The charts indicated appropriate notifications were made and the resident's discharges were safe. Interviews were conducted on 04/26/2025 from 4:15 PM to 5:30 PM, with ADM, DON, ADON N, MDS R, LSW, CM T, RN G (1st shift), RN H (2nd shift), LVN S (2nd shift), LVN O (2nd shift), LVN L (1st shift), LVN J (1st shift) RN U (1st shift) regarding training on discharge planning for residents included: ensure that nursing/social services staff follow up with aftercare services and MD/PCP to confirm resident client service status; ensure who and where the resident will be living and if supervision was needed or left alone; ensure cognitively impaired residents are not transported via public transportation; ensure all assessments, care plan, and MDS are completed prior to discharging the resident, and ensure the NP and MD were notified prior to discharge of date, plan, and time of discharge in order to obtain additional services and approvals for the resident to discharge. The staff said that follow up calls would be conducted to confirm follow up appointments and services for aftercare. Ensure the POA/RP have the correct contact information of the pharmacy and MD/PCP are provided to pick up RX's and for the follow up appointment in two weeks; ensure the POA/RP have knowledge of the delivery timeframe for DME and expectations of billing; ensure the resident's POA/RP were present at discharge to transport from the facility. In an interview with the ADM and DON on 04/26/2025 at 5:48 PM, both stated that ongoing monitoring and auditing by the IDT, DON, ADON, and LSW will completed for accuracy of resident assessments, discharge planning, discharge summary's, resident cognitive and functional abilities, referral and notification of resident's after care services, follow up calls to after care service providers within 24 to 48 hours to ensure residents service implementation and resident safety. Record review of the facility policy untitled and undated reflected in part Policy Statement.: A licensed Administrator is responsible for the day-to-day functions of the facility Policy interpretation and implementation: he is governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility .Ensuring that each resident's right to fair and equitable treatment, self. determination, individuality, privacy, confidentiality of information, property, and civil rights, including the right to lodge a complaint, are strictly enforced .Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities. Delegation of authority/chain of command: In the absence of the Administrator, the Assistant Administrator or Director of Nursing Services is authorized to act in the Administrator's behalf. Should both the Administrator and the Assistant Administrator or Director of Nursing Services be absent, the chain of command as established by this facility shall be followed. A complete outline of the Administrator's duties and responsibilities is contained in his/her job description. The Administrator was informed the Immediate Jeopardy was removed on 05/26/2025 at 5:45 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

Based on observations, interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 3 (Resident #1, #6, and #7) of 8 residents reviewed for completion, in that: 1. The facility failed to ensure Resident #1 admission MDS was completed, reviewed, and signed by the designated RN/DON, and discharge MDS was completed prior to discharge on [DATE]. 2. The facility failed to ensure Resident #6's admission MDS was completed after admission on [DATE]. 3. The facility failed to ensure Resident #7's quarterly section GG was completed, reviewed, and signed by all disciplines. These failures could prevent communication about a resident's status from being transmitted to CMS and could interfere with residents receiving needed services before and after discharge. Findings included: Resident #1 Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 03/31/2025. DX included: Acute kidney failure (failing kidney function), unspecified dementia (cognitive decline), abnormalities of the gait, unsteadiness on fee, Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), and hypokalemia (low potassium levels). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected section GG for resident functional abilities were left blank, indicating she was not assessed at discharge on [DATE]. The discharge MDS was not signed by authorized personnel as of 4/25/2025 when the surveyor entered. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Resident #1 was at risk of falls. During an interview with Resident #1 on 04/14/2025 at 10:00 AM she was observed at the hospital with admission date of 3/31/2025. and was interviewable, confused and could not recall daily routines, where she lived, nor her discharge home details. She has lost her ID card, purse, and cell phone. She can't recall the last time she used the items. Resident #6 Record review of R#6's face sheet dated 04/14/2025 reflected he was an [AGE] year-old male that was admitted on [DATE]. Resident's current DX: muscle wasting and atrophy, multiple sites (age related loss of muscles), Malignant neoplasm prostate (cancerous tumor in the prostate gland), DM 2 (irregular blood sugar levels, abnormal gait.) Record review of Resident #6 's entry MDS revealed the date of entry 04/03/2025, from acute care (hospital) for skilled care. An admission MDS for Resident #6 was not found or saved in his electronic records. Record review of Resident # 6's BIMS assessment dated [DATE] reflected BIMS score of 15, indicating he was cognitively intact. Record review of Resident # 6's care plan dated 04/03/2025 reflected Resident has a skin tear and is at risk for skin tears due to Fragile skin .resident is on Anticoagulant therapy r/t Atrial fibrillation (irregular heartbeat resident has the potential for s/sx of complications of cardiac problems due to coronary artery disease (heart disease) r/t atrial fibrillation, hypercholesterolemia (abnormal high levels of cholesterol in blood), hypertension (high blood pressure) .resident has an ostomy and is At risk for complications including but not limited to stoma (surgical opening in abdomen), irritation, bleeding and ischemia (reduced blood supply to areas of the body). Cancer (uncontrolled growth of cells), Bowel obstruction, Trauma, ileus (intestine stop moving properly), Hernia (condition of part of an organ is displaced), Sigmoid volvulus (condition where the lower part of the large intestine, twist, and cause bowel obstruction) Resident has a disorder/diagnosis uses antidepressant medication. At risk for side effects. Depression. Record review MD Progress Note dated 04/11/2025 reflected Dizziness/Weakness HPI (history of present illness): Pt is an 82 [years old] [male] who presented to OSH (occupational safety and health) with dizziness and weakness. Pt found to have AKI (acute kidney injury), hyperkalemia (low levels of sodium in the blood) and hyponatremic (elevated potassium in the blood). CT (computed tomography x-ray images) scan with perianal abscess and Fournier's gangrene (deadly infection involving the genitals). Pt had debridement (dead skin) of perianal area on 02/10/2025 and had a diverting colostomy (opening in the colon) on 02/12/2025. Pt started on IV (intravenous) ABX (antibiotics). Pt was then sent to IPR (inpatient rehabilitation). Once pt was stable, pt was noted to benefit from continued medical oversight and therapy before dc to home, so pt was transferred to [the facility] for such needs. This section of the record review relates to the resident needs and treatment while at the facility that was not addressed in his missing MDS assessment. During an observation and interview with Resident #6 on 04/14/25 at 11:04 AM he was observed lying in bed watching television. He had no concerns with his care while at the facility. Resident #6's call light was in reach, along with water and other items. Resident #7 Record review of Resident #7's face sheet dated 04/25/2025 reflected he was a [AGE] year-old male that was admitted on [DATE]. Resident's current DX: single subsegmental thrombotic pulmonary embolism (blood clot in pulmonary artery) w/o acute Cor pulmonale (enlarge abnormal heart), sickle cell, emphysema ( disorder affecting the tiny air sacs of the lungs), COPD (chronic obstructive pulmonary disease damage to the airways or other parts of the lung), End stage renal disease (severely damaged kidneys unable to function properly dependence on dialysis medical procedure that filters the blood, removes waste products). Record review of Resident #7 's quarterly MDS 04/01/2025 reflected a BIMS score of 15 indicating he was cognitively intact. Health conditions of shortness of breath with, continuous oxygen and dialysis addressed and active discharge planning. Resident #7's section GG was not completed, and the assessment had not been signed by staff that completing the form. Record review of Resident # 7's care plan dated 03/31/2025 reflected Resident #7 is on PO Antibiotic therapy r/t infection Enhanced Barrier Precautions - At risk for infection r/t Wounds, Indwelling medical device .resident is at risk for Ineffective Airway Clearance d/t COPD . has the potential for s/sx of Congestive Heart Failure . resident has Oxygen Therapy r/t COPD and Emphysema .at risk for falls r/t impaired balance unaware of safety needs. Resident #7's care plan did not address discharge planning. In an interview with Resident #7 on 04/14/2025 at 11:20 AM, he said he was receiving therapy and had no concerns with his care. Resident #7 was observed moving down the hall in his wheelchair with oxygen NC in place. He said he was ready to discharge home. During an interview with MDS R on 04/26/2025 3:59 PM she said she had been working at the facility for approximately 2 years as the MDS. She said the MDS staff coordinates along with the DON and other disciplines to complete the MDS assessments. She stated the MDS coordinators complete the MDS assessments. She stated the discharge assessments should be completed after the resident's discharges from the facility. However, the MDS department was short staffed, and the assessments were delayed. She stated that the potential negative outcome for missed MDS or discharge assessments could be they don't have a true picture of the residents in the building. She said all MDS assessments should be signed by the discipline completing each section (SW, DM, ADON, DON). The DON reviews the completed sections and signs as reviewed and completed. During an interview with the DON on 04/26/2025 at 5:05 PM she stated that MDS assessment should be completed timely as it drives the goals of the care plan goals and interventions. The DON said that all MDS assessments must be signed by each discipline, then she reviews for accuracy and signs for completion. The DON said the MDS assessments were not signed, due to a staffing shortage. The DON said they have hired a new MDS worker, but she could not recall her start date. During an interview with the ADM on 04/26/2025 at 5:25 PM she stated the MDS coordinator was responsible for completed timely MDS assessments and the DON will review and sign the document for completion. She stated she was not sure why the MDS assessments were missed. She stated that discharge MDS assessments were not a requirement. She stated the potential negative outcome for missed MDS assessments or late submissions was inaccurate data to CMS. Record review of facility policy dated December 2016 titled Policy Statement Comprehensive assessments will be conducted to assist in developing person-centered care plans .Policy Interpretation and Implementation .Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions .Assessment and information collection includes (WHAT, WHERE and WHEN?). The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient .Assess the individual Gather relevant information from multiple sources, including: Observation Physical assessment .Symptom or condition-related assessments .Resident and family interview .Hospital discharge summaries .Consultant reports .Lab and diagnostic test results; and .Evaluations from other disciplines (for example, dietary, respiratory, social services ) .Complete the Minimum Data Set within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate) .Link these to problems and diagnoses they are supposed to be treating .Identify overall care goals and specific objectives of individual treatments .Evaluate whether or not these treatments are accomplishing the anticipated results .Make decisions about care and treatment .Apply clinical reasoning to assessment information and determine the most appropriate interventions.

