Every finding on record at Misty Willow Healthcare and Rehabilitation Center

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the resident's comprehensive assessment for 1 closed record (CR #1) and 3 of 3 residents reviewed for quality of care.The facility failed to seek medical guidance or report a fall that resulted in injury, including pain, swelling and a broken femur, to CR #1 for approximately 3-days.The facility nurse failed to assess CR #1 after a fall. On 03/06/2026 at 06:38 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/08/2026 12:46 p.m. the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.These failures could place residents at risk or delay of appropriate medical treatment leading to pain, discomfort, and death.This was determined to be an IJ on 03/06/226 at 6:38 p.m. Administrator (ADM) and director of nursing (DON) were notified. The ADM was provided and signed the IJ template on 03/06/2026 at 06:42 p.m. Findings included: Record review of CR #1's face sheet dated 05/21/2025 reflected CR #1 was a [AGE] year-old female, admitted on [DATE] and discharged on 02/16/2026. CR #1's diagnoses included hypertension (high blood pressure, a chronic condition where blood force against artery walls is consistently too high), type 2 diabetes mellitus without complications (indicates a diagnosis of chronic high blood sugar where the condition has not yet caused damage to organs, nerves, or blood vessels), anemia (occurs when there is not enough hemoglobin, or there are not enough red blood cells), unspecified fall, hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke: issue death (necrosis) in the brain caused by blocked blood flow) affecting left non-dominant side, nontraumatic intracerebral hemorrhage in hemisphere (fetal stroke), cognitive communication deficit (an impairment in communication-verbal or non-verbal-resulting from underlying cognitive issues rather than primary language or speech deficits), muscle weakness, muscle wasting and atrophy, other lack of coordination, morbid (severe) obesity due to excess calories. Record review of CR #1's discharge Minimum Data Set (MDS) dated [DATE] reflected CR #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating CR #1 was cognitively intact. The MDS indicated in section GG: functional abilities/mobile devices; wheelchair for mobility CR #1 required the following:Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk and limbs and provides more than half the effort.Sit to lying: The ability to move from sitting onside of bed to lying flat on the bed. Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds truck and limbs and provides more than half the effort.Laying to sitting on side of bed: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk and limbs and provides more than half the effort.Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair or on the side of the bed. Dependent - Helper does all of the effort. Resident did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity.Chair/Bed-to-chair transfer: The ability to transfer to and from a bed to a chair (wheelchair). Dependent - Helper does all of the effort. Resident did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity.Section - Active Diagnoses: Stroke Record review of CR #1's undated Care Plan reflected she had left sided hemiplegia/hemiparesis related to (r/t) hemorrhage, stroke date created and initiated: 09/13/2024, hypertension r/t stroke date initiated and created 09/13/2024, she may use mobility bar(s) to roll side to side or scoot up in the bed. Date initiated/created on: 09/19/2025, she was at risk for impaired cognitive function/dementia or impaired thought processes date initiated/created 09/04/2024 and revised on 09/11/2024, she had assistance with daily living (ADL) self-care performance deficit r/t left hemiplegia, morbid obesity date initiated/created: 09/04/2024 and revision on 12/10/2025, she was at risk for falls r/t weakness, hemiplegia and hemiplegia and hemiparesis following cerebral infarction affecting left side date initiated and created 09/04/2024. Record review of CR #1's progress notes dated 02/13/26 at 08:58 a.m. reflected CR #1 was prescribed as needed (PRN) acetaminophen for general discomfort pain. Record review of CR #1's progress notes dated 02/13/26 at 04:14 a.m., reflected CR #1 received PRN acetaminophen for headache, pain scale 0. Record review of CR #1's incident report dated 02/15/2026 at 11:24 a.m., reflected CR #1 was alert in bed in a supine position alleging a fall a few days ago. The incident report reflected CR #1 was unable to give a specific day and indicated there were no witnesses. Record review of CR #1's progress notes dated 02/16/2026 at 10:30 a.m. reflected CR #1's skin was checked finding her skin warm and dry, skin color within normal limits (WNL) and turgor was normal. CR #1 refused to turn- unable to evaluate posterior. CR #1 transferred to hospital with acetaminophen administered. Record review of CR #1's progress notes dated 02/16/2026 at 12:07 a.m., reflected CR #1 received PRN acetaminophen for headache. Record review of CR #1's progress notes dated 02/16/2026 at 12:17 p.m., reflected CR #1 had a change of condition reporting new or worsening pain, pain scale 9. Record review of CR #1's progress notes, dated 02/16/26 at 02:09 p.m. reflected CR #1 had leg pain. Progress notes reflected CR #1's left leg was swollen and painful to touch with a pain level of 9 in the left leg. Medicated and assessed by assistant director of nursing (ADON), DON, and medical doctor (MD) made aware and ordered to send CR #1 out by way of (via) 911. Further review of CR #1's progress notes for 02/13/2026 to 01/16/2026 revealed no documentation related to a fall. Record review of facility's disciplinary actions dated 02/16/2026, reflected certified nursing assistant (CNA) A and CNA B were terminated for failure to report a fall to the charge nurse and licensed vocational nurse (LVN) A was terminated for failure to assess CR #1 after the fall and report the fall to DON. Record review of complaint received to Health and Human Services dated 02/18/2026 reflected CR #1 fell on [DATE], while the CR #1 was being transferred from her bed to the wheelchair and in the process the resident's leg was stuck under the bed. On 02/16/2026 that resident was sent out to higher level care hospital, the resident was diagnosed with a left femur fracture. The facility staff reported the reason it took a few days to have the resident sent out was because the resident had not vocalized pain nor was any swelling noted. The family was not made away from the fall until 02/16/2026 at time of transfer to the hospital. As of 02/18/2026, the resident was awaiting surgery to correct the fracture. No copy of an incident report was provided or received as of 02/18/2026. Record review of CR #1's 02/2026 medication administration record (MAR) reflected resident was ordered Acetaminophen tablet 325 milligram (mg) to be given two-tablets by mouth every six-hours PRN for general discomfort pain as of order date 08/30/2024. For monitoring and assessed level of pain using the 0 - 10 scale: 0=no pain, 1-3=mild pain, 4- 6= moderate pain, 7-10=severe pain every shift - order date 08/29/2024. On 02/14/2026 at 08:58 a.m. CR #1 received medication and reported a 4-pain level. On 02/15/2026 CR #1 had a 0-pain level. On 02/16/2026 at 12:07 p.m. CR #1 received medication and reported a 10-pain level. Interview with CR #1 on 02/19/2026 at 05:40 p.m. CR #1 stated she fell but could not recall the exact day or time but thought it was after dinner on 02/14/2026. She stated CNA A and CNA B tried transferring her from the wheelchair into her bed. She stated her leg slipped forward, and she heard a crack sound, and the CNAs lowered her to the floor. She stated while on the floor the CNAs immediately tried to pick her up and put her onto the bed, but her leg got caught under the wheelchair and she told the CNAs to wait and back up the wheelchair first. She stated the CNAs had a hard time getting her up and her leg then got caught under the bed. She stated she heard one of the CNAs say, Obviously we're not strong enough she stated referring to the lack of strength the CNAs had to get the resident off the floor. She stated that the CNAs had not attempted to notify a nurse nor had a nurse come to assess her for pain or injuries. She stated that she was hollering and crying when the CNAs attempted to get her off the floor due to pain from the fall. She stated the evening of 02/14/2026 she had a hard time sleeping and she tossed and turned from her discomfort. She stated she had not reported the discomfort to the evening staff even though her pain level was at 9 and she cried replaying the incident in her mind all evening. She stated during breakfast 02/15/2026 she received Tylenol because she told the nurse she had pain in her back and lower tailbone and then pain to the upper part of her left leg due to the fall. She stated once she received the pain medication, she was able to sleep and the following day 02/16/2026 she told her CNA she needed more Tylenol and then the ADON came to assess her and the facility called 911 and sent her to the hospital. She stated at the hospital she learned she had a fractured left leg and on 02/17/2027 she had surgery. She stated that she had a roommate, but she could not recall if Resident #1 was on her side of the room nearest the window when the fall occurred. During an interview on 02/19/2026 at 09:47 a.m., the DON stated she learned on 02/16/2026 that CR #1 fell on [DATE] when CNA A and CNA B were transferring the resident from her wheelchair to the bed. She stated she learned that the resident's leg slipped and her foot moved forward from under her and two CNAs lowered the resident to the floor and contacted LVN A to come assess CR #1. She stated LVN A came to assist the resident finding no injuries or pain and the resident voiced that she had no pain and was fine to transfer back to the bed. She stated thereafter the CNAs assisted the resident back to the bed with no further issues or complaints from the resident as a result of the fall. She stated on 02/16/2026, ADON A was informed that CR #1 was having pain and went to assess the resident. She stated ADON A found that the resident had pain in her left extremity (leg) with edema (swelling) and the resident pointed to the top of left leg. She stated that the resident voiced to ADON A had pain resulting from a fall that occurred a couple days ago. She stated ADON A called the resident's physician who agreed to provide the resident with pain medication, X-radiation (x-rays) and transfer the resident from the facility via 911 to obtain a higher level of care at a hospital emergency room (ER). She stated that the family contacted the facility on Monday to understand how the fall had occurred resulting in the CR #1's pain. During an interview on 02/19/2026 at 03:13 p.m., the DON stated that it was the facility's protocol to call the DON whenever there was a fall in the facility whether it was an assisted fall or not. She stated she was not notified that CR #1 fell on [DATE] during a staff assisted transfer. She stated on 02/16/2026, she interviewed CR #1 who stated she fell a couple of days ago but could not recall the exact date or time and provided descriptions of the staff that assisted her. She stated that she began an investigation and learned that CNA A and CNA B had been on shift and worked the hall CR #1 was on and that they were transferring CR #1 on 02/15/2026 when CR fell, resulting CR #1's leg fracture. She stated LVN A had not contacted her about CR #1's fall. She stated she interviewed CNA A and CNA B who both stated that the resident's fall was reported to LVN A. She stated LVN A stated that she had not been made aware that CR #1 had a fall. She stated therefore CR #1's family was not informed of the resident's fall until 02/16/2026. She stated CNA A, CNA B, and LVN A were all terminated. She stated that LVN A had a previous write-up/disciplinary action for failure to notify the DON of a resident's change of condition. She stated on 02/16/2026 the facility's nursing staff received an in-service training on ANE and reporting falls to the DON. She stated she was not made aware CR #1 stated that her leg had gotten caught under the wheelchair and bed. During an interview on 02/20/2026 at 12:12 p.m. CNA A stated she would not provide a statement. During an interview on 02/20/2026 at 12:13 p.m. CNA B stated she started working at the facility on 02/13/2026 on a 2:00 p.m. to 10:00 p.m. shift. CNA B stated on 02/13/2026 at about 6:30 p.m., CNA A asked her to assist with CR #1's wheelchair to bed transfer. She stated she assisted CNA A getting CR #1 out of the wheelchair when the resident started slipping and they slowly lowered CR #1 onto the floor and CNA A went to alert the resident's nurse. She stated they waited for a nurse to come for about 10 minutes, but no one came and CR #1 complained of being cold on the floor. She stated they then got the resident off the floor and into the bed. She stated CR #1 had not verbalized any pain, swelling, nor had the resident cried, or grimaced with pain. She stated she had not seen the resident after that date/time. She stated on 02/16/2026 when she went to work at 2:00 p.m., an ADON informed her the resident was sent out to the hospital with complaints of leg pain as result of the fall and that she would be suspended pending investigation. She stated she had received an ANE in-service training 2-weeks prior that also covered the facility's fall protocol. She stated that the fall protocol required all falls to be reported to the resident's nurse immediately. During an interview on 02/20/2026 at 12:26 p.m. LVN A stated she only worked as needed (PRN) on Saturdays and Sundays from 7:00 a.m. to 7:00 p.m., never any Fridays. LVN A stated on 02/15/2026 at 11:24 a.m. via text ADON A questioned her about CR #1's fall. She stated she told ADON she was not made aware CR #1 fell and ADON A requested she assess CR #1. She stated she attempted to perform a skin and pain assessment on CR #1 on 02/15/2026, about 12:00 p.m., but the CR #1 would not allow her to touch her, denied any pain, and the resident stated to leave her alone, and she stated that the resident had not asked for pain medication. She stated she cared for the CR #1 in the past who was a quiet and pleasant resident who mostly stayed in her room watching television. She stated she was asked to come into the facility on [DATE] and was dismissed/fired for failure to report a fall and contact the resident's physician and family. She stated CR #1 had not had a fall on her shift and had communicated that with ADON A and requested the fall protocol. She stated that ADON A told her that all falls were to be reported to the DON and to notify the resident's physician. She stated she had not had an alleged fall while working for the facility and could not recall when she had a fall in-service training and noted that she had an ANE in-service training on 02/16/2026 by ADON A noting forms of abuse were sexual, financial, emotional, and physical. During an interview on 02/20/2026 at 01:24 p.m. ADON A stated that on 02/16/2026 she interviewed CR #1 who stated she fell a few days ago and the staff picked her up and placed her back into the bed and on that day, the resident stated her leg was hurting. She stated that the DON performed a skin and pain assessment on the resident and found that the resident's leg was warm to touch and swollen. ADON stated CR #1's days were off (she was confused about the days) and the fall took place on 02/15/2026. During an interview on 02/20/2026 at 11:43 a.m. Resident #1 stated she was CR #1's roommate prior to the resident discharging to the ER. She stated that she was not in the room when the CR #1 fell. She stated she could not recall the exact date of time but knew it was sometime over the weekend of 2/13/2026 - 02/15/2026. She stated that the CR #1 was sitting in her bed crying in a curled-up position. She stated she asked CR #1 what was wrong and was told she had a nasty fall a few hours ago and was in pain. She stated the CR #1 laid in the bed whining and whimpering all day. She stated that evening when she received her PRN pain medication, CR #1 asked for some too and received something. She stated a few days later CR #1 was in her bed curled up crying again and said she had fell, but stated the story was different but could not recall details of either story. She stated after the DON spoke to CR #1 on 02/16/2026 about her fall, she asked the DON what was wrong with CR #1. She stated that the DON told her that CR #1 had a fall on 02/15/2026. She stated that Resident had not fallen on 02/15/2026, because Resident had told her a few days prior about fall when she was crying. During an interview on 03/06/2026 at 01:26 p.m. ADM stated he was the facility's abuse coordinator (AC), and it was his expectation that facility staff report all allegations of ANE to him immediately. He stated the facility's investigation found that CR #1's fall occurred on 02/14/26 in the evening after dinner and because the CR #1 was cognitively intact and able to account for the event, and he did not initiate an incident report because of the recount. He stated he and the DON interviewed CR #1 on the morning of 02/16/2026 and CR #1 stated that her pain had begun that morning. He stated CR #1 not verbalized pain to any staff at the time CR #1 indicated she had fell. During an interview on 03/06/26 at 02:31 p.m. ADON A stated that on 02/15/2026, LVN A stated CR #1 told her she fell. ADON stated that LVN A did not feel that was accurate, because no staff had reported a fall to LVN A. ADON A stated she instructed LVN A to assess CR #1 and report the findings to the DON. During an interview on 03/06/2026 at 02:57 p.m. the MD stated the DON called on the morning of 02/16/2026 reporting that CR #1 fell on [DATE]. The MD stated she ordered CR #1 received x-rays, but due to CR #1's pain the DON requested CR #1 be immediately sent out for higher level of care via 911 transport and MD agreed. MD stated sometime between 02/17/2026 and/or 2/18/2026 she and the DON spoke to three members of CR #1's family via telephone who had questions CR #1's fall and how CR #1 could have sustained a femur fracture. MD stated she informed the CR #1's family that CR #1's x-rays results showed CR #1 had deep mineralization the biological process of depositing calcium and phosphate minerals into the collagen matrix of bone, creating a rigid, strong, and dense structure) to the bones in and around the fracture area, noting, due to CR #1's age and condition made the bones brittle and susceptible to fractures. She stated individuals of younger age, who sustained that same fall would not necessarily experience bone fractures. She stated 1 of CR #1's family members noted that CR #1 usually when and if concerns arose, was her own advocate and if CR #1 was not able to handle the concerns would reach out to the family for assistance. MD stated from her understanding, CR #1 had not reached out other her family regarding the assisted fall. MD stated as a result of CR #1's fall, CR #1 could experience immediately, delayed, and/or progressive pain depending on the swelling of CR #1 tissue around her femur bone. During an interview on 03/06/2026 at 05:28 p.m. with ADM and DON, DON stated through the course of the facility's investigation of CR's fall the facility believed that on 02/15/26 after dinner, CNA A and CNA B assisted CR #1 from her wheelchair to bed when CR #1 communicated that she was slipping and the CNAs proceeded based on the fall process to lower CR #1 to the floor in a seated position. The DON stated once on the floor, 1-of the CNAs went to the nursing station to report the fall to a nurse. She stated that neither of the CNAs could identify which nurse CR's fall was reported to. The DON stated on 02/16/2026 ADON B reported to her that CR #1 had pain due to a fall. The DON stated ADON B assessed the CR #1 finding that CR #1 had pain and pointed to her the top area of her left leg. The DON stated that CR stated the pain resulted from a fall that occurred a few days prior when CNAs A and B attempted to transfer from her from the wheelchair to the bed. The DON stated that ADON C contacted MD who ordered x-rays. The DON stated that because of CR's pain, requested MD sent CR #1 to the ER for high level of care due and MD agreed. The DON stated that ADON C contacted the family and informed them of CR #1 anticipated transfer to the hospital. The DON stated later that same day she learned from the hospital liaison that CR #1 sustained a left hip fracture and was awaiting surgery. DON stated that same day, LVN A, CNA A and CNA B were suspended pending an investigation of CR #1's injury. The DON stated 02/17/26 the family telephoned questioning how CR #1 could have sustained a fracture to her hip by simply sitting on the floor and reported they were calling the state to report the incident. The DON stated she add MD to the call with CR #1's family and MD explained due to CR #1's diagnosis of osteoporosis, brittle bones, B-12 deficiency, and muscle weakness CR #1's bones were demineralized causing CR #1's bones to fracture easily. The DON stated on 02/17/26 the facility held a standard of care meeting with the facility's department heads to discuss how to increase awareness as falls and see where the facility could tighten up on delegating tasks, identify issues, and develop a plan resolve. The DON stated at present the process and review of falls was ongoing, and medical doctor was involved in the process. The DON stated on as of this date, the facility completed a complete audit of resident's care plans focusing transfer needs. The DON stated that therapy lead the audit and ensured that every resident had updated interventions on their care plans, but noted that all care plans were updated, none needing updates. She stated on 02/16/2026 and 02/17/2026 the facility staff received in-service training lead by the therapy department on proper body alignment, items needed for transfer, and understanding residents with high fall risk. She further stated that falls is a facility concern not a nursing concern that was to be covered and monitored by all staff from all departments. On 02/19/2026 an investigation initiated and the state investigator provided an Immediate Jeopardy (IJ) Template notification that the regulatory services had determined that the condition at the facility constituted an immediate jeopardy to resident health and safety. The facility failed to seek medical guidance or report a fall that resulted in injury, including pain, swelling and a broken femur, to CR #1 for approximately 3-days. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice. The facility nurse failed to assess Resident #1 after an assisted fall. The following plan of removal was submitted by the facility and was accepted on 03/07/2026 at 02:01 p.m.IJ F684Plan-of-Removal03/07/2026Per the information outlined in the IJ template provided on March 6, 2026, at 6:38 p.m., the facility failed to assess Resident #1 following an assisted fall. The following actions were taken in response:The Medical Director was notified of the IJ on March 6, 2026, by the Executive Director and the Director of Nursing (DON).A necessary or needed (ad hoc) meeting was conducted on March 6, 2026, during which the Head-to-Toe Assessment and Fall Management System policies were reviewed by the Medical Director, DON, and Executive Director. No policy revisions were identified or implemented at that time.Fall Management System education was initiated on March 6, 2026, for nursing staff by the DON, ADON, RN Clinical Resources, and Cluster Nursing RN Leadership. Target completion date: 03/07/2026.On 03/06/26, Clinical RN Resources & Cluster Clinical DON(s), RN(s), conducted and completed facility wide audit for last 30 days Incidents/Accidents/Falls audit. No further findings similar to deficient practice were identified.DON, ADON(s), Clinical RN Resources will conduct and complete assessments for all residents including pain assessment by 03/07/26.All licensed nurses are required to complete education and competency check-offs for Head-to-Toe Assessments, including pain assessments. This process began on March 6, 2026, and is being facilitated by the DON, ADON, RN Clinical Resources, and Cluster Nursing RN Leadership. Target completion date: 03/07/2026.Education and competency validations will be completed in person with all nursing staff by 03/07/2026, prior to the start of their next scheduled shift. A member of the nursing management team will be present at the facility during each shift change to ensure completion. Staff will not be permitted to work on the floor until all training and competency requirements are met. This education will also be incorporated into new hire orientation and completed by PRN staff prior to working independently on the floor. These staff members will likewise not be permitted to work without completion of the required training and knowledge validation.An additional ad hoc meeting addressing the items identified in the IJ template will be held on March 7, 2026. Attendees will include the Medical Director, RN Clinical Resources, Administrator, Director of Nursing, ADON(s), and Cluster Clinical DONs (RNs). This meeting will include a review of the plan for removal and associated interventions.The DON, ADON, or RN Clinical Resources will review and verify completion of a comprehensive head-to-toe assessment, including skin and pain assessments, for all fall incident reports daily. Random Nursing staff post-fall knowledge checks will be conducted three times per week X 01 week, two times per week x 02 weeks, and once a week x 01 week or until substantial compliance has been achieved.Charge Nurse was terminated effective 02/16/26 and CR#1 was transferred to the hospital per Physician Order on 02/16/26. CR#1 has not returned to the facility.A summary of the IJ findings and corrective action plan will be reviewed by the QAPI Committee weekly for four weeks or until substantial compliance is established, and then monthly for 90 days to ensure substantial compliance. The investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an observation on 03/06/2026 at 6:46 p.m. CNA C and CNA D were observed transferring Resident #3 from chair to bed by use of mechanical lift. Resident #3 had a lift pad between him and the wheelchair. CNAs were observed attaching the metal clams to secure the pad to the mechanical lift and used the lift to raise resident out of the chair and repositing the resident over his bed lowing him onto the bed. Once resident was lowered to the bed CNAs removed the pads clamp connectors from the mechanical lift and assisted resident by repositioning him higher into the bed. During an interview on 03/09/2026 at 9:01 a.m. CNA F indicated she would assisted Resident #4 from her bed into a wheelchair. CNA F placed a gait belt around Resident #4's waist, lowered her bed, and brought the resident's wheelchair in the bedside in the a wheel lock positioning. She assisted resident swing her legs off the bed placing them onto the floor. Staff stood in front of the resident. Resident# 4 placed her arms around CNA F's neck as the staff lifted and stood the resident with the gait belt around the waist. CNA F turned resident from the bed and sat her into the wheelchair at bedside. CNA F pulled at the gait belt to repositing the resident higher into the chair until resident stated she was comfortable. CNA F removed the gait belt and stated the transfer was complete. During an interview on 03/06/2026 at 6:20 p.m. CNA C stated she started working for the facility in May of 2025 on the 2:00 p.m. to 10:00 p.m. shifts. She stated on this date she received in-service training that covered resident transfer protocols. She stated that before every transfer she was to review the resident's care plan to check to see if the resident required a 1 or 2 person transfer assistance or a mechanical lift and stated that they were to never transfer residents with a mechanical lift alone. She stated all transfers required for staff use of a gait belt around a resident's waist. She stated the in-services further covered properly aligning the resident's body before, during and after transfer while using a gait belt. She stated she received an in-service on fall preventions which required ensuring resident's call light and other personal needs items of the residents were within reach, noting if the resident has a star on their name tag outside the room, represents a falling star/fall risk, ensure beds were at lowest positing to the floor. She stated that the following were forms of abuse: physical, mental, involuntary seclusion, verbal, sexual, and financial, and closing a door on a resident and not going back to check on them was a form of neglect. She stated that the ADM was the facility's AC who all ANE were reported to verbally not via a text. She stated in the event the ADM was unreachable she would report ANE to the charge nurse on duty, DON and/or social worker (SW). During an interview on 03/06/2026 at 6:29 p.m. CNA D stated she worked for the facility for the last 4-months on the 6 a.m. to 2 p.m. shift. She stated as a CNA she was responsible for ensuring residents were safe during the transfers by ensuring wheelchairs were locked at all times during transfer, gait belt was used, all mechanical lifts required two persons. She stated she received an in-service training on fall preventions that covered: noting star stickers on a resident's name on the door meant the resident was a falling star/fall risk, ensuring call lights and items on bedside table such as water and other personal essentials were within a resident's reach at all times, and bed in lowest position at all times. She stated she also received an in-service training on ANE and noted that the ADM was the facility's AC whose allegations of abuse were reported. She stated if the ADM was unreachable to report ANE she would report to the DON, and/or charge nurse on shift. She noted the following as forms of abuse: physical, verbal, sexual, mental, involuntary seclusion, financial, and stopping a resident from doing what they want to do. During an interview on 03/08/2026 at 12:59 p.m. registered nurse (RN) A stated that she worked for the facility PRN as a charge nurse from 7 a.m. to 7 p.m. She stated on this date; she received in-service training that covered her as a change nurse and her responsibilities to performing physical assessments who had a fall. She stated the in-service covered notification DON, the resident's MD and the resident's responsible party (RP) of a fall. She was responsible for performing and completing a resident's falls assessment, pain assessment, and noting any injuries such as open areas on the skin, signs and symptoms (s/sx) or complaints of pain. She stated it was also fall protocol not to move the resident after a fall until after the MD gave orders to move the resident. She stated the in-service further covered following up with residents who had an unwitnessed fall with 3-days of vitals and checking pain levels. She stated the in-service training covered change of condition assessments if new or progress

Based on interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 closed record (CR #1) of 4 residents reviewed for resident rights. The facility failed to follow their fall protocols and ensured CR #1 received a nursing assessment. This failure could affect the residents who require assistance with their ADLs from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth. The findings included: Record review of CR #1's face sheet dated 05/21/2025 reflected CR #1 was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 02/16/2025. CR #1's diagnosis of unspecified fall, hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke: issue death (necrosis) in the brain caused by blocked blood flow) affecting left non-dominant side, nontraumatic intracerebral hemorrhage in hemisphere (fetal stroke), cognitive communication deficit (an impairment in communication-verbal or non-verbal-resulting from underlying cognitive issues rather than primary language or speech deficits), muscle weakness, muscle wasting and atrophy, other lack of coordination, morbid (severe) obesity due to excess calories. Record review of CR #1's discharge Minimum Data Set (MDS) dated [DATE] reflected CR #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating CR #1 had a cognitively intact mental status and required helper assistants with sitting to laying, laying to sitting on side of bed, sitting to standing, and char it to bed transfer Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity with an active stroke diagnosis. Record review of CR #1's undated Care Plan reflected she was at risk for falls r/t weakness, hemiplegia and hemiplegia and hemiparesis following cerebral infarction affecting left side date initiated and created 09/04/2024. Record review of complaint received 02/18/2026 reflected CR #1 had an assistant fall on 02/13/2026, where resident's leg slipped from under her and became stuck underneath the bed will staff attempted to transfer her from her wheelchair to her bed. On 02/16/2026 that resident was sent to the hospital and diagnosed with a left femur fracture. The facility reported that the resident had not vocalized pain nor did not note swelling as the reason for not sending the resident out to the hospital immediately after the fall. On 02/16/2026 at time of transfer to the hospital, the facility made the family aware of the fall. As of 02/18/2026, the resident was awaiting surgery to correct the fracture. Record review of CR #1's February medication administration record (MAR) for monitoring and assess level of pain using the 0 - 10 scale: 0=no pain, 1-3=mild pain, 4- 6= moderate pain, 7-10=severe pain every shift - order date 08/29/2024 reflected on 02/14/2026 resident had a 4 pain level, on 02/15/2026 resident had a 0 pain level, and on 02/16/2026 resident had a 10 pain level. During an interview on 02/19/2026 at 05:40 p.m. CR #1 stated she could not recall the exact day or time, but it was on 02/14/2026 after dinner that she had a fall while being assisted from her wheelchair to the bed by certified nursing assistant (CNA) A and CNA B. She stated that the CNAs tried getting her out of her wheelchair and into the bed, her leg slipped forward and she heard a crack sound, and the CNAs lowered her to the floor. She stated she was sitting on the floor crying while the CNAs struggled to get her up into bed. She stated once in bed, she struggled to sleep that evening tossing and turned into discomfort with a pain level of 9 of 10, 10 being the worst. She stated she also was sad and replayed the fall repeatedly in her mind all evening. She stated on 02/15/2026 at breakfast, she received Tylenol for the fall and a preexisting pain. She stated once she received the pain medication, she was able to sleep better. She stated on 02/16/2026 she told her CNA she needed more Tylenol and then ADON came to assess her, and the facility called 911 and sent her to the hospital. She stated at the hospital she learned she had a fracture break to her left leg and on 02/17/2027 she had surgery to the area. During an interview on 02/19/2026 at 09:47 a.m. DON stated she learned on 02/16/2026 that on 02/15/2026 CNA A and CNA B were transferring the resident from her wheelchair to the bed CR #1 had an assisted fall and the resident's leg had slipped forward. She stated that the CNAs lowered the resident to the floor and contacted licensed vocational nurse (LVN) A. She stated LVN A came to assess the resident finding no injuries or pain. She stated thereafter the CNAs assisted the resident back to the bed with no further issues or complaints from the resident as a result of the fall. She stated on 02/16/2026 ADON Awas informed that CR #1 was having pain. She stated ADON A assessed CR #1 and found that the resident had pain in her left extremity (leg) with edema (swelling) at the top of her left leg. She stated the resident voiced to the ADON had the pain resulting from a fall that occurred a couple days prior. She stated that ADON called the resident's physician and the resident was provided with pain medication and an x-rays and then was transferred to the hospital's emergency room (ER). She stated that the Family contacted the facility on Monday to understand how the fall had occurred resulting in the resident's pain. During an interview on 02/19/2026 at 3:13 p.m. DON stated that it had been the facility's protocol that all falls were to be reported to her. She stated on 02/16/2026, she was notified of CR #1's fall that had taken place on 02/15/2026. She stated on that same day she interviewed CR #1, learning the fall occurred a few days prior, but the resident could not recall the exact date or time and only provided a description of the staff that assisted her. She stated that she began an investigation and learned that CNA A and CNA B had been on shift and worked the hall CR #1 was on. She stated that LVN A had not contacted her about the resident's fall. She stated she interviewed CNA A and CNA B who both stated that the resident's fall was reported to LVN A. She stated that LVN A stated that she had not been made aware that CR #1's fall. She stated therefore CR #1's family had not received the fall informed on the resident until 02/16/2026. She stated that CNA A, CNA B, and LVN A were terminated. She stated that LVN A had a previous write-up/disciplinary action for failure to notify the DON of a resident's change of condition. She stated on 02/16/2026 the facility's nursing staff received an in-service training on abuse, neglect and exploitation (ANE) and reporting falls to the DON. During an interview on 02/20/2026 at 12:12 p.m. CNA A started she would not provide a statement. During an interview on 02/20/2026 at 12:13 p.m. CNA B started working at the facility on 02/13/2026 from 2:00 p.m. to 10:00 p.m. and stated on 02/13/2026 at about 06:30 p.m. CNA A asked her to assist with CR #1's wheelchair to bed transfer. She stated during the transfer, resident started to slip and they slowly lowered the resident onto the floor. She stated that CNA A went to alert the resident's nurse at the nurse's station who after 10 minutes had not come to assess resident. She stated that the resident began complaining about being cold on the floor. She stated that the resident had not verbalized any pain, had not been crying. She stated on 02/16/2026 when she came on shift at 2:00 p.m., ADON informed her the resident was sent out to the hospital with complaints of leg pain as result of the fall. She stated she was suspended pending an investigation. During an interview on 02/20/2026 at 12:26 p.m. LVN A stated she worked as needed (PRN) on Saturdays and Sundays from 7:00 a.m. to 7:00 p.m. only and had not worked on 02/13/2026. She stated on 02/15/2026 at 11:24 a.m. she was questioned via text by ADON about a fall that CR #1 had and requested that the resident receive a full body assessment. She stated on 02/15/2026 about 12 p.m., the resident would not allow her to be touched for an assessment and stated she was not in pain. She stated on 02/16/2026 and was dismissed/fired for failure to report a fall. During an interview on 02/20/2026 at 01:24 p.m. ADON stated that on 02/16/2026 she interviewed CR #1's who stated she had a fall a few days ago and the staff picked her up and placed her back into the bed and on that day, the resident stated her leg was hurting. She stated that the DON performed a skin and pain assessment on the resident and found that the resident's leg was warm to touch and swollen. The ADON stated that residents' days were off and the fall took place on 02/15/2026. During an interview on 02/20/2026 at 11:43 a.m. Resident #2 stated that she was CR #1's roommate prior to the resident discharging to the ER. She stated that she was not in the room when the resident fell. She stated she could not recall the exact date of time but knew it was sometime over the weekend of 2/13/2026 - 02/15/2026. She stated that the resident was sitting in her bed crying in a curled-up position. She stated she asked the resident what was wrong and was told she had a nasty fall a few hours ago and was in pain. She stated the resident lay in the bed whining and whimpering all day. She stated that evening when she received her PRN pain medication, CR #1 asked for some too and received something. She stated that then a few days later the resident was in her bed curled up crying again and said she had a fall, but stated that the story was different then what CR #1 first shared, but that she could not recall what the details of either story were, she only remember what CR #1 had told her over the weekend and then what she told the DON on 02/16/2026 were two different stories. She stated after the DON spoke to CR #1 on 02/16/2026 about her fall, she asked the DON what was wrong with CR #1. She stated that the DON told her that CR #1 had a fall on 02/15/2026. She stated that Resident had not fallen on 02/15/2026, because Resident had told her a few days prior about fall when she was crying. During an interview on 03/06/2026 at 01:09 p.m. DON stated that on 02/16/2026 sometime during the late part of the morning meeting, ADON B asked her to step into the hall and notified her that CR #1 had complained of pain in her lower extremity after a post fall. She stated she went into CR #1's room to find that the resident had pain to lower extremity after post fall. DON stated MD was contacted ordered an x-ray and 2- tables Tylenol 650mg/Administered. DON stated due to the pain, CR #1 was transported 911 to the hospital for x-rays to be performed at a higher level of care center for immediate attention to the resident's pain. During an interview on 03/06/2026 at 01:26 p.m. ADM stated CR #1 had to have had her assisted fall on 02/14/2026. He stated it had been his expectation that he would have been notified immediately if a resident had a fall to know he needed to complete an incident report. He stated because CR #1 was able to explain the fall and there were two witnessing CNAs he had not completed an incident report. At the time of the assisted fall, it was reported that the resident had not verbalized any pain. He stated on 02/16/2026 the resident made her first complaint of pain, and the DON addressed the resident and sent CR #1 to the hospital immediately. During an interview on 03/06/2026 at 02:31 p.m. ADON B stated that she received a call from LVN A on 02/15/2026 that CR #1 had informed LVN A she had a fall. She stated that from what LVN A understood no fall had been reported to her. She stated she advice LVN A to perform a head-to-toe assessment and report back the findings. She stated that LVN A attempted to perform the assessment, but that CR #1 refused and stated that she had no pain. Record review of policy titled Resident Rights and Responsibilities, Notice of dated 11/2025 reflected: Policy: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as, the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility.Procedure: 1. Prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights and a copy of all rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility. The resident will also be provided with a State developed notice of Medicaid rights and obligations, if any.2. The resident will be required to sign a statement acknowledging that he/she was informed of his/her rights and responsibilities. (See Resident Rights Form)3. Should a resident be found incompetent by a court of law, the resident's representative shall act on behalf of the resident.4. The facility will inform the resident of his/her rights and responsibilities in a language that is both clear and understandable to the resident. Should the resident's knowledge of English be inadequate for understanding such rights and responsibilities, his/her rights and responsibilities will be explained in the language that is familiar to the resident.5. For foreign languages commonly encountered in our community the facility will provide the resident with written and oral translations of his/her rights and responsibilities through an interpreter. If the foreign language is not common to our community, the representative (sponsor) may sign that he/she has interpreted the statement of rights and responsibilities to the resident.6. Should the resident be hearing impaired and communicate by signing, the resident will be informed of his/her rights and responsibilities through an interpreter.7. To assure that our residents, staff, and visitors are continually informed and aware of resident rights, grievance procedures, and responsibilities, large print copies may be posted in a prominent area in the facility.8. Written copies of resident rights and responsibilities are available upon request and may be obtained from the social services department during normal office hours (8:00 a.m.- 5:00 p.m., Monday-Friday (except holidays)).9. The resident will be promptly informed, both orally and in writing, of a change in resident rights and when changes occur in facility rules that govern the resident's conduct or responsibilities.

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure food was properly stored, labeled, and dated in the walk-in refrigerator, walk-in freezer, and dry goods pantry. The facility failed to ensure dietary staff used facial hair restraints while in the kitchen properly while food was actively being prepared. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include: Observation of the walk-in refrigerator on 12/02/2025 at 8:47 AM revealed:1. One open box on bottom shelf exposing raw, in-shell eggs on trays undated2. One open box on 4th shelf down of bulk raw bacon in an open plastic bag exposed to air, no open date on box3. One bag on 2nd shelf down of sliced potatoes was open and top loosely folded over not secured, no dates on bag Observation of the walk-in freezer on 12/02/2025 at 8:55 AM revealed:1. One open box on middle shelf of individually quick-frozen raw chicken in open bag and not dated2. One open box on middle shelf of bulk corn dogs, interior bag opened, and items exposed to air, not dated Observation of dry goods storage on 12/02/2025 at 9:00AM revealed:1. One open bag on middle shelf of basmati rice, rice exposed to air, not dated2. One open bag on middle shelf of grits, top loosely rolled down and not secured, dated opened 12/23. Floors under shelving have debris and particles spilled from open bags and dirty4. One pan covered in foil on bottom shelf with tear containing unknown contents dated 4/16/255. One bag of cornmeal on bottom shelf open and top loosely rolled down unsecured and undated6. One bag of sugar on bottom shelf open and top loosely rolled down unsecured and undated Observation on 12/02/2025 at 11:28 AM of kitchen stove with uncovered food items cooking and steam table area revealed the DM draining oil from a deep fryer not wearing a beard net. In an interview on 12/0/2025 at 9:15 AM, DA E stated that whoever returned food items to the refrigerator, freezer, or pantry was responsible for making sure it (the food item) was closed and dated properly. DA E stated that the DM was responsible for the kitchen staff and ensured proper procedures were followed. In an interview on 12/02/2025 at 11:30 AM, the DM stated he had a beard net on earlier when he started changing the oil in the fryer and stepped away to handle another task. He forgot to replace the beard net when he returned to the active cooking area of the kitchen. The DM stated that he would start keeping a closer watch on how food items were put away after packaging was opened, that he checked more often for proper labeling on opened packaging, and that items were stored so that they were protected from possible contamination. The DM stated the risk of improperly stored items was potential for residents to become ill, item could be contaminated by pests, attracting pests/mice, premature spoilage of items, and no way to know when items were opened to comply with facility policy of use within 3 days of opening. The DM stated he would order food safe storage bags to seal open items into that should be delivered by Friday, 12/5/25, he would ensure all opened food items were securely wrapped in plastic wrap until bags received, and would in-service kitchen staff on proper food labeling and storage. In an interview on 12/04/2025 at 3:04 PM, the Administrator stated that improperly stored food items could be a risk for cross contamination from other items that would impact residents. The Administrator stated that items not labeled when received and when opened would have posed a risk of items being safe to consume based on knowing correct expiration date and correct consume by dated based on item specifications as some will need to be used sooner than others. The Administrator stated that labelling items was also important to follow a first in first out use theory to avoid waste. In an interview on 12/04/2025 at 3:36 PM, the DON stated there was a risk to residents from improper food storage of items becoming contaminated and potential for residents to become sick. Record review of Food Storage Policy/Procedure revised 8/2007 revealed the following:Policy: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner.Procedures:1. Food storage areas shall be clean at all times. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 3 of 3 meals observed (lunches on 12/02/2025, 12/03/2025, and 12/04/2025) and reviewed for proper textures. The facility failed to ensure that mechanical soft foods were served at the proper texture on 12/02/2025, 12/03/2025, and 12/05/2025. This failure could affect all residents on mechanical soft texture diets by placing them at risk for choking and weight loss.Findings Included: Observation of meal service on 12/02/2025 at 12:20 PM revealed [NAME] F plating a mechanical soft meal of chicken enchiladas, Spanish rice, and refried beans. [NAME] F quickly hand-chopped the enchilada in the pan with the serving spatula before plating. The chicken in the enchiladas was originally sliced. There was no check to ensure the chicken or tortilla pieces were adequate in size for a mechanical soft diet. Observation of lunch test trays of regular texture and mechanical soft texture on 12/03/2025 at 12:10 PM revealed boneless pork chop with gravy, sliced carrot coins, mashed potatoes and a bread roll with a slice of cake for dessert. The mechanical soft plate had the pork chop finely minced with gravy on top, however no mechanical alterations to the carrots, bread roll, or cake. Observation of mechanical soft meal tray on 12/04/2025 at 1:14 PM on 100 hall revealed a plate that appeared untouched consisting of red beans and rice with pork, halved brussels sprouts, and a bread roll. The red beans and rice with pork was the same texture and particle size as the regular texture plate, brussels sprouts were halved, and bread roll was served whole. During interview on 12/02/2025 at 12:20 PM, [NAME] F stated that the chicken enchiladas were premade and received frozen; once baked the tortillas were soft enough from the sauce. [NAME] F stated that his hand chopping of the enchilada was adequate to meet mechanical soft because the residents could chew it to make it smaller if they wanted. During interview on 12/02/2025 at 2:05 PM, the DM stated he did not observe the mechanical soft plates as he was assisting with making the deli sandwiches some residents had requested as an alternate meal. The DM stated that he was unaware that [NAME] F was not uniformly chopping the chicken enchiladas for the mechanical soft plates and would address the different textures of each order type with all kitchen staff. The DM stated there were currently 16 residents who had orders for mechanical soft diets however that number could vary each day depending on who was in the facility for each meal. During interview on 12/04/2025 at 2:33PM, the DM stated that a mechanical soft serving of food should have flavor, taste good, be appetizing in appearance, and should be chopped or ground fine but still have texture and be identifiable compared to other plates when placed side by side. The DM, when shown a photograph of brussels sprouts cut in half on a 12/04/2025 lunch plate, stated he had made the substitution for fried okra as he knew the residents on a mechanical soft diet could not chew the fried vegetables. The DM, when showed the photograph of the carrot slices from the 12/03/2025 lunch plate, stated he thought the carrots were fine as they were a soft texture and did not think about the size as they easily cut with a fork. The DM stated that after seeing the photographs the risks to residents on mechanical soft diet orders were not being able to chew or swallow the items and may cause the resident to choke. During interview on 12/04/2025 at 3:04 PM, the Administrator stated that concerns with a mechanical soft diet would first be discussed with a clinical staff member to verify if the plate was appropriate. The Administrator stated as he did not have a clinical background, he may become concerned if he saw mechanical soft on a meal ticket and observed the same sized food items as on a regular texture serving. The Administrator stated that there could be a risk to residents of a swallow issue, and a risk of choking. The Administrator, when shown a photograph of brussels sprouts cut in half on a lunch plate on 12/04/3035, stated he would question what was observed and ask the kitchen team, dietician, or clinical team for clarification on size and for help understanding what thetexture size should have been. During interview on 12/04/2025 at 3:36 PM, the DON stated that a mechanical soft diet should be a soft texture that was chopped or very small, fine pieces of food that were easy to chew and swallow. When shown photograph of brussels sprouts cut in half and served with a mechanical soft lunch tray on 12/04/2025, the DON stated the vegetable was too large for a mechanical soft item and needed to be smaller pieces. The DON stated that the photograph shown of cooked carrot slices served at lunch on 12/03/2025 were also too large in size. The DON stated the risk of serving food items that were ordered to be mechanical soft in too large of pieces was residents choking or aspirating on the food items. Record review of Therapeutic Diets Policy/Procedures, revised 10/2007 and reviewed 05/2021, revealed:Policy:It is the policy of this facility that therapeutic diets shall be prescribed by the attending physician.Procedures:1. A therapeutic diet must be prescribed by the resident's attending physician.2. Prescribed therapeutic diets are reviewed regularly along with other orders.3. Routine therapeutic menus are planned by the corporate office or dietary manager and approved by the registered dietician; however, unusual or complex therapeutic diets are planned in writing by the registered dietician. 4. A tray identification system is established to ensure that each resident receives his/her diet as ordered.5. The dietician and dietary manager record in the resident's medical record significant information relating to the resident's response to his/her therapeutic diet. 6. Mechanically altered diets will be considered therapeutic diets.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 3 (Residents #45, #73, and #89) of 8 residents reviewed for refrigerators in the rooms. The facility failed to monitor temperatures and did not put thermometers in Residents #45, #73, and #89's refrigerators. These failures could affect residents by placing them at risk for food-borne illnesses. Finding included: Resident #89Record review of Resident # 89's face sheet, dated 12/02/25, revealed she was a [AGE] year-old female with an original admission date of 01/28/22 and readmitted to the facility on [DATE]. Her primary diagnosis was cerebral infraction due to embolism of the middle cerebral artery (this is a stroke caused by a blood clot in the brain). Record review of Resident #89's care plan initiated on 01/27/24 revealed Resident #89 had occasional nausea and vomiting. The goal was to have minimal or no nausea and vomit. Interventions included Avoid foods that cause intestinal hyperactivity, caffeine, carbonated beverages, chocolate, or acidic items like orange juice. Observation and interview with Resident #89 on 12/2/25 at 10:12 AM and 12:49 PM revealed she had two small refrigerators. No temperature log was attached to the two refrigerators, and there were no thermometers inside both refrigerators. Resident #89 said she had been at the facility for 5 years. She said that she had just gotten two small refrigerators a couple of months ago. She said that she was not aware that she needed a thermometer inside to monitor the temperatures. She said she could tell by touching the items by the coolness of the item that both refrigerators were working well. She said she did not recall anyone checking the temperatures in the two refrigerators. She said she could see why it was important to monitor the temperature for food safety. She said that she had not consumed anything that had spoiled in her refrigerators. Resident#45 Record review of Resident # 45's face sheet, dated 12/02/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure and right-side paralysis and weakness following stroke. Record review of Resident#45's care plan initiated on 03/18/24 revealed Resident #45 had occasional nausea and vomiting. The goal was to have minimal or no nausea and vomit. The interventions were to educate residents/family/caregivers about the relationship of nausea and vomiting to food, medicine, treatment regimen, disease process and psychosocial factors. To teach resident/family/caregivers to identify and avoid causative factors. Resident #73Record review of Resident # 73's face sheet, dated 12/02/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in hemisphere subcortical (this is a stroke caused by blood vessel rapture), diabetes mellitus II (uncontrolled blood sugars), and communication difficulty. Record review of Resident #73's care plan initiated 09/13/24 revealed a focus of diabetes mellitus II; the goal was to have no complications related to diabetes through the review date. The interventions included discussing mealtimes, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, and compliance with nutritional regimen. Observation and interview with Resident #45 and #93 on 12/02/25 at 12:23 PM revealed two personal refrigerators for Resident #45 and #73. No temperature log was attached to the two refrigerators, and there were no thermometers inside both refrigerators. Resident #45 said that she did not recall anyone checking her fridge temperature, but she also had not eaten any food that would make her sick from her refrigerators. Resident #73 said that she bought her own snacks and had the fridge cleaned out if anything was bad from there. In an interview with CNA D on 12/3/25 at 12:50 PM, she said she had been at the facility for four and a half months. She said that she was not sure who was responsible for monitoring the temperature logs. She said maybe the housekeeping was responsible. She said it was important to monitor the refrigerator temperature because some residents had milk, and it could go bad and cause them to become sick. In an interview with Housekeeping Aide G on 12/04/25 at 11:58 AM, she said she was informed by her supervisor yesterday (12/03/25) to start monitoring the refrigerators daily. She said prior to yesterday she was not sure who was monitoring them. She said she had been instructed to make sure all refrigerators had thermometers, daily temperature log, food was labelled, and it could only be in the fridge for 3 days if it was from the facility, and to report to maintenance if the refrigerator was not getting cold. She said the risk of not checking temps or not having a thermometer was that the food could make the residents sick if it went bad. Interview with the Housekeeping Supervisor 12/04/25 at 10:30 AM revealed the nursing department had been responsible for monitoring the refrigerators but now as of yesterday 12/3/25, the housekeeping will monitor them. He said he did not know why they were not monitored or why they did not have thermometers. He said, moving forward, he got thermometers in each refrigerator and added a temperature log to each refrigerator. He said the risk of not being monitored was food illness. In an interview with the ADON on 12/04/25 at 11:33 AM, he said he thought the housekeeping department was keeping logs of temperatures for the refrigerators. He said the safe temperature was between 30 to 41 degrees. He said he did not know why the temperature logs were not done or why there were no thermometers in some of the refrigerators. He said they now have a solid plan with the housekeeping being responsible for making sure that all refrigerators have temperature logs and inside they have thermometers. The ADON said that he was not aware that Resident #89 had two refrigerators because they looked colorful and looked like storage containers. He said he will personally see to it that Residents #45 and #73 had thermometers and temp logs. He said the risk was not knowing what the temperature was inside the refrigerators. Interview with the Administrator on 12/04/25 at 04:10 PM revealed he was not aware that some refrigerators had no thermometers in them. He said when he was notified, he sent someone to go to the store and buy some. He said they did not have a concrete plan on who was monitoring but now moving forward they have assigned housekeeping to be responsible for making sure all refrigerators have thermometers and that the logs are completed daily. He said he has also instructed department head during the guardian angel rounds to check the temp logs to make sure it is done. He said the expectation was that daily refrigerators were checked by staff. He said it was a food safety concern and could have an impact on their health. Record Review of the Facility policy titled Resident Personal Food Storage revised 04/2025 revealed Food or beverage brought in from outside sources for storage in the facility pantries, refrigeration units or personal resident room refrigeration units will be monitored by designated staff for food safety) 4. All refrigeration units will have internal thermometers to monitor food storage temperatures. Units must maintain safe internal temperatures in accordance with State and Federal standards for safe food storage temperatures. Staff will monitor and document unit refrigerator temperatures .

Based on observations, interviews, and record reviews, the facility failed to ensure that resident's environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent accidents for 2 (Residents #21 and #47) of 15 residents reviewed for accidents. The facility failed to ensure Residents #21 and #47 had an environment free of accident and hazards by not providing a safe shower chair that had wobbly, loose, unsteady legs. This failure affected residents by placing them at risk of slipping and falling while taking a shower. Findings include: Record review of Resident #21's Face Sheet dated 12-4-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #21 had a primary diagnosis of acute on chronic systolic congestive heart failure (a condition where the ventricle struggles to pump effectively. It signifies a sudden worsening of long-standing heart weakness (systolic failure) where the heart can't pump enough blood, leading to fluid buildup) with secondary diagnoses of muscle weakness, lack of coordination, anxiety disorder, and chronic kidney disease. Record review of Resident #21's annual MDS assessment dated [DATE] signified a BIMS score of 14 revealing she was cognitively intact. The functional ability section revealed Resident #21 needed assistance to shower where the helper does less than half of the effort by lifting, holding, supporting the trunk or limbs. The same level of assistance was needed to transfer in and out of the shower. A record review of Resident #21's care plan dated 10-12-2025 indicated she was at risk for falls related to muscle weakness and needs assistance with activities of daily living. In an observation and interview, on 12-2-2025 at 12:50 PM, Resident #21 was observed sitting in a wheelchair in her room. Resident #21 said when staff take her to shower, they sat her in a shower chair where the legs moved around and wobbled. Resident #21 said she told the staff that the chair was unsafe, and staff told her they would see what they could do. However, nothing had changed since she told them. Resident #21 said she felt unsafe sitting in the shower chair because it could make her fall. Record review of Resident #47's Face Sheet, dated 12-04-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of cerebral aneurysm (a weak spot in a brain artery wall that bulges or balloons out, forming a small, blood-filled sac, similar to a tiny balloon or bubble on a weak part of a tire, which can leak or burst, causing a dangerous brain bleed), and secondary diagnoses of muscle weakness, epilepsy (a chronic neurological disorder causing recurrent, unprovoked seizures from abnormal brain electrical activity, also known as a seizure disorder), chronic diastolic congestive heart failure (when the heart muscle becomes stiff and thick, struggling to relax and fill properly with blood between beats, leading to symptoms like shortness of breath, fatigue, and swelling), and cerebrospinal fluid drainage device (a surgically implanted medical system used to divert excess cerebrospinal fluid from the brain or spinal cord to another part of the body, where it can be absorbed naturally). A record review of Resident #47's Quarterly MDS, dated [DATE], revealed Resident #47 had a BIMS score of 11 which indicated mild cognitive impairment. The functional ability section revealed Resident #47 needed assistance to shower where the helper does less than half of the effort by lifting, holding, supporting the trunk or limbs. The same level of assistance was needed to transfer in and out of the shower. A record review of Resident #47's Care Plan dated 7-28-2025, indicated Resident #47 had an activity of daily living deficit requiring showering assistance and was a fall risk. In an observation and interview, on 12-3-2025 at 2:20 PM, Resident #47 was sitting in her wheelchair at a resident council meeting. Resident #47 stated that the shower chair she had been put in was very flimsy because the legs wobbled. Resident #47 said she has told the CNA, who was showering her, about the chair being unsafe, but the CNA responded that she could not do anything about it. Resident #47 said the condition of the shower chair made her feel unsafe. In an observation on 12-2-2025 at 1:00 PM, it was discovered that the shower chair in the shower for the 400-Hallway had wobbly legs and was unsafe for use. A video was taken of the shower chair. In an interview and observation, on 12-3-2025 at 3:00 PM, it was revealed that CNA A had worked at the facility for 7 months, worked the 2:00 PM-10:00 PM shift, and worked the 400 hallway. CNA A said she gave showers to residents in the 400-hallway area. CNA A was shown the shower room for the 400-hallway and the shower chair being used. CNA A said the potential problem with that shower chair was that it was not safe and could cause someone to fall. CNA A said the shower room used to have a shower bench, but it became unsafe to use, and the facility removed it. CNA A said she does not use the shower chair to shower residents. CNA A said she believed the facility had ordered a new shower bench, and staff were waiting for it to arrive. CNA A said staff were responsible for ensuring showers were safe. In an interview, on 12-3-2025 at 3:43 PM, it was revealed that LVN B had worked at the facility for 4 months, worked a 12-hour shift from 7:00 AM-7:00 PM, and worked the 400-hall. When LVN B saw the shower chair in the 400-hall shower room, she said it had wobbly legs and it was unsafe. LVN B said she was not aware of the faulty shower chair. LVN B said the concern for staff using this shower chair was that a resident could possibly get injured by falling. LVN B said the CNA's who showered residents were responsible for reporting faulty shower chairs to the maintenance department. The maintenance department was responsible for either repairing or replacing faulty chairs. LVN B said the facility had a software program called TELS within the PCC software, whereby staff can let the maintenance department know of a problem that needs fixing. In an interview and observation on 12-3-2025 at 4:00 PM, the DON was shown the shower chair in the 400-hall shower room. The DON said the problem or concern with the shower chair was that it was unsafe and could potentially cause a resident to fall. The DON said she was taking the shower chair out of use now. The DON said the CNA's giving showers were responsible for reporting unsafe shower chairs to a nurse, and the nurse can either report the problem to management or put the information in the TELS system in PCC to let the maintenance staff know they need to either fix or replace the shower chair. The DON said her expectation was that only safe shower chairs were to be used at the facility. In an interview on 12-4-2025, at 11:20 AM, with the Administrator, it was revealed that the Administrator was responsible for ensuring that the shower chairs used at the facility were safe. The Administrator said the staff who were showering residents were responsible for letting the facility know that a shower chair was not safe to use. The Administrator said his expectation was that the facility would study shower chairs and consider changing the model of chair they were using. The Administrator said if a shower chair had unstable legs his concern was that it might not be safe for the residents. Review of the facility's Quality of Care ADL, Services to carry out policy, revised 01-2020, revealed, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities.

Number of residents sampled: Number of residents cited: Based on observation, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 (Resident #25) residents reviewed for peripheral intravenous care. The facility failed to ensure physician orders for Resident #25 were followed to change PICC (PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes every 7 days as ordered. This failure could affect residents by placing them at risk of infection. Findings included: Record review of Resident #25's face sheet dated 12/02/25 indicated Resident #25 was a [AGE] year-old female with an initial admission on [DATE] and readmitted to the facility on [DATE] with a primary diagnosis of other acute osteomyelitis Right ankle and foot (this is an active bone infection in the ankle and foot). Record review of Resident #25's Quarterly MDS dated [DATE] indicated Resident #25 had a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #25s Physician order summary for December 2025 reflected PICC line care: Change PICCline dressing every 7 days if site is visible for assessment. Change dressing PRN if wet, soiled, saturated or loose. every night shifts every 7 day(s) - Order date-11/24/2025. Record review of Resident #25's care plan initiated on 11/12/25 indicated Resident #25 had osteomyelitis to my right ankle. The goal was to be free from complications related to infection through the review date. The interventions were to administer Ceftazidime and Vancomycin (types of antibiotics) intravenously for 37 days and to follow facility policy and procedures for line listing, summarizing and reporting infections. Observation on 12/02/25 at 4:46 PM, revealed Resident #25 was not interviewable. On her upper right arm was a PICC line with two ports dated 11/20/25. The PICC line dressing was intact, not loose and not saturated or soiled. In an interview with LVN C on 12/02/25 at 4:55 pm, she stated that she knew that all PICC line dressings were changed every 7 days. She said that she thought Resident #25's PICC dressing was dated 11/27/25 which meant it would be changed in a couple of days. She said she assessed the PICC line before medication administration earlier today to make sure there was no redness, swelling, pain, or any discoloration. She said that it was an honest mistake to have misread the date. She said that the risk of not changing IV dressing was infection. She said that she would consult with the DON so that it could be changed today. LVN C said that she knew how to change the IV dressing. Observation on 12/03/25 at 09:06 AM, revealed Resident#25's PICC dressing was changed and dated 12/02/25. An interview with the DON on 12/04/25 at 1:20 PM revealed that nurses were responsible for assessing PICC line dressings and completing dressing changes as ordered weekly. She said all PICC line dressing changes should be documented by the nurses. She said she did not know how the IV dressing change was missed. She said if the IV dressing did not get changed as ordered, then there was potential for an infection. Interview with the Administrator on 12/04/25 at 04:10 PM, he said the expectation was for nursing to work with Director of Nursing and have processes in place to prevent the risk of infection. Record review facility policy tilted PICC line dressing change revised on 07/13 reflected. The transparent dressing is changed every 7 days or sooner when it becomes loosened to the point of compromising sterility or presents a risk of accidental dislodgment of the catheter. An accumulation of moisture, fluid, blood, or exudate, can also be criteria for a dressing change.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one of five residents (Resident#71) reviewed for medication administration of insulin. LVN C failed to clean and disinfect Resident #71's skin before administering Insulin on his upper right arm on 12/02/25. This failure affected the residents by placing them at an increased and unnecessary risk of exposure to infections. Findings included: Record review of Resident #71's face sheet dated 12/02/25, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of prostate (this is Cancer of the prostate), cerebral infarction (stroke), and diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified (this is uncontrolled blood sugars diseases with nerve pain). Record review of Resident #71's Quarterly MDS dated [DATE] reflected a BIMS score of 10, indicating moderate cognitive impairment. MDS also revealed Resident #71 did not have any skin conditions related to diabetes. Record Review of Resident #71'2 active physician orders for December 2025 reflected- NovoLog Flex Pen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 2u; 201 - 250 = 4u; 251 - 300 = 6u; 301 - 350 = 8u; 351 - 400 = 10u; 401 - 450 = 12u 451 and up call md, subcutaneously two times a day for diabetes mellitus. Ordered 1/27/25. Record review of Resident #71's care plan revised on 09/06/21 indicated a focus of potential for pressure ulcerdevelopment related to the need for education on frequent repositioning. The goal was for Resident #71 to have intact skin, free of redness, blisters or discoloration by/through review date. The interventions included Monitor/document/report to Medical Doctor PRN changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Observation on 12/02/25 at 4:45 PM with LVN C revealed she checked Resident #71's blood sugar. Blood sugar reading was 262. She said that she would administer 6 units of sliding scale Insulin Aspart. Resident #71 was lying in his bed facing the window on his left side with the upper right arm up. LVN asked Resident #71 where he wanted the injection, and he pointed to his upper right arm. LVN C pushed Resident #71's shirt sleeves up and without disinfecting the area she gave him 6 units of insulin. Interview with LVN C on 12/02/25 at 4:47 PM, when LVN C said that she missed disinfecting the area before giving Resident #71 his injection. She said that she did not know why she missed the step, could be because she was nervous being watched. She said the risk of not disinfecting the skin before insulin administration was a risk of exposing Resident #71 to infection. An interview with the DON on 12/04/25 at 1:20 PM, she said that she was not aware of the incident with the insulin. She said LVN C did not tell her. She said the expectation was that the skin would be disinfected by cleaning the area with an alcohol pad before insulin administration. She said that some of these mistakes should not happen because it was nursing practice to disinfect the skin before any injections. Record review facility policy titled Injection Insulin revision date 07/2017 revealed . 13. Cleanse injection site with alcohol Record review facility policy titled Administering Medications revised date 04/2020 reflected. Medication shall be administered in a safe and timely manner and as prescribed.2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and or have related functions. 14. Staff shall follow established facility infection control procedures (example given, hand washing, antiseptic technique, gloves, isolation precaution, etc.) when theses apply to the medication administration.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of five residents (Resident #92) reviewed for storage of medication. LVN B failed to ensure Pregabalin (control drug), Levetiracetam [seizure medication], Baclofen [pain medication] and multi vitamins were not stored at Resident #92's bedside table and failed to ensure it was secured in the medication cart or medication room when she was not at the bedside on 12/03/25. This failure could place residents at risk of medication misuse and accidental ingestion. The findings include: Record review of Resident #92's face sheet dated 12/03/25 revealed a [AGE] year-old female with an initial admission to the facility on [DATE] and was readmitted on [DATE] with a primary diagnosis of unspecified multiple sclerosis (this is an immune system disorder that causes the body to attack its own healthy cells). Her secondary diagnosis was paraplegia (in ability to voluntarily move the lower parts of the body), impulsiveness, high blood pressure, and gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individuals who have difficulty swallowing). Record review of Resident #92's MDS dated [DATE] indicated Resident #92 had a BIMS score of 00, indicating severe cognitive impairment. The MDS indicated he had a feeding tube and received 501 cc/day or more fluid and 51% or more of her calories through the g-tube. Record review of Resident #92's care plan initiated on 04/21/22 revealed a focus: I receive routine vitamins/supplements.Goal: I will be free from adverse drug reactions through the review date 02/19/26. Interventions: Discuss with residents and family about the number and type of medications a resident was taking and the potential for drug interactions and side effects from over-medication. Record review of Resident #92 MAR dated 12/03/25 reflected the following medications were due to be administered at 09:00 AM-Pregabalin Oral Capsule 50 MG [Control drug anticonvulsant used to treat nerve pain] Give 1 capsule via PEG-Tube one time a day related to MULTIPLE SCLEROSIS-Baclofen Oral Tablet 10 MG [medication to treat muscle spasm] Give 1 tablet via PEG-Tube two times a day related to MULTIPLE SCLEROSIS- Cholecalciferol Oral Tablet 25 MCG (1000 Unit) [Vitamin D]. Give 1 tablet via PEG-Tube two times a day for supplement- Levetiracetam Oral Solution 500 ML/5MG [Seizure medication] Give 10 ml via PEG-Tube two times a day related to MULTIPLE SCLEROSIS- Centrum Oral Liquid (Multiple Vitamins w/ Minerals) Give 15 ml via PEG-Tube one time a day for supplement multi Vite liquid During continuous medication observation on 12/03/25 from 08:25 AM to 08:40 AM with LVN B, she prepared the medications (Pregabalin, Baclofen, Cholecalciferol, Levetiracetam, and Centrum) in individual cups and took the medication and water to flush g-tube into Resident #92's room onto the bedside. As LVN B was flushing the residents' g-tube, LVN B said the g-tube had a slight blockage towards the end of the visible tube of the G-tube. She said that she needed to go and get something in the medication room to help dissolve the blockage. She walked away at 08:38 AM, leaving the medications at the bedside. LVB did not lock the medication into the medication cart nor take it with her to the medication room; she left the medication in Resident #92's room on her bedside table. No staff were in the room, and LVN B could not visually see the medications. The DON came to Resident #92's room and removed the medications at 08:41 AM. Interview with the DON on 12/03/25 at 08:41 AM she said that LVN B should not have left the medication at the bedside. She said it was the nurse's responsibility to make sure that the medication was secured. She said that it was a medication safety concern to leave medications unattended, and she would do a one-on-one in-service with her. She said the risk was unauthorized access to the medications. In an interview with LVN B on 12/03/25 at 4:02 PM, she said that it was an honest mistake. She was just trying to unblock the g-tube so that she would give the resident her medications. She said that the DON did a one-on-one training about medication safety with her after the incident today. She said the risk of leaving medication unattended was that anyone could have access to it. Interview with the DON on 12/04/25 at 1:20 PM, she said she had started in-servicing the current staff and was still working on oncoming staff which included all nurses and medication aides on medication safety. She revealed names on the in-service sheet that had already completed the in-service, including the one-on-one sheet that she had completed with LVN B on 12/03/25. Record review in-service titled Controlled Medications-Storage and Reconciliation led by DON on 09/12/25 revealed 30 staff including CNAs, Medication aides, nurses and LVN B had completed training. Review of the facility's policy, titled Storage of Medications, revised 04/2007, reflected in part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage .

Based on observations, interviews and record review, the facility failed to have evidence that all alleged violations of sexual abuse were thoroughly investigated for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse. The facility failed to take steps to prevent further potential abuse and take appropriate corrective action as a result of investigation findings when CR #1 sexually abused CR #2, an unidentified female resident and Resident #5 within a 4-month period between 4/19/25 and 8/3/25. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. The findings included: Resident #5 Record review of Resident #5's admission Record generated on 9/19/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease, muscle weakness, macular degeneration, anxiety disorder and bipolar disorder. She was [AGE] years of age. Record review of Resident #5's Care Plan dated 11/14/22 revealed she was at risk of impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included:- Administer medications as ordered. (created on 2/24/23)- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.Use simple directive sentences. (created on 11/14/22)- Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. (created on 2/24/23)- Needs supervision/assistance with all decision making. (created on 11/14/22) Record review of Resident #5's Care Plan dated 3/20/25 revealed she had a potential for behavioral problems related to self-propelling in a wheelchair and at times refused to be redirected. Interventions included:- Anticipate and meet needs. (created on 3/20/25)- Stop and talk with resident when passing by. (created on 3/20/25)- Engage in simple, structured activities such as bible study, nail spa and church services. (created on 11/20/23).- Introduce to residents with similar background, interests and encourage/facilitate interaction. (created on 11/20/23)- Needs assistance/escort activity functions. (created on 11/20/23). Record review Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating severe cognitive impairment. She required partial/moderate assistance for transfers, used a wheelchair for mobility, and required supervision while ambulating. In an observation on 9/17/25 at 3:58pm, Resident #5 was sitting in a wheelchair in a common area of the facility. She was not interviewable. She propelled herself in her wheelchair using her feet to ambulate. Record review of Resident #5's Nurse Progress Note dated 4/19/25 at 8:52am revealed a nurse documented the following: Notified by CNA this resident was coming down the hall, another male resident was coming the opposite way, the male resident stopped this resident and reached out and was touching her breast. full body assessment of resident for any injuries or bruising, no noted injuries or bruising from interaction noted . CR #2 Record review of CR #2's admission Record generated on 9/18/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia, depression and adjustment disorder. She was [AGE] years of age. Record review of CR #2's Care Plan dated 5/8/25 revealed she was at risk of impaired cognitive function or impaired thought processes. Interventions included:- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.use simple, directive sentences.- Social Services to provide psychosocial support as needed. Further record review of CR #2's Care Plan dated 5/8/25 revealed she was an elopement risk/wanderer related to disoriented to place, impaired safety awareness. The care plan stated she wandered into other resident's rooms and was initiated on 6/4/25. Interventions included:- Document wandering behavior and attempt diversional interventions.- Monitor wander guard placement on left lower leg. Record review of CR #2's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she has severe cognitive impairment. She was dependent on staff for transfers, walking and assistance with using a manual wheelchair. Record review of CR #2's Nurse Progress Note dated 7/14/25 at 6:06pm revealed LVN E documented that a CNA reported that another resident was observed touching CR #2's breast over her clothing. The nurse completed a full body assessment with no pain or injury. Record review of CR #2's nurse progress notes revealed on 7/15/25 at 10:30pm, she was observed walking with a walker into another resident's room and she was redirected. On 7/16/25 at 6:54pm, CR #2 was diverted out of entering other resident's room. On 7/18/25 at 6:26pm, a nurse noted CR #2 was redirected several times when going into other resident's rooms. In a telephone interview on 9/18/25 at 5:11pm, CR #2's Responsible Party said CR #2's medical condition affected her memory. She said when she was at the facility she was fondled by a male resident a couple of times. She said CR #2 would not have liked that at all. She said CR #2 could not remember the incidents when she asked her about them. She said she felt like CR #2 needed a room closer to the nurse's station for more supervision. She said CR #2 had dementia, did not know how to speak for herself and wandered. She described CR #2 as an independent, outspoken church-lady. CR #1 Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes, chronic obstructive pulmonary disease, cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated 'that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed she was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 and signed by the Administrator revealed on 4/19/25, CR #1 touched Resident #5's left breast area. Resident #5 was assessed on 4/19/25 at 8:10am and education was provided to CR #1 that the behavior was inappropriate. The nurse notified Resident #5's responsible party and physician, CR #1's responsible party. The psychological service provider assessed CR #1 on 4/19/25 at 2:20pm and made a recommendation for behavioral hospital evaluation. Education was provided to facility staff regarding resident rights, types of abuse, abuse reporting, resident-to-resident altercation reporting guidelines. The Administrator noted the allegation was unsubstantiated, stating, (CR #1) did not exhibit any signs or symptoms of the inappropriate behavior. Facility staff, who witnessed the incident intervened immediately and separate the residents for resident safety. (Psychological Services) provider assessed (CR #1) on 4/19/25 and sent the referral for in-patient treatment.(CR #1) is currently at the hospital.(Resident #5) is also stable with normal vitals and no signs or symptoms of distress. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25) Cognitive assessment (created 5/1/25) Evaluate for side effects of medications (created 5/1/25) Psychiatric/psychogeriatric consult as indicated. (created 5/1/25) Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. When asked about interventions for CR #1 to prevent behaviors like this, she said separate him from the residents he was bothering, provide activities and provide 1:1 supervision. She said she could not recall if CR #1's interventions were updated when he returned from the behavioral hospital in April 2025, and could not recall if she received training on his interventions. She said she stopped working at the facility in June 2025. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, 'That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said she was not informed of CR #1's sexual behaviors when she started caring for him. She said she heard rumors from other staff but had not experienced it herself. She said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina during her shift and a CNA reported it to her. She said the incident would have been reportable based on the abuse policy, so she would have reported it to the Former DON. She said CR #1 roamed around the facility freely when he was not provided 1:1 supervision. She said it would have been impossible to keep an eye on him. LVN B said she was not provided any in-services regarding his behaviors or interventions. She said the in-services she received were generally about abuse reporting and behavior monitoring. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said she was not aware of CR #1's sexual behaviors or sexual abuse allegations prior to witnessing an incident in May 2025. She said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift and it happened after lunchtime. She said she believed the female resident was Resident #5, but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. In a telephone interview on 9/18/25 at 11:30am, LVN C said she did not have anything in place, and she was not told to have anything in place before CR #1 touched CR #2's breast. She said it was reported to her that he had a history of sexual behaviors. She said, I didn't have any interventions with him, that was the care plan team's job. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said she was shocked to learn that CR #1 had sexually inappropriate behaviors. She said she first found out about his behaviors when they had in-services regarding sexual abuse and reporting. She said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of CR #1's Social Service progress notes revealed on 7/17/25 at 1:39pm, the Social Worker documented that she was providing ongoing education and resources to CR #1's responsible party related to CR #1's behaviors. She stated she provided a list of facilities to consider for transfer and the responsible party was undecided. Record review of CR #1's Social Services progress notes revealed on 7/18/25 at 11:13am, a referral was pending with a local behavioral health hospital. On 7/21/25 at 4:49pm, a referral was submitted to a local nursing facility. On 7/31/25 at 4:46pm, a referral was submitted to another local nursing facility. Record review of a Provider Investigation Report dated 7/21/25 and signed by the Administrator revealed on 7/14/25, CNA B observed CR #1 touch CR #2's right breast area. The charge nurse received an order to send CR #1 to an acute care hospital for a psychological evaluation and further assessment. CR #1 refused to go to the hospital on 7/14/25 and 1:1 supervision was provided. CR #1 agreed to go to the hospital on 7/15/25 and returned on 7/15/25 with no new orders. All staff were educated on the topics of resident rights, types of abuse, mandatory reporting for any alleged or witnessed abuse immediately. The Administrator noted that the allegation was substantiated. CR #1 was seen by Psychological Services on 7/17/25 with no change to established plan of care. Social Services provided psychosocial support to CR #2 with no further concerns identified. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated on on one sitter.sent out to (local acute care hospital). Record review of a Provider Investigation Report dated 8/10/25 signed by the Administrator revealed on 8/3/25, CNA C observed CR #1 touch CR #2's breast and inner thigh area. The charge nurse assessed CR #2 and notified her responsible party and physician. Charge nurse received orders from CR #1's physician to be sent to an acute care hospital and was provided 1:1 supervision until he discharged . CR #1 was transferred to another facility when he left the acute care hospital. The Administrator noted the allegation was substantiated. In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her 2nd day at the facility. She said she was told that CR #1 had a tendency to make sexual comments and had an incident with another resident. She said she did not review CR #1's care plan. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said before the incident between CR #1 and CR #2 in August 2025, she heard from other staff about CR #1's sexual behaviors, but did not know for sure. She said she was not informed of interventions or prevention measures. She said she had a few in-services regarding reporting incidents of sexual abuse to the Administrator and DON. She said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head near the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 2:42pm, the Social Worker said after CR #1 inappropriately touched a resident in April 2025, the facility staff had a meeting with him and his family to discuss the behavior, the facility's expectations, and process that would follow if it happened again. She said the facility staff were monitoring his behavior and provided supervision. She said they tried to find CR #1 long-term placement after the incident in July 2025. She said she worked with his family members to send referrals to their preferred facility. After the incident in July 2025, CR #1 was provided increased monitoring and he was not provided 1:1 supervision. She said he liked to go outside and sit on the porch. She said CR #1 had critical thinking and understood conversations. She said Resident #5 and CR #2 could communicate but could not comprehend what was going on. In an interview on 9/18/25 at 4:12pm, the DON said in a meeting with CR #1's family members in April 2025 they reported that CR #1 had a history of sexual abuse or sexual behaviors when he was at home with his family. She said they had a recent change in management and she knew the previous DON was working on reeducation. She said the facility did not provide in-services specifically about CR #1 and the education provided to staff after incidents was about reporting abuse to the Administrator and resident rights. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025 but if he had he would have reported it to HHSC and completed an investigation. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. He said CR #2 and Resident #5 had poor cognition and did not approach the point of assessing their ability to consent. In an interview on 9/19/25 at 1:19pm, the Administrator, when asked about protection measures that were in place for Resident #5 after the sexual abuse incident in April 2025, he said Resident #5 wandered the hallways daily. He said they tried to bring her to the activity room and keep Resident #5 away from CR #1. He said he was not aware of an incident or behaviors occurring in May 2025. He said the staff should know to report incidents to the Administrator since he is the abuse coordinator. He said he could not say why it was not reported. He said if he was aware he would follow same course of action and identify victim, get them psychological support, assess, notify, and look at changes to the plan of care. He said after the incident that occurred between CR #1 and CR #2 in July 2025, he was sent to the hospital and returned the same day. He said when he returned, he spoke to the resident about the behavior and how it could not reoccur. He said he could not prevent CR #2 from being in the hallway, and did not move her to a different room. He said he was unsure what else he could have done. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. She said she was not aware of the incident that occurred in May 2025. In a telephone interview on 9/19/25 at 12:11pm, the Psychiatric NP said there was no approved treatment for inappropriate sexual behaviors. He said they will try and antidepressant. He said when CR #1 returned from the behavioral health hospital, they put him on Depakote. He said he had to decrease the dosage because he was experiencing sedative side effects. In an telephone interview on 9/19/25 at 1:53pm, the Psychiatric NP said on 7/17/25 he increased CR #1's antidepressant dose. He said he could not remember if he made recommendations for supervision as there was nothing in his notes about supervision. He said they talk about each case during weekly meetings. When asked about facility staff stating he recommended to discontinue 1:1 supervision, he said he must have decided CR #1 was stable. He said the facility would closely monitor him but not continue 1:1 supervision unless they were concerned about something. He said he ultimately put the decision for amount of supervision on the facility because they were with the resident. He said it would be difficult for the facility to prevent him from having sexual behaviors. In a telephone interview on 9/24/25 at 12:29pm, ADON B said Resident #5 had a behavior of wandering in her wheelchair. He said the staff knew to supervise and redirect her when needed. He said he could not recall if Resident #5's plan of care changed after she was sexually abused by CR #1 in April 2025. He said after the sexual abuse incident in July 2025 between CR #1 and CR #2, he said they watched CR #1 when he was around a female resident. He said they did not want to isolate anyone and wanted to respect their privacy. When asked about abuse prevention, he said he would follow the guidance of the DON and Administrator. Record review of the facility's policy titled 'Abuse: Prevention of and Prohibition Against' dated 12/2024 stated, .Investigation. All identified events are reported to the Administrator immediately. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm (See, Protection, below).All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. Protection.If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation:.Increase supervision of the alleged victim and residents.Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety.Reporting/Response.At the conclusion of the investigation, the Facility will take action, as necessary, in light of the information gathered, which may include but is not limited to: If the allegation is substantiated, analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred, and determining what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services, if appropriate; Training staff on changes made and demonstration of staff competency after training is implemented; Identifying staff responsible for the implementation of corrective action; The expected date for implementation; and Identifying staff responsible for monitoring the implementation of the plan. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of Removal F610: Abuse Investigation The facility failed to have evidence that all alleged violations of sexual abuse are thoroughly investigated and failed to take steps to prevent further potential abuse and take appropriate corrective action as a result of investigation findings.1. Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by the RN, Clinical Resource on 09/19/25. Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.4. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed on 9/19/25 and No additional discrepancies were identified. Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents. 5. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.6. DON/ designee/ Cluster Partners will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated appropriately. This will be completed by 9/19/25. 7. DON/ Designee will review the 24-[NAME]

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's nursing, mental and psychosocial needs for 1 of 17 residents (CR #1) reviewed for comprehensive care plans in that: CR #1's care plan was not revised when he sexually abused Resident #5, an unidentified resident and CR #2 and had one sexual inappropriate behavior within a 4-month period between 4/19/25 and 8/3/25. Nursing staff, including LVN B, CNA A, LVN C, CNA B, LVN D and CNA C, were unaware of interventions for CR #1 that would prevent further sexual abuse from occurring. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of not having their behavioral needs met, which could lead to abuse, emotional distress and serious harm. The findings included: Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes, chronic obstructive pulmonary disease, cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated 'that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed he was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 and signed by the Administrator revealed on 4/19/25, CR #1 touched Resident #5's left breast area. Resident #5 was assessed on 4/19/25 at 8:10am and education was provided to CR #1 that the behavior was inappropriate. The nurse notified Resident #5's responsible party and physician, CR #1's responsible party. The psychological service provider assessed CR #1 on 4/19/25 at 2:20pm and made a recommendation for behavioral hospital evaluation. Education was provided to facility staff regarding resident rights, types of abuse, abuse reporting, resident-to-resident altercation reporting guidelines. The Administrator noted the allegation was unsubstantiated, stating, (CR #1) did not exhibit any signs or symptoms of the inappropriate behavior. Facility staff, who witnessed the incident intervened immediately and separate the residents for resident safety. (Psychological Services) provider assessed (CR #1) on 4/19/25 and sent the referral for in-patient treatment.(CR #1) is currently at the hospital.(Resident #1) is also stable with normal vitals and no signs or symptoms of distress. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25) Cognitive assessment (created 5/1/25) Evaluate for side effects of medications (created 5/1/25) Psychiatric/psychogeriatric consult as indicated. (created 5/1/25) Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. When asked about interventions for CR #1 to prevent behaviors like this, she said separate him from the residents he was bothering, provide activities and provide 1:1 supervision. She said she could not recall if CR #1's interventions were updated when he returned from the behavioral hospital in April 2025 and could not recall if she received training on his interventions. She said she stopped working at the facility in June 2025. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, 'That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said she was not informed of CR #1's sexual behaviors when started caring for him. She said she heard rumors from other staff but had not experienced it herself. She said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina during her shift and a CNA reported it to her. She said the incident would have been reportable based on the abuse policy, so she would have reported it to the Former DON. She said CR #1 roamed around the facility freely when he was not provided 1:1 supervision. She said it would have been impossible to keep an eye on him. She said was not provided any in-services regarding his behaviors or interventions. She said the in-services she received were generally about abuse reporting and behavior monitoring. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said she was not aware of CR #1's sexual behaviors or sexual abuse allegations prior to witnessing an incident in May 2025. She said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift and it happened after lunchtime. She said she believed the female resident was Resident #5, but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. In a telephone interview on 9/18/25 at 11:30am, LVN C said she did not have anything in place, and she was not told to have anything in place before CR #1 touched CR #2's breast. She said it was reported to her that he had a history of sexual behaviors. She said, I didn't have any interventions with him, that was the care plan team's job. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said she was shocked to learn that CR #1 had sexually inappropriate behaviors. She said she first found out about his behaviors when they had in-services regarding sexual abuse and reporting. She said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of a Provider Investigation Report dated 7/21/25 and signed by the Administrator revealed on 7/14/25, CNA B observed CR #1 touch CR #2's right breast area. The charge nurse received an order to send CR #1 to an acute care hospital for a psychological evaluation and further assessment. CR #1 refused to go to the hospital on 7/14/25 and 1:1 supervision was provided. CR #1 agreed to go to the hospital on 7/15/25 and returned on 7/15/25 with no new orders. All staff were educated on the topics of resident rights, types of abuse, mandatory reporting for any alleged or witnessed abuse immediately. The Administrator noted that the allegation was substantiated. CR #1 was seen by Psychological Services on 7/17/25 with no change to established plan of care. Social Services provided psychosocial support to CR #2 with no further concerns identified. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated on on one sitter.sent out to (local acute care hospital). Record review of a Provider Investigation Report dated 8/10/25 signed by the Administrator revealed on 8/3/25, CNA C observed CR #1 touch CR #2's breast and inner thigh area. The charge nurse assessed CR #2 and notified her responsible party and physician. Charge nurse received orders from CR #1's physician to be sent to an acute care hospital and was provided 1:1 supervision until he discharged . CR #1 was transferred to another facility when he left the acute care hospital. The Administrator noted the allegation was substantiated. In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her 2nd day at the facility. She said she was told that CR #1 had a tendency to make sexual comments and had an incident with another resident. She said she did not review CR #1's care plan. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said before the incident between CR #1 and CR #2 in August 2025, she heard from other staff about CR #1's sexual behaviors, but did not know for sure. She said she was not informed of interventions or prevention measures. She said she had a few in-services regarding reporting incidents of sexual abuse to the Administrator and DON. She said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head hear the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 2:42pm, the Social Worker said after CR #1 inappropriately touched a resident in April 2025, the facility staff had a meeting with him and his family to discuss the behavior, the facility's expectations, and process that would follow if it happened again. She said the facility staff were monitoring his behavior and provided supervision. She said they tried to find CR #1 long-term placement after the incident in July 2025. She said she worked with his family members to send referrals to their preferred facility. After the incident in July 2025, CR #1 was provided increased monitoring and he was not provided 1:1 supervision. She said he liked to go outside and sit on the porch. She said CR #1 had critical thinking and understood conversations. She said Resident #5 and CR #2 could communicate but could not comprehend what was going on. In an interview on 9/18/25 at 4:12pm, the DON said in a meeting with CR #1's family members in April 2025 they reported that CR #1 had a history of sexual abuse or sexual behaviors when he was at home with his family. She said the facility communicated care plan interventions to nursing staff by conducting nurse huddles daily at 9am and 4pm, conducting in-services, all-staff meetings monthly and utilizing the resident's electronic medical record. She said they had a recent change in management and she knew the previous DON was working on reeducation. She said the facility did not provide in-services specifically about CR #1 and the education provided to staff after incidents was about reporting abuse to the Administrator and resident rights. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025 but if he had he would have reported it to HHSC and completed an investigation. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. He said CR #2 and Resident #5 had poor cognition and did not approach the point of assessing their ability to consent. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. She said she was not aware of the incident that occurred in May 2025. She said care plan revisions were a collaborative effort but was mostly completed by the MDS nurse. She said she could not recall who was responsible for care planning between April 2025 and July 2025 since they had some turnover in the role. In an interview on 9/20/25 at 12:25pm, after reviewing CR #1's care plan for sexually inappropriate behaviors, the DON said she would like to see that care plans are revised after each incident to include what new interventions were implemented. She said there should be more interventions listed for CR #1. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of Removal F656: Care PlansThe Facility failed to develop and implement a comprehensive person-centered care plan for Resident#3 when he sexually abused Residents #1 and #2 and had one sexual inappropriate behavior within a 4-month period. The facility failed to ensure nursing staff were aware of interventions that would prevent further sexual abuse from occurring. 1. The medical director was notified of the IJ on 09/19/2025 at 4:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director and clinical resource with no changes made on 09/19/25. 3. MDS, LVN, Resource conducted a 1-on-1 education and training on the MDS coordinators for creating comprehensive person-centered care plan. Target completion date: 09/20/20254. A facility wide audit was performed on 09/19/2025 to identify any other residents demonstrating sexually inappropriate behaviors. No other residents were identified.5. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.6. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON, clinical resource/ designee will be responsible that all staff are trained before working. To validate the knowledge check for Licensed Nurses and CNA's, the DON/Designee will quiz 5 random Nursing and CNA staff daily x 1week, then twice a week x 2 weeks and once a week x 2 weeks, or until substantial compliance has been achieved. Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents.7. If in the future, a resident demonstrates sexually inappropriate behavior, it will be added to the resident care profile which will be visible to the nurses. 8. MDS/ designee will be responsible for updating the care plans.9. An ad hoc (a non-scheduled QA meeting) meeting will be called regarding items in the IJ templates and will be completed on 09/20/25. Attendees will include the DON, Administrator, Medical Director, ADON, Clinical Resource which will include the plan of removal items and interventions.10. DON/ designee will educate all nurses by 09/20/25 regarding resident care profile and CNAs regarding Kardex to identify residents for sexually inappropriate behaviors. Any remaining Licensed Nurses and CNAs staff member(s) pending Education/Training checks will complete the Training/Education prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training/education.11. Safe-Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to report any abuse. & who is the Abuse Coordinator for facility/ who to report for alleged abuse. Interviewed residents were able to answer for who to report at facility for any alleged abuse.12. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 09/19/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of the facilities IJ Template revealed it was signed by the Medical Director (undated). Record review of a Grievance Log and Incident Log dated May 2025 to September 2025 revealed the DON reviewed both and signed her name on the documents. Record review of Safe Survey Questionnaires for Alleged Abuse conducted by the Social Worker revealed she interviewed 18 residents. All residents stated they would speak to SW or administrator if abuse occurred, all satisfied with care, no problems with other residents, staff. RR of In-service attendance records dated 9/19/25 revealed the DON presented in-services to all staff, including administrative staff and nursing staff, therapy, housekeeping, maintenance. Topics included: - Abuse prevention, freedom from abuse and neglect.- Reporting alleged violations of abuse, neglect, exploitation and mistreatment.- Reporting suspicion of a crime, freedom from abuse, neglect and exploitation. Record review of an In-Service Attendance Record dated 9/20/25 at 11:00am revealed the Clinical Resource provided education to the Administrator, DON and Social Worker on the topic of conducting abuse and incident investigations/interviews which included the following: Define types of incidents requiring an investigation and reporting to appropriate agencies; Initiated the investigation and preparing for the interview- Includes review of medical records and assessment findings physical, psychological impact, personnel files, training records, policies, equipment, scene of the incident, staff schedules and assignments; Techniques for completing a successful and through interview; Analyze findings from investigation and interviews; Develop plan to prevent future occurrences and care plan updates; Maintaining investigation files and completing final report to appropriate agencies; Evaluation used scenario-based presentations with learner replies demonstrating learned techniques. Interviews with CNA D, MA A, CNA E, LVN F, CNA F, CNA G, LVN G and LVN H on 9/21/25 between 5:37am and 3:31pm revealed they could reiterate the in-services they received, including a resident's right to be free from sexual abuse, their responsibility regarding incidents of abuse, abuse prevention, behaviors that could lead to abuse and identifying and locating care plan areas and interventions. Interviews with the Social Worker, Administrator, DON and ADON on 9/21/25 between 1:57pm and 2:34pm revealed they could reiterate he in-services the received, including their responsibility regarding the abuse policy, abuse investigation, abuse prevention and care plan revisions. In an interview on 9/21/25 at 2:01pm, the MDS Coordinator said she had worked at the facility for one month. She said they audited all resident's care plans to ensure there were current. She said she was responsible for care planning. She said she was informed of incidents by attending morning meetings and reviewing falls and changes of condition. On 9/21/25 at 3:37pm, the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse. The facility failed to implement written policies regarding abuse prevention and protection when CR #1 sexually abused Resident #5, an unidentified female resident, and CR #2 within a 4-month period between 4/19/25 and 8/3/25. The facility failed to ensure LVN B and CNA A, with knowledge of an allegation of sexual abuse on 5/21/25, reported the abuse immediately to the Administrator. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. The findings included: Record review of the facility's policy titled 'Abuse: Prevention of and Prohibition Against' dated 12/2024 stated, .Prevention.The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by.Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the Facility has deployed the correct number of competent staff on each shift to meet the needs of the residents. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as.Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing. Wandering into other's rooms/space. Protection.If an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation:.Increase supervision of the alleged victim and residents.Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.If the allegation of abuse, neglect, misappropriation of resident property, or exploitation involves another resident, the Facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. If a room change is appropriate, advise the residents and/or resident representatives of reason for the change in writing. Continue to assess, monitor and intervene as necessary to maximize resident health and safety. Resident #5 Record review of Resident #5's admission Record generated on 9/19/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease, muscle weakness, macular degeneration, anxiety disorder and bipolar disorder. She was [AGE] years of age. Record review of Resident #5's Care Plan dated 11/14/22 revealed she was at risk of impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included: - Administer medications as ordered. (created on 2/24/23)- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.Use simple directive sentences. (created on 11/14/22)- Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. (created on 2/24/23)- Needs supervision/assistance with all decision making. (created on 11/14/22) Record review of Resident #5's Care Plan dated 3/20/25 revealed she had a potential for behavioral problems related to self-propelling in a wheelchair and at times refused to be redirected. Interventions included: - Anticipate and meet needs. (created on 3/20/25)- Stop and talk with resident when passing by. (created on 3/20/25)- Engage in simple, structured activities such as bible study, nail spa and church services. (created on 11/20/23). - Introduce to residents with similar background, interests and encourage/facilitate interaction. (created on 11/20/23)- Needs assistance/escort activity functions. (created on 11/20/23). Record review Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating severe cognitive impairment. She required partial/moderate assistance for transfers, used a wheelchair for mobility, and required supervision while ambulating. In an observation on 9/17/25 at 3:58pm, Resident #5 was sitting in a wheelchair in a common area of the facility. She was not interviewable. She propelled herself in her wheelchair using her feet to ambulate. Record review of Resident #5's Nurse Progress Note dated 4/19/25 at 8:52am revealed a nurse documented the following: Notified by CNA this resident was coming down the hall, another male resident was coming the opposite way, the male resident stopped this resident and reached out and was touching her breast. full body assessment of resident for any injuries or bruising, no noted injuries or bruising from interaction noted . CR #2 Record review of CR #2's admission Record generated on 9/18/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia, depression and adjustment disorder. She was [AGE] years of age. Record review of CR #2's Care Plan dated 5/8/25 revealed she was at risk of impaired cognitive function or impaired thought processes. Interventions included: - Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.use simple, directive sentences. - Social Services to provide psychosocial support as needed. Further record review of CR #2's Care Plan dated 5/8/25 revealed she was an elopement risk/wanderer related to disoriented to place, impaired safety awareness. The care plan stated she wandered into other resident's rooms and was initiated on 6/4/25. Interventions included: - Document wandering behavior and attempt diversional interventions.- Monitor wander guard placement on left lower leg. Record review of CR #2's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she has severe cognitive impairment. She was dependent on staff for transfers, walking and assistance with using a manual wheelchair. Record review of CR #2's Nurse Progress Note dated 7/14/25 at 6:06pm revealed LVN E documented that a CNA reported that another resident was observed touching CR #2's breast over her clothing. The nurse completed a full body assessment with no pain or injury. Record review of CR #2's nurse progress notes revealed on 7/15/25 at 10:30pm, she was observed walking with a walker into another resident's room and she was redirected. On 7/16/25 at 6:54pm, CR #2 was diverted out of entering other resident's room. On 7/18/25 at 6:26pm, a nurse noted CR #2 was redirected several times when going into other resident's rooms. In a telephone interview on 9/18/25 at 5:11pm, CR #2's Responsible Party said CR #2's medical condition affected her memory. She said when she was at the facility she was fondled by a male resident a couple of times. She said CR #2 would not have liked that at all. She said CR #2 could not remember the incidents when she asked her about them. She said she felt like CR #2 needed a room closer to the nurse's station for more supervision. She said CR #2 had dementia, did not know how to speak for herself and wandered. She described CR #2 as an independent, outspoken church-lady. CR #1 Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes, chronic obstructive pulmonary disease, cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated 'that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed she was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 and signed by the Administrator revealed on 4/19/25, CR #1 touched Resident #5's left breast area. Resident #5 was assessed on 4/19/25 at 8:10am and education was provided to CR #1 that the behavior was inappropriate. The nurse notified Resident #5's responsible party and physician, CR #1's responsible party. The psychological service provider assessed CR #1 on 4/19/25 at 2:20pm and made a recommendation for behavioral hospital evaluation. Education was provided to facility staff regarding resident rights, types of abuse, abuse reporting, resident-to-resident altercation reporting guidelines. The Administrator noted the allegation was unsubstantiated, stating, (CR #1) did not exhibit any signs or symptoms of the inappropriate behavior. Facility staff, who witnessed the incident intervened immediately and separate the residents for resident safety. (Psychological Services) provider assessed (CR #1) on 4/19/25 and sent the referral for in-patient treatment.(CR #1) is currently at the hospital.(Resident #5) is also stable with normal vitals and no signs or symptoms of distress. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25) Cognitive assessment (created 5/1/25) Evaluate for side effects of medications (created 5/1/25) Psychiatric/psychogeriatric consult as indicated. (created 5/1/25) Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. When asked about interventions for CR #1 to prevent behaviors like this, she said separate him from the residents he was bothering, provide activities and provide 1:1 supervision. She said she could not recall if CR #1's interventions were updated when he returned from the behavioral hospital in April 2025, and could not recall if she received training on his interventions. She said she stopped working at the facility in June 2025. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, 'That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said she was not informed of CR #1's sexual behaviors when she started caring for him. She said she heard rumors from other staff but had not experienced it herself. She said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina during her shift and a CNA reported it to her. She said the incident would have been reportable based on the abuse policy, so she would have reported it to the Former DON. She said CR #1 roamed around the facility freely when he was not provided 1:1 supervision. She said it would have been impossible to keep an eye on him. LVN B said she was not provided any in-services regarding his behaviors or interventions. She said the in-services she received were generally about abuse reporting and behavior monitoring. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said she was not aware of CR #1's sexual behaviors or sexual abuse allegations prior to witnessing an incident in May 2025. She said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift and it happened after lunchtime. She said she believed the female resident was Resident #5, but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. In a telephone interview on 9/18/25 at 11:30am, LVN C said she did not have anything in place, and she was not told to have anything in place before CR #1 touched CR #2's breast. She said it was reported to her that he had a history of sexual behaviors. She said, I didn't have any interventions with him, that was the care plan team's job. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said she was shocked to learn that CR #1 had sexually inappropriate behaviors. She said she first found out about his behaviors when they had in-services regarding sexual abuse and reporting. She said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of CR #1's Social Service progress notes revealed on 7/17/25 at 1:39pm, the Social Worker documented that she was providing ongoing education and resources to CR #1's responsible party related to CR #1's behaviors. She stated she provided a list of facilities to consider for transfer and the responsible party was undecided. Record review of CR #1's Social Services progress notes revealed on 7/18/25 at 11:13am, a referral was pending with a local behavioral health hospital. On 7/21/25 at 4:49pm, a referral was submitted to a local nursing facility. On 7/31/25 at 4:46pm, a referral was submitted to another local nursing facility. Record review of a Provider Investigation Report dated 7/21/25 and signed by the Administrator revealed on 7/14/25, CNA B observed CR #1 touch CR #2's right breast area. The charge nurse received an order to send CR #1 to an acute care hospital for a psychological evaluation and further assessment. CR #1 refused to go to the hospital on 7/14/25 and 1:1 supervision was provided. CR #1 agreed to go to the hospital on 7/15/25 and returned on 7/15/25 with no new orders. All staff were educated on the topics of resident rights, types of abuse, mandatory reporting for any alleged or witnessed abuse immediately. The Administrator noted that the allegation was substantiated. CR #1 was seen by Psychological Services on 7/17/25 with no change to established plan of care. Social Services provided psychosocial support to CR #2 with no further concerns identified. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated on on one sitter.sent out to (local acute care hospital). Record review of a Provider Investigation Report dated 8/10/25 signed by the Administrator revealed on 8/3/25, CNA C observed CR #1 touch CR #2's breast and inner thigh area. The charge nurse assessed CR #2 and notified her responsible party and physician. Charge nurse received orders from CR #1's physician to be sent to an acute care hospital and was provided 1:1 supervision until he discharged . CR #1 was transferred to another facility when he left the acute care hospital. The Administrator noted the allegation was substantiated. In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her 2nd day at the facility. She said she was told that CR #1 had a tendency to make sexual comments and had an incident with another resident. She said she did not review CR #1's care plan. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said before the incident between CR #1 and CR #2 in August 2025, she heard from other staff about CR #1's sexual behaviors, but did not know for sure. She said she was not informed of interventions or prevention measures. She said she had a few in-services regarding reporting incidents of sexual abuse to the Administrator and DON. She said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head near the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 2:42pm, the Social Worker said after CR #1 inappropriately touched a resident in April 2025, the facility staff had a meeting with him and his family to discuss the behavior, the facility's expectations, and process that would follow if it happened again. She said the facility staff were monitoring his behavior and provided supervision. She said they tried to find CR #1 long-term placement after the incident in July 2025. She said she worked with his family members to send referrals to their preferred facility. After the incident in July 2025, CR #1 was provided increased monitoring and he was not provided 1:1 supervision. She said he liked to go outside and sit on the porch. She said CR #1 had critical thinking and understood conversations. She said Resident #5 and CR #2 could communicate but could not comprehend what was going on. In an interview on 9/18/25 at 4:12pm, the DON said in a meeting with CR #1's family members in April 2025 they reported that CR #1 had a history of sexual abuse or sexual behaviors when he was at home with his family. She said they had a recent change in management and she knew the previous DON was working on reeducation. She said the facility did not provide in-services specifically about CR #1 and the education provided to staff after incidents was about reporting abuse to the Administrator and resident rights. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025 but if he had he would have reported it to HHSC and completed an investigation. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. He said CR #2 and Resident #5 had poor cognition and did not approach the point of assessing their ability to consent. In an interview on 9/19/25 at 1:19pm, the Administrator, when asked about protection measures that were in place for Resident #5 after the sexual abuse incident in April 2025, he said Resident #5 wandered the hallways daily. He said they tried to bring her to the activity room and keep Resident #5 away from CR #1. He said he was not aware of an incident or behaviors occurring in May 2025. He said the staff should know to report incidents to the Administrator since he is the abuse coordinator. He said he could not say why it was not reported. He said if he was aware he would follow same course of action and identify victim, get them psychological support, assess, notify, and look at changes to the plan of care. He said after the incident that occurred between CR #1 and CR #2 in July 2025, he was sent to the hospital and returned the same day. He said when he returned, he spoke to the resident about the behavior and how it could not reoccur. He said he could not prevent CR #2 from being in the hallway, and did not move her to a different room. He said he was unsure what else he could have done. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. She said she was not aware of the incident that occurred in May 2025. In a telephone interview on 9/19/25 at 12:11pm, the Psychiatric NP said there was no approved treatment for inappropriate sexual behaviors. He said they will try and antidepressant. He said when CR #1 returned from the behavioral health hospital, they put him on Depakote. He said he had to decrease the dosage because he was experiencing sedative side effects. In an telephone interview on 9/19/25 at 1:53pm, the Psychiatric NP said on 7/17/25 he increased CR #1's antidepressant dose. He said he could not remember if he made recommendations for supervision as there was nothing in his notes about supervision. He said they talk about each case during weekly meetings. When asked about facility staff stating he recommended to discontinue 1:1 supervision, he said he must have decided CR #1 was stable. He said the facility would closely monitor him but not continue 1:1 supervision unless they were concerned about something. He said he ultimately put the decision for amount of supervision on the facility because they were with the resident. He said it would be difficult for the facility to prevent him from having sexual behaviors. In a telephone interview on 9/24/25 at 12:29pm, ADON B said Resident #5 had a behavior of wandering in her wheelchair. He said the staff knew to supervise and redirect her when needed. He said he could not recall if Resident #5's plan of care changed after she was sexually abused by CR #1 in April 2025. He said after the sexual abuse incident in July 2025 between CR #1 and CR #2, he said they watched CR #1 when he was around a female resident. He said they did not want to isolate anyone and wanted to respect their privacy. When asked about abuse prevention, he said he would follow the guidance of the DON and Administrator. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of RemovalF607: Abuse The facility failed to implement their written policies that prohibit and prevent abuse in that the facility failed to take measures to prevent and protect residents from sexual abuse.1. Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3. The ED/ DON/ Social Worker and RN, Clinical Resource will be trained on Abuse/ Neglect Investigation and Reporting by Risk Management Resource on 9/20/2025. This included how to conduct a thorough investigation to implement measures to prevent further incidents which would protect other residents.4. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by RN, Clinical Resource on 09/19/25. Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training & Knowledge check will complete the Training & Knowledge Check including Post-Test prior to the start of their next will be completed with all staff prior to the scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan. 5. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working.6. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation is identified, this will be investigated and reported as per provider letter. This audit was completed on 9/19/25 and No additional discrepancies were identified. Admissions Coordinator/ Designee will check Sex-Offender registry before admission. Any new potential new admissions, flagged for Inappropriate sexual behaviors, will not be admitted ensuring the protection of in-house residents. 7. Safe-Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident(s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility to repor

Based on observation, interviews, and record review, the facility failed to ensure each resident was free from abuse for 2 of 17 residents (CR #2, Resident #5) reviewed for abuse in that: 1. CR #1 sexually abused Resident #5 on 4/19/25 when he touched her breast.2. CR #1 sexually abused an unknown female resident on 5/21/25 when he touched her thigh.3. CR #1 sexually abuse CR #2 on 7/14/25 when he touched her breast and on 8/3/25 when he touched her breast and in between her thighs. An IJ was identified on 9/19/25. The IJ template was provided to the facility on 9/19/25 at 4:52pm. While the IJ was removed on 9/21/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness. The findings included: Resident #5 Record review of Resident #5's admission Record generated on 9/19/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), muscle weakness, macular degeneration (an eye disease that causes vision loss), anxiety disorder (a mental health condition characterized by excessive worry, fear and nervousness) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs). She was [AGE] years of age. Record review of Resident #5's Care Plan dated 11/14/22 revealed she was at risk of impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included: - Administer medications as ordered. (created on 2/24/23)- Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.Use simple directive sentences. (created on 11/14/22)- Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. (created on 2/24/23)- Needs supervision/assistance with all decision making. (created on 11/14/22) Record review of Resident #5's Care Plan dated 3/20/25 revealed she had potential for behavioral problems related to self-propelling in a wheelchair and at times refused to be redirected. Interventions included: - Anticipate and meet needs. (created on 3/20/25)- Stop and talk with resident when passing by. (created on 3/20/25)- Engage in simple, structured activities such as bible study, nail spa and church services. (created on 11/20/23). - Introduce to residents with similar background, interests and encourage/facilitate interaction. (created on 11/20/23)- Needs assistance/escort activity functions. (created on 11/20/23). Record review Resident #5's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 0, indicating severe cognitive impairment. She required partial/moderate assistance for transfers, used a wheelchair for mobility, and required supervision while ambulating. Record review of Resident #5's Nurse Progress Note dated 4/19/25 at 8:52am revealed a nurse documented the following: Notified by CNA this resident was coming down the hall, another male resident was coming the opposite way, the male resident stopped this resident and reached out and was touched her breast. full body assessment of resident for any injuries or bruising, no noted injuries or bruising from interaction noted . In an observation on 9/17/25 at 3:58pm, Resident #5 was sitting in a wheelchair in a common area of the facility. She was not interviewable. She propelled herself in her wheelchair using her feet to ambulate. CR #2 Record review of CR #2's admission Record generated on 9/18/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia, depression and adjustment disorder. She was [AGE] years of age. Record review of CR #2's Care Plan dated 5/8/25 revealed she was at risk of impaired cognitive function or impaired thought processes. Interventions included: - Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions.use simple, directive sentences. - Social Services to provide psychosocial support as needed. Further record review of CR #2's Care Plan dated 5/8/25 revealed she was an elopement risk/wanderer related to disoriented to place, impaired safety awareness. The care plan stated she wandered into other resident's rooms and was initiated on 6/4/25. Interventions included: - Document wandering behavior and attempt diversional interventions.- Monitor wander guard placement on left lower leg. Record review of CR #2's admission MDS assessment dated [DATE] revealed she had a BIMS of 1, indicating she has severe cognitive impairment. She was dependent on staff for transfers, walking and assistance with using a manual wheelchair. Record review of CR #2's Nurse Progress Note dated 7/14/25 at 6:06pm revealed LVN E documented that a CNA reported that another resident was observed touching CR #2's breast over her clothing. The nurse completed a full body assessment with no pain or injury. Record review of CR #2's nurse progress notes revealed on 7/15/25 at 10:30pm, she was observed walking with a walker into another resident's room and she was redirected. On 7/16/25 at 6:54pm, CR #2 was diverted out of entering other resident's room. On 7/18/25 at 6:26pm, a nurse noted CR #2 was redirected several times when going into other resident's rooms. In a telephone interview on 9/18/25 at 5:11pm, CR #2's Responsible Party said CR #2's medical condition affected her memory. She said when she was at the facility she was fondled by a male resident a couple of times. She said CR #2 would not have liked that at all. She said CR #2 could not remember the incidents when she asked her about them. She said she felt like CR #2 needed a room closer to the nurse's station for more supervision. She said CR #2 had dementia, did not know how to speak for herself and wandered. She described CR #2 as an independent, outspoken church-lady. CR #1 Record review of CR #1's care profile generated on 9/17/25 revealed he was admitted to the facility on [DATE]. He had diagnoses of diabetes (a chronic condition where the body cannot regulate blood sugar levels effectively), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), cognitive communication deficit, adjustment disorder with anxiety, and dementia. He was [AGE] years of age. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 3, indicating he had severe cognitive impairment. He had a PHQ-9 score of 7, indicating he had mild depression symptoms. No behaviors were noted. He required supervision for transfers and wheelchair mobility assistance. Record review of CR #1's Nurse Progress Note dated 4/19/25 at 8:43am revealed LVN A documented the following: Notified by CNA this resident was coming down the hall, another resident was coming the opposite was (sic), this resident stopped resident in the hall and was seen by CNA reaching out and touching the female residents (sic) breast, the female resident was trying to move his hand away and notified me the nurse. I spoke with resident about how this was inappropriate and he should not be touching other resident in that way. Resident stated 'that's my friend and I was just saying hello.' Removed female resident from the situation.notified Administrator and DON.will be keeping residents apart and this resident in line of sight for monitoring. Further record review of CR #1's Nurse Progress Notes revealed he was sent to a local Behavioral hospital on 4/19/25 and returned on 4/29/25. Record review of a Provider Investigation Report dated 4/25/25 revealed a witness statement from CNA T. CNA T wrote, (CR #1) was rolling his wheelchair from (the hallway) towards the main nursing station. (Resident #5) was also in her wheelchair in (hallway). As (CR #1) approached closer to (Resident #5), he stopped his wheelchair and started touching (Resident #5) inappropriately on her left breast area and (Resident #5) was trying to push away (CR #1)'s hand. I immediately intervened and separated the residents. Record review of CR #1's care plan dated initiated on 5/1/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. Interventions included: Assess and anticipate resident needs: food thirst, toileting, comfort level etc. (created 5/1/25); Cognitive assessment (created 5/1/25); Evaluate for side effects of medications (created 5/1/25); Psychiatric/psychogeriatric consult as indicated. (created 5/1/25). Record review of CR #1's Nurse Progress Note dated 5/17/25 at 12:46pm revealed LVN A documented the following: Resident was told several times by a female resident to please leave her alone and stop talking to her, resident would not listen and kept staring and trying to ask her questions, another nurse intervened and asked resident to move away from the female, female resident stated he was making her feel uncomfortable, resident continued to try to talk to female, finally resident rollway away to hallway, then was seen stopping and looking every residents (sic) room for a couple of minutes before rolling to the next doorway, this nurse approached resident asking why he was looking in everyone's room, he stated just wanted to see what they were doing. Educated on giving people privacy. In a telephone interview on 9/18/25 at 10:07am, LVN A said when she worked at the facility, she cared for CR #1. She said CR #1 would say inappropriate comments to female residents or try to touch them inappropriately. She said when CR #1 started displaying these behaviors, he would talk to residents who could speak up for themselves and ask him to stop. She said when CR #1 touched Resident #5 inappropriately, Resident #5 could not ask him to stop. Record review of CR #1's Nurse Progress Note dated 5/21/25 at 12:13am revealed LVN B documented the following: Upon arrival at facility (CNA A) reported that resident (CR #1) was caught in the dining room with his hand under the table trying to inappropriately touch a female resident. When asked to remove his hand resident stated, 'That's my wife.' Female resident was removed from dining room. CNA says the incident was reported.will monitor. In a telephone interview on 9/18/25 at 10:30am, LVN B said there was an incident in May 2025 when CR #1 tried to grab another resident's vagina area during her shift and a CNA reported it to her. In a telephone interview on 9/19/25 at 11:56am, LVN B said she could not remember the name of the resident who CR #1 tried to touch in May 2025. She said it was a resident who had poor cognition. In an interview on 9/18/25 at 3:00pm, CNA A said on the day of the incident, she was charting when she looked into the dining room and saw a female resident sitting with CR #1, and CR #1's hand was on her thigh beneath the table. She said it occurred on the 2pm-10pm shift, and it happened after lunchtime. She said she believed the female resident was Resident #5 but could not say for sure. She said the female resident did not react to being touched. She said she told LVN A and LVN B. She said CR #1 liked to give other residents snacks like chips and candy. Record review of CR #1's MDS assessment dated [DATE] revealed he had a BIMS of 11, indicating moderate cognitive impairment. He had a PHQ-9 score of 1, indicating minimal depression symptoms. No behaviors were noted. He required setup assistance for sit to stand and chair/bed-to-chair transfers and was independent with wheelchair mobility. Record review of CR #1's Nurse Progress Note dated 7/14/25 at 7:24pm revealed LVN C documented the following: CNA reported to supervisor that resident was observed touching the breast of another resident. Resident will received (sic) order from MD to go to (local behavioral hospital), RP notified. Record review of CR #1's Nurse Progress Notes dated between 7/14/25 at 10:00pm and 7/15/25 at 7:15am revealed a nurse documented every 15-minute observations of CR #1. On 7/15/25 at 2:46pm, a nurse documented CR #1 was transferred to a local acute care hospital. A nurse documented that he returned with a diagnosis of injury to left rotator cuff on 7/15/25 at 10:45pm. The nurse stated, ADON, (Administrator) and family made aware and will address further in the morning. Record review of CR #1's care plan updated on 7/15/25 revealed he had the potential to demonstrate sexually inappropriate behaviors toward female residents and staff related to poor impulse control. The following interventions were added: New order to send to (behavioral hospital), monitor by staff until transfer. (created 7/15/25) Stop and guide resident away from behavioral act. (created 7/15/25) Record review of a witness statement dated 7/14/25 and signed by the Administrator revealed CNA B stated on 7/14/25 at approximately 4:40pm, she witnessed CR #1 touching CR #2's breast area. In a telephone interview on 9/18/25 at 11:30am, LVN C said it was reported to her that he had a history of sexual behaviors. She said in July 2025, a CNA witnessed CR #1 touch CR #2 inappropriately. She said the CNA immediately separated them, put CR #1 on 1:1 supervision, and notified the DON. She said CR #1 was on 1:1 supervision until he left for the hospital. She said she could not remember what happened when CR #1 returned from the hospital but believed 1:1 supervision continued. In an interview on 9/20/25 at 2:15pm, CNA B said CR #1 was cognitively intact and went to church every Sunday. She said CR #2 had short-term memory loss and could not remember one conversation to the next. She said CR #2 used a wheelchair and wandered around the facility. She said CR #2 liked to go by CR #1's room because he kept snacks in his room. She said one day about a month and a half ago, CR #2 was in CR #1's room laying down with his head by the footboard and touching CR #2's breast. She said she removed CR #2 from the room, notified the Administrator and the LVN E. She said after the incident, she kept an eye of CR #1 and made sure no one went into his room. She said CR #2 wandered and she tried to keep track of where she was at all times. She said interventions to prevent another incident of abuse was primarily supervision. Record review of CR #1's Social Service progress notes revealed on 7/17/25 at 1:39pm, the Social Worker documented that she was providing ongoing education and resources to CR #1's responsible party related to CR #1's behaviors. She stated she provided a list of facilities to consider for transfer and the responsible party was undecided. Record review of CR #1's Social Services progress notes revealed on 7/18/25 at 11:13am, a referral was pending with a local behavioral health hospital. On 7/21/25 at 4:49pm, a referral was submitted to a local nursing facility. On 7/31/25 at 4:46pm, a referral was submitted to another local nursing facility. Record review of CR #1's Nurse Progress Note dated 8/3/25 at 6:03pm, LVN D documented the following: Aide found resident in this resident room and he was touching breast and inner thighs inappropriate (sic). Resident looked at the aide who spoke to this nurse and he said you tattled on me. Staff got resident out. Notified DON. Notified MD. Notified Administrator. Activated one on one sitter (a method of monitoring provided by one person to another).sent out to (local acute care hospital). Record review of a witness statement signed by CNA C dated 8/3/25 revealed on 8/3/25 around 2:45pm, she searched for CR #2 in the hallway and found her in CR #1's room. I witnessed, (CR #1) was laying on the footboard side of this bed and he was touching (CR #2) inappropriately on her left breast and saw (CR #2) had a donut in her hand, which was given by (CR #1) from his bag full of donuts. As I started approaching to move (CR #2) away from (CR #1), he stating touching (CR #2) (sic) inside upper legs area. I immediately verbalized, '(CR #1), please stop'. After hearing me, he stopped touching (CR#2) and in told him that I will go ahead and notify the charge nurse. In response (CR #1) responded stating, 'Don't do that. Don't tell her.' In a telephone interview on 9/18/25 at 11:49am, LVN D said she worked at the facility briefly to help since she worked at the same company. She said an incident occurred with CR #1 during her second day at the facility. She said a CNA reported to her that CR #1 offered the resident across the hall a donut then touched her inappropriately in her room. She said the CNA separated them, put him on 1:1 supervision, reported it to the DON, then he left for the hospital. In a telephone interview on 9/18/25 at 12:12pm, CNA C said she was caring for CR #1 and CR #2 when an incident occurred in August 2025. She said CR #2 moved around the facility in a wheelchair. She said they were directly across the hall from each other. She said on the day of the incident, she noticed she had not seen CR #2 in a while. She said when she walked into her room, CR #1 was laying on the bed with his head near the footboard with a bag of donut holes. She said he was touching CR #2's breast and between her legs. She said she told him, You know that is wrong. She said he responded, Please don't tell. She said she removed CR #2 from the room and informed the nurse. She said the nurse told her to monitor him so she stayed by his room until she left for the day. In an interview on 9/18/25 at 4:56pm, the DON said after CR #1's first sexual abuse incident in April 2025 he was sent to a psychiatric hospital and returned with no recommendations for 1:1 supervision. She said there was not a need for it based on report to the facility. She said he continued psychology services at the facility. She said she was not aware of the incident that occurred in May 2025. She said after CR #1's sexual abuse incident in July 2025, they implemented 1:1 supervision until his psychiatrist discontinued the intervention. She said after the incident in August 2025 he (CR#1) was placed on 1:1 supervision and was discharged immediately to the hospital and did not return. In an interview on 9/18/25 at 6:36pm, the Administrator said after CR #1's first sexual abuse incident in April 2025, they started discussions with his family and learned that he had similar behaviors with his family members. He said if the behavior did not improve then he would need to be discharged . He said after the incident, he would keep his hands to himself in the common areas and would sit on the patio. He said he was not aware of the incident that happened in May 2025. He said when another incident occurred in July 2025, they tried to give CR #1's family member the final call on locating another facility for him. He said CR #1 could propel himself in his wheelchair and they monitored him but also wanted to protect his privacy. He said the last two sexual abuse incidents occurred in a resident's room. He said they were trying to balance supervision and privacy. He said the incidents were surprising and there were no signs or indications that he would act again. He said he told CR #1 that his behavior was inappropriate. In a telephone interview on 9/19/25 at 11:21am, the Former DON said that she worked at the facility until 7/8/25. She said CR #1 had no sexual behaviors prior to the first sexual abuse incident in April 2025. She said after the incident, he was on psychology services, increased monitoring, and believed they updated his care plan. Record review of the facility's Abuse: Prevention of and Prohibition Against policy revised on 12/2024 stated, It is the policy of this facility that each resident has the right to be free from abuse, neglect.abuse is willful infliction of injury.physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes.sexual abuse. This was determined to be an Immediate Jeopardy (IJ) on 9/19/25 at 4:52pm. The Administrator was provided with the IJ template on 9/19/25 at 4:42pm and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 9/20/25 at 7:41pm: Plan of RemovalF600: AbuseThe facility failed to ensure residents were free from abuse when a male resident touched a female resident sexually inappropriately. The facility failed to protect residents from additional abuse immediately after each sexual abuse incident. 1. Facility Medical Director was notified of the IJ on 09/19/2025 at 04:50 pm by the Administrator.2. Abuse, Neglect and Exploitation Policy reviewed by Medical Director, DON, and ED with no changes made on 09/19/25. 3. Resident#1 is no longer the resident at the facility. CR #1 was discharged to a appropriate facility on 08/03/2025 per Responsible Party/Family approval/consent. Resident #5, CR #2 (Victim) and CR #1 (Alleged Perpetrator), Responsible Party/Family were notified on the same date for each reported incident(s) dated 4/19/25; 07/14/25 & 08/03/25. 4. Training and knowledge checks (Post-Test) were initiated with all staff on shift on 09/19/25 at 5PM regarding Resident Abuse, Neglect & Exploitation, Resident Abuse Prevention & Prohibition to include resident rights to be free of sexual abuse from staff or fellow resident(s). This training was given by the RN, Clinical Resource on 09/19/25. Training & Knowledge Check including Post-Test will be completed with all staff by 09/20/25. Any remaining staff member(s) pending Training and knowledge check will complete the Training and Knowledge Check prior to the start of their next scheduled shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. In addition, Nurses will be reeducated by DON/Designee to click the box (in the system) for the note to go to the 24-hour report; if any behaviors are identified this will be added to the resident care profile to monitor behaviors - check care plan, as additional intervention tool to ensure timely interventions/investigation(s) are implemented.5. DON/ designee/ Cluster Partners (Sister Facility Administrator(s) & DON(s) will review incident reports from the last 4 months, to identify any similar allegations; if a similar allegation was identified, this will be investigated and reported as per provider letter. This audit was completed on 9/19/25 and No additional discrepancies were identified. Admissions Coordinator/ Designee will check Sex-Offender registry before admission as additional intervention to identify potential new admission resident for similar sexual behavior. Any new potential resident, flagged for Inappropriate sexual behaviors, will not be admitted to facility to ensure the Abuse Prevention & Prohibition for in-house residents and staff. This a facility intervention, not a policy change.6. DON/ designee will review the 24-hour report daily for identified behaviors. 7. An ad hoc (a non-scheduled QA meeting) meeting will be called regarding items in the IJ templates and will be completed on 09/20/25. Attendees included the DON, Administrator, Medical Director, ADON, Clinical Resource, with inclusion the plan of removal items and interventions.8. Safe- Surveys were conducted on 09/19/25 by Licensed Social Worker, with no additional or similar concerns about individual safety verbalized by Interviewed resident (s). Interviewable resident(s) were included in the Safe-Surveys. The Safe-Survey Questionnaire entails facility staff providing care with dignity & respect, any form of Abuse either by Staff or resident, patient safety & who is the Abuse Coordinator for facility/ who to report for alleged abuse. Interviewed residents were able to answer who to report at (to) facility for any alleged abuse. 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 09/19/25 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of the facilities IJ Template revealed it was signed by the Medical Director (undated). Record review of a Grievance Log and Incident Log dated May 2025 to September 2025 revealed the DON reviewed both and signed her name on the documents. Record review of Safe Survey Questionnaires for Alleged Abuse conducted by the Social Worker revealed she interviewed 18 residents. All residents stated they would speak to the social worker or administrator if abuse occurred, all residents were satisfied with care, and they reported no problems with other residents, staff. Record Review of In-service attendance records dated 9/19/25 revealed the DON presented in-services to all staff, including administrative staff and nursing staff, therapy, housekeeping, maintenance. Topics included: - Abuse prevention, freedom from abuse and neglect.- Reporting alleged violations of abuse, neglect, exploitation and mistreatment.- Reporting suspicion of a crime, freedom from abuse, neglect and exploitation. Record review of an In-Service Attendance Record dated 9/20/25 at 11:00am revealed the Clinical Resource provided education to the Administrator, DON and Social Worker on the topic of conducting abuse and incident investigations/interviews which included the following: Define types of incidents requiring an investigation and reporting to appropriate agencies; Initiated the investigation and preparing for the interview- Includes review of medical records and assessment findings physical, psychological impact, personnel files, training records, policies, equipment, scene of the incident, staff schedules and assignments; Techniques for completing a successful and through interview; Analyze findings from investigation and interviews; Develop plan to prevent future occurrences and care plan updates; Maintaining investigation files and completing final report to appropriate agencies; Evaluation used scenario-based presentations with learner replies demonstrating learned techniques. Interviews with CNA D, MA A, CNA E, LVN F, CNA F, CNA G, LVN G and LVN H on 9/21/25 between 5:37am and 3:31pm revealed they could reiterate the in-services they received, including a resident's right to be free from sexual abuse, their responsibility regarding incidents of abuse, abuse prevention, behaviors that could lead to abuse and identifying and locating care plan areas and interventions. Interviews with the Social Worker, Administrator, DON and ADON on 9/21/25 between 1:57pm and 2:34pm revealed they could reiterate he in-services the received, including their responsibility regarding the abuse policy, abuse investigation, abuse prevention and care plan revisions. In an interview on 9/21/25 at 2:01pm, the MDS Coordinator said she had worked at the facility for one month. She said they audited all residents' care plans to ensure they were current. She said she was responsible for care planning. She said she was informed of incidents by attending morning meetings and reviewing falls and changes of condition. On 9/21/25 at 3:37pm, the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy as the facility continued to monitor the implementation and effectiveness of their corrective systems.

Based on interview and record review, the facility failed to inform each resident of his or her visitation rights and related facility policy and procedures, including any safety restrictions or limitation on such rights, the reason for the restriction or limitation, and to whom the restrictions apply for 1 of 17 residents (Resident #2) reviewed for resident rights. Resident #2 was not informed by the facility when her family member was no longer allowed to visit due to safety restrictions after February 2025. This failure placed residents at risk of not being informed of their rights, confusion and sadness. The findings included: Record review of Resident #2's admission Record generated on 9/23/25 revealed she was admitted to the facility on [DATE]. She had diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), adjustment disorder (a mental disorder defined by maladaptive response to a psychosocial stressor) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). She was [AGE] years of age. Record review of Resident #2's admission Agreement dated 1/23/24 and signed by Resident #2's family member revealed the family member acknowledged that she was informed verbally and in writing of the resident right's as guaranteed through applicable federal and state laws. Record review of Resident #2's Care Plan dated 1/15/24 revealed she was using an antidepressant medication related to depression. Interventions included monitoring, documenting and reporting to physicians for ongoing signs or symptoms of depression, including sadness, irritability, anger, crying, worthlessness, etc. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed she had a BIMS of 8, indicating she had moderate cognitive impairment. She reported feeling sometimes lonely or isolated from those around her. Record review of Resident #2's electronic medical record revealed there were no documents or progress notes regarding visitation restriction. In an interview on 9/17/25 at 10:22am, Resident #2 said she missed her family member, Family Member A, since he was not allowed to visit. She said Family Member A was no longer allowed to visit because he liked LVN R and would look at her. She said the staff asked the family member to leave her alone. She said one staff member yelled at Family Member A because he liked LVN R, and the family member yelled back and threatened him. She said, I cry because I miss him, it's been so long. She said she had not seen him in months. She said she never received a policy or notice about the visitation restriction. In a telephone interview on 9/19/25 at 11:21am, the Former DON said Family Member A was not allowed to visit because he stalked a charge nurse and the police were involved. She said the Administrator handled the situation, so he would know more about it. She said that was all she remembered. In an interview on 9/23/25 at 11:55am, the Social Worker said she was aware that Resident #2's Family Member A could not visit. She said she did know the details. In an interview on 9/23/25 at 3:15pm, the Administrator said Resident #2's family member, Family Member A, was trying to engage in an inappropriate relationship with LVN R. He said he dropped gifts on her car. He said the employee went to the police and filed a complaint. He said they followed the guidance of the police department which was to not allow him on the facility premises. He said Family Member A became aggressive and loud when they informed him of the visitation restriction. He said he was unaware of the facility provided any type of notice to Resident #2. He said some of the incident occurred in February 2025 when he was on leave. He said he review and let me know. In an interview on 9/24/25 at 9:43am, the Administrator said the AIT was at the facility in February 2025 when Family Member A was informed that he was not allowed to visit. He said Family Member A made threatening remarks during the interaction with the AIT. When asked what kind of threatening remarks, he said the family member stated he was going to beat someone. He said Resident #2 was informed by her other family members that he could no longer visit. He said he was unsure if a facility staff member discussed the visitation restriction with her. In a telephone interview on 9/24/25 at 10:21am, the AIT said he was at the facility temporarily when the Administrator was on leave. He said he was told by a staff member that Family Member A could not be at the facility. He said he spoke Spanish, so he volunteered to inform the family member. He said he told Family Member A that he was trespassing and had to leave, then the family member threatened to beat the staff and accused them of lying. He said the police were called and escorted him out. He said he could not remember the following: the staff member who told him that he could not visit, who made the decision regarding the visitation restriction, whether Family Member A was informed of the visitation restriction prior to conversation he had with him, and whether Resident #2 was informed of the visitation restriction. In a telephone interview on 9/24/25 at 10:47am, Resident #2's family member, Family Member B, stated Family Member A was caught looking at a staff member at the facility. Family member B said the staff told Family Member A that he could no longer visit the facility. Family member B said the police were present but did not charge him with any crime. In a telephone interview on 9/24/25 at 12:29pm, ADON B said LVN R told him that she was uncomfortable around Family Member A. He said he noticed Family Member A would stare at LVN R, put flowers on her car and follow her outside. He said LVN R thought she needed a restraining order. ADON B said he told Family Member A that he could not have these behaviors, and Family Member A threatened to kill him and verbally assaulted him. He said he notified the DON and the Administrator. He said he believed Family Member B told Resident #2 about the visitation restriction regarding Family Member A. In an interview on 9/24/25 at 2:50pm, the Administrator said they did not review the resident rights policy when addressing the visitation regarding Resident #2 and Family Member A. He said they reviewed the incidents from the perspective of staff safety. He said Resident #2 was upset because he tried to cheat on her. He said Resident #2 had not expressed concerns about the visitation restriction. He said it was not documented in her medical record because it was more of an issue between Family Member A and an employee. He said LVN R did not receive any type of documentation from the police except for a report number. Record review of the facility policy regarding Visitation Rights of Residents dated 1/2025 stated, It is the policy of this facility to inform each resident and/or resident representative of the rights to receive visitors based on their preferences and any clinical or safety restrictions or limitation on these rights.