Based on observation, interview, and record review the facility failed to develop and implement a person-centered comprehensive care plan to include measurable objectives and timeframes to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being for 4 of 10 (Resident #1, #6, #7, and #8) residents reviewed for comprehensive care plans in that: 1.The facility failed to ensure Resident #1's care plan addressed her anxiety and discharge goals, objectives, and interventions. 2. The facility failed to ensure Resident #6, #7, and #8's care plan addressed their discharge goals, objectives, and interventions. Findings included: Record review of Resident #1's face sheet dated 04/11/2025 Revealed she was a 73- year-old female admitted to the facility on [DATE] and discharged on [DATE]. DX included: Acute kidney failure (failing kidney function), unspecified dementia (cognitive decline), abnormalities of the gait, unsteadiness on fee, Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .), hypokalemia (low potassium levels). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. The MDS assessment reflected section GG for resident functional abilities were left empty, indicating she was not assessed at discharge on 03/31/2025. The discharge MDS was not signed by authorized personnel. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's has a potential for ADL Self-care Performance Deficit r/t Dementia. Resident requires assistant from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 requires supervision and cuing for bed mobility and transfers. Resident has impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status .resident was at risk of falls r/t tunable gate, dementia. Resident #1's care plan did not address discharge goals, objectives, and interventions. During an interview with Resident #1 on 04/25/2025 at 10:00 AM she was interviewable, confused and could not recall daily routines, where she lived, nor her discharge home details. She has lost her ID card, purse, and cell phone. She can't recall the last time she used the items. Resident # 6 Record review of Resident #6's face sheet dated 04/14/2025 reflected he was an [AGE] year-old male that was admitted on [DATE]. Resident's current DX: muscle wasting and atrophy, multiple sites (age related loss of muscles), Malignant neoplasm prostate (cancerous tumor in the prostate gland), DM 2 (irregular blood sugar levels), abnormal gait. Record review of Resident #6 's entry MDS revealed entry date 04/03/2025 from hospital to facility for skilled care. Record review of Resident # 6's BIMS assessment dated [DATE] was a score of 15, indicating he was cognitively intact. Record review of Resident # 6 's Care Plan dated 04/03/2025 reflected Resident has a skin tear and is at risk for skin tears due to Fragile skin .resident is on Anticoagulant therapy r/t Atrial fibrillation (irregular heartbeat resident has the potential for s/sx of complications of cardiac problems due to coronary artery disease (heart disease) r/t atrial fibrillation, hypercholesterolemia (abnormal high levels of cholesterol in blood), hypertension (high blood pressure) .resident has an ostomy and is At risk for complications including but not limited to stoma (surgical opening in abdomen), irritation, bleeding and ischemia (reduced blood supply to areas of the body). Cancer (uncontrolled growth of cells), Bowel obstruction, Trauma, ileus (intestine stop moving properly), Hernia (condition of part of an organ is displaced), Sigmoid volvulus (condition where the lower part of the large intestine, twist, and cause bowel obstruction) Resident has disorder/diagnosis uses antidepressant medication. At risk for side effects. Depression. Resident #6's care plan did not address his discharge goals, objectives, and interventions. During an observation and interview with Resident #6 on 04/14/25 at 11:04 AM revealed the resident lying in bed with no concerns with hygiene or room hazards. His call light was within reach, ostomy bag, and interviewable. Resident #6 stated he was at the facility for a short-term staff for therapy. He had no concerns with care, services, or treatment. Resident stated staff are responding and treating him with respect and dignity. Resident #7 Record review of Resident #7's face sheet dated 04/25/2025 reflected he was a [AGE] year-old male that was admitted on [DATE]. Resident's current DX: single subsegmental thrombotic pulmonary embolism (blood clot in pulmonary artery) w/o acute Cor pulmonale (enlarge abnormal heart), sickle cell, emphysema ( disorder affecting the tiny air sacs of the lungs), COPD (chronic obstructive pulmonary disease (damage to the airways or other parts of the lung), End stage renal disease (severely damaged kidneys unable to function properly) dependence on dialysis medical procedure that filters the blood, removes waste products). Record review of Resident #7 's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating he was cognitively intact. Health conditions of shortness of breath with, continuous oxygen and dialysis addressed and active discharge planning. Record review of Resident #7's Care plan dated 03/31/2025 reflected [Resident] is on PO Antibiotic therapy r/t infection [Resident]Enhanced Barrier Precautions - [Resident] At risk for infection r/t Wounds, [Resident] Indwelling medical device . [Resident] is at risk for Ineffective Airway Clearance d/t COPD . [Resident] has the potential for s/sx of Congestive Heart Failure . [Resident] has Oxygen Therapy r/t COPD and Emphysema .at risk for falls r/t impaired balance unaware of safety needs. Resident #7's care plan did not address his discharge goals, objectives, and interventions. During an observation and interview with Resident #7 on 4/25/25 at 11:08 AM, he was in the hallway in his wheelchair with a NC with no concerns with hygiene or care. His ankles and feet were observed swollen and he denied pain. He stated that he would be discharging home soon with his sisters and they would transport. Resident #8 Record review of Resident #8's face sheet dated 04/14/2025 reflected he was a [AGE] year-old male that was admitted on [DATE]Resident's current DX: anemia (limited red blood cells) , hyperlipidemia (high cholesterol), depression (feeling down), hypertension (high blood pressure) chronic systolic (congestive) heart failure (a long-term condition where the heart's left ventricle doesn't pump blood effectively, leading to a reduced ejection fraction.), seizure, atrial fibrillation, cerebral infarction (stroke) without residual deficits, hemiplegia and hemiparesis (impaired movement on one side, but hemiplegia is a more severe condition with a complete lack of motor function.), following cerebral infarction affecting left dominant side, muscle weakness, other lack of coordination, cognitive communication deficit (difficulty communicating) acute respiratory failure with hypoxia (respiratory can't deliver oxygen effectively). Record review of Resident #8 's admission MDS dated [DATE] reflected a BIMS score of 12 indicating he was moderately impaired cognitively. Resident #8 required staff supervision and assistance for ADLS and eating. Record review of Resident # 8's Care Plan dated 03/26/2025 revealed: The resident has surgical incision to . resident is Moderate risk for falls r/t impaired mobility, left sided hemiparesis, HX of CVA the (Left Chest) r/t Pacemaker surgery .resident uses antidepressant medication. At risk for side effects. Depression .resident has pain related to impaired mobility . Resident #8's Depression. Resident #8's care plan did not address discharge, goals, objectives, and interventions. During an interview with Resident #8 on 04/11/2025 at 10:55 AM revealed he would be discharged home with his wife and family soon and they would provide transportation. He was not sure if additional services would be ordered for aftercare at this time. During an interview with ADON N on 04/26/25 at 12:35 PM she said all care plans should be completed timely and accurately to guide the resident's care needs while at a skilled facility and address the plan of discharge. Failure to complete and document discharge plans in the care plan could lead to goals for aftercare not being met. During an interview with the DON on 04/26/2025 at 5:05 PM revealed she was responsible along with the nurses to monitor and update resident care plans for changes and goals while at the facility. She stated that care plans were not updated for discharge information as the discharge assessment plan conducted by the nurses provided this information. Discharge planning addressees the plan along with other disciplines (SW/CM) During an interview with the ADM on 04/25/2025 at 5:25 PM revealed she expects the staff to complete the care plans timely and accurately to address the residents' needs. ADM said resident's goals for treatment should include discharge planning. She stated the discharge planning will address the resident needs once the discharge was planned. The policy for the care plan was requested on 04/11/2025 and was not provided. Review of federal guidelines for care plans. S483.21(b) Comprehensive Care Plans S483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under S483.24, S483.25 or S483.40; and (ii) Any services that would otherwise be required under S483.24, S483.25 or S483.40 but are not provided due to the resident's exercise of rights under S483.10, including the right to refuse treatment under S483.10(c)(6). (iv)In consultation with the resident and the resident's representative(s)-(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. S483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally competent and trauma-informed.

Based on interview and record review the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed within 14 days for 1 of 3 residents (Residents #1) reviewed for significant change. The facility failed to ensure Resident # 1 had a Significant Change Assessment completed after she had a change in altered mental status. This failure could contribute to providing an inaccurate assessment of resident's most current medical condition and could lead to failure to not provide necessary care. Findings included: Record review of Resident #1's face sheet, dated 04/11/2025, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. DX included: unspecified dementia (cognitive decline) and Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory.). Record review of Resident #1's discharge MDS assessment, dated 03/31/2025, reflected the resident had a BIMS score of 8, indicating she was moderately impaired cognitively. Record review of Resident #1's care plan, dated 03/13/2025, reflected that Resident #1's had a potential for ADL Self-care Performance Deficit r/t Dementia. Resident required assistance from staff for toileting, bathing, personal hygiene, and dressing. Resident #1 required supervision and cuing for bed mobility and transfers. Resident had impaired cognitive function/impaired thought process r/t dementia .intervention Observe/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Record review of progress note dated 03/28/2025 at 2:48 PM by NP reflected Assessment and Plan: Pt currently will benefit from continuous 24hr care for medication, skin care, education, and reinforcement in therapies along with psychiatric medical care/recommendations for ongoing medical issues. Will need to include family education/training and possible DME assessment -Precautions: Acute Metabolic Encephalopathy [a brain dysfunction caused by a sudden imbalance in the body's metabolism, leading to changes in brain function, such as confusion, disorientation, or memory loss.] oriented X3, baseline dementia. Record review of Resident #1's progress note dated 3/31/2025 at 9:29 PM, NP reflected suspected progressive dementia - supportive care. Record review of Resident #1's MD orders dated 03/26/2025 reflected the following: Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth every 8 hours as needed for Anxiety . Hydroxyzine Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety. During a phone interview with ADON T on 04/11/2025 at 11:35 AM she stated that Resident #1 was observed during her stay (03/12/2025 to 03/31/2025) with increased impaired cognition, confusion, and altered mental status, t herefore, required more assistance with care and should not be discharged home alone to care for herself. During a phone interview with ADON N on 04/25/2025 at 12:35 PM she reported that this was the second admission for Resident #1. In her first admission she was cognitively alert and oriented, however her readmission on 03/12/2025 she had been observed with increased confusion, memory loss, and required more supervision for care needs during her stay (03/12/2025 to 03/31/2025P. During a phone interview with NP on 04/25/2025 at 10:45 AM she stated that Resident #1's confusion and cognition was progressive, and she required supervision if discharged home. During an interview on 04/26/2025 at 5:05 PM the DON stated her expectation was a Significant Change Assessment should have been completed within after 14 days of Resident #1 having an altered mental status related to dementia. The DON stated the MDS nurse was responsible to complete the Significant Change and nursing was responsible to notify MDS with the change. The DON stated the effect on residents could have received incorrect services and supervision at discharge. During an interview on 04/26/2025 at 3:59 PM with MDS R nurse she was responsible to complete the Significant Change Assessment. The nurse working with Resident #1 and IDT team should have triggered for a Significant Change Assessment to be completed and should have been completed when the resident was diagnosed with dementia, confusion, and decline in cognition and ADL's. The MDS R stated the MDS nurse was responsible to complete the MDS and the DON reviews, audits and signs the completed assessment. MDS R stated the effect on residents could have been plan of care not being updated . MDS Coordinator R said a MDS for significant change should be completed when a resident had changes in altered mental status, dx, medications, medical history . Review of CMS 'S State Operations Manual-Appendix PP February 24, 2025, revealed: INTENT S483.20(b)(2)(ii) To ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process. DEFINITIONS S483.20(b)(2)(ii) Significant Change is a major decline or improvement in a resident's status that 1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered self-limiting (NOTE: Self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.); 2) impacts more than one area of the resident's health status; and 3) requires interdisciplinary review and/or revision of the care plan .Significant Change in Status Assessment (SCSA) is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline .GUIDANCE S483.20(b)(2)(ii) . The facility should document in the medical record when the determination is made that the resident meets the criteria for a Significant Change in Status Assessment Examples of Decline include, but are not limited to o Resident's decision-making ability has changed; Record review of facility policy dated December 2016 titled Change in a Resident's Condition or Status Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); .Impacts more than one area of the resident's health status; .Requires interdisciplinary review and/or revision to the care plan; .