Based on interviews, and record review, the facility failed to ensure residents were receiving person-centered Quality of Care for 1 residents (CR#1 ) of 8 residents reviewed. The facility failed to ensure CR #1 was properly transferred from the floor to the bed when displaying signs/symptoms of a fracture (pain, deformity, etc). CR #1 sustained a hip fracture. The facility failed to acknowledge CR#1's verbal complaint of pain by picking her up off the floor possibly causing more harm. The facility failed to follow physician orders and administer CR #1's pain medication (PRN). This failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:34 p.m. While the IJ was removed on [DATE] at 7:22pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm, emotional distress, mental anguish, and death. Findings Include: Record review of CR#1's face sheet dated [DATE] reflected an [AGE] year-old female, with an original admitted [DATE]. Her diagnosis included: Cerebral Infarction of the right middle cerebral artery (stroke), hypertension (high blood pressure) and gastro-esophageal (digestive disorder). Record review of CR#1's Quarterly MDS dated [DATE], revealed the following: CR#1's BIMS score of 06 (severe cognitive impairment), CR#1's Functional Limitation in Range of Motion indicates an impaired Upper and Lower Extremities, uses motorized wheelchair, is dependent on staff for all of her ADL needs, including, rolling to left and right; has had no fall history. Record review of CR#1's orders dated [DATE] revealed, CR#1 was prescribed Aspirin 81 Oral Tablet chewable, Give 1 by mouth one time a day for blood clot prevention. Start date [DATE]; Change NEB MASK/TBING Every Sunday every night shift every Sun. Order date [DATE]; Atorvastatin Calcium 40 MG Tablet, give 1 tablet at bedtime for cholesterol, Start date [DATE]; Apixaban (blood thinner) dated [DATE]; Carvedilol 6.25 MG for htn Hold for SBP less than 120 or HR less than 60. Start Date [DATE] at 9:00pm; Blue-Emu Maximum Pain Relief External Cream 10% (Trolamine Salicylate (used for temporary relief of minor pain associated with arthritis)) apply to hips/knees topically every shift for pain. Order date [DATE] at 8:11am. Record review of CR #1's care plan dated [DATE], revealed the following care areas: Focus: [CR #1] has alteration in musculoskeletal status r/t CVA (stroke) with left sided Hemiplegia (paralysis). Dated initiated, created and revision on [DATE]. Interventions: [CR #1] needs to change position. Alternated periods of rest with activity out of bed in order to prevent respiratory complications, dependent edema, flexion (bending) deformity and skin pressure areas. Dated initiated and created on [DATE]. Interventions: [CR #1] Monitor/ document for risk of falls. Educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls. Date initiated and created on [DATE]; [DATE]; monitor/document to MD PRN s/sx or complications related to arthritis. Focus: [CR #1] I have had a Cerebral Vascular Accident (stroke). Dated initiated, created and revision on [DATE]. Goal: [CR #1] Will be free from s/sx of complications of CVA (stroke) (DVT, Contractures (permanent or temporary tightening of soft tissues, muscles, tendons, ligaments, or skin that restricts normal movement), aspirations pneumonia (lung infection), dehydration (body loses more fluid than it takes in)). Dated initiated, created and target on [DATE]. Interventions: [CR #1] Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat. Dated initiated, created on [DATE]. Focus: [CR #1] I receive routine Anticoagulant therapy r/t hx of CVA (stroke). Dated initiated and created on[DATE]. Goal: [CR #1] Will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Dated initiated and created on[DATE]. Target Date: [DATE]. Interventions: [CR#1] Labs as ordered. Report abnormal lab results to the MD. Dated initiated and created on[DATE]; Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, bleeding, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Dated initiated and created on[DATE]. Focus: [CR #1] Has potential impairment to skin integrity r/t decreased mobility and poor oral intake. Dated initiated and revision on [DATE]. Goal: [CR #1] Will be free from injury through the review date. Dated initiated and created on [DATE]. Target date: [DATE]. Interventions: [CR#1] Assist with and encourage turning and repositioning. Focus: [CR #1] I have an ADL Self Care Performance Deficit r/t weakness, CVA, impaired mobility. Dated initiated and created on [DATE]. Goal: [CR#1] Will safely perform Bed Mobility, Transfers, Eating, dressing, Grooming. Toilet Use and Personal Hygiene with modified independence through the review date. Dated initiated and created on [DATE]. Revision [DATE]. Target Date: [DATE]. Interventions: [CR#1] Converse with resident while providing care Dated initiated and created on [DATE]. Revision [DATE]. Target Date: [DATE]; Mobility bars for turning and repositioning Dated initiated and created on [DATE]; Toilet Use (toilet transfer, toilet hygiene): Requires staff participation to use toilet. Date initiated and created on [DATE]. Revision [DATE]. Focus: [CR #1] I am at risk for falls r/t left sided hemiplegia from CVA (stroke), impaired mobility (a limitation in a person's ability to move around easily and independently. Dated initiated and created on [DATE]. Revision [DATE]. Goal: [CR#1] Will not sustain serious injury through the review date. Dated initiated and created on [DATE]. Target Date: [DATE]. Interventions: [CR#1] Bed in lowest position as resident will allow. Dated initiated and created on [DATE]. Revision on [DATE]. Record review of the facility's video dated [DATE], revealed the following: 6:26am Resident #2 is seen coming out of the room and walking down the hall. 6:27am Resident #2 is at the nurses' station where LVN A was sitting at the nurses' station along with CNA C who was at the desk and CNA B who was standing at the desk. Resident #2 appeared to have made a statement then leaves nursing desk at 6:28am. At this time, CNA B paused before joining Resident #2, then both began walking down the hall. 6:28am Resident#2 and CNA B walked into CR#1's room. You can see CNA D, who was carrying a trash bag, walking past CR#1's room, then being alerted by CNA B. CNA D continued to another room and placed the trash bag, then proceeded to nurses' station and notified LVN A and CNA C, which is when all 3 proceeded down the hall at 6:28am. 6:30am WCN entered CR#1's room. 6:31am CNA C was observed casually walking to the nursing station, then making the 911 call. 6:31 am CNA B and CNA D exited CR#1's room, which left Resident #2 and CR#1 in the room alone. 6:32 WCN goes back into the room after getting supplies. 6:33 CNA C called DON. 6:38am CNA places Resident #2 in wheelchair and removes her from room. 6:39 CNA B leaves room. 6:41pm EMS arrives to the facility and enters building at 6:42am 6:44am enters CR#1's room. 6:51am EMS exits the facility with CR#1, At 6:52am outside of the facility, EMS covers CR#1 with a sheet. During the video, it was observed that all the staff left CR#1's room, while Resident #2 was still in the room with CR#1. Record Review of nursing notes written by WCN dated [DATE] at 8:27am, revealed, Resident observed lying on the floor feet facing foot bed, vitals taken, pain assessment made, head to toe assessment performed. Resident vitals ,d+[DATE] P-76 C/O pain from hip. PRN aspirin administered, resident noted with cut by right eye, EMS services immediately contacted, skin tear on left arm. Resident was not aware of how they ended up on the floor, seen by wound care physician, wounds cleansed, with wound cleanser, cut medicated with collagen powder, ST addressed with xeroform and dry dressing. RP notified; Dr. notified. Record Review of the EMS run report revealed, EMS arrived at the facility on [DATE] at 6:37am. Facility reported resident fell off bed. Patient presents with laceration above right eyebrow and swelling to right cheekbone and has a bloody nose. Patient is laying on nursing home bed with no sheets. Nursing home staff must have picked her up to the floor and placed her on bed with no sheets. There was blood all over the floor around the bed. Nursing home staff stated that patient is always altered that is her normal baseline state of mind. Patient presents with right hip in an abnormal position. Nursing home facility states that that is normal for her. Patient is complaining of right hip pain. PT (Patient) denies neck or back pain. Patient transported to trauma hospital as a precaution due to unknown patient hip history. Pt presents in an altered state. Nurse stated altered is baseline. Vitals assessed and recorded. Patient found to be at 88% at room air. Patient placed on nasal cannula at 3 liters and O2 sat improved to 95%. EKG show sinus rhythm. 18 Gage IV established in patients' right forearm. Patient transported to trauma facility. Pt history of blood thinners. Record review of the Local Hospital Trauma notes dated [DATE] at 7:47am, revealed the following: *Secondary Impressions: Accidental fall, Closed head injury, Frail elderly, intraventricular hemorrhage (serious brain bleed that occurs when blood enters the brain's ventricles), Nursing home resident, Right femoral fracture (also known as a broken bone), Sepsis (infection in the blood), TBI (traumatic brain injury) (brain damage), Transient hypotension 9 (temporary drop in blood pressure), Traumatic subarachnoid hemorrhage (bleeding in the space between the brain and thin membrane): *Resident was brought in by EMS from a nursing home bed for the evaluation of a closed head injury. On examination, the patient is frail, pale, thin malnourished, appearing chronically ill. Contracted left upper extremity. Contracted right lower extremity with the right lower extremely severely exaggerated internal rotation and shortening. Neurovascular intact in all extremities. Neurologically appears to be at baseline. She is screaming articulated normal speech. Localizing pain. Moving all extreme appropriately. She has a traumatic abrasion/laceration to the right supraorbital region (above the eye). Mild ecchymosis (bruise) to the right periorbital region(area around the eye socket). *Radiology of XR Pelvis area revealed, comminuted, minimally displaced right femur intertrochanteric fracture (a break in the bone (femur) just below the hip joint, between the greater and lesser trochanters (an attachment points for muscles) with varus angulation (deformity where the distal segment of a bone is angled inward, toward the midline of the body). *Head CT (imaging): Diffuse subarachnoid (a bleeding that occurs in the space between the brain and the thin membranes that cover it). *Blood tests showed WBC 22.7 (high) and Sepsis. Record Review of Facility's last vitals taken for CR#1: [DATE] Pain taken at 3:07am 0 value [DATE] Blood Pressure taken at 8:19pm ,d+[DATE] [DATE] Pulse taken at 8:19pm 66 bpm [DATE] Wts (Weights) taken at 3:51pm 91.2 Lbs [DATE] O2 stats taken at 9:23pm 95.0% [DATE] Temp taken at 3:10pm Record Review of Pain Management Review dated [DATE] at 6:57am, revealed change in condition, and the Pain Interview indicated the CR#1 was able to be interviewed, she was not hurting, has not had pain in the last 5 days, and there were no possible indicators for pain. Record Review of Fall Risk Evaluation completed by LVN A on [DATE] at 6:53am revealed, CR#1 stated was disoriented x 1, has history of falls in the past 3 months, no noted drop in blood pressure, and CR#1 has No Present predisposing conditions of Hypotension, Vertigo, CVA, Parkinson's Disease, Loss of Limb(s), seizures, arthritis, osteoporosis, fractures, Multiple Sclerosis, Wandering. During a interview on [DATE] at 2:50pm with Admin - as the video played it showed all staff leave out of CR#1. The Admin stated staff should not have left the two residents (CR#1 and Resident #2) in the room by themselves. He stated only one staff was good enough to get a nurse. He stated it took 3 minutes from the time CR#1 was found and staff calling 911. He stated he did not know if 3 minutes was an appropriate time to call 911. During a interview on [DATE] at 12:05 with RP#2 who stated CR#1 is a roommate to Resident#2. He stated he visits often, either daily or every other day. RP#2 stated when visiting he stayed around 2 hours. He stated that he has observed CR#1 just lying in the same position during the time he was visiting. He stated CR#1 appeared to be bedbound and didn't move at all. RP#2 stated she didn't talk. During a interview on [DATE] at 12:40pm with CNA A stated she is familiar with CR#1 and she can hardly move because she is bedridden. CNA stated on [DATE] around 6:30am she observed EMS coming to CR#1's room. She stated CR#1 was not assigned to her. During a interview on [DATE] at 12:49pm with CNA B stated she was at the nursing desk around 6:10am when CR#1's roommate, Resident #2, walked up and said her roommate was on the floor. She stated she followed Resident #2 to the room and observed CR#1 on the floor between in a perpendicular position. She stated CR#1 was face down and bleeding in head area. She stated she couldn't recall seeing a fall mat by CR#1's bed. During a telephone Interview on [DATE] at 1:55pm with RP#1 stated he received a call from the facility around 6:30am from an unknown person indicating CR#1 had fallen in her room and staff would keep an eye on her. He stated there was no urgency from the staff member. RP#1 stated at 8:00am (1.5 hours later) he received another call from the facility stating 911 had been called and CR#1 had been taken to hospital just for observation. RP#1 stated minutes after receiving the call from the facility, he received a call from the hospital informing him that CR#1 was unconscious, suffering from a brain bleed and multiple hip fractures; and instructed him to hurry to the ER room. RP#1 stated he called the facility and spoke with ADON A who told him that he received a call around 5:00am this morning and that staff found CR#1 on the floor while they were doing their rounds. ADON A told RP#1 he didn't know much, but when he got to the facility, he would find out more and give him a call with an update. RP#1 stated according to the hospital CR#1 arrived at the hospital at 7:37am and was admitted 9:00am. He stated he spoke with the trauma doctor who told him due to the extent of resident injuries she would need to contact Hospice. RP#1 stated CR#1 died from her injuries around 5:00pm. RP#1 stated CR#1 is completely immobile and not able to move herself. He stated CR#1 leans on her left side; however, he found it to be odd that the injury is on the right side of the body. During a interview on [DATE] at 2:45pm ADON - stated he received a call around 6:13am from CNA C who informed him CR#1 was found on the floor. ADON stated he spoke with RP#1 but couldn't remember all of the details of the conversation. He stated he told RP#1 that he was still trying to find out details of CR#1's fall. During a interview on [DATE] at 2:50pm with WCN who stated he was summoned to CR#1's room a little after 6:00am by CNA C who informed him that CR#1 was on the floor face down bleeding. WCN stated upon his arrival to the room, he observed CR#1 in a vertical (perpendicular) position and positioned in between the two beds. WCN further described the position CR#1 face down on the floor bleeding, her head was toward her bed and her feet was toward Resident#2's bed. WCN stated LVN A was conducting a head-to-toe assessment. During the assessment, WCN heard CR#1 complain her hip was hurting and there was no pain in her head. WCN stated after LVN A completed the assessment, he and LVN A picked CR#1 up and put her in the bed. WCR stated CR#1 sustained a 1cm gash above her, he believes, right eye. WCN stated after CR#1 continued to be complained about her hip he directed CNA C to call 911. During a interview on [DATE] at 3:51pm with CNA C stated she began work at 6:13am. She stated she was seated at the nursing desk when Resident#2 arrived at the desk and informed nurses CR#1 had fallen. She stated CNA B walked with Resident#2 back to her room. CNA B returned to nursing station and reported CR#1 was on the floor bleeding and it was fresh blood. CNA C stated when she arrived at the room, she observed CR#1 on the floor face down between the two beds. Stated CNA B went and got WCN. When the WCN arrived, he told her to call 911. During a interview on [DATE] at 4:05pm with LVN A, she stated CNA B returned to the nursing desk and said CR#1 was on the floor and bleeding. She stated when she arrived at CR#1's room she observed CR#1 on floor, face down, and bleeding from her face. LVN A stated she did not assist in putting resident in the bed. She stated she noted there was a laceration above CR#1 eye area where she was bleeding. Stated at no time had the roommate come to the desk. Stated WCN did vitals and cleaned up resident face before leaving. Stated she arrived in the room and told WCN, CR#1 needed to go to the hospital she hit her head. This was after 6am. Stated CNA C called 911. She worked 300 Hall. LVN A stated CR#1 was stated she needed creme for her hip. During a telephone interview on [DATE] at 5:06pm with CNA D stated she was not assigned the 100 hall and CR#1 was not on her list. She stated she heard CR#1 had fallen. During a follow Up Interview on [DATE] at 10:00pm with CNA A, she was asked to clarify the earlier interview. CNA A stated she was assigned to 100 hall but was 30 minutes late. She stated she arrived at 6:30am. CNA A stated when she got on the 100 hall, she was informed by another CNA that CR#1 had fallen. She stated she went in the room and the WCN was cleaning blood off CR#1's face, while she was lying on her bed. CNA A stated WCN directed her to get additional towels and blankets so that he could clean the blood off the floor as he was stepping in it. CNA A stated about 10 minutes later (6:40am) EMS arrived at CR#1's door. During a telephone interview on [DATE] at 10:15pm with CNA E, she stated she worked the 100 hall and was responsible for CR#1. She stated she worked on ([DATE]) Tuesday night (10:00pm -6:00am). CNA E stated she made her last round between 4:30am-4:45am. She stated CR#1 was in her bed. CNA E stated its really odd that CR#1 fell out of bed, since the resident is bedbound and rarely moves. CNA E stated she clocked out at 6:15am and there were no issues with the resident. During an Interview on [DATE] at 4:00pm with DON, she stated the protocol for unwitnessed fall with injury was staff should alert nurse, complete patient assessment, stay with patient, depending on nursing assessment patient can go out to hospital and MD, family notified. The DON stated staff should not move a resident with a head injury; unless the resident is in a position where additional harm may exist, then the nurses are to use their judgement. The DON stated CR#1 should have been moved to determine what could be done in house until EMS arrives. She further stated CR#1 should have been picked up and placed in bed based on the nursing assessment. She stated CR#1 did hit her head; however, there were no bulging and/or abnormalities to determine if she needed to stay on the floor or moved. DON stated in this case, CR#1, after nursing assessments, there were no abnormalities. The DON stated 911 was called because of head bleeding. It was considered an emergency because she was on blood thinners. DON stated she was notified at 6:30am and believes staff followed protocol in CR#1's case and there is nothing she would have expected differently. She reiterated she believed what nursing staff did what they had to do to get CR#1 treatment. DON stated CR#1 was not mobile. She stated CR#1 could wiggle but not sit up on her own. DON stated that speaking with nursing staff that work with CR#1, she was able to scootch her body. DON stated she feels like CR#1 may have scooted and slid off the side of the bed. The DON stated CR#1 could feed herself slightly, but staff would have to straighten her up in the bed to eat. The DON stated she has never had an extensive conversation with CR#1 but stated she could ask for drinks from time to time and she would give it to her. DON stated CR#1 was not in therapy. . During aInterview [DATE] at 4:24pm with Admin, he stated he is the abuse coordinator. He stated his expectations were for all staff to follow policy for abuse, report immediately, within two hours report per policy. He stated prevention strategy was being consistent with the reporting abuse process, continuing to educate staff and ongoing abuse and neglect training. He stated he expected all staff to enter the building (facility) with a mindset of treating residents with dignity and respect and resolve issues for customer satisfaction. His expectation of the DON was to provide the best care possible to residents with compassion and respect. The Admin stated the only time he would suspect abuse was dependent on if there was a witness or not; and after a full investigation has been completed. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:34 p.m. While the IJ was lowered on [DATE] at 7:22pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Name of facility: [facility name] Date: [DATE] Tag: F-684 Problem: The facility failed to assess the resident and call 911 immediately on [DATE], after a resident reported that her roommate was on the floor. Immediate Action: 1.The medical director was notified of IJ on [DATE] by Executive Director 2.Head to toe guidelines were reviewed by Medical Director, DON, and ED with no changes made [DATE] parentheses (see attached) 3.Education initiated with all licensed nurses on head-to-toe assessments, when to complete an assessment and calling 911 on [DATE] by DON, ADON, Clinical Resources and Cluster Nursing Leadership completion date [DATE] 4.All licensed nurses will complete competency on head-to-toe assessments started on [DATE]. Completion day [DATE] 5.This training and competencies will be completed in person with all staff prior to the start of their shift a member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 6.And ad hoc meeting regarding items in the IJ template will be completed on [DATE]. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources and will include the plan of removal items and intervention. Surveyor confirmed the facility implemented their plan of removal and monitoring began on [DATE]. During a telephone interview[DATE] 11:42pm with LVN B stated she had training before her shift started. Stated the training was on abuse and neglect, reporting incidents. She stated the Admin and ADON took employees to office, where the employees were given a posttest then training. She stated abuse can be identified by bruises on a resident, or when resident says don't hurt me when providing care, the resident is jumpy and acting in an unusual behavior like scared. LVN B stated the assessment training was about falls, etc , which when a resident has a witnessed or unwitnessed fall, a full body assessment should be completed immediately. Any incident of finding resident do not move call 911. Stated if any resident is bleeding from head, I call 911 immediately. LVN stated nursing staff should never leave resident by themselves always have someone with resident. The head-to-toe assessment consists of checking entire body, vital signs, check body for any injuries, if able, move patient limbs ROM. All nursing staff is required to document in PCC (nursing notes) and complete an incident report. She stated she worked the morning that the situation occurred with CR#1 but did not assist anyone in putting resident in the bed. During a telephone interview [DATE] 11:59pm with LVN A - Stated she received training on full body assessments. Call 911 tell them that it is an emergency. Abuse coordinator is the Administration. LVN A stated the ADON gave a pretest on falls and abuse. They were true false questions on falls and abuse. Stated a resident with a fall and obvious head injuries complete assessments, take vitals, call MD and EMS services if need to be sent out. Stated it's important to document on an incident report and transferred to the nurses' notes in PCC. LVN A stated and another lady got her off the floor. One leg was bent under the other. Stated her leg was folded. Not sure if it was a fixed position. Believes it was a left leg under the right folded at a 45-degree angle. A resident should never be left alone, and someone should be with the resident at all times because anything can happen. LVNA stated she believe the CNA that assisted WCN was CNA D. During a telephone interview[DATE] at 12:20am with CNA E stated she had in service ,d+[DATE] times this week. CNA E stated she had a training on abuse and neglect. Completed a quiz a true or false test. Stated if she comes up on a resident that has fallen, she will summon her nurse, ensure resident is secured if alone, and call out loud from hallway to get a nurse. She stated there should always be an urgency. Stated if a resident was on ground you don't touch until a nurse is available to assess them then follow their directions. Stated an example of abuse was refusing to clean patient, using resident personal property for own personal gain, and physical abuse. She stated she did not assist resident in bed. She did not know CR#1 had fallen. During a telephone interview on [DATE] at 12:35am with CNA I stated she was on vacation the last (two) 2 weeks and returned last night. Stated she had in-service training on abuse, reporting, posttest. Abuse is verbally badgering a resident; an example of exploitation is personal gain for something that belongs to a resident. If you see resident on floor, do not touch, go, and get nurse, stated after the nurse completes her assessment the nurse will instruct you on whether the resident can be moved. You must follow instructions given by the nurse. Was not at the facility when CR#1 fell . If there is a fall or other unusual activities it should be reporter to nursing staff and followed up by an incident report. During an Interview on [DATE] at 6:15am with CNA D stated she has been in serviced on abuse and 911 calls. She stated she learned that to call 911 you have to say it's an emergency. CNA D stated she would call 911 if nurse tells her to call, she will call. CNA D stated the types of abuse are physical, can't hit residents. If an employee put their hands on a resident, it should be reported to nurse or the DON and ADON and Admin. Admin was the Abuse Coordinator. CNA D stated some of the s/s of resident abuse are observed by bruises or suspicious injuries on the resident's body. CNA D stated she just helped the WCN pick CR#1 up off the floor, she was doing patient care on another resident. She stated CNA B came and got her and said CR#1 was on the floor. CNA D was leaving room [ROOM NUMBER] and then went to resident room and CR#1 was on the floor. CNA D said CR#1's head was at the headboard and her feet were at the floorboard and CR#1 was laying on her side right side, but head was on the floor. CNA D stated she was shaken up because she had never seen CR#1 move. She stated the staff in the room when she arrived was WCN, CNA B, and CNA C. CNA D stated she thought WCN did an assessment on CR#1, but wasn't because she walked out of the room. WCN had CR#1 from the shoulders and CNA D had her legs. Before picking her up he checked temp, blood pressure and asked her what day it was. She picked her up and then walked out, she couldn't see her like that. CR#1 said she needed cream for her right hip, but she says that every day. CNA D noticed that her hip looked like it was out of place, after she got her in the bed, she said it looked like something was wrong with her hip. Her leg was just limp. She told WCN that and he had CNA C call 911. It was the WCN's idea to pick her up off the ground. She said she didn't realize the hip looked like that until they got her in the bed. She said she didn't think she could have injured her she had her ankles. WCN's arms were under CR#1's arm pit cradled, and CNA D had her ankles. The bed was low. CR#1 did not have a scoop mattress. During an Interview on [DATE] at 6:34 am CNA F stated she was in-serviced on abuse, elopement, and so many others before she started her shift. She stated the types of abuse on residents are physical, mental, financial, and sexual abuse. CNA F stated the Admin is the Abuse Coordinator. CNA F stated she would intervene if she was witnessing abuse and would report immediately. She stated one sign of abuse is when a resident has been physically abused and their behavior changes. CNA F stated s/s of abuse is residents being jumpy, saying don't hurt me, suspicious injuries, bruises. She stated when told to call 911 you must tell them it's an emergency. With unwitnessed or witnessed falls, the nurses perform head to toe assessments. During an Interview on [DATE] at 6:38 am CNA C stated she was in serviced on abuse, neglect, exploitation and for calling 911. She stated when calling 911 you are supposed to tell dispatcher it's an emergency. CNA C stated examples of abuse are financial, isolation, physical, mental and sexual. She stated when a resident is scared of someone, or they may tell you they have been abused. CNA C stated she would report to Admin immediately. She stated the Admin's telephone number is everywhere around the building so if he's not at the facility you can still contact him. She stated if two residents are engaged in an altercation, she would separate them. CNA C stated she called 911 when CR#1 fell . She stated 911 asked her, what's your emergency, medical or fire? CNA C stated, medical. She stated then 911 asked, what's the emergency, which was when CNA C stated, we have a patient laying on the floor. She stated the 911 operator asked [TRUNCATED]

Based on interviews, and record review, the facility failed to ensure residents were free from Accident Hazards and Supervision for 1 resident (CR#1) of 8 residents reviewed for Accident Hazards and Supervision. The facility failed to ensure each CR #1 was transferred properly after she was found face down on the floor, sustaining multiple injuries, including laceration above the eye, closed head injury and broken femur. The facility failed to acknowledge CR#1's verbal complaint of pain by picking her up off the floor possibly causing more harm. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 4:34 p.m. While the IJ was removed on 03/29/2025 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm. Findings Include: Record review of CR#1's face sheet dated 11/8/2023 reflected an [AGE] year-old female, with an original admitted [DATE]. Her diagnosis included: Cerebral Infarction of the right middle cerebral artery (stroke), hypertension (high blood pressure) and gastro-esophageal (digestive disorder). Record review of CR#1's Quarterly MDS dated [DATE], revealed the following: CR#1's BIMS score of 06 (severe cognitive impairment), CR#1's Functional Limitation in Range of Motion indicates an impaired Upper and Lower Extremities, uses motorized wheelchair, is dependent on staff for all of her ADL needs, including, rolling to left and right; has had no fall history. Record review of CR#1's orders dated 11/8/2023 revealed, CR#1 was prescribed Aspirin 81 Oral Tablet chewable, Give 1 by mouth one time a day for blood clot prevention. Start date 11/9/2023; Change NEB MASK/TBING Every Sunday every night shift every Sun. Order date 5/20/2024; Atorvastatin Calcium 40 MG Tablet, give 1 tablet at bedtime for cholesterol, Start date 11/9/2023; Apixaban (blood thinner) dated 11/8/2023; Carvedilol 6.25 MG for htn Hold for SBP less than 120 or HR less than 60. Start Date 6/28/2024 at 9:00pm; Blue-Emu Maximum Pain Relief External Cream 10% (Trolamine Salicylate (used for temporary relief of minor pain associated with arthritis)) apply to hips/knees topically every shift for pain. Order date 2/19/2025 at 8:11am. Record review of CR #1's care plan dated 11/8/2023, revealed the following care areas: Focus: [CR #1] has alteration in musculoskeletal status r/t CVA (stroke) with left sided Hemiplegia (paralysis). Dated initiated, created and revision on 12/12/2023. Interventions: [CR #1] needs to change position. Alternated periods of rest with activity out of bed in order to prevent respiratory complications, dependent edema, flexion (bending) deformity and skin pressure areas. Dated initiated and created on 12/12/2023. Interventions: [CR #1] Monitor/ document for risk of falls. Educate resident, family/caregivers on safety measures that need to be taken in order to reduce risk of falls. Date initiated and created on 12/12/2023; 12/12/2023; monitor/document to MD PRN s/sx or complications related to arthritis. Focus: [CR #1] I have had a Cerebral Vascular Accident (stroke). Dated initiated, created and revision on 12/12/2023. Goal: [CR #1] Will be free from s/sx of complications of CVA (stroke) (DVT, Contractures (permanent or temporary tightening of soft tissues, muscles, tendons, ligaments, or skin that restricts normal movement), aspirations pneumonia (lung infection), dehydration (body loses more fluid than it takes in)). Dated initiated, created and target on 12/12/2023. Interventions: [CR #1] Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat. Dated initiated, created on 12/12/2023. Focus: [CR #1] I receive routine Anticoagulant therapy r/t hx of CVA (stroke). Dated initiated and created on12/12/2023. Goal: [CR #1] Will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Dated initiated and created on12/12/2023. Target Date: 1/6/2025. Interventions: [CR#1] Labs as ordered. Report abnormal lab results to the MD. Dated initiated and created on12/12/2023; Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, bleeding, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Dated initiated and created on12/12/2023. Focus: [CR #1] Has potential impairment to skin integrity r/t decreased mobility and poor oral intake. Dated initiated and revision on 5/11/2024. Goal: [CR #1] Will be free from injury through the review date. Dated initiated and created on 5/11/2024. Target date: 1/6/2025. Interventions: [CR#1] Assist with and encourage turning and repositioning. Focus: [CR #1] I have an ADL Self Care Performance Deficit r/t weakness, CVA, impaired mobility. Dated initiated and created on 11/9/2023. Goal: [CR#1] Will safely perform Bed Mobility, Transfers, Eating, dressing, Grooming. Toilet Use and Personal Hygiene with modified independence through the review date. Dated initiated and created on 11/9/2023. Revision 11/10/2023. Target Date: 1/6/2025. Interventions: [CR#1] Converse with resident while providing care Dated initiated and created on 11/9/2023. Revision 11/10/2023. Target Date: 1/6/2025; Mobility bars for turning and repositioning Dated initiated and created on 1/27/2025; Toilet Use (toilet transfer, toilet hygiene): Requires staff participation to use toilet. Date initiated and created on 11/10/2023. Revision 11/10/2023. Focus: [CR #1] I am at risk for falls r/t left sided hemiplegia from CVA (stroke), impaired mobility (a limitation in a person's ability to move around easily and independently. Dated initiated and created on 11/9/2023. Revision 2/20/2024. Goal: [CR#1] Will not sustain serious injury through the review date. Dated initiated and created on 11/9/2023. Target Date: 1/6/2025. Interventions: [CR#1] Bed in lowest position as resident will allow. Dated initiated and created on 11/9/2023. Revision on 4/21/2024. Record review of the Local Hospital Trauma notes dated 3/4/25 at 7:47am, revealed the following: *Secondary Impressions: Accidental fall, Closed head injury, Frail elderly, intraventricular hemorrhage (serious brain bleed that occurs when blood enters the brain's ventricles), Nursing home resident, Right femoral fracture (also known as a broken bone), Sepsis (infection in the blood), TBI (traumatic brain injury) (brain damage), Transient hypotension 9 (temporary drop in blood pressure), Traumatic subarachnoid hemorrhage (bleeding in the space between the brain and thin membrane): *Resident was brought in by EMS from a nursing home bed for the evaluation of a closed head injury. On examination, the patient is frail, pale, thin malnourished, appearing chronically ill. Contracted left upper extremity. Contracted right lower extremity with the right lower extremely severely exaggerated internal rotation and shortening. Neurovascular intact in all extremities. Neurologically appears to be at baseline. She is screaming articulated normal speech. Localizing pain. Moving all extreme appropriately. She has a traumatic abrasion/laceration to the right supraorbital region (above the eye). Mild ecchymosis (bruise) to the right periorbital region (area around the eye socket). *Radiology of XR Pelvis area revealed, comminuted, minimally displaced right femur intertrochanteric fracture (a break in the bone (femur) just below the hip joint, between the greater and lesser trochanters (an attachment points for muscles) with varus angulation (deformity where the distal segment of a bone is angled inward, toward the midline of the body). *Head CT (imaging): Diffuse subarachnoid (a bleeding that occurs in the space between the brain and the thin membranes that cover it). *Blood tests showed WBC 22.7 (high) and Sepsis. Record Review of Facility's last vitals taken for CR#1: 3/4/2025 Pain taken at 3:07am 0 value 3/3/2025 Blood Pressure taken at 8:19pm 127/69 3/3/2025 Pulse taken at 8:19pm 66 bpm 2/7/2025 Wts (Weights) taken at 3:51pm 91.2 Lbs 12/2/2024 O2 stats taken at 9:23pm 95.0% 11/12/2024 Temp taken at 3:10pm Record Review of Fall Risk Evaluation completed by LVN A on 3/4/2025 at 6:53am revealed, CR#1 stated was disoriented x 1, has history of falls in the past 3 months, no noted drop in blood pressure, and CR#1 has No Present predisposing conditions of Hypotension, Vertigo, CVA, Parkinson's Disease, Loss of Limb(s), seizures, arthritis, osteoporosis, fractures, Multiple Sclerosis, Wandering. Record Review of Facility's policy dated 05/2007 revealed, a transfer is the safe movement of a resident from one surface to another. FLOOR TO BED 1. Two-person lift a. Preparation 1. Ensure the bed is at a comfortable height and the area is free of obstacles. b. Positioning 1. One person kneels on the side of the resident 2. One person kneels on the opposite side of the resident 3. Support the head, torso, and hips. c. Lifting 1. Both people gently lift the resident off the floor keeping their back straight and using their legs for power. d. Transfer 1. Move the resident to the bed ensuring a smooth and controlled transfer. During an Interview on 3/5/2025 at 2:50pm with WCN stated he heard CR#1 complain her hip was hurting and there was no pain in her head. WCN stated after A completed the assessment, and he ruled out any head injury, he felt it was okay to move resident to the bed. He stated he and LVN A picked CR#1 up and put her in the bed. WCR stated CR#1 sustained a 1cm gash above her, he believes, right eye. WCN stated after CR#1 continued to be complained about her hip he directed CNA C to call 911. During an Interview on 3/6/2025 at 4:00pm with DON, she stated the protocol for unwitnessed fall with injury was staff should alert nurse, complete patient assessment, stay with patient, depending on nursing assessment patient can go out to hospital and MD, family notified. The DON stated staff should not move a resident with a head injury; unless the resident is in a position where additional harm may exist, then the nurses are to use their judgement. The DON stated CR#1 should have been moved to determine what could be done in house until EMS arrives. She further stated CR#1 should have been picked up and placed in bed based on the nursing assessment. She stated CR#1 did hit her head; however, there were no bulging and/or abnormalities to determine if she needed to stay on the floor or moved. DON stated in this case, CR#1 could be moved, after nursing assessments, because there were no abnormalities. During a Follow-up Interview on 3/7/25 3:14pm with WCN who reiterated CR#1 was face down on the floor. He stated there were no bulging or contusion, and CR#1 told him she only had pain in her hip before he moved her. WCN stated CR#1's vitals were checked. He stated CR#1 was about 96% for 02 stats. WCN stated CR#1 was not on oxygen. WCN stated he had given CR#1 aspirin for PRN (Given as needed) for her hip pain. WCN stated, CR#1 was lifted by her head and legs. When asked who assisted him in lifting CR#1, he stated, I lifted with a black girl. He stated he had upper body, and the CNA had the feet area. WCN stated CR#1 complained of hip pain, but he moved her anyway. WCN stated he should not have moved her. WCN stated he could have furthered injured resident and fractured her hip when he moved her. WCN stated he has had Unwitnessed Fall Training, which consist of reporting, vitals, documentation, neuro checks, contact family, MD, and DON. During a Telephone Interview on 3/7/25 11:59pm with LVN A -. LVN A stated another lady got CR#1 off the floor. She stated One of CR#1's legs was bent under the other. Stated her leg was folded. Not sure if it was a fixed position. Believes it was a left leg under the right folded at a 45-degree angle. LVN A stated she believe the CNA that assisted WCN was CNA D. During an Interview on 3/8/2025 at 6:15am with CNA D stated she just helped the WCN pick CR#1 up off the floor, she was doing patient care on another resident. She stated CNA B came and got her and said CR#1 was on the floor. CNA D was leaving room [ROOM NUMBER] and then went to resident room and CR#1 was on the floor. CNA D said CR#1's head was at the headboard and her feet were at the floorboard and CR#1 was laying on her side right side, but head was on the floor. CNA D stated WCN had CR#1 from the shoulders and CNA D had her legs. Before picking her up he checked temp, blood pressure and asked her what day it was. She picked her up and then walked out, she couldn't see her like that. She stated CR#1 said she needed cream for her right hip, but she says that every day. CNA D noticed that her hip looked like it was out of place, after she got her in the bed, she said it looked like something was wrong with her hip. Her leg was just limp. She told WCN that and he had CNA C call 911. It was the WCN's idea to pick her up off the ground. She said she didn't realize the hip looked like that until they got her in the bed. She said she didn't think she could have injured her she had her ankles. WCN's arms were under CR#1's arm pit cradled, and CNA D had her ankles. The bed was low. CR#1 did not have a scoop mattress. During an Interview on 3/8/2025 at 6:54am with ADON he stated no one should ever move a resident unless assessment determines no harm was done. ADON stated he does not have x-ray vision so he would ask the resident about pain and if resident says no pain, then its ok, but if the resident says they have hip pain, that resident should not be moved and staff would want call ambulance, because a stretcher would stabilize the resident. You don't want to further injure the resident. ADON stated every resident that hits the floor doesn't mean that they fractured something. He stated that what's included in an assessment, is pain level, resident alertness, bleeding, bruising, anything new scarring skin tears. All vitals, blood pressure, pulse, oxygen, blood sugars, O2 sats and temperature should be documented in the computer (PCC-Nursing Notes). ADON stated if it's not documented it's not done. During a Telephone Interview on 3/8/25 at 7:00pm with DON- stated a head-to-toe assessment was for emergency situations was to assess the resident for pain or injury, alertness, consciousness, abnormalities, broken bones, bleeding, and breathing. The DON stated she was notified of CR#1's fall at 6:31am. The DON stated the proper way to move the resident off the floor is to ensure resident and staff are not injured during the move. She stated two people must pick up a person from the floor. The DON stated staff were to make sure patient is secured from floor to bed, the upper body, lower body should be secured. The DON stated when picking up residents you are not to grab them by their clothing or ankles. She stated the lower body was described as grabbing the resident under their bottom and the other hand supporting their legs and lifting them up. The upper body was supporting their head and back. She stated sometimes during a residents' fall, getting a Hoyer lift may create more time for transporting resident off the floor. The DON stated that based on what the nurses told her during CR#1's assessment, she would not do anything differently. She stated she also spoke with the Medical Director and the doctor was also in agreement with nursing staff's actions. An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 4:34 p.m. While the IJ was lowered on 03/29/2025 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Name of facility: [Facility Name] Date: 3/6/2025 Tag: F-689 Problem: The facility failed to ensure the resident environment remain free of accident hazards as is possible and residents receive adequate supervision and assistance when being transferred. The fill of solidity fell to properly transfer CR #1 from the floor causing an injury and being hospitalized . Immediate Action: 1. Medical director was notified of IJ on 3/27/2025 at 6:16 PM by Executive Director 2. What to do when a resident falls, including when and if to transfer was reviewed by Medical Director, DON, and ED with no changes made 3/27/25 (see attached) 3. Education initiated with all nursing staff by on what to do if a resident falls to include if and when to transfer on 3/27/2025 by DON, ADON, Clinical Resources and Cluster Nursing Leadership completion date 3/28/2025. 4. All falls were reviewed by clinical resource 3/28/2025, no negative outcomes were identified. (See attached) 5. All nursing staff will complete competency post on what to do if a resident falls to include when and if to transfers started on 3/27/2025. Completion date 3/28/2025 6. Education initiated on transferring a resident from the floor to the bed to all nursing staff by therapy department with all nursing staff 3/27/25. Anticipated completion date 3/28/25. 7. All Nursing staff will complete a competency (return demonstration) on transferring a resident from the floor to the bed initiated 3/27/25 Anticipated completion date 3/28/25. 8. This training and competencies will be completed in person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff completed training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These will not be allowed to work unless they have received their training and knowledge check. 9. And ad hoc meeting regarding items in the IJ template will be completed on 3/28/2025. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources and will include the plan of removal items and interventions. 10. DON/ADON/Designee will verify staff competency with staff weekly using what to do when a resident falls to include when and if the transfer (case scenarios) 11. The summary of the IJ and corrective actions to be reviewed by QAPI committee x 4 weeks or until substantial compliance established and continuing monthly for 90 days to ensure ongoing compliance. During an interview on 3.28.25 at 4:00pm with the DOT it was revealed she has completed therapy training with the first and second shift staff, LVN, ADON, DON on the proper way to transfer a resident off the floor into the bed. She states she went over the initial policies of finding a resident on the floor, calling for a nurse, after the assessment and getting permission, the resident should be picked up by at least 2 people, The head, neck, torso, and legs should be secured. It is not advisable to pick someone up by their ankles. She stated the legs, at the mid knee area is where someone should start. Staff must bend their knees when lifting to ensure no injuries. 3.28.25 at 5:25PM POR for F689 Accepted and Monitoring began at 5:30PM 3.28.25 at 5:30PM monitoring began interviewing facility staff employees, (ADON B; CNA's C, H, I, L,O, P, M, N; DON; LVN's C, D, E, and N; RN's B, C and D) revealed, each were interviewed and completed online continuing education training in all areas of patient care with Relias (internet training); Train the Trainer for ADON's by the pharmacist; protocol for resident unwitnessed falls and head to toe assessments, transferring resident from the floor to the bed or wheelchair properly, completing training on falls by using posttest and demonstrating the proper way of transferring resident from the floor. During a Follow-Up Interview on 3.29.25 at 3:10 PM with DON revealed in-services will be monitored by utilizing cluster partners (other facility's under same corporate office) who will come out to the facility and conduct random interviews with staff. Continuous QAPI discussions. DON stated she conducted the in-service 12 medication administration training and found that staff needed updates. She stated there were some rights added as when she started in the nursing field there were only 5 medication administration rights training. The DON stated the MAR and TAR will be monitored by running daily reports to ensure proper documentation with confirmation of new medications. The reports will be daily with or without her working at the facility. The DON stated the system she will use to verify staff competencies would be audits, random questioning, and return demonstration (having staff give examples). The DON stated the most important thing learned from these citations was documentation is a big key in success and failure, and she learned more about staff weakness and strengths. 3.29.25 at 3:30pm IJ Lowered: The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. During an interview on 3.29.25 at 4:45PM with Administrator- He stated the IJ's have taught him to look at processes and that documentation needs to be specific and completed on time. He stated more awareness is being put in place to ensure the documentation is appropriate along with ensuring in-service training is continuous in areas of resident care. The DON will view all documentation by running daily reports and confirming new medications.

Based on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for CR#1 & CR#2 of 8 residents reviewed for pharmacy services. The facility failed to ensure CR #1 received his medication as ordered when WCN administered non-scheduled aspirin without an order when CR #1 had a known head injury. The facility failed to ensure CR#2 recevied his IV antibiotic medication as ordered by the physician. An Immediate Jeopardy (IJ) was identified on 03.27.25 at 4:34 p.m. While the IJ was lowered on 03.29.25 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of receiving inadequate treatments or results or ingesting medications for which they were not prescribed and ineffective therapeutic outcomes by not documenting when medications were given or not given. Findings included: Record review of CR#1's face sheet dated 11/8/2023 reflected an [AGE] year-old female, with an original admitted [DATE]. Her diagnosis included: Cerebral Infarction of the right middle cerebral artery (stroke), hypertension (high blood pressure) and gastro-esophageal (digestive disorder). Record review of CR#1's Quarterly MDS dated [DATE], revealed the following: CR#1's BIMS score of 06 (severe cognitive impairment), CR#1's Functional Limitation in Range of Motion indicates an impaired Upper and Lower Extremities, uses motorized wheelchair, is dependent on staff for all of her ADL needs, including, rolling to left and right; has had no fall history. Record review of CR#1's orders dated 11/8/2023 revealed, CR#1 was prescribed Aspirin 81 Oral Tablet chewable (No order for aspirin to be used as a PRN pain medication). Give 1 by mouth one time a day for blood clot prevention. Start date 11/9/2023; Apixaban (blood thinner) dated 11/8/2023. Record Review of Medication Administration policy dated 05/2007 reveals the following: 2. Medications must be administered in accordance with the written orders of the attending physician. NOTE: If a dose seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current diagnosis or condition, the nurse should contact the physician. 3. All current drugs and dosage schedules must be recorded on the resident's electronic medication administration record (MAR). 8. Unless otherwise specified by the resident's attending physician, routine medications should be administered as schedules. 10. The nurse administering the medications must initial the resident's electronic MAR, on the appropriate line and date for that specific day. Record Review of nursing notes written by WCN dated 3/4/2025 at 8:27am, revealed, Resident observed lying on the floor feet facing foot bed, vitals taken, pain assessment made, head to toe assessment performed. Resident vitals 180/90 P-76 C/O pain from hip. PRN aspirin administered, resident noted with cut by right eye, EMS services immediately contacted, skin tear on left arm. Resident was not aware of how they ended up on the floor, seen by wound care physician, wounds cleansed, with wound cleanser, cut medicated with collagen powder, ST addressed with xeroform and dry dressing. RP notified; Dr. notified. During the follow-Up Interview on 3.26.25 at 5:08pm with DON revealed she did not know CR#1 had sepsis prior to her hospitalization . She stated labs were not necessary because CR#1 never exhibited any symptoms that would be a cause for labs. DON stated because of the lack of symptoms, nursing staff did not monitor for signs or symptoms of sepsis. The DON stated labs are only ordered for someone in CR#'1's condition (CVA, Anticoagulants) when there are indicators like when there is a change of condition. DON stated when medications are administered, nursing staff must follow physician orders. She stated WCN gave CR#1 and aspirin (PRN) because it was for pain. The DON stated she spoke with the facility's medical director and CR#1's physician and was informed that CR#1's outcome would not have changed her injuries. CR#2 Record review of CR#2's undated face sheet revealed a [AGE] year-old male initially admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with a diagnosis of anemia (iron deficiency), hypertension (high blood pressure), Renal failure ( kidneys lose the ability to filter waste), Obstructive uropathy (urinary tract disorder); Dementia (decline in cognitive abilities), seizure disorder (abnormal brain signals). Record review of CR#2's Quarterly MDS dated [DATE], revealed the following: CR#2's did not have a BIMS score, which indicates a severe cognitive impairment; CR#2 uses a wheelchair; dependent on staff for toileting, showering, and getting dressed; totally dependent on staff for sitting and lying in bed; CR#2 is always incontinent for urinary. Record review of CR#2's orders dated, 2/13/2025 for Trileptal oral tablet 300 MG give 1 tablet by mouth two times a day for status epilepticus (start date 1/26/2025 at 5:00pm); Apixaban Oral Tablet by mouth two times a day for anticoagulant for 30 days (start 2/18/2025 at 8:00am); Apixaban Oral tablet 5 MG give 2 tablet by mouth two times a day of Anticoagulant for 3 days (start date-2/14/2025); change intravenous tubing with new IV bag every day shift (order date 1/26/2025 at 10:20am-D/C dated 2/26/2025 at 12:20am); Meropenem intravenous solution reconstituted 1 GM-Use 1 gram intravenously one time a day for UTI for 9 days (order date 1/24/2025 at 7:14pm); Midline care: Change Central Line/Mid line dressing Q 7 days if visible for assessment. Change dressing PRN if wet, soiled, saturated or loose every day shift every 7 days (order date 1/26/2025 at 10:20am-D/C dated 2/13/2025); Mid line flushing: Flush with 5cc 0.9% NS IV solution before and after each med administration every day shift (order date 1/26/2025-D/D dated 2/14/2025); Tombramycin Sulfate Injection Solution 80 MG/2ML_use 4 ml intravenously one time a day every Mon, Wed, Fri for give after HD SEND WITH RESIDENT TO HD. THEY CAN ADMINISTER THERE (order datre 2/13/2025 4:29pm - D/C dated 2/14/2025 at 12:53pm); Cefdnir Capsule 300 MG_Give 1 capsule by mouth two times a day for infection for 7 days (order date 2/26/2025 at 0022); Insert peripheral IV one time only for IV antibiotics until 2/14/2025 11:59pm (order date 2/14/2025 at 7:11pm). Record review of CR #2's care plan dated, revealed the following care areas: Focus: [CR#2] has renal insufficiency r/t CKD stage 5 Hemodialysis 3X/WEEK EVER MWF. Created and initiated on 8/6/2024 and revision 2/24/2025. Goal: [CR#2] will be free from infection through the review date. Date initiated and created 8/6/2024, Target date 1/21/2025. Interventions: [CR#2] Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; seizures. Date initiated 8/6/2024. Focus: [CR#2] has a Urinary Tract Infection. Date initiated, created and revised on 1/29/2025. Goal: [CR#2] Urinary tract infection will resolve without complications by review date. Date initiated and created 1/29/2025. Target date: 1/21/2025 Interventions: [CR#2] Give antibiotic therapy as ordered, Monitor/document for side effects and effectiveness. Created 1/29/2025; Monitor/document/report to MD PRN for s/sx of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral changes. Date initiated 1/29/2025; Obtain vital signs as ordered. Focus: [CR#2] At risk for impaired cognitive function/dementia or impaired thought processes r/t dx of Dementia, metabolic encephalopathy (serious neurological condition when the brain is damaged). BIMS score of 6 (Severe Impairment). Date initiated 7/19/2024 and revision on 8/6/2024. Goal: [CR#2] Will maintain the level of cognitive function through the review date. Target Date: 1/21/2025. Interventions: [CR#2] Communicate with family/caregivers regarding residents' capabilities and needs; Discuss concerns about confusion, disease process and alternative placement with family/caregivers; monitor/document/report to MD any changes in cognitive function, specifically changes in: decision understanding others, level of consciousness, mental status. Date created 8/6/2024. Focus: [CR#2] ADL Self Care Performance Deficit r/t impaired mobility, dementia. Created 7/19/2024 and Revision on 8/6/2024. Goal: [CR#2] Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and personal hygiene with modified independence through the review date. Target date 1/21/2025. Interventions: [CR#2] Discuss with resident/family POA care any concerns related to loss of independence, decline in function; Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function; Skin Inspection: Requires SKIN inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Focus: [CR#2] Has bowel/bladder incontinence r/t Dementia, History of UTI, Impaired Mobility. Created and initiated on 8/6/2024. Goal: [CR#2] Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Target date: 1/21/2025. Interventions: [CR#2] Monitor/document for s/sx UTI: Pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Initiate and Created 8/6/2024; Monitor/Document/report to MD possible medical causes of incontinence bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Date initiated 8/6/2024. Focus: [CR#2] I am resistive to care will not allow staff to dress change, shower, and is refusing medication. CR#2 pulled out midline 1/28. Dated initiated 7/22/2024 and revision 1/29/2025. Goal: [CR#2] Will cooperate with care through next review date. Target 1/21/2025. Interventions: [CR#2] Allow to make decisions about treatment regime to provide a sense of control; educate resident/family/caregivers of possible outcome(s) of not complying with treatment care; encourage as much participation/interaction by the resident as possible during care activities. Initiated 7/22/2024. Focus: [CR#2] Potential for a behavior problem r/t not drinking water, only consuming coffee and eating sugar packets. Educate provided on the need for water consumption. Goal: [CR#2] Will have fewer episodes by review date. Created and initiated 11/15/2024. Target 1/21/2025. Interventions: [CR#2] Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Created 11/15/2024. Focus: [CR#2] Potential to demonstrate physical behaviors r/t Dementia; I have a habit of unplugging items to conserve energy. Date initiated and revision 1/10/2025. Goal: [CR#2] Will demonstrate effective coping skills through the review date. Target 1/21/2025. Interventions: [CR#2] Assess and address for contributing sensory deficits; provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; Document observed behavior and attempted interventions; Monitor/document/report to MD of danger to self and others. Date initiated 1/10/2025. Focus: [CR#2] At risk for falls r/t hx of falls, impaired mobility. Initiated 7/19/2024. Revision 8/6/2024. Goal: [CR#2] Will be free of falls through the review date. Target: 1/21/2025 Interventions: [CR#2] Be sure call light is within reach and encourage to use it to call for assistance as needed; Falling star program; Keep items, water, etc, in reach. Focus: [CR#2] CR#2 had an actual fall related to poor communication/comprehension: 12/18/2024: Fall with no injury; 12/22/2024: Fall with no injury. (Created 11/19/2024. Revision on 2/24/2025) Goal: [CR#2] Will resume usual activities without further incident through the review date. Target 1/21/2025. Interventions: [CR#2] Psych consult (Continue interventions on the at-risk plan. Focus: [CR#2] Has potential for pressure ulcer development r/t impaired mobility. Dated initiate 7/19/2024; Revision 8/6/2024. Goal: [CR#2] Will have intact skin, free of redness, blisters, or discoloration by/through review date. Target 1/21/2025. Interventions: [CR#2] Weekly head to toe skin at risk assessment. Initiated and Created 7/19/2024. Record Review of hospital discharge summary dated 2/13/2025 revealed, instructions for administering the medication through catheter every other day. Give after HD for 3 sessions Monday, Wednesday Friday. Record Review of nursing notes dated 2/17/2025 at 1:12pm by LVN D revealed, attempted to put IV line in CR#2 to receive post HD medication. CR#2 refused. Will try again upon return. Record review of nursing notes dated 2/17/2025 at 1:12pm by LVN D revealed an attempt to put IV line in resident to receive post HD medication. Resident refused. Record Review of nursing notes dated 2/18/2025 at 10:11am by LVN D revealed, CR#2 continues to refuse IV insertion. NP contacted for other options. Awaiting reply. Record Review fax dated 2/20/2025 at 1:30pm from ADON to dialysis, revealed CR#2 face sheet, diagnosis, hospital orders and hospital discharge instructions. Record Review of nursing notes dated 2/24/2025 at 11:55am by ADON revealed dialysis called in regards of tobramycin IV CR#2 is to receive x3 doses after dialysis. Facility stated fax received and antibiotics on order. Record Review of nursing notes dated 2/24/2025 at 1:42pm by RN revealed CR#2 leaving for dialysis via EMS, vitals stable BP 110/62 T 98.4, HR 88 RR 18. Orientation at baseline CR#2 stated he was tired. No signs of distress noted. Record review of nursing notes dated 2/25/2025 at 12:14pm revealed CR#2 lethargic, temp of 100.3 NP notified. New orders given for Rocephin injection, labs, cxr. 02 at 2L NC. FM at bedside. 650 mg of Tylenol given for fewer per NP. COC complete, labs drawn, results pending. Change of Condition: Symptoms or signs noted of condition change: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Altered mental status. Vital signs on 2/25/2025 revealed the following: BP 103/54 - 2/25/2025 at 1:13 sitting l/arm P76 -2/25/2025 at 1:13 R 18.0 2/25/2025 at 1:13 T 98.3 2/25/2025 (Forehead) at 1:13 02 92% 2/25/2025 at 1:12 Method: Oxygen via Nasal Cannula Record Review of nursing notes regarding CR#2's last vitals taken below: O2 Stats: 2/26/2025 at 9:45am 92% Oxygen via Nasal Cannula Pain Level: 2/24/2025 at 9:06pm O value Numerical Respiration: 2/26/2025 at 9:45am 32 Breaths/min Pulse: 2/26/2025 at 9:45am 75 bpm regular Blood Pressure: 2/26/2025 at 6:53am 12//65 Lying arm; 2/26/2025 at 9:45am 140/72 Lying arm. Weights: 2/18/2025 at 9:56am 200.4 lbs. Record review of nursing notes dated 2/26/2025 at 12:14am revealed CR#2's Xray results: Bilateral Interstitial infiltrates, concerning for edema vs PNA, nonspecific: Reported to On-Call N/O: Lasix 40mg QD x 3 days Cefdinir 300 mg BID x 7 days Record review of nursing notes dated 2/26/2025 at 9:46am by ADON, revealed Medical Director given the results of the Xray and lab results and ordered CR#2 to be sent out to ER for further work up. Record review of CR#2's report from hospital revealed the following report dated 2/26/2025: CR#2 arrived at the hospital at 9:43am via, EMS. O2 Flow rate (l/min) 4 l/min 02 Delivery Method: Nasal Canula. Vitals: BP: 137/67 Pulse: 76 Resp: 16 Temp: 102.5 F (39.2 C) Temp src: Temporal GCS Total: 12 Blood Glucose Meter (mg/dl): 158 ECG Performed: Yes (NSR) During a telephoned Interview on 3/4/25 at 10:02am with FM stated CR #2 is no longer able to walk, talk, eat or swallow because of sepsis in his blood from having a serious UTI that the facility would not ensure he received his medicine for. FM stated her Resident #2 came to the facility because of his chronic UTI and Infusion (antibiotics through IV). She stated her Resident #2 had a picc line (a thin, flexible tube inserted into a vein near the heart), which is where the antibiotics were administered by a nurse. She stated the UTI is a chronic issue for CR #2. FM stated CR #2 did not have sepsis when he was released from the hospital February 13, 2025. FM stated she came to the facility Tuesday February 25, 2025, at 9:00am. Stated she gave CR #2 a kiss on his forehead and his eyes were rolling in the back of his head. She spoke with the nurse at this time. She stated she was a little irritated that the nurse didn't know he had a temperature but did not checked vitals. She stated ADON A came to the room and the nurse was finally getting the temperature. She stated the nurse took Resident #2's temperature and it was 102.8 and he appeared to be lethargic. At this time, she requested CR #2 to be put on oxygen. She stated CR #2 had received orders when he was released from the hospital on February 13, 2025, for antibiotics due to his UTI. FM stated at this time she was informed by the ADON A, that the medication (Tobramycin) for his UTI that was ordered on February 13, 2025, was never administered, and had expired because the Dialysis never gave it to him per hospital orders. FM stated this negligence caused CR #2 to have a more serious UTI and infection in his blood. FM stated ADON A told her the dialysis people were supposed to give the anti-biotics through the picc line, but they hadn't as of this date. She further stated the ADON A told her the medication had expired; however, due to CR #2's fever, ADON A administered a medication called, Rocephin (used for infections). FM stated after being administered the shot CR #2 immediately broke out into a profuse sweat all over his body. The ADON A told her that CR #2 was breaking his fever and that the sweating was okay. FM stated she's not sure how long CR #2 had been in this feverish lethargic condition. She stated facility sent CR #2 out to the hospital early that morning and never called her to even ensure he was sent out. She stated CR #2 had fallen a few weeks ago and now he has seizures. She stated CR #2 was in ICU a few weeks ago before he was released from the hospital, he now has had dialysis and he had the dialysis port, which is how the medication for his UTI was to be administered. FM stated the ADON told her that CR #2 would get antibiotics in the dialysis, but failed to tell her Dialysis never gave him the anti-biotics. She stated now the infection has spread from a UTI to Blood Infection. During an Interview on 3/4/25 at 2:44pm with ADON stated CR #2 was sent to hospital because he was lethargic. He stated there was an order for Tobramycin, an antibiotic for the UTI, which was identified through labs while at the hospital. ADON A stated CR #2 returned to facility from hospital on 2.13.25. The CR #2 also returned from hospital with and order to be given 3 doses of tobramycin over the next 3 dialysis services which was to be administered after dialysis session, starting February 14, 2025. The ADON A stated he personally sent the medication to dialysis, along with the order from hospital. He stated he did not know that the initial dose was not administered to CR #2 until he went into the medicine refrigerator on February 17, 2025, to retrieve CR #2's second dose. At this time, he stated he seen the initial dose from February 14, 2025. He stated he immediately called Dialysis and was informed that their protocol was to receive an email from the hospital, and they would fill the medication through their own system. The ADON A stated they further told him that they are not allowed to accept medication. ADON stated resident had been without the medication for a week and he wasn't getting any antibiotics during that time. He stated he called the doctor. Stated the Dr stated to send the order to dialysis, but ADON A told her that they refused to administer. At this time, he was given an order from the NP to put an IV in Resident #2's arm so facility nurses could administer the antibiotic. He stated on February 17, 2025, at 1:13pm, attempted prevention measures by trying to put an IV in Resident #2's arm and he refused on 2/17/25 at 1:13pm and again on 2/18/25 at 10:11am. The ADON A stated with Resident refusal for the IV port, the medication expired. ADON A stated he received an order from the NP to administer the Rocephin 1mg and Tylenol 650. He stated he was not aware that Resident #2 began to sweat profusely. He stated Resident #2 was talking to his FM during this time. The ADON stated on 2/20/2024, he faxed the order to dialysis in hopes of them filling the Thrombosis prescription. He stated he called dialysis to let them know he just faxed the order and was told they did not have the medication and it would take 7-10 to get it. During an Interview on 3/5/2025 at10:00am with HAP- HAP stated CR #2 had an admittance from February 5, 2025 and discharged on [DATE]. HAP stated on February 6, 2025, CR #2 labs showed he had a bacteria called pseudomonas, which is why he was prescribed Tobramycin. He stated there was an order for the medication to be administered by dialysis staff after his procedure. The antibiotic was for three doses. He stated the medication should have been given by the dialysis staff through the dialysis IV port, not the facility staff. He stated that according to the records, on February 11, 2025, at 10:00am, dialysis was set up by the hospital social worker. At this time, the order was given to the dialysis staff. HAP stated that there must have been a mix-up in the communication between the hospital, dialysis, and the facility. However, he stated that the attending physician at the nursing facility should've figured it out even if CR #2 was sent back to the hospital to get the medication. This medicine was extremely important as the resident had an active bacterium. HAP stated CR #2 return to the hospital, February 26, 2025, and he now has a different bacteria called Staphylococcus Aureus. The order for Tobramycin would not have been affective for CR #2 anyway. Therefore, the resident, even if he had taken, the order would not have gotten better because he had a different bacterium. Doctor indicated that both bacteria are more healthcare bacteria, where they are contracted in healthcare rehab facilities. During an Interview on 3/5/25 at 12:10pm with Dialysis CNM who stated he was made aware CR #2 was to receive 3 doses of Tobramycin; however, dialysis did not receive any notification from the hospital which is protocol. CR #2's first dialysis appointment was 2/14/2025. States the order was sent with medication and they don't take orders from other doctors. He also stated there was no medicine on hand at this time. He stated he received a fax order from the facility on February 20, 2025, and the medicine arrived at the Dialysis center on February 28, 2025. He stated they have no records of the orders from the hospital on 2/11/2025. During an telephone Interview on 3/9/2025 at 11:19am with FM - Stated she received a call from a doctor at the hospital who told her that based on CR#2's wounds he would require surgery to insert a rectal tube. She stated the doctor reiterated CR#2's should be strongly considered for Hospice due the wound and blood infection. During a follow up Interview on 3/10/2025 at 9:45am with FM - who stated the facility never called and say CR#2 was refusing medication. The facility would call FM when he needed a shower and was refusing, then family would talk with CR#2 and CR#2 would comply. During a follow-up Interview on 3/11/2025 at 10:00am with FM stated the facility has always called her or another family member whenever CR #2 would refuse showers. She stated either of them would come to the facility and assist staff in giving Resident #2 his showers. FM stated this has happened on at least two occasions. She stated other times the facility had called was when CR #2 was walking and naked and pee, poop, and urine everywhere in the middle of the night. The facility called FM. However, FM stated she never received a called saying there was any problem getting the meds thru dialysis or that CR #2 had refused his med. She stated when she was informed by the facility that CR #2 hadn't had his medicine from dialysis, she went to the dialysis to speak with someone. FM stated Dialysis told her that they had already explained to the nursing facility they could not administer that kind of medication, so they would have to get another kind of med. During this time, FM stated CR #2 had already missed all 3 doses of his medication and at this time he was not talking, his fever was 102, and his forehead was hot, yet the ADON stated he was ok. FM stated the ADON told nurse to go get meds so they can start administering medications for his infection. The ADON administered Rocephin medication, which he gave a shot in the buttocks area. FM stated ADON asked her to hold CR #2 while he administered the shot because it would typically burn. FM stated she tried getting him to eat doughnuts, but CR #2 would only open his mouth but could not chew. FM stated the ADON informed her that CR #2 had a sacrum wound. FM stated CR #2 had never had a wound prior to admittance to this facility. She stated had she known CR #2 had a wound she would not have left him in the facility. She found out about the wound Tuesday February 24, 2025, and he was sent to the hospital on Wednesday February 25, 2025. During an interview on 3/11/25 at 10:50am with NP - Confirmed CR#2 was his resident when CR#2 was in the facility. NP initially stated he didn't' know why CR#2 was given the medication to be administered at dialysis, then stated, I think it was an antibiotic because CR#2 had recurring UTI's. NP confirmed the medication should have been administered to CR#2 while at dialysis. He stated it was an IV medication to be administered in the dialysis port and the dialysis people know how to administer it. If the medication was given at facility, it will be washed out by dialysis procedure, which is why the nephrologist always want to administer at dialysis. However, NP stated dialysis did not carry the medication, and they refused to give the medication that accompanied CR#2 from NF. He stated at this time he was informed that CR#2 had missed one dose. NP stated he informed the nursing facility staff to reach out to the nephrologist to see if they could order another medication or something else that they had since CR#2 was not getting the medication he should be getting for an infection. He stated the nephologist was the physician who originally ordered the medication and staff needed to follow up with them. The NP stated at this time he assumed the facility had reached out to the nephrologist as directed and they were given a different type of medication. NP further stated he directed staff to put in a Peripheral IV only with nephrologist approval to give medication. He stated nursing staff can't just put line on dialysis patient without nephrologist approval. NP stated nursing staff could have either got the medication changed or administer themselves through a midline (a thin tube inserted into a vein), but they needed to consult with nephologist first. NP stated the facility never called him back afterwards with any results, so he assumed the medication was either changed or given. NP stated facility staff did not report any clinical symptoms that CR#2 had an untreated infection, no fever no chills reported, and no change in mood. He stated there was nothing reported to him that would indicate CR#2 had an untreated infection. NP stated he received a second telephone call from the facility indicating CR#2 had a symptom but couldn't recall what it was. He stated the exact time he was notified by nursing staff would be in the nursing notes, because he couldn't remember. He stated he knew he was not getting it, but don't know how many doses were missed at that time. NP stated he thought he ordered a dose of Rocephin, which was an antibiotic that would treat CR#2 symptoms for 24-48 hours and directed nursing staff to monitor vitals, and report to him any changes of conditions. NP stated he would have not advised staff to send CR#2 out to the hospital unless his vitals and symptoms worsen after given Rocephin. NP stated he was not saying to wait for a problem before doing something, but 24-48 hours would have been a good time to see if medication from nephologist could be changed. NP stated he reinforced instructions to facility staff to follow-up with nephrologist. He doesn't know if the nephologist ordered anything else. NP stated hospitals expects certain levels of care from nursing facilities then just always sending residents out without doing a full work up. He stated hospitals diagnose and do interventions, but they expect nursing facilities to treat residents as much as they can. He stated nursing should report any other change of condition to him. NP stated a lot of things that could happen when a resident's medication for infection isn't administered. He stated lethargy on dialysis patient could be caused by conditions other than sepsis. During an Interview on 3/11/2025 at 11:54 am. with DON stated she knew on Friday, February 14, 2025, that the facility was sending abx with CR #2 to dialysis. DON stated she was at a function with other administrative staff and was not in the facility the week of February 17, 2025, but to her understanding she did not give any additional order, just waiting for dialysis to obtain the meds. DON stated she did know on Friday February 14, 2025, CR #2 did not get his medication. She stated ADON informed her on Monday February 17th, 2025, he was sending the orders to dialysis center. DON stated she never spoke with the nephrologist concerning CR #2 not getting his medication. She stated when a resident does not get prescribed antibiotics there is a potential to go septic (life threatening condition that occurs when a body-wide infection causes dangerously low blood pressure and organ damage). DON stated CR #2 situation was unique because the order was for dialysis to administer the medication and not the facility. DON stated CR #2's physician was Medical Director for the facility and was also aware of what was going on. She stated the nursing notes noted CR #2's change of condition. The DON stated she understood that there was an attempt to start IV on Resident #2 in the facility, but CR #2 refused the IV. DON feels staff were communicating and following up with Resident #2's doctor, but unsure if staff painted a clear enough picture of everything they did as far documentation goes. During a Telephone interview on 3/11/25 at 1:55pm with Medical Director revealed, she was aware of the issues surrounding CR #2 and his medication. She stated staff was in constant contact with the Dialysis and informed the Nephologist is the prescribing doctor over that department and ordered the medication. She stated without the medication a resident could present confused, infection. She further stated the facility attempted to initiate an IV in CR#2's arm and he refused. An Immediate Jeopardy (IJ) was identified on 03.27.25 at 4:34 p.m. While the IJ was lowered on 03.29.25 at 3:30pm, the facility remained out of compliance at the severity level of no actual harm with potential for more tha [TRUNCATED]

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Staff (CNA W) reviewed for infection control. - The facility failed to ensure CNA W followed proper hand hygiene during incontinent . - The Wound Care Nurse did not practice hand hygiene before and after wound care for Resident #20. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Record review of Resident # 10's annual MDS assessment, dated 07/15/24, reflected a [AGE] year-old female with an admitted [DATE]. Her diagnoses included urinary tract infection, cerebrovascular disease ( stroke, brain aneurysms and cerebral arteriovenous/blood clots), muscle wasting and atrophy, stage 4, type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or can't use insulin properly, causing blood sugar levels to rise) without complications, morbid obesity due to excess calories. Record review of Resident #10's annual MDS assessment dated [DATE] revealed she had a BIMS score of 11/15 (moderately cognitively impaired). She required extensive assistance of two-persons with all ADLs and was always incontinent of bowel and bladder. Record review of Resident #44's care plan, dated 3/31/24, reflected, . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent An observation on 08/28/24 at 10:35 a.m. revealed CNA BB entered Resident #10's room preparing to provide incontinence care. CNA W washed her hands and put on cleaned gloves did not change gloves, using the same gloved hands , picked up the clean wipes from the container on the bedside table and unfastened Resident #10 's brief soiled with urine. CNA W assisted the resident to roll on her right side. CNA W took a peri-wipe and wiped in-between residents' rectal area . With the same gloves, CNA W applied barrier cream to a chafed area on the resident buttocks and then removed the soiled brief and placed a clean brief under the resident and assisted her to roll back onto her back and fastened the brief. CNA W removed her gloves and did not wash her hands. She picked up a clean blanket from Resident #10 's drawer and place it, on Resident #10. Review of CNA W's skill checks dated 07/30/24 reflected she was competent in performing peri-care and hand hygiene. Interview with CNA W on 08/29/24 at 10:15 a.m. she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them at risk of infections. Interview with DON on 08/29/24 at 02:00 p.m., the DON said CNA W's should wash or sanitize her hands when soiled and after changing gloves. DON said CNA W would be retrained before working with incontinent residents. Resident #20 Record review of Resident #20's face sheet dated 08/29/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #20's diagnoses included the following: dementia (memory loss), retention of urine (unable to empty the bladder completely), acute (suddenly) kidney failure, hydronephrosis (buildup of fluid in a kidney due to a backup urine), benign (non-cancerous) prostatic hyperplasia (prostate enlargement) and, diabetes mellitus (too much sugar in the blood). Observation on 08/29/2024 at 3:22PM of wound care nurse entering Resident #20's room to assess the resident's heels. The wound care nurse did not wash or sanitize her hands before applying gloves to assess the resident's heels. After assessing the resident's heels, the wound care nurse removed her gloves and balled the gloves up in her hand before leaving the resident room without washing or sanitizing her hands. Interview on 08/30/24 at 1:37PM with the wound care nurse, she said she had forgotten to wash her hands prior to and after assessing Resident #20's heels on 08/29/2024. The wound care nurse said hand washing was important to prevent infections. Record review of the facility's policy titled Handwashing/Hand Hygiene (revised May of 2007) revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; Or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. Record review of the facility's policy titled, Perineal care, revised March 2017, reflected, .Wash and dry hands thoroughly .put on gloves .wash perineal area, wiping from front to back .Separate labia and wash area downward from front to back . Assist the resident to turn on her side .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly

Based on observation, interview, and record review, the facility failed to provide dignity and respect for 1 of 6 (Resident #20) residents observed for dignity in that: -The facility failed to close the blinds to Resident # 20's window during Foley catheter care. This failure could place residents who require assistance with care at risk for embarrassment and lower self-esteem. Findings include: Record review of Resident #20's face sheet dated 08/29/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #20's diagnoses included the following: dementia (memory loss), retention of urine (unable to empty the bladder completely), acute (suddenly) kidney failure, hydronephrosis (build up of fluid in a kidney due to a backup in urine), benign (non-cancerous) prostatic hyperplasia (prostate enlargement) and, diabetes mellitus (too much sugar in the blood). Record review of Resident #20's MDS (5-day scheduled Assessment) dated 07/09/2024 reflected a BIMS score of 9 indicating resident cognition was moderately impaired. Section H (Bladder and Bowel) reflected that resident was frequently incontinent of urine. Record review of Resident #20's Physician Order Summary Report reflected the following order: - Dated 07/18/2024 catheter type: 16 Fr #10 ML to closed urinary drainage system-diagnosis for BPH. Record review of Resident #20's care plan dated 08/29/24 reflected that resident had an indwelling catheter due to BPH with an intervention that included: provide catheter care every shift and as needed. Further review reflected that resident was being care planned for ADL self-care performance r/t impaired mobility with an intervention to promote dignity by ensuring privacy. Observation on 08/28/24 at 10:20AM revealed Resident #20 was resting in bed B by the window. Resident had an indwelling Foley catheter bag draining to gravity on the right side of bed. Observation on 08/29/24 at 1:35PM of Foley catheter care for Resident #20 by CNA X and CNA Y. Resident window blinds were open. CNA X and CNA Y proceeded with care by pulling resident covers back to clean resident groin (area between the stomach and thigh on both sides of the body) and urinary meatus (opening where urine exits) without closing the blinds on the window. Interview on 08/29/24 at 1:40PM with CNA Y, she said she gave herself on a scale from 1-10 a 7.5 because she should have closed resident blinds on window for privacy to promote dignity. Interview on 08/29/24 at 2:00PM with the DON, she said whenever staff provided care for the resident (s), privacy should be provided to promote dignity. Record review of the facility policy on Dignity revised October 2009 reflected in part: . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .

Based on observation, interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 6 residents (Resident # 20) reviewed for pressure sores in that: - The facility failed to off load Resident #20's heels by floating them on a pillow or by placing heel protectors on resident heels to prevent further skin breakdown. This failure affected one resident and placed him at risk of developing further skin breakdown or developing of new pressure injury. Findings include: Record review of Resident #20's face sheet dated 08/29/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #20's diagnoses included the following: dementia (memory loss), retention of urine (unable to empty the bladder completely), acute (suddenly) kidney failure, hydronephrosis (buildup of fluid in a kidney due to a backup urine), benign (non-cancerous) prostatic hyperplasia (prostate enlargement) and, diabetes mellitus (too much sugar in the blood). Record review of Resident #20's MDS (5-day scheduled Assessment) dated 07/09/2024 reflected a BIMS score of 9 indicating resident cognition was moderately impaired. Section GG (Functional Abilities) of the MDS reflected that resident required maximal assistance. Section M of the MDS reflected that resident did not have any ulcers, wounds and skin problems. Record review of Resident #20's care plan dated 07/01/2024 revised 07/15/2024 reflected that resident was being care planned for potential for pressure ulcer development r/t impaired mobility with intervention for weekly head to toe skin assessments. Further review reflected resident being care planned for a pressure ulcer to right heel dated 08/27/2024. The interventions included the following: -Administer treatments as ordered and monitor for effectiveness. -Encourage to turn reposition, provide assistance as necessary. -Float heels as tolerated. Record review of Resident #20's Physician Order Summary Report reflected the following orders: -Dated 08/26/2024 right heel: apply betadine and leave heel open every day for wound healing (discontinue 08/29/2024) -Dated 08/29/2024 Right heel: Apply skin prep and leave heel open to healing Record review of Resident #20's TAR dated 08/2024 revealed that the facility was following physician orders for wound to the right heel in applying medication to right heel. Record review of Resident #20's weekly skin assessment dated [DATE] reflected right heel pressure wound measuring 6cm x7.5 cm width x 0 cm in depth unstageable. Observation on 08/29/24 at 1:35PM revealed Resident #20 was in bed with the staff CNA X and CNA Y preparing to provide Foley catheter care for resident. Resident #20's heels were not off loaded off the bed nor was the resident wearing any heel protectors. Resident #20 was observed having skin breakdown to his right heel with skin discoloration. The right heel had a black large circle with no drainage observed. When the staff was done with providing care for Resident #20, they repositioned the resident in bed on his back without offloading the resident's heels. Interview with CNA Y on 08/29/2024 at 1: 45PM, she said she was Resident #20's CNA. CNA Y said Resident #20's heels should have been offloaded to prevent skin breakdown. CNA Y began to look in the resident's drawers in the room. CNA Y found heel protectors in one of the resident's drawers. Interview on 08/29/24 at 1:50PM with RN Z, she said it was the nurse's responsibility as well as the CNA's to ensure resident's heels were being offloaded to prevent pressure injury. Interview on 08/29/2024 at 2:00PM the DON said heel protectors should be used or the staff should be offloading the residents' heels to prevent pressure injury. Record review of the facility policy on Quality of Care (Skin and Wound Monitoring and Management) revised 12/ 2023 reflected in part . A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and . a resident having pressure injury (s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing .Unstageable pressure injury: Obscured full- thickness skin loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dry black hard necrotic{dead tissue} tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed .

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 7 residents (CR #1, Resident #2, and Resident #3) reviewed for quality of care. The facility failed to provide daily wound care/treatments for CR #1, Resident #2, and Resident #3 as ordered by the physicians and resulted in the development of skin infections for CR #1 and Resident #3. The facility failed to implement CR #1's physician's order for wet to dry dressings 2 - 3x per day (11/14/2022) when she exhibited symptoms of infection. These failures could place residents with skin breakdown at risk of further skin injury and infection. The findings included: CR #1 Record review of CR #1's face sheet dated 01/10/2023 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acquired absence of the left leg above knee, cognitive communication deficit (difficulty with thinking and how someone uses language), chronic pain syndrome (persistent pain that carries on for longer than twelve weeks despite medication or treatment), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and muscle wasting and atrophy (the decrease in size and wasting of muscle tissue). She was discharged to an acute care hospital on 11/25/2022. Record review of CR #1's MDS dated [DATE] revealed she had a BIMS score of 15 (cognitively intact); she did not exhibit behaviors of rejecting care; she required extensive physical assistance from at least one staff member for bed mobility, transfers locomotion, dressing, toilet use, and personal hygiene; she required total assistance from staff for bathing; she was wheelchair bound; she was always incontinent of bowel and bladder; she received PRN pain medications; she was at risk of developing pressure ulcers/injuries; she was admitted with one stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough [dead skin separating from living tissue]); and she had surgical wounds. Record review of CR #1's care plan revised on 11/14/2022 revealed she had pressure ulcers or the potential for pressure ulcer development (no location was specified) (Goal: Pressure ulcer will show signs of healing and remain free from infection. Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Encourage fluid intake and assist to keep skin hydrated. Monitor nutritional status. Needs monitoring/reminding/assistance to turn/reposition. Notify nurse immediately of any new areas of skin breakdown. Obtain and monitor lab/diagnostic work. Requires pressure relieving /reducing device on bed/chair. Weekly head-to-toe assessment). Record review of CR #1's physician's orders for November 2022 revealed the following: Cleanse Left AKA surgical incision site with normal saline, pat dry. Apply Alginate calcium and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse Left AKA surgical incision site with normal saline, pat dry. Cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/20/2022. Start Date- 11/21/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/23/2022). Cleanse left groin surgical area with normal saline, pat dry. Apply Alginate calcium and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse left groin surgical area with normal saline, pat dry. Cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/20/2022. Start Date- 11/21/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/23/2022). Cleanse right groin surgical area with normal saline, pat dry. Apply Alginate calcium and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse right groin surgical area with normal saline, pat dry. Cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/20/2022. Start Date- 11/21/2022. No end date was listed. Cleanse sacrum open area with normal saline, pat dry. Apply Alginate calcium and cover with gauze dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse sacrum open area with normal saline, pat dry. Apply Santyl and cover with gauze dry dressing daily and PRN every day shift for wound care. Order Date- 11/10/2022. Start Date- 11/11/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/23/2022). Cleanse sacrum open area with normal saline, pat dry. Apply dry absorptive dressing daily and PRN every day shift for wound care. Order Date- 11/06/2022. Start Date- 11/07/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/10/2022). Record review of CR #1's TAR for November 2022 revealed the following: Cleanse sacrum open area with normal saline, pat dry. Apply Santyl and cover with gauze dry dressing daily and PRN every day shift for wound care. Order Date- 11/10/2022. D/C Date-11/23/2022. The entry boxes for Saturday (11/12/2022), Sunday (11/13/2022), Saturday, (11/19/2022), and Sunday (11/20/2022) were blank, indicating the treatment had not been completed on those days. Monitor all surgical incision sites as well as left thigh surgical incision site with staples intact for s/s of infection daily every day shift for wound care. Order Date- 11/11/2022. D/C Date- 11/20/2022. The entry box was blank for Saturday (11/12/2022), Sunday (11/13/2022), Saturday, (11/19/2022), and Sunday (11/20/2022), indicating the observations had not been completed on those days. Record review of CR #1's wound care physician's progress notes dated 11/23/2022 revealed, . Focused Wound Exam (Site 1), Stage 4 Pressure Wound Sacrum Full Thickness . Wound Progress: No Change . Site 1: Surgical Excisional Debridement Procedure (Indication for procedure: Remove necrotic tissue and establish the margins of viable tissue) . Record review of CR #1's SBAR Communication Form completed by LVN B on 11/13/2022 revealed, . 9. Pain Evaluation: The resident has new pain (no location was documented) . 25. Summarize your observations and evaluation: noted yellow drainage at surgical site NP notified . Date and time of clinician notification: 11/13/2022, 4:10 p.m., Recommendation of Primary Clinician: monitor for signs and symptoms of infection . Record review of CR #1's SBAR Communication Form completed by LPN A on 11/25/2022 revealed, . 8. Skin Evaluation: Describe symptoms or signs: drainage from left stump surgical wound. 9. Pain Evaluation: The resident has new pain of the left stump . 25. Summarize your observations and evaluation: resident has purulent drainage coming from left aka surgical site with pain . Date and time of clinician notification: 11/25/2022, 9:00 a.m., Recommendation of Primary Clinician: Transfer to local acute care hospital . Record review of CR #1's progress notes for November 2022 revealed the following: On 11/13/2022 at 5:16 p.m., LVN B wrote, left leg surgical site yellow drainage noted, right surgical site small open hole dressing change was done will continue to monitor On 11/14/2022 at 2:09 p.m., LVN B wrote, NP Notified wants to continue to monitor surgical site for signs and symptoms of infection. On 11/14/2022 at 2:10 p.m., LVN B wrote, spoke with vascular surgeon's nurse, she would like wet to dry dressing 2-3 times a day. On 11/17/2022 at 1:37 p.m., LPN A wrote, Back from appointment (with vascular surgeon), No new orders. Stable. On 11/24/2022 at 4:04 a.m., RN D wrote, Blood was oozing from the incision sites in her groin. Waiting for PCP response. On 11/25/2022 at 2:50 p.m., LPN A wrote, Spoke with vascular surgeon. New order to transfer to local acute care hospital ER for possible wound infection. Record review of CR #1's hospital records, including emergency room notes, laboratory tests, treatment plan, and discharge summary, revealed she was admitted to the hospital from the ED on 11/25/2022 and was discharged on [DATE]. The document revealed, Chief Complaint: Wound infection. Patient had surgery in October 2022, left aka that appears to be infected, also complains of sacral pain and possible infection in groin area. History of Present Illness: . Resident is a [AGE] year-old female with status post AKA of the left lower extremity who has subsequently developed wound infections to the stump, the groin bilaterally, and the sacrum . Patient has increased drainage and pain from the sites and has been brought in for treatment . Location: Open wounds left stump AKA and bilateral groin and sacrum with drainage. Severity: Severe . Progression: Worsening . Sepsis Score: 0 . Medications Given: Ceftriaxone (Rocephin) (antibiotic) Intravenously, Vancomycin (antibiotic) Intravenously . Laboratory Findings: . 11/26/2022: WBC - 11.07 (high), 11/27/2022: WBC - 22.52 (high) . In a telephone interview with CR #1's family member on 01/10/2022 at 9:45 a.m., he stated CR #1 was admitted to the facility with wounds, but she did not get consistent wound care at the facility. He said another family member visited CR #1 on Thanksgiving Day, 11/24/2022, and during a diaper change, the other family member noted both of CR #1's groin wounds (left and right) were bleeding. The other family member said the nurse looked at the bleeding wounds and was like, What do you want me to do about it? The family member said the next day, 11/25/2022, CR #1 was in a lot of pain. He said he took photos of all CR #1's infected wounds and sent to them to CR #1's vascular surgeon. The family member said the vascular surgeon said CR #1 had infections and needed to go to hospital. The family member said CR #1 was diagnosed with infections to her sacral wound and stump. The family member said CR #1 stayed in the hospital about one week to clean out the infections the facility failed to care for. In an interview with the DON on 01/10/2023 at 11:58 a.m., she stated the facility lost their wound care nurse in December 2022 (she could not recall the exact date), so the nurses were responsible for completing wound care for their assigned halls. The DON said the vascular surgeon CR #1 had been seeing said CR #1 needed to go to the hospital for an infection on 11/25/2022. The DON said CR #1 had an appointment for wound evaluation on the following week, but the vascular surgeon said to send CR #1 to the hospital to let them look at the wounds in case they needed to be drained. The DON said CR #1's family initiated the transfer to the hospital because CR #1 complained to them about pain. The DON said CR #1's family member took pictures of her wounds and sent them to her doctor. The DON said the wound care doctor did not evaluate surgical wounds and CR #1 was seen by the wound care doctor on 11/23/2022 with no new orders related to infection. The DON said she was away from the facility quite a bit over the last three months due to illness, so she did not know all the information about CR #1. In an interview with CR #1's NP on 01/10/2023 at 12:30 p.m., she said a facility nurse (she could not recall the nurse's name) called her the day before CR #1 left the facility (11/24/2022). The NP said the nurse told her CR #1's wounds (she could not recall which wounds were discussed with the nurse at that time) started to look infected with symptoms of increased drainage and [NAME] in color. The NP said it did not sound like gangrene or emergent, so she asked them to make a surgical appointment for evaluation. In a telephone interview with CR #1's wound care physician on 01/10/2023 at 2:21 p.m., he stated he saw CR #1 on 11/23/2022 and there was no pain associated with her wounds at that time. He said he debrided CR #1's stage 4 sacral wound because it had necrotic tissue but no infection. He said he also looked at CR #1's surgical wounds at the request of her doctor. He said he would have documented any signs of infection and that would have automatically populated an order for wound culture. In an interview with RN D on 01/13/2023 at 10:53 a.m., he stated he normally worked the 7:00 p.m. - 7:00 a.m. shift. He stated he had not worked for the past month due to death in his family. He said the wound care nurse was still there the last time he worked in the facility. He said he did recall seeing residents' wound dressings with incorrect dates. He said CR #1's wounds were so bad they were oozing, and she was really in pain. He said CR #1 once complained to him that her wounds were not being dressed daily, so he provided wound care for her on that day (he could not recall the date of this incident). Resident #2 Record review of Resident #2's face sheet dated 01/10/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with muscle weakness, diabetes mellitus type 2 (a chronic condition that effects the way the body processes blood sugar), heart failure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acquired absence of left toes, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record review of Resident #2's MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); he did not exhibit behavior of rejection of care; he required limited physical assistance from at least one staff for bed mobility, dressing, toilet use, and personal hygiene; he was totally dependent on staff for bathing; he was wheelchair bound; he was occasionally incontinent of bladder and frequently incontinent of bowel; he did not receive pain medication; he was not at risk for developing pressure ulcers and did not have unhealed pressure ulcers/injuries; and he had surgical wounds which required wound care. Record review of Resident #2's care plan revised 11/14/2022 revealed he had actual impairment to skin integrity due to surgical wound left foot and cancerous ulcer to top of head (Goal: Will not have a re-hospitalization within 30 days. Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Cleanse area to the left foot with NS, apply skin prep pad and wrap with kerlex, change every other day. Cleanse area to head with NS, apply xeroform gauze and silver alginate and cover daily. Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration to MD. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface); he was on antibiotic therapy due to wound infection (date initiated 10/27/2022) (Goal: Will be free of any discomfort or adverse side effects. Interventions: Administer medication as ordered. Notify physician if signs and symptoms of infection worsen or do not resolve); and he had the potential for pressure ulcer development due to muscle weakness (Goal: Will have intact skin, free of redness, blisters or discoloration. Interventions: Administer treatments as ordered and monitor for effectiveness. Has pressure relieving/reducing device on bed. Notify nurse immediately of any new areas of skin breakdown). Observation and interview with Resident #2 on 01/10/2023 at 3:00 p.m., revealed he was alert and oriented. Observation of Resident #2's wound dressings revealed five wounds on his left leg from foot to thigh dated 1/07/23, one on the right thigh dated 01/07/2023, and one on his head dated 01/07/2023. Resident #2 said he usually received wound care every other day. He said he had not been out to the hospital or had wound infections recently. Record review of Resident #2's physician's orders for December 2022 and January 2023 revealed the following: Cleanse left leg post-surgery site open areas with normal saline, pat dry. Apply dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse wound to scalp site with normal saline, pat dry. Apply xeroform and cover with dry absorptive dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Record review of Resident #2's TAR for December 2022 revealed the following: Cleanse left leg post-surgery site open areas with normal saline, pat dry. Apply dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/10/2022. D/C Date- 12/14/2022. The entry boxes for 12/11/2022, 12/12/2022, and 12/13/2022 were blank, indicating the treatments not been completed on those days. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/10/2022. D/C Date- 12/14/2022. The entry boxes for 12/11/2022, 12/12/2022, and 12/13/2022 were blank, indicating the treatments not been completed on those days. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/10/2022. D/C Date- 12/14/2022. The entry boxes for 12/11/2022, 12/12/2022, and 12/13/2022 were blank, indicating the treatments not been completed on those days. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse wound to scalp site with normal saline, pat dry. Apply xeroform and cover with dry absorptive dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Left Distal medial calf: Cleanse open areas with normal saline, pat dry. Apply Collagen sheet then secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Left leg: Cleanse open areas with normal saline, pat dry. Apply dry gauze dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Left medial calf: Cleanse open areas with normal saline, pat dry. Apply Collagen sheet then secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Left medial foot: Cleanse area with normal saline, pat dry. Apply Santyl to necrotic tissue then secure with dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C Date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Right thigh: Cleanse open areas with normal saline, pat dry. Apply Collagen sheet then secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Scalp wound: cleanse area with normal saline, pat dry. Apply xeroform sterile gauze and secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Record review of Resident #2's TAR for January 2023 revealed the following: Cleanse left leg post-surgery site open areas with normal saline, pat dry. Apply dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse wound to scalp site with normal saline, pat dry. Apply xeroform and cover with dry absorptive dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Record review of Resident #2's wound care physician's notes dated 01/07/2023 revealed, Focused Wound Exam (Site 1) Wound Scalp Full Thickness. Etiology: Neoplasm. Wound Progress: No Change .; Focused Wound Exam (Site 2) Post-Surgical Wound of the Left Medial Foot Full Thickness. Wound Progress: Improved .; Focused Wound Exam (Site 3) Post-Surgical Wound of the Left Leg Full Thickness. Wound Progress: Improved. Site 3: Surgical Excisional Debridement Procedure to remove necrotic tissue and establish the margins of viable tissue .; Focused Wound Exam (Site 4) Post-Surgical Wound of the Right Thigh Full Thickness. Wound Progress: No Change .; Focused Wound Exam (Site 5) Post-Surgical Wound of the Left, Medial Leg Full Thickness. Wound Progress: Improved .; Focused Wound Exam (Site 6) Post-Surgical Wound of the Left, Medial Calf Full Thickness. Wound Progress: Improved .; Focused Wound Exam (Site 7) Post-Surgical Wound of the Left, Distal, Medial Calf Full Thickness. Wound Progress: Improved. In an interview with LVN E on 01/10/2023 at 3:10 p.m., she said the facility's nurses worked 12-hour shifts and the nurses were responsible for providing wound care for residents on their halls. LVN E said even numbered rooms got wound care during the night shift and the odd numbered rooms got wound care on the day shift. LVN E said Resident #2 should receive wound care on the night shift. In a telephone interview with RN F on 01/10/2023 at 4:10 p.m., she stated she worked the 7:00 p.m. - 7:00 a.m. shift. She said there was no wound care nurse, so each nurse did their own wounds (on their assigned hall). She said on her shift, she should do even numbered rooms. RN F said she had been doing all of her assigned wounds, but for the past two days, 01/07/2023 and 01/08/2023, the morning nurse said she did the wounds. RN F said there was a misunderstanding on 01/08/2023 because she thought the wounds had already been done. She said her mistake was that she did not go back and check for herself. She said the other nurse (the morning nurse) was an agency staff. RN F said the last time she provided wound care acre to the residents on her hall was 01/07/2023. RN F stated the negative outcome of failing to provide daily wound care could be infection, but none of the residents on her hall developed infections. She said she would be sure to check her residents' wounds daily even when someone else tells her they did the wound care. She said she worked on 01/07/2023 and 01/08/2023. Observation of wound care by LVN E on 01/13/2023 at 11:30 a.m., revealed treatment for all wounds were provided according to physician's orders. In an interview with LVN E on 01/13/2023 at 11:39 a.m., she said Resident #2's wounds were not done that morning (01/13/2023) because when she started, the resident said his wounds were not supposed to be done daily. Resident #3 Record review of Resident #3's face sheet dated 01/10/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), cognitive communication deficit (difficulty with thinking and how someone uses language), dysphagia (difficulty swallowing), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), cellulitis of right lower limb (a potentially serious bacterial skin infection), acquired absence of right leg above knee, gangrene (dead tissue caused by an infection or lack of blood flow), heart failure, retention of urine, and gastrostomy status (opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of Resident #3's MDS dated [DATE] revealed he had a BIMS score of 2 (severe cognitive impairment); he did not exhibit behaviors of rejection of care; he required extensive physical assistance from at least one staff member for bed mobility, dressing, and personal hygiene; he required total assistance from at least two staff for transfers; he required limited assistance for bathing; he was wheelchair bound; he did not have an indwelling catheter; he was always incontinent of bowel and bladder; he did not receive pain medications; and he was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries; he had surgical wounds which required wound care. Record review of Resident #3's care plan revised on 11/05/2022 revealed he had potential for skin breakdown due to decreased mobility (Goal: Resident will be free from skin injury. Interventions: Encourage good nutrition and hydration. Heel Protectors as ordered); he had gangrene affecting the right great toe (Goal: Resident will have no complications due to gangrene. Interventions: Betadine to right great toe. Monitor for changes. Notify doctor of ant significant changes); and he had a suprapubic catheter due to neurogenic bladder (urinary condition in people who lack bladder control due to a brain, spinal cord or nerve problem) (Goal: Resident will show no s/sx of urinary infection. Interventions: Catheter care every shift, monitor urethral site for s/s of skin breakdown. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Change drainage bag monthly. Change Foley catheter monthly. Record/report to doctor for s/sx of UTI). Observation and interview with Resident #3 on 01/10/2023 at 3:25 p.m. revealed he was alert and in bed. Resident #3's gastrostomy tube site dressing revealed it was dated 01/05/2023. Observation of the dressing above his suprapubic catheter revealed it was dated 01/05/2023. Resident #3 stated the nurses only did his gastrostomy tube and catheter care ever 2-3 days. He stated nobody ever did his care daily. Record review of Resident #3's physician's orders for December 2022 and January 2023 revealed the following: Suprapubic catheter site care - Cleanse with soap and water, pat dry one time a day for suprapubic catheter care. Order Status: Active. Order Date- 11/04/2022. Start Date- 11/05/2022. Cleanse G-Tube stoma with NS, pat dry and apply dry dressing every day shift. Order Status: Active. Order Date- 11/10/2022. Start Date- 11/11/2022 Record review of Resident #3's MAR for December 2022 revealed the following: Suprapubic catheter site care - Cleanse with soap and water, pat dry one time a day for suprapubic catheter care. Order Date- 11/04/2022. All entry boxes were checked and initialed, indicating all treatments were completed each day in December 2022. Cleanse G-Tube stoma with NS, pat dry and apply dry dressing every day shift. Order Date- 11/10/2022. All entry boxes were checked and initialed, indicating all treatments were completed each day in December 2022. Record review of Resident #3's MAR for January 2023 revealed the following: Suprapubic catheter site care - Cleanse with soap and water, pat dry one time a day for

Based on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when a significant change in condition occurred for one of 45 residents (CR #138) reviewed for notification of change in condition, in that: -CR#138's physician was not promptly consulted when the resident complained multiple times of chest pain, shortness of breath and experienced a nose bleed indicating a significant change in vital signs/condition. -CR#138's representative was not notified of the resident's change in condition after the resident complained multiple times of chest pain, shortness of breath, experienced a nose bleed, and expired in the facility the same day. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at actual harm that is not an immediate jeopardy with a scope identified as isolated. The facility was continuing to in-service staff and monitor the training and the Plan of Removal for effectiveness. These failures affected one discharged resident who died in the facility. Intake TX# 683 / 0 Findings include: CR #138 Record review of CR #138's face sheet dated [DATE] revealed a [AGE] year-old male admitted from an acute care hospital to the facility on [DATE]. CR #138's [DIAGNOSES REDACTED]. CR #138's was pronounced dead in the facility on [DATE]. Record review of CR #138's admission MDS revealed the assessment was started on [DATE] but was not completed. The identification information, section A, was the only section completed. Record of CR #138's admission assessment on [DATE] at 1:15 a.m. by LVN C which revealed blood pressure of ,[DATE], pulse of 82, respirations of 18, oxygen saturation of 97% on oxygen and temperature of 98.1. The note indicated CR #138 denied pain under the cardiovascular section. LVN C charted he had no shortness of breath; normal respiratory rate and his lung sounds were clear. Record review of CR #138's progress notes dated [DATE] at 9:18 p.m. by RN A revealed MD saw CR #138. RN A revealed CR #138 tolerated all given care and treatment. No signs or symptoms of distress and will continue to monitor. RN A completed a daily skilled note on [DATE] at 9:33 p.m. and revealed CR #138 was alert and orientated x3. His heart had a regular rhythm and respirations were normal on oxygen and oxygen saturation was 97%. Record review of CR #138's progress note by the Nurse Practitioner was completed on [DATE] revealed she discussed the medical status with nursing staff and reviewed his chart. An assessment was completed as a follow-up for [MEDICAL CONDITIONS], urinary tract infection, diabetes mellitus, and [MEDICAL CONDITION]. During review of his systems she revealed that CR #138 has concerns of shortness of breath upon exertion, increased urinary frequency with decrease urine flow and general weakness. She revealed his vitals were blood pressure of ,[DATE], pulse of 68, respiratory of 18, and temperature of 97.3. No pain was indicated. During her exam she identified that he was alert and awake. He was not in acute distress. His mucous membranes were moist. His respiratory was stable with oxygen between ,[DATE] liters/ nasal canula and his cardiac status revealed heart had a regular rate and rhythm. She identified under the assessment that his blood pressure had been stable on the [MEDICATION NAME] 25 mg every 12 hours. Record review of CR #138's consolidated physician's orders [REDACTED]. -[MEDICATION NAME] Nebulization Solution (2.5 mg/3ml) 0.083% 3 ml, inhale orally via nebulizer every 6 hours as needed for [MEDICATION NAME] - start date [DATE] -Aspirin Tablet Chewable 81 mg, give 1 tablet by mouthy one time a day for CAD,[MEDICAL CONDITION]- start date [DATE] -[MEDICATION NAME]-[MEDICATION NAME] Solution 0XXX,[DATE].5 (3) mg/3ml, 1unit inhale orally three times a day for [MEDICATION NAME] - start date [DATE] -[MEDICATION NAME] Tablet 40 mg ([MEDICATION NAME]), give 1 tablet by mouth two times a day for [MEDICAL CONDITION] - start date [DATE] -[MEDICATION NAME] Tablet 25 mg, give 1 tablet by mouth two times a day for HTN, Hold for BP less than ,[DATE] or HR less than 60 - start date [DATE] -[MEDICATION NAME] Tablet 75 mg ([MEDICATION NAME] Bisulfate), give 1 tablet by mouth one time a day for CAD - start date [DATE] -Temazapam Capsule 15 mg, give 1 capsule by mouth as needed for Sleep bedtime as needed - start date [DATE] -Bloody nose and bleeding wounds may be an Emergency as they may not stop on their own. Notify MD if bleeding persists - dated [DATE] -Full Code: Use AED (Automated External Defibrillator) with CPR during Sudden [MEDICAL CONDITION] Record review of CR #138's care plan with a revision date of [DATE] revealed he had [MEDICAL CONDITION] and was taking [MEDICATION NAME], (a diuretic) [MEDICATION NAME] (to treat blood pressure, chest pains, and heart failure) and [MEDICATION NAME] (a blood thinner). Interventions listed on the care plan were for staff to encourage adequate nutrition, give cardiac medications, monitor labs, and encourage resident to avoid salt or high sodium foods. Record review of CR #138's PT (physical therapy) note dated [DATE] at 3:30 p.m. by PT revealed that during the session the resident got tired very easily and demonstrated low cardiorespiratory endurance with high RPE (rating of perceived exertion) during activities. PT had to encourage deep breathing exercises during every movement for cardiopulmonary recovery. Interview on [DATE] at 11:05 a.m. OT stated she went into CR #138's room to provide therapy on [DATE] before lunch. OT said CR #138 was complaining of chest pain and had a bloody nose when she entered his room. OT said the resident was alert and orientated x 3. CR #138 said he was mad due to the pain he was having, but not mad at anyone in general. She said she checked his blood pressure with a wrist cuff and noted it was low at ,[DATE]. OT said she went and immediately reported this to LVN A. LVN A came in the resident's room and checked his vital signs which she said the BP was now ,[DATE], pulse 140, and oxygen saturation was 97% on 2.5 liter of oxygen per minute. OT said LVN A reassured the resident and repositioned him with pillows behind his back to help him breathe better. Interview via telephone on [DATE] at 9:40 a.m. with LVN A, she said she was in CR #138's room between 8:00 a.m. and 9:00 a.m. and gave him a breathing treatment and he was ok. She then said shortly before noon a CNA had told her CR #138 was complaining of shortness of breath. LVN A said he was complaining of not being able to sleep at night. LVN A said his oxygen saturation was 97% and she reassured him he was getting oxygen and he could breathe. LVN A reported the OT called her down to CR #138's room because she had checked his blood pressure and it was low. His blood pressure was normal, but his heart rate was high at 140. She said CR #138's chest hurt, and he was nervous. She also indicated he had a small amount of blood coming from his nose. She said she had wiped the blood off his mustache and cleaned up the rest of the blood and he had no more bleeding. She said he was repeatedly saying he could not sleep, and he could not breathe. She said she went into his room four or five different times from 12:00 p.m to 1:45 p.m. LVN A said CR #138 was given a pain pill, she thought it was a [MEDICATION NAME] during one of her visits to his room. LVN A said she was last in CR #138's room at approximately 1:45 p.m. LVN A reported she reassured the resident that the physician had ordered a sleeping pill he could have that evening and she would let the next nurse know. She instructed the CNA to assist him up in his wheelchair. LVN A said she did not call the physician because she did not think it was relevant because CR #138 told her he gets nervous. LVN A said she questioned the resident what he did when he got nervous and he explained to her that he gets up out of bed into his wheelchair. LVN A said she did see a nose bleed for CR #138 but did not think it was significant enough and it was not gushing. She said I neglected to chart the nose bleed because of everything else. I had not looked at all his diagnoses. He told me he had an open-heart surgery. She said she was not aware of a physician's orders [REDACTED]. She said when she went back another time when the resident said his chest hurt, LVN A asked CR #138 to describe the pain and he said it aches and it was not a sharp pain. LVN A said she reported onto ,[DATE] p.m. nurse RN A that CR #138 had a sleeping pill and was upset that he could not get it yet. LVN A said she was not sure if she reported the breathing issue to the next nurse. LVN A said the facility policy for a change in condition is to call the doctor. She said she did not think this was a change of condition and he had no other complaint after a while. LVN A said she did not do a full assessment on CR #138 nor a pain assessment for his pain medication as the medication was to relieve his anxiety. Interview on [DATE] at 10:27 a.m. CNA B said she worked the 6:00 a.m.-2:00 p.m. shift on [DATE]. She said CNA A was assigned to CR #138 the day of the incident. She said CR #138 was having problems with breathing on [DATE]. CNA B explained she first went into CR #138's room mid-morning about 9:00 a.m. and he was complaining of not being able to breathe. She said he put his call light on again, approximately 30 minutes later, and he was continuing to complain of not being able to breathe. The last time she went into his room was before lunch and he was up in his wheelchair and complaining of not being able to breathe. Each time she was in CR #138's room and he would complain she went to LVN A to report his complaints of shortness of breath. CNA B said she thought LVN A was going into the resident's room, but she would go do other resident care and did not see LVN A go into CR #138's room. She explained the last time she was in the room for CR #138 he was in his wheelchair and she assisted CNA A to get him back into bed and made him comfortable. She revealed she made rounds with the 2:,[DATE]:00 p.m. shift but did not report to the next shift about CR #138 because he was not her assigned resident. Interview on [DATE] at 10:43 a.m. CNA A confirmed she had worked on [DATE] in the AM with CR #138. CNA revealed the resident was fine when she did her initial rounds around 6:00 a.m. that morning. She said she gave CR #138 his breakfast and he then complained he could not breathe. CNA A said she said immediately to LVN A about CR #138's complaint. She said she saw LVN A go into his room, and she continued with other resident's care. CNA A said she went back CR #138's room before lunch and he continued to complain that he could not breathe. CNA A said she said this immediately to LVN A who instructed her to assist the resident up into his wheelchair. She then saw CNA B answer CR #138's call light and she was by CNA B that he was still complaining he could not breathe. CNA A said she and CNA C assisted CR #138 up into his wheelchair. She said he continued to complain of not being able to breathe. She adjusted the air conditioning in the room and applied his oxygen. CNA A said she had gone to LVN A about 4 times that morning to let her know about CR #138's complaints. She said the therapy department had also been in his room and he was complaining to them about chest pain. She revealed she did see he had a bloody nose during one of her times in the room and she had said that to LVN A. CNA A said CR #138 ate the fruit cup only from his lunch tray and did not want the lunch because he did not feel good. CNA A said she had worked on Sunday [DATE] and the resident had no shortness of breath or complaints on that day. CNA A said when she had received report from the night CNA on the morning of [DATE] CR #138 had had a good night and there were no complaints or concerns. She said when she had left her shift at 2:00 p.m. on [DATE] she had said to the on-coming CNA about CR #138 complaining of shortness of breath and not feeling well. CNA A said she had only witnessed LVN A go into CR #138's room one time during her shift. CNA A stated, My opinion if they say they are not feeling well, and we see a change in condition I think they should go check on them. CNA A said she felt like LVN A should have checked on CR #138 more often. Record review of CR #138's progress notes dated [DATE] at 12:16 p.m. by LVN A which revealed CR #138 was complaining of not being able to breathe. His oxygen via nasal canula at 2 liters per minute and oxygen saturation was 97%. Blood pressure was ,[DATE], heart rate of 140. The note revealed he was encouraged to deep breaths and try to relax. LVN A explained to him that his oxygen sat was 97% which meant he was getting oxygen into his blood stream and to just try to relax. LVN A medicated CR#138 for pain earlier to help alleviate anxiousness. LVN A said CR#138 wanted his sleep medication but it was ordered for the evening. Interview on [DATE] at 9:59 a.m. the DON, she said she expected her nurses to report a change of condition to the physician. She reported she was not aware of CR #138's change in condition on [DATE]. She said she would have expected staff to notify her of CR#138's change of condition. She said she was not aware of CR #138's nose blood until she read LVN A's witness statement. She said that this information was not in LVN A's nurses note, and it should have been in her note. DON said during her investigation/ interview with LVN A she said, she thought the nose bleed was because CR#138 had a dry nose with his use of oxygen. LVN A reported to the DON she did not feel it was a change in condition and was not aware of an order if CR #138 has a nose bleed. She explained that was a concern with LVN A that she did not recognize the change or document the change. DON said that, for a change of status, a nurse is to notify the responsible party and physician and she would like to be informed as well. Record review of facility provider investigation report dated [DATE] and sent to HHSC, revealed the facility identified that there was no change of status initiated for CR #138. Interview on [DATE] at 3:25 p.m. with RN A confirmed she was working on [DATE] on the 2:00 p.m.-10:00 p.m. shift. RN A said she received a report from LVN A the 6:00 a.m.-2:00 p.m. nurse. She explained LVN A told her, he was fine and his oxygen saturations were good. She did not tell her anything else about CR #138. RN A said CR #138 did not say anything or complain about anything. She explained she went to give him his sleeping pill at 8:10 p.m. RN A said at 8:50 p.m. or 8:45 p.m. the CNA C came and got her on 300 hall and reported CR #138 was unresponsive. She went on to state EMS responded and pronounced the resident deceased . Surveyor attempted to interview CNA C via phone on [DATE] at 3:46 p.m. and 3:54 p.m. and left a voicemail. Surveyor attempted to contact CNA C on [DATE] at 9:58 p.m. No return call was received from CNA C before exit. Interview on [DATE] at 8:29 a.m. with Corporate Nurse with the DON present, she said their investigation timeline for CR #138's incident, and she explained that documents reviewed by her and the DON said there was no documentation or notification to the primary care physician. They explained LVN A was called at 10:23 p.m. and asked about CR #138. LVN A said she did not call the physician. The Corporate Nurse explained that they investigated the therapy notes and identified a note from OT which indicated the resident had chest pain on [DATE] written by OT. She explained LVN A did not feel a change of condition happened. The Corporate Nurse went on to say LVN A thought the pulse was elevated because of anxiety and he had anxiety several times. Corporate Nurse was concerned that LVN A identified a nosebleed and did not document the incident. She said that is why they decided to call the incident into HHSC because the resident had a change in condition that was not documented, and LVN A did not follow the change of condition process. Interview with Administrator on [DATE] at 11:10 a.m. said an incident was called into HHSC on [DATE] because LVN A did not follow policy which caused a possible neglect situation. He said LVN A did not notify the primary care physician, responsible party, DON of CR #138's change of condition and did not report onto the next shift. He said LVN A identified CR #138 was complaining of chest pain, shortness of breath and nose bleed. He reported that the nurse did assess, took vitals, repositioned and encouraged deep breathing, but there was no documentation of CR #138's change. He said staff should report to ADON, DON or Administrator if a resident was not receiving necessary care. The Administrator said he was not aware of CR #138's change of condition on [DATE]. He said LVN A was aware of CR #138 status after the CNA's had told her several times and the resident continued to complain. He said the CNA's reported to LVN A but did not report to anyone else and the CNA's did not report to the facility administration. He said there was no action taken until after CR #138's death. The Administrator said during the investigation, it was identified she reported that LVN A did not feel CR #138's status was significant; the nose bleed was not enough to report to the doctor. Interview on [DATE] at 12:36 p.m. with CR #138's family member, she said the resident was admitted to the facility on [DATE] at approximately 2:00 a.m. She said he was there because she could not care for him at home because he had recent problems with shortness of breath, needed oxygen and wanted to sit upright and had no hospital bed at home. She also revealed he had increased anxiety because of his shortness of breath. She also reported he had increased swelling all over his body. She said these concerns developed Mid (MONTH) and he had never been on oxygen before. She said the day of CR #138's death she did not visit him, nor did she get a phone call from the staff at the facility for any reason on [DATE]. She said she did not hear from him much on Friday morning. She said she received a call around 9:00 p.m. by EMT who reported CR #138 had passed away. The family member reported she came to the facility on [DATE] possibly right before 11:00 p.m. She said when she saw him at that time, he had some dried blood under his nostril and in his mustache. Interview on [DATE] at 3:26 p.m. with CR #138's physician, she said CR #138 had a history of [REDACTED]. The physician stated his medical associate saw the resident on Friday [DATE] and ordered a sleeping pill for the resident because he was complaining of not being able to sleep well. The physician said the resident has recently been having some shortness of breath. He reported he did not receive a call on [DATE] from the facility staff regarding CR #138's status. The physician reported that if CR #138 had an elevated pulse, low blood pressure and complaints of chest pain that this could have been a change in CR #138's status and would have expected to be notified. Record review of facility policy for Notification, Physician or Responsible Party revised (MONTH) 2007 read in part . It is the policy of this facility to promptly notify the resident, his/ her attending physician, and/ or family/ responsible party of changes in the resident's condition and/ or status. 1. The nurse supervisor will notify the resident's attending the physician when: b. There is a significant change in the resident's physical mental, or psychosocial status; f. Deemed necessary or appropriate in the best interest of the resident. 2. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's family/ responsible party when: b. There is a significant change in the resident's physical mental, or psychosocial status; f. Deemed necessary or appropriate in the best interest of the resident. Review of facility policy for Abuse: Prevention of and Prohibition Against revised [DATE] read in part . The facility Administrator and DON were notified on [DATE] at 2:20 p.m. that an Immediate Jeopardy situation had been identified due to the above failures and a plan of removal was requested. A plan of removal was accepted was accepted after a revision on [DATE] at 11:30 a.m. The Plan included: 1. RN to review change of condition log for identification of and follow up actions taken for any change of condition. Change of condition audit of Electronic Health Record was initiated [DATE] at approximately at 3:30 p.m. and completed at 11:30 p.m. by RNs. This change of condition audit included bedside assessment of each resident in facility. The change of condition log is a QA process and updated daily as part of oversight activities; the change of condition process includes review of any new physician orders [REDACTED]. 2. Training began at approximately 10 p.m. on [DATE] and will be completed by 3:00 p.m. today [DATE] for staff who have worked a shift since that time. Training will continue as staff report to work prior to accepting assignment, until training is complete. DON and /or Clinical Resources are conducting this education. The education is being given to Licensed Nurses, CNAs, Therapy Services, Dietary, and Housekeeping Personnel. Policy and expectation for change of condition, has been reviewed by QAPI and the Medical Director. The source documents used as reference for training included tools from the 'Interact Version 4.0 for Nursing Homes', and does include cardiac distress as part of emergency/immediate notifications for SBAR process, Change in Condition/when to report to MD,NP,PA, and Stop and Watch tools. 3. Contract and PRN staff knowledge will be validated prior to accepting assignment by DON or designee. Education record for employees; fulltime, PRN and contract labor, will be maintained by DON or designee throughout entirety of survey, then maintained by HR director as part of employee files going forward. 4. Medical Director notified of IJ and updated on preexisting QA plan related to ongoing investigation and current QAPI. Medical Director was notified of IJ at approximately 2:25 p.m. on [DATE]. Off cycle QA meeting is scheduled today for 12:30 p.m. Monitoring 1. DON or RN Clinical Resource will review training completed daily until 100% compliance. DON and HR Director will review new hires and contract labor to ensure training is ongoing prior to accepting assignment of floor. 2. Administrator/DON to provide update to QAPI and Medical Director at end of day daily starting [DATE] and continue until IJ is lifted with weekly review until substantial compliance is achieved. Monitoring Visit on [DATE] was conducted to verify the Plan of Removal. The surveyors interviewed 5 LVNs, 4 CNAs, 1 Med Aid, 1 MDS Nurse, and 2 housekeepers who indicated that they had in-services/trainings on Change of Condition, Stop and Watch, Abuse/Neglect, Resident Change of Condition, and Who/When to Report concerns prior to starting their jobs. Record review Plan of Removal documentation of In-Services dated [DATE] through [DATE] that included: Change of Condition Logs, All Resident assessments for change of condition, Staff training on Change of Condition, Response to Medical Emergencies, and an Assessment Questionnaires for each staff member. LVN C was suspended on [DATE] and terminated on [DATE]. Based on the interviews conducted with the staff and record review of the documentation provided on the in-services provided to staff, it was determined that the facility had complete the Facility Plan of Removal. On [DATE] at 11:30 a.m. the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity of actual harm that is not an immediate jeopardy with a scope identified as isolated. The facility was continuing to in-service staff and monitor the training and the Plan of Removal for effectiveness.

Based on interview and record review, the facility failed to provide necessary care and services to allow the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 45 residents (CR#138) reviewed for quality of life. -The Facility failed to follow CR #138's physician orders [REDACTED]. -Facility Staff failed to assess and monitor CR 138's vital signs, and inform the residents' physician of a significant change in his vital signs and change of condition after several reported complaints of shortness of breath and chest pains. -Facility Staff failed to communicate to the next shift staff of CR#138's change in condition, to assess, and monitor the resident for change of condition, which resulted in the death of CR #138 on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at actual harm that is not an immediate jeopardy with a scope identified as isolated. The facility was continuing to in-service staff and monitor the training and the Plan of Removal for effectiveness. These failures could result in a decline in residents' health condition which could lead to to increased illness or death Intake TX# 683 / 0 Findings include: CR #138 Record review of CR #138's face sheet dated [DATE] revealed a [AGE] year-old male admitted from an acute care hospital to the facility on [DATE]. CR #138's [DIAGNOSES REDACTED]. CR #138's was pronounced dead in the facility on [DATE]. Record review of CR #138's admission MDS revealed the assessment was started on [DATE] but was not completed. The identification information, section A, was the only section completed. Record of CR #138's admission assessment on [DATE] at 1:15 a.m. by LVN C which revealed blood pressure of ,[DATE], pulse of 82, respirations of 18, oxygen saturation of 97% on oxygen and temperature of 98.1. The note indicated CR #138 denied pain under the cardiovascular section. LVN C charted he had no shortness of breath; normal respiratory rate and his lung sounds were clear. Record review of CR #138's progress notes dated [DATE] at 9:18 p.m. by RN A revealed MD saw CR #138. RN A revealed CR #138 tolerated all given care and treatment. No signs or symptoms of distress and will continue to monitor. RN A completed a daily skilled note on [DATE] at 9:33 p.m. and revealed CR #138 was alert and orientated x3. His heart had a regular rhythm and respirations were normal on oxygen and oxygen saturation was 97%. Record review of CR #138's progress note by the Nurse Practitioner was completed on [DATE] revealed she discussed the medical status with nursing staff and reviewed his chart. An assessment was completed as a follow-up for [MEDICAL CONDITIONS], urinary tract infection, diabetes mellitus, and [MEDICAL CONDITION]. During review of his systems she revealed that CR #138 has concerns of shortness of breath upon exertion, increased urinary frequency with decrease urine flow and general weakness. She revealed his vitals were blood pressure of ,[DATE], pulse of 68, respiratory of 18, and temperature of 97.3. No pain was indicated. During her exam she identified that he was alert and awake. He was not in acute distress. His mucous membranes were moist. His respiratory was stable with oxygen between ,[DATE] liters/ nasal canula and his cardiac status revealed heart had a regular rate and rhythm. She identified under the assessment that his blood pressure had been stable on the [MEDICATION NAME] 25 mg every 12 hours. Record review of CR #138's consolidated physician's orders [REDACTED]. -[MEDICATION NAME] Nebulization Solution (2.5 mg/3ml) 0.083% 3 ml, inhale orally via nebulizer every 6 hours as needed for [MEDICATION NAME] - start date [DATE] -Aspirin Tablet Chewable 81 mg, give 1 tablet by mouthy one time a day for CAD,[MEDICAL CONDITION]- start date [DATE] -[MEDICATION NAME]-[MEDICATION NAME] Solution 0XXX,[DATE].5 (3) mg/3ml, 1unit inhale orally three times a day for [MEDICATION NAME] - start date [DATE] -[MEDICATION NAME] Tablet 40 mg ([MEDICATION NAME]), give 1 tablet by mouth two times a day for [MEDICAL CONDITION] - start date [DATE] -[MEDICATION NAME] Tablet 25 mg, give 1 tablet by mouth two times a day for HTN, Hold for BP less than ,[DATE] or HR less than 60 - start date [DATE] -[MEDICATION NAME] Tablet 75 mg ([MEDICATION NAME] Bisulfate), give 1 tablet by mouth one time a day for CAD - start date [DATE] -Temazapam Capsule 15 mg, give 1 capsule by mouth as needed for Sleep bedtime as needed - start date [DATE] -Bloody nose and bleeding wounds may be an Emergency as they may not stop on their own. Notify MD if bleeding persists - dated [DATE] -Full Code: Use AED (Automated External Defibrillator) with CPR during Sudden [MEDICAL CONDITION] Record review of CR #138's provider investigation report dated [DATE] and sent to HHSC, revealed the facility identified that there was no change of status initiated for CR #138. Record review of the 24-hour report dated [DATE] for ,[DATE] p.m. shift revealed CR #138 complained of shortness of breath. His oxygen saturation was 97% on 2 to 2.5 liter per minute. Encouraged him to relax. Record review of CR #138's care plan with a revision date of [DATE] revealed he had [MEDICAL CONDITION] and was taking [MEDICATION NAME], (a diuretic) [MEDICATION NAME] (to treat blood pressure, chest pains, and heart failure) and [MEDICATION NAME] (a blood thinner). Interventions listed on the care plan were for staff to encourage adequate nutrition, give cardiac medications, monitor labs, and encourage resident to avoid salt or high sodium foods. Record review of CR #138's PT (physical therapy) note dated [DATE] at 3:30 p.m. by PT revealed that during the session the resident got tired very easily and demonstrated low cardiorespiratory endurance with high RPE (rating of perceived exertion) during activities. PT had to encourage deep breathing exercises during every movement for cardiopulmonary recovery. Record review of CR #138's progress notes dated [DATE] at 9:18 p.m. by RN A indicated his MD saw CR#138. RN A indicated CR #138 tolerated all given care and treatments. No signs or symptoms of distress and will continue to monitor. RN A completed a daily skilled note on [DATE] at 9:33 p.m. and revealed CR #138 was alert and orientated x 3. His heart had a regular rhythm and respirations were normal on oxygen and oxygen saturation was 97%. Record review of CR #138's progress notes dated [DATE] at 12:16 p.m. by LVN A which revealed CR #138 was complaining of not being able to breathe. His oxygen via nasal canula at 2 liters per minute and oxygen saturation was 97%. Blood pressure was ,[DATE], heart rate of 140. The note revealed he was encouraged to deep breaths and try to relax. LVN A explained to him that his oxygen sat was 97% which meant he was getting oxygen into his blood stream and to just try to relax. LVN A medicated CR#138 for pain earlier to help alleviate anxiousness. LVN A said CR#138 wanted his sleep medication but it was ordered for the evening. Record review of progress notes for CR #138 at [DATE] at 8:50 p.m. by RN A which revealed CNA came to inform her that CR#138 was unresponsive. She saw CR#138 unresponsive, CPR started, 911 called while CPR continued until Paramedics arrived. We were about to apply the AED, the paramedics walked in and 1 of them told us not to apply the AED And to discontinue the CPR that the resident was dead. RP and physician were notified. Closed record review of a progress note dated [DATE] by medical doctor revealed CR #138 was complaining of [MEDICAL CONDITION] and constipation. The note indicated he reviewed CR's medications and an exam was completed. He revealed the resident was awake and alert. He revealed the resident had no acute distress. Under respiratory the medical doctor indicated CR #138 had no retractions and no use of accessory muscles. Section of cardiovascular system the medical doctor checked CR's heart was at a regular rate and rhythm. The doctor indicated on his note that his mucous membranes were moist and benign oropharynx. The progress note revealed CR #138's vitals as blood pressure of ,[DATE], pulse of 72, respirations of 16 and temperature of 97.3 and pain was not circled in the assessment. Interview on [DATE] at 11:05 a.m. OT stated she went into CR #138's room to provide therapy on [DATE] before lunch. OT said CR #138 was complaining of chest pain and had a bloody nose when she entered his room. OT said the resident was alert and orientated x 3. CR #138 said he was mad due to the pain he was having, but not mad at anyone in general. She said she checked his blood pressure with a wrist cuff and noted it was low at ,[DATE]. OT said she went and immediately reported this to LVN A. LVN A came in the resident's room and checked his vital signs which she said the BP was now ,[DATE], pulse 140, and oxygen saturation was 97% on 2.5 liter of oxygen per minute. OT said LVN A reassured the resident and repositioned him with pillows behind his back to help him breathe better. Interview via telephone on [DATE] at 9:40 a.m. with LVN A, she said she was in CR #138's room between 8:00 a.m. and 9:00 a.m. and gave him a breathing treatment and he was ok. She then said shortly before noon a CNA had told her CR #138 was complaining of shortness of breath. LVN A said he was complaining of not being able to sleep at night. LVN A said his oxygen saturation was 97% and she reassured him he was getting oxygen and he could breathe. LVN A reported the OT called her down to CR #138's room because she had checked his blood pressure and it was low. His blood pressure was normal, but his heart rate was high at 140. She said CR #138's chest hurt, and he was nervous. She also indicated he had a small amount of blood coming from his nose. She said she had wiped the blood off his mustache and cleaned up the rest of the blood and he had no more bleeding. She said he was repeatedly saying he could not sleep, and he could not breathe. She said she went into his room four or five different times from 12:00 p.m to 1:45 p.m. LVN A said CR #138 was given a pain pill, she thought it was a [MEDICATION NAME] during one of her visits to his room. LVN A said she was last in CR #138's room at approximately 1:45 p.m. LVN A reported she reassured the resident that the physician had ordered a sleeping pill he could have that evening and she would let the next nurse know. She instructed the CNA to assist him up in his wheelchair. LVN A said she did not call the physician because she did not think it was relevant because CR #138 told her he gets nervous. LVN A said she questioned the resident what he did when he got nervous and he explained to her that he gets up out of bed into his wheelchair. LVN A said she did see a nose bleed for CR #138 but did not think it was significant enough and it was not gushing. She said I neglected to chart the nose bleed because of everything else. I had not looked at all his diagnoses. He told me he had an open-heart surgery. She said she was not aware of a physician's orders [REDACTED]. She said when she went back another time when the resident said his chest hurt, LVN A asked CR #138 to describe the pain and he said it aches and it was not a sharp pain. LVN A said she reported onto ,[DATE] p.m. nurse RN A that CR #138 had a sleeping pill and was upset that he could not get it yet. LVN A said she was not sure if she reported the breathing issue to the next nurse. LVN A said the facility policy for a change in condition is to call the doctor. She said she did not think this was a change of condition and he had no other complaint after a while. LVN A said she did not do a full assessment on CR #138 nor a pain assessment for his pain medication as the medication was to relieve his anxiety. Interview on [DATE] at 10:27 a.m. CNA B said she worked the 6:00 a.m.-2:00 p.m. shift on [DATE]. She said CNA A was assigned to CR #138 the day of the incident. She said CR #138 was having problems with breathing on [DATE]. CNA B explained she first went into CR #138's room mid-morning about 9:00 a.m. and he was complaining of not being able to breathe. She said he put his call light on again, approximately 30 minutes later, and he was continuing to complain of not being able to breathe. The last time she went into his room was before lunch and he was up in his wheelchair and complaining of not being able to breathe. Each time she was in CR #138's room and he would complain she went to LVN A to report his complaints of shortness of breath. CNA B said she thought LVN A was going into the resident's room, but she would go do other resident care and did not see LVN A go into CR #138's room. She explained the last time she was in the room for CR #138 he was in his wheelchair and she assisted CNA A to get him back into bed and made him comfortable. She revealed she made rounds with the 2:,[DATE]:00 p.m. shift but did not report to the next shift about CR #138 because he was not her assigned resident. Interview on [DATE] at 10:43 a.m. CNA A confirmed she had worked on [DATE] in the AM with CR #138. CNA revealed the resident was fine when she did her initial rounds around 6:00 a.m. that morning. She said she gave CR #138 his breakfast and he then complained he could not breathe. CNA A said she said immediately to LVN A about CR #138's complaint. She said she saw LVN A go into his room, and she continued with other resident's care. CNA A said she went back CR #138's room before lunch and he continued to complain that he could not breathe. CNA A said she said this immediately to LVN A who instructed her to assist the resident up into his wheelchair. She then saw CNA B answer CR #138's call light and she was by CNA B that he was still complaining he could not breathe. CNA A said she and CNA C assisted CR #138 up into his wheelchair. She said he continued to complain of not being able to breathe. She adjusted the air conditioning in the room and applied his oxygen. CNA A said she had gone to LVN A about 4 times that morning to let her know about CR #138's complaints. She said the therapy department had also been in his room and he was complaining to them about chest pain. She revealed she did see he had a bloody nose during one of her times in the room and she had said that to LVN A. CNA A said CR #138 ate the fruit cup only from his lunch tray and did not want the lunch because he did not feel good. CNA A said she had worked on Sunday [DATE] and the resident had no shortness of breath or complaints on that day. CNA A said when she had received report from the night CNA on the morning of [DATE] CR #138 had had a good night and there were no complaints or concerns. She said when she had left her shift at 2:00 p.m. on [DATE] she had said to the on-coming CNA about CR #138 complaining of shortness of breath and not feeling well. CNA A said she had only witnessed LVN A go into CR #138's room one time during her shift. CNA A said she felt like LVN A should have checked on CR #138 more often. Interview on [DATE] at 9:59 a.m. the DON, she said she expected her nurses to report a change of condition to the physician. She reported she was not aware of CR #138's change in condition on [DATE]. She said she would have expected staff to notify her of CR#138's change of condition. She said she was not aware of CR #138's nose blood until she read LVN A's witness statement. She said that this information was not in LVN A's nurses note, and it should have been in her note. DON said during her investigation/ interview with LVN A she said, she thought the nose bleed was because CR#138 had a dry nose with his use of oxygen. LVN A reported to the DON she did not feel it was a change in condition and was not aware of an order if CR #138 has a nose bleed. She explained that was a concern with LVN A that she did not recognize the change or document the change. DON said that, for a change of status, a nurse is to notify the responsible party and physician and she would like to be informed as well. Record review of facility provider investigation report dated [DATE] and sent to HHSC, revealed the facility identified that there was no change of status initiated for CR #138. Interview on [DATE] at 3:25 p.m. with RN A confirmed she was working on [DATE] on the 2:00 p.m.-10:00 p.m. shift. RN A said she received a report from LVN A the 6:00 a.m.-2:00 p.m. nurse. She explained LVN A told her, he was fine and his oxygen saturations were good. She did not tell her anything else about CR #138. RN A said CR #138 did not say anything or complain about anything. She explained she went to give him his sleeping pill at 8:10 p.m. RN A said at 8:50 p.m. or 8:45 p.m. the CNA C came and got her on 300 hall and reported CR #138 was unresponsive. She went on to state EMS responded and pronounced the resident deceased . Surveyor attempted to interview CNA C via phone on [DATE] at 3:46 p.m. and 3:54 p.m. and left a voicemail. Surveyor attempted to contact CNA C on [DATE] at 9:58 p.m. No return call was received from CNA C before exit. Interview on [DATE] at 4:02 p.m. with LVN B, he said around 8:30 p.m. RN A came to the nurses' station and said she thought her resident had passed. RN-A called 911 and they both ran down to CR #138's room with the crash cart. He said CR #138's color was pale grayish, his skin was cool to touch, and he was not breathing. He said he started CPR on CR for about 5 minutes before EMS arrived. He said when EMS arrived they pulled down on his jaw, and they explained that his skin was gray, cool and his jaw was locked. EMS did not try to work on him and told him and RN-A to stop the code. Record review of Harris County Institute of Forensic Sciences dated [DATE] at 9:43 p.m. revealed 911 was called at 8:46 p.m. and fire department confirmed the death for CR #138 at the facility. Interview on [DATE] at 8:29 a.m. with Corporate Nurse with the DON present, she said their investigation timeline for CR #138's incident, and she explained that documents reviewed by her and the DON said there was no documentation or notification to the primary care physician. They explained LVN A was called at 10:23 p.m. and asked about CR #138. LVN A said she did not call the physician. The Corporate Nurse explained that they investigated the therapy notes and identified a note from OT which indicated the resident had chest pain on [DATE] written by OT. She explained LVN A did not feel a change of condition happened. The Corporate Nurse went on to say LVN A thought the pulse was elevated because of anxiety and he had anxiety several times. Corporate Nurse was concerned that LVN A identified a nosebleed and did not document the incident. She said that is why they decided to call the incident into HHSC because the resident had a change in condition that was not documented, and LVN A did not follow the change of condition process. Interview with Administrator on [DATE] at 11:10 a.m. said an incident was called into HHSC on [DATE] because LVN A did not follow policy which caused a possible neglect situation. He said LVN A did not notify the primary care physician, responsible party, DON of CR #138's change of condition and did not report onto the next shift. He said LVN A identified CR #138 was complaining of chest pain, shortness of breath and nose bleed. He reported that the nurse did assess, took vitals, repositioned and encouraged deep breathing, but there was no documentation of CR #138's change. He said staff should report to ADON, DON or Administrator if a resident was not receiving necessary care. The Administrator said he was not aware of CR #138's change of condition on [DATE]. He said LVN A was aware of CR #138 status after the CNA's had told her several times and the resident continued to complain. He said the CNA's reported to LVN A but did not report to anyone else and the CNA's did not report to the facility administration. He said there was no action taken until after CR #138's death. The Administrator said during the investigation, it was identified she reported that LVN A did not feel CR #138's status was significant; the nose bleed was not enough to report to the doctor. Interview on [DATE] at 12:36 p.m. with CR #138's family member, she said the resident was admitted to the facility on [DATE] at approximately 2:00 a.m. She said he was there because she could not care for him at home because he had recent problems with shortness of breath, needed oxygen and wanted to sit upright and had no hospital bed at home. She also revealed he had increased anxiety because of his shortness of breath. She also reported he had increased swelling all over his body. She said these concerns developed Mid (MONTH) and he had never been on oxygen before. She said the day of CR #138's death she did not visit him, nor did she get a phone call from the staff at the facility for any reason on [DATE]. She said she did not hear from him much on Friday morning. She said she received a call around 9:00 p.m. by EMT who reported CR #138 had passed away. The family member reported she came to the facility on [DATE] possibly right before 11:00 p.m. She said when she saw him at that time, he had some dried blood under his nostril and in his mustache. Interview on [DATE] at 3:26 p.m. with CR #138's physician, she said CR #138 had a history of [REDACTED]. The physician stated his medical associate saw the resident on Friday [DATE] and ordered a sleeping pill for the resident because he was complaining of not being able to sleep well. The physician said the resident has recently been having some shortness of breath. He reported he did not receive a call on [DATE] from the facility staff regarding CR #138's status. The physician reported that if CR #138 had an elevated pulse, low blood pressure and complaints of chest pain that this could have been a change in CR #138's status and would have expected to be notified. Record review of facility policy for Notification, Physician or Responsible Party revised (MONTH) 2007 read in part . It is the policy of this facility to promptly notify the resident, his/ her attending physician, and/ or family/ responsible party of changes in the resident's condition and/ or status. 1. The nurse supervisor will notify the resident's attending the physician when: b. There is a significant change in the resident's physical mental, or psychosocial status; f. Deemed necessary or appropriate in the best interest of the resident. 2. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's family/ responsible party when: b. There is a significant change in the resident's physical mental, or psychosocial status; f. Deemed necessary or appropriate in the best interest of the resident. Review of facility policy for Abuse: Prevention of and Prohibition Against revised [DATE] read in part . The facility Administrator and DON were notified on [DATE] at 2:20 p.m. that an Immediate Jeopardy situation had been identified due to the above failures and a plan of removal was requested. A plan of removal was accepted was accepted after a revision on [DATE] at 11:30 a.m. The Plan included: 1. RN to review change of condition log for identification of and follow up actions taken for any change of condition. Change of condition audit of Electronic Health Record was initiated [DATE] at approximately at 3:30 p.m. and completed at 11:30 p.m. by RNs. This change of condition audit included bedside assessment of each resident in facility. The change of condition log is a QA process and updated daily as part of oversight activities; the change of condition process includes review of any new physician orders [REDACTED]. 2. Training began at approximately 10 p.m. on [DATE] and will be completed by 3:00 p.m. today [DATE] for staff who have worked a shift since that time. Training will continue as staff report to work prior to accepting assignment, until training is complete. DON and /or Clinical Resources are conducting this education. The education is being given to Licensed Nurses, CNAs, Therapy Services, Dietary, and Housekeeping Personnel. Policy and expectation for change of condition, has been reviewed by QAPI and the Medical Director. The source documents used as reference for training included tools from the 'Interact Version 4.0 for Nursing Homes', and does include cardiac distress as part of emergency/immediate notifications for SBAR process, Change in Condition/when to report to MD,NP,PA, and Stop and Watch tools. 3. Contract and PRN staff knowledge will be validated prior to accepting assignment by DON or designee. Education record for employees; fulltime, PRN and contract labor, will be maintained by DON or designee throughout entirety of survey, then maintained by HR director as part of employee files going forward. 4. Medical Director notified of IJ and updated on preexisting QA plan related to ongoing investigation and current QAPI. Medical Director was notified of IJ at approximately 2:25 p.m. on [DATE]. Off cycle QA meeting is scheduled today for 12:30 p.m. Monitoring 1. DON or RN Clinical Resource will review training completed daily until 100% compliance. DON and HR Director will review new hires and contract labor to ensure training is ongoing prior to accepting assignment of floor. 2. Administrator/DON to provide update to QAPI and Medical Director at end of day daily starting [DATE] and continue until IJ is lifted with weekly review until substantial compliance is achieved. Monitoring Visit on [DATE] was conducted to verify the Plan of Removal. The surveyors interviewed 5 LVNs, 4 CNAs, 1 Med Aid, 1 MDS Nurse, and 2 housekeepers who indicated that they had in-services/trainings on Change of Condition, Stop and Watch, Abuse/Neglect, Resident Change of Condition, and Who/When to Report concerns prior to starting their jobs. Record review Plan of Removal documentation of In-Services dated [DATE] through [DATE] that included: Change of Condition Logs, All Resident assessments for change of condition, Staff training on Change of Condition, Response to Medical Emergencies, and an Assessment Questionnaires for each staff member. LVN C was suspended on [DATE] and terminated on [DATE]. Based on the interviews conducted with the staff and record review of the documentation provided on the in-services provided to staff, it was determined that the facility had complete the Facility Plan of Removal. On [DATE] at 11:30 a.m. the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity of actual harm that is not an immediate jeopardy with a scope identified as isolated. The facility was continuing to in-service staff and monitor the training and the Plan of Removal for effectiveness.