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .There is a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for pain management. The facility failed to adequately assess and treat Resident #1's severe breakthrough pain as he was screaming in unrelenting pain. The noncompliance was identified as past noncompliance. The Immediate Jeopardy was identified on 02/05/25 at 1:02 PM and was removed on 02/05/25 at 4:15 PM. The facility corrected the noncompliance before the investigation began on 02/04/25. The Immediate Jeopardy occurred in the past and the facility had already corrected the non-compliance. This failure could place residents at risk for unnecessary pain, discomfort and a decreased quality of life. Findings included: Record review of Resident #1's electronic face sheet, dated 02/04/25, reflected a [AGE] year-old male, who admitted to the facility initially on 06/15/22, and had a readmitted [DATE]. Resident #1 had a diagnosis of Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (high blood pressure), Dementia (decline in mental abilities), Heart Failure, and History of Falling. Record review of Resident #1's care plan, dated 06/29/22 was the only care plan listed for the resident from a previous admission. The past care plan did reflect a history of pain due to a past pelvic fracture. The care plan reflected the goal was for Resident #1 to remain free from pain or at a level of discomfort acceptable to the resident. The care plan also reflected a goal of decreased pain within one hour of intervention. The interventions listed on the care plan for pain were to administer pain medications per the physician's orders, given PRN medications for breakthrough as per the physician's orders, note effectiveness, and to report complaints and non-verbal signs. Record review of Resident #1's electronic record reflected no documented pain assessments on 1/31/25 or 02/01/25. Record review of Resident #1's physician's orders dated 02/04/25, reflected the following: Tramadol HCl Tablet 50 MG Give one tablet by mouth every four hours as needed for moderate and severe pain, order date 02/01/25 Tylenol 8-hour Arthritis Pain oral tablet extended release 650 MG (Acetaminophen) Give 1 tablet by mouth three times a day for pain, order date 02/01/25 Monitor pain every shift, order date 01/31/25 Record review of Resident #1's Nurse Administration Record, dated [DATE], reflected the following: Monitor pain every shift, with a start date of 02/01/25 and an end date of 02/03/25. Record review of the progress notes on Resident #1's electronic record, dated 02/04/25, reflected the following: 02/01/25 18:17 (6:17 PM) Note Text : late entry: patient was found on floor of room, patient had no skin tears, bp 186/90 p100, patient expressed pain through with consistent yelling ow and help me he also kept grabbing his right hip and refused to lay on that side when being assessed. NP D and DON [DON] were notified as well. wife stated patient can take 650mg tylenol for relief. this nurse administered the 650mg tylenol and patient showed relief. NP [NP D] ordered full pelvic xray. [DON] ordered tramadol and tylenol. this nursehas entered orders. patient is in need of a sitter due to his urge to wander to prevent falls, bed has been in low position since admission on 1/31/2025. plan of care ongoing. Author: [LVN A] 02/01/25 21:15 (9:15 PM) While waiting for the X-ray results, the family requested the resident be sent to the emergency room due to pain. A 911 call made, EMS arrived and transport the resident to [Hospital name]. RP is present, and the administration notified. Author: [ LVN B] Record review of Resident #1's hospital document dated 02/04/25, reflected Resident #1 was diagnosed with a right hip fracture that required surgery. In an interview on 02/04/25 at 11:10 AM, NP C stated the facility called her, and let her know Resident #1 was in pain, but did not mention he had a fall. She stated right after the call, she sent the order for tramadol on 02/01/25 at 11:30 AM to the facility staff. In a telephone interview on 02/04/25 at 12:37 PM, Resident #1' Family Member confirmed that Resident #1 had a hip fracture and had surgery the morning of 02/04/25. The Family Member stated they arrived at the facility around 9:50 AM on 02/01/25, and the fall must have occurred before then. The Family Member stated Resident #1 was screaming and yelling in pain when they arrived at the facility to visit. The Family Member stated no one was going into Resident #1's room to assist him. The Family Member stated they requested to speak with the DON, but the DON was not there. The Family Member stated the MOD came into the room to talk to them around 10:30-11:00 AM. The MOD informed her that pain medication and x-rays were requested. In an interview with the DON, on 02/04/25 at 12:57 PM, the DON stated Resident #1 fell on [DATE]. The DON stated it was an unwitnessed fall. She stated LVN A heard Resident #1 yell, and went in to see him on the floor. The DON stated during the admission, the day before, the Family Member of Resident #1 informed the facility that Resident #1 was a little impulsive and moved around often. The DON stated the facility put interventions in place like the bed at the lowest level and placed two fall mats around his bed. The DON stated she was not sure exactly what time the fall occurred, but LVN A sent her a text message around 9:26 AM about Resident #1's fall. The DON stated LVN A contacted NP D and requested x-rays around the same time. The DON stated at 11:26 AM, she spoke with NP D, and NP D informed her she was out of the country, but she was able to provide an order for the x-rays. The DON stated NP D told her to contact NP C to get the order for pain medication. The DON stated by 11:30 AM, the facility had received the order for the Arthritis Tylenol and the Tramadol. The DON stated she was not sure if Resident #1 had any pain medications between 9:00 AM and 11:30 AM. She stated Resident #1 did not admit to the facility the day before with any pain medication. The DON stated the staff at the facility were immediately in-serviced starting on 02/02/25 regarding pain management, notification of changes, documentation, resident rights, and abuse and neglect. She stated they started reviewing all resident files and medication records to check for any additional concerns. In an interview on 02/04/25 at 1:26 PM, the MOD stated she was the manager during that weekend when Resident #1 had the incident. She stated she arrived at the facility around 10:20 AM, made her rounds on the other side of the facility, then made her way to the side where Resident #1's room was, around 11:00 AM or 11:15 AM on 02/01/5. The MOD stated LVN A did not tell her about any incident with Resident #1, but the resident's Family Member was present in the room and informed her that Resident #1 was in pain. She stated she asked the Family Member had Resident #1 received any medication for pain, and the Family Member stated they were not aware of any pain medication given to Resident #1. The MOD stated Resident #1 was laying on his back and did appear to be in pain. The MOD stated she went to his nurse, who was LVN A, and LVN A stated she gave him some pain medication about 30 minutes ago. She stated LVN A stated she had contacted NP D for pain medication, and wife told her he could take Tylenol. The MOD stated after speaking with LVN A, she contacted the DON, because the DON can get orders quicker than the nurses at times. The MOD stated x-rays sometimes took longer on the weekend. She stated she did not check back with the resident or LVN A, because she had not heard anything else about the incident before she left work. The MOD stated they did start in-services on Sunday 02/02/25. She stated she received an in-service on abuse and neglect, pain management, resident rights, notify of changes, documentation, and incidents. The MOD stated she was informed to contact the DON or an ADON immediately if there were concerns with anything at the facility regarding pain management. In a telephone interview on 02/04/25 at 2:05 PM, NP D stated LVN A contacted her around 10:42 AM after the fall happened. She stated LVN A told her he had a fall and was screaming in pain. NP D stated she told LVN A to get x-rays, and LVN A told her Resident #1 had a hip injury in the past and it was normal for him to be in a little pain. She stated she had to repeat to the nurse to get the x-ray. NP D stated she did not receive the x-ray results until the next day. She stated she was informed LVN A was fairly new and called the wrong x-ray company, so it took a little longer than normal. In a follow-up interview on 02/04/25 at 2:20 PM, the DON confirmed LVN A contacted another x-ray company that the facility didn't normally use, so it did take longer to get the results. The DON stated she did not see on the MAR where the Tramadol was given to Resident #1, but she would research a little more. She stated Resident #1 did get Tylenol. She stated she was unsure of what time Resident #1 received Tylenol that morning, because LVN A did not mark the Tylenol as given on the MAR. The DON stated LVN A did leave a progress note around 1:30 PM, stating she administered Tylenol earlier that day. In a telephone interview on 02/04/25 at 3:07 PM, Medication Assistant E stated he was the one that administered the Tylenol to Resident #1 around 2 something in the afternoon on 02/01/25. He stated he remembered giving him the Tylenol, because he crushed his medications. He stated he was not able to swallow pills. He stated no one was present in the room other than he and Resident #1. He stated he did see Resident #1's family member in the facility. Medication Assistant A stated he was told by staff that Resident #1 did fall. He stated Resident #1 kept telling him he was in pain. He stated if Resident #1 had an order for Tramadol, he would not be the staff member to administer that medication. He stated LVN A would have been the one to administer Tramadol. Medication Assistant E stated he was present at the facility when Resident #1 was transported to hospital, but he could not remember what time. He stated it was before he left work, and he left work around 10:00 PM. A telephone interview was attempted with LVN B on 02/04/25 at 3:15 PM, but there was no answer. In a telephone interview on 02/04/25 at 3:22 PM, LVN A stated she no longer was working at the facility. She stated she already told everyone what happened. LVN A stated Resident #1 had an unwitnessed fall around breakfast time on 02/01/25. She stated she did not remember the exact time of the fall. She stated she immediately contacted NP D, who gave her orders for x-rays. She stated she had to put the x-ray order into the system to request the x-ray company to come to the facility. LVN A stated the x-ray company arrived at the facility around 5:00 PM that evening, on 02/01/25. She stated she believed she received an order for pain medication around mid-day but did not recall the time. LVN A stated all she knew was Resident #1 received a dose of Tylenol, but she did not remember the time she administered it. She stated she crushed it and put it in applesauce, because the resident was on a pureed diet. LVN A stated Resident #1 did not yell as much after he received the Tylenol. She stated she did not complete the pain assessments or neuro checks, because Resident #1 was not yelling as much as he was that morning. LVN A stated the Tramadol never arrived. She stated she was in-serviced on pain management and fired. LVN A stated that was all she was going to say about the incident and hung up the telephone. On 02/04/25 at 3:55 PM, Surveyor and the ADON reviewed the medication cart, and Resident #1 did not have any Tramadol on the medication cart. The over-the-counter Tylenol was on the medication cart. The ADON stated she would contact the pharmacy to see if the Tramadol was taken from the e-kit. On 02/04/25 at 5:13 PM, via email, the DON stated the Tramadol was never delivered on 02/01/25, because the pharmacy noticed Resident #1 was sent to the hospital. She stated the Tramadol was never pulled from the e-kit either. In an interview on 02/05/25 at 10:03 AM, the Weekend Supervisor RN stated she was aware of the incident with Resident #1 and LVN A. She stated she arrived to work that Saturday, 02/01/25 around 8 something that morning. The Weekend Supervisor RN stated the DON asked her to go check on LVN A around 10:00 AM. She stated the DON stated LVN A may need some help. The Weekend Supervisor RN stated the DON told her LVN A said Resident #1 was demented, that LVN A wanted to send him out to the hospital, and that LVN A felt that Resident #1 was not appropriate for the facility. The Weekend Supervisor RN stated she went to check on LVN A and she stated she could hear Resident #1 screaming. The Weekend Supervisor RN stated LVN A told her he had been screaming all morning. She stated she asked LVN A what was wrong with him, and she told her he had a fall. The Weekend Supervisor RN stated LVN A told her his bed was at the lowest level when he fell on the fall mat. The Weekend Supervisor RN stated she asked if he was given any medication for pain, and LVN A stated he did not have any medication on his chart for pain. The Weekend Supervisor RN stated she did not believe LVN A told the DON that resident had a current fall but just that he had a past hip injury. She stated LVN A told her she had already contacted the nurse practitioner and had requested x-rays. She stated Resident #1's family was at the facility that day, and they had not complained anymore about the pain. She stated she didn't hear him screaming anymore, so she did not know there was still an issue with pain management. The Weekend Supervisor RN stated after the incident, the following day, the staff received in-services on abuse and neglect, pain management, documentation, resident rights, incidents, and notifying the appropriate people. She stated she was informed to contact the DON if there were any future issues with pain management. The Weekend Supervisor RN stated the risk of not following up on pain management is that Resident #1 would continue to be in pain and also the quality of care. In a follow-up interview on 02/05/25 at 10:43 AM, the DON stated LVN A called her around 9:30 AM on 02/01/25, told her that Resident #1 fell . She stated she told LVN A to do an incident report, follow through with the pain assessments, to notify the family and doctor, and asked if pain medications were on board. The DON stated she initially told LVN A to contact NP D, but she also contacted NP D. The DON stated NP D told her to contact NP C for the pain medication. She stated she received the order for x-ray and pain medication and forwarded those orders to LVN A at 11:32 AM on 02/01/25. She stated she was unaware on 02/01/25 that the pain medication, Tramadol, was not received. The DON stated LVN A should have followed through with completing pain assessments throughout the shift. She stated the pharmacy the facility used was in Sulphur Springs, Texas (about 95 miles away). The DON stated the pharmacy had two drop times: 2:00 PM and midnight. She stated LVN A did not follow up with the pharmacy about the Tramadol. She stated if she was aware the Tramadol had not arrived, she could have gotten it from the e-kit. The DON stated the risk of LVN A not following through with pain management or sending the resident to the hospital sooner was Resident #1 might have suffered longer. In an interview on 02/05/25 at 11:08 AM, the Administrator stated LVN A and the Weekend Supervisor RN were responsible for following up on the pain assessments and pain management for Resident #1. She stated there should have been an initiative to get the Tramadol from the e-kit when Resident #1 was still complaining of pain. She stated LVN A should have completed pain asessments throughout the shift. The Administrator stated she felt there was not really a risk since Resident #1 did receive the Tylenol. The Administrator stated after the incident, starting on 02/02/25, the facility completed in-services on abuse and neglect, pain management, incidents, incident reporting, resident rights, notification of changes, pain assessments, and documentation. The Administrator stated on 02/02/25, the DON started an audit to ensure all nurses complete pain assessments, incident reports, and neuro checks. The Administrator stated she has reviewed and will continue to review and verify during the morning stand up meetings Monday through Friday. The Administrator stated on the weekend, she, the DON, and the weekend supervisors would monitor and review. She stated with pain management, the DON and the ADONs have started doing audits with new admissions as well as current residents. She stated they started a checklist to ensure orders are in place, the DON has started a report on medications ordered. The Administrator stated the DON started daily audits, and she has weekly audits. The administrator stated the DON and ADONs have started monitoring all changes in condition and the managers review during the daily stand-up meeting. The Administrator stated on the weekends, the DON and ADONs would do check-ins. She stated mass text messages were sent to the nurse staff to contact the DON or ADONs on the weekend concerning pain management. An Immediate Jeopardy for past non-compliance was identified on 02/05/25. The Administrator was notified of the Immediate Jeopardy for past non-compliance on 02/05/25 at 1:02 PM and were provided with the Immediate Jeopardy Template. The facility was not asked to provide a Plan of Removal, since the Immediate Jeopardy occurred in the past and the facility had already corrected the non-compliance. Record review of a document titled, Emergency Plan of Correction dated 02/03/25, reflected the following: Emergency Plan of Correction Risk Management/ Pain Management 2/3/2025 Problem: Timely Incident Reporting/ Timely Incident Accident Documentation Initiation/ Pain Management Immediate Action: All Nursing Staff ln-service, scrubbed risk management documentation, and mass text to notify all staff to call DON and Administrator of any incident/accident immediately Date Completed: 2/2/25 Systemic: DON, ADON, and Administrator will promptly assess documentation for MD and family notification. And assess orders for need for pain regimen and management. Date Completed:2 2/2/25 - ongoing. Monitoring: Daily monitoring of risk management tab and pain assessment. In an interview on 02/05/25 at 1:56 PM, Caregiver G stated she received in-services on abuse and neglect, resident rights, pain management, notifying a nurse or management if a resident complains about pain, documentation, incident reporting, and fall prevention within the last two days. She stated she was trained to let a nurse know if a resident had an accident or if the resident was in pain. She states she was in-serviced on following up to ensure the nurse checked on the resident. She stated if that resident still complained of pain, she would let the DON know. In an interview on 02/05/25 at 2:11 PM, Medication Assistant H stated she was in-serviced on Monday about abuse and neglect, resident rights, pain management, incident reports, documentation, notifying nurses of incidents, and fall prevention. She stated she was in-serviced about letting a nurse know if a resident was in pain, so the nurses could do pain assessments. She stated she could provide pain medication if it was available and if the resident had not already had pain medications. She stated some medications have to be given by the nurse. In an interview on 02/05/25 at 2:24 PM, RN I stated she worked on the weekend, and she received in-services then. She stated the in-service were over pain management, pain assessments, neuro checks, incident reports, documentation, notification of changes, resident rights, and abuse and neglect. She stated if there was any time of pain management with a resident, all nurses were to follow-up with management. In an interview on 02/05/25 at 2:33 PM, LVN J stated he received in-services this week over abuse and neglect, pain management, fall prevention, documentation, assessments, checks, and notifying the families and the physician. He stated he was told to update the DON with any pain management concerns. He stated he was informed if he worked on the weekends to follow up with the weekend supervisor, ADON, or DON with concerning pain management. In an interview on 02/05/25 at 2:43 PM, ADON F stated she received in-services on Monday regarding pain management, abuse and neglect, resident rights, documentation, fall prevention, chain of command, notification of changes, incidents, and accidents. She stated when there is an incident like a fall, the pain assessments, neuro checks, incident reports, and overall documentation should be available in their electronic system. Record review of a document titled, Record of Disciplinary Measure, dated 02/02/25, reflected LVN A was disciplined and terminated for resident abuse, neglect, or failure to report such incidents immediately and failure to follow facility rules, policies, and procedures. The document reflected LVN A had a patient under her care who had a fall on 02/01/25 and nurse failed to complete neuro checks/assessments and to monitor Resident #1 after the fall. Record review of an in-service titled, Abuse and Neglect dated 02/02/25, and covered the facility's abuse and neglect policy. All care staff on the employee roster received the in-service. Record review of an in-service titled, incident/accident/neuro checks dated, 02/02/25, and covered accident, incidents, chain of command, and documentation. All care staff on the employee roster received the in-service. Record review of an in-service titled, Nurses Falls Witnessed and Unwitnessed, dated 02/02/25, and noted it covered, falls, incidents, pain management, medication orders, x-rays, sending residents out to the hospital, and notifying management, including the DON, as well as the doctor and the family. All care staff on the employee roster received the in-service. Record review of the facility's policy titled, Pain Management, dated 2001, with a revision date of April 2009, reflected the following: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain. b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. Recognizing Pain: I. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body;

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of three residents reviewed for change in physical, mental, or psychosocial status. 1. The facility failed to complete routine neuro checks after Resident #1 had a fall on the morning of 02/01/25, and continued to have pain. The noncompliance was identified as past noncompliance. The facility corrected the noncompliance before the investigation began on 02/04/25. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, or hospitalization . Findings included: Record review of Resident #1's electronic face sheet, dated 02/04/25, reflected a [AGE] year-old male, who admitted to the facility initially on 06/15/22, and had a readmitted [DATE]. Resident #1 had a diagnosis of Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (high blood pressure), Dementia (decline in mental abilities), Heart Failure, and History of Falling. Record review of Resident #1's care plan, dated 06/29/22 was the only care plan listed for the resident from a previous admission. The past care plan did reflect a history of pain due to a past pelvic fracture. The care plan reflected the goal was for Resident #1 to remain free from pain or at a level of discomfort acceptable to the resident. The care plan also reflected a goal of decreased pain within one hour of intervention. The interventions listed on the care plan for pain were to administer pain medications per the physician's orders, given PRN medications for breakthrough as per the physician's orders, note effectiveness, and to report complaints and non-verbal signs. Record review of Resident #1's electronic record reflected no documented pain assessments on 1/31/25 or 02/01/25. Record review of Resident #1's physician's orders dated 02/04/25, reflected the following: Tramadol HCl Tablet 50 MG Give one tablet by mouth every four hours as needed for moderate and severe pain, order date 02/01/25 Tylenol 8-hour Arthritis Pain oral tablet extended release 650 MG (Acetaminophen) Give 1 tablet by mouth three times a day for pain, order date 02/01/25 Monitor pain every shift, order date 01/31/25 Record review of Resident #1's Nurse Administration Record, dated [DATE], reflected the following: Monitor pain every shift, with a start date of 02/01/25 and an end date of 02/03/25. Record review of the progress notes on Resident #1's electronic record, dated 02/04/25, reflected the following: 02/01/25 18:17 (6:17 PM) Note Text : late entry: patient was found on floor of room, patient had no skin tears, bp 186/90 p100, patient expressed pain through with consistent yelling ow and help me he also kept grabbing his right hip and refused to lay on that side when being assessed. NP D and DON [DON] were notified as well. wife stated patient can take 650mg tylenol for relief. this nurse administered the 650mg tylenol and patient showed relief. NP [NP D] ordered full pelvic xray. [DON] ordered tramadol and tylenol. this nursehas entered orders. patient is in need of a sitter due to his urge to wander to prevent falls, bed has been in low position since admission on 1/31/2025. plan of care ongoing. Author: [LVN A] 02/01/25 21:15 (9:15 PM) While waiting for the X-ray results, the family requested the resident be sent to the emergency room due to pain. A 911 call made, EMS arrived and transport the resident to [Hospital name]. RP is present, and the administration notified. Author: [ LVN B] Record review of Resident #1's hospital document dated 02/04/25, reflected Resident #1 was diagnosed with a right hip fracture that required surgery. In a telephone interview on 02/04/25 at 12:37 PM, Resident #1' Family Member confirmed that Resident #1 had a hip fracture and had surgery the morning of 02/04/25. The Family Member stated they arrived at the facility around 9:50 AM on 02/01/25, and the fall must have occurred before then. The Family Member stated Resident #1 was screaming and yelling in pain when they arrived at the facility to visit. The Family Member stated no one was going into Resident #1's room to assist or assess him. The Family Member stated they requested to speak with the DON, but the DON was not there. The Family Member stated the MOD came into the room to talk to them around 10:30-11:00 AM. The MOD informed her that pain medication and x-rays were requested. In an interview with the DON, on 02/04/25 at 12:57 PM, the DON stated Resident #1 fell on [DATE]. The DON stated NP D told her to contact NP C to get the order for pain medication. The DON stated by 11:30 AM, the facility had received the order for the Arthritis Tylenol and the Tramadol. The DON stated she was not sure if Resident #1 had any pain medications between 9:00 AM and 11:30 AM. She stated Resident #1 did not admit to the facility the day before with any pain medication. The DON stated the staff at the facility were immediately in-serviced starting on 02/02/25 regarding pain management, notification of changes, documentation, resident rights, and abuse and neglect. She stated they started reviewing all resident files and medication records to check for any additional concerns. In a telephone interview on 02/04/25 at 3:22 PM, LVN A stated she no longer was working at the facility. She stated she already told everyone what happened. LVN A stated Resident #1 had an unwitnessed fall around breakfast time on 02/01/25. She stated she did not remember the exact time of the fall. She stated she immediately contacted NP D, who gave her orders for x-rays. She stated she had to put the x-ray order into the system to request the x-ray company to come to the facility. LVN A stated the x-ray company arrived at the facility around 5:00 PM that evening, on 02/01/25. She stated she believed she received an order for pain medication around mid-day but did not recall the time. LVN A stated all she knew was Resident #1 received a dose of Tylenol, but she did not remember the time she administered it. She stated she crushed it and put it in applesauce, because the resident was on a pureed diet. LVN A stated Resident #1 did not yell as much after he received the Tylenol. She stated she did not complete the pain assessments or neuro checks, because Resident #1 was not yelling as much as he was that morning. LVN A stated the Tramadol never arrived. She stated she was in-serviced on pain management and fired. LVN A stated that was all she was going to say about the incident and hung up the telephone. In an follow-up interview on 02/05/25 at 10:43 AM, the DON stated LVN A told her she did not document the neuro checks, because she did not complete the neuro checks, because she thought Resident #1 was better. She stated LVN A should have continued to do neuro checks throughout the shift. The DON stated that discrepancy was a reason why LVN A was terminated. The DON stated the risk of not completing the neuro checks was Resident #1 possibly suffered longer. In an interview on 02/05/25 at 11:08 AM, the Administrator stated LVN A and the Weekend Supervisor RN were responsible for following up neuro checks for Resident #1. The Administrator stated after the incident, starting on 02/02/25, the facility completed in-services on abuse and neglect, pain management, incidents, incident reporting, resident rights, notification of changes, assessments, and documentation. The Administrator stated on 02/02/25, the DON started