Based on interview and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 45 residents (CR #138), reviewed for competent nursing staff -LVN A failed to identify a significant change in condition experienced by CR #138 -LVN A failed to notify CR #138's physician of a change in condition -LVN A failed to notify on-coming shift staff of CR #138's change in condition and failed to document her observations in CR #138's clinical record. -Facility nursing staff failed to assess and document CR #138's condition from [DATE] at 12:16 p.m. to 8:50 p.m., when he was found unresponsive. These failures resulted in an IJ (immediate jeopardy) on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as isolated because the facility was continuing to in-service staff and monitor their Plan of Removal for effectiveness. These failures affected 1 resident who died because of a delay in appropriate medical treatment resulting in the resident's death. Intake TX# 683 / 0 Findings included: Record review of Chapter 217 Standards of Nursing Practice revealed: The Texas Board of Nursing . All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: . (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; . Record review of CR #138's face sheet revealed a [AGE] year-old male admitted from acute care hospital to the facility on [DATE] he was discharged [DATE] due to his death at the facility. CR #138's [DIAGNOSES REDACTED]. Record review of CR #138's revealed on entry MDS assessment was completed on [DATE], the identification information, section A was the only section completed. Record review revealed CR #138's admission assessment on [DATE] at 1:15 a.m. by LVN C revealed blood pressure of ,[DATE], pulse of 82, respirations of 18, oxygen saturation of 97% on oxygen and temperature of 98.1. The note indicated CR#138 denied pain under cardiovascular. LVN C charted he had no shortness of breath; normal respiratory rate and his lung sounds were clear. Record review revealed a daily skilled assessment for CR #138 was completed on [DATE], two on [DATE] and one on [DATE]. All the assessments identified his cardiovascular system as a regular rhythm and his respiratory system as normal with no shortness of breath. Record review of CR #138's consolidated physician's orders [REDACTED]. -[MEDICATION NAME] Nebulization Solution (2.5 mg/3ml) 0.083% 3 ml, inhale orally via nebulizer every 6 hours as needed for [MEDICATION NAME] - start date [DATE] -Aspirin Tablet Chewable 81 mg, give 1 tablet by mouthy one time a day for CAD,[MEDICAL CONDITION]- start date [DATE] -[MEDICATION NAME]-[MEDICATION NAME] Solution 0XXX,[DATE].5 (3) mg/3ml, 1unit inhale orally three times a day for [MEDICATION NAME] - start date [DATE] -[MEDICATION NAME] Tablet 40 mg ([MEDICATION NAME]), give 1 tablet by mouth two times a day for [MEDICAL CONDITION] - start date [DATE] -[MEDICATION NAME] Tablet 25 mg, give 1 tablet by mouth two times a day for HTN, Hold for BP less than ,[DATE] or HR less than 60 - start date [DATE] -[MEDICATION NAME] Tablet 75 mg ([MEDICATION NAME] Bisulfate), give 1 tablet by mouth one time a day for CAD - start date [DATE] -Temazapam Capsule 15 mg, give 1 capsule by mouth as needed for Sleep bedtime as needed - start date [DATE] -Bloody nose and bleeding wounds may be an Emergency as they may not stop on their own. Notify MD if bleeding persists - dated [DATE] -Full Code: Use AED (Automated External Defibrillator) with CPR during Sudden [MEDICAL CONDITION] Record review of CR #138's progress note dated [DATE] written by medical doctor revealed CR #138 was complaining of [MEDICAL CONDITION] and constipation. The note indicated he reviewed CR's medications and an exam was completed. He revealed the resident was awake and alert. He revealed the resident had no acute distress. Under respiratory the medical doctor indicated CR #138 had no retractions and no use of accessory muscles. Section of cardiovascular system the medical doctor checked CR's heart was at a regular rate and rhythm. The doctor indicated on his note that his mucous membranes were moist and benign oropharynx. The progress note revealed CR #138's vitals as blood pressure of ,[DATE], pulse of 72, respirations of 16 and temperature of 97.3 and pain was not circled. Record review of CR #138's progress notes revealed a note on [DATE] at 9:18 p.m. by RN A indicated MD saw CR#138. RN A indicated CR #138 tolerated all given care and treatments. No signs or symptoms of distress and will continue to monitor. RN A completed a daily skilled note on [DATE] at 9:33 p.m. and revealed CR #138 was alert and orientated x 3. His heart had a regular rhythm and respirations were normal on oxygen and oxygen saturation was 97%. Record review of CR #138's progress note by the nurse practitioner was completed on [DATE] revealed she discussed the medical status with nursing staff and reviewed his chart. An assessment was completed as a follow-up for [MEDICAL CONDITIONS], urinary tract infection, diabetes mellitus, and [MEDICAL CONDITION]. During review of his systems she revealed that CR #138 has concerns of shortness of breath upon exertion, increased urinary frequency with decrease urine flow and general weakness. She revealed his vitals were blood pressure of ,[DATE], pulse of 68, respiratory of 18, and temperature of 97.3. No pain was indicated. During her exam she identified that he was alert and awake. He was not in acute distress. His mucous membranes were moist. His respiratory was stable with oxygen between ,[DATE] liters/ nasal canula and his cardiac status revealed heart had a regular rate and rhythm. She identified under the assessment that his blood pressure had been stable on the [MEDICATION NAME] 25 mg every 12 hours. Record review of CR #138's progress notes at [DATE] at 8:50 p.m. by RN A revealed CNA came to inform her that CR#138 was unresponsive. She saw CR#138 unresponsive, CPR started, 911 called while CPR continued until Paramedics arrived. We were about to apply the AED, the paramedics walked in and 1 of them told us not to apply the AED And to discontinue the CPR that the resident was dead. RP and physician were notified. Record review of the 24-hour report dated [DATE] for ,[DATE] p.m. shift revealed CR #138 complained of shortness of breath. His oxygen saturation was 97% on 2 to 2.5 liter per minute. Encouraged him to relax. Record review of LVN A's witness statement dated [DATE], time unknown revealed around noon CNA had came to her regarding CR #138 because he was complaining of not being able to breath. His oxygen saturation was 97% on nasal canula oxygen. Resident was complaining of not being able to sleep and it made him nervous. CR #138 was complaining of chest hurting. LVN A revealed his arms were moving and no shortness of breath noted. He reported the pain in his chest was an ache, not a sharpness or heaviness; the pain does not come and go. Vital signs were taken with arm cuff and identified blood pressure of 102/ 76 and heart rate of 140. LVN A encouraged deep breathing and relaxing. He reported he was nervous several times. Around lunch someone reported CR #138's nose was bleeding. LVN A wrote she assessed him for the nose bleed and his nose was red, not gushing blood nor a steady flow. She wrote she cleaned his nose, face and oxygen tubing; the bleeding had stopped. At 12:30 p.m. LVN A gave CR #138 a pain pill. No further complaints of chest pain. CR #138 requested to sleep and LVN A turned out the light and pulled the door partly closed so he could relax. LVN A wrote she had gone into his room at approximately 1:00 p.m., 1:30 p.m. and last time was 1:45 p.m. Record review of CR #138's care plan date revised on [DATE] revealed he had [MEDICAL CONDITION] and was taking [MEDICATION NAME]. The interventions were to encourage adequate nutrition, give cardiac medications, monitor labs, and encourage resident to avoid salt or high sodium foods. Record review of Harris County Institute of Forensic Sciences dated [DATE] at 9:43 p.m. revealed 911 was called at 8:46 p.m. and fire department confirmed the death for CR #138 at the facility. His [DIAGNOSES REDACTED]. Record review of CR #138's progress notes revealed there was a note [DATE] at 12:16 p.m. by LVN A which revealed CR was complaining of not being able to breathe. His oxygen via nasal canula at 2 liter per minute and oxygen saturation was 97%. Blood pressure was ,[DATE], heart rate of 140. The note revealed he was encouraged to deep breath and try to relax. LVN A explained to him that his oxygen sat was 97% which meant he was getting oxygen into his blood stream and to just try to relax. LVN A gave CR #138 medication for pain earlier to help alleviate anxiousness. LVN A wrote that CR#138 wanted his sleep medication but it was order for evening time. Record review of CR #138's OT (occupational therapy) note dated [DATE] at 12:34 p.m. by OT revealed CR #138 complained of not feeling well. He was complaining of chest pain on OT arrival in room. OT identified CR was on continuous oxygen at 2.5 liter per minute with oxygen saturation of 94%, blood pressure ,[DATE], and a pulse of 75. OT revealed she had called the nurse into CR's room immediately. Nurse checked and closely monitored during session. OT note revealed CR had excessive fatigue just with sitting supported in bed with getting adjustment of comfort position. Nurse checked x 2 during session at start and end. OT identified she had a 30-minute therapy session with CR #138. Record review of a witness statement by CNA B dated [DATE], time unknown revealed she had gone into CR #138's room three times on her shift on [DATE] to answer his call light. Each time he complained of being short of breath. He was wearing oxygen and he was alert and talking. Each time I reported CR #138's complaint of being short of breath to my charge nurse LVN A. CNA B revealed she saw LVN A walk down the hall to check on him. Record review of a witness statement by CNA A dated [DATE], time unknown which revealed CR #138 was in bed, appeared to be anxious and complaining of shortness of breath around 11:00 a.m. CNA A revealed she reported this to LVN A. After lunch LVN A requested CNA A to get CR #138 up in wheelchair. CNA A and CNA B assisted CR #138 into his wheelchair. He again was complaining of being short of breath and appeared anxious. He was alert and talking normal. CNA A reported again to LVN A that he was complaining of being short of breath. Interview on [DATE] at 11:05 a.m., OT said she went into CR #138's room to work with him before lunch on [DATE] . She reported she knew CR #138's therapy session was before lunch because his tray came during the 30-minute session. OT reported she did not document immediately after the therapy session ended, but she documented after her lunch was completed. OT said he complained of chest pain and had a small bloody nose when she entered his room. OT said CR #138 was alert and orientated x 3. He said he was mad because of the pain he was having, but not mad any anyone in general. She said she checked his blood pressure with a wrist cuff and noted it was low at ,[DATE]. OT said she went to get LVN A who was assigned to the hall. The nurse came in shortly after and checked his blood pressure ,[DATE], pulse 140, and oxygen saturation 97% on 2.5 liter per minute. OT said LVN A reassured the resident and repositioned him with pillows behind his back to help him breath better. OT said she reoriented CR #138 to the call light prior to leaving the room. Interview on [DATE] at 9:40 a.m. with LVN A revealed she was in CR #138's room between 8:00 a.m. or 9:00 a.m. and gave him a breathing treatment and he was ok. She then reported shortly before noon a CNA had told her CR #138 was complaining of shortness of breath. LVN A said he was complaining of not being able to sleep at night. LVN A said his oxygen saturation was 97% and reassured him he was getting oxygen and he could breath. She said she checked his concentrator water bottle and tubing and it was working properly. LVN A said the OT had called her down to CR #138's room because she had checked his blood pressure and it was low. His blood pressure was normal, but his heart rate was high at 140. She said CR#138's chest hurt, and he was nervous. She also indicated he had a small amount of nose bleed. She said she had wiped the blood off his mustache and cleaned up the rest of the blood and he had no more bleeding. She said he was repeatedly saying he could not sleep, and he could not breathe. She said she went into his room four or five different times from 12:00 p.m. to 1:45 p.m. LVN A said CR #138 was given a pain pill, she thought it was a [MEDICATION NAME] during one of her visits to his room. LVN A said she was last in CR #138's room at approximately 1:45 p.m. She indicated physical therapy was in the room, but she was not aware of what they did, nor did they communicate with her regarding CR #138 prior to a therapy session. She said she tried to make him comfortable and reposition him. LVN A said she did not call the physician because she did not think it was relevant. LVN A revealed she did see a nose bleed for CR #138 but did not think it was significant enough and it was not gushing. She said I neglected to chart the nose bleed because of everything else. I had not looked at all his diagnoses. He told me he had an open-heart surgery. She said she was not aware of an order related to a nose bleed. She revealed when she went back another time when he said his chest hurt, LVN A asked CR #138 to describe the pain and he said it aches and it was not a sharp pain. LVN A said she did not remember what she documented on the 24-hour report. LVN A revealed she reported onto ,[DATE] p.m. nurse RN A that CR #138 had a sleeping pill and was upset that he could not get it yet. LVN A said she was not sure if she reported the breathing issue to the next nurse. LVN A revealed the facility policy for a change in condition is to call the doctor. She said she did not think this was a change of condition and he had no other complaint after a while. LVN A said she had written a nursing note on CR #138, but she did not remember what she wrote. LVN A revealed she did not do a full assessment on CR #138 nor a pain assessment for his pain medication. An interview on [DATE] at 9:59 a.m. with the DON said she expected her nurses to report a change of condition to the physician. She reported she was not aware of CR #138's change in condition on [DATE], she said she would have expected staff to notify her of CR #138's change of condition. She revealed she was not aware of CR #138's nose blood until she read LVN A's witness statement. She said that this information was not in LVN A's nurses note, she said it should have been in her note. The DON said LVN A told her she thought CR #138's nose was bleeding because of a dry nose related to oxygen use when she interviewed LVN A for the investigation. During that interview, LVN A told the DON she did not feel it was a change in condition and was not aware of an order to report to the physician when CR #138 had a nose bleed. The DON explained that it was a concern that LVN A did not recognize the change in condition and that she did not document the change. The DON said the facility suspended LVN A for these concerns until the investigation was completed. The DON said that, for changes of status, a nurse was to notify the responsible party and physician and she would like to be inform as well. The DON also said if CNAs identified something different from a norm for a resident they were to notify the charge nurses. She said that she just started in her position, but she had been training the CNAs on the Stop and Watch to inform the nurses of a residents changes of condition. The DON said on [DATE] LVN A worked the 6:00 a.m.- 2:00 p.m. shift and RN A worked 2:00 p.m. to 10:00 p.m. She reported she was notified of CR #138's death at 8:50 p.m. The DON reported a daily skilled assessment should have been completed daily on CR #138. The DON said the facility-initiated training on abuse and neglect and change of condition after the death of CR #138. She said after she was notified of his death she informed the Administrator and the Corporate Nurse. The DON reported that they called an unexpected death into HHSC on [DATE]. Record review of CR #138's provider investigation report revealed the facility identified that there was no change of status initiated for CR #138. Interview on [DATE] at 10:27 a.m. with CNA B revealed she works the 6:00 a.m.-2:00 p.m. shift. She said hall 200 was her assigned hall she worked. She said on [DATE] she worked the front part of the hall and CNA A worked the back part of the hall, but we assist each other with all residents. She said CNA A was assigned to CR #138 the day of the incident. She said CR #138 was having problems with breathing on [DATE]. CNA B explained that she first went into CR #138's room mid-morning about 9:00 a.m. and he was complaining of not being able to breath. She said he put his call light on again, approximately 30 minutes later, around 10:30 a.m. and he was continuing to complain of not being able to breath. The last time she went into his room it was before lunch and he was up in his wheelchair and complaining of not being able to breath. Each time she was in CR #138's room and he would complain she went back to LVN A to report his complaints of shortness of breath. CNA B said she thought LVN A was going into the resident's room, but CNA A said she could not say she went into his room because she continued to do patient care on other residents after she reported to LVN A. She explained the last time she was in the room for CR #138 he was in his wheelchair and she assisted CNA A helping to get him back into bed and made him comfortable with his bed elevated all the way up and pillows behind his back. She reported that if it usually took too long for a nurse to check on a resident she would get another nurse to check on the resident. CNA B said she had seen LVN A get up and she thought she was getting up to check on him. She revealed she make rounds with the 2:,[DATE]:00 p.m. shift. She said she was not assigned to him, so she did not report any concerns to the CNA. Interview on [DATE] at 10:43 a.m., CNA A confirmed she had worked on [DATE] in the morning with CR #138. CNA A said CR #138 was fine when she did her initial rounds around 6:00 a.m. When she gave CR #138 his breakfast, he was complaining he could not breathe. CNA A said she reported immediately this complaint to LVN A. She said she saw LVN A go into his room. CNA A said when she went into his room before lunch, he complained that he could not breathe. CNA A said she told LVN A who instructed them to put him up in his wheelchair. She then saw CNA B answer CR #138's call light and CNA B told her that he was still complaining he could not breathe. CNA A went on to say he ate his lunch and she and another CNA assisted CR #138 up in his wheelchair. She said he continued to complain of not being able to breathe. She adjusted the air conditioning in the room and applied his oxygen. CNA A said she had gone to LVN A about 4 times to let her know about CR #138's complaints. She said he did not complain to her about chest pain. She said she saw he had a bloody nose during one of her times in the room and she told LVN A; LVN A answered ok. CNA A said he ate the fruit cup from his lunch tray and did not want the lunch. He said to her he did not feel good. She said when she had left her shift at 2:00 p.m. she reported to the on-coming CNA about CR #138 complaining of shortness of breath and not feeling well. CNA A said she feels like LVN A should have checked on CR #138 more often. CNA A said if she felt adequate interventions were not taken by her nurse she would report to the ADON and DON. She said she only reported to LVN A, the charge nurse assigned to CR #138. She did not tell the ADON or the DON. Interview on [DATE] at 3:25 p.m. with RN A confirmed she was working on [DATE] on the 2:00 p.m.-10:00 p.m. shift. RN A said she came on her shift and made rounds on her residents around 2:00 p.m. and there were no problems. CR #138 did not say anything or complain about anything. RN A checked his blood sugar around 4 p.m. and CR #138 did not say anything or make a complaint. She reported he tried to eat his dinner during one of her checks on him and he was ok. RN A said she started a breathing treatment around 6:00 p.m. She said his oxygen saturation was 98% on oxygen. RN A said at that time he requested his sleeping pill. She said the doctor discontinued his [MEDICATION NAME] on Friday and started him on [MEDICATION NAME]. She explained she went to give him his sleeping pill at 8:10 p.m. RN A said at 8:50 p.m. or 8:45 p.m. the CNA C came and got her on 300 hall and reported CR #138 was unresponsive. RN A said CNA C told her she went into CR #138's room to change his brief and saw he was unresponsive. RN A said she went immediately down to his room with blood pressure cuff. She reported she did some vitals and she felt a faint jugular pulse. She explained she had turned up his oxygen on his concentrator. She reported his blood sugar was 141. At that time, she said she left CNA C in room and ran to the nurses' station to get help, crash cart and call 911. RN A said when she returned he was taking apneic breaths. She checked vitals and his blood sugar was 140, blood pressure was 104/ systolic unknown, temperature of 96 and no oxygen saturations. She said she immediately call LVN B to initiate CPR, she was setting up the AED at the foot of the bed and the CNA C was in the room assisting. RN A said she applied the shock pads and turned on the machine. She said she could not remember what the defibrillator said. RN A explained that when the defibrillator was applied that is also when EMS arrived on scene for CR #138. She explained the EMS checked for CR #138's jugular pulse and then instructed the facility staff to stop the code and to not shock him with the AED. RN A stated CR #138's jugular pulse was still good before EMS got there. RN A explained LVN B did CPR on the resident for approximately 5 minutes before EMS arrived in the facility. She said she explained to EMS what happened. She said EMS asked if CR #138 ever left the facility, if he was a IV drug user, and when he was admitted to the facility. RN A said EMS told them not to change his brief because he had a bowel movement. RN A said the EMS told her that they would not transport him to the hospital because his jugular was not detectable. She said EMS did not ask her about CR #138's advance directives. She explained the police and medical examiner came and pronounced CR #138's death. RN A said she received report from LVN A from 6:00 a.m.-2:00 p.m. nurse. She explained LVN A told me he was fine; his oxygen saturations were good. She did not tell me anything else about CR#138. She explained that a skilled care assessment should be done daily on skilled residents. She explained she did a skilled assessment on CR #138 during his breathing treatments on [DATE] and wrote them down on a piece of paper but did not chart because he had passed away before she entered it into the computer and did not think she needed to as at that point. RN A later said during the interview that her and LVN A went through the 24-hour report paper and she said the only thing was he wanted a sleeping pill and he could not sleep. She explained CR #138 ate some of his dinner but not all of it, then went on to say she could not remember if he ate all or how much. RN A said she explained to CR #138 that she would give him his breathing treatment after he was done eating. She also explained that she would give him his sleeping pill around 8:00 p.m. RN A said she was in CR #138's room ,[DATE] times throughout her shift. RN A explained a change of condition is a change of what is not normal for the person. When asked if she had any recent trainings she stated, I think so, I had a change of condition training. I do a lot of trainings. She said I had CPR. During CPR I had AED training. Facility I am not sure if they trained me. RN A said when an emergency comes up the staff were to check on the resident, call others for help, call the doctor and 911. She explained the CNA C did not do anything but just come and tell her and she went on to say they really don't do anything. RN A said when she went to call 911 CNA C stayed with the resident. Surveyor attempted to interview with CNA C via phone on [DATE] at 3:46 p.m. and 3:54 p.m. and left a voicemail. Surveyor attempted to contact CNA C on [DATE] at 9:58 p.m. During interview on [DATE] at 8:29 a.m. corporate nurse and DON revealed that they had difficulty getting CNA C to answer her phone for a witness statement. Corporate Nurse reported she finally was able to get in touch with her and received a different number. Surveyor asked the Corporate Nurse to attempt to contact CNA C to have her call the surveyors state phone for an interview. No interview obtained with CNA C. Interview on [DATE] at 4:02 p.m., LVN B confirmed he was present at the facility on [DATE]. LVN B he was sitting at the desk charting around 8 or 8:30ish p.m. when RN A said she thought her resident had passed. He said he did not remember if she ran to the nurses' station, LVN B said RN A had just appeared. LVN B said he heard her say he is not breathing to the nurse practitioner who was also at the nurses' station. RN A called 911 and we both ran down to CR #138's room with the crash cart. LVN B reported CR #138's color was pale grayish; his skin was cool to touch, he was not breathing, and he had expired. He explained in his professional opinion the resident had expired for maybe 1 hour or longer. LVN B explained he initiated CPR on CR for about 5 minutes before EMS arrived. He said when EMS arrived they pulled down on his jaw, and they explained that his skin was gray, cool and his jaw was locked. EMS did not try to work on him and told him and RN A to stop the code. LVN B explained the AED was applied by RN A and turned on, but the AED instructed No shock advised continue CPR. LVN B said there was no CNA in the room until the end right before EMS arrived. He was unsure where the CNA was. The CNA that arrived in the room was CNA C. LVN B said that they were short staff that night and there were only 3 CNAs for the whole building. LVN B explained he had training on change of condition yesterday. He explained that he was supposed to notify the physician and family if they identified a change in condition with a resident. He explained he had no training on the AED, but he knew where it was and how to use it. LVN B revealed he was CPR certified and due in (MONTH) 2019. He explained if he was in an emergent situation he would have screamed out into the hall for staff to come to the room and start CPR and somebody else to get the crash cart. LVN B said it would have been better for RN A to stay with the body and it was not good that she was talking to the nurse practitioner during this emergent situation. Interview on [DATE] at 8:29 a.m. with Corporate Nurse with the DON present, she said their investigation timeline for CR #138's incident, and she explained that documents reviewed by her and the DON said there was no documentation or notification to the primary care physician. The Corporate Nurse reported at approximately 9:30 p.m. on [DATE] she received a call from the DON about CR #138 expiring. When she reviewed the documents, there was no documentation or notification to the primary care physician. They explained LVN A was called on [DATE] at 10:23 p.m. and asked about CR #138. LVN A told them she did not call the physician. The Corporate Nurse explained that they investigated the therapy notes and identified a note written by OT which indicated the resident had chest pain on [DATE]. She explained LVN A did feel a change of condition happened. The Corporate Nurse went on to say the LVN A thought the pulse was elevated because of anxiety and he had anxiety several times. Corporate Nurse was concerned that LVN A identified a nosebleed and did not document the incident. She said that was why they decided to call the incident into HHSC because the resident had a change in condition that was not documented. LVN A did not follow the change of condition process. They asked LVN A to write a statement and she was placed on leave until the investigation was completed. They reported that LVN B reported to the facility the incident was bad but would not give the facility a statement of the incident. They reported that LVN B told them that he had told the state everything and he left the facility. The Corporate Nurse did say she was able to inform LVN B to report concerns but there were some concerns that the information was unclear. The Corporate Nurse reported LVN B had already resigned and his last day of employment was to be [DATE]. The Corporate Nurse reported there was no set amount of training for a charge nurse and a floor nurse and went on to say they are all the same. Nurses must have 20 hours of LMS training. The Corporate Nurse explained her expectation to possibly prevent this incident was to have nurse in charge to call the physician about the nosebleed, chest pain, document it on change of condition log, notify DON, and RP. A change of condition is a vital tool because the patient has a history, identifies what the primary physician wants and documents vitals and assessment. She would have expected the nurses to do more documentation and there was a form for each shift, the 24-hour report. The Corporate Nurse reported CR #138 had some concerning diagnosis, vitals and heart rate. The Corporate Nurse reported in-servicing was initiated on abuse/ neglect, change of condition and notification of PCP was initiated on the night of [DATE] on the phone with staff and she said it continued [DATE], [DATE] and [DATE]. She said that they discovered a concern with their emergency response protocol and initiated a training in the evening of [DATE]. The Corporate Nurse reported the facility policy was for one CPR Certified nurse to always be in the building. She stated, We have had a change of leadership more than I would like to talk about. During a review of employee files, they realized that there was a concern of staff being CPR certified. She revealed that a CPR training was going to be held on [DATE] for both any staff who would like to attend. The Corporate Nurse said that nursing should be documenting on a resident who is admitted under skilled at least every shift. She also reported any nurse who gives a resident a pain medication should at least do a pain assessment and follow-up of the effectiveness of the medication. The DON and Corporate Nurse reported typically there are ,[DATE] staff on the ,[DATE] p.m. shift. The a (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care based on the comprehensive assessment and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR #1) of 26 residents reviewed for pharmacy services, in that: The facility failed to monitor CR #1 after an episode of [DIAGNOSES REDACTED] which required two shots of [MEDICATION NAME] to elevate her blood sugar. As a result, CR #1 was transferred to the local hospital. This failure affected one transferred resident who required hospitalization and placed 11 current residents with orders for [MEDICATION NAME] at risk for diabetic complications after an episode of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE]/2018. CR #1 had the following Diagnoses: [REDACTED]. Record review of CR #1's care plan, date initiated 03/21/2018 revealed there was no care plan related to complications of diabetes including [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Record review of CR #1's consolidated Physician orders [REDACTED]. [MEDICATION NAME] Emergency Kit 1mg, inject 1 dose intramuscularly as needed for [DIAGNOSES REDACTED] if blood glucose is less than 60, give [MEDICATION NAME] 1mg IM, repeat blood glucose test in 15 minutes and call physician for further instructions. Record review of CR #1's nursing progress note completed by LVN #12 revealed on 04/04/18 at 9:00pm, CR #1's blood sugar was 56 mg/dl and 1 [MEDICATION NAME] shot was given. CR #1's blood sugar was rechecked after 15 minutes and was still 56 mg/dl. LVN #12 documented the physician was called and he gave an order to give another [MEDICATION NAME] shot and check blood sugar after 15 minutes and if blood sugar level was normal do lab work, hemoglobin A1C in the morning. Further review revealed at 9:30pm, CR #1's blood sugar was 94mg/dl. Nursing note indicated this blood sugar was within normal limits and nursing would continue to monitor. Further review of the same nursing progress notes revealed CR #1 received no further blood sugar checks, snack provided or monitoring completed related to [DIAGNOSES REDACTED] throughout the night of 04/04/18 and early morning of 04/05/18. Interview with LVN #12 on 04/06/18 at 2:37pm revealed on 4/4/18, CR #1 had a low blood sugar around 9:00pm of 56mg/dl. LVN #12 indicated she tried to give CR #1 orange juice, but she refused to drink it. LVN #12 stated she called the physician and an order was given for one shot of [MEDICATION NAME], then recheck her blood sugar in 15 minutes. LVN #12 stated when she rechecked CR #1's blood sugar it was still 56 mg/dl. LVN #12 revealed she called the doctor again and another order was given for a second [MEDICATION NAME] shot and wait 15 minutes then recheck blood sugar at 9:30pm. LVN #12 stated CR #1's accu-check reading at 9:30pm was 94 mg/dl. The physician had also ordered to check CR #1's Hemoglobin A1c in the morning. LVN #12 stated that she used two [MEDICATION NAME] shots from the E-kit on 04/04/18. LVN #12 stated she did not call the pharmacy to reorder [MEDICATION NAME] because she wasn't aware she should have called the pharmacy for replacements. LVN #12 stated no additional blood sugar checks were conducted during her shift and she did not think to offer CR #1 a snack because it was nighttime. Record review of CR #1's nursing progress note on 4/5/18 at 6:45am completed by LVN #20 revealed she entered CR #1's room to check her blood sugar before breakfast. LVN #20 was unable to arouse CR #1. LVN #20 documented CR #1's blood sugar was 38 mg/dl and she attempted to administer glucose gel by mouth but CR #1 was unable to swallow the gel. Further review indicated CR #1 had no response to painful stimuli or chest rub. CR #1's Nurse Practitioner was notified of CR #1's change of condition and orders were received to send CR #1 to the hospital. LVN #20 called 911 and EMS arrived at 7:00am, at which time a peripheral IV was started and [MEDICATION NAME] was administered. EMS personnel revealed CR #1's blood sugar was 29 before [MEDICATION NAME] was administered. Around 7:20am CR #1's blood sugar was 181 mg/dl and she was awake and moaning; but not oriented. CR #1's blood sugar was rechecked after a few minutes and it was 95 mg/dl. Interview on 04/06/18 at 1:58pm, LVN #20 revealed on 04/05/18, she started doing blood sugar checks around 6:30am. LVN #20 stated CR #1's blood sugar was 38 mg/dl and CR #1 was not responding to any stimuli. LVN #20 called LVN #4 and told her to go get the [MEDICATION NAME] from the E-kit. LVN #4 then came back to CR #1's room and told LVN #20 there was no [MEDICATION NAME] in the E-Kit because CR #1 used two shots of [MEDICATION NAME] last night. LVN #20 explained she tried to give the glucose gel orally but CR #1 was not swallowing. LVN #20 said she called 911 and CR #1's nurse practitioner who gave an order to send CR #1 to the emergency room . LVN #20 stated when the EMS arrived, they started [MEDICATION NAME] and informed her that CR #1's blood sugar was 181 mg/dl and she was moaning. Around 7:50 am, CR #1 left the facility with the EMS. Observation on 04/06/18 at 11:10am of the 200 and 300 hall nurse medication cart did not reveal any [MEDICATION NAME] kits in the cart. Observation on 04/06/18 at 11:13am of the facility's six E-kits located in the medication room, revealed none contained [MEDICATION NAME]. One E-kit revealed two containers of oral glucose gel. Record review of E-kit delivery invoice dated 4/3/18 revealed E-kit #466 contained 2 [MEDICATION NAME] kits and 3 containers of oral glucose gel. Record review of E-kit #466's Usage Notification sheet revealed no documentation of when the two [MEDICATION NAME] kits and one oral glucose gel were removed from the kit and used. Observation on 4/6/18 at 11:39am of the 100 hall cart revealed that there was no [MEDICATION NAME] kits in the cart. Interview with LVN #4 on 04/06/18 at 1:58pm revealed she went with LVN #20 to administer glucose gel but CR #1 would not take it and LVN #20 called the doctor. LVN #4 stated she went back to her hall at that time. Interview with ADON #1 on 4/6/18 at 10:24am revealed that all residents with diabetes have an order stating: if blood sugar is less than 60 mg/dl give [MEDICATION NAME] and call MD. ADON #1 indicated that CR #1's blood sugar started going down on 4/4/18 during the 2:00pm-10:00pm shift. ADON #1 indicated LVN #12 took two [MEDICATION NAME] from the E-kit on 4/4/18. ADON #1 stated that she was not sure if LVN #12 reordered the [MEDICATION NAME] kits and if she did, it would not have arrived at the facility until 2:00pm on 4/5/18. Observation on 04/06/18 at 12:10pm, the same E-kit #466 reviewed with LVN #19 revealed no [MEDICATION NAME] kits. Observation on 04/06/18 at 12:50pm of the facility crash cart revealed no [MEDICATION NAME] kits and two oral [MEDICATION NAME] gel. During a telephone interview on 4/6/18 at 12:20pm, the pharmacy technician indicated the pharmacy usually delivered the [MEDICATION NAME] in an E-kit but sometimes an order would come in for a particular resident. The call was transferred at 12:22pm to the pharmacy manager who stated they did not deliver any [MEDICATION NAME] on 4/5/18. During another telephone interview on 4/6/18 at 3:11pm, the pharmacy manager revealed STAT orders were delivered between 2 to 4 hours. He said the pharmacy closed at 10:00pm, but if the nursing facility called before 10:00pm they would still deliver the order within 2-4 hours. If the order was called after 10:00pm, the pharmacy would deliver after 8:00am the next business day, because they opened at 8:00am. Interview on 04/06/18 at 11:39am, LVN #4 revealed diabetic residents had a PRN order for [MEDICATION NAME]. She stated when needed, she obtained the [MEDICATION NAME] from the E-kit. LVN #4 stated if a resident's accu-check is below 60 mg/dl she would use the [MEDICATION NAME] kit first because she had the order and would later tell the doctor what she did. She stated if there was no [MEDICATION NAME] kit she would notify the DON, call pharmacy and check the crash cart because one should be in the crash cart. LVN #4 revealed the STAT orders from the pharmacy took 4 hours to arrive at the facility. Record review of the clinical management meeting notes for 4/4/18 and 4/5/18 revealed CR #1 did not go to [MEDICAL TREATMENT] on 4/3/18 because she was not feeling well. On 4/5/18 the clinical management meeting notes did not indicate the need to replace the E-kit stock for [MEDICATION NAME] kits. It did reveal CR #1 had an SBAR for a Hemaglobin A1c, no indication that the [MEDICATION NAME] was used due to low blood sugar. In an interview on 4/10/18 at 1:48pm, the DON revealed the nurses had been trained to reorder [MEDICATION NAME] when the nursing facility used one. She indicated the nurse who worked on the evening of 4/4/18 with CR #1 sent a fax to the pharmacy for a refill of the [MEDICATION NAME] on the E-Kit, but the pharmacy did not fill it. She indicated she was unsure why there was no follow-up from staff the next day on 4/5/18 for the medication to be replaced. In an interview on 4/10/18 at 12:30pm, the pharmacy manager stated that the whole E-kit was replaced if something was used out of it. The pharmacy manager revealed that the E-kit was replaced on 4/3/18 and 4/6/18. Record review of a fax transmission report revealed the facility faxed a refill request to the pharmacy on 4/4/18 at 9:33pm. In an interview on 4/10/18 at 3:10pm, the ADON #1 stated they used to be better at keeping fax confirmation receipts but since they did not have this fax receipt, they had the pharmacy fax over a copy. In an interview on 4/10/18 at 3:48pm, the pharmacy manager reiterated that the only notification received from the facility regarding a need for [MEDICATION NAME] was on 4/3/18 and 4/6/18. When told that the facility had a copy of a request faxed on 4/4/18, he stated he did not know anything about that request and even asked for a copy of it. He stated he was going to talk with the pharmacy technician, but he did not see any faxed forms regarding the need for replacement of the E-kit or the [MEDICATION NAME] on 4/4/18 or 4/5/18. Interview on 4/24/18 at 7:55am, LVN #5 revealed she had never been involved in a situation when the facility did not have the medication a resident needed. LVN #5 stated if a medication was unavailable from the medication cart or the E-Kit, she would notify the doctor to see if an alternative could be given. Observation on 4/24/18 at 8:00am with LVN #2 present, revealed 2 sealed [MEDICATION NAME] kits located in the injections E-Kit stored in the medication room. Interview at the same time with LVN #2 revealed he had never encountered a time when he didn't have the medications that he needed. LVN #2 further stated when he removed an item from the E-Kit, he would complete the E-Kit usuage form and fax it immediately to the pharmacy so they would know something had been taken from the E-Kit. LVN #2 stated that form would then be filed in the pharmacy communication binder located on top of the rolling E-Kit stored in the medication room. Telephone interview on 4/24/18 at 11:11am, the pharmacy manager revealed the pharmacy only sends 2 [MEDICATION NAME] kits in each injection E-Kit. The pharmacy manager stated the facility would never have more than 2 [MEDICATION NAME] kits at one time. When asked if the facility could request additional [MEDICATION NAME] kits if needed, the pharmacy manager stated there were not provisions in place to send more than 2 [MEDICATION NAME] kits at this time. When asked about the facility's usage of [MEDICATION NAME] kits, the pharmacy manager stated in the last 6 months the facility only requested additional [MEDICATION NAME] kits once in (MONTH) (YEAR). Record review of the facility Emergency Procedures: [DIAGNOSES REDACTED] policy dated 5/2007 revealed, in part: 1. If non-responsive, initiate facility emergency response. 2. Observe for the following signs and symptoms: . J. Difficulty speaking, thick tongue feeling, inability to swallow. 3. Obtain finger stick blood sugar level. 4. When nurse determines resident is hypoglycemic, check chart for blood sugar glucose orders. If no orders, notify physician: give four ounces of fruit juice (orange or apple) if resident has no allergies [REDACTED].>5. If resident rallies immediately and is able to swallow; follow up with food if it is more than thirty minutes until the next meal. 6. Supervise that resident eats food and does not fall back to sleep. Due to disorientation and/ or lethargy, resident may need to be fed. . According to the DON, on 4/10/18 there were 25 residents with a [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (CR #1) of 26 residents reviewed for pharmacy services, in that: The facility failed to ensure there were [MEDICATION NAME] shots available in the facility for treatment of [REDACTED]. CR #1 required a physician ordered [MEDICATION NAME] shot due to her blood sugar dropping to 38 mg/dl but none were available in the facility. As a result, CR #1 was transferred to the local hospital. This failure affected one transferred resident who required hospitalization and placed 11 current residents with orders for [MEDICATION NAME] at risk for diabetic complications without needed and ordered interventions available. Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE]/2018. CR #1 had the following Diagnoses: [REDACTED]. Record review of CR #1's care plan, date initiated 03/21/2018 revealed there was no care plan related to complications of diabetes including [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. Record review of CR #1's consolidated Physician orders [REDACTED]. [MEDICATION NAME] Emergency Kit 1mg, inject 1 dose intramuscularly as needed for [DIAGNOSES REDACTED] if blood glucose is less than 60, give [MEDICATION NAME] 1mg IM, repeat blood glucose test in 15 minutes and call physician for further instructions. Record review of CR #1's nursing progress note completed by LVN #12 revealed on 04/04/18 at 9:00pm, CR #1's blood sugar was 56 mg/dl and 1 [MEDICATION NAME] shot was given. CR #1's blood sugar was rechecked after 15 minutes and was still 56 mg/dl. LVN #12 documented the physician was called and he gave an order to give another [MEDICATION NAME] shot and check blood sugar after 15 minutes and if blood sugar level was normal do lab work, hemoglobin A1C in the morning. Further review revealed at 9:30pm, CR #1's blood sugar was 94mg/dl. Nursing note indicated this blood sugar was within normal limits and nursing would continue to monitor. Further review of the same nursing progress notes revealed CR #1 received no further blood sugar checks, snack provided or monitoring completed related to [DIAGNOSES REDACTED] throughout the night of 04/04/18 and early morning of 04/05/18. Interview with LVN #12 on 04/06/18 at 2:37pm revealed on 4/4/18, CR #1 had a low blood sugar around 9:00pm of 56mg/dl. LVN #12 indicated she tried to give CR #1 orange juice, but she refused to drink it. LVN #12 stated she called the physician and an order was given for one shot of [MEDICATION NAME], then recheck her blood sugar in 15 minutes. LVN #12 stated when she rechecked CR #1's blood sugar it was still 56 mg/dl. LVN #12 revealed she called the doctor again and another order was given for a second [MEDICATION NAME] shot and wait 15 minutes then recheck blood sugar at 9:30pm. LVN #12 stated CR #1's accu-check reading at 9:30pm was 94 mg/dl. The physician had also ordered to check CR #1's Hemoglobin A1c in the morning. LVN #12 stated that she used two [MEDICATION NAME] shots from the E-kit on 04/04/18. LVN #12 stated she did not call the pharmacy to reorder [MEDICATION NAME] because she wasn't aware she should have called the pharmacy for replacements. LVN #12 stated no additional blood sugar checks were conducted during her shift and she did not think to offer CR #1 a snack because it was nighttime. Record review of CR #1's nursing progress note on 4/5/18 at 6:45am completed by LVN #20 revealed she entered CR #1's room to check her blood sugar before breakfast. LVN #20 was unable to arouse CR #1. LVN #20 documented CR #1's blood sugar was 38 mg/dl and she attempted to administer glucose gel by mouth but CR #1 was unable to swallow the gel. Further review indicated CR #1 had no response to painful stimuli or chest rub. CR #1's Nurse Practitioner was notified of CR #1's change of condition and orders were received to send CR #1 to the hospital. LVN #20 called 911 and EMS arrived at 7:00am, at which time a peripheral IV was started and [MEDICATION NAME] was administered. EMS personnel revealed CR #1's blood sugar was 29 before [MEDICATION NAME] was administered. Around 7:20am CR #1's blood sugar was 181 mg/dl and she was awake and moaning; but not oriented. CR #1's blood sugar was rechecked after a few minutes and it was 95 mg/dl. Interview on 04/06/18 at 1:58pm, LVN #20 revealed on 04/05/18, she started doing blood sugar checks around 6:30am. LVN #20 stated CR #1's blood sugar was 38 mg/dl and CR #1 was not responding to any stimuli. LVN #20 called LVN #4 and told her to go get the [MEDICATION NAME] from the E-kit. LVN #4 then came back to CR #1's room and told LVN #20 there was no [MEDICATION NAME] in the E-Kit because CR #1 used two shots of [MEDICATION NAME] last night. LVN #20 explained she tried to give the glucose gel orally but CR #1 was not swallowing. LVN #20 said she called 911 and CR #1's nurse practitioner who gave an order to send CR #1 to the emergency room . LVN #20 stated when the EMS arrived, they started [MEDICATION NAME] and informed her that CR #1's blood sugar was 181 mg/dl and she was moaning. Around 7:50 am, CR #1 left the facility with the EMS. Observation on 04/06/18 at 11:10am of the 200 and 300 hall nurse medication cart did not reveal any [MEDICATION NAME] kits in the cart. Observation on 04/06/18 at 11:13am of the facility's six E-kits located in the medication room, revealed none contained [MEDICATION NAME]. One E-kit revealed two containers of oral glucose gel. Record review of E-kit delivery invoice dated 4/3/18 revealed E-kit #466 contained 2 [MEDICATION NAME] kits and 3 containers of oral glucose gel. Record review of E-kit #466's Usage Notification sheet revealed no documentation of when the two [MEDICATION NAME] kits and one oral glucose gel were removed from the kit and used. Observation on 4/6/18 at 11:39am of the 100 hall cart revealed that there was no [MEDICATION NAME] kits in the cart. Interview with LVN #4 on 04/06/18 at 1:58pm revealed she went with LVN #20 to administer glucose gel but CR #1 would not take it and LVN #20 called the doctor. LVN #4 stated she went back to her hall at that time. Interview with ADON #1 on 4/6/18 at 10:24am revealed that all residents with diabetes have an order stating: if blood sugar is less than 60 mg/dl give [MEDICATION NAME] and call MD. ADON #1 indicated that CR #1's blood sugar started going down on 4/4/18 during the 2:00pm-10:00pm shift. ADON #1 indicated LVN #12 took two [MEDICATION NAME] from the E-kit on 4/4/18. ADON #1 stated that she was not sure if LVN #12 reordered the [MEDICATION NAME] kits and if she did, it would not have arrived at the facility until 2:00pm on 4/5/18. Observation on 04/06/18 at 12:10pm, the same E-kit #466 reviewed with LVN #19 revealed no [MEDICATION NAME] kits. Observation on 04/06/18 at 12:50pm of the facility crash cart revealed no [MEDICATION NAME] kits and two oral [MEDICATION NAME] gel. During a telephone interview on 4/6/18 at 12:20pm, the pharmacy technician indicated the pharmacy usually delivered the [MEDICATION NAME] in an E-kit but sometimes an order would come in for a particular resident. The call was transferred at 12:22pm to the pharmacy manager who stated they did not deliver any [MEDICATION NAME] on 4/5/18. During another telephone interview on 4/6/18 at 3:11pm, the pharmacy manager revealed STAT orders were delivered between 2 to 4 hours. He said the pharmacy closed at 10:00pm, but if the nursing facility called before 10:00pm they would still deliver the order within 2-4 hours. If the order was called after 10:00pm, the pharmacy would deliver after 8:00am the next business day, because they opened at 8:00am. Interview on 04/06/18 at 11:39am, LVN #4 revealed diabetic residents had a PRN order for [MEDICATION NAME]. She stated when needed, she obtained the [MEDICATION NAME] from the E-kit. LVN #4 stated if a resident's accu-check is below 60 mg/dl she would use the [MEDICATION NAME] kit first because she had the order and would later tell the doctor what she did. She stated if there was no [MEDICATION NAME] kit she would notify the DON, call pharmacy and check the crash cart because one should be in the crash cart. LVN #4 revealed the STAT orders from the pharmacy took 4 hours to arrive at the facility. Record review of the clinical management meeting notes for 4/4/18 and 4/5/18 revealed CR #1 did not go to [MEDICAL TREATMENT] on 4/3/18 because she was not feeling well. On 4/5/18 the clinical management meeting notes did not indicate the need to replace the E-kit stock for [MEDICATION NAME] kits. It did reveal CR #1 had an SBAR for a Hemaglobin A1c, no indication that the [MEDICATION NAME] was used due to low blood sugar. In an interview on 4/10/18 at 1:48pm, the DON revealed the nurses had been trained to reorder [MEDICATION NAME] when the nursing facility used one. She indicated the nurse who worked on the evening of 4/4/18 with CR #1 sent a fax to the pharmacy for a refill of the [MEDICATION NAME] on the E-Kit, but the pharmacy did not fill it. She indicated she was unsure why there was no follow-up from staff the next day on 4/5/18 for the medication to be replaced. In an interview on 4/10/18 at 12:30pm, the pharmacy manager stated that the whole E-kit was replaced if something was used out of it. The pharmacy manager revealed that the E-kit was replaced on 4/3/18 and 4/6/18. Record review of a fax transmission report revealed the facility faxed a refill request to the pharmacy on 4/4/18 at 9:33pm. In an interview on 4/10/18 at 3:10pm, the ADON #1 stated they used to be better at keeping fax confirmation receipts but since they did not have this fax receipt, they had the pharmacy fax over a copy. In an interview on 4/10/18 at 3:48pm, the pharmacy manager reiterated that the only notification received from the facility regarding a need for [MEDICATION NAME] was on 4/3/18 and 4/6/18. When told that the facility had a copy of a request faxed on 4/4/18, he stated he did not know anything about that request and even asked for a copy of it. He stated he was going to talk with the pharmacy technician, but he did not see any faxed forms regarding the need for replacement of the E-kit or the [MEDICATION NAME] on 4/4/18 or 4/5/18. Interview on 4/24/18 at 7:55am, LVN #5 revealed she had never been involved in a situation when the facility did not have the medication a resident needed. LVN #5 stated if a medication was unavailable from the medication cart or the E-Kit, she would notify the doctor to see if an alternative could be given. Observation on 4/24/18 at 8:00am with LVN #2 present, revealed 2 sealed [MEDICATION NAME] kits located in the injections E-Kit stored in the medication room. Interview at the same time with LVN #2 revealed he had never encountered a time when he didn't have the medications that he needed. LVN #2 further stated when he removed an item from the E-Kit, he would complete the E-Kit usuage form and fax it immediately to the pharmacy so they would know something had been taken from the E-Kit. LVN #2 stated that form would then be filed in the pharmacy communication binder located on top of the rolling E-Kit stored in the medication room. Telephone interview on 4/24/18 at 11:11am, the pharmacy manager revealed the pharmacy only sends 2 [MEDICATION NAME] kits in each injection E-Kit. The pharmacy manager stated the facility would never have more than 2 [MEDICATION NAME] kits at one time. When asked if the facility could request additional [MEDICATION NAME] kits if needed, the pharmacy manager stated there were not provisions in place to send more than 2 [MEDICATION NAME] kits at this time. When asked about the facility's usage of [MEDICATION NAME] kits, the pharmacy manager stated in the last 6 months the facility only requested additional [MEDICATION NAME] kits once in (MONTH) (YEAR). Record review of the facility Emergency Procedures: [DIAGNOSES REDACTED] policy dated 5/2007 revealed, in part: 1. If non-responsive, initiate facility emergency response. 2. Observe for the following signs and symptoms: . J. Difficulty speaking, thick tongue feeling, inability to swallow. 3. Obtain finger stick blood sugar level. 4. When nurse determines resident is hypoglycemic, check chart for blood sugar glucose orders. If no orders, notify physician: give four ounces of fruit juice (orange or apple) if resident has no allergies [REDACTED].>5. If resident rallies immediately and is able to swallow; follow up with food if it is more than thirty minutes until the next meal. 6. Supervise that resident eats food and does not fall back to sleep. Due to disorientation and/ or lethargy, resident may need to be fed. . According to the DON, on 4/10/18 there were 25 residents with a [DIAGNOSES REDACTED].

Based on observations, interview, and record review the facility failed to maintain a drug regimen system free from unnecessary drugs for one (Resident #246) of 18 residents reviewed for medication administration, in that: MA F continued to administer [MEDICATION NAME] to Resident #246 after she returned to the facility in a lethargic state. As a result, Resident #246 was unable to eat and open her right eye. LVN B and RN B failed to monitor the side effects of Resident #246's medication. Resident #246 had to be transferred to a local hospital for further evaluation. These failures affected 1 resident (Resident #246) and placed 37 residents residing on the 100 and 300 halls at risk for injury and harm related to receiving unnecessary medications. Findings Include: Record review of Resident #246's clinical record revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #246's Admission MDS dated [DATE], revealed Resident #246's cognition was severely impaired. Further review revealed the resident had a positive PASRR sceening due to her [DIAGNOSES REDACTED].#246 had a functional limitation in range of motion and her lower extremities were impaired on both sides. Further review revealed she needed the extensive physical assistance of 1-2 persons for ADLs. Record review of Resident #246's physician orders dated January 2018 revealed the following medications: [REDACTED] [MEDICATION NAME] Sodium ([MEDICATION NAME]) Tablet Extended Release 24 Hour 250mg- Give 1 tablet by mouth at bedtime for anticonvulsant give with 500mg to equal 750mg [MEDICATION NAME] Sodium ([MEDICATION NAME]) Tablet Extended Release 24 Hour 500mg - Give 1 tablet by mouth every 12 hours for Anticonvulsant Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) Tablet 200mg give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) Tablet 50mg give 1 tablet by mouth two times a day for [MEDICAL CONDITION] [MEDICATION NAME] Tablet 100mg give 1 tablet by mouth at bedtime for Depression with agitation Record review of Resident #246's care plan dated January 2018 revealed: Focus Resident is currently taking Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 200mg Date initiated: 12/27/2017 Interventions Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 12/27/2017 Record review of www.[MEDICATION NAME].com, updated December 2017, revealed in part: The most common side effects are drowsiness, dry mouth, constipation, dizziness, increased appetite, upset stomach, weight gain, fatigue, disturbance in speech and language, and stuffy nose. Continued record review of Resident #246's care plan dated January 2018 revealed: Focus Resident currently taking [MEDICATION NAME] 100mg at bedtime for depression. Date initiated: 1/10/2018 Interventions Administer medications as ordered. Monitor/document for side effects and effectiveness. Observe for side effects of anti-depressant medication: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, [MEDICAL CONDITION], withdrawal, decline in ability to help with/do, ADLs, continence, cognitive function, constipation, fecal impaction, no voiding, shuffle gait, rigid muscles, difficulty ambulating, balance problems, accidents, dizziness/[MEDICAL CONDITION], falls, movement problems, tremors, diarrhea, fatigue, [MEDICAL CONDITION], appetite, wt. loss, muscle cramps, and nausea/vomiting. Date initiated: 1/10/18 Continued record review of Resident #246's care plan dated January 2018 revealed: Focus At risk for falls related to generalized weakness and fear of falling. Date initiated: 12/19/2017 Goal Will not sustain serious injury through the review date. Observation on 1/8/18 at 3:40pm the surveyor observed Resident #246 in the hallway sitting in a wheelchair slumped over. She was surrounded by the DON, CNA V and LVN P. Resident #246 was very lethargic and slow to respond to verbal stimuli. The DON told CNA V to take the resident back to the room she was previous in because her discharged was going to be cancelled. Observations of Resident #246 revealed that she was so sleepy, she was unable to lift her feet as CNA V was wheeling her back to the room. Interview on 1/8/18 at 3:50pm, CNA V said that Resident #246 had previously been living at a group home. She was placed in the lobby area to wait for the staff from the group home to pick her up because the resident had been discharged . When the staff from the group home arrived they noticed that the resident was very lethargic and difficult to arouse. CNA V said the group home staff refused to take Resident #246 back because that was not the resident's normal behavior and they were concerned. Interview on 1/8/18 at 4:20pm, LVN P revealed Resident #246 was sleepy and the DON had performed vitals on the resident. The surveyor asked LVN P was there any medications the Resident #246 was given that would cause her to be lethargic or sleepy. She said the resident was receiving the following medications at night: [MEDICATION NAME] 750mg, [MEDICATION NAME] 100mg, and [MEDICATION NAME] 200mg. She further stated that Resident #246 also received the following medication throughout the day: [MEDICATION NAME] 500mg in the morning and [MEDICATION NAME] 50 mg twice a day. When the surveyor voiced concerns about the amount of medications the resident was getting, LVN P quickly said that she was going to speak with the facility social worker to schedule a psychiatrist evaluation to revise Resident #246's medications. During the same interview, LVN P said that Resident #246 had returned from a hospital visit on the current medications and they had not been adjusted. The surveyor asked the nurse if any doctor had seen the resident since she admitted to the facility and she said the facility physician visited the residents twice a week at night but she was unsure if the resident had been seen. LVN P said she had taken care of Resident #246 since she admitted to the facility and the resident often appeared sleepy. Observation on 1/8/18 at 4:24pm of Resident #246 revealed she was in bed asleep with the head of the bed elevated. The resident has 2 liters of oxygen going via a nasal cannula. The surveyor called the resident's name and she did not respond. The surveyor could hear the resident snoring. Interview on 1/9/18 at 7:37am with LVN N revealed that Resident #246 had fallen three times since yesterday evening. He said she fell on [DATE] during the evening shift, then again today around 4:30am. The resident fell a third time ninety minutes later at 6:00am and sustained a large hematoma to the left side of her forehead and was transferred to a local hospital. Observation on 1/9/18 at 3:00pm revealed that Resident #246 was not in her room on the 300 hall. Interview on 1/9/18 at 3:00pm with LVN N revealed that Resident #246 had returned to the facility and was now being housed on the 100 hall. The surveyor asked LVN N to see a copy of Resident #246's discharge papers. LVN N said that the resident did not return to the facility with any discharge papers. Asked the nurse how would he know what care and/or treatment was provided for the resident during the hospital visit and what care needed to be continued. LVN N said that the EMS told him the resident had a CT scan of the head which was negative. The surveyor asked LVN N if there were any paperwork that the EMS staff may have brought with the resident for the transport. He said there was not any paper work from the EMS staff, he only signed the electronic tablet. The surveyor asked the nurse if it was okay to except a verbal report for the CT scan results from the EMS staff. LVN N said it was unusual for the EMS staff not to have any paperwork. LVN N said that the hospital staff did not call to say that Resident #246 was returning to the facility. LVN N stated he did not attempt to call the hospital to get a report and/or discharge papers. Record review of Resident #246's December 2017 and January 2018 Progress Notes revealed no head to toe assessment was performed, no vital signs were documented, and the facility physician was not notified of the resident's return from the hospital on [DATE]. The last vital signs that were documented were on 12/27/17 at 3:06pm by LVN N. Interview on 1/9/18 at 3:45pm with RN B revealed she had worked for the facility since October 2017. She stated she had seen Resident #246 at shift change and received report from LVN N. RN B stated she was told by LVN N in the shift change report that Resident #246 did not return to the facility with discharge paperwork. She stated she was told by LVN N that Resident #246 had had a fall and was moved from the 300 hall to the 100 hall when she returned from the hospital. RN B said she was not told if an assessment had been performed on the resident since her return to the facility. RN B said she had done Resident #246's vital signs already but had not started a flow sheet yet. During the same interview RN B stated she did not know what care Resident #246 had received while at the hospital or the results of the resident's CT scan of the head. When the surveyor asked RN B what the plan of care for Resident #246 was since she had not returned with discharged orders, she said she would have the CNA check the resident more frequently to make sure her needs were being met. RN B stated she did not continue to try to get the results of the CT scan of the head or discharge papers for the resident. RN B said it was the responsibility of the nurse who admitted the resident to get the discharge papers and results of any test done. Interview on 1/10/18 at 8:00am with LVN B revealed she had worked for the facility for 2 years and she was the nurse responsible for Resident #246 at this time. LVN B informed the surveyor that she did not know much about Resident #246 because the resident had recently been moved from the 300 hall to the 100 hall. When the surveyor asked LVN B if she knew what had happen to Resident #246 her response was she believed the resident had had a fall over the weekend. She went on to say that the resident had thrown herself out of the bed because she wanted a coke which was how she fell . During the same interview, LVN B said she had received report from the night nurse but the nurse didn't tell her much about Resident #246. The nurse said there were not any discharge papers from the hospital the resident was discharge from. She said if a resident returned to the facility after having anything that needed to be reported to the physician, such as a CT scan, Medical Records would call the hospital and have the report faxed over. When the report was faxed over, Medical Records would scan the results into the computer. Interview on 1/10/18 at 11:40am with Medical Records revealed she has worked at the facility since February 2017. When asked if she had obtained the CT scan results, Medical Records admitted she had not called the hospital nor did she have the results of the CT scan. Observation and interview on 1/10/18 at 12:15pm revealed CNA Z attempting to feed Resident #246 her lunch in bed. The resident was very lethargic and could barely open her right eye. CNA Z stated this was unusual behavior for Resident #246. There was an unopened can of coke on the resident's lunch tray. CNA Z said that Resident #246 loved cokes and when she told the resident there was a coke there, she did not get a response from the resident. CNA Z said that the resident would usually perk right up whenever she could have a coke. The surveyor attempted to speak to the resident but the resident did not respond. Interview on 1/10/18 at 12:25pm the surveyor asked MA F if she had recently given Resident #246 any medication. She acknowledged she had given Resident #246 [MEDICATION NAME] 50mg about 20 minutes earlier. The surveyor told MA F that the resident was very sleepy to the point where she was unable to eat her lunch. MA F responded that Resident #246 was always sleepy and she acknowledged that the resident was sleepy when she gave her the [MEDICATION NAME]. Interview on 1/10/18 at 1:25pm the surveyor asked LVN N if he obtained Resident #246's results of the CT scan of the head. He said he had called the local hospital twice and was put on hold. He didn't say when he had called. The surveyor asked LVN B if he had called the doctor to let him know that Resident #246 was back in the facility and he said he did. The surveyor asked about the resident having vital signs done when he received the resident because there was no documentation of the doctor being called or the vital signs. He said that the vital signs were written down somewhere and walked off. Record review of Resident #246's Progress Notes as of 1/10/18 at 4:00pm revealed Resident #246's doctor was not called when she returned to the facility post fall. Record review revealed the nursing staff never received report on the resident from the local hospital, discharge paperwork, or the results of the resident's CT scan of the head. Observation and interview on 1/10/18 at 2:00pm revealed that Resident #246 was still very lethargic. The surveyor asked LVN B about Resident #246's lethargy, to which she replied Resident #246 only wants to sleep and when she is awake, she will keep hollering that she wants to go back to bed. LVN B was asked by the surveyor to assess Resident #246. LVN B made several attempts to get a blood pressure with a wrist blood pressure cuff and was unsuccessful. She found another cuff and was able to get a blood pressure of 97/69. LVN B attempted to get an oxygen saturation level on Resident #246. The monitor registered between 86% to 91% for about 10 minutes before the levels started to climb and finally got to 99%. While standing at Resident #246's bedside, the surveyor could hear a crackled sound coming from the resident as she breathed. The surveyor asked LVN B if she would listen to the resident's lung sounds. The nurse used a stethoscope to listen to the resident's lungs, and said her lung sounds were clear. Then LVN B said she would call the doctor and get an order for [REDACTED]. Interview on 1/10/18 at 2:40pm with MA F revealed that she was aware that one of the side effects of [MEDICATION NAME] was drowsiness. The surveyor asked MA F her reasoning for giving Resident #246 a medication that could cause drowsiness when the resident was already sleepy without consulting with the nurse first. She said she went into the resident's room and told her she had her medications and the resident responded by saying okay. MA F said if she went into a resident's room to give them medication and she was unable to get them to wake up, then she would call the nurse and the nurse would say to hold the medication. Interview on 1/10/18 at 3:10pm with RN B revealed that Resident #246 had a decline in neuro status. She said the resident was more lethargic, was unable to open the right eye enough for the pupil to be checked, and her hand grasp was now weak. Interview on 1/10/18 at 3:40pm the DON said she had seen Resident #246 and this was the resident's normal behavior. She said the resident had been seen by a pharmacist on 1/9/18 and the psychiatrist was in-house and would see the resident today. The DON said she was told by an unnamed nurse that she believed the resident was getting too much medication. The DON said she did tell the nurse that if that was what she thought, why hadn't she called the doctor. Interview on 1/10/18 at 3:55pm the DON approached the surveyor with the Lead Clinical Nurse. The DON said they both had seen the resident and came to the conclusion that the best thing for the resident was to send her to the hospital to be evaluated. Record review of the facility policy titled Policy/Procedure- Nursing Clinical- Medication Administration-Oral, Revised May 2007 revealed: Administering Unit Doses and previously prepared drugs: Take vital signs if required. Hold drugs if indicated. The facility census dated 1/8/18 revealed 38 residents resided on the 100 and 300 halls.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #246) of 19 residents reviewed for quality of care, in that: -The facility failed to document Resident #246's three falls on 01/08/2018 and 01/09/2018. -The facility failed to assess and monitor Resident #246 after the three falls. -The facility failed to complete neuro checks after the three reported falls. -The facility failed to notify Resident #246's physician of the falls. -The facility failed to obtain Resident #246's orders for care after the resident returned from the hospital. -LVN N and RN B failed to notify Resident #246's physician that she had returned to the facility post fall with head injury. -MA F administered [MEDICATION NAME] to Resident #246 while she was in a lethargic state. -LVN B and RN B failed to monitor the side effects of Resident #246's medication. Resident #246 had to be transferred to a local hospital for further evaluation. These failures affected one resident and placed 37 additional residents who resided on the 100 and 300 halls at risk of not receiving prompt medical interventions. Findings: Record review of Resident #246's clinical record revealed a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #246's Admission MDS dated [DATE], revealed Resident #246's cognition was severely impaired. Further review revealed the resident had a positive PASRR sceening due to her [DIAGNOSES REDACTED].#246 had a functional limitation in range of motion and her lower extremities were impaired on both sides. Further review revealed she needed the extensive physical assistance of 1-2 persons for ADLs. Record review of Resident #246's physician orders [REDACTED]. [MEDICATION NAME] Sodium ([MEDICATION NAME]) Tablet Extended Release 24 Hour 250mg- Give 1 tablet by mouth at bedtime for anticonvulsant give with 500mg to equal 750mg [MEDICATION NAME] Sodium ([MEDICATION NAME]) Tablet Extended Release 24 Hour 500mg - Give 1 tablet by mouth every 12 hours for Anticonvulsant Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) Tablet 200mg give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) Tablet 50mg give 1 tablet by mouth two times a day for [MEDICAL CONDITION] [MEDICATION NAME] Tablet 100mg give 1 tablet by mouth at bedtime for Depression with agitation Record review of Resident #246's care plan dated January 2018 revealed: Focus Resident is currently taking Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 200mg Date initiated: 12/27/2017 Interventions Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 12/27/2017 Record review of www.[MEDICATION NAME].com, updated December 2017, revealed in part: The most common side effects are drowsiness, dry mouth, constipation, dizziness, increased appetite, upset stomach, weight gain, fatigue, disturbance in speech and language, and stuffy nose. Continued record review of Resident #246's care plan dated January 2018 revealed: Focus Resident currently taking [MEDICATION NAME] 100mg at bedtime for depression. Date initiated: 1/10/2018 Interventions Administer medications as ordered. Monitor/document for side effects and effectiveness. Observe for side effects of anti-depressant medication: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, [MEDICAL CONDITION], withdrawal, decline in ability to help with/do, ADLs, continence, cognitive function, constipation, fecal impaction, no voiding, shuffle gait, rigid muscles, difficulty ambulating, balance problems, accidents, dizziness/[MEDICAL CONDITION], falls, movement problems, tremors, diarrhea, fatigue, [MEDICAL CONDITION], appetite, wt. loss, muscle cramps, and nausea/vomiting. Date initiated: 1/10/18 Continued record review of Resident #246's care plan dated January 2018 revealed: Focus At risk for falls related to generalized weakness and fear of falling. Date initiated: 12/19/2017 Goal Will not sustain serious injury through the review date. Observation on 1/8/18 at 3:40pm the surveyor observed Resident #246 in the hallway sitting in a wheelchair slumped over. She was surrounded by the DON, CNA V and LVN P. Resident #246 was very lethargic and slow to respond to verbal stimuli. The DON told CNA V to take the resident back to the room she was previous in because her discharged was going to be cancelled. Observations of Resident #246 revealed that she was so sleepy, she was unable to lift her feet as CNA V was wheeling her back to the room. Interview on 1/8/18 at 3:50pm, CNA V said that Resident #246 had previously been living at a group home. She was placed in the lobby area to wait for the staff from the group home to pick her up because the resident had been discharged from the facility. When the staff from the group home arrived they noticed that the resident was very lethargic and difficult to arouse. CNA V said the group home staff refused to take Resident #246 back because that was not the resident's normal behavior and they were concerned. Interview on 1/8/18 at 4:20pm, LVN P revealed Resident #246 was sleepy and the DON had performed vitals on the resident. The surveyor asked LVN P was there any medications the Resident #246 was given that would cause her to be lethargic or sleepy. She said the resident was receiving the following medications at night: [MEDICATION NAME] 750mg, [MEDICATION NAME] 100mg, and [MEDICATION NAME] 200mg. She further stated that Resident #246 also received the following medication throughout the day: [MEDICATION NAME] 500mg in the morning and [MEDICATION NAME] 50 mg twice a day. When the surveyor voiced concerns about the amount of medications the resident was getting, LVN P quickly said that she was going to speak with the facility social worker to schedule a psychiatrist evaluation to revise Resident #246's medications. During the same interview, LVN P said that Resident #246 had admitted to the facility on the current medications and they had not been adjusted. The surveyor asked the nurse if any doctor had seen the resident since she admitted to the facility and she said the facility physician visited the residents twice a week at night but she was unsure if the resident had been seen. LVN P said she had taken care of Resident #246 since she admitted to the facility and the resident often appeared sleepy. Observation on 1/8/18 at 4:24pm of Resident #246 revealed she was in bed asleep with the head of the bed elevated. The resident has 2 liters of oxygen going via a nasal cannula. The surveyor called the resident's name and she did not respond. The surveyor could hear the resident snoring. Interview on 1/9/18 at 7:37am with LVN N revealed that Resident #246 had fallen three times since yesterday evening. He said she fell on [DATE] during the evening shift, then again today around 4:30am. The resident fell a third time ninety minutes later at 6:00am and sustained a large hematoma to the left side of her forehead and was transferred to a local hospital. Observation on 1/9/18 at 3:00pm revealed that Resident #246 was not in her room on the 300 hall. Interview on 1/9/18 at 3:00pm with LVN N revealed that Resident #246 had returned to the facility from a local hospital and was now being housed on the 100 hall. The surveyor asked LVN N to see a copy of Resident #246's discharge papers. LVN N said that the resident did not return to the facility with any discharge papers. Asked the nurse how would he know what care and/or treatment was provided for the resident during the hospital visit and what care needed to be continued. LVN N said that the EMS told him the resident had a CT scan of the head which was negative. The surveyor asked LVN N if there were any paperwork that the EMS staff may have brought with the resident for the transport. He said there was not any paper work from the EMS staff, he only signed the electronic tablet. The surveyor asked the nurse if it was okay to except a verbal report for the CT scan results from the EMS staff. LVN N said it was unusual for the EMS staff not to have any paperwork. LVN N said that the hospital staff did not call to say that Resident #246 was returning to the facility. LVN N stated she did not attempt to call the hospital to get a report and/or discharge papers. Record review of Resident #246's December 2017 and January 2018 Progress Notes revealed no head to toe assessment was performed, no vital signs were documented, and the facility physician was not notified of the resident's return from the hospital on [DATE]. The last vital signs that were documented were on 12/27/17 at 3:06pm by LVN N. Interview on 1/9/18 at 3:45pm with RN B revealed she had worked for the facility since October 2017. She stated she had seen Resident #246 at shift change and received report from LVN N. RN B stated she was told by LVN N in the shift change report that Resident #246 did not return to the facility with discharge paperwork. She stated she was told by LVN N that Resident #246 had had a fall and was moved from the 300 hall to the 100 hall when she returned from the hospital. RN B said she was not told if an assessment had been performed on the resident since her return to the facility. RN B said she had done Resident #246's vital signs already but had not started a flow sheet yet. During the same interview RN B stated she did not know what care Resident #246 had received while at the hospital or the results of the resident's CT scan of the head. When the surveyor asked RN B what the plan of care for Resident #246 was since she had not returned with discharged orders, she said she would have the CNA check the resident more frequently to make sure her needs were being met. RN B stated she did not continue to try to get the results of the CT scan of the head or discharge papers for the resident. RN B said it was the responsibility of the nurse who admitted the resident to get the discharge papers and results of any test done. Interview on 1/10/18 at 8:00am with LVN B revealed she had worked for the facility for 2 years and she was the nurse responsible for Resident #246 at this time. LVN B informed the surveyor that she did not know much about Resident #246 because the resident had recently been moved from the 300 hall to the 100 hall. When the surveyor asked LVN B if she knew what had happen to Resident #246 her response was she believed the resident had had a fall over the weekend. She went on to say that the resident had thrown herself out of the bed because she wanted a coke which was how she fell . During the same interview, LVN B said she had received report from the night nurse but the nurse didn't tell her much about Resident #246. The nurse said there were not any discharge papers from the hospital the resident was discharge from. She said if a resident returned to the facility after having anything that needed to be reported to the physician, such as a CT scan, Medical Records would call the hospital and have the report faxed over. When the report was faxed over, Medical Records would scan the results into the computer. Interview on 1/10/18 at 11:40am with Medical Records revealed she has worked at the facility since February 2017. When asked if she had obtained the CT scan results, Medical Records admitted she had not called the hospital nor did she have the results of the CT scan. Observation and interview on 1/10/18 at 12:15pm revealed CNA Z attempting to feed Resident #246 her lunch in bed. The resident was very lethargic and could barely open her right eye. CNA Z stated this was unusual behavior for Resident #246. There was an unopened can of coke on the resident's lunch tray. CNA Z said that Resident #246 loved cokes and when she told the resident there was a coke there, she did not get a response from the resident. CNA Z said that the resident would usually perk right up whenever she could have a coke. The surveyor attempted to speak to the resident but the resident did not respond. Interview on 1/10/18 at 12:25pm the surveyor asked MA F if she had recently given Resident #246 any medication. She acknowledged she had given Resident #246 [MEDICATION NAME] 50mg about 20 minutes earlier. The surveyor told MA F that the resident was very sleepy to the point where she was unable to eat her lunch. MA F responded that Resident #246 was always sleepy and she acknowledged that the resident was sleepy when she gave her the [MEDICATION NAME]. Interview on 1/10/18 at 1:25pm the surveyor asked LVN N if he obtained Resident #246's results of the CT scan of the head. He said he had called the local hospital twice and was put on hold. He didn't say when he had called. The surveyor asked LVN B if he had called the doctor to let him know that Resident #246 was back in the facility and he said he did. The surveyor asked about the resident having vital signs done when he received the resident because there was no documentation of the doctor being called or the vital signs. He said that the vital signs were written down somewhere and walked off. Record review of Resident #246's Progress Notes as of 1/10/18 at 4:00pm revealed Resident #246's doctor was not called when she returned to the facility post fall. Record review revealed the nursing staff never received report on the resident from the local hospital, discharge paperwork, or the results of the resident's CT scan of the head. Observation and interview on 1/10/18 at 2:00pm revealed that Resident #246 was still very lethargic. The surveyor asked LVN B about Resident #246's lethargy, to which she replied Resident #246 only wants to sleep and when she is awake, she will keep hollering that she wants to go back to bed. LVN B was asked by the surveyor to assess Resident #246. LVN B made several attempts to get a blood pressure with a wrist blood pressure cuff and was unsuccessful. She found another cuff and was able to get a blood pressure of 97/69. LVN B attempted to get an oxygen saturation level on Resident #246. The monitor registered between 86% to 91% for about 10 minutes before the levels started to climb and finally got to 99%. While standing at Resident #246's bedside, the surveyor could hear a crackled sound coming from the resident as she breathed. The surveyor asked LVN B if she would listen to the resident's lung sounds. The nurse used a stethoscope to listen to the resident's lungs, and said her lung sounds were clear. Then LVN B said she would call the doctor and get an order for [REDACTED]. Interview on 1/10/18 at 2:40pm with MA F revealed that she was aware that one of the side effects of [MEDICATION NAME] was drowsiness. The surveyor asked MA F her reasoning for giving Resident #246 a medication that could cause drowsiness when the resident was already sleepy without consulting with the nurse first. She said she went into the resident's room and told her she had her medications and the resident responded by saying okay. MA F said if she went into a resident's room to give them medication and she was unable to get them to wake up, then she would call the nurse and the nurse would say to hold the medication. Interview on 1/10/18 at 3:10pm with RN B revealed that Resident #246 had a decline in neuro status. She said the resident was more lethargic, was unable to open the right eye enough for the pupil to be checked, and her hand grasp was now weak. Interview on 1/10/18 at 3:40pm the DON said she had seen Resident #246 and this was the resident's normal behavior. She said the resident had been seen by a pharmacist on 1/9/18 and the psychiatrist was in-house and would see the resident today. The DON said she was told by an unnamed nurse that she believed the resident was getting too much medication. The DON said she did tell the nurse that if that was what she thought, why hadn't she called the doctor. Interview on 1/10/18 at 3:55pm the DON approached the surveyor with the Lead Clinical Nurse. The DON said they both had seen the resident and came to the conclusion that the best thing for the resident was to send her to the hospital to be evaluated. Record review of the facility document titled Policy/Procedures- Notification, Physician or Responsible Party Revised 8/2007 revealed: It is the policy of this facility to promptly notify the resident, his/her attending physician, and/or family/responsible party of changes in the resident's condition and/or status. Procedures: 1. The Nurse Supervisor will notify the resident's attending physician when: A. The resident is involved in any accident or incident which results in an injury including injuries of an unknown source. B. There is a significant change in the resident's physical, mental, or psychosocial status. C. There is a need to alter the resident's treatment significantly. 2. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's condition or status. Record review of the facility document titled Policy/Procedure- Nursing Clinical- Neurological Evaluation, Revised 5/2007 revealed: POLICY: It is the policy of this facility to gather accurate nursing data necessary for a comprehensive neurological assessment. All incidents involving trauma to the head will result in a comprehensive neurological assessment for a minimum of seventy-two (72) hours. PR(NAME)EDURE: A neurological assessment flow sheet will be utilized for all residents sustaining head trauma due to fall or other incidents. POLICY: It is the policy of the facility that neurological evaluation will be completed by a licensed nurse. The first examination of the resident is important to establish a baseline for the future assessments. Any resident having an injury involving the head or an unobserved fall will have neuro checks and vital signs taken at least every eight hours for twenty-four hours or per specific facility, policy or physician's orders [REDACTED].>A comprehensive neurological assessment will be done as follows: Every 15 minutes x 4 Every 30 minutes x 4 Every hour x 4 Every shift x 72 hours 1. Document action required to elicit response on Neurological Evaluation Sheet. 2. Level of Consciousness: The resident's level of consciousness is assigned to one of five levels: A. Oriented to person, place, or thing. B. Lethargic: oriented, but drowsy. C. Stuporous: Less responsive and in a sleep-like state. Not comparable to normal from which a resident can be aroused for short intervals only. D. Semi-comatose: responds to painful stimuli only. E. Comatose: Complete loss of consciousness from which the resident cannot be aroused. Record review of the facility document titled Policy/Procedure- Nursing Administration- Change of condition Reporting, Revised 5/2007 revealed: POLICY: It is the policy of this facility that all changes in resident condition will be communicated to the physician. PURPOSE: To clearly define guidelines for timely notification of a change in resident condition. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met. Routine Medical Change: 1. All symptoms and unusual signs will be communicated to the physician promptly. 2. The nurse in charge is responsible for notification of physician prior to the end of assigned shift when a significant change in resident's condition is noted. 3. Document resident change of condition and response in nursing progress notes, on 24 Hour Report Form and update resident Care Plan, as indicated. Follow-up: 1. The licensed nurse responsible for the resident will continue assessment and documentation every shift for at least 72 hours or until condition has stabled. 2. Resident with acute medical changes (and some routine changes), will be listed on the 24 Hour Report and have progress and needs clearly communicated to each shift. Facility census dated 1/8/18 revealed 38 residents resided on the 100 and 300 halls.

Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident #1) reviewed for neglect were free from neglect in that: -CNA A failed to protect Resident #1 by not following the Care plan while providing incontinent care. Resident #1 fell and sustained a laceration on the left eyebrow line and left frontal scalp hematoma. Resident #1 experienced pain as a result of the fall. -CNA A provided incontinent care with Resident # 1 without assistance when Resident #1's care plan specified 2 person assist during bed mobility, transfer and toilet use. This failure affected one resident and placed nine additional dependent residents at risk for falls, injury, hospitalization , pain, and neglect. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #1's MDS, dated [DATE], revealed: BIMS Score of 0, which indicated Resident #1's cognition was severely impaired. Further review of MDS revealed Resident #1 needed extensive assistance with ADL, specifically, 2 person assist during bed mobility, transfer and toilet use. Record review of Resident #1's care plan dated 08/19/16, revealed Resident #1 needed extensive assistance with ADL, specifically, 2 person assist during bed mobility, transfer and toilet use. Interview on 10/10/17 at 10:44a.m., DON stated Resident #1 fell off the bed when CNA A turned the resident to the left during incontinent care. She stated the bed was locked, but moved when she leaned on the bed. She stated Resident #1 was care planned for total care and two person assist with bed mobility, transfer, dressing and bathing. Interview on 10/10/17 at 1:29p.m., LVN B stated after she assessed Resident #1 and applied a pressure dressing, she gave Resident #1 pain medication because she was in pain. Then she notified Resident #1's doctor who gave the order to transfer Resident #1 to the ER. Interview on 10/10/17 at 1:51p.m., CNA A stated she was providing incontinent care for the resident and she turned her to the left side. While she was cleaning her she leaned on the bed and it moved while the wheels were locked. That was when the resident fell out of the bed. During the same interview, CNA A also stated she had previously been providing incontinent for Resident #1 by herself and she had been working in the facility for one year. CNA A stated she could go to the P[NAME] in the kydex section to see what level of care Resident #1 needed but she did not check it before she provided care to Resident #1. CNA A stated the DON told her Resident #1 required a 2 person assist after the incident. CNA A stated she did all her training upon hire and participated during in- services on transfers, incontinent care and ADL care before and after the incident. Record review of the hospital record dated 08/06/17, chief complaint: laceration on the left for head S/P fall. Further review revealed CT of the head without contrast revealed left frontal scalp hematoma. Resident was administered [MEDICATION NAME]-[MEDICATION NAME] 2.5-108.3/5ml solution, 10ml was given though [DEVICE] at 2:00p.m. Record review of the facility policy/procedure revised 11/2007 stated: it is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Facility form 672, dated 10/10/17, identified 10 dependent residents.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents, in that: -CNA A failed to provide Resident #1 with incontinent care in accordance with the plan of care. Resident #1 fell and sustained a laceration on the left eyebrow line. This failure affected one resident and placed nine additional dependent residents at risk for injury. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Record review of Resident #1's MDS, dated [DATE], revealed: BIMS Score of 0, which indicated Resident #1's cognition was severely impaired. Further review of MDS revealed Resident #1 needed extensive assistance with ADL, specifically, 2 person assist during bed mobility, transfer and toilet use. Record review of Resident #1's care plan dated 08/19/16, revealed Resident #1 needed extensive assistance with ADL, specifically, 2 person assist during bed mobility, transfer and toilet use. Interview on 10/10/17 at 10:44a.m., DON stated Resident #1 fell off the bed when CNA A turned the resident to the left during incontinent care. She stated the bed was locked, but moved when she leaned on the bed. She stated Resident #1 was care planned for total care and two person assist with bed mobility, transfer, dressing and bathing. Interview on 10/10/17 at 1:29p.m., LVN B stated after she assessed Resident #1 and applied a pressure dressing, she gave Resident #1 pain medication because she was in pain. Then she notified Resident #1's doctor who gave the order to transfer Resident #1 to the ER. Interview on 10/10/17 at 1:51p.m., CNA A stated she was providing incontinent care for the resident and she turned her to the left side. While she was cleaning her she leaned on the bed and it moved while the wheels were locked. That was when the resident fell out of the bed. During the same interview, CNA A also stated she had previously been providing incontinent for Resident #1 by herself and she had been working in the facility for one year. CNA A stated she could go to the P[NAME] in the kydex section to see what level of care Resident #1 needed but she did not check it before she provided care to Resident #1. CNA A stated the DON told her Resident #1 required a 2 person assist after the incident. CNA A stated she did all her training upon hire and participated during in- services on transfers, incontinent care and ADL care before and after the incident. Record review of the hospital record dated 08/06/17, chief complaint: laceration on the left for head S/P fall. Further review revealed CT of the head without contrast revealed left frontal scalp hematoma. Resident was administered hydrocodone-acetaminophen 2.5-108.3/5ml solution, 10ml was given though [DEVICE] at 2:00p.m. Record review of the facility policy/procedure revised 11/2007 stated: it is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Facility form 672, dated 10/10/17, identified 10 dependent residents.

Based on observation, interview and record review, the facility failed to ensure the right to be free from neglect for two of seven residents (CR #3 and Resident #1) reviewed for neglect. - The facility failed to draw CR #3's STAT BMP laboratory orders for 10.5 hours. -The facility failed to notify the MD of CR #3's critical Potassium levels for 5.25 hours. -The facility failed to send CR #3 to the hospital for 14 hours after the NP instructed them to do so. -The facility failed to provide assessments and closely monitor the vital signs when CR #3 had a change in her condition. LVN A and LVN B did not assess CR #3's condition and vital signs during the night shift prior to being found unresponsive on [DATE] at 7:11 a.m. CR #3 was pronounced dead 26 minutes after arrival to the emergency room . -The facility failed to provide assessments and closely monitor the vital signs when CR #3 had a change in her condition. LVN A and LVN B did not assess CR #3's condition and vital signs during the night shift prior to being found unresponsive on [DATE] at 7:11 a.m. CR #3 was pronounced dead 26 minutes after arrival to the emergency room . -The facility failed to have adequate trained staff to evacuate Resident #1 from the building in the event of an emergency. She said she felt fearful when she was was forgotten in her room during an actual tornado alert. An IJ was identified on [DATE] and [DATE]. While the IJs were removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness and train staff. These failures affected one former resident (CR#3) who died 26 minutes after arrival to the emergency room and one resident at the facility (Resident #1) and placed the other 87 residents at the facility at risk of not receiving adequate care, fear, injuries, decline in their health condition well-being and death. Findings included: Intakes # 4, # 6 and # 8 CR #3 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #3 was found unresponsive and was sent to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of the 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfer, dressing, toileting and personal hygiene and supervision for walking in room and in corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: [AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed the BMP test was omitted on the requisition order. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 3:15 p.m. Late entry by LVN C .CR #3 went to therapy and therapist checked oxygen saturation and read 78%. Checked CR #3's oxygen saturation upon returning to room and oxygen saturation read 82%. Immediately placed CR #3 on oxygen at 2 liters. Oxygen continued to rise to 89%. Vital signs blood pressure ,[DATE], pulse 71, temperature 98.4 and respirations 15 - 16 breaths per minute with no labored breathing. Contacted NP with results on low oxygen and informed her that the oxygen was rising and asked if CR #3 could go out to hospital. Informed oncoming nurse . -[DATE] at 4:16 p.m. by LVN C NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . -[DATE] at 4:20 p.m. by LVN C NP called and informed of oxygen saturation . (NP) stated that we could send CR #3 out to hospital. Informed nurse on duty of decision . Record review of CR #3's electronic vital signs record revealed in part: -[DATE] at 4:42 p.m. Blood pressure ,[DATE] and pulse 64 beats per minute. Further record review revealed no further vitals sign assessments for CR #3. Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). This was the original STAT ordered lab the NP ordered at 9:30 a.m. that was omitted of the first lab requisition form. Further record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 7:57 p.m. by RN D Given order by NP to increase CR #3's [MEDICATION NAME] to 8 mg by mouth every 4 hours as needed for nausea which was entered into the computer and faxed to pharmacy . Record review of CR #3's electronic MAR indicated [REDACTED] Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part; -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Continued record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 1:46 a.m. by LVN A Potassium 6.2. Dr. A informed. Awaiting call back. -[DATE] at 1:49 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain. CR #3 requested for muscle spasms -[DATE] at 2:30 a.m. by LVN A CR #3 lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. A paged of Critical Potassium levels of 6.2. -[DATE] at 3:10 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain effective Further record review of the progress/nurses notes revealed no further attempts to contact the MD for the critical Potassium levels, no vital sign assessments or any further assessments during the night shift. Record review of CR #3's MD orders dated [DATE] revealed in part; -[MEDICATION NAME] tablet 350 mg, give 0.5 tablet by mouth every 6 hours as needed for muscle spasm/back pain. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 2:14 p.m. by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to CR #3's to check oxygen saturation. Upon entering room CR #3's eyes were closed and she was non-responsive to verbal and tactile stimuli. CR #3 was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. CR #3 was last observed sleeping in bed at approx 6:30 A.M. Notified emergency contact at approx 7:40 a.m. that CR #3 was observed unresponsive and that she should go to the hospital where CR #3 was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full arrest. -At 8:25 a.m. Preceding the arrest, CR #3 was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: CR #3 has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. CR #3 was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she had arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She said LVN B told her CR #3 had critical potassium levels during the night shift and that the MD had not returned the call yet. LVN A who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me staff had not follow up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room at that moment still with the phone on my hands and the NP on the line, CR #3 was found not breathing, and no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview with the ADON A at that time, she stated the night shift tried to call the MD but the MD was not reach. ADON A then said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said the other medical director called the facility during the night shift on [DATE] for another resident and LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. LVN C, stated she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. and said she called the NP to notify her CR #3 oxygen levels were low. The NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C said it was around 3:50 p.m. on [DATE] when she got the order. LVN C continued saying she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via text message and the staff would usually call, page or text the MD or the NP. When asked to see the text she said that she had erased the text message from the NP. Continued phone interview with LVN C at that time, she stated whenever a resident had a change in condition, the staff was supposed to complete a change in condition form in the computer, like an SBAR, when they would write their assessments, MD and RP notifications . S said she did not complete that assessment on CR #3. In a phone interview on [DATE] at 4:42 p.m. LVN A, he stated he was the charge nurse for CR #3 from 10:00 p.m. on [DATE] to at around 3:00 a.m. on [DATE] and further said I wasn't supposed to even being there on that day and continued saying I did not get any report regarding any change in condition regarding CR #3. I knew about the critical values of her laboratory results, I paged the MD twice and did not get any respond. Then I left at around 3:00 a.m. and gave report to LVN B so she could follow up and pass the information to the day shift. LVN A then said the other medical director called the facility on [DATE] regarding another resident and he did not notify him about CR #3 because he was very busy with this other resident who had a PICC line. He said but I heard that the day shift was able to get hold of the NP. Further interview with LVN A at that time, he stated critical laboratory values was a change in condition and he was supposed to contact the MD or the DON if unable to contact the MD He said In this place everything is so confused, I don't even know who the DON was. LVN A then said he was supposed to check the vital signs of CR #3 but he only checked the oxygen saturation. He said RN D didn't really tell me anything about CR #3. We were supposed to do the eINTERAC change of condition documentation in the computer but I can't explain why I did not do it. I don't know why. I should had monitored any cardiac issues, blood pressure and heart rate due to her high potassium levels. I was overwhelmed. In an interview on [DATE] at 5:00 p.m. RN D, stated she was the charge nurse for CR #3 on [DATE] during the 2:00 p.m. to 10:00 p.m. shift and then said during change of shift report CR #3 was sleepy and she asked about CR #3's oxygen saturation. The morning shift nurse told her it was around the 80's and that she had increased the oxygen to 4 liters and she re-checked the oxygen and it was 89 to 90%. RN D said during her shift, the laboratory collected blood from CR #3 that was ordered during the day shift. RN D said LVN C never told her about the orders to transfer CR #3 to the hospital. RN D continued saying she spoke with the NP because the NP wanted to know the laboratory results for CR #3 but she did not receive any reports from the laboratory. She never knew the NP wanted CR #3 to go to the hospital. When asked about the order to increase [MEDICATION NAME] for CR #3 for nausea and vomiting, RN D stated she did not remember if CR #3 had any nausea that day . Continued interview on [DATE] at 5:15 p.m. with RN D, she said whenever a resident had a change in condition, there was an eINTERACT form to complete on the computer where the nurse writes the assessments and then said I did not check if someone had completed a change of condition form on CR #3. It should had been completed on the day shift on [DATE]. In a phone interview on [DATE] at 9:15 a.m. LVN B, stated LVN A left the building on [DATE] at around 3:30 a.m. He told her everything was fine and that CR #3 did not have any issues. LVN B further said LVN A did not mention to her anything about the laboratory values of CR #3 but that she knew the laboratory had called at 1:30 a.m. to report critical values because she was the one who got the call and gave the message to LVN A. LVN B continued saying she also knew LVN A had paged the MD twice and she did not receive any MD calls for the rest of the shift. LVN B then said she did not try calling the MD for CR #3's critical laboratory values and she did not do any vital signs for CR #3 either. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. The NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. The NP then said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. The NP continued saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory results. At that moment, ADON A told her CR #3 was still in the facility and the NP asked ADON A for CR #3's vital signs right away including oxygen saturation. Further interview at that time the NP, stated she was surprise to find out CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing and it was at that time ADON A told her CR #3 was unresponsive. The NP then said I don't understand why the nurses did not follow the orders and called for laboratory blood work STAT, if it wasn't that I called them the next morning at 7:00 a.m. and inquired about CR #3 status , what if I did not call?. I gave STAT laboratory blood work orders, I expected the results right away. When I did not hear anything during the night shift, I thought CR #3 was sent to hospital but I decided to follow up with the facility the next morning. I even told them 'you guys are not following orders' . In an interview on [DATE] at 3:52 p.m. with the Administrator, she stated STAT laboratory orders needed to be call immediately to the laboratory and the policy was for the laboratory to come and draw the blood within 4 hours and 1 to 2 hours to get the results back. Administrator then said once the nurse gets the orders, the nurse will enter the order in the computer and then would follow on the order. She further said the nurse who gets the laboratory results is the nurse who will follow up with the MD. Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away, if the MD does not answer, then the medical director, facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical directors answer, then the nurse is supposed to call the DON and the Administrator so we can help in getting hold of the doctors. Continued interview with the Administrator, she stated whenever a resident has a change in condition, they are supposed to complete an eINTERACT form in the computer. She further said the interact form was a tool built in the computer system for changes in condition where it will trigger on what will need to happened. The Administrator further said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Further interview on [DATE] at 4:00 p.m. with the Administrator, she stated RN D told her on [DATE] at around 5:45 p.m. CR #3 had some abnormal vitals and that RN D had talked to the MD or the NP. She was told orders were to monitor CR #3's oxygen saturation and if the oxygen would drop, to send CR #3 to the hospital. The Administrator further said CR #3's vitals got better and CR #3 was improving. Everything got looking good. The Administrator then said RN D got the STAT laboratory orders for CR #3 on [DATE] at around 5:45 p.m. then the laboratory called with abnormal values at around 1:00 a.m. They tried to reach the MD, then I am foggy about it. They attempted to call the MD twice. They heard back from the MD 5 minutes before CR #3 coded. Staff gave CR #3 CPR and sent her to hospital. I believed CR#3 was even admitted to ICU before she died . CR #3 had been in the facility for one week, she was here for therapy. Continued interview with the Administrator on [DATE] at 4:09 p.m. She stated facility staff did not call her on [DATE] when they were unable to contact the MD for CR #3's critical laboratory values but believed the former DON was contacted. In a second interview on [DATE] at 4:45 p.m. LVN C, she said on [DATE] the NP came to visit CR #3 in the morning and gave STAT laboratory blood work. LVN C then said she was not sure how long do they have to call the laboratory for STAT orders but she believed they have 4 hours to call the laboratory. LVN C further said she texted the NP on [DATE] regarding CR #3's condition because her oxygen saturations were on the 80's and when she got the text back from the NP, she went and told RN D. LVN C then said The nurse who gets the order is the one responsible of inputting the order on the computer system. I did not do it because I was leaving to my home. I should had done it. I should had completed an eINTERACT assessment on CR #3 as well. Further interview with LVN C, she stated the first time she called the laboratory for STAT orders she only called for the urinalysis and the BNP (Beta Naturetic Peptide) because she misread the orders. She said later during change of shift, she found out together with RN D she had omitted the STAT orders for BMP (basic metabolic panel) and RN D was to follow up with it. LVN C further said she did not notify the NP about the mistake in transcribing orders to the laboratory requisition form. In a phone interview on [DATE] at 5:09 p.m. with the laboratory, technician stated they received a call from the facility on [DATE] at 12:12 p.m. for STAT order request for urinalysis and the BNP (Beta Naturetic Peptide) for CR #3 and on [DATE] at 5:06 p.m. they received another STAT order request for BMP for CR #3. Resident #1 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1 admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Continued record review revealed Resident #1 was at risk of developing pressure sores and was not on a turning/repositioning program. She received application of non-surgical dressing and ointment/medications other than to feet. Record review of Resident #1's care plan initiated [DATE] revealed in part: -Focus: At risk for an ADL self care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with bed mobility, dressing, grooming, toilet/incontinent needs and personal hygiene. She required extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Further record review revealed no information on her care plan related to the need of an oversize bed with interventions on how to maneuver her oversized bed in the event of an emergency that required evacuation. Record review of facility grievance dated [DATE] revealed in part: .Print individual's name: (Resident #1's) family member. Describe concern using factual terms: On Friday, [DATE], (Resident #1) was cleaned up at 8:00 p.m. so she started to urinate during the night. I asked that she get cleaned up at 10:00 a.m The CNA knew so we waited both me and (Resident #1), we ended up going to sleep so by the time we woke up, it was 5:30 p.m. so I went back with the nurse and told him and the nurse said he will let the 2 to 10:00 p.m. CNA know. Her CNA said she will come after dinner so by the time came (Resident #1) was soaking wet and full of bowel movement to the point that the bed was soaked, the same thing happened Sunday [DATE]th. Informed Administrator . Record review of the facility's In-service education record dated [DATE] with title Resident #1's bed revealed that training was given to only 11 facility staff members. Further record review revealed that 9 staff members were from the 6:00 a.m. to 2:00 p.m. shift, 1 staff member was from the 2:00 p.m. to 10:00 p.m. shift and 1 staff member from the 10:00 p.m. to 6:00 a.m. shift. Record review of Resident #1's social progress notes dated [DATE] at 1:30 p.m. revealed in part: Spoke with Resident #1 and family member and Resident #1 was very upset and frustrated and stated that she does not feel comfortable because during the tornado warning , she (Resident #1) was never brought out to the hallway. She stated that she was told from the Administrator that they would have to break down the bed to get it out of the room. Resident #1 stated that staff just pulled the curtains closed during the storm. Resident #1 stated that the Administrator told her that a tornado would hit the 100 hall first if anything were to happened.(Resident #1 was on the 300 hallway). Resident #1 stated that she found out that by law, all residents were to be pulled out into the hallway .Resident #1 stated that she was told by the Administrator that the facility has the staff and personnel to address her needs. Resident #1 stated that she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. Resident #1 does not understand why it takes so long for the staff to come and clean her up. She stated that she needs to be cleaned up fist to receive physical therapy which she has missed due to not being cleaned in a timely manner. Resident #1 stated that her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. Resident #1 is very angry and wants something to be done . Further record review of Resident #1's social progress notes dated [DATE] at 2:30 p.m. revealed in part: .Resident #1 stated that she was furious because she felt lied to. She stated that she was last cleaned at 9:00 p.m. on [DATE] and will finally get cleaned up at 2:00 p.m. on [DATE]. Resident #1 stated that she felt that she was lied to by the Administrator prior to being admitted just to get her to the facility to get paid and now that her 20 days are up, she feels like she is overlooked. Resident #1 requested to speak with someone who can ensure that she gets cleaned and the proper care she is entitled to In an interview on [DATE] at 8:58 a.m. with Resident #1 and her family member, she stated she did not feel safe at the facility because there had been a tornado warning few days ago and staff took all residents out to the hallways and she was left in her room. Resident #1 further said staff only closed her curtains. She felt very afraid because she was not evacuated from her room like the other residents. Resident #1 continued saying she was not able to get up or walk on her own. Observation revealed the measurements of the width of Resident #1's bed was 52 inches (from side rail to side rail). The measurements of the width of Resident #1's room door was 44 inches. Further interview at that time with Resident #1 and her family member present, Resident #1 stated facility staff was only providing incontinent care at 9:00 p.m. and 3:00 p.m. and then said I have wounds in my legs and the stool and urine are getting into my wounds. I haven't being cleaned today at all. I don't even know who my aide was. Staff don't come to see me in hours. If I pressed my call light, they will not come until around 11:30 a.m. I am very aware of what's going on, how about the people who are not aware of themselves?. Last night my brief was changed at 9:00 p.m. Normally staff don't change my brief during the night shift. I would like to be cleaned during the night but they don't come, even to check on me. Like now, if I would go and asked them to clean me because I feel that my brief is already soiled, they will say they are busy with breakfast. Every day I don't get care until around 1:30 p.m. or 3:00 p.m. Further interview at that time, Resident #1's family member stated since Resident #1 is in the facility, they haven't cleaned her before 1:00 p.m. Continued interview at on [DATE] at 9:10 a.m. Resident #1 stated my hair was not washed until 21 days after I was admitted to the facility, nobody comes to turn me in bed like they did at the hospital. I get my therapy late because I get cleaned up late. The Administrator told me before coming to the facility they had the staff to care for me. She promised me a lot of things. She told me I was going to be fully taken care of. My family member is the one taking care of me, he would try to help me get cleaned up because the staff is busy. My back hurts, my buttocks hurts. I feel soiled. I can smell myself. In an interview on [DATE] at 11:06 a.m. with Resident #1, she stated nobody had come to her room to check on her and offer to clean her and further said I don't even know who my aide is, since 9:00 p.m. last night that they did incontinent care, nobody has come to check if I need care. In an interview on [DATE] at 11:13 a.m. CNA I, stated she was the aide assigned to care for Resident #1. When asked what time she was going to do care for Resident #1, CNA I stated We need 6 to 7 people to do incontinent care for Resident #1 and the Central Supply person is helping me on gathering all the staff. I can't do it by myself. Observation on [DATE] at 11:40 a.m. during incontinent care to Resident #1 revealed that 6 staff members came to assist with incontinent care. CNA J, CNA W and CNA X supported Resident #1's abdominal fold up while CNA I and CNA Y each held open one leg. Central Supply person (who was also a CNA) cleaned Resident #1's abdominal fold and front perineal area. Further observation at that time revealed that Resident #1's had a rectangular moisture sheet approx 6 inches by 14 inches, under her abdominal area and one between her upper thighs and the moisture sheet that was in between Resident #1's upper thighs was completely soaked and was

Based on observation, interview, and record review the facility failed to ensure sufficient staffing to provide nursing related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of one Residents (R #1) reviewed for nursing services. -The facility failed to have sufficient staffing on the 10:00 p.m.-6:00 a.m. shift to provide incontinent care to Resident #1 and to evacuate her from the building in the event of an emergency. Resident #1 was afraid when she was forgotten during and actual tornado alert. Her hair was not washed for 21 dys. She could smell herself and felt humiliated. She was angry, frustrated and felt like she was lied to. She was afraid that her wounds would become infected An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to facility requiring more time to train staff and monitor the plan of removal for effectiveness. This failure placed one resident residing in the facility and placed 87 residents at risk for failure to have sufficient staffing to meet the residents care needs. Findings include: Intake # 6 and # 8 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1 admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Continued record review revealed that Resident #1 was at risk of developing pressure sores and was not on a turning/repositioning program. She received application of non-surgical dressing and ointment/medications other than to feet. Record review of Resident #1's care plan initiated [DATE] revealed in part: -Focus: At risk for an ADL self care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with bed mobility, dressing, grooming, toilet/incontinent needs and personal hygiene. She required extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Further record review revealed no information on her care plan related to the need of an oversize bed with interventions on how to maneuver her oversized bed in the event of an emergency that required evacuation. Record review of facility grievance dated [DATE] revealed in part: .Print individual's name: Resident #1's family member. Describe concern using factual terms: On Friday, [DATE], Resident #1 was cleaned up at 8:00 p.m. so she started to urinate during the night. I asked that she get cleaned up at 10:00 a.m The CNA knew so we waited both me and Resident #1, we ended up going to sleep so by the time we woke up, it was 5:30 p.m. so I went back with the nurse and told him and the nurse said that he will let the 2 to 10:00 p.m. CNA know. Her CNA said she will come after dinner so by the time came Resident 31 was soaking wet and full of bowel movement to the point that the bed was soaked, the same thing happened Sunday [DATE]th. Informed Administrator . Record review of the facility's In-service education record dated [DATE] with title Resident #1's bed revealed that training was given to only 11 facility staff members. Further record review revealed that 9 staff members were from the 6:00 a.m. to 2:00 p.m. shift, 1 staff member was from the 2:00 p.m. to 10:00 p.m. shift and 1 staff member from the 10:00 p.m. to 6:00 a.m. shift. Record review of Resident #1's social progress notes dated [DATE] at 1:30 p.m. revealed in part: Spoke with Resident #1 and family member and Resident #1 was very upset and frustrated and stated that she does not feel comfortable because during the tornado warning , she (Resident #1) was never brought out to the hallway. She stated that she was told from the Administrator that they would have to break down the bed to get it out of the room. Resident #1 stated that staff just pulled the curtains closed during the storm. Resident #1 stated that the Administrator told her that a tornado would hit the 100 hall first if anything were to happened.(Resident #1 was on the 300 hallway). Resident #1 stated that she found out that by law, all residents were to be pulled out into the hallway. Resident #1 also was very upset about being told by the Administrator that the facility had the staff to address her needs Resident #1 stated that she was told by the Administrator that the facility has the staff and personnel to address her needs. Resident #1 stated that she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. Resident #1 does not understand why it takes so long for the staff to come and clean her up. She stated that she needs to be cleaned up first to receive physical therapy which she has missed due to not being cleaned in a timely manner. Resident #1 stated that her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. Resident #1 is very angry and wants something to be done . Further record review of Resident #1's social progress notes dated [DATE] at 2:30 p.m. revealed in part: .Resident #1 stated that she was furious because she felt lied to. She stated that she was last cleaned at 9:00 p.m. on [DATE] and will finally get cleaned up at 2:00 p.m. on [DATE]. Resident #1 stated that she felt that she was lied to by the Administrator prior to being admitted just to get her to the facility to get paid and now that her 20 days are up, she feels like she is overlooked. Resident #1 requested to speak with someone who can ensure that she gets cleaned and the proper care she is entitled to In an interview on [DATE] at 8:58 a.m. with Resident #1 and her family member, she stated that she did not feel safe at the facility because there had been a tornado warning few days ago and that staff took all residents out to the hallways and that she was left in her room. Resident #1 further said that staff only closed her curtains and that she felt very afraid because she was not evacuated from her room like the other residents. Resident #1 continued saying that she was not able to get up or walk on her own. Observation revealed the measurements of the width of Resident #1's bed was 52 inches (from side rail to side rail). The measurements of the width of Resident #1's room door was 44 inches. Further interview at that time with Resident #1 with her family member present, Resident #1 stated that facility staff was only providing incontinent care at 9:00 p.m. and 3:00 p.m. She said I have wounds in my legs and the stool and urine are getting into my wounds. I haven't being cleaned today at all. I don't even know who my aide was. Staff don't come to see me in hours. If I pressed my call light, they will not come until around 11:30 a.m. I am very aware of what's going on, how about the people who are not aware of themselves?. Last night my brief was changed at 9:00 p.m. Normally staff don't change my brief during the night shift. I would like to be cleaned during the night but they don't come, even to check on me. Like now, if I would go and asked them to clean me because I feel that my brief is already soiled, they will say they are busy with breakfast. Every day I don't get care until around 1:30 p.m. or 3:00 p.m. Further interview at that time, Resident #1's family member stated since Resident #1 is in the facility, they haven't cleaned her before 1:00 p.m. Continued interview at on [DATE] at 9:10 a.m. Resident #1 stated my hair was not washed until 21 days after I was admitted to the facility, nobody comes to turn me in bed like they did at the hospital. I get my therapy late because I get cleaned up late. The Administrator told me before coming to the facility that they had the staff to care for me. She promised me a lot of things. She told me I was going to be fully taken care of. My family member is the one taking care of me, he would try to help me get cleaned up because the staff is busy. My back hurts, my buttocks hurts. I feel soiled. I can smell myself. In an interview on [DATE] at 11:06 a.m. with Resident #1, she stated that nobody had come to her room to check on her and offer to clean her and further said I don't even know who my aide is, since 9:00 p.m. last night that they did incontinent care, nobody has come to check if I need care. In an interview on [DATE] at 11:13 a.m. with CNA I, she stated that she was the aide assigned to care for Resident #1. When asked what time she was going to do care for Resident #1, CNA I stated We need 6 to 7 people to do incontinent care for Resident #1 and the Central Supply person is helping me on gathering all the staff. I can't do it by myself. Observation on [DATE] at 11:40 a.m. during incontinent care to Resident #1 revealed that 6 staff members came to assist with incontinent care. CNA J, CNA W and CNA X supported Resident #1's abdominal fold up while CNA I and CNA Y each held open one leg. Central Supply person (who is also a CNA) cleaned Resident #1's abdominal fold and front perineal area. Further observation at that time revealed that Resident #1's had a rectangular moisture sheet approx 6 inches by 14 inches, under her abdominal area and one between her upper thighs and the moisture sheet that was in between Resident #1's upper thighs was completely soaked and was dark brown in color. Continued observation at that time revealed a very strong urine and stool odor in the room. Further observation at that time during incontinent care, while Resident #1 was turned to her side revealed that 3 staff were needed to turned Resident #1 to her side and other 3 staff were needed to support Resident #1 on the other side of the bed while she was being turned to her side. Continued observation revealed that Resident #1's brief was completely soiled up to the back of the brief. The brief was dark yellow in color and had stool on it. There was stool also on the buttocks of Resident #1. Resident #1 was lying on 2 pads that had a large dark brown colored ring where Resident #1 was lying from the buttocks area to her mid thighs. Under the pads there was a sling (staff used sling to move Resident #1 up in bed) that had also a large circular wet area on the direction where Resident #1 was lying down. While Resident #1 was on her side, she required 3 staff to hold her on her side on the side she was facing, 2 staff to hold Resident #1 on her back while the other staff was providing the incontinent care. Continued observation on [DATE] at 12:23 p.m. at end of incontinent care, Resident #1 was assisted up on her bed. 3 staff were on one side and 3 other staff were on the other side. Further observation at that time revealed that it took 6 staff members to do incontinent care and took 43 minutes to complete the procedure. In an interview on [DATE] at 10:32 p.m. with CNA V, she stated that she was the aide taking care of Resident #1 and that it was her first time in the facility. She further said that she was told that Resident #1 required 6 people to do incontinent care and that the staff from 2:00 p.m. to 10:00 p.m. had just cleaned Resident #1. When asked if she was trained on how to evacuate Resident #1 out of her room in case of an emergency, CNA V stated No and then said I worked in another facility, I just came today to help them out. In an interview on [DATE] at 10:36 p.m. with Resident #1, she stated that she was cleaned only twice during the day, at 2:15 p.m. and 9:00 p.m. Resident #1 then said that in order to move her bed out of the room, the side arm rests of the bed needed to come out. She further said that few staff were trained during the day shift when she first got the bed delivered and then said that facility had not done further training on how to operate her bed to the rest of the staff. Further interview with Resident #1, she stated that after the incident of the tornado warning when she was left on her room alone, she said that the Administrator told her that she was left on her room so she would not feel uncomfortable on the hallway. Resident #1 continued saying that some staff told her on the day of the tornado warning that they would come and get her out of the room unless the tornado would really hit the building. At that time, Resident #1 stated If a tornado had really hit the building, I don't think they would had come back to get me, forget it, they would had tried to save themselves. In an interview on [DATE] at 11:00 p.m. with LVN B, she stated that there were 3 CNA's and 2 nurses for the night shift at the facility. She further said that she was the charge nurse for Resident #1. When asked how would she evacuate Resident #1 from her room in case of an emergency, LVN B responded Resident #1's bed would not fit thru the door and to be honest, we don't have the staff. I don't know what would we do, will call 911. We have raised the same question before because it's hard. I have not received any emergency training on Resident #1 and do not know how to maneuver her bed. I would not know what to do. Just call 911. LVN B further stated that there were 3 CNA's and 2 nurses for the night shift at the facility. She further said that she was the charge nurse for Resident #1. She then said that during the night shift, they would only go to Resident #1 room unless she put her light on and then said Resident #1 gets her incontinent care during the pm shift when there is more staff. If she had a bowel movement during the night shift and she would want to have incontinent care, it would take all the staff in the facility during the night shift, all the 5 staff working on the facility. In an interview on [DATE] at 11:05 p.m. with LVN S, she stated that she was a full time nurse on the 10:00 p.m. to 6:00 a.m. shift and said that she had not received any training on how to evacuate Resident #1 from her room in case of an emergency and further said In case of a fire, we know the bed can't roll, well with a draw sheet. It takes 6 to 7 people just to turn Resident #1 in bed, we are 5 staff today working in the facility during the night shift, the bed is too big to get thru the door and I am not sure if we can take the bed apart, I don't know what will we do. In an interview on [DATE] at 11:13 p.m. with CNA U, she stated that she was a full time CNA working on the night shift. She further said that she had not received any training on how to evacuate Resident #1 in case of an emergency and then said we would call the fire department and would tell them to hurry up because we would not be able to evacuate her by ourselves. She further said that it would take 5 to 6 people to move Resident #1 and if Resident #1 needed incontinent care the 3 aides and the 2 nurses in the facility would have to assist with her care. In an interview on [DATE] at 11:20 p.m. with CNA T, she stated that she was a full time CNA working on the night shift and said that she had not received any training on how to evacuate Resident #1 out of her room in case of an emergency and further said I have no idea what will we do. The bed might not fit thru the door, it's not enough staff at night to lift her up with a sheet. We would just try to secure her in her room or try to lift her, we are strong. Continued interview with CNA T, she then said I don't think we are equipped for Resident #1, we usually work 3 aides and 2 nurses at the night shift and it takes about 6 people to do care for her. If we needed to clean her, the whole building of staff would have to go and care for her and it would take 35 to 40 minutes. In an interview on [DATE] at 9:38 a.m. with the Administrator, she stated that on the day of the tornado warning, it was around 6:45 a.m. sometime in January, that the facility had to evacuate the residents due to the tornado warning and further said we got the residents to the hallway. Then Resident #1's family member came to me and told me that Resident #1 was very nervous and then I remember that before Resident #1 came to the facility, she told me not to make her feel that she was in a nursing home, so what we did, to not to increase her anxiety, I decided to leave her on her room, we closed her blinds and pulled her curtains. For Resident #1's window to be destroyed by a tornado, the whole front of the building needed to be destroyed. If pressure would built inside the building, we would have to open Resident #1's window or we would have to ask Resident #1 if she would like to come out of the room. Tornado warning did not stop on that day until 8:30 a.m. Further interview with the Administrator at that time, she stated that Resident #1's side rails would have to come out of the bed in order to be able to move the bed out of the room. She then said that the Therapy Director and Central Supply person were trained on how to break the bed down in an emergency situation. Administrator continued saying that she knew Therapy Director and Central Supply person trained some staff but she did not know who and said she was going to get the training records for surveyor. Administrator then said that disaster plan in-services are done annually on the month of April and upon orientation. In an interview on [DATE] at 9:58 a.m. with Central Supply, she stated that she got trained by the bed company representative on how to operate Resident #1's bed but that she did not give any training to anyone else and further said the staff who was here at the facility at that time were trained on how to operate Resident #1's bed. In an interview on [DATE] at 10:05 a.m. with Therapy Director, he stated that the day when Resident #1 had her bed delivered, he was instructed by the bed company representative on how to operate the bed. He then said that there was other staff present but he did not remember who they were or the exact date. Therapy Director continued saying that he did trained some of the CNA's from the day shift, whoever was around, on how to manipulate Resident #1's side rails and what to do in case of a code emergency but he was not sure if nursing had additional training with the rest of the staff on how to maneuver Resident #1's bed. In a second interview on [DATE] at 11:00 a.m. with the Administrator, when asked if the night shift had any training on emergency procedures on Resident #1, how to evacuate her in an emergency, how to maneuver her bed in case of an emergency, the Administrator responded that's what I had been looking for because the training we had was mostly for the day shift, it was supposed to be done but not sure if it was done. It was supposed to happened but I can't find the training records, but in the worst scenario, we will come tonight to train them. When told that nobody from the night shift knew how to operate Resident #1's bed or how to evacuate Resident #1 in case of an emergency, the Administrator said we will come tonight to train them. Further interview with the Administrator, she stated that the night shift usually works together on helping Resident #1 with her care and further said I was under the impression that Resident #1 had incontinent care every morning at 6:00 a.m. Resident #1 gets care at certain times only because she does not want to be bother. Administrator further said that she has not heard any concerns related to the care of Resident #1. In an interview on [DATE] at 2:40 p.m. with Resident #1, she stated that she never requested only certain times and that she has not refused any care or that staff checks on her during the night time and further said Like this morning, I did not get cleaned until 12:00 p.m. It makes me want to cry. I have history of getting skin infections. Last night they cleaned me around 9:00 p.m. and did not get incontinent care until 12:00 p.m. today. Since 8:00 a.m. I had been waiting for somebody to come but they did not come until 12:00 p.m. I urinated and defecated on myself since early morning. The pad underneath me is always so wet because I urinate and urinate and urinate on it. I cry and get so frustrated because I know I smell, I smell my urine. I have not refused any care. I was told I was going to be bathe every other day and I don't. In an interview on [DATE] at 3:08 p.m. with Central Supply, she stated that she was assigned with Resident #1 during the day shift and that she was scheduled for shower and said that she was going to stay over to bathe Resident #1. Central Supply further said that she did not give incontinent care to Resident #1 earlier on the shift because Resident #1 was eating breakfast. The Administrator stated on [DATE] at 3:20 p.m. that the facility did not have a policy and procedure for staffing. Record review of - NWS Houston (@NWSHouston) [DATE] Tornado warnings dotted counties along the Gulf Coast beginning late Tuesday night, reaching and including the metro Houston area during the pre-dawn hours of Wednesday. Record review of the facility's Disaster Risk assessment dated [DATE] revealed that the facility was somewhat likely for the following disasters: Hurricane, tornado/severe storms, flooding, lightning and extreme heat. Record review of the facility's Internal/External disaster plan revised on [DATE] reads in part .Tornado/Severe Storm: If notice is given, take the following steps: 1.- turn on hallway lights, 2.- Close all drapes, blinds, 3.- Evacuate all rooms to the immediate hallways, 4.- Protect all patients 5.- Do not open doors or windows Record review of the facility's document with title Evacuation of Patients in Bari Rehab Beds revealed in part In the event that it should become necessary to evacuate a bed-bound patient in a Bari-Rehab bed, please follow the instructions on how to retract the bed Instruction for expanding/retracting bed deck . emergency hand crank . Side rail instructions .adjusting side rail trouble shooting instructions . Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health Dignity and respect You have the right to live in safe, decent, and clean conditions, be free from neglect be treated with dignity, consideration and respect Make your own choices regarding personal care . Record review of the facility policy and procedure Incontinent Care revised ,[DATE] revealed in part: It is the policy of this facility to remove urine or feces from skin Further record review revealed no information on how often the facility provided incontinent care to the residents. Record review of the facility policy and procedure ADL, Services to carry out revised ,[DATE] revealed in part: It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .2.- Residents who are unable to carry out activities of daily living will receive necessary services to maintain: grooming, personal hygiene . Record review of the facility policy and procedure Turning rounds revised ,[DATE] revealed in part; It is the policy of this facility to 1.- Cleanse, refresh and reposition bedfast residents on a regular basis An IJ was identified on [DATE] at 11:56 am and the Administrator, the Clinical Resource Nurse and the Executive Market Director were informed at that time. The POR was accepted on [DATE] at 4:00 pm. The POR included: Immediate Action: 1.- We are actively seeking to discharge the resident from the bariatric resident from the facility to a facility that can better meet her needs. 2.- On [DATE], we tested and ensured that the bariatric bed can be easily be removed from the room in the event of an emergency evacuation. 3.- Charge nurse will be responsible for directing staff to evacuate such identified patients according to the emergency preparedness plan. Education on the emergency preparedness plan began [DATE]. The process for breaking down the bariatric bed for removal from the room was added to the disaster plan on [DATE]. The process is detailed with the attached guide, and the staff are to follow the normal evacuation procedures, using the set routes and evacuation order, per the disaster plan. 4.- The Director of Therapy or designee will be in-service all staff with return demonstration on the proper procedures on how to breakdown facility's bariatric beds according to manufacturer's instructions, beginning [DATE]. 5.- Staffing coordinator or designee is reviewing schedule with DON or designee every shift to ensure adequate staff to meet resident needs, including emergency situations. 6.-The above training will begin on [DATE] and will continue until all nursing staff have been in-serviced. Staff will not be allowed to resume resident care responsibilities or other duties until trained. 7.- Facility is voluntarily stopping admissions effective [DATE] until substantial compliance is achieved. The Administrator / Designee will ensure that the above training is completed as planned. Two-four staff are required to breakdown and push the bed. Evacuation routes areas listed in the disaster plan. Staff is trained annually and upon orientation on the disaster plan. Then number of staff on the night shift was assessed on [DATE] to ensure adequate staffing in case of an emergency evacuation by the Administrator. Administrator has signed a contract with an agency to ensure that we have two additional staff members on the night shift beginning tonight, [DATE], making it 7 staff members based on the current census. Facility Human Resource designee is actively hiring and orientating new staff members for the 10 to 6 a.m. shift to ensure resident needs are met and that resident safety is ensured in the event of an evacuation route would take 20 to 30 minutes depending upon if the evacuation needs to be to another compartment or out of the building. The building is designed and broken into fire compartments so that a total evacuation would not be needed unless the entire building is engulfed in flames. Beginning [DATE], all new admissions will be screened prior to admission by DON/Designee to determine if they are bed-bound bariatric patients who would need the above procedures. All bariatric patients needing the above procedures will have their care plans updated by [DATE]. As of this time, there are no other bariatric residents requiring special evacuation procedures. DON/Designee will monitor any change in residents' transfer status at weekly Standard of Care meeting beginning [DATE]. All circumstances requiring evacuation as per the Fire and Disaster Manual will trigger the above procedures. Continue to look for alternate placement for patient where needs can be better met. Monitoring: In an interview on [DATE] at 10:20 a.m. with LVN G and LVN H, both stated that they had been trained on the bed operation for Resident #1 and how to evacuate her in case of an emergency. In an interview on [DATE] at 10:30 a.m. with LVN E, she stated that she had been trained on Emergency procedures with Resident #1 and how to maneuver her bed in case of evacuation emergency. In an interview on [DATE] at 10:40 a.m. with LVN F, he stated that he had been trained on How to operate Resident #1's bed, how to remove the side rails in an event of evacuation including for CPR emergencies. In an interview on [DATE] at 1:00 p.m. with CNA I, she stated that she had been trained on Emergency procedures for Resident #1 and how to maneuver her bed including how to remove the side rails in an event of evacuation emergency. She also said that they were trained on how to prepare Resident #1's bed if she needed CPR. In an interview on [DATE] at 1:40 p.m. with CNA J, she stated that she was also trained on emergency procedures for Resident #1's bed. CNA J also said that she felt confident on how to maneuver Resident #1's bed for evacuation and CPR. In an interview on [DATE] at 1:52 p.m. with LVN K, she stated that she had been trained on how to break Resident #1's bed in an event of evacuation to wheeled the bed out of the room and how to deflate her mattress for CPR. In an interview on [DATE] at 2:00 p.m. with CNA L and CNA M, both said that they attended training regarding how to operate Resident #1's bed including how to remove the side rails to make sure the bed can be evacuated out of the room and how to deflate the bed for CPR. In an interview on [DATE] at 2:10 p.m. with CNA N, she stated that she had received training on emergency procedure for Resident #1 and how to maneuver her bed. In an interview on [DATE] at 2:35 p.m. with CNA O, she stated that she was also trained on how to make Resident #1's bed smaller to make it fit thru the door in an event of an emergency. She also said that training included for CPR and how to operate the bed without electricity. In an interview on [DATE] at 3:05 P.m. with LVN P, she stated that she received training on [DATE] on how to maneuver Resident #1's bed and emergency procedures for Resident #1 including evacuation. In an interview on [DATE] at 4:20 p.m. with CNA Q she stated that she was also trained on how to operate Resident #1's bed and what to do in an event of an emergency including evacuation. In an interview on [DATE] at 4:25 p.m. with RN R, she stated that she had been trained on how to break Resident #1's bed in an event of evacuation to wheeled the bed out of the room and how to deflate her mattress for CPR. In a phone interview on [DATE] at 4:30 p.m. with LVN A, he stated that he had been trained on how to maneuver Resident #1's bed, how to move the bed out of the room and other emergency techniques including CPR and what to do with the bed if no electricity. He also said that he was working on the night shift on [DATE] with Resident #1 and that he already knew how to direct the staff in case of an emergency. In a phone interview on [DATE] at 4:40 p.m. with LVN S, she stated that she was trained last night on emergency procedures with Resident #1 including evacuation and how to work Resident #1's bed, including CPR and how to manually operate the bed if no electricity. In an phone interview on [DATE] at 4:58 p.m. with CNA T, she stated that she was also trained on how to operate Resident #1's bed in an event of evacuation. She said that she knew what to do now in an event of an emergency a

Based on observation, interview and record review, the facility failed to implement their policy that prohibited neglect for two of seven residents (CR #3 and Resident #1) reviewed for neglect. - The facility failed to draw CR #3's STAT BMP laboratory orders for 10.5 hours. -The facility failed to notify the MD of CR #3's critical Potassium levels for 5.25 hours. -The facility failed to send CR #3 to the hospital for 14 hours after the NP instructed them to do so. -The facility failed to provide assessments and closely monitor the vital signs when CR #3 had a change in her condition. LVN A and LVN B did not assess CR #3's condition and vital signs during the night shift prior to being found unresponsive on [DATE] at 7:11 a.m. CR #3 was pronounced dead 26 minutes after arrival to the emergency room . -The facility failed to have adequate trained staff to evacuate Resident #1 from the building in the event of an emergency. She said she felt fearful when she was was forgotten in her room during an actual tornado alert. -The facility failed to have adequate staffing on the 10:00 p.m.-6:00 a.m. shift to provide Resident #1's incontinent care to protect her wounds causing her emotional distress when she said she smelled herself and felt humiliated. An IJ was identified on [DATE] and [DATE]. While the IJs were removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness and train staff. These failures affected one former resident (CR#3) who died 26 minutes after arrival to the emergency room and one resident at the facility (Resident #1) and placed the other 87 residents at the facility at risk of not receiving adequate care, fear, injuries, decline in their health condition well-being and death. Findings included: Intakes # 4, # 6 and # 8 Record review of the facility policy and procedure revised ,[DATE] Abuse prevention and reporting revealed in part: .Neglect: Action or inaction that avoids or prevents physical, mental harm, pain, demonstrates disregard or consequences that may constitute a clear and present danger . Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health Dignity and respect You have the right to live in safe, decent, and clean conditions, be free from neglect be treated with dignity, consideration and respect Make your own choices regarding personal care . CR #3 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #3 was found unresponsive and was sent to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of the 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfer, dressing, toileting and personal hygiene and supervision for walking in room and in corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: [AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed the BMP test was omitted on the requisition order. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 3:15 p.m. Late entry by LVN C .CR #3 went to therapy and therapist checked oxygen saturation and read 78%. Checked CR #3's oxygen saturation upon returning to room and oxygen saturation read 82%. Immediately placed CR #3 on oxygen at 2 liters. Oxygen continued to rise to 89%. Vital signs blood pressure ,[DATE], pulse 71, temperature 98.4 and respirations 15 - 16 breaths per minute with no labored breathing. Contacted NP with results on low oxygen and informed her that the oxygen was rising and asked if CR #3 could go out to hospital. Informed oncoming nurse . -[DATE] at 4:16 p.m. by LVN C NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . -[DATE] at 4:20 p.m. by LVN C NP called and informed of oxygen saturation . (NP) stated that we could send CR #3 out to hospital. Informed nurse on duty of decision . Record review of CR #3's electronic vital signs record revealed in part: -[DATE] at 4:42 p.m. Blood pressure ,[DATE] and pulse 64 beats per minute. Further record review revealed no further vitals sign assessments for CR #3. Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). This was the original STAT ordered lab the NP ordered at 9:30 a.m. that was omitted of the first lab requisition form. Further record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 7:57 p.m. by RN D Given order by NP to increase CR #3's [MEDICATION NAME] to 8 mg by mouth every 4 hours as needed for nausea which was entered into the computer and faxed to pharmacy . Record review of CR #3's electronic MAR indicated [REDACTED] Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part; -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Continued record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 1:46 a.m. by LVN A Potassium 6.2. Dr. A informed. Awaiting call back. -[DATE] at 1:49 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain. CR #3 requested for muscle spasms -[DATE] at 2:30 a.m. by LVN A CR #3 lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. A paged of Critical Potassium levels of 6.2. -[DATE] at 3:10 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain effective Further record review of the progress/nurses notes revealed no further attempts to contact the MD for the critical Potassium levels, no vital sign assessments or any further assessments during the night shift. Record review of CR #3's MD orders dated [DATE] revealed in part; -[MEDICATION NAME] tablet 350 mg, give 0.5 tablet by mouth every 6 hours as needed for muscle spasm/back pain. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 2:14 p.m. by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to CR #3's to check oxygen saturation. Upon entering room CR #3's eyes were closed and she was non-responsive to verbal and tactile stimuli. CR #3 was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. CR #3 was last observed sleeping in bed at approx 6:30 A.M. Notified emergency contact at approx 7:40 a.m. that CR #3 was observed unresponsive and that she should go to the hospital where CR #3 was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full arrest. -At 8:25 a.m. Preceding the arrest, CR #3 was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: CR #3 has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. CR #3 was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she had arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She said LVN B told her CR #3 had critical potassium levels during the night shift and that the MD had not returned the call yet. LVN A who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me staff had not follow up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room at that moment still with the phone on my hands and the NP on the line, CR #3 was found not breathing, and no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview with the ADON A at that time, she stated the night shift tried to call the MD but the MD was not reach. ADON A then said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said the other medical director called the facility during the night shift on [DATE] for another resident and LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. LVN C, stated she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. and said she called the NP to notify her CR #3 oxygen levels were low. The NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C said it was around 3:50 p.m. on [DATE] when she got the order. LVN C continued saying she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via text message and the staff would usually call, page or text the MD or the NP. When asked to see the text she said that she had erased the text message from the NP. Continued phone interview with LVN C at that time, she stated whenever a resident had a change in condition, the staff was supposed to complete a change in condition form in the computer, like an SBAR, when they would write their assessments, MD and RP notifications . S said she did not complete that assessment on CR #3. In a phone interview on [DATE] at 4:42 p.m. LVN A, he stated he was the charge nurse for CR #3 from 10:00 p.m. on [DATE] to at around 3:00 a.m. on [DATE] and further said I wasn't supposed to even being there on that day and continued saying I did not get any report regarding any change in condition regarding CR #3. I knew about the critical values of her laboratory results, I paged the MD twice and did not get any respond. Then I left at around 3:00 a.m. and gave report to LVN B so she could follow up and pass the information to the day shift. LVN A then said the other medical director called the facility on [DATE] regarding another resident and he did not notify him about CR #3 because he was very busy with this other resident who had a PICC line. He said but I heard that the day shift was able to get hold of the NP. Further interview with LVN A at that time, he stated critical laboratory values was a change in condition and he was supposed to contact the MD or the DON if unable to contact the MD He said In this place everything is so confused, I don't even know who the DON was. LVN A then said he was supposed to check the vital signs of CR #3 but he only checked the oxygen saturation. He said RN D didn't really tell me anything about CR #3. We were supposed to do the eINTERAC change of condition documentation in the computer but I can't explain why I did not do it. I don't know why. I should had monitored any cardiac issues, blood pressure and heart rate due to her high potassium levels. I was overwhelmed. In an interview on [DATE] at 5:00 p.m. RN D, stated she was the charge nurse for CR #3 on [DATE] during the 2:00 p.m. to 10:00 p.m. shift and then said during change of shift report CR #3 was sleepy and she asked about CR #3's oxygen saturation. The morning shift nurse told her it was around the 80's and that she had increased the oxygen to 4 liters and she re-checked the oxygen and it was 89 to 90%. RN D said during her shift, the laboratory collected blood from CR #3 that was ordered during the day shift. RN D said LVN C never told her about the orders to transfer CR #3 to the hospital. RN D continued saying she spoke with the NP because the NP wanted to know the laboratory results for CR #3 but she did not receive any reports from the laboratory. She never knew the NP wanted CR #3 to go to the hospital. When asked about the order to increase [MEDICATION NAME] for CR #3 for nausea and vomiting, RN D stated she did not remember if CR #3 had any nausea that day . Continued interview on [DATE] at 5:15 p.m. with RN D, she said whenever a resident had a change in condition, there was an eINTERACT form to complete on the computer where the nurse writes the assessments and then said I did not check if someone had completed a change of condition form on CR #3. It should had been completed on the day shift on [DATE]. In a phone interview on [DATE] at 9:15 a.m. LVN B, stated LVN A left the building on [DATE] at around 3:30 a.m. He told her everything was fine and that CR #3 did not have any issues. LVN B further said LVN A did not mention to her anything about the laboratory values of CR #3 but that she knew the laboratory had called at 1:30 a.m. to report critical values because she was the one who got the call and gave the message to LVN A. LVN B continued saying she also knew LVN A had paged the MD twice and she did not receive any MD calls for the rest of the shift. LVN B then said she did not try calling the MD for CR #3's critical laboratory values and she did not do any vital signs for CR #3 either. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. The NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. The NP then said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. The NP continued saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory results. At that moment, ADON A told her CR #3 was still in the facility and the NP asked ADON A for CR #3's vital signs right away including oxygen saturation. Further interview at that time the NP, stated she was surprise to find out CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing and it was at that time ADON A told her CR #3 was unresponsive. The NP then said I don't understand why the nurses did not follow the orders and called for laboratory blood work STAT, if it wasn't that I called them the next morning at 7:00 a.m. and inquired about CR #3 status , what if I did not call?. I gave STAT laboratory blood work orders, I expected the results right away. When I did not hear anything during the night shift, I thought CR #3 was sent to hospital but I decided to follow up with the facility the next morning. I even told them 'you guys are not following orders' . In an interview on [DATE] at 3:52 p.m. with the Administrator, she stated STAT laboratory orders needed to be call immediately to the laboratory and the policy was for the laboratory to come and draw the blood within 4 hours and 1 to 2 hours to get the results back. Administrator then said once the nurse gets the orders, the nurse will enter the order in the computer and then would follow on the order. She further said the nurse who gets the laboratory results is the nurse who will follow up with the MD. Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away, if the MD does not answer, then the medical director, facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical directors answer, then the nurse is supposed to call the DON and the Administrator so we can help in getting hold of the doctors. Continued interview with the Administrator, she stated whenever a resident has a change in condition, they are supposed to complete an eINTERACT form in the computer. She further said the interact form was a tool built in the computer system for changes in condition where it will trigger on what will need to happened. The Administrator further said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Further interview on [DATE] at 4:00 p.m. with the Administrator, she stated RN D told her on [DATE] at around 5:45 p.m. CR #3 had some abnormal vitals and that RN D had talked to the MD or the NP. She was told orders were to monitor CR #3's oxygen saturation and if the oxygen would drop, to send CR #3 to the hospital. The Administrator further said CR #3's vitals got better and CR #3 was improving. Everything got looking good. The Administrator then said RN D got the STAT laboratory orders for CR #3 on [DATE] at around 5:45 p.m. then the laboratory called with abnormal values at around 1:00 a.m. They tried to reach the MD, then I am foggy about it. They attempted to call the MD twice. They heard back from the MD 5 minutes before CR #3 coded. Staff gave CR #3 CPR and sent her to hospital. I believed CR#3 was even admitted to ICU before she died . CR #3 had been in the facility for one week, she was here for therapy. Continued interview with the Administrator on [DATE] at 4:09 p.m. She stated facility staff did not call her on [DATE] when they were unable to contact the MD for CR #3's critical laboratory values but believed the former DON was contacted. In a second interview on [DATE] at 4:45 p.m. LVN C, she said on [DATE] the NP came to visit CR #3 in the morning and gave STAT laboratory blood work. LVN C then said she was not sure how long do they have to call the laboratory for STAT orders but she believed they have 4 hours to call the laboratory. LVN C further said she texted the NP on [DATE] regarding CR #3's condition because her oxygen saturations were on the 80's and when she got the text back from the NP, she went and told RN D. LVN C then said The nurse who gets the order is the one responsible of inputting the order on the computer system. I did not do it because I was leaving to my home. I should had done it. I should had completed an eINTERACT assessment on CR #3 as well. Further interview with LVN C, she stated the first time she called the laboratory for STAT orders she only called for the urinalysis and the BNP (Beta Naturetic Peptide) because she misread the orders. She said later during change of shift, she found out together with RN D she had omitted the STAT orders for BMP (basic metabolic panel) and RN D was to follow up with it. LVN C further said she did not notify the NP about the mistake in transcribing orders to the laboratory requisition form. In a phone interview on [DATE] at 5:09 p.m. with the laboratory, technician stated they received a call from the facility on [DATE] at 12:12 p.m. for STAT order request for urinalysis and the BNP (Beta Naturetic Peptide) for CR #3 and on [DATE] at 5:06 p.m. they received another STAT order request for BMP for CR #3. Resident #1 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1 admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Continued record review revealed Resident #1 was at risk of developing pressure sores and was not on a turning/repositioning program. She received application of non-surgical dressing and ointment/medications other than to feet. Record review of Resident #1's care plan initiated [DATE] revealed in part: -Focus: At risk for an ADL self care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with bed mobility, dressing, grooming, toilet/incontinent needs and personal hygiene. She required extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Further record review revealed no information on her care plan related to the need of an oversize bed with interventions on how to maneuver her oversized bed in the event of an emergency that required evacuation. Record review of facility grievance dated [DATE] revealed in part: .Print individual's name: (Resident #1's) family member. Describe concern using factual terms: On Friday, [DATE], (Resident #1) was cleaned up at 8:00 p.m. so she started to urinate during the night. I asked that she get cleaned up at 10:00 a.m The CNA knew so we waited both me and (Resident #1), we ended up going to sleep so by the time we woke up, it was 5:30 p.m. so I went back with the nurse and told him and the nurse said he will let the 2 to 10:00 p.m. CNA know. Her CNA said she will come after dinner so by the time came (Resident #1) was soaking wet and full of bowel movement to the point that the bed was soaked, the same thing happened Sunday [DATE]th. Informed Administrator . Record review of the facility's In-service education record dated [DATE] with title Resident #1's bed revealed that training was given to only 11 facility staff members. Further record review revealed that 9 staff members were from the 6:00 a.m. to 2:00 p.m. shift, 1 staff member was from the 2:00 p.m. to 10:00 p.m. shift and 1 staff member from the 10:00 p.m. to 6:00 a.m. shift. Record review of Resident #1's social progress notes dated [DATE] at 1:30 p.m. revealed in part: Spoke with Resident #1 and family member and Resident #1 was very upset and frustrated and stated that she does not feel comfortable because during the tornado warning , she (Resident #1) was never brought out to the hallway. She stated that she was told from the Administrator that they would have to break down the bed to get it out of the room. Resident #1 stated that staff just pulled the curtains closed during the storm. Resident #1 stated that the Administrator told her that a tornado would hit the 100 hall first if anything were to happened.(Resident #1 was on the 300 hallway). Resident #1 stated that she found out that by law, all residents were to be pulled out into the hallway .Resident #1 stated that she was told by the Administrator that the facility has the staff and personnel to address her needs. Resident #1 stated that she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. Resident #1 does not understand why it takes so long for the staff to come and clean her up. She stated that she needs to be cleaned up fist to receive physical therapy which she has missed due to not being cleaned in a timely manner. Resident #1 stated that her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. Resident #1 is very angry and wants something to be done . Further record review of Resident #1's social progress notes dated [DATE] at 2:30 p.m. revealed in part: .Resident #1 stated that she was furious because she felt lied to. She stated that she was last cleaned at 9:00 p.m. on [DATE] and will finally get cleaned up at 2:00 p.m. on [DATE]. Resident #1 stated that she felt that she was lied to by the Administrator prior to being admitted just to get her to the facility to get paid and now that her 20 days are up, she feels like she is overlooked. Resident #1 requested to speak with someone who can ensure that she gets cleaned and the proper care she is entitled to In an interview on [DATE] at 8:58 a.m. with Resident #1 and her family member, she stated she did not feel safe at the facility because there had been a tornado warning few days ago and staff took all residents out to the hallways and she was left in her room. Resident #1 further said staff only closed her curtains. She felt very afraid because she was not evacuated from her room like the other residents. Resident #1 continued saying she was not able to get up or walk on her own. Observation revealed the measurements of the width of Resident #1's bed was 52 inches (from side rail to side rail). The measurements of the width of Resident #1's room door was 44 inches. Further interview at that time with Resident #1 and her family member present, Resident #1 stated facility staff was only providing incontinent care at 9:00 p.m. and 3:00 p.m. and then said I have wounds in my legs and the stool and urine are getting into my wounds. I haven't being cleaned today at all. I don't even know who my aide was. Staff don't come to see me in hours. If I pressed my call light, they will not come until around 11:30 a.m. I am very aware of what's going on, how about the people who are not aware of themselves?. Last night my brief was changed at 9:00 p.m. Normally staff don't change my brief during the night shift. I would like to be cleaned during the night but they don't come, even to check on me. Like now, if I would go and asked them to clean me because I feel that my brief is already soiled, they will say they are busy with breakfast. Every day I don't get care until around 1:30 p.m. or 3:00 p.m. Further interview at that time, Resident #1's family member stated since Resident #1 is in the facility, they haven't cleaned her before 1:00 p.m. Continued interview at on [DATE] at 9:10 a.m. Resident #1 stated my hair was not washed until 21 days after I was admitted to the facility, nobody comes to turn me in bed like they did at the hospital. I get my therapy late because I get cleaned up late. The Administrator told me before coming to the facility they had the staff to care for me. She promised me a lot of things. She told me I was going to be fully taken care of. My family member is the one taking care of me, he would try to help me get cleaned up because the staff is busy. My back hurts, my buttocks hurts. I feel soiled. I can smell myself. In an interview on [DATE] at 11:06 a.m. with Resident #1, she stated nobody had come to her room to check on her and offer to clean her and further said I don't even know who my aide is, since 9:00 p.m. last night that they did incontinent care, nobody has come to check if I need care. In an interview on [DATE] at 11:13 a.m. CNA I, stated she was the aide assigned to care for Resident #1. When asked what time she was going to do care for Resident #1, CNA I stated We need 6 to 7 people to do incontinent care for Resident #1 and the Central Supply person is helping me on gathering all the staff. I can't do it by myself. Observation on [DATE] at 11:

Based on observation, interview and record review, the Administration failed to oversee the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for two of seven residents (CR#3 and Resident #1) reviewed for quality of care. -The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect. -The Administrator failed to monitor the system of communication between nurses to follow up with critical laboratory reports and MD notification. --The Administrator failed to supervise and monitor the former DON to ensure she carried out her responsibilities in the areas of assessment and monitoring of medical conditions, such as monitoring of vital signs when a resident had a change in condition including MD notifications and follow up timely with MD orders. -The Administrator failed to monitor that the facility had sufficient staff during the night shift to provide care for Resident #1 who required 6 to 7 staff to provide incontinent care and failed to make sure staff on all shifts were trained on how to evacuate a bariatric resident who had an oversized bed in an event of an emergency. An IJ was identified on [DATE] and [DATE]. While the IJ's were removed on [DATE] the facility remained out of compliance at a scope of widespread and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident (CR#3) who died 26 minutes after arrival to the emergency room and one resident at the facility (Resident #1) whose needs were not met due to insufficient staff and placed the other 87 residents at the facility at risk of not receiving adequate care, fear, injuries, decline in their health condition well-being, delayed evacutations and death. Findings included: Intakes # 4, # 6 and # 8 In an interview on [DATE] at 11:00 a.m. the DON, stated she was new in the facility. She said her first day of employment was [DATE]. The DON then said she started to meet in person all the nurses in the facility so they knew who she was and to provided them her contact information. In an interview on [DATE] at 11:38 a.m. the Administrator, stated the facility had completed new teams for clinicals because the process previously used was not working. She then said the Clinical Resource Nurse had just trained her on what to look for as an Administrator concerning changes in condition of residents. The Administrator said the facility was implementing a new change of condition log as part of the POR. Further interview with the Administrator at that time, she stated she was aware CR #3 had some abnormal vital signs but she was not aware of any STAT laboratory orders or that the nurses were not able to contact the MD. She then said she was not aware either that the NP had given orders for CR #3 to be sent to the hospital the day before that she was found unconscious. Administrator continued saying that when she learned about CR #3's symptoms on [DATE], she was expecting and assuming that CR #3 was going to be sent to the hospital and it was not until the next day staff told her CR #3 had coded in the facility. Continued interview with the Administrator, she said she was aware staff were trained initially on Resident #1's bed but she was not aware staff from the night shift did not know how to operate Resident #1's bed and was not aware Resident #1 had incontinent care only twice in a 24 hour period. CR #3 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #3 was found unresponsive and was sent to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of the 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfer, dressing, toileting and personal hygiene and supervision for walking in room and in corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: XXX[AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed that BMP test was omitted in requisition order. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 3:15 p.m. Late entry by LVN C .CR #3 went to therapy and therapist checked oxygen saturation and read 78%. Checked CR #3's oxygen saturation upon returning to room and oxygen saturation read 82%. Immediately placed CR #3 on oxygen at 2 liters. Oxygen continued to rise to 89%. Vital signs blood pressure ,[DATE], pulse 71, temperature 98.4 and respirations 15 - 16 breaths per minute with no labored breathing. Contacted NP with results on low oxygen and informed her that the oxygen was rising and asked if CR #3 could go out to hospital. Informed oncoming nurse . -[DATE] at 4:16 p.m. by LVN C NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . -[DATE] at 4:20 p.m. by LVN C NP called and informed of oxygen saturation . (NP) stated that we could send CR #3 out to hospital. Informed nurse on duty of decision . Record review of CR #3's electronic vital signs record revealed in part: -[DATE] at 4:42 p.m. Blood pressure ,[DATE] and pulse 64 beats per minute. Further record review revealed no further vitals sign assessments for CR #3. Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). This was the STAT test ordered by the NP at 9:30 a.m. that morning) Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part; -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Continued record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 1:46 a.m. by LVN A Potassium 6.2. Dr. A informed. Awaiting call back. -[DATE] at 1:49 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain. CR #3 requested for muscle spasms -[DATE] at 2:30 a.m. by LVN A CR #3 lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. A paged of Critical Potassium levels of 6.2. Further record review of the progress/nurses notes revealed no further attempts to contact the MD for the critical Potassium levels, no vital sign assessments or any further assessments during the night shift. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 2:14 p.m. by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx. 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to CR #3's to check oxygen saturation. Upon entering room CR #3's eyes were closed and she was non-responsive to verbal and tactile stimuli. CR #3 was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. CR #3 was last observed sleeping in bed at approx 6:30 A.M. Notified emergency contact at approx. 7:40 a.m. that CR #3 was observed unresponsive and that she should go to the hospital where CR #3 was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full arrest. -At 8:25 a.m. preceding the arrest, CR #3 was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: CR #3 has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. CR #3 was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. with ADON A, she stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She then said that LVN B told her CR #3 had critical potassium levels during the night shift and the MD had not returned the call yet and LVN A who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me staff had not followed up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room at that moment still with the phone on my hands and the NP on the line, CR #3 was found not breathing, and no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview with the ADON A at that time, she stated the night shift tried to call the MD but the MD was not reach. ADON A then said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said that the other medical director called the facility during the night shift on [DATE] for another resident and that LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. with LVN C, she stated that she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. and said she called the NP to notify her CR #3 oxygen levels were low and the NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C then said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C said it was around 3:50 p.m. on [DATE] when she got the order. LVN C continued saying she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via text message and the staff would usually call, page or text the MD or the NP and then said she had erased the text message from the NP. Continued phone interview with LVN C at that time, she stated whenever a resident had a change in condition, the staff was supposed to complete a change in condition form in the computer that was like an SBAR where they would write their assessments, MD and RP notifications and then said that she did not complete that assessment on CR #3. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. NP then said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. NP continued saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory results and at that moment, ADON A told her CR #3 was still in the facility and NP asked ADON A for CR #3's vital signs right away including oxygen saturation. Further interview at that time the NP, stated she was surprise to find out that CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing it was at that time that ADON A told her that CR #3 was unresponsive. NP then said I don't understand why the nurses did not follow the orders and called for the laboratory blood work STAT. If it wasn't that I called them the next morning at 7:00 a.m. and inquired about CR #3 status what would have happened? What if I did not call? I gave STAT laboratory blood work orders, I expected the results right away. When I did not hear anything during the night shift, I thought CR #3 was sent to hospital but I decided to follow up with the facility the next morning. I even told them you guys are not following orders' . In an interview on [DATE] at 3:52 p.m. the Administrator, stated STAT laboratory orders needed to be call immediately to the laboratory and the policy was for the laboratory to come and draw the blood within 4 hours and 1 to 2 hours to get the results back. The Administrator then said once the nurse gets the orders, the nurse will enter the order in the computer and then would follow on the order. She further said that the nurse who gets the laboratory results is the nurse who will follow up with the MD. Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away.If the MD does not answer, then the medical director, the facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical directors answer, then the nurse is supposed to call the DON and the Administrator so we can help in getting hold of the doctors. Continued interview with the Administrator at that time, she stated whenever a resident has a change in condition, staff are supposed to complete an eINTERACT form in the computer. She further said the interact form was a tool built in the computer system for changes in condition where it will trigger on what will need to happened. Administrator further said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Resident #1 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1 admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Continued record review revealed Resident #1 was at risk of developing pressure sores and was not on a turning/repositioning program. She received application of non-surgical dressing and ointment/medications other than to feet. Record review of Resident #1's care plan initiated [DATE] revealed in part: -Focus: At risk for an ADL self care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with bed mobility, dressing, grooming, toilet/incontinent needs and personal hygiene. She required extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Further record review revealed no information on her care plan related to the need of an oversize bed with interventions on how to maneuver her oversized bed in the event of an emergency that required evacuation. Record review of facility grievance dated [DATE] revealed in part: .Print individual's name: (Resident #1's) family member. Describe concern using factual terms: On Friday, [DATE], (Resident #1) was cleaned up at 8:00 p.m. so she started to urinate during the night. I asked that she get cleaned up at 10:00 a.m The CNA knew so we waited both me and Resident #1, we ended up going to sleep so by the time we woke up, it was 5:30 p.m. so I went back with the nurse and told him and the nurse said that he will let the 2 to 10:00 p.m. CNA know. Her CNA said she will come after dinner so by the time came (Resident #1) was soaking wet and full of bowel movement to the point that the bed was soaked, the same thing happened Sunday [DATE]th. Informed Administrator . Record review of the facility's In-service education record dated [DATE] with title Resident #1's bed revealed that training was given to only 11 facility staff members. Further record review revealed that 9 staff members were from the 6:00 a.m. to 2:00 p.m. shift, 1 staff member was from the 2:00 p.m. to 10:00 p.m. shift and 1 staff member from the 10:00 p.m. to 6:00 a.m. shift. Record review of Resident #1's social progress notes dated [DATE] at 1:30 p.m. revealed in part: Spoke with Resident #1 and family member and Resident #1 was very upset and frustrated and stated that she does not feel comfortable because during the tornado warning , she (Resident #1) was never brought out to the hallway. She stated that she was told from the Administrator that they would have to break down the bed to get it out of the room. Resident #1 stated staff just pulled the curtains closed during the storm. Resident #1 stated the Administrator told her a tornado would hit the 100 hall first if anything were to happened.(Resident #1 was on the 300 hallway). Resident #1 stated she found out that by law, all residents were to be pulled out into the hallway. Resident #1 also was very upset about being told by the Administrator the facility had the staff to address her needs. Resident #1 stated she was told by the Administrator that the facility has the staff and personnel to address her needs. Resident #1 stated she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. Resident #1 does not understand why it takes so long for the staff to come and clean her up. She stated she needs to be cleaned up first to receive physical therapy which she has missed due to not being cleaned in a timely manner. Resident #1 stated her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. Resident #1 is very angry and wants something to be done . Further record review of Resident #1's social progress notes dated [DATE] at 2:30 p.m. revealed in part: .Resident #1 stated she was furious because she felt lied to. She stated she was last cleaned at 9:00 p.m. on [DATE] and will finally get cleaned up at 2:00 p.m. on [DATE]. Resident #1 stated she felt she was lied to by the Administrator prior to being admitted just to get her to the facility to get paid and now that her 20 days are up, she feels like she is overlooked. Resident #1 requested to speak with someone who can ensure she gets cleaned and the proper care she is entitled to In an interview on [DATE] at 8:58 a.m. with Resident #1 and her family member, she stated that she did not feel safe at the facility because there had been a tornado warning few days ago and staff took all residents out to the hallways and she was left in her room. Resident #1 further said staff only closed her curtains and she felt very afraid because she was not evacuated from her room like the other residents. Resident #1 continued saying that she was not able to get up or walk on her own. Observation revealed the measurements of the width of Resident #1's bed was 52 inches (from side rail to side rail). The measurements of the width of Resident #1's room door was 44 inches. Continued interview at on [DATE] at 9:10 a.m. Resident #1 stated my hair was not washed until 21 days after I was admitted to the facility, nobody comes to turn me in bed like they did at the hospital. I get my therapy late because I get cleaned up late. The Administrator told me before coming to the facility that they had the staff to care for me. She promised me a lot of things. She told me I was going to be fully taken care of. My family member is the one taking care of me, he would try to help me get cleaned up because the staff is busy. My back hurts, my buttocks hurts. I feel soiled. I can smell myself. In an interview on [DATE] at 11:13 a.m. with CNA I, she stated that she was the aide assigned to care for Resident #1. When asked what time she was going to do care for Resident #1, CNA I stated We need 6 to 7 people to do incontinent care for Resident #1 and the Central Supply person is helping me on gathering all the staff. I can't do it by myself. Observation on [DATE] at 11:40 a.m. during incontinent care to Resident #1 revealed that 6 staff members came to assist with incontinent care. CNA J, CNA W and CNA X supported Resident #1's abdominal fold up while CNA I and CNA Y each held open one leg. Central Supply person (who was also a CNA) cleaned Resident #1's abdominal fold and front perineal area. Further observation at that time revealed that Resident #1's had a rectangular moisture sheet approx 6 inches by 14 inches, under her abdominal area and one between her upper thighs and the moisture sheet that was in between Resident #1's upper thighs was completely soaked and was dark brown in color. Continued observation at that time revealed a very strong urine and stool odor in the room. Further observation at that time during incontinent care, while Resident #1 was turned to her side revealed that 3 staff were needed to turned Resident #1 to her side and other 3 staff were needed to support Resident #1 on the other side of the bed while she was being turned to her side. Continued observation revealed that Resident #1's brief was completely soiled up to the back of the brief. The brief was dark yellow in color and had stool on it. There was stool also on the buttocks of Resident #1. Resident #1 was lying on 2 pads that had a large dark brown colored ring where Resident #1 was lying from the buttocks area to her mid thighs. Under the pads there was a sling (staff used sling to move Resident #1 up in bed) that had also a large circular wet area on the direction where Resident #1 was lying down. While Resident #1 was on her side, she required 3 staff to be holding her on her side on the side she was facing, 2 staff to be holding Resident #1 on her back while the other staff was providing the incontinent care. Continued observation on [DATE] at 12:23 p.m. at end of incontinent care, Resident #1 was assisted up in her bed. 3 staff were on one side and 3 other staff were on the other side. Further observation at that time revealed that it took 6 staff members to do incontinent care and took 43 minutes to complete the procedure. In an interview on [DATE] at 10:32 p.m. with CNA V, she stated that she was the aide taking care of Resident #1 and it was her first time in the facility. She further said she was told that Resident #1 required 6 people to do incontinent care and the staff from 2:00 p.m. to 10:00 p.m. had just cleaned Resident #1. When asked if she was trained on how to evacuate Resident #1 out of her room in case of an emergency, CNA V stated No and then said I worked in another facility, I just came today to help them out. Further interview with Resident #1, she stated that after the incident of the tornado warning when she was left on her room alone, she said the Administrator told her that she was left on her room so she would not feel uncomfortable on the hallway. Resident #1 continued saying that some staff told her on the day of the tornado warning that they would come and get her out of the room unless the tornado would really hit the building. At that time, Resident #1 stated If a tornado had really hit the building, I don't think they would had come back to get me, forget it, they would had tried to save themselves. In an interview on [DATE] at 11:00 p.m. with LVN B, she stated that there were 3 CNA's and 2 nurses for the night shift at the facility. She further said she was the charge nurse for Resident #1. When asked how would she evacuate Resident #1 from her room in case of an emergency, LVN B responded Resident #1's bed would not fit thru the door and to be honest, we don't have the staff. I don't know what we would we do, will call 911. We have raised the same question before because it's hard. I have not received any emergency training on Resident #1 and do not know how to maneuver her bed. I would not know what to do. Just call 911. LVN B further stated that there were 3 CNA's and 2 nurses for the night shift at the facility. She further said she was the charge nurse for Resident #1. She then said that during the night shift, they would only go to Resident #1 room if she put her light on and then said Resident #1 gets her incontinent care during the pm shift when there is more staff. If she had a bowel movement during the night shift and she would want to have incontinent care, it would take all the staff in the facility during the night shift, all the 5 staff working on the facility. In an interview on [DATE] at 11:05 p.m. with LVN S, she stated that she was a full time nurse on the 10:00 p.m. to 6:00 a.m. shift and said she had not received any training on how to evacuate Resident #1 from her room in case of an emergency and further said In case of a fire, we know the bed can't roll, well with a draw sheet. It takes 6 to 7 people just to turn Resident #1 in bed, we are 5 staff today working in the facility during the night shift. The bed is too big to get thru the door and I am not sure if we can take the bed apart, I don't know what will we do. In an interview on [DATE] at 11:13 p.m. with CNA U, she stated that she was a full time CNA working on the night shift. She further said that she had not received any training on how to evacuate Resident #1 in case of an emergency and then said we would call the fire department and would tell them to hurry up because we would not be able to evacuate her by ourselves. She further said that it would take 5 to 6 people to move Resident #1 and if Resident #1 needed incontinent care the 3 aides and the 2 nurses in the facility would have to assist with her care. In an interview on [DATE] at 11:20 p.m. with CNA T, she stated that she was a full time CNA working on the night shift and said that she had not received any training on how to evacuate Resident #1 out of her room in case of an emergency and further said I have no idea what we would do. The bed might not fit thru the door. There is not enough staff at night to lift her up with a sheet. We would just try to secure her in her room or try to lift her, we are strong. Continued interview with CNA T, she then said I don't think we are equipped for Resident #1, we usually work 3 aides and 2 nurses at the night shift and it takes about 6 people to do care for her. If we needed to clean her, the whole building of staff would have to go and care for her and it would take 35 to 40 minutes. In an interview on [DATE] at 9:38 a.m. the Administrator, stated around 6:45 a.m. sometime in January, the facility had to evacuate the residents due to the tornado warning and further said we got the residents to the hallway. Then Resident #1's family member came to me and told me that Resident #1 was very nervous and then I remember before Resident #1 came to the facility, she told me not to make her feel that she was in a nursing home, so what we did, to not to increase her anxiety, I decided to leave her on her room. We closed her blinds and pulled her curtains. For Resident #1's window to be destroyed by a tornado, the whole front of the building needed to be destroyed. If pressure would build inside the building, we would have to open Resident #1's window or we would have to ask Resident #1 if she would like to come out of the room. Tornado warning did not stop on that day until 8:30 a.m. Further interview with the Administrator at that time, she stated Resident #1's side rails would have to come out of the bed in order to be able to move the bed out of the room. She then said that the Therapy Director and Central Su

Based on interview and record review the facility failed to promptly notify the ordering physician or nurse practitioner of laboratory results that fell outside of the clinical reference ranges for one of seven residents reviewed for laboratory results. (CR#3). -The facility failed to consult with CR #3's Physician or Nurse Practitioner when the resident had a critical Potassium laboratory value. CR #3 was found unresponsive 5.5 hours after the laboratory called the facility with a critical result Potassium level and she was pronounced dead 26 minutes after arrival to the emergency room . An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one (CR #3) and placed 88 residents at the facility at risk of having abnormal labs and not having their physician notified, resulting in a delay in medical intervention or death. Findings Included: Intake # 4 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #3 was found unresponsive and was sent to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of the 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfer, dressing, toileting and personal hygiene and supervision for walking in room and in corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: [AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed that BMP test was omitted on the requisition order. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 3:15 p.m. Late entry by LVN C .CR #3 went to therapy and therapist checked oxygen saturation and read 78%. Checked CR #3's oxygen saturation upon returning to room and oxygen saturation read 82%. Immediately placed CR #3 on oxygen at 2 liters. Oxygen continued to rise to 89%. Vital signs blood pressure ,[DATE], pulse 71, temperature 98.4 and respirations 15 - 16 breaths per minute with no labored breathing. Contacted NP with results on low oxygen and informed her the oxygen was rising and asked if CR #3 could go out to hospital. Informed oncoming nurse . -[DATE] at 4:16 p.m. by LVN C NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . -[DATE] at 4:20 p.m. by LVN C NP called and informed of oxygen saturation . (NP) stated that we could send CR #3 out to hospital. Informed nurse on duty of decision . Record review of CR #3's electronic vital signs record revealed in part: -[DATE] at 4:42 p.m. Blood pressure ,[DATE] and pulse 64 beats per minute. Further record review revealed no further vitals sign assessments for CR #3. Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). This requisition was for the STAT test ordered at 9:30 am by the NP that had been omitted from the first lab requisition order. Further record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 7:57 p.m. by RN D Given order by NP to increase CR #3's [MEDICATION NAME] to 8 mg by mouth every 4 hours as needed for nausea which was entered into the computer and faxed to pharmacy . Record review of CR #3's electronic MAR indicated [REDACTED] Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part; -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Continued record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 1:46 a.m. by LVN A Potassium 6.2. Dr. (P) informed. Awaiting call back. -[DATE] at 1:49 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain. CR #3 requested for muscle spasms -[DATE] at 2:30 a.m. by LVN A CR #3 lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. (P) paged of Critical Potassium levels of 6.2. -[DATE] at 3:10 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain effective (documentation indicated monitoring the effectiveness of the medication) Further record review of the progress/nurses notes revealed no further attempts to contact the MD for the critical Potassium levels, no vital sign assessments or any further assessments during the night shift. Record review of CR #3's MD orders dated [DATE] revealed in part; -[MEDICATION NAME] tablet 350 mg, give 0.5 tablet by mouth every 6 hours as needed for muscle spasm/back pain. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 2:14 p.m. by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx. 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to CR #3's to check oxygen saturation. Upon entering room CR #3's eyes were closed and she was non-responsive to verbal and tactile stimuli. CR #3 was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. CR #3 was last observed sleeping in bed at approx. 6:30 A.M. Notified emergency contact at approx. 7:40 a.m. CR #3 was observed unresponsive and she should go to the hospital where CR #3 was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full arrest. -At 8:25 a.m. Preceding the arrest, CR #3 was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: CR #3 has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. CR #3 was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She said LVN B told her CR #3 had critical potassium levels during the night shift and the MD had not returned the call yet. LVN A who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me staff had not follow up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room still with the phone in my hands and the NP on the line, CR #3 was found not breathing and with no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview the ADON A at that time, stated the NOC shift tried to call the MD but the MD was not reach. ADON A then said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said the other medical director called the facility during the NOC shift on [DATE] for another resident and LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. LVN C, stated she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. and she called the NP to notify her CR #3 oxygen levels were low and the NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C then said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C then said it was around 3:50 p.m. on [DATE] when she got the order. LVN C continued she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via text message and the staff would usually call, page or text the MD or the NP. When asked if text could be reviewed she said that she had erased the text message from the NP. Continued phone interview LVN C, stated whenever a resident had a change in condition, the staff was supposed to complete a change in condition form in the computer that was like an SBAR when they would write their assessments, MD and RP notifications and she did not complete that assessment on CR #3. In a phone interview on [DATE] at 4:42 p.m. LVN A, he stated he was the charge nurse for CR #3 from 10:00 p.m. on [DATE] to at around 3:00 a.m. on [DATE] and further said I wasn't supposed to even being there on that day and I did not get any report regarding any change in condition regarding CR #3. I knew about the critical values of her laboratory results, I paged the MD twice and did not get any respond. Then I left at around 3:00 a.m. and gave report to LVN B so she could follow up and pass the information to the day shift. LVN A said the other medical director called the facility on [DATE] regarding another resident and he did not notify him about CR #3 because he was very busy with this other resident who had a PICC line and said but I heard that the day shift was able to get hold of the NP. Further in the same interview LVN A stated critical laboratory values was a change in condition and he was supposed to contact the MD or the DON if unable to contact the MD and then said In this place everything is so confusing, I don't even know who the DON is. LVN A then said he was supposed to check the vital signs of CR #3 but he only checked the oxygen saturation and said RN D didn't really tell me anything about CR #3. We were supposed to do the eINTERAC change of condition documentation in the computer but I can't explain why I did not do it. I don't know why. I should had monitored any cardiac issues, blood pressure and heart rate due to her high potassium levels. I was overwhelmed. In an interview on [DATE] at 5:00 p.m. RN D, stated she was the charge nurse for CR #3 on [DATE] during the 2:00 p.m. to 10:00 p.m. shift and that during change of shift report CR #3 was sleepy and she asked about CR #3's oxygen saturation and the morning shift nurse told her it was around the 80's. She increased the oxygen to 4 liters and she re-checked the oxygen and was then 89 to 90%. RN D said during her shift, the laboratory collected blood from CR #3 that was ordered during the day shift. RN D then said LVN C never told her about the orders to transfer CR #3 to the hospital. RN D continued saying she spoke with the NP because the NP wanted to know the laboratory results for CR #3 but she did not receive any reports from the laboratory and she never knew the NP wanted CR #3 to go to the hospital. When asked about the order to increase [MEDICATION NAME] for CR #3 for nausea and vomiting, RN D stated she did not remember if CR #3 had any nausea that day. Continued interview on [DATE] at 5:15 p.m. RN D, said whenever a resident had a change in condition, there was an eINTERACT form to complete on the computer where the nurse writes the assessments and then said I did not check if someone had completed a change of condition form on CR #3. It should had been completed on the day shift on [DATE]. In a phone interview on [DATE] at 9:15 a.m. LVN B, stated LVN A left the building on [DATE] at around 3:30 a.m. and he told her everything was fine and that CR #3 did not have any issues. LVN B further said LVN A did not mention to her anything about the laboratory values of CR #3 but she knew the laboratory had called at 1:30 a.m. to report critical values because she was the one that got the call and then gave the message to LVN A. LVN B continued saying she also knew LVN A had paged the MD twice and she did not receive any MD calls for the rest of the shift. LVN B said she did not try calling the MD for CR #3's critical laboratory values and she did not do any vital signs for CR #3 either. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. The NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. NP then said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. NP continued saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory results and at that moment, ADON A told her CR #3 was still in the facility. The NP asked ADON A for CR #3's vital signs right away including oxygen saturation. Further interview at that time the NP, stated she was surprise to find out CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing. ADON A told her CR #3 was unresponsive. NP then said she did not understand why the nurses did not follow the orders and get the laboratory blood work STAT. She stated she gave STAT laboratory blood work orders and expected the results right away. When she did not hear anything during the NOC shift, she thought CR #3 was sent to hospital but decided to follow up with the facility the next morning. She even told them you guys are not following orders . In an interview on [DATE] at 3:52 p.m. the Administrator, stated STAT laboratory orders needed to be call immediately to the laboratory and the policy was for the laboratory to come draw the blood within 4 hours and within 1 to 2 hours to get the results back. The Administrator then said once the nurse gets the orders, the nurse will enter the order in the computer, Staff would then would follow up on the order. She further said the nurse who gets the laboratory results is the nurse who will follow up with the MD. The Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away. If the MD does not answer, then the medical director, the facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical directors answer, then the nurse is supposed to call the DON and the Administrator so we can help in getting hold of the doctors. Continued interview with the Administrator at that time, she stated whenever a resident has a change in condition, staff were upposed to complete an eINTERACT form in the computer. She said the interact form was a tool built in the computer system for changes in condition where it triggers on what would need to happen next. Administrator said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Further interview on [DATE] at 4:00 p.m. the Administrator, stated RN D told her on [DATE] at around 5:45 p.m. CR #3 had some abnormal vitals. RN D had talked to the MD or the NP and she was told orders were to monitor CR #3's oxygen saturation and if the oxygen level drop, to send CR #3 to the hospital. The Administrator said CR #3's vitals got better and CR #3 was improving. Everything got to looking good. The Administrator said RN D got the STAT laboratory orders for CR #3 on [DATE] at around 5:45 p.m. then the laboratory called with abnormal values at around 1:00 a.m. They tried to reach the MD, then I am foggy about it. They attempted to call the MD twice. They heard back from the MD 5 minutes before CR #3 coded. Staff gave CR #3 CPR and sent her to hospital. I believed CR#3 was even admitted to ICU before she died . CR #3 had been in the facility for one week, she was here for therapy. Continued interview with the Administrator on [DATE] at 4:09 p.m. she stated facility staff did not call her on [DATE] when they were unable to contact the MD for CR #3's critical laboratory values but believed the former DON was contacted. In a second interview on [DATE] at 4:45 p.m. LVN C, said on [DATE] the NP came to visit CR #3 in the morning and gave STAT laboratory blood work. LVN C said she was not sure how long they have to call the laboratory for STAT orders but she believed they had 4 hours to call the laboratory. LVN C further said she texted the NP on [DATE] regarding CR #3's condition because her oxygen saturations were on the 80's and when she got the text back from the NP, she went and told RN D. LVN C said the nurse who gets the order is the one responsible of inputting the order in the computer system. She did not do it because she was leaving to go home. She said she should have done it. She should have completed an eINTERACT assessment on CR #3 as well. Further interview with LVN C, she stated the first time she called the laboratory for STAT orders she only called for the urinalysis and the BNP (Beta Naturetic Peptide) because she misread the orders. Later during change of shift, she found out together with RN D she had omitted the STAT orders for BMP (basic metabolic panel) and RN D was to follow up with it. LVN C further said she did not notify the NP about the mistake in transcribing the orders to the laboratory requisition form. In a phone interview on [DATE] at 5:09 p.m. the laboratory, technician stated they received a call from the facility on [DATE] at 12:12 p.m. for STAT order request for urinalysis and the BNP (Beta Naturetic Peptide) for CR #3. On [DATE] at 5:06 p.m. they received another STAT order request for BMP for CR #3. Record review of http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm: revealed [MEDICAL CONDITION] means an abnormally elevated level of potassium in the blood. The normal potassium level in the blood isCmilliequivalents per liter (mEq/L). Potassium levels between 5.1 mEq/L to 6.0 mEq/L reflect mild [MEDICAL CONDITION]. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate [MEDICAL CONDITION], and levels above 7 mEq/L are severe [MEDICAL CONDITION]. Extremely high levels of potassium in the blood (severe [MEDICAL CONDITION]) can lead to [MEDICAL CONDITION] and death. Record review of the facility policy and procedure Change of condition reporting revised ,[DATE] revealed in part: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation If unable to contact attending physician or alternate physician timely, notify Medical Director for follow up to change in resident condition Follow-up. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy two (72) hours or until condition has stabilized .Comprehensive Care Plan will be updated/revised accordingly. Record review of the facility policy and procedure Laboratory Services revised ,[DATE] revealed in part: .2.- STAT orders are done as soon as possible within facility defined time frames . Record review of the facility policy and procedure Labs, abnormal revised ,[DATE] revealed in part: It is the policy of this facility to inform physician immediately to assist in diagnosing resident appropriately based on the Laboratory results. The RN Supervisor will care plan only the abnormal laboratory results which requires blood levels such as abnormal Potassium that could manifest complications in the short term care plan . Record review of the facility's undated protocol with title Labs revealed in part: It is everyone's responsibility to follow up on all labs in a timely manner. STAT labs.: You are expected to get your laboratory results within 4 hours. If you do not receive then in that time. Notify your ED/DON immediately. Once you receive your result notify MD of results. Call responsible party of laboratory results. Document in progress notes the laboratory results, MD and RP notification. The resident will then be in every shift documentation for 72 hours until resolved. If laboratory is abnormal you are required do the following: 1.- Notify the MD and RP. Place patient in follow up and chart on patient every shift. If you are unable to reach MD YOU MUST NOTIFY THE ED/DON IMMEDIATELY . Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health . An IJ was identified on [DATE] at 4:35 pm and the Administrator and DON were informed at that time. The POR was accepted on [DATE] at 3:38 pm. The POR included: Immediate action: 1.- Resident affected by this deficient practiced was discharged to hospital [DATE]. Laboratory audits to determine all residents affected by this deficient practice including: 1.- Laboratory audit performed by Clinical Resources to review all current laboratory orders at facility began on [DATE] with laboratory vendor - ACL laboratory and completed [DATE]. 2.- Medical records designee puling all orders for laboratory in PCC for all current residents for review, completed [DATE]. 3.-Review of all Telephone Orders by Clinical Resource to ensure no new orders for laboratory have been missed completed [DATE]. 4.- Clinical Resource completed audit of laboratory requisition book where laboratory orders are noted by laboratory after laboratory are drawn completed [DATE]. 5.- Charge Nurse designated to check laboratory website to pull results each shift beginning [DATE]. 6.- Any abnormal or critical laboratory to be communicated to physician/designee and RP on [DATE] (no critical laboratory were founds). 7.- DON to notify laboratory vendor to email STAT laboratory and / or abnormal results to DON and ADON's email in addition to calling the facility as part of new process beginning [DATE]. DON and ADON have email access ,[DATE]. 8.- All current resident's charts were audited for potential change of condition on [DATE] by Clinical Resource. No change of conditions were found. At time of this plan of removal, no other residents identified with laboratory issues. (12:00 p.m.). Education/In-service: 1.- In-service started [DATE] at 5:05 p.m. with licensed nurses including change of condition, using SBAR form, Stop and Watch, notifications, and Resident Behavior and Facility practice related to change of condition. In the event a licensed nurse cannot reach the attending physician, charge nurse will contact either DON or Administrator and Medical Director. The Medical Directors have provided the DON and Administrator with alternate methods to contact them rapidly. In-service started on [DATE] with all licensed nursing staff regarding each Medical Directors preferred methods of communication. 2.- As part of in-service new DON (start date [DATE]) introduced to staff and shared her contact information. 3.- DON and ADON will divide building each taking two hall to follow up daily on any change of condition, new laboratory orders, abnormal laboratory, fall, etcetera starting [DATE]. 4.- Change of Condition log will be utilized and review in daily stand up meeting with leadership IDT starting [DATE]. 5.- Licensed charge nurses were educated on [DATE] to follow up on each change of condition for 72 hours or until condition stable or resolved beginning [DATE]-17. 6.- Medical Directors notified of IJ and associated Plan of Removal. Dr. Palacios was notified via phone on [DATE] at 6:00 p.m. and Dr. Hanif was notified in person on [DATE] at 8:45 a.m. 7.- In-serviced CNA's on reporting change of condition and the Stop and Watch tool on [DATE]. Any staff not available for any in-service will be in-serviced before they are allowed to go on the floor to work a shift. Monitoring: RN corporate nurse resource has been assigned to facility to monitor plan of removal by: 1.- Daily monitoring of laboratory results by charge nurses on each shift beginning [DATE]. 2.- Daily review of change of condition log, and 72 hours follow up. 3.- Ongoing in-service on change of condition, notification, laboratory process. 4.- Daily QA analysis of admissions and readmissions including an updates to plan of care. 5.- QAPI committee to meet review Plan of removal daily until immediacy lifted, then weekly until compliance achieved. Monitoring: In an interview on [DATE] at 4:05 p.m. LVN C, stated she had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said that STAT laboratory orders needed to be called to the laboratory immediately. LVN C said whenever they get laboratory results, staff was supposed to call the MD, and if the MD was not available, to call the Medical Director. If the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN C continued saying they were supposed to check the fax machine and follow up with the laboratory every one hour on pending laboratory reports. LVN C further said she was also trained on follow MD orders timely and accurately. In an interview on [DATE] at 10:20 a.m. LVN G and LVN H, both stated they had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said STAT laboratory orders needed to be called to the laboratory immediately. LVN G said whenever they get laboratory results, staff was supposed to call the MD as soon as possible. If the MD was not available, to call the Medical Director and if the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN H continued saying training included information on following MD orders. In an interview on [DATE] at 10:30 a.m. LVN E, stated she had been trained on change of condition, assessments, vital signs and documentation including the SBAR tool in the computer system. She also said training included the Stop and Watch form staff would complete to report changes in condition to nurses. LVN E further said training included laboratory orders, follow up and immediate notification to the MD of any critical values and staff was made aware the chain of notification in case the MD was not able to be contacted that included the DON and Administrator. In an interview on [DATE] at 10:40 a.m. LVN F, stated he had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said STAT laboratory orders needed to be called to the laboratory immediately. LVN F then said whenever they get laboratory results, staff was supposed to call the MD as soon as possible, and if the MD was not available, to call the Medical Director. If the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN F continued saying training included information on following MD orders. In an interview on [DATE] at 1:00 p.m. CNA I, stated she had been trained on using the Stop and Watch tool to notify to the nurses any changes in condition of the residents. In an interview on [DATE] at 1:40 p.m. with CNA J, stated she was also trained on using the Stop and Watch tool for notification on any changes in condition she observed with any of the residents. In an interview on [DATE] at 1:52 p.m. LVN K, stated she had been trained on abnormal laboratory results and immediate MD notification. She then said the fax machine was supposed to be checked every one hour. She said if she could not get hold of the MD, she was supposed to call the Medical Director, the DON and the Administrator. She continued saying she was also trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs and documentation including the Stop and Watc

Based on observation, interview and record review, the facility failed to effectively train all employees on emergency and evacuation procedures in the event of an emergency that required evacuation for one of seven residents ( Resident #1) who was reviewed for emergency evacuations. -The facility failed to train employees working on the night shift on how to evacuate Resident #1 from her room. Resident #1 weighed 792 lbs and had an oversized bed which would not fit through the room door unless physically altered. Resident #1 felt scared when she was forgotten and left in her room during an actual tornado alert. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm, that is not immediate jeopardy due to facility requiring more time to train staff and monitor the plan of removal for effectiveness. This failure affected one resident at the facility (Resident #1) when she could not be evacuated from her room in case of and emergency situation and placed 87 other residents at risk of injury or death. Findings include: Intake # 6 and # 8 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1 admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on the unit and off the unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Record review of Resident #1's care plan initiated [DATE] revealed in part: -Focus: At risk for an ADL self care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Further record review revealed no information on her care plan related to the need of an oversize bed with interventions on how to maneuver her oversized bed in the event of an emergency that required evacuation. Record review of the facility's In-service education record dated [DATE] with title Resident #1's bed revealed training was given to only 11 facility staff members. Further record review revealed 9 staff members were from the 6:00 a.m. to 2:00 p.m. shift, 1 staff member was from the 2:00 p.m. to 10:00 p.m. shift and 1 staff member from the 10:00 p.m. to 6:00 a.m. shift. Record review of Resident #1's social progress notes dated [DATE] at 1:30 p.m. revealed in part: Spoke with Resident #1 and her family member and Resident #1 was very upset and frustrated and stated that she does not feel comfortable because during the tornado warning, she (Resident #1) was never brought out to the hallway. She stated she was told from the Administrator they would have to break down the bed to get it out of the room. Resident #1 stated staff just pulled the curtains closed during the storm. Resident #1 stated the Administrator told her a tornado would hit the 100 hall first if anything were to happen. (Resident #1 was on the 300 hallway). Resident #1 stated she found out that by law, all residents were to be pulled out into the hallway. Resident #1 also was very upset about being told by the Administrator the facility had the staff to address her needs. In an interview on [DATE] at 8:58 a.m. with Resident #1, she stated she did not feel safe at the facility because there had been a tornado warning few days ago and staff took all residents out to the hallways and she was left in her room. Resident #1 further said staff only closed her curtains and that she felt very afraid because she was not evacuated from her room like the other residents. Resident #1 continued saying she was not able to get up or walk on her own. Observation revealed the measurements of the width of Resident #1's bed was 52 inches (from side rail to side rail). The measurements of the width of Resident #1's room door was 44 inches. In an interview on [DATE] at 10:32 p.m. with CNA V, she stated that she was the aide taking care of Resident #1 and that it was her first time in the facility. She further said that she was told that Resident #1 required 6 people to do incontinent care and that the staff from 2:00 p.m. to 10:00 p.m. had just cleaned Resident #1. When asked if she was trained on how to evacuate Resident #1 out of her room in case of an emergency, CNA V stated No and then said I worked in another facility, I just came today to help them out. In an interview on [DATE] at 10:36 p.m. with Resident #1, she stated in order to move her bed out of the room, the side arm rests of the bed needed to come off. She further said few staff were trained during the day shift when she first got the bed delivered. She said the facility had not done further training on how to operate her bed to the rest of the staff. Further interview with Resident #1, she stated after the incident of the tornado warning when she was left on her room alone, she said the Administrator told her she was left on her room so she would not feel uncomfortable in the hallway. Resident #1 continued saying some staff told her on the day of the tornado warning they would come and get her out of the room if the tornado would really hit the building. At that time, Resident #1 stated If a tornado had really hit the building, I don't think they would had come back to get me. Forget it. They would had tried to save themselves. In an interview on [DATE] at 11:00 p.m. LVN B, stated there were 3 CNA's and 2 nurses for the night shift at the facility. She further said she was the charge nurse for Resident #1. When asked how she would evacuate Resident #1 from her room in case of an emergency, LVN B responded Resident #1's bed would not fit thru the door and to be honest, we don't have the staff. I don't know what we would do, I would call 911. We have raised the same question before because it's hard. I have not received any emergency training on Resident #1 and do not know how to maneuver her bed. I would not know what to do. Just call 911. In an interview on [DATE] at 11:05 p.m. LVN S, stated she was a full time nurse on the 10:00 p.m. to 6:00 a.m. shift and she had not received any training on how to evacuate Resident #1 from her room in case of an emergency. She said in case of a fire, she know the bed did not roll well. She said it took 6 to 7 people just to turn Resident #1 in bed, and they had 5 staff today working in the facility during the night shift. The bed was too big to get thru the door and she was not sure if we can take the bed apart. I don't know what we would do. In an interview on [DATE] at 11:13 p.m. with CNA U, stated at she was a full time CNA working on the night shift. She said she had not received any training on how to evacuate Resident #1 in case of an emergency and we would call the fire department and tell them to hurry up because we would not be able to evacuate her by ourselves. In an interview on [DATE] at 11:20 p.m. CNA T, stated she was a full time CNA working on the night shift and she had not received any training on how to evacuate Resident #1 out of her room in case of an emergency. She said I have no idea what we would do. The bed might not fit thru the door. There is not enough staff at night to lift her up with a sheet. We would just try to secure her in her room or try to lift her. We are strong. Continued interview with CNA T, she said I don't think we are equipped for Resident #1. We usually work 3 aides and 2 nurses at the night shift and it takes about 6 people to do care for her. In an interview on [DATE] at 9:38 a.m. the Administrator, stated around 6:45 a.m. sometime in January, the facility had to evacuate the residents due to the tornado warning and we got the residents to the hallway. Then Resident #1's family member came to me and told me Resident #1 was very nervous. I remembered before Resident #1 came to the facility, she told me not to make her feel like she was in a nursing home, so what we did, as to not to increase her anxiety, I decided to leave her on her room. We closed her blinds and pulled her curtains. For Resident #1's window to be destroyed by a tornado, the whole front of the building needed to be destroyed. If pressure would build inside the building, we would have to open Resident #1's window or we would have to ask Resident #1 if she would like to come out of the room. The tornado warning did not stop on that day until 8:30 a.m. Further interview with the Administrator at that time, she stated Resident #1's side rails would have to come off of the bed in order to be able to move the bed out of the room. She then said the Therapy Director and Central Supply person were trained on how to break the bed down in an emergency situation. The Administrator continued saying she knew theTherapy Director and Central Supply person trained some staff but she did not know who and said she was going to get the training records for the surveyor to review. The Administrator said the disaster plan in-services were done annually oin the month of April and upon new hire orientation. In an interview on [DATE] at 9:58 a.m. with Central Supply, she stated she got trained by the bed company representative on how to operate Resident #1's bed but she did not give any training to anyone else and further said the staff who was here at the facility at that time were trained on how to operate Resident #1's bed. In an interview on [DATE] at 10:05 a.m. the Therapy Director, stated the day when Resident #1 had her bed delivered, they were instructed by the bed company representative on how to operate the bed. He then said there was other staff present but he did not remember who they were or the exact date. The Therapy Director continued saying he did train some of the CNA's from the day shift, whoever was around, on how to manipulate Resident #1's side rails and what to do in case of a code emergency but he was not sure if nursing had additional trainings with the rest of the staff on how to maneuver Resident #1's bed. In a second interview on [DATE] at 11:00 a.m. with the Administrator, when asked if the night shift had any training on emergency procedures on Resident #1. On how to evacuate her in an emergency, how to maneuver her bed in case of an emergency, the Administrator responded that's what I had been looking for because the training we had was mostly for the day shift. It was supposed to be done but not sure if it was done. It was supposed to happen but I can't find the training records, but in the worst scenario, we will come tonight to train them. When informed that nobody from the night shift knew how to operate Resident #1's bed or how to evacuate Resident #1 in case of an emergency, the Administrator said we will come tonight to train them. Record review of - NWS Houston (@NWSHouston) [DATE] Tornado warnings dotted counties along the Gulf Coast beginning late Tuesday night, reaching and including the metro Houston area during the pre-dawn hours of Wednesday. Record review of the facility's Disaster Risk assessment dated [DATE] revealed that the facility was somewhat likely for the following disasters: Hurricane, tornado/severe storms, flooding, lightning and extreme heat. Record review of the facility's Internal/External disaster plan revised on [DATE] reads in part .Tornado/Severe Storm: If notice is given, take the following steps: 1.- turn on hallway lights, 2.- Close all drapes, blinds, 3.- Evacuate all rooms to the immediate hallways, 4.- Protect all patients 5.- Do not open doors or windows Record review of the facility's document with title Evacuation of Patients in Bari Rehab Beds revealed in part In the event that it should become necessary to evacuate a bed-bound patient in a Bari-Rehab bed, please follow the instructions on how to retract the bed Instruction for expanding/retracting bed deck . emergency hand crank . Side rail instructions .adjusting side rail trouble shooting instructions . An IJ was identified on [DATE] at 11:56 a.m. and the Administrator, the Clinical Resource Nurse and the Executive Market Director were informed at that time. The POR was accepted on [DATE] at 4:00 pm. The POR included: Immediate Action: 1.- We are actively seeking to discharge the resident from the bariatric resident from the facility to a facility that can better meet her needs. 2.- On [DATE], we tested and ensured that the bariatric bed can be easily be removed from the room in the event of an emergency evacuation. 3.- Charge nurse will be responsible for directing staff to evacuate such identified patients according to the emergency preparedness plan. Education on the emergency preparedness plan began [DATE]. The process for breaking down the bariatric bed for removal from the room was added to the disaster plan on [DATE]. The process is detailed with the attached guide, and the staff are to follow the normal evacuation procedures, using the set routes and evacuation order, per the disaster plan. 4.- The Director of Therapy or designee will be in-service all staff with return demonstration on the proper procedures on how to breakdown facility's bariatric beds according to manufacturer's instructions, beginning [DATE]. 5.- Staffing coordinator or designee is reviewing schedule with DON or designee every shift to ensure adequate staff to meet resident needs, including emergency situations. 6.-The above training will begin on [DATE] and will continue until all nursing staff have been in-serviced. Staff will not be allowed to resume resident care responsibilities or other duties until trained. 7.- Facility is voluntarily stopping admissions effective [DATE] until substantial compliance is achieved. The Administrator / Designee will ensure the above training is completed as planned. Two-four staff are required to breakdown and push the bed. Evacuation routes areas listed in the disaster plan. Staff is trained annually and upon orientation on the disaster plan. The number of staff on the night shift was assessed on [DATE] to ensure adequate staffing in case of an emergency evacuation by the Administrator. Administrator has signed a contract with an agency to ensure that we have two additional staff members on the night shift beginning tonight, [DATE], making it 7 staff members based on the current census. Facility Human Resource designee is actively hiring and orientating new staff members for the 10 to 6 a.m. shift to ensure resident needs are met and that resident safety is ensured in the event of an evacuation route would take 20 to 30 minutes depending upon if the evacuation needs to be to another compartment or out of the building. The building is designed and broken into fire compartments so that a total evacuation would not be needed unless the entire building is engulfed in flames. Beginning [DATE], all new admissions will be screened prior to admission by DON/Designee to determine if they are bed-bound bariatric patients who would need the above procedures. All bariatric patients needing the above procedures will have their care plans updated by [DATE]. As of this time, there are no other bariatric residents requiring special evacuation procedures. DON/Designee will monitor any change in residents' transfer status at weekly Standard of Care meeting beginning [DATE]. All circumstances requiring evacuation as per the Fire and Disaster Manual will trigger the above procedures. Continue to look for alternate placement for patient where needs can be better met. Monitoring: In an interview on [DATE] at 10:20 a.m. with LVN G and LVN H, both stated they had been trained on the bed operation for Resident #1 and how to evacuate her in case of an emergency. In an interview on [DATE] at 10:30 a.m. LVN E, stated she had been trained on Emergency procedures with Resident #1 and how to maneuver her bed in case of evacuation emergency. In an interview on [DATE] at 10:40 a.m. LVN F, stated he had been trained on how to operate Resident #1's bed, how to remove the side rails in an event of evacuation including for CPR emergencies. In an interview on [DATE] at 1:00 p.m. CNA I, stated she had been trained on Emergency procedures for Resident #1 and how to maneuver her bed including how to remove the side rails in an event of evacuation emergency. She also said they were trained on how to prepare Resident #1's bed if she needed CPR. In an interview on [DATE] at 1:40 p.m. CNA J, stated she was also trained on emergency procedures for Resident #1's bed. CNA J also said she felt confident on how to maneuver Resident #1's bed for evacuation and CPR. In an interview on [DATE] at 1:52 p.m. LVN K, stated she had been trained on how to break Resident #1's bed in an event of evacuation to wheel the bed out of the room and how to deflate her mattress for CPR. In an interview on [DATE] at 2:00 p.m. CNA L and CNA M, both said they attended training regarding how to operate Resident #1's bed including how to remove the side rails to make sure the bed can be evacuated out of the room and how to deflate the bed for CPR. In an interview on [DATE] at 2:10 p.m. CNA N, stated she had received training on emergency procedure for Resident #1 and how to maneuver her bed. In an interview on [DATE] at 2:35 p.m. CNA O, stated she was also trained on how to make Resident #1's bed smaller to make it fit thru the door in an event of an emergency. She also said training included for CPR and how to operate the bed without electricity. In an interview on [DATE] at 3:05 P.m. LVN P, stated she received training on [DATE] on how to maneuver Resident #1's bed and emergency procedures for Resident #1 including evacuation. In an interview on [DATE] at 4:20 p.m. CNA Q stated she was also trained on how to operate Resident #1's bed and what to do in an event of an emergency including evacuation. In an interview on [DATE] at 4:25 p.m. RN R, stated she had been trained on how to break down Resident #1's bed in an event of evacuation to wheel the bed out of the room and how to deflate her mattress for CPR. In a phone interview on [DATE] at 4:30 p.m. LVN A, stated he had been trained on how to maneuver Resident #1's bed, how to move the bed out of the room and other emergency techniques including CPR and what to do with the bed if no electricity. He also said he was working on the night shift on [DATE] with Resident #1 and he already knew how to direct the staff in case of an emergency. In a phone interview on [DATE] at 4:40 p.m. LVN S, stated she was trained last night on emergency procedures with Resident #1 including evacuation and how to work Resident #1's bed, including CPR and how to manually operate the bed if no electricity. In a phone interview on [DATE] at 4:58 p.m. CNA T, stated she was also trained on how to operate Resident #1's bed in an event of evacuation. She said she knew what to do now in an event of an emergency and how to evacuate Resident #1. In an interview on [DATE] at 5:03 p.m. CNA U, stated she was trained on emergency procedures with Resident #1 and she was working with Resident #1 on the night shift as well (was working double on [DATE]) and she felt confident on how to evacuate and help Resident #1 in an event of an emergency. CNA U then said training included how to operate Resident #1's bed and how to evacuate her out of the room during any emergency. Further record review of facility In-service Training Attendance record dated [DATE] revealed nursing staff were educated regarding how to operate Resident #1's bed, how to remove the side rails in an event of evacuation and CPR emergencies. Training also included other emergencies such as no electricity and how to manually operate Resident #1's bed. Training included returned demonstration. Attached were the signatures of staff attending the trainings. The Administrator was informed on [DATE], at 5:20 p.m. the IJ was lowered; however, the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm, that is not immediate jeopardy due to facility needing more time to train the staff. Administrator said there was only one resident in the facility who required a bariatric bed.