an audit to ensure all nurses complete pain assessments, incident reports, and neuro checks. The Administrator stated she has reviewed and will continue to review and verify during the morning stand up meetings Monday through Friday. The Administrator stated on the weekend, she, the DON, and the weekend supervisors would monitor and review. She stated with pain management, the DON and the ADONs have started doing audits with new admissions as well as current residents. She stated they started a checklist to ensure orders are in place, the DON has started a report on medications ordered. The Administrator stated the DON started daily audits, and she has weekly audits. The administrator stated the DON and ADONs have started monitoring all changes in condition and the managers review during the daily stand-up meeting. The Administrator stated on the weekends, the DON and ADONs would do check-ins. She stated mass text messages were sent to the nurse staff to contact the DON or ADONs on the weekend concerning pain management. In an interview on 02/05/25 at 1:56 PM, Caregiver G stated she received in-services on abuse and neglect, resident rights, pain management, notifying a nurse or management if a resident complains about pain, documentation, incident reporting, and fall prevention within the last two days. She stated she was trained to let a nurse know if a resident had an accident or if the resident was in pain. She states she was in-serviced on following up to ensure the nurse checked on the resident. She stated if that resident still complained of pain, she would let the DON know. In an interview on 02/05/25 at 2:11 PM, Medication Assistant H stated she was in-serviced on Monday about abuse and neglect, resident rights, pain management, incident reports, documentation, notifying nurses of incidents, and fall prevention. She stated she was in-serviced about letting a nurse know if a resident was in pain, so the nurses could do pain assessments. She stated she could provide pain medication if it was available and if the resident had not already had pain medications. She stated some medications have to be given by the nurse. In an interview on 02/05/25 at 2:24 PM, RN I stated she worked on the weekend, and she received in-services then. She stated the in-service were over pain management, pain assessments, neuro checks, incident reports, documentation, notification of changes, resident rights, and abuse and neglect. She stated if there was any time of pain management with a resident, all nurses were to follow-up with management. In an interview on 02/05/25 at 2:33 PM, LVN J stated he received in-services this week over abuse and neglect, pain and neuro checks, fall prevention, documentation, assessments, checks, and notifying the families and the physician. He stated he was told to update the DON with any pain management concerns. He stated he was informed if he worked on the weekends to follow up with the weekend supervisor, ADON, or DON with concerning pain management. In an interview on 02/05/25 at 2:43 PM, ADON F stated she received in-services on Monday regarding neuro checks, abuse and neglect, resident rights, documentation, fall prevention, chain of command, notification of changes, incidents, and accidents. She stated when there is an incident like a fall, the pain assessments, neuro checks, incident reports, and overall documentation should be available in their electronic system. Record review of a document titled, Record of Disciplinary Measure, dated 02/02/25, reflected LVN A was disciplined and terminated for resident abuse, neglect, or failure to report such incidents immediately and failure to follow facility rules, policies, and procedures. The document reflected LVN A had a patient under her care who had a fall on 02/01/25 and nurse failed to complete neuro checks/assessments and to monitor Resident #1 after the fall. Record review of an in-service titled, Abuse and Neglect dated 02/02/25, and covered the facility's abuse and neglect policy. All care staff on the employee roster received the in-service. Record review of an in-service titled, incident/accident/neuro checks dated, 02/02/25, and covered accident, incidents, chain of command, and documentation. All care staff on the employee roster received the in-service. Record review of an in-service titled, Nurses Falls Witnessed and Unwitnessed, dated 02/02/25, and noted it covered, falls, incidents, pain management, medication orders, x-rays, sending residents out to the hospital, and notifying management, including the DON, as well as the doctor and the family. All care staff on the employee roster received the in-service. Record review of the facility's policy titled, Accepts and Incidents- Reporting and Investigating, and dated 2001 with a revision date of April 2010, reflected the following: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation I. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident fonn: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; I. Follow-up infonnation; m. Other pertinent data as necessary or required

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for accuracy of medical records in that: 1. LVN A did not document the administration of Tylenol Arthritis 650 MG on the Medication Administration Record during the morning shift on 02/01/25 for Resident #1 and failed to document the time of the Tylenol Arthritis 650 MG administration on the progress notes in Resident #1's file. 2. LVN A failed to document any pain assessments or neuro checks for Resident #1 after he had a fall on the morning of 02/01/25. The noncompliance was identified as past noncompliance. The facility corrected the noncompliance before the investigation began on 02/04/25. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. Findings included: Record review of Resident #1's electronic face sheet, dated 02/04/25, reflected a [AGE] year-old male, who admitted to the facility initially on 06/15/22, and had a readmitted [DATE]. Resident #1 had a diagnosis of Type 2 Diabetes (body does not use insulin effectively or does not produce enough insulin), Essential Hypertension (high blood pressure), Dementia (decline in mental abilities), Heart Failure, and History of Falling. Record review of the February Medication Administration Record for Resident #1, dated 02/04/25, reflected no documentation of Resident #1 receiving the Tylenol on the morning of 02/01/25. Record review of Resident #1's physician's orders dated 02/04/25, reflected the following: Tramadol HCl Tablet 50 MG Give one tablet by mouth every four hours as needed for moderate and severe pain, order date 02/01/25 Tylenol 8-hour Arthritis Pain oral tablet extended release 650 MG (Acetaminophen) Give 1 tablet by mouth three times a day for pain, order date 02/01/25 Monitor pain every shift, order date 01/31/25 Record review of Resident #1's Nurse Administration Record, dated [DATE], reflected the following: Monitor pain every shift, with a start date of 02/01/25 and an end date of 02/03/25. Record review of the progress notes on Resident #1's electronic record, dated 02/04/25, reflected the following: 02/01/25 18:17 (6:17 PM) Note Text : late entry: patient was found on floor of room, patient had no skin tears, bp 186/90 p100, patient expressed pain through with consistent yelling ow and help me he also kept grabbing his right hip and refused to lay on that side when being assessed. NP and DON [DON name] were notified as well. wife stated patient can take 650mg Tylenol for relief. this nurse administered the 650mg Tylenol and patient showed relief. NP [NP name] ordered full pelvic x-ray. [DON name] ordered tramadol and Tylenol. this nursehas entered orders. patient is in need of a sitter due to his urge to wander to prevent falls, bed has been in low position since admission on 1/31/2025. plan of care ongoing. Author: [LVN A name] Record review of a document titled, Record of Disciplinary Measure dated 02/02/25, reflected LVN A was disciplined and terminated for resident abuse, neglect, or failure to report such incidents immediately and failure to follow facility rules, policies, and procedures. The document reflected LVN A had a patient under her care who had a fall on 02/01/25 and nurse failed to complete neuro checks/assessments and to monitor Resident #1 after the fall. Record review of Resident #1's electronic medical records reflected there were no neuro checks documented, and there were no pain assessments documented on 02/01/25. In a telephone interview on 02/04/25 at 3:22 PM, LVN A stated she gave Resident #1 Tylenol after his fall on 02/01/25. She stated she did not remember the time she administered the Tylenol. LVN A stated she did not know why she did not document the Tylenol was given on the Medication Administration Record. She stated she documented it on a late entry in the progress notes. LVN A stated she assessed him right after his unwitnessed fall. LVN A stated she did not complete neuro checks or pain assessments throughout her shift on 02/01/25, because Resident #1 was not yelling as much as he was that morning. In an interview on 02/05/25 at 10:43 AM, the DON stated LVN A should have documented the administration of the Tylenol on the Medication Administration Record if it was given. The DON stated LVN A documented it on the progress notes, but LVN A did not document the time the medication was given. The DON stated LVN A should have completed and documented neuro checks and pain assessments throughout her shift. She stated she failed to document those checks and assessments. The DON stated LVN A did not complete the incident report until Sunday, 02/02/25. She stated if she would have completed the incident report timely, the incident report would have prompted her to do all of the assessments and checks. The DON stated the risk of not documenting any of that was a visit from the state, a lawsuit, or putting the corporation or resident at risk. The DON stated documentation was very vital. In an interview on 02/05/25 at 11:08 AM, the Administrator stated LVN A failed to document the medication as given on the Medication Administration Record, and she failed to complete and document neuro checks and pain assessments during her shift. The Administrator stated the risk of LVN A not documenting was the resident not getting a good assessment. Record review of a document titled, Emergency Plan of Correction dated 02/03/25, reflected the following: Emergency Plan of Correction Risk Management/ Pain Management 2/3/2025 Problem: Timely Incident Reporting/ Timely Incident Accident Documentation Initiation/ Pain Management Immediate Action: All Nursing Staff ln-service, scrubbed risk management documentation, and mass text to notify all staff to call DON and Administrator of any incident/accident immediately Date Completed: 2/2/25 Systemic: DON, ADON, and Administrator will promptly assess documentation for MD and family notification. And assess orders for need for pain regimen and management. Date Completed:2 2/2/25 - ongoing. Monitoring: Daily monitoring of risk management tab and pain assessment. In an interview on 02/05/25 at 1:56 PM, Caregiver G stated she received in-services on abuse and neglect, resident rights, pain management, notifying a nurse or management if a resident complains about pain, documentation, incident reporting, and fall prevention within the last two days. She stated she was trained to let a nurse know if a resident had an accident or if the resident was in pain. She states she was in-serviced on following up to ensure the nurse checked on the resident. She stated if that resident still complained of pain, she would let the DON know. In an interview on 02/05/25 at 2:11 PM, Medication Assistant H stated she was in-serviced on Monday about abuse and neglect, resident rights, pain management, incident reports, documentation, notifying nurses of incidents, and fall prevention. She stated she was in-serviced about letting a nurse know if a resident was in pain, so the nurses could do pain assessments. She stated she could provide pain medication if it was available and if the resident had not already had pain medications. She stated some medications have to be given by the nurse. In an interview on 02/05/25 at 2:24 PM, RN I stated she worked on the weekend, and she received in-services then. She stated the in-service were over pain management, pain assessments, neuro checks, incident reports, documentation, notification of changes, resident rights, and abuse and neglect. She stated if there was any time of pain management with a resident, all nurses were to follow-up with management. In an interview on 02/05/25 at 2:33 PM, LVN J stated he received in-services this week over abuse and neglect, pain management, fall prevention, documentation, assessments, checks, and notifying the families and the physician. He stated he was told to update the DON with any pain management concerns. He stated he was informed if he worked on the weekends to follow up with the weekend supervisor, ADON, or DON with concerning pain management. In an interview on 02/05/25 at 2:43 PM, ADON F stated she received in-services on Monday regarding pain management, abuse and neglect, resident rights, documentation, fall prevention, chain of command, notification of changes, incidents, and accidents. She stated when there is an incident like a fall, the pain assessments, neuro checks, incident reports, and overall documentation should be available in their electronic system. Record review of a document titled, Record of Disciplinary Measure, dated 02/02/25, reflected LVN A was disciplined and terminated for resident abuse, neglect, or failure to report such incidents immediately and failure to follow facility rules, policies, and procedures. The document reflected LVN A had a patient under her care who had a fall on 02/01/25 and nurse failed to complete neuro checks/assessments and to monitor Resident #1 after the fall. Record review of an in-service titled, Abuse and Neglect dated 02/02/25, and covered the facility's abuse and neglect policy. All care staff on the employee roster received the in-service. Record review of an in-service titled, incident/accident/neuro checks dated, 02/02/25, and covered accident, incidents, chain of command, and documentation. All care staff on the employee roster received the in-service. Record review of an in-service titled, Nurses Falls Witnessed and Unwitnessed, dated 02/02/25, and noted it covered, falls, incidents, pain management, medication orders, x-rays, sending residents out to the hospital, and notifying management, including the DON, as well as the doctor and the family. All care staff on the employee roster received the in-service. Record review of the facility's policy titled, Pain Assessment and Management, dated 2001, with a revision date of April 2009, reflected the following: Documentation l. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. The facility's Medication Administration policy was requested on 02/04/25 at 9:50 AM from the DON but not received.