Based on interview and record review, the facility failed to consult with the physician when there was a significant change in the physical, mental, or psychosocial status of one of seven residents (CR #3) who were reviewed for physician's consults due to a change in condition as evidenced by: -The facility failed to draw CR #3's STAT BMP for 10.5 hours. -The facility failed to consult with CR #3's MD the critical Potassium blood level for 5.25 hours. CR #3 was found unresponsive on [DATE] at 7:11 a.m. and was pronounced dead 26 minutes after transferred to the hospital's emergency room . An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility required more time to train staff and monitor the plan of removal for effectiveness. This failure affected one former resident (CR #3) and placed 23 residents on the 200 hallway in the facility at risk for their physicians not being consulted when they had a change in condition which could result in a delay in medical treatment, the development of new or worsening medical conditions, diminished quality of life, hospitalization and death. Findings included: Intake # 4 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female. She was admitted to the facility on [DATE] with following Diagnoses: [REDACTED]. CR #3 was found unresponsive and was transferred to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of CR #3's 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She required supervision for walking in the room, in the corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: . [AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed the BMP test, which was also ordered by NP, was omitted in the requisition order. Record review of CR #3's progress/nurses notes revealed in part: -[DATE] at 4:16 p.m. written by LVN C NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part: -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 1:46 a.m. written by LVN A Potassium 6.2. Dr. A informed. Awaiting call back. -[DATE] at 2:30 a.m. by LVN A (CR #3) lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. (P) paged of Critical Potassium levels of 6.2. Further record review of the progress/nurses notes revealed no further attempts to contact the MD concerning the critical Potassium levels. No vital sign assessments or any further assessments documented during the night shift. Record review of CR #3's progress/nurses notes revealed in part: -[DATE] at 2:14 p.m. written by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx. 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to (CR #3's) to check oxygen saturation. Upon entering room (CR #3's) eyes were closed and she was non-responsive to verbal and tactile stimuli. (CR #3) was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. (CR #3) was last observed sleeping in bed at approx. 6:30 A.M. Notified emergency contact at approx. 7:40 a.m. that (CR #3) was observed unresponsive and that she should go to the hospital where (CR #3) was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full (cardiac) arrest. -At 8:25 a.m. preceding the arrest, (CR #3) was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: (CR #3) has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. (CR #3) was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A then said that she arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She said LVN B told her CR #3 had a critical potassium level during the night shift and that the MD had not returned the call yet. LVN B also reported that LVN A, who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me that staff had not follow up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room at that moment still with the phone in my hands and the NP on the line, CR #3 was found not breathing, and no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview with ADON A at that time, she stated the night shift tried to call the MD but the MD was not reached. ADON A said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said that the other medical director called the facility during the night shift on [DATE] for another resident and that LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. LVN C, stated she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. She said she called the NP to notify her that CR #3's oxygen levels were low and the NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C said it was around 3:50 p.m. on [DATE] when she got the order from the NP. LVN C continued saying she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via a text message and the staff would usually call, page or text the MD or the NP. When asked to see the text message she said she had erased the text message from the NP. Continued phone interview with LVN C at 4:25 P.M. on [DATE], she stated whenever a resident had a change in condition, the staff was to complete a change in condition form in the computer that was like an SBAR when they would write their assessments, MD and RP notifications. She then said that she did not complete that assessment on CR #3. In a phone interview on [DATE] at 4:42 p.m. LVN A, he stated he was the charge nurse for CR #3 from 10:00 p.m. on [DATE] to around 3:00 a.m. on [DATE] and further said I wasn't supposed to even be there on that day and continued saying I did not get any report regarding any change in condition regarding (CR #3). I knew about the critical values of her laboratory results, I paged the MD twice and did not get any response. Then I left at around 3:00 a.m. and gave report to LVN B so she could follow up and pass the information to the day shift. LVN C then said the other medical director called the facility on [DATE] regarding another resident and he did not notify him about CR #3 because he was very busy with this other resident who had a PICC line and then said but I heard that the day shift was able to get hold of the NP. Further interview with LVN A at 4:42 p.m. on [DATE], he stated critical laboratory values was a change in condition and he was supposed to contact the MD or the DON if unable to contact the MD and then said In this place everything is so confusing. I don't even know who the DON is. LVN A then said that he was supposed to check the vital signs of CR #3 but he only checked the oxygen saturation and said RN D didn't really tell me anything about CR #3. We were supposed to do the eINTERAC change of condition documentation in the computer but I can't explain why I did not do it. I don't know why. I should had monitored any cardiac issues, blood pressure and heart rate due to her high potassium levels. I was overwhelmed. In an interview on [DATE] at 5:00 p.m. RN D, stated she was the charge nurse for CR #3 on [DATE] during the 2:00 p.m. to 10:00 p.m. shift and then said during the change of shift report CR #3 was sleepy. When she asked about CR #3's oxygen saturation, the morning shift nurse told her it was around the 80's. The nurse had increased the oxygen to 4 liters, had re-checked the oxygen and the it was in the 89 to 90%. RN D said during her shift, the laboratory collected blood from CR #3 that was ordered during the day shift. RN D said LVN C never told her about any or orders to transfer CR #3 to the hospital. RN D said she spoke with the NP because the NP wanted to know the laboratory results for CR #3 but she had not received any reports from the laboratory and she never knew the NP ordered CR #3 to go to the hospital. Continued interview on [DATE] at 5:15 p.m. RN D, said whenever a resident had a change in condition, there was an eINTERACT form to complete on the computer where the nurse writes the assessments. She said I did not check if someone had completed a change of condition form on CR #3. It should had been completed on the day shift on [DATE]. In a phone interview on [DATE] at 9:15 a.m. LVN B, stated LVN A left the building on [DATE] at around 3:30 a.m. and he told her everything was fine and that CR #3 did not have any issues. LVN B further said LVN A did not mention to her anything about the laboratory values of CR #3 but she knew the laboratory had called at 1:30 a.m. to report critical values because she was the one who got the call and then gave the message to LVN A. LVN B continued saying she also knew LVN A had paged the MD twice and she did not receive any MD calls for the rest of the shift. LVN B then said she did not try calling the MD for CR #3's critical laboratory values and she did not do any vital signs for CR #3 either. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. The NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. The NP said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. The NP continued by saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory result. She said it was at that moment, ADON A told her CR #3 was still in the facility. The NP then asked ADON A for CR #3's vital signs right away including her oxygen saturation. Further interview at that time the NP, stated she was surprise to find out CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing. It was at that time ADON A told her CR #3 was unresponsive. The NP then said I don't understand why the nurses did not follow the orders and request for the laboratory blood work STAT. I called them the next morning at 7:00 a.m. and inquired about CR #3 status, what if I did not call?. I gave STAT laboratory blood work orders, I expected the results right away. When I did not hear anything during the night shift, I thought CR #3 was sent to hospital but I decided to follow up with the facility the next morning. I even told them, you guys are not following orders . In an interview on [DATE] at 3:52 p.m. the Administrator, stated that STAT laboratory orders needed to be called immediately to the laboratory and the policy was for the laboratory to come and draw the blood within 4 hours and they had 1 to 2 hours to get the results back to the facility. The Administrator then said once the nurse gets the orders, the nurse would enter the order in the computer and then would follow up on the order. She further said the nurse who received the laboratory results was the nurse who would follow up with the MD. The Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away. If the MD does not answer then one of the medical directors would be called. The facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical director's answer, then the nurse was to call the DON and the Administrator so we could help in getting a hold of the doctors. Continued interview with the Administrator at that time, she stated whenever a resident had a change in condition, the staff were supposed to complete an eINTERACT form in the computer. She further said the interact form was a tool built in the computer system for changes in condition where it would trigger on what would need to happened. The Administrator further said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Further interview on [DATE] at 4:00 p.m. the Administrator, stated RN D told her on [DATE] at around 5:45 p.m. CR #3 had some abnormal vitals and that RN D had talked to the MD or the NP. She was told orders were to monitor CR #3's oxygen saturation and if the oxygen dropped, to send CR #3 to the hospital. The Administrator further said CR #3's vitals got better and CR #3 was improving and everything got to looking good. The Administrator then said RN D got the STAT laboratory orders for CR #3 on [DATE] at around 5:45 p.m. then the laboratory called with abnormal values at around 1:00 a.m. They tried to reach the MD, then I am foggy about it. They attempted to call the MD twice. They heard back from the MD 5 minutes before CR #3 coded. Staff gave CR #3 CPR and sent her to hospital. I believed CR#3 was even admitted to ICU before she died . CR #3 had been in the facility for one week. She was here for therapy. Continued interview with the Administrator on [DATE] at 4:09 p.m. she stated that facility staff did not call her on [DATE] when they were unable to contact the MD for CR #3's critical laboratory values but believed the former DON was contacted. In a second interview on [DATE] at 4:45 p.m. with LVN C, she said on [DATE] the NP came to visit CR #3 in the morning and gave STAT laboratory blood work. LVN C said she was not sure how long they have to call the laboratory for STAT orders but she believed they had 4 hours to call the laboratory. LVN C further said she texted the NP on [DATE] regarding CR #3's condition because her oxygen saturations were in the 80's and when she got the text back from the NP, she went and told RN D. LVN C said The nurse who gets the order is the one responsible of inputting the order on the computer system. I did not do it because I was leaving to my home. I should had done it. I should had completed an eINTERACT assessment on CR #3 as well. Further interview with LVN C, she stated the first time she called the laboratory for STAT orders she only called for the urinalysis and the BNP (Beta Naturetic Peptide) because she misread the orders and later during change of shift, she found out together with RN D that she had omitted the STAT orders for BMP (basic metabolic panel) and RN D followed up with it. LVN C further said she did not notify the NP about the mistake in transcribing orders to the laboratory requisition form. In a phone interview on [DATE] at 5:09 p.m. the laboratory, technician stated they received a call from the facility on [DATE] at 12:12 p.m. for STAT order request for urinalysis and the BNP (Beta Naturetic Peptide) for CR #3 and on [DATE] at 5:06 p.m. they received another STAT order request for BMP for CR #3. Record review of http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm: revealed [MEDICAL CONDITION] means an abnormally elevated level of potassium in the blood. The normal potassium level in the blood isCmilliequivalents per liter (mEq/L). Potassium levels between 5.1 mEq/L to 6.0 mEq/L reflect mild [MEDICAL CONDITION]. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate [MEDICAL CONDITION], and levels above 7 mEq/L are severe [MEDICAL CONDITION]. Extremely high levels of potassium in the blood (severe [MEDICAL CONDITION]) can lead to [MEDICAL CONDITION] and death. Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health . Record review of the facility policy and procedure Change of condition reporting revised ,[DATE] revealed in part: .It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation . If unable to contact attending physician or alternate physician timely, notify Medical Director for follow up to change in resident condition Follow-up. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy two (72) hours or until condition has stabilized .Comprehensive Care Plan will be updated/revised accordingly. Record review of the facility policy and procedure Laboratory Services revised ,[DATE] revealed in part: .2- STAT orders are done as soon as possible within facility defined time frames . Record review of the facility policy and procedure Labs, abnormal revised ,[DATE] revealed in part: It is the policy of this facility to inform physician immediately to assist in diagnosing resident appropriately based on the Laboratory results. The RN Supervisor will care plan only the abnormal laboratory results which requires blood levels such as abnormal Potassium that could manifest complications in the short term care plan . Record review of the facility's undated protocol with title Labs revealed in part: It is everyone's responsibility to follow up on all labs in a timely manner. STAT labs: You are expected to get your laboratory results within 4 hours. If you do not receive then in that time. Notify your ED/DON immediately. Once you receive your result notify MD of results. Call responsible party of laboratory results. Document in progress notes the laboratory results, MD and RP notification. The resident will then be in every shift documentation for 72 hours until resolved. If laboratory is abnormal you are required do the following: 1- Notify the MD and RP. Place patient in follow up and chart on patient every shift. If you are unable to reach MD YOU MUST NOTIFY THE ED/DON IMMEDIATELY . An IJ was identified on [DATE] at 4:35 pm and the Administrator and DON were informed at that time. The POR was accepted on [DATE] at 3:38 pm. The POR included: Immediate action: 1- Resident affected by this deficient practiced was discharged to hospital [DATE]. Laboratory audits to determine all residents affected by this deficient practice including: 1.- Laboratory audit performed by Clinical Resources to review all current laboratory orders at facility began on [DATE] with laboratory vendor - ACL laboratory and completed [DATE]. 2.- Medical records designee pulling all orders for laboratory in PCC for all current residents for review, completed [DATE]. 3.-Review of all Telephone Orders by Clinical Resource Nurse to ensure no new orders for laboratory have been missed completed [DATE]. 4.- Clinical Resource Nurse completed audit of laboratory requisition book where laboratory orders are noted by laboratory after laboratory are drawn completed [DATE]. 5.- Charge Nurse designated to check laboratory website to pull results each shift beginning [DATE]. 6.- Any abnormal or critical laboratory to be communicated to physician/designee and RP on [DATE] (no critical laboratory were founds). 7.- DON to notify laboratory vendor to email STAT laboratory and / or abnormal results to DON and ADON's email in addition to calling the facility as part of new process beginning [DATE]. DON and ADON have email access ,[DATE]. 8.- All current resident's charts were audited for potential change of condition on [DATE] by Clinical Resource Nurse. No change of conditions were found. At time of this plan of removal, no other residents identified with laboratory issues. (12:00 p.m.). Education/In-service: 1.- In-service started [DATE] at 5:05 p.m. with licensed nurses including change of condition, using SBAR form, Stop and Watch, notifications, and Resident Behavior and Facility practice related to change of condition. In the event a licensed nurse cannot reach the attending physician, charge nurse will contact either DON or Administrator and Medical Director. The Medical Directors have provided the DON and Administrator with alternate methods to contact them rapidly. In-service started on [DATE] with all licensed nursing staff regarding each Medical Directors preferred methods of communication. 2.- As part of in-service new DON (start date [DATE]) introduced to staff and shared her contact information. 3.- DON and ADON will divide building each taking two hall to follow up daily on any change of condition, new laboratory orders, abnormal laboratory, fall, etcetera starting [DATE]. 4.- Change of Condition log will be utilized and review in daily stand up meeting with leadership IDT starting [DATE]. 5.- Licensed charge nurses were educated on [DATE] to follow up on each change of condition for 72 hours or until condition stable or resolved beginning [DATE]-17. 6.- Medical Directors notified of IJ and associated Plan of Removal. Dr. A was notified via phone on [DATE] at 6:00 p.m. and Dr. B was notified in person on [DATE] at 8:45 a.m. 7.- In-serviced CNA's on reporting change of condition and the Stop and Watch tool on [DATE]. Any staff not available for any in-service will be in-serviced before they are allowed to go on the floor to work a shift. Monitoring: RN corporate nurse resource has been assigned to facility to monitor plan of removal by: 1.- Daily monitoring of laboratory results by charge nurses on each shift beginning [DATE]. 2.- Daily review of change of condition log, and 72 hours follow up. 3.- Ongoing in-service on change of condition, notification, laboratory process. 4.- Daily QA analysis of admissions and readmissions including an updates to plan of care. 5.- QAPI committee to meet review Plan of removal daily until immediacy lifted, then weekly until compliance achieved. Monitoring of the plan: In an interview on [DATE] at 4:05 p.m. LVN C, stated she had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said STAT laboratory orders needed to be called to the laboratory immediately. LVN C then said whenever they get laboratory results, staff was supposed to call the MD, and if the MD was not available, to call the Medical Director and if the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN C continued saying they were supposed to check the fax machine and follow up with the laboratory every one hour on pending laboratory reports. LVN C further said she was also trained on follow MD orders timely and accurately. In an interview on [DATE] at 10:20 a.m. with LVN G and LVN H, both stated they had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said STAT laboratory orders needed to be called to the laboratory immediately. LVN G then said whenever they get laboratory results, staff was to call the MD as soon as possible, and if the MD was not available, to call the Medical Director. If the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN H continued saying training included information on following MD orders. In an interview on [DATE] at 10:30 a.m. LVN E, stated she had been trained on change of condition, assessments, vital signs and documentation including the SBAR tool in the computer system. She also said training included the Stop and Watch form staff would complete to report changes in condition to nurses. LVN E further said training included laboratory orders, follow up and immediate notification to the MD of any critical values. The staff was made aware the chain of notification in case the MD was not able to be contacted that included the DON and Administrator. In an interview on [DATE] at 10:40 a.m. LVN F, stated he had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports. He said STAT laboratory orders needed to be called to the laboratory immediately. LVN F then said whenever they get laboratory results, staff was supposed to call the MD as soon as possible, and if the MD was not available, to call the Medical Director. If the Medical Director was not available the staff was to call the DON and the Administrator. LVN F continued saying training included information on following MD orders. In an interview on [DATE] at 1:00 p.m. CNA I, stated she had been trained on using the Stop and Watch tool to notify to the nurses of any changes in condition of the residents. In an interview on [DATE] at 1:40 p.m. CNA J, stated she was trained on using the Stop and Watch tool for notification on any changes in condition she observed with any of the residents. In an interview on [DATE] at 1:52 p.m. LVN K, stated she had been trained on abnormal laboratory results and immediate MD notification. She said the fax machine was supposed to be checked every one hour. She said if she could not get hold of the MD, she was supposed to call the Medical Director, the DON and the Administrator. She continued saying she was also trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs and documentation including the Stop and Watch tool. In an interview on [DATE] at 2:00 p.m. CNA L and CNA M, both said they attended training regarding changes in condition and notification to the licensed nurse. Both said they were introduced to the Stop and Watch tool to report any changes in condition they observed to any of their residents. In an interview on [DATE] at 2:10 p.m. CNA N, stated she had received training on reporting changes in condition and the completion of the Stop and Watch form they were supposed to give to the nurses for any changes in condition on the residents. In an interview on [DATE] at 2:35 p.m. CNA O, stated she was also trained on using the Stop and Watch tool for notification on any changes in condition she observed with any of the residents. In an interview on [DATE] at 3:05 P.m. LVN P, stated she had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports. She said STAT laboratory orders needed to be called to the laboratory immediately. LVN P then said whenever they get laboratory results, staff was supposed to call the MD as soon as possible, and if the MD was not available, to call the Medical Director. If the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN P continued saying that training included information on following MD orders. In an interview on [DATE] at 4:20 p.m. CNA Q stated she was also trained on using the Stop and Watch tool for notification on any changes in condition she observed with any of the residents. In an interview on [DATE] at 4:25 p.m. RN R, stated she had been trained on abnormal laboratory results and immediate MD notification. She then said the fax machine w

Based on interview and record review the facility failed to provided care and services according to the comprehensive assessment and physician's orders for one of seven residents on hall 200 (CR #3) who were reviewed for care provided according to physician's orders -The facility failed to order STAT laboratory tests for CR #3. Timely. CR#3's BMP (Basic Metabolic Panel) STAT lab test was not ordered by facility staff for 10 ½ hours after the order was received from the NP (Nurse Practitioner). The resident had a critical Potassium laboratory value. CR #3 was found unresponsive 5.5 hours after the laboratory called the facility with the critical result Potassium level and she was pronounced dead 26 minutes after arrival to the emergency room . -The facility failed to transfer CR #3 to the hospital as ordered by the NP for almost 14 hours. CR #3 was found unresponsive at 7:11 am on [DATE], was transferred to the hospital where she was pronounced dead 26 minutes later. An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one (CR #3) and placed 23 residents at the facility at risk of having a delay in medical intervention or death due to staff not providing care per the physician's orders. Findings Included: Intake # 4 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #3 was found unresponsive and was sent to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of the 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfer, dressing, toileting and personal hygiene and supervision for walking in room and in corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: [AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed that BMP test was omitted on the requisition order. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 3:15 p.m. Late entry by LVN C .CR #3 went to therapy and therapist checked oxygen saturation and read 78%. Checked CR #3's oxygen saturation upon returning to room and oxygen saturation read 82%. Immediately placed CR #3 on oxygen at 2 liters. Oxygen continued to rise to 89%. Vital signs blood pressure ,[DATE], pulse 71, temperature 98.4 and respirations 15 - 16 breaths per minute with no labored breathing. Contacted NP with results on low oxygen and informed her the oxygen was rising and asked if CR #3 could go out to hospital. Informed oncoming nurse . -[DATE] at 4:16 p.m. by LVN C .NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . -[DATE] at 4:20 p.m. by LVN C NP called and informed of oxygen saturation . (NP) stated that we could send CR #3 out to hospital. Informed nurse on duty of decision . Record review of CR #3's electronic vital signs record revealed in part: -[DATE] at 4:42 p.m. Blood pressure ,[DATE] and pulse 64 beats per minute. Further record review revealed no further vitals sign assessments for CR #3. Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). This requisition was for the STAT test ordered at 9:30 am by the NP that had been omitted from the first lab requisition order. Further record review of CR #3's progress/nurses notes revealed in part: -[DATE] at 7:57 p.m. by RN D Given order by NP to increase CR #3's [MEDICATION NAME] to 8 mg by mouth every 4 hours as needed for nausea which was entered into the computer and faxed to pharmacy . Record review of CR #3's electronic MAR indicated [REDACTED] Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part; -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Continued record review of CR #3's progress/nurses notes revealed in part: -[DATE] at 1:46 a.m. by LVN A Potassium 6.2. Dr. A informed. Awaiting call back. -[DATE] at 2:30 a.m. by LVN A CR #3 lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. A paged of Critical Potassium levels of 6.2. Further record review of the progress/nurses notes revealed no further attempts to contact the MD for the critical Potassium levels, no vital sign assessments or any further assessments during the night shift. Record review of CR #3's progress/nurses notes revealed in part: -[DATE] at 2:14 p.m. by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx. 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to CR #3's to check oxygen saturation. Upon entering room CR #3's eyes were closed and she was non-responsive to verbal and tactile stimuli. CR #3 was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. CR #3 was last observed sleeping in bed at approx. 6:30 A.M. Notified emergency contact at approx. 7:40 a.m. CR #3 was observed unresponsive and she should go to the hospital where CR #3 was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full (caridac) arrest. -At 8:25 a.m. preceding the arrest, CR #3 was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: CR #3 has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. CR #3 was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was at that time she saw CR#3 sleeping. She said LVN B told her CR #3 had critical potassium levels during the night shift and the MD had not returned the call yet. LVN A who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me staff had not follow up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room still with the phone in my hands and the NP on the line, CR #3 was found not breathing and with no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview the ADON A at that time, stated the night shift tried to call the MD but the MD was not reach. ADON A then said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said the other medical director called the facility during the night shift on [DATE] for another resident and LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. LVN C, stated she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. and she called the NP to notify her CR #3 oxygen levels were low and the NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C then said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C then said it was around 3:50 p.m. on [DATE] when she got the order. LVN C continued she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via text message and the staff would usually call, page or text the MD or the NP. When asked if text could be reviewed she said that she had erased the text message from the NP. Continued phone interview LVN C, stated whenever a resident had a change in condition, the staff was supposed to complete a change in condition form in the computer that was like an SBAR when they would write their assessments, MD and RP notifications and she did not complete that assessment on CR #3. In a phone interview on [DATE] at 4:42 p.m. LVN A, he stated he was the charge nurse for CR #3 from 10:00 p.m. on [DATE] to at around 3:00 a.m. on [DATE] and further said I wasn't supposed to even being there on that day and I did not get any report regarding any change in condition regarding CR #3. I knew about the critical values of her laboratory results, I paged the MD twice and did not get any respond. Then I left at around 3:00 a.m. and gave report to LVN B so she could follow up and pass the information to the day shift. LVN A said the other medical director called the facility on [DATE] regarding another resident and he did not notify him about CR #3 because he was very busy with this other resident who had a PICC line and said but I heard that the day shift was able to get hold of the NP. Further in the same interview LVN A stated critical laboratory values was a change in condition and he was supposed to contact the MD or the DON if unable to contact the MD and then said In this place everything is so confusing, I don't even know who the DON is. LVN A then said he was supposed to check the vital signs of CR #3 but he only checked the oxygen saturation and said RN D didn't really tell me anything about CR #3. We were supposed to do the eINTERAC change of condition documentation in the computer but I can't explain why I did not do it. I don't know why. I should had monitored any cardiac issues, blood pressure and heart rate due to her high potassium levels. I was overwhelmed. In an interview on [DATE] at 5:00 p.m. RN D, stated she was the charge nurse for CR #3 on [DATE] during the 2:00 p.m. to 10:00 p.m. shift and that during change of shift report CR #3 was sleepy and she asked about CR #3's oxygen saturation and the morning shift nurse told her it was around the 80's. She increased the oxygen to 4 liters and she re-checked the oxygen and was then 89 to 90%. RN D said during her shift, the laboratory collected blood from CR #3 that was ordered during the day shift. RN D then said LVN C never told her about the orders to transfer CR #3 to the hospital. RN D continued saying she spoke with the NP because the NP wanted to know the laboratory results for CR #3 but she did not receive any reports from the laboratory and she never knew the NP wanted CR #3 to go to the hospital. When asked about the order to increase [MEDICATION NAME] for CR #3 for nausea and vomiting, RN D stated she did not remember if CR #3 had any nausea that day. Continued interview on [DATE] at 5:15 p.m. RN D, said whenever a resident had a change in condition, there was an eINTERACT form to complete on the computer where the nurse writes the assessments and then said I did not check if someone had completed a change of condition form on CR #3. It should had been completed on the day shift on [DATE]. In a phone interview on [DATE] at 9:15 a.m. LVN B, stated LVN A left the building on [DATE] at around 3:30 a.m. and he told her everything was fine and that CR #3 did not have any issues. LVN B further said LVN A did not mention to her anything about the laboratory values of CR #3 but she knew the laboratory had called at 1:30 a.m. to report critical values because she was the one that got the call and then gave the message to LVN A. LVN B continued saying she also knew LVN A had paged the MD twice and she did not receive any MD calls for the rest of the shift. LVN B said she did not try calling the MD for CR #3's critical laboratory values and she did not do any vital signs for CR #3 either. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. The NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. NP then said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. NP continued saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory results and at that moment, ADON A told her CR #3 was still in the facility. The NP asked ADON A for CR #3's vital signs right away including oxygen saturation. Further interview at that time the NP, stated she was surprise to find out CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing. ADON A told her CR #3 was unresponsive. NP then said she did not understand why the nurses did not follow the orders and get the laboratory blood work STAT. She stated she gave STAT laboratory blood work orders and expected the results right away. When she did not hear anything during the night shift, she thought CR #3 was sent to hospital but decided to follow up with the facility the next morning. She even told them you guys are not following orders . In an interview on [DATE] at 3:52 p.m. the Administrator, stated STAT laboratory orders needed to be call immediately to the laboratory and the policy was for the laboratory to come draw the blood within 4 hours and within 1 to 2 hours to get the results back. The Administrator then said once the nurse gets the orders, the nurse will enter the order in the computer. Staff then would follow up on the order. She further said the nurse who gets the laboratory results is the nurse who will follow up with the MD. The Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away. If the MD does not answer, then the medical director, the facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical director's answer, then the nurse is supposed to call the DON and the Administrator so we can help in getting hold of the doctors. Continued interview with the Administrator at that time, she stated whenever a resident has a change in condition, staff were supposed to complete an eINTERACT form in the computer. She said the interact form was a tool built in the computer system for changes in condition where it triggers on what would need to happen next. Administrator said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Further interview on [DATE] at 4:00 p.m. the Administrator, stated RN D told her on [DATE] at around 5:45 p.m. CR #3 had some abnormal vitals. RN D had talked to the MD or the NP and she was told orders were to monitor CR #3's oxygen saturation and if the oxygen level drop, to send CR #3 to the hospital. The Administrator said CR #3's vitals got better and CR #3 was improving. Everything got to looking good. The Administrator said RN D got the STAT laboratory orders for CR #3 on [DATE] at around 5:45 p.m. then the laboratory called with abnormal values at around 1:00 a.m. They tried to reach the MD, then I am foggy about it. They attempted to call the MD twice. They heard back from the MD 5 minutes before CR #3 coded. Staff gave CR #3 CPR and sent her to hospital. I believed CR#3 was even admitted to ICU before she died . CR #3 had been in the facility for one week, she was here for therapy. Continued interview with the Administrator on [DATE] at 4:09 p.m. she stated facility staff did not call her on [DATE] when they were unable to contact the MD for CR #3's critical laboratory values but believed the former DON was contacted. In a second interview on [DATE] at 4:45 p.m. LVN C, said on [DATE] the NP came to visit CR #3 in the morning and gave STAT laboratory blood work. LVN C said she was not sure how long they have to call the laboratory for STAT orders but she believed they had 4 hours to call the laboratory. LVN C further said she texted the NP on [DATE] regarding CR #3's condition because her oxygen saturations were on the 80's and when she got the text back from the NP, she went and told RN D. LVN C said the nurse who gets the order is the one responsible of inputting the order in the computer system. She did not do it because she was leaving to go home. She said she should have done it. She should have completed an eINTERACT assessment on CR #3 as well. Further interview with LVN C, she stated the first time she called the laboratory for STAT orders she only called for the urinalysis and the BNP (Beta Naturetic Peptide) because she misread the orders. Later during change of shift, she found out together with RN D she had omitted the STAT orders for BMP (basic metabolic panel) and RN D was to follow up with it. LVN C further said she did not notify the NP about the mistake in transcribing the orders to the laboratory requisition form. In a phone interview on [DATE] at 5:09 p.m. the laboratory, technician stated they received a call from the facility on [DATE] at 12:12 p.m. for STAT order request for urinalysis and the BNP (Beta Naturetic Peptide) for CR #3. On [DATE] at 5:06 p.m. they received another STAT order request for BMP for CR #3. Record review of http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm: revealed [MEDICAL CONDITION] means an abnormally elevated level of potassium in the blood. The normal potassium level in the blood isCmilliequivalents per liter (mEq/L). Potassium levels between 5.1 mEq/L to 6.0 mEq/L reflect mild [MEDICAL CONDITION]. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate [MEDICAL CONDITION], and levels above 7 mEq/L are severe [MEDICAL CONDITION]. Extremely high levels of potassium in the blood (severe [MEDICAL CONDITION]) can lead to [MEDICAL CONDITION] and death. Record review of the facility policy and procedure Change of condition reporting revised ,[DATE] revealed in part: .It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. If unable to contact attending physician or alternate physician timely, notify Medical Director for follow up to change in resident condition Follow-up. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy two (72) hours or until condition has stabilized .Comprehensive Care Plan will be updated/revised accordingly. Record review of the facility policy and procedure Laboratory Services revised ,[DATE] revealed in part: .2.- STAT orders are done as soon as possible within facility defined time frames . Record review of the facility policy and procedure Labs, abnormal revised ,[DATE] revealed in part: It is the policy of this facility to inform physician immediately to assist in diagnosing resident appropriately based on the Laboratory results. The RN Supervisor will care plan only the abnormal laboratory results which requires blood levels such as abnormal Potassium that could manifest complications in the short term care plan . Record review of the facility's undated protocol with title Labs revealed in part: It is everyone's responsibility to follow up on all labs in a timely manner. STAT labs.: You are expected to get your laboratory results within 4 hours. If you do not receive then in that time. Notify your ED/DON immediately. Once you receive your result notify MD of results. Call responsible party of laboratory results. Document in progress notes the laboratory results, MD and RP notification. The resident will then be in every shift documentation for 72 hours until resolved. If laboratory is abnormal you are required do the following: 1.- Notify the MD and RP. Place patient in follow up and chart on patient every shift. If you are unable to reach MD YOU MUST NOTIFY THE ED/DON IMMEDIATELY . Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health . An IJ was identified on [DATE] at 4:35 pm and the Administrator and DON were informed at that time. The POR was accepted on [DATE] at 3:38 pm. The POR included: Immediate action: 1.- Resident affected by this deficient practiced was discharged to hospital [DATE]. Laboratory audits to determine all residents affected by this deficient practice including: 1.- Laboratory audit performed by Clinical Resources to review all current laboratory orders at facility began on [DATE] with laboratory vendor - ACL laboratory and completed [DATE]. 2.- Medical records designee pulling all orders for laboratory in PCC for all current residents for review, completed [DATE]. 3.-Review of all Telephone Orders by Clinical Resource Nurse to ensure no new orders for laboratory have been missed completed [DATE]. 4.- Clinical Resource Nurse completed audit of laboratory requisition book where laboratory orders are noted by laboratory after laboratory are drawn completed [DATE]. 5.- Charge Nurse designated to check laboratory website to pull results each shift beginning [DATE]. 6.- Any abnormal or critical laboratory to be communicated to physician/designee and RP on [DATE] (no critical laboratory were founds). 7.- DON to notify laboratory vendor to email STAT laboratory and / or abnormal results to DON and ADON's email in addition to calling the facility as part of new process beginning [DATE]. DON and ADON have email access ,[DATE]. 8.- All current resident's charts were audited for potential change of condition on [DATE] by Clinical Resource Nurse. No change of conditions were found. At time of this plan of removal, no other residents identified with laboratory issues. (12:00 p.m.). Education/In-service: 1.- In-service started [DATE] at 5:05 p.m. with licensed nurses including change of condition, using SBAR form, Stop and Watch, notifications, and Resident Behavior and Facility practice related to change of condition. In the event a licensed nurse cannot reach the attending physician, charge nurse will contact either DON or Administrator and Medical Director. The Medical Directors have provided the DON and Administrator with alternate methods to contact them rapidly. In-service started on [DATE] with all licensed nursing staff regarding each Medical Directors preferred methods of communication. 2.- As part of in-service new DON (start date [DATE]) introduced to staff and shared her contact information. 3.- DON and ADON will divide building each taking two hall to follow up daily on any change of condition, new laboratory orders, abnormal laboratory, fall, etcetera starting [DATE]. 4.- Change of Condition log will be utilized and review in daily stand up meeting with leadership IDT starting [DATE]. 5.- Licensed charge nurses were educated on [DATE] to follow up on each change of condition for 72 hours or until condition stable or resolved beginning [DATE]-17. 6.- Medical Directors notified of IJ and associated Plan of Removal. Dr. A was notified via phone on [DATE] at 6:00 p.m. and Dr. B was notified in person on [DATE] at 8:45 a.m. 7.- In-serviced CNA's on reporting change of condition and the Stop and Watch tool on [DATE]. Any staff not available for any in-service will be in-serviced before they are allowed to go on the floor to work a shift. Monitoring: RN corporate nurse resource has been assigned to facility to monitor plan of removal by: 1.- Daily monitoring of laboratory results by charge nurses on each shift beginning [DATE]. 2.- Daily review of change of condition log, and 72 hours follow up. 3.- Ongoing in-service on change of condition, notification, laboratory process. 4.- Daily QA analysis of admissions and readmissions including an updates to plan of care. 5.- QAPI committee to meet review Plan of removal daily until immediacy lifted, then weekly until compliance achieved. Monitoring: In an interview on [DATE] at 4:05 p.m LVN C said she was trained on follow MD orders timely and accurately. In an interview on [DATE] at 10:20 a.m. LVN G and LVN H, both stated they had been trained on following MD orders. In an interview on [DATE] at 10:30 a.m. LVN E, stated she had been trained on following MD orders. In an interview on [DATE] at 10:40 a.m. LVN F, stated he had been trained on following MD orders. In an interview on [DATE] at 1:52 p.m. LVN K, stated she had been trained on following MD orders. In an interview on [DATE] at 3:05 P.m. LVN P, stated she had been trained on following MD orders. In an interview on [DATE] at 4:25 p.m. RN R, stated she had been trained on following MD orders. In a phone interview on [DATE] at 4:30 p.m. LVN A, stated he had been trained on following MD orders. In a phone interview on [DATE] at 4:40 p.m. LVN S, stated she had been trained on following MD orders. Record review of facility In-service Training Attendance record dated [DATE] revealed that nursing staff were educated regarding change in condition assessments, following MD orders and abnormal laboratory reports. Attached was also found the signatures of staff attending the training. The Administrator was informed on [DATE], at 5:20 p.m. the IJ was lowered; however, the facility remained out of compliance at an pattern level and a severity of actual harm that is not an IJ due to facility needing more time to train the staff. The Administrator reported 23 residents resided on hall 200.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of seven residents on the 200 hall (CR #3) reviewed for care provided. - The facility failed to draw CR #3's STAT BMP laboratory orders for 10.5 hours. -The facility failed to notify the MD of CR #3's critical Potassium levels for 5.25 hours. -The facility failed to send CR #3 to the hospital for 14 hours after the NP instructed them to do so. -The facility failed to provide assessments and closely monitor the vital signs when CR #3 had a change in her condition. LVN A and LVN B did not assess CR #3's condition and vital signs during the night shift prior to being found unresponsive on [DATE] at 7:11 a.m. CR #3 was pronounced dead 26 minutes after arrival to the emergency room . An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one former resident (CR#3) who died 26 minutes after arrival to the emergency room and placed 23 other residents at the 200 hall at the facility at risk of not receiving adequate assessments, delay in appropriate medical treatment, the development of new or worsening medical condition, decline in their health condition well-being and death. Findings included: Intake # 4 Record review of the facility face sheet revealed CR# 3 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #3 was found unresponsive and was sent to the hospital on [DATE] and was pronounced dead 26 minutes after arrival to the emergency room . Record review of the 5 day MDS assessment dated [DATE] revealed CR #3 required limited assistance for bed mobility, transfer, dressing, toileting and personal hygiene and supervision for walking in room and in corridor, locomotion and eating. CR #3 was always continent of bowel and had an indwelling catheter for urine. Record review of CR #3's electronic and paper records revealed CR #3 did not have a care plan. Record review of CR #3's NP progress notes dated [DATE] revealed in part: [AGE] year old female readmitted at the hospital for frequent falls. She is here for rehab. Past medical history for hypertension, [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] .STAT BNP (Pro) (Beta Naturetic Peptide - test to help detect, diagnose, and evaluate the severity of heart failure), BMP (basic metabolic panel, blood work that assess electrolytes and kidney function) and urinalysis. Assessment/Plan: [MEDICAL CONDITION] - BUN (Blood Urea Nitrogen) / Creatinine (test to assess kidney function) high on [DATE]. Will re-check STAT today . Record review of CR #3's physician's telephone orders signed by the NP and dated [DATE] at 9:30 a.m. revealed orders in part: - STAT urinalysis, BMP and Pro BNP . Record review of CR#3's laboratory requisition form dated [DATE] revealed a collection time of 1:52 p.m. for urinalysis and BNP (Beta Naturetic Peptide). Further record review revealed the BMP test which was ordered at the same time was omitted in lab requisition order. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 3:15 p.m. Late entry by LVN C .CR #3 went to therapy and therapist checked oxygen saturation and read 78%. Checked CR #3's oxygen saturation upon returning to room and oxygen saturation read 82%. Immediately placed CR #3 on oxygen at 2 liters. Oxygen continued to rise to 89%. Vital signs blood pressure ,[DATE], pulse 71, temperature 98.4 and respirations 15 - 16 breaths per minute with no labored breathing. Contacted NP with results on low oxygen and informed her that the oxygen was rising and asked if CR #3 could go out to hospital. Informed oncoming nurse . -[DATE] at 4:16 p.m. by LVN C NP into see CR #3 and RP concerned that CR #3 is having kidney issues. Orders to have STAT urinalysis, BNP and Pro BNP .All orders completed . -[DATE] at 4:20 p.m. by LVN C NP called and informed of oxygen saturation . (NP) stated that we could send CR #3 out to hospital. Informed nurse on duty of decision . Record review of CR #3's electronic vital signs record revealed in part: -[DATE] at 4:42 p.m. Blood pressure ,[DATE] and pulse 64 beats per minute. Further record review revealed no further vitals sign assessments for CR #3. Further record review of CR #3's laboratory requisition form dated [DATE] revealed a collection time of 8:00 p.m. for BMP (basic metabolic panel). This was the STAT test which was orignally ordered by the NP at 9:30 am, 10 ,[DATE] hours prior. Further record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 7:57 p.m. by RN D Given order by NP to increase CR #3's [MEDICATION NAME] to 8 mg by mouth every 4 hours as needed for nausea which was entered into the computer and faxed to pharmacy . Record review of CR #3's electronic MAR indicated [REDACTED] Record review of CR #3's laboratory report dated [DATE] at 12:18 a.m. revealed in part; -Potassium level 6.2 mEq/L Reference range (3.5 - 5.3). Continued record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 1:46 a.m. by LVN A Potassium 6.2. Dr. A informed. Awaiting call back. -[DATE] at 1:49 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain. CR #3 requested for muscle spasms -[DATE] at 2:30 a.m. by LVN A CR #3 lying in bed, no complaints of pain or nausea. Oxygen saturation 94% at 3 liters of oxygen. Assisted to restroom with 1 person assistance. Tolerated ambulation well. Dr. A paged of Critical Potassium levels of 6.2. -[DATE] at 3:10 a.m. by LVN A [MEDICATION NAME] (muscle relaxant) tablet 350 mg. Give 0.5 tablet by mouth every 6 hours as needed for muscle spasm / back pain effective (documentation indicated monitoring the effectiveness of the medication) Further record review of the progress/nurses notes revealed no further attempts to contact the MD for the critical Potassium levels, no vital sign assessments or any further assessments during the night shift. Record review of CR #3's MD orders dated [DATE] revealed in part; -[MEDICATION NAME] tablet 350 mg, give 0.5 tablet by mouth every 6 hours as needed for muscle spasm/back pain. Record review of CR #3's progress/nurses notes revealed in part; -[DATE] at 2:14 p.m. by ADON A Received in report that laboratory reported a critical potassium level and no new orders obtained as of that time. Contacted NP with laboratory results approx 7:06 a.m. NP returned call at 7:11 a.m. requesting oxygen saturation levels. Reported back to CR #3's to check oxygen saturation. Upon entering room CR #3's eyes were closed and she was non-responsive to verbal and tactile stimuli. CR #3 was not breathing, no pulse palpable, skin warm to touch. Code called, CPR initiated and 911 called. Fire department arrived and took over CPR until paramedics arrived. CR #3 was last observed sleeping in bed at approx 6:30 A.M. Notified emergency contact at approx 7:40 a.m. that CR #3 was observed unresponsive and that she should go to the hospital where CR #3 was transferred . Record review of CR #3's hospital records from the emergency room revealed in part: Arrival date/time: [DATE] at 8:05 a.m. -At 8:25 a.m. [AGE] years old white female presents to ED via unassigned with complaints of Full arrest. -At 8:25 a.m. Preceding the arrest, CR #3 was found down by nursing home staff. The arrest occurred at the nursing home. The arrest was not witnessed by others. Bystanders at the scene performed CPR. -EMS (emergency medical service) care prior to arrival: Initiation of ACLS (advanced cardiac life support), peripheral IV, was successfully placed. 15 minutes elapsed prior to ACLS. ACLS has been in progress for 45 minutes. ACLS details: initial rhythm was asystole (flat line in electrocardiogram). [MEDICATION NAME] ([MEDICATION NAME]) intravenous 8 doses. Response to therapy: Continued arrest. Arrest was first noted at 7:15 a.m. asystole was presenting rhythm, there may have been PEA (pulseless electrical activity) at one point. --At 8:31 a.m. ED course: CR #3 has been under CPR for more than 45 minutes with no ROSC (return of spontaneous circulation). While there was not a definitive airway, after 45 minutes of CPR and 9 rounds of [MEDICATION NAME], did not feel like any further attempts at airway wound lead to different outcome other than death. CR #3 was pronounced. -Diagnosis: [REDACTED]. In an interview on [DATE] at 2:08 p.m. ADON A, stated she was the charge nurse for CR #3 on [DATE] when she was found unresponsive. ADON A said she had arrived at the facility and started her rounds alone looking at the residents at around 6:30 a.m. and it was then she saw CR#3 sleeping. She said LVN B told her CR #3 had critical potassium levels during the night shift and the MD had not returned the call yet. LVN A who was assigned to CR #3 during the night shift, had gone home earlier on the shift. ADON A then said when LVN B told me that staff had not follow up with the MD regarding the critical potassium levels, I texted the NP and the NP called me within a couple of minutes. I gave her the critical values of potassium for CR #3 and she asked me for CR #3's oxygen saturation levels because CR #3 was having problems with her oxygen on [DATE]. When I went to the room at that moment still with the phone in my hands and the NP on the line, CR #3 was found not breathing, and no vital signs. CPR was started and 911 was called. CR #3 died in route to the hospital. Further interview with the ADON A at that time, she stated the night shift tried to call the MD but the MD was not reach. ADON A then said facility protocol is that if the MD does not return the calls, we were supposed to call the medical director, but CR #3's MD was the medical director. Facility has another medical director that we were supposed to call if the first medical director does not answer the calls. LVN B said the other medical director called the facility during the night shift on [DATE] for another resident and LVN A forgot to mention about the critical potassium values of CR #3. Continued interview the ADON A on [DATE] at 2:20 p.m. said critical laboratory values was a change in condition and the facility staff was supposed to complete a change of condition assessment in the computer where it prompt staff to assess the resident, notify MD and RP. ADON A further said that if for any reason the MD or another medical director was unable to be located, the staff was supposed to notify the DON. She said she did not know if the previous DON was aware of the situation with CR #3. When asked if CR #3 had any assessments previous to being found unresponsive or any vital signs, ADON A then looked at the computed and then said there is none, last vital signs were on [DATE] at 4:42 p.m. In a phone interview on [DATE] at 4:25 p.m. LVN C, stated she was the charge nurse for CR #3 on [DATE] from 6 a.m. to 2:00 p.m. and said she called the NP to notify her CR #3 oxygen levels were low and the NP called her at the end of her shift and told her to send CR #3 to the hospital. LVN C then said she told the 2:00 to 10:00 p.m. shift nurse who was RN D about the order to send CR #3 to the hospital. LVN C then said it was around 3:50 p.m. on [DATE] when she got the order. LVN C continued saying she did not transcribe the order to CR #3's chart because she was going home and she had already talked to RN D about the new orders. LVN C further said she got the orders via text message and the staff would usually call, page or text the MD or the NP. When asked if the text could be reviewed she said she had erased the text message from the NP. Continued phone interview LVN C at that time, stated whenever a resident had a change in condition, the staff was supposed to complete a change in condition form in the computer, that was like an SBAR where they would write their assessments, MD and RP notifications. She said she did not complete that assessment on CR #3. In a phone interview on [DATE] at 4:42 p.m. LVN A, he stated he was the charge nurse for CR #3 from 10:00 p.m. on [DATE] to at around 3:00 a.m. on [DATE] and further said I wasn't supposed to even being there on that day. He said I did not get any report regarding any change in condition regarding CR #3. I knew about the critical values of her laboratory results, I paged the MD twice and did not get any response. Then I left at around 3:00 a.m. and gave report to LVN B so she could follow up and pass the information to the day shift. LVN A said the other medical director called the facility on [DATE] regarding another resident and he did not notify him about CR #3 because he was very busy with this other resident who had a PICC line. He said but I heard that the day shift was able to get hold of the NP. Further interview LVN A at that time, he stated critical laboratory values was a change in condition and that he was supposed to contact the MD or the DON if unable to contact the MD. He said In this place everything is so confusing. I don't even know who the DON is. LVN A said he was supposed to check the vital signs of CR #3 but he only checked the oxygen saturation. He said RN D didn't really tell me anything about CR #3. We were supposed to do the eINTERAC change of condition documentation in the computer but I can't explain why I did not do it. I just don't know why. I should had monitored any cardiac issues, blood pressure and heart rate due to her high potassium levels. I was overwhelmed. In an interview on [DATE] at 5:00 p.m. RN D, stated she was the charge nurse for CR #3 on [DATE] during the 2:00 p.m. to 10:00 p.m. shift and then said during change of shift report CR #3 was sleepy and she asked about CR #3's oxygen saturation. The morning shift nurse told her it was around the 80's and she had increased the oxygen to 4 liters and re-checked the oxygen and it was 89 to 90%. RN D then said during her shift, the laboratory collected blood from CR #3 that was ordered during the day shift. RN D then said LVN C never told her about the orders to transfer CR #3 to the hospital. RN D continued saying she spoke with the NP because the NP wanted to know the laboratory results for CR #3 but she did not receive any reports from the laboratory and she never knew the NP wanted CR #3 to go to the hospital. When asked about the order to increase [MEDICATION NAME] for CR #3 for nausea and vomiting, RN D stated she did not remember if CR #3 had any nausea that day . Continued interview on [DATE] at 5:15 p.m. with RN D, she said whenever a resident had a change in condition, there was an eINTERACT form to complete on the computer where the nurse writes the assessments. She said I did not check if someone had completed a change of condition form on CR #3. It should had been completed on the day shift on [DATE]. In a phone interview on [DATE] at 9:15 a.m. LVN B, stated LVN A left the building on [DATE] at around 3:30 a.m. and he told her everything was fine and CR #3 did not have any issues. LVN B further said LVN A did not mention to her anything about the laboratory values of CR #3 but she knew the laboratory had called at 1:30 a.m. to report critical values because she was the one that got the call and then gave the message to LVN A. LVN B continued saying she also knew LVN A had paged the MD twice. She did not receive any MD calls for the rest of the shift. LVN B then said she did not try calling the MD for CR #3's critical laboratory values and she did not do any vital signs for CR #3 either. In a phone interview on [DATE] at 3:29 p.m. the NP, stated she came to the facility on [DATE] and saw CR #3 and ordered STAT laboratory blood work because when she saw CR #3 she did not look good. The NP stated she did not hear anything about the results of the laboratory blood work for CR #3 after she gave the orders. The NP then said the following morning she called the facility to find out if CR #3 was sent to the hospital as she had ordered on [DATE] and to find out about the laboratory results. The NP continued saying on [DATE] at around 7:00 a.m. she called the facility and spoke to ADON A and asked about CR #3 and how come she did not hear about the laboratory results. She said at that moment, ADON A told her CR #3 was still in the facility and the NP asked ADON A for CR #3's vital signs right away including oxygen saturation. Further interview at that time the NP, stated she was surprise to find out CR #3 was not in the hospital and requested CR #3's vital signs because she wanted to know how she was doing. ADON A told her CR #3 was unresponsive. The NP then said I don't understand why the nurses did not follow the orders and call for the laboratory blood work STAT. if it wasn't that I called them the next morning at 7:00 a.m. and inquired about CR #3 status what would have happened? What if I did not call?. I gave STAT laboratory blood work orders, I expected the results right away. When I did not hear anything during the night shift, I thought CR #3 was sent to hospital but I decided to follow up with the facility the next morning. I even told them 'you guys are not following orders' . In an interview on [DATE] at 3:52 p.m. the Administrator, stated STAT laboratory orders needed to be call immediately to the laboratory and the policy was for the laboratory to come and draw the blood within 4 hours and 1 to 2 hours to get the results back. The Administrator then said once the nurse gets the orders, the nurse will enter the order in the computer and then would follow on the order. She further said the nurse who gets the laboratory results is the nurse who will follow up with the MD. The Administrator further said for STAT abnormal laboratory results, the nurses will call the MD right away, if the MD does not answer, then the medical director. The facility has 2 medical directors, if one does not answer, then we will call the other medical director. If none of the medical directors answer, then the nurse is supposed to call the DON and the Administrator so we can help in getting hold of the doctors. Continued interview with the Administrator at that time, she stated whenever a resident has a change in condition, they were supposed to complete an eINTERACT form in the computer. She further said the interact form was a tool built in the computer system for changes in condition where it will trigger on what will need to happened. The Administrator further said the interact tool would guide the nurses on calling the MD, the RP and to follow up on assessments. Further interview on [DATE] at 4:00 p.m. with the Administrator, she stated RN D told her on [DATE] at around 5:45 p.m. CR #3 had some abnormal vitals and RN D had talked to the MD or the NP. She was told the orders were to monitor CR #3's oxygen saturation and if the oxygen would drop, to send CR #3 to the hospital. The Administrator further said CR #3's vitals got better and CR #3 was improving and everything was looking good. The Administrator then said RN D got the STAT laboratory orders for CR #3 on [DATE] at around 5:45 p.m. then the laboratory called with abnormal values at around 1:00 a.m. They tried to reach the MD, then I am foggy about it. They attempted to call the MD twice. They heard back from MD 5 minutes before CR #3 coded. Staff gave CR #3 CPR and sent her to hospital. I believed CR#3 was even admitted to ICU before she died . CR #3 had been in the facility for one week, she was here for therapy. Continued interview with the Administrator on [DATE] at 4:09 p.m. she stated facility staff did not call her on [DATE] when they were unable to contact the MD for CR #3's critical laboratory values but believed the former DON was contacted. In a second interview on [DATE] at 4:45 p.m. LVN C, she said on [DATE] the NP came to visit CR #3 in the morning and gave STAT laboratory blood work. LVN C said she was not sure how long do they had to call the laboratory for STAT orders but she believed they had 4 hours to call the laboratory. LVN C further said she texted the NP on [DATE] regarding CR #3's condition because her oxygen saturations were on the 80's and when she got the text back from the NP, she went and told RN D. LVN C then said The nurse who gets the order is the one responsible of inputting the order on the computer system. I did not do it because I was leaving to my home. I should had done it. I should had completed an eINTERACT assessment on CR #3 as well. Further interview with LVN C, she stated the first time she called the laboratory for STAT orders she only called for the urinalysis and the BNP (Beta Naturetic Peptide) because she misread the orders and later during change of shift, she found out together with RN D she had omitted the STAT orders for BMP (basic metabolic panel) and that RN D was to follow up with it. LVN C further said she did not notify the NP about the mistake in transcribing orders to the laboratory requisition form. In a phone interview on [DATE] at 5:09 p.m. the laboratory, technician stated they received a call from the facility on [DATE] at 12:12 p.m. for STAT order request for urinalysis and the BNP (Beta Naturetic Peptide) for CR #3 and on [DATE] at 5:06 p.m. they received another STAT order request for BMP for CR #3. Record review of http://www.medicinenet.com/[MEDICAL CONDITION]/article.htm: revealed [MEDICAL CONDITION] means an abnormally elevated level of potassium in the blood. The normal potassium level in the blood isCmilliequivalents per liter (mEq/L). Potassium levels between 5.1 mEq/L to 6.0 mEq/L reflect mild [MEDICAL CONDITION]. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate [MEDICAL CONDITION], and levels above 7 mEq/L are severe [MEDICAL CONDITION]. Extremely high levels of potassium in the blood (severe [MEDICAL CONDITION]) can lead to [MEDICAL CONDITION] and death. Record review of the facility policy and procedure Change of condition reporting revised ,[DATE] revealed in part: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation If unable to contact attending physician or alternate physician timely, notify Medical Director for follow up to change in resident condition Follow-up. The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy two (72) hours or until condition has stabilized .Comprehensive Care Plan will be updated/revised accordingly. Record review of the facility policy and procedure Laboratory Services revised ,[DATE] revealed in part: .2.- STAT orders are done as soon as possible within facility defined time frames . Record review of the facility policy and procedure Labs, abnormal revised ,[DATE] revealed in part: It is the policy of this facility to inform physician immediately to assist in diagnosing resident appropriately based on the Laboratory results. The RN Supervisor will care plan only the abnormal laboratory results which requires blood levels such as abnormal Potassium that could manifest complications in the short term care plan . Record review of the facility's undated protocol with title Labs revealed in part: It is everyone's responsibility to follow up on all labs in a timely manner. STAT labs.: You are expected to get your laboratory results within 4 hours. If you do not receive then in that time. Notify your ED/DON immediately. Once you receive your result notify MD of results. Call responsible party of laboratory results. Document in progress notes the laboratory results, MD and RP notification. The resident will then be in every shift documentation for 72 hours until resolved. If laboratory is abnormal you are required do the following: 1.- Notify the MD and RP. Place patient in follow up and chart on patient every shift. If you are unable to reach MD YOU MUST NOTIFY THE ED/DON IMMEDIATELY . Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health . An IJ was identified on [DATE] at 4:35 pm and the Administrator and DON were informed at that time. The POR was accepted on [DATE] at 3:38 pm. The POR included: Immediate action: 1.- Resident affected by this deficient practiced was discharged to hospital [DATE]. Laboratory audits to determine all residents affected by this deficient practice including: 1.- Laboratory audit performed by Clinical Resources to review all current laboratory orders at facility began on [DATE] with laboratory vendor - ACL laboratory and completed [DATE]. 2.- Medical records designee pulling all orders for laboratory in PCC for all current residents for review, completed [DATE]. 3.-Review of all Telephone Orders by Clinical Resource Nurse to ensure no new orders for laboratory have been missed completed [DATE]. 4.- Clinical Resource Nurse completed audit of laboratory requisition book where laboratory orders are noted by laboratory after laboratory are drawn completed [DATE]. 5.- Charge Nurse designated to check laboratory website to pull results each shift beginning [DATE]. 6.- Any abnormal or critical laboratory to be communicated to physician/designee and RP on [DATE] (no critical laboratory were founds). 7.- DON to notify laboratory vendor to email STAT laboratory and / or abnormal results to DON and ADON's email in addition to calling the facility as part of new process beginning [DATE]. DON and ADON have email access ,[DATE]. 8.- All current resident's charts were audited for potential change of condition on [DATE] by Clinical Resource Nurse. No change of conditions were found. At time of this plan of removal, no other residents identified with laboratory issues. (12:00 p.m.). Education/In-service: 1.- In-service started [DATE] at 5:05 p.m. with licensed nurses including change of condition, using SBAR form, Stop and Watch, notifications, and Resident Behavior and Facility practice related to change of condition. In the event a licensed nurse cannot reach the attending physician, charge nurse will contact either DON or Administrator and Medical Director. The Medical Directors have provided the DON and Administrator with alternate methods to contact them rapidly. In-service started on [DATE] with all licensed nursing staff regarding each Medical Directors preferred methods of communication. 2.- As part of in-service new DON (start date [DATE]) introduced to staff and shared her contact information. 3.- DON and ADON will divide building each taking two hall to follow up daily on any change of condition, new laboratory orders, abnormal laboratory, fall, etcetera starting [DATE]. 4.- Change of Condition log will be utilized and review in daily stand up meeting with leadership IDT starting [DATE]. 5.- Licensed charge nurses were educated on [DATE] to follow up on each change of condition for 72 hours or until condition stable or resolved beginning [DATE]-17. 6.- Medical Directors notified of IJ and associated Plan of Removal. Dr. A was notified via phone on [DATE] at 6:00 p.m. and Dr. B was notified in person on [DATE] at 8:45 a.m. 7.- In-serviced CNA's on reporting change of condition and the Stop and Watch tool on [DATE]. Any staff not available for any in-service will be in-serviced before they are allowed to go on the floor to work a shift. Monitoring: RN corporate nurse resource has been assigned to facility to monitor plan of removal by: 1.- Daily monitoring of laboratory results by charge nurses on each shift beginning [DATE]. 2.- Daily review of change of condition log, and 72 hours follow up. 3.- Ongoing in-service on change of condition, notification, laboratory process. 4.- Daily QA analysis of admissions and readmissions including an updates to plan of care. 5.- QAPI committee to meet review Plan of removal daily until immediacy lifted, then weekly until compliance achieved. Monitoring: In an interview on [DATE] at 4:05 p.m. LVN C, stated she had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said that STAT laboratory orders needed to be called to the laboratory immediately. LVN C then said whenever they get laboratory results, staff was supposed to call the MD, and if the MD was not available, to call the Medical Director and if the Medical Director was not available that the staff was supposed to call the DON and the Administrator. LVN C continued saying staff were supposed to check the fax machine and follow up with the laboratory every one hour on pending laboratory reports. LVN C said she was also trained on follow MD orders timely and accurately. In an interview on [DATE] at 10:20 a.m. with LVN G and LVN H, both stated they had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said STAT laboratory orders needed to be called to the laboratory immediately. LVN G then said whenever they get laboratory results, staff was supposed to call the MD as soon as possible, and if the MD was not available, to call the Medical Director and if the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN H continued saying training included information on following MD orders. In an interview on [DATE] at 10:30 a.m. with LVN E, she stated she had been trained on change of condition, assessments, vital signs and documentation including the SBAR tool in the computer system. She also said training included the Stop and Watch form staff would complete to report changes in condition to nurses. LVN E further said training included laboratory orders, follow up and immediate notification to the MD of any critical values and staff was made aware the chain of notification in case the MD was not able to be contacted that included the DON and Administrator. In an interview on [DATE] at 10:40 a.m. with LVN F, he stated he had been trained on assessments with change in condition and the eINTERACT tool, assessments, vital signs, laboratory reports and said STAT laboratory orders needed to be called to the laboratory immediately. LVN F then said whenever they get laboratory results, staff was supposed to call the MD as soon as possible, and if the MD was not available, to call the Medical Director and if the Medical Director was not available the staff was supposed to call the DON and the Administrator. LVN F continued saying training included information on following MD orders. In an

Based on observation, interview and record review, the facility failed to treat and care in a manner and in an environment that promoted maintenance or enhanced the quality of life for one of seven residents (Resident #1) reviewed for care provided to promote dignity. -The facility staff failed to provide timely incontinent care, bathing and personal care to Resident #1. Resident #1 did not have a shower for 37 days. She said she smelled herself and felt humiliated. She was angry, frustrated and felt like she was lied to. She was afraid that her wounds would become infected. This affected one resident and placed the other 87 residents at risk for a loss of dignity, low self-esteem and respect in full recognition of his or her individuality. Findings include: Intakes # 6 and # 8 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1 admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Continued record review revealed Resident #1 was at risk of developing pressure sores and was not on a turning/repositioning program. She received application of non-surgical dressing and ointment/medications other than to feet. Record review of Resident #1's care plan initiated 1/6/2017 revealed in part: -Focus: At risk for an ADL self care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with bed mobility, dressing, grooming, toilet/incontinent needs and personal hygiene. She required extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Personal hygiene: Requires total assistance with personal hygiene care. Immobility: Requires staff participation (5-7) for incontinent care. Record review of facility grievance dated 1/9/2017 revealed in part: .Print individual's name: (Resident #1's ) family member. Describe concern using factual terms: On Friday, January 6, Resident #1 was cleaned up at 8:00 p.m. so she started to urinate during the night. I asked that she get cleaned up at 10:00 a.m The CNA knew so we waited both me and (Resident #1), we ended up going to sleep so by the time we woke up, it was 5:30 p.m. so I went back with the nurse and told him and the nurse said that he will let the 2 to 10:00 p.m. CNA know. Her CNA said she will come after dinner so by the time came Resident #1 was soaking wet and full of bowel movement to the point that the bed was soaked, the same thing happened Sunday January 8th. Informed Administrator . Record review of Resident #1's social progress notes dated 1/18/2017 at 1:30 p.m. revealed in part: Spoke with (Resident #1) and family member and (Resident #1) was very upset and frustrated. She stated that she was told by the Administrator that the facility has the staff and personnel to address her needs. (Resident #1) stated that she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. (Resident #1) does not understand why it takes so long for the staff to come and clean her up. She stated that she needs to be cleaned up first to receive physical therapy which she has missed due to not being cleaned in a timely manner. (Resident #1) stated that her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. (Resident #1) is very angry and wants something to be done . Further record review of Resident #1's social progress notes dated 1/19/2017 at 2:30 p.m. revealed in part: .(Resident #1) stated that she was furious because she felt lied to. She stated that she was last cleaned at 9:00 p.m. on 1/18/2017 and will finally get cleaned up at 2:00 p.m. on 1/19/2017. (Resident #1) stated that she felt that she was lied to by the Administrator prior to being admitted just to get her to the facility to get paid and now that her 20 days are up, she feels like she is overlooked. (Resident #1) requested to speak with someone who can ensure that she gets cleaned and the proper care she is entitled to In an interview and observation on 1/31/2017 at 8:58 a.m. with Resident #1 and her family member, revealed there was a pervasive smell of urine and stool upon entering her room. Resident #1 stated facility staff was only providing incontinent care at 9:00 p.m. and 3:00 p.m. and then said I have wounds in my legs and the stool and urine are getting into my wounds. I haven't being cleaned today at all. I don't even know who my aide was. Staff don't come to see me in hours. If I press my call light, they will not come until around 11:30 a.m. I am very aware of what's going on, how about the people who are not aware of themselves?. Last night my brief was changed at 9:00 p.m. Normally staff don't change my brief during the night shift. I would like to be cleaned during the night but they don't come, even to check on me. Like now, if I would go and asked them to clean me because I feel that my brief is already soiled, they will say they are busy with breakfast. Every day I don't get care until around 1:30 p.m. or 3:00 p.m. Further interview at that time, Resident #1's family member stated since Resident #1 is in the facility, they haven't cleaned her before 1:00 p.m. Continued interview at on 1/31/2017 at 9:10 p.m. Resident #1 stated my hair was not washed until 21 days after I was admitted to the facility, nobody comes to turn me in bed like they did at the hospital. I get my therapy late because I get cleaned up late. The Administrator told me before coming to the facility that they had the staff to care for me. She promised me a lot of things. She told me I was going to be fully taking care of. My family member is the one taking care of me, he would try to help me get cleaned up because the staff is busy. My back hurts, my buttocks hurts. I feel soiled. I can smell myself. In an interview on 1/31/2017 at 11:06 a.m. with Resident #1, she stated that nobody had come to her room to check on her and offer to clean her and further said I don't even know who my aide is, since 9:00 p.m. last night when they did incontinent care, nobody has come to check if I need care. In an interview on 1/31/2017 at 11:13 a.m. CNA I, stated she was the aide assigned to care for Resident #1. When asked what time she was going to do care for Resident #1, CNA I stated We need 6 to 7 people to do incontinent care for Resident #1 and the Central Supply person is helping me on gathering all the staff. I can't do it by myself. Observation on 1/31/2017 at 11:40 a.m. during incontinent care to Resident #1 revealed that 6 staff members came to assist with incontinent care. CNA J, CNA W and CNA X supported Resident #1's abdominal fold up while CNA I and CNA Y each held open one leg. Central Supply person (who is also a CNA) cleaned Resident #1's abdominal fold and front perineal area. Further observation at that time revealed that Resident #1's had a rectangular moisture sheet approx 6 inches by 14 inches, under her abdominal area and one between her upper thighs and the moisture sheet that was in between Resident #1's upper thighs was completely soaked and was dark brown in color. Continued observation at that time revealed a very strong urine and stool odor in the room. Further observation at that time during incontinent care, while Resident #1 was turned to her side revealed 3 staff were needed to turned Resident #1 to her side and another 3 staff were needed to support Resident #1 on the other side of the bed while she was being turned to her side. Continued observation revealed Resident #1's brief was completely soiled up to the back of the brief. The brief was dark yellow in color and had stool on it. There was stool also on the buttocks of Resident #1. Resident #1 was lying on 2 pads that had a large dark brown colored ring where Resident #1 was lying from the buttocks area to her mid thighs. Under the pads there was a sling (staff used sling to move Resident #1 up in bed) that also had a large circular wet area on the direction where Resident #1 was lying down. While Resident #1 was on her side, she required 3 staff to hold her on her side on the side she was facing, 2 staff to hold Resident #1 on her back while the other staff was providing the incontinent care. Continued observation on 1/31/2017 at 12:23 p.m. at end of incontinent care, Resident #1 was assisted up on her bed. 3 staff were on one side and 3 other staff were on the other side. Further observation at that time revealed that it took 6 staff members to do incontinent care and took 43 minutes to complete the procedure. In an interview on 2/1/2017 at 10:32 p.m. CNA V, stated she was the aide taking care of Resident #1 and it was her first time in the facility. She further said she was told Resident #1 required 6 people to do incontinent care and the staff from 2:00 p.m. to 10:00 p.m. had just cleaned Resident #1. In an interview on 2/1/2017 at 10:36 p.m. with Resident #1, she stated that she was cleaned only twice during the day, at 2:15 p.m. and 9:00 p.m. In an interview on 2/1/2017 at 11:00 p.m. LVN B, stated there were 3 CNA's and 2 nurses for the night shift at the facility. She further said she was the charge nurse for Resident #1. She said during the night shift, they would only go to Resident #1 room if she put her light on and then said Resident #1 gets her incontinent care during the pm shift when there is more staff. If she had a bowel movement during the night shift and she would want to have incontinent care, it would take all the staff in the facility during the night shift. She stated there were only 5 staff working in the facility at night. In an interview on 2/1/2017 at 11:05 p.m. LVN S, stated she was a full time nurse on the 10:00 p.m. to 6:00 a.m. shift and said if Resident #1 would need any care during the nights shift, they would have to use all the staff present at the facility because it would take 6 to 7 people just to turn Resident #1 in bed. In an interview on 2/1/2017 at 11:13 p.m. CNA U, stated she was a full time CNA working on the night shift. She further said it would take 5 to 6 people to move Resident #1 and if Resident #1 needed incontinent care the 3 aides and the 2 nurses in the facility would have to assist with her care. In an interview on 2/1/2017 at 11:20 p.m. CNA T, stated she was a full time CNA working on the night shift and said I don't think we are equipped for Resident #1. We usually work 3 aides and 2 nurses at the night shift and it takes about 6 people to do incontinent care for her. If we needed to clean her, the whole building of staff would have to go and care for her and it would take 35 to 40 minutes. In an interview on 2/2/2017 at 11:03 a.m. the Administrator, stated the night shift usually works together on helping Resident #1 with her care and further said I was under the impression that Resident #1 had incontinent care every morning at 6:00 a.m. Resident #1 gets care at certain times only because she does not want to be bothered. The Administrator further said she had not heard any concerns related to the care of Resident #1. In an interview on 2/2/2017 at 2:40 p.m. Resident #1, stated she never requested only certain times for care to be provided and she had not refused any care. She stated staff does not check on her during the night time and further said Like this morning, I did not get cleaned until 12:00 p.m. It makes me want to cry. I have a history of getting skin infections. Last night they cleaned me around 9:00 p.m. and I did not get incontinent care again until 12:00 p.m. today. Since 8:00 a.m. I had been waiting for somebody to come but they did not come until 12:00 p.m. I urinated and defecated on myself since early morning. The pad underneath me is always so wet because I urinate and urinate and urinate on it. I cry and get so frustrated because I know I smell. I smell my urine. I have not refused any care. I was told I was going to be bathed every other day and I don't get bathed. In an interview on 2/2/2017 at 3:08 p.m. with Central Supply, stated she was assigned with Resident #1 during the day shift and she was scheduled for a shower. She said she was going to stay over to bathe Resident #1. Central Supply further said she did not give incontinent care to Resident #1 earlier on the shift because Resident #1 was eating breakfast. The Administrator stated on 2/3/2017 at 3:20 p.m. the facility did not have a policy and procedure for staffing. Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health Dignity and respect You have the right to live in safe, decent, and clean conditions, be free from neglect be treated with dignity, consideration and respect Make your own choices regarding personal care . Record review of the facility policy and procedure Incontinent Care revised 5/2007 revealed in part: It is the policy of this facility to remove urine or feces from skin Further record review revealed no information on how often the facility provided incontinent care to the residents. Record review of the facility policy and procedure ADL, Services to carry out revised 11/2007 revealed in part: It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .2.- Residents who are unable to carry out activities of daily living will receive necessary services to maintain: grooming, personal hygiene . Record review of the facility policy and procedure Turning rounds revised 11/2007 revealed in part; It is the policy of this facility to 1.- Cleanse, refresh and reposition bedfast residents on a regular basis The CMS form 672 revealed 88 residents in the facility.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one of seven residents (Resident #1) reviewed for ADL care. -The facility staff failed to provide timely incontinent care to Resident #1 and her brief and underneath pads were heavily saturated with urine and stool. There were multiple dried urine stained circles going from under Resident #1's thighs to under her back where her pad had been saturated in urine and stool and left to dry. She said she could smell herself and felt humiliated. This failure affected one resident and placed an additional 54 residents who were occasionally or frequently incontinent of bladder or bowel at risk for not receiving care and assistance when needed. Findings included: Intakes # 6 and # 8 Record review of the facility face sheet revealed Resident #1 was a [AGE] year old female. She was admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]., unspecified and essential (primary) hypertension. Record review of Resident #1's admission assessment dated [DATE] revealed she was cognitively intact with a BIMS score of 15 out of a possible 15. She required extensive assistance of two or more person for bed mobility, and was total dependent on two or more person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, personal hygiene and bathing. Resident #1 was always incontinent of bowel and bladder. Further record review revealed a weight of 792 lbs and 64 inches in height. Continued record review revealed Resident #1 was at risk of developing pressure sores and was not on a turning/repositioning program. She received application of non-surgical dressing and ointment/medications other than to feet. Record review of Resident #1's care plan initiated 1/6/2017 revealed in part: -Focus: At risk for an ADL self-care performance deficit related to limited mobility, limited ROM. All due to severe [MEDICAL CONDITION] and severe [MEDICAL CONDITION] (swelling that occurs in the arms or legs). Has limited physical movement being total dependent related to disease process, [MEDICAL CONDITION], weakness and limited movement. -Goal: Resident #1 will be safely assisted with performance with bed mobility, dressing, grooming, toilet/incontinent needs and personal hygiene. She required extensive assist of 5 to 7 staff members. -Interventions: Bed mobility: is totally dependent on staff for repositioning and turning in bed. Requires 5 to 7 staff member to turn and reposition and provided treatment. Personal hygiene: Requires total assistance with personal hygiene care. Immobility: Requires staff participation (5-7) for incontinent care. Record review of facility grievance dated 1/9/2017 revealed in part: .Print individual's name: (Resident #1's) family member. Describe concern using factual terms: On Friday, January 6, (Resident #1) was cleaned up at 8:00 p.m. so she started to urinate during the night. I asked that she get cleaned up at 10:00 a.m The CNA knew so we waited both me and (Resident #1), we ended up going to sleep so by the time we woke up, it was 5:30 p.m. so I went back with the nurse and told him and the nurse said that he will let the 2 to 10:00 p.m. CNA know. Her CNA said she will come after dinner so by the time came Resident 31 was soaking wet and full of bowel movement to the point that the bed was soaked, the same thing happened Sunday January 8th. Informed Administrator . Record review of Resident #1's social progress notes dated 1/18/2017 at 1:30 p.m. revealed in part: Spoke with (Resident #1) and family member and (Resident #1) was very upset and frustrated. She stated that she was told by the Administrator that the facility has the staff and personnel to address her needs. (Resident #1) stated that she felt lied to because she sits in her own urine and feces for hours and that the urine and feces go into her wounds. (Resident #1) does not understand why it takes so long for the staff to come and clean her up. She stated that she needs to be cleaned up first to receive physical therapy which she has missed due to not being cleaned in a timely manner. (Resident #1) stated that her family member will go up to the front to ask for assistance but it still takes a very long time for the staff to come and clean her up. (Resident #1) is very angry and wants something to be done . Further record review of Resident #1's social progress notes dated 1/19/2017 at 2:30 p.m. revealed in part: . (Resident #1) stated that she was furious because she felt lied to. She stated that she was last cleaned at 9:00 p.m. on 1/18/2017 and will finally get cleaned up at 2:00 p.m. on 1/19/2017. (Resident #1) stated that she felt that she was lied to by the Administrator prior to being admitted just to get her to the facility to get paid and now that her 20 days are up, she feels like she is overlooked. (Resident #1) requested to speak with someone who can ensure that she gets cleaned and the proper care she is entitled to In an interview and observation on 1/31/2017 at 8:58 a.m. with Resident #1 and her family member, revealed there was pervasive smell of urine and stool upon entering her room. Resident #1 stated facility staff was only providing incontinent care at 9:00 p.m. and 3:00 p.m. and then said I have wounds in my legs and the stool and urine are getting into my wounds. I haven't being cleaned today at all. I don't even know who my aide was. Staff don't come to see me in hours. If I pressed my call light, they will not come until around 11:30 a.m. I am very aware of what's going on. How about the people who are not aware of themselves? Last night my brief was changed at 9:00 p.m. Normally, staff don't change my brief during the night shift. I would like to be cleaned during the night but they don't come, even to check on me. Like now, if I would go and ask them to clean me because I feel that my brief is already soiled, they would say they were busy with breakfast. Every day I don't get care until around 1:30 p.m. or 3:00 p.m. Further interview at that time, Resident #1's family member stated since (Resident #1) has been in the facility, they haven't cleaned her before 1:00 p.m. Continued interview on 1/31/2017 at 9:10 a.m. Resident #1 stated my hair was not washed until 21 days after I was admitted to the facility. Nobody comes to turn me in bed like they did at the hospital. I get my therapy late because I get cleaned up late. The Administrator told me before coming to the facility that they had the staff to care for me. She promised me a lot of things. She told me I was going to be fully taken care of. My family member is the one taking care of me. He would try to help me get cleaned up because the staff is busy. My back hurts, my buttocks hurts. I feel soiled. I can smell myself. In an interview on 1/31/2017 at 11:06 a.m. with Resident #1, she stated nobody had come to her room to check on her and offer to clean her. She further said I don't even know who my aide is since 9:00 p.m. last night when they did incontinent care. Nobody has come to check to see if I need care. In an interview on 1/31/2017 at 11:13 a.m. CNA I, stated she was the aide assigned to care for Resident #1. When asked what time she was going to do care for Resident #1, CNA I stated We need 6 to 7 people to do incontinent care for Resident #1