Based on record reviews, and interviews, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of one resident reviewed for pressure ulcers. The facility failed to provide Resident #1 with proper wound care in a timely manner resulting in the resident being transferred to a local hospital with wounds to the left lateral knee, left lower leg, and left second and fourth toes. The failure placed residents at risk of the worsening of pressure ulcers. Findings included: Review of Resident #1's EHR revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of left lower leg fracture and multiple right rib fractures post motor vehicle crash. He was discharged from the facility on 11/10/22 to the VA hospital. Review of Resident #1's Admission MDS, dated [DATE], revealed a BIMS score to assess for cognitive ability was not completed. His Functional Status indicated he required the assistance on one person for most of his ADLs. The Skin Condition section of the MDS reflected Resident #1 had no skin issues, to include no pressure ulcers or deep tissue injuries. Review of Resident #1's Discharge MDS, dated [DATE], reflected the resident had two unstageable pressure ulcers. Review of Resident #1's care plan, dated 11/02/22, revealed on his Initial Skin Assessment he was at risk for pressure ulcers related to weakness. On 11/07/22, pressure ulcer to left leg was added to the care plan, and dated for 11/04/22. Interview on 12/07/22 at 9:00 AM with Resident #1, in his hospital room, revealed he had been in an car accident on 10/18/22 and was admitted to a local hospital. He was diagnosed with a left leg fracture and multiple right rib fractures. Upon discharge, he was sent to the facility for rehabilitation. He stated he had no skin issues when he was admitted , and he was wearing an orthopedic boot on his left lower leg. He stated he did not feel the facility was providing good care because he developed skin breakdown under the boot, and no one did anything about it for several days. He finally requested to be transferred to the VA hospital on 11/10/22. Review on 12/08/22 at 11:40 AM of Resident #1's EHR revealed a Weekly Skin Review was completed on 11/02/22, and it indicated no skin issues. Review of Weekly Skin Review on 11/08/22 indicated three wounds on the resident's left lower leg, two deep tissue injuries, and one trauma related injury. The deep tissue injuries measured 4 cm x 3 cm and 3 cm x 2 cm. The trauma injury measured 6 cm x 3 cm x 0.3 cm. Review of Resident #1's Discharge Summary from the local hospital, dated 10/31/22, indicated the resident's skin was warm and dry, no mention of any wounds on the resident's left lower leg. Review of Nurse Practitioner progress notes on 11/02/22 and 11/05/22 indicated no skin issues. The notes reflected: Skin is warm and dry with no rash. A progress note on 11/07/22 indicated bruises to LUA [left upper arm], rashes, immobilizer LLL [left lower leg]. Review of Resident #1's Emergency Department Clinical Note, dated 11/10/22, indicated wounds to left lateral knee, left lower leg, and left 2nd and 4th toes since in Methodist rehab. Review of Skin/Wound note created on 11/07/22, and back dated for 11/04/22, by Wound Care Nurse reveled: .removed immobilizer was able to fully assess leg, noted wounds to left lateral upper leg scant serous exudate, wound to lower left lower lateral leg slough noted to wound adherent dry, new orders to apply santyl, calcium alginate cover with ABD pad, apply anasept gel calcium alginate to upper left leg wound, continue betadine to left knee wound cover with ABD pad, wrap leg with kerlix and ace wrap due to edema to leg daily wound MD will follow up and treat, resident needs follow up appt with orthopedic, wife noted at bedside aware of wound status. Review of physician wound care orders revealed they were entered by Wound Care Nurse on 11/07/22 and back dated to 11/04/22. Review of Resident #1's physician orders revealed an order, dated 11/06/22, for Lidocaine patch to left ankle and left knee to be applied daily for pain control. Review of Resident #1's MAR revealed the lidocaine patch was applied to left knee and ankle daily from 11/06/22 - 11/10/22. Interview on 12/08/22 at 2:58 PM. the Wound Care Nurse stated she was made aware by his nurse of Resident #1's wounds on 11/04/22 and began treatment of them immediately. She stated orthopedic boots are known to cause skin breakdown because they do not fit very well. She had no explanation of why skin assessments did not reflect skin issues until 11/07/22. She stated whomever applied the lidocaine patches should have reported the skin breakdown. She stated her orders and notes were back dated to 11/04/22 because she did not have time to enter them until Monday 11/07/22. She did not explain how the nursing staff would have known to provide wound care over the weekend if the orders were not entered until 11/07/22. She stated a delay in wound treatment could allow the wounds to worsen. Interview on 12/08/22 at 2:50 PM, the ADON stated residents should be assessed by the admitting nurse and by each nurse on each shift for any changes or new complaints. Wounds should be reported to the Wound Care Nurse immediately so she can begin treatments. The Wound Care Nurse can initiate treatments based on protocols until the physician can assess them. The nurses can also begin treatment if the Wound Care Nurse is not present.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers in that: The facility failed to ensure the physician was notified of Resident #1's wound on admission, obtain wound care orders on admission, assess and document a detailed description of Resident #1's wound on admission. LVN C failed to provide Resident #1's physician ordered wound care on 03/13/22. These failures could place residents at risk for unidentified wounds/skin injuries and deterioration of existing wounds/skin injuries. Findings included: Review of Resident #1's closed clinical records revealed an admission MDS assessment, dated 02/05/22. The MDS assessment reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's undated admission record reflected a discharge date of [DATE]. The MDS assessment reflected Resident #1 required extensive assistance of two people for bed mobility/transfers, dressing and extensive assistance of one person for personal hygiene. Section M of the MDS assessment related to skin conditions, reflected venous and arterial ulcers were present and the current number of unhealed pressure ulcer/injury was 4 unstageable wounds due to coverage of the wound bed by slough- (tan, green, or brown colored dead tissue) and/or eschar- (tan, brown or black colored thick leathery dead tissue). According to the MDS assessment Section M was completed on 02/05/22. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission assessment dated [DATE] , revealed LVN A documented the resident admitted to the facility with intact skin. Review of Resident #1's Nurse progress notes dated 02/01/22 reflected LVN B documented the resident admitted with peri-area redness but no skin breakdown in the area, pressure ulcer to the left heel and was wearing a heel protector. There was no complete assessment of the left heel pressure ulcer to include color, description, type of tissue and/or the presence of exudate. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical therapy notes documented by the PTA dated 02/07/22 reflected the therapist removed Resident #1's left foot heel protector on 02/07/22 and found the resident's left heel saturated, with an open area and notified the nurse. Review of Resident #1's WCP notes/assessment dated [DATE] reflected Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's WCP notes/assessment dated [DATE] reflected Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Unstageable necrosis to the left heel measuring 10.5 by 7.5 by 0.1 cm (length by width by depth), light serosanguinous exudate, 80 % thick adherent black necrotic tissue. 2. Unstageable DTI to the right heel measuring 3.5 by 2.5 cm, DTI with intact skin no exudate 3. Unstageable DTI to the right buttock measuring 3.5 by 5.0 by 0.1 cm, light serosanguinous exudate 4. Unstageable DTI to the left buttock measuring 3.5 by 4.0 cm. no exudate, DTI with intact skin. Interviews were conducted with LVN A on 03/16/22 and 03/17/22 at 4:26 p.m. and 11:25 a.m. respectively. The nurse stated she was not assigned to Resident #1 on 02/01/22 and did not perform an admission skin assessment for the resident. She stated she assisted with the admission by asking some of the admission interview questions and entering the responses into the computer. She further stated she might have provided care for Resident #1 once or twice but did not remember if the resident had any skin issues. She was unable to recall who the other nurse was and denied documenting on the admission assessment the resident's skin was intact. She stated anyone could add to the assessment she opened if it had been left open and not locked. Interview with LVN B on 03/16/22 at 10:24 a.m. revealed she was an agency nurse and had never provided care for Resident #1. She stated she assisted with the resident's admission but was not assigned to provide care. She was assigned by one of the Managers (unable to recall who) to complete the skin assessment and document in the progress notes. She stated there was another nurse who handled the paperwork to include orders, and the nurse assigned to the resident also completed portions of the admission. She stated she recalled Resident #1 having a dressing to the left heel, she removed the dressing and noted an open area without drainage or bleeding. She stated she replaced the same dressing as the resident did not want to be touched. She stated she was unable to recall the size of the wound, but it was not large. She did not obtain orders and did not recall if she told the nurse assigned or the nurse who was responsible for the orders about the wound. Three nurses participated in the admission, but she was unable to recall who the other two nurses were. When queried about why she did not document a full description/assessment, she stated while she made sure to remove the dressing to see what the wound looked like it had been an oversite on her part to not document what she saw. Interview with the TN on 03/17/22 at 11:38 a.m. revealed she was not on duty on Saturday 03/13/22. She stated nurses were expected to perform resident treatments/wound care. Interview with the PTA on 03/17/22 at 2:29 p.m. related to her notes dated 02/07/22. She stated she removed Resident #1's pressure relief boot and noticed an open, saturated wound to the left heel without a dressing in place. She notified the nurse (unable to recall who) immediately. Interview with the DON on 03/16/22 at 1:49 p.m. revealed she was not working at the facility when Resident #1 admitted . She stated she did not know if the resident admitted with pressure ulcer/wounds or not. Interview with the previous DON via phone was attempted on 03/18/22 at 3:15 p.m. a message left but no return call was received. Interview with LVN C on 03/18/22 at 8:35 a.m. revealed she was an agency nurse and the charge nurse providing care for Resident #1 on 03/13/22 from 6:00 a.m. to 6:00 p.m. She stated she did not provide any wound care for the resident on 03/13/22 because someone told her the TN was on duty and she assumed the TN would provide wound care. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Right heel- cleanse with normal saline/wound cleanser, pat dry, apply [MEDICATION(S)] and leave open to air daily. Left and right first toe- cleanse with normal saline/wound cleanser, pat dry, apply [MEDICATION(S)], leave open to air daily. Resident #1's Treatment Administration Records dated March 2022 reflected wound care was not provided on 03/13/22 for the residents left heel, right heel, and left and right first toes. Interview with the DON on 03/18/22 at 12:30 p.m. revealed she became aware on Monday 03/14/22, of Resident #1's wound care being omitted on Sunday 03/13/22. She stated she sent the TN to assess the resident and provide wound care on Monday 03/14/22, and in-service training had been provided to nurses about never assuming the TN was on duty or would be completing wound care. Resident #1's closed clinical records reflected the WCP managed the resident's wounds weekly, and treatments included surgical debridement to remove necrotic tissue. WCP notes/assessment dated [DATE] reflected the resident's left heel, right and left buttock wounds were improving due to decreased necrotic tissue. There was no evidence the wounds were restaged after debridement. Review of hospital records revealed Resident #1 discharged and transferred to the facility on ,d+[DATE]. There was no evidence of pressure ulcers upon discharge from the hospital. Interview with the DON on 03/18/22 at 1:09 p.m. and 2:50 p.m. about nurses following physician ordered wound care and her expectations related to admission wound/skin assessments. She stated it was important to provide wound care as ordered by the physician. She stated nurses should assess/inspect every inch of a resident's skin on admission and if a wound or impaired skin integrity was noted a full assessment of what the nurse saw should be documented to include the location, color, and any odor. The DON further stated the physician should be notified for wound care orders because if orders were not obtained and/or wound care not provided according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's P/P related to wound care orders and skin/wound assessments was requested on 03/18/22. The facility's procedure entitled Wound Care revised December 2011 was provided by the DON on 03/18/22. The procedure reflected the purpose was to provide guidelines for the care of wounds to promote healing. The procedure addressed the steps for providing wound care to include verifying there were physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/18/22 the DON provided the facility's procedure entitled Admission assessment and Follow Up: Role of the Nurse revised September 2012. The procedure reflected steps included conducting an admission assessment (history and physical), including a skin assessment, contacting the physician to communicate and review the findings of the initial assessment, obtaining admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No requested policies were provided. Review of the National Pressure Ulcer Advisory Panel's Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Skin and tissue assessments are important in pressure ulcer prevention, classification, diagnosis, and treatment. Documenting the findings of all comprehensive skin assessments is essential for monitoring the progress of the individual and aiding in communication between professionals.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #1, and #2) of 3 residents reviewed for quality of care. The facility failed to initiate Resident #1's monitoring for side effects related to anticoagulation medication until 8 days after receiving the medication. The facility failed to initiate Resident #2 's monitoring for side effects related to anticoagulation medication until 8 days after receiving the medication. An Immediate Jeopardy (IJ) was identified on 01/27/22 at 3:30 p.m. While the IJ was removed on 01/29/22, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of delays in treatment and care which could result in life-threating infection, which could manifest into other health complications, and death. Findings included: Review of Resident #1's undated electronic clinical record revealed the resident was a [AGE] year old female admitted to the facility on [DATE]. Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 01/16/22, reflected Resident #1 had received anticoagulant medication, required setup help with dressing/hygiene, one-person physical assistance with transfers/ambulation, was independent in eating and always incontinent of bowel and bladder. The resident's BIMS score was 5 indicating cognitive impairment. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Plan of Care, dated 01/21/22, reflected goal and intervention to observe, document, report to MD as needed signs and symptoms of anticoagulant complications: blood, tinged or flank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headache, bruising, shortness of breath, sudden changes in mental status, and vital signs. Review of Resident # 1's Medication Administration Records, for January 2022, reflected Resident #1 had been receiving [MEDICATION(S)] 5000 unit/ml 1ml subcutaneously every 8 hours for anticoagulant since 01/11/22. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 01/27/22 of Resident #1 at 1:00 p.m. revealed the resident in her bed, comfortable, well dressed, completing her lunch meal. When the resident was asked how she was doing, she smiled with no reply. Review of Resident #2's undated electronic Admission record revealed the resident was a [AGE] year old female admitted to the facility on [DATE]. Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated 01/16/22, reflected Resident #2 had received anticoagulant medication, required setup help with dressing/hygiene, one-person physical assistance with transfers/ambulation, was independent in eating and always incontinent of bowel and bladder. The resident's BIMS score was a 5 indicating cognitive impairment. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 2's Plan of Care, dated 01/22/22, reflected no goals and interventions for anticoagulation ([MEDICATION(S)]) usage. Review of Resident # 2's Medication Administration Records, for January 2022, reflected Resident #2 had been receiving [MEDICATION(S)] 5000 unit/ml 1ml subcutaneously two times a day for anticoagulant since 01/20/22. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 01/27/22 at 1:20 p.m. revealed Resident #2 sitting up in her wheelchair with a hospital gown on. The resident was noted to have ecchymosis (bruising) areas on both arms. Interview on 01/27/22 at 6:00 p.m. with LVN C revealed she was an agency nurse. LVN C said that anticoagulants, such as [MEDICATION(S)], were given, there should be a stop date, unless the physician had clarified otherwise and that should be documented in the clinical record. LVN C was asked if she had taken care of Resident #27, Resident #1, or Resident #2, and the LVN said she had worked with Resident #1 and recalled giving her [MEDICATION(S)] injections but recalled there was a stop date. When the LVN was asked where they document the monitoring she said, in the progress notes. Interview on 01/27/22 at 6:15 p.m. with LVN D revealed he was an agency nurse that had worked for the facility for about two months. LVN D said if he had just been in-serviced on anticoagulant medications. LVN D said if an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LVN was asked where he would document his monitoring, abnormal bruising and/or bleeding from nose, gums, blood in urine or stool Q shift, he said there was a box that would pop up to remind them that they must document in the MAR. During this interview there was an agency nurse that was taking over the shift for LVN D and this LVN G was asked what she would do if she had a resident in the facility that was on anticoagulants, and she said, What he said pointing at LVN D. Interview on 01/27/22 at 6:20 p.m. with LVN E, she said she was an agency nurse and she had worked on Hall 400 before but did not know Resident #27. The LVN said she would need to know about the medication and what the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN E said the nurse who took the order should be getting that information. When LVN E was asked what she would do if she did not have a stop date, she said she would not give the medication until she followed up with the physician, then she would document it. The LVN was ask what would she monitor for, she said bleeding. The LVN was asked where she would document her monitoring and she said in the progress notes. Review of the list dated 01/28/22 of residents receiving anticoagulant medications, that was provided by the facility reflected that 9 residents were identified that required the physician to order monitoring for anticoagulants medications. Interview on 01/28/22 at 3:43 p.m. with the COO revealed the facility had identified during an audit that there were 10 residents that had been identified that required orders for monitoring for side effect for the anticoagulant medications, they were receiving. According to prescribing information from the packet insert provided by the pharmacy for [MEDICATION(S)] Injectable accessed on 01/27/22, reflected patients who were on Low-dose Prophylaxis of Postoperative [CONDITION(S)] 5.000 units every 8-12 hours thereafter for 7 days or until the patient is fully ambulatory, whichever is longer Bleeding is the most common side effect The facility's policy/procedure Medication Therapy, revised April2007 and identified as current by the COO reflected .each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks .all medications orders will be supported by appropriate care processes and practices All decisions related to medications shall include appropriate elements of the care process, such as: a. adequately detailed assessments; b. review of causes of symptoms; periodically , and when circumstances are present that represent a greater risk for medication-related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences The DON, Administrator and the COO were notified on 01/27/22 at 3:30 p.m. that an Immediate Jeopardy was identified on 01/27/22. The IJ template was provided and the facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 01/28/22 at 6:30 p.m. and reflected the following: What corrective actions have been implemented for the identified residents? 1. The following action items were implemented immediately on 1/27/22. a. Resident #1 (EP) record was reviewed by Clinical Services Director, and [MEDICATION(S)] was discontinued on 1/27/22 at 2:18 p.m In further reviewing the patient's chart with the patient's attending physician, prescribed the [MEDICATION(S)] to continue on 1/28/22 until the patient discharges due to patients current clinical condition. Attending MD stated in this review to continue with the monitoring measures that were in place for resident EP since the patient admitted on [DATE] with the order reading 'Monitor resident for abnormal bruising and/or bleeding from nose, gums, blood in urine or stool Q Shift'. b. The resident was assessed by the unit manager, and no adverse effects to resident were noted and assessment summary is noted in patient's progress note. c. All resident's orders were reviewed by DON on 1/27/22 to identify other residents receiving Anticoagulant medications. Clinical Services Director, and Unit Mangers, contacted the MD for each resident on an anticoagulant medication to request a stop date and monitoring orders. Conversation with the MD was documented in the resident progress notes and monitoring orders were imputed if applicable. Results: Physicians added Monitoring orders on 9 patients per facilities request who have orders for Anticoagulant medications. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. An in-service was initiated on 1/27/22, by the Clinical Services Director, with the DON, and unit managers, on reviewing the order listing report and progress notes to ensure that any new orders for anticoagulant medications for current or new residents have documentation in the progress note of the physician being notified and requested a stop date and monitor orders. If follow up is needed due to not being able to reach MD then nurse manager will contact facility medical director, to request stop date and monitoring orders. b. An immediate in-service was initiated by the Clinical Services Director, DON, and Unit Mangers, on 1/27/22, with all charge nurses on identifying new orders for Anticoagulants for current or newly admitted residents. The in-service included contacting the physician to request stop dates for anticoagulants and monitoring orders. Charge nurse will verbalize summary of education to educator and sign the in-service for understanding. Licensed nurses will need to complete this education in person or via phone prior to the start of their next shift. Facility will contact all licensed nurses by 1/29/22. Nurses that are unable to come to the facility by 1/29/22 will be educated via phone by the DON and witnessed by Clinical services director. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return by DON or Unit Manager before start of their scheduled shift. Agency nurses will be in-serviced by the DON or Unit Manger prior to the start of their shift. c. The facility DON, RN or Unit Managers will in-service new hires during orientation, on identifying anticoagulants that require monitoring. The in-service will include requesting stop dates for anticoagulants and monitoring orders. How will the system be monitored to ensure compliance? a. The DON, and /or unit managers, or designee will review all new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The DON, and /or unit managers, or designee will round on patients with Anticoagulant medications to follow up that monitoring orders in place are being followed. c. Staffing Coordinator, Unit manager, or designee will review the schedule on a daily basis to ensure that all nurses have received the education on identifying Anticoagulant medications to ensure monitoring orders and stop dates are in place when applicable. Discrepancies noted during reviews will be immediately corrected and reported to the Quality Assurance and Performance Improvement Committee. d. The DON/designee will review all new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . e. Administrator will review the audit reports and round on patients who are on anticoagulant medications a minimum of five days a week to ensure nurse managers are following the plan of correction until compliance has been meet. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 1/27/22 with the Quality Program Director. The Quality Program Director has reviewed and agrees with this plan. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews conducted with 25 nurses; 19 LVNs: LVN A, LVN D, LVN F, LVN H, LVN I ,LVN J, LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, LVN S, LVN T, LVN U, LVN V, 1 RN W, and 6 agency nurses: LVN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, across multiple shifts 01/28/22 6:00 a.m. to 6:00 p.m. and 01/29/22 from 5:00 a.m. until 6:00 p.m., revealed the nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on contacting the physician and verifying new orders for anticoagulant medications. They stated they were instructed to call the physician or nurse practitioner and verify the anticoagulant medications and a stop date, with clarification for labs and guidance on what symptoms to monitor for. The nurses were aware of the information book with information on anticoagulant for each medication and that the book was located at each nurse's station. The Unit managers were able to verbalize their role in follow-up for new admission and new orders, they are to check each day and follow-up checking the orders, documentation for stop date, and monitoring for the side effects that the physician had indicated. The Unit managers were able to verbalize that they had assigned areas that they were to round on to see the residents on anticoagulants. When the Unit managers were asked where they would receive the information for new admission and new orders for resident on anticoagulants, they were able to verbalize the new order listing report. Review of the in-service training records, dated 01/27/22 and 01/29/22, revealed staff received training related to admission/new orders for anticoagulant medications and verification of medications. The charge nurse was to contact the physician to request a stop date and monitoring. The charge nurse was to document the physician response and if unable to reach the physician, report to oncoming nurse the for follow-up with physician. Tasks not completed in the admission or new orders should be reported and handed off to the oncoming shift for completion. The Chief Operating Officer and Clinical Service Director were notified on 01/29/22 at 8:30 a.m. the Immediate Jeopardy was removed. While the IJ was removed on 01/29/22, the facility remained out of compliance at the severity level of actual harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed for quality of care. Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to initiate and administer Resident #1's physician ordered IV antibiotic therapy three times daily to treat an infection for more than 40 hours after admission. The facility failed to administer Resident #1's physician ordered medications to treat [CONDITION(S)] for more than 36 hours after admission and medications to treat hypertension for more than 48 hours after admission. The facility failed to provide Resident #1 with consistent PICC line flushes resulting in the need for placement of a new PICC line on 10/12/21 and administered flushes without orders. An Immediate Jeopardy (IJ) was identified on 10/09/21 at 6:10 p.m. While the IJ was removed on 10/16/21, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of delays in treatment and care which could result in life-threating infection, which could manifest into other health complications, pain, amputation, and death. Findings included: Review of Resident #1's undated electronic Admission record revealed the resident was a [AGE] year old male admitted to the facility on [DATE]. Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] reflected the resident required setup help with dressing/hygiene, one-person physical assistance with transfers/ambulation, was independent in eating and always continent of bowel and bladder. The resident's BIMS score was 15 indicating cognition was intact. Review of Resident#1's progress notes dated 10/12/21 reflect the resident's PICC line was replaced during the night shift. Interview with Resident #1 and family on 10/13/21 at 5:26 p.m. revealed they were concerned the resident's condition would digress and he might require amputation. They stated Resident #1 admitted from the hospital to the facility on Saturday evening 10/09/21, for IV antibiotic therapy and physical therapy. They stated in the hospital the resident was facing amputation of the right foot until the physician decided to try aggressive treatment to include scrapping to remove the infection and gangrene. The physician told them the resident's wound was improved prior to discharge to the facility. They stated they were told at the hospital the IV antibiotic should be started immediately. When the resident arrived at the facility, he did not receive any medications to include medications to treat [CONDITION(S)] and hypertension until Monday 10/11/21, and it was 72 hours before the resident received the IV antibiotic. They stated the PICC line was only flushed at the family's insistence once on Sunday and once again on Monday before becoming clogged and had to be replaced. They further stated on Monday 10/11/21, facility staff admitted the resident's delay in receiving PICC line care and medications was because the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 stated he felt as if he was in a mental fog and not thinking clearly due to missing so many doses of his [CONDITION(S)] medication. Observation and interview on 10/14/21 at 3:18 p.m. revealed Resident #1, was sitting on his bedside with an antibiotic infusing via a Midline IV line in the left upper arm. The resident stated when he arrived at the facility Saturday evening (10/09/21) facility staff were not able to provide him with any information related to his medications. He stated he had been feeling mixed up in the head and was not sure if he received medications late Sunday night. The resident's sister was on the phone and confirmed the resident was not as mentally clear as usual due to not receiving his [CONDITION(S)] medication. She stated she had been communicating with facility staff and the resident did not receive any medications until Monday (10/11/21). Review of hospital records revealed Resident #1 admitted [DATE] to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital course of treatment included antibiotic therapy, surgical incision and drainage with deep debridement. Review of Resident #1's undated hospital discharge summary with a print date of 10/09/21 revealed discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge summary reflected discharge medications included [MEDICATION(S)] (treats diabetes) 500 milligrams orally two time a day, [MEDICATION(S)] (treats diabetes) inject 1.8 milligrams daily, [MEDICATION(S)] (treats [CONDITION(S)]) 25-100 milligrams orally one tablet three times daily, [MEDICATION(S)] (lowers cholesterol) 40 milligrams orally at bedtime, [MEDICATION(S)] (treats high blood pressure) 10 milligrams orally every day, [MEDICATION(S)] (treats high blood pressure) 25 milligrams orally two times daily, and the antibiotic [MEDICATION(S)] 2 grams in 50 ML of dextrose, iso-os every eight hours IV. Interview and record review of a two-page undated document entitled chart review with a print date of 10/09/21. The CN stated the document was Resident #1's hospital discharge orders and stated the medications listed on the discharge summary were not the discharge medications. Review of the document revealed medications to include: [MEDICATION(S)] (treats [CONDITION(S)] 25-100 milligrams orally one tablet three times daily, [MEDICATION(S)] (lowers cholesterol) 40 milligrams orally at bedtime, [MEDICATION(S)] (treats high blood pressure) 10 milligrams orally every day, [MEDICATION(S)] (treats high blood pressure) 25 milligrams orally two times daily [MEDICATION(S)] (an antibiotic) 2 grams in 50 ML of dextrose, iso-os every eight hours IV. There was no [MEDICATION(S)] or [MEDICATION(S)] listed on the document. Review of Resident #1's facility admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional orders dated 10/11/21 included the antidiabetic medication [MEDICATION(S)]. Review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation of the PICC line being flushed until Monday (10/11/21) at 8:00 p.m. The initial dose of antibiotic was administered on Monday (10/11/21) at 3:00 p.m. The medication [MEDICATION(S)] was not administered until Monday (10/11/21) at 11:30 a.m. The medication [MEDICATION(S)] was not administered until Monday (10/11/21) at 4:00 p.m. The medication [MEDICATION(S)] was not administered until Tuesday (10/12/21) at 8:00 a.m. Interview with LVN D on 10/15/21 at 7:45 p.m. revealed she was an agency nurse and was assigned to provide care for Resident #1 on Saturday 10/09/21 and Monday 10/11/21 during the night shifts. She stated on Saturday the resident stated he needed his IV antibiotic started and voiced concerns of not wanting to lose his leg. She stated she did not administer any medication during her shift on Saturday because the medications including the antibiotic had not been delivered and she did not flush the PICC line because were not orders to flush the line. She stated on Monday she provided the night dose of the antibiotic and when she flushed the PICC line there was resistance. The IV antibiotic took over two hours to infuse and orders were received to replace the line. However, the resident declined at that time. LVN D stated she did not receive a full orientation or training prior to working at the facility. She stated she basically received a rundown of the halls she was assigned to work. She further stated if she needed help, she would ask another nurse and hopefully there would be a facility nurse available and not another agency nurse who had no more orientation than she did. Interviews with LVN E on 10/16/21 at 10:23 a.m. and 11:52 a.m. revealed she was the only facility nurse who worked weekends. She stated she was assigned to provide care for Resident #1 on Sunday (10/10/21) during the 6:00 a.m. to 6:00 p.m. shift. She stated she did not provide any medications to the resident because there was something wrong with the orders, they were incomplete and pending in the computer. She stated, It was a mess. She stated there were no medications to include the IV antibiotic available to administer. According to LVN E she flushed the resident's PICC line without difficulty, and it was patent. She communicated with Resident #1's physician related to Resident #1's medication orders. She stated by the time she left work none of the resident's medications had been delivered and the orders had not been verified by the physician. Interview with the DON on 10/14/21 at 10:45 a.m. revealed there had been an issue during the past weekend with a resident who admitted on Saturday (10/09/21). The DON identified the resident as Resident #1 and stated the agency nurse (LVN G) on duty put admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated there was normally a weekend manager on duty, but the manager was off. She stated she had started to train a facility nurse on each shift a few weeks ago on the admission process and how to audit to ensure all admissions were completed correctly. The DON did not have any evidence of the training to provide. She further stated UM A was on call during the weekend and had more information about what occurred with Resident #1. Interview with UM A on 10/14/21 at 11:23 a.m. revealed she communicated with Resident #1' s family on Sunday 10/10/21 to address their concern of wanting to know what the resident's blood glucose results were and if the resident was receiving medications. According to UM A Resident #1 told staff (unable to recall what staff) he would take his own medications until facility medications arrived from the pharmacy. She stated the admitting nurse (LVN G) should have called and/or texted the physician to verify orders and inform the physician the resident had arrived. The policy/process was for the nurse to fax the orders or send the orders to the pharmacy via the computer. When the orders are sent via the computer the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was not aware the medications had not been put into the computer correctly, just that they had not arrived. Interview with NP on 10/15/21 at 12:30 p.m. and 10/18/21 at 5:55 p.m. revealed neither she nor the physician had received any notification of Resident #1's arrival to the facility. The NP stated she became aware of Resident #1's admission to the facility when she arrived at the facility on Monday 10/11/21 to make rounds. When she printed the patient list, she saw a new patient, Resident #1 was listed. She stated facility nurses should have contacted her or the physician to verify the resident's orders to include medications. She stated antibiotic therapy should have been started immediately and a missed dose was not good. Additionally, she stated possible consequences of not starting the antibiotic was the infection could build up and get worse. The faster the antibiotic is started, and missed doses added to the end should be ok. She further stated any medications missed over time could cause symptoms the medications were treating to return depending on how long the medication stays in the system. Interview with UM B on 10/14/21 at 12:36 p.m. revealed she was the UM B for Hall 400 where Resident #1 resided. She stated she was not aware of any new admission arriving on Saturday (10/09/21). When she arrived to work on Monday (10/11/21) she was informed by one of the physicians there was a resident with a lot of complaints. She immediately went to Resident #1's room and was informed of concerns with the resident's medications. She stated she discovered the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She made sure the orders were input correctly, medications were ordered, and she completed the admission assessment. She stated she checked the emergency medication kit, but the medications and the antibiotic Resident #1 needed was not available. UM B further stated, Resident #1's family told her to be sure the resident's PICC line was flushed and she obtained and provided the flush solution to the charge nurse on duty. Additionally, UM B stated the resident received the first dose of IV antibiotic on Monday. However, the medication was infusing slowly, and orders were received to place a new IV access. Interview with LVN C on 10/14/21 at 1:30 p.m. revealed she provided care for Resident #1 on Monday (10/11/21) during the day shift and the resident's medications had not been delivered. Resident #1 had some of his own medications, some were in medication bottles and some were in a med-[NAME] case. LVN C stated she administered medications for the resident during her shift using the personal medications from the bottles and from the med-[NAME] case. She used her phone and a pill identifier website to identify the medications in the med-[NAME] case. She stated she flushed the resident's PICC line during her shift with a prefilled syringe of 10 milliliters of normal saline even though there were no orders for PICC line flushes. Additionally, LVN C stated Resident #1 was very anxious due to whatever occurred during the weekend. Interview with the DON on 10/15/21 at 1:10 p.m. revealed agency nurses had not been trained over the facility's processes to include inputting orders into the computer and admitting new residents. She stated training was not provided, because the previous management team had not provided the training and she was in the process of training and hiring facility nurses to ensure there would be a trained facility nurse on duty at all times to perform audits of new admissions. Interview with DON on 10/16/21 at 9:55 a.m. she stated the nurse on duty Sunday administered some of Resident #1's medications from his personnel supply. Interview with LVN F on 10/16/21 at 1:23 p.m. revealed he was the agency nurse assigned to provide care for Resident #1 on Monday (10/11/21) during the 2:00 p.m. to 10:00 p.m. shift. He stated he administered the first dose of the resident's IV antibiotic Monday evening. When he flushed the resident's PICC line he noticed it was somewhat sluggish and the IV antibiotic infused slowly. Orders were received to have the IV line replaced and the IV tech arrived to replace it prior to the end of his shift. He further stated he administered some evening medications from the resident's personal medications and signed them off on the MAR. He stated he had not been trained by the facility on the use of the computer program but was familiar with the program from working at other facilities. Interview with the CN on 10/16/21 at 8:15 p.m. revealed there were no procedures to address the usage of the facility's computer system in the admission process or for inputting orders into the computer system. According to www.pdr.net accessed on 10/21/21, Patients who reduce or stop the anti-[CONDITION(S)] medication [MEDICATION(S)] can potentially develop a syndrome that causes symptoms of fever, muscle rigidity and altered mental status changes. Abrupt discontinuation should be avoided. The facility's policy/procedure Central Venous and Midline Catheter Flushing, dated revised 04/2016 and identified as current by the DON reflected the purpose was to maintain patency of the midline and central catheters, prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication was administered into the venous system. The facility's policy/procedure to address nursing responsibilities for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON provided the facility's policy Physician Medication Orders, dated revised 04/2016 and identified it as current by the DON. , the policy revealed paper and written orders were addressed but not the input of orders into the computer. No procedure was provided related to inputting orders or the facility's computer system. The facility's policy Admissions Policies, dated revised 12/2006 and identified as current by the DON. reflected written policies and procedures governing admissions to the facility would be maintained on a current basis to ensure fair and impartial admission practices. The primary purpose of the admission policies was to establish uniform guidelines for personnel to follow in admitting residents to the facility. There was no procedure of how to perform an admission to include usage of the facility's computer system in the admission process. The DON and the CN were notified on 10/15/21 at 6:10 p.m. that an Immediate Jeopardy was identified on 10/15/21. The IJ template was provided and the facility was asked to provide a Plan of Removal to address the immediate Jeopardy. The Facility's Plan of Removal was accepted on 10/16/21 at 10:47 a.m. and reflected the following: What corrective actions have been implemented for the identified residents? 1. The following action items were implemented immediately on 10/11/21. a. Resident #1 (AC) record was reviewed, and medications were entered into PCC. b. Residents medications were administered from resident's personal supply that resident brought with him. c. No adverse effects were noted. d. Wound vac was placed on 10/12/21 when order was received from primary physician. e. The following action items were implemented immediately on 10/15/21. f. All admissions since 10/9/21, were audited for accurate transcription of orders and availability of medications/treatments. Were any discrepancies found? How were other residents at risk to be affected by this deficient practice identified? 1. All Newly and readmitted residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. All resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. An in-service was initiated on 10/15/21, by the CSD with the DON and nurse managers on admission process, ordering and entering medications into the electronic record and medication/treatment availability. Licensed nurses will not be allowed to work until they complete this in-service. c. An immediate in-service was initiated on 10/15/21, with all charge nurses on admission process, ordering and entering medications into the electronic record and medication/treatment availability. d. An in-service binder will be developed to be reviewed by each new agency nurse, prior to beginning shift, on admission process, ordering and entering medications/treatments into the electronic record, ordering medications from pharmacy and medication/treatment availability via in person or telephone. e. The facility will in-service new hires during orientation, on admission process, ordering and entering medications into the electronic record and medication/treatment availability. New hires will not be allowed to work until this education is completed. How will the system be monitored to ensure compliance? a. The DON/designee will review all new admission records to ensure accurate order transcription into the electronic record and medication/treatment availability daily for 6 weeks. b. Discrepancies noted during reviews will be immediately corrected and reported to the Quality Assurance and Performance Improvement Committee. c. The Administrator/designee will audit the admission reviews, review of transcription and medication/treatment availability 2x week X 6 weeks. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 10/15/21 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Interviews conducted with 8 LVNs (7 agency and one facility nursing staff) across multiple shifts on 10/16/21 from 2:04 p.m. to 3:55 p.m. revealed the nurses were able to verbalize comprehension of the in-service training provided. They stated they had been in-serviced on contacting the physician or NP and verifying new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated they were instructed to call the pharmacy to follow-up to ensure orders were received. The nurses were aware of the procedural book with step-by-step instructions for entering orders into the computer and that the book was located at each nurse's station. Review of the in-service training records dated 10/15/21 and 10/16/21 revealed staff received training related to admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tasks not completed in the admission should be reported and handed off to the oncoming shift for completion. New after hour orders entered in the computer system will be verified by pharmacy. A notebook developed for staff included step-by-step instructions for inputting orders into the computer system and included a licensed nurse reference guideline for admitting a resident to include required assessments to complete and admission checklist. The Corporate Nurse was notified on 10/16/21 at 4:30 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 10/16/21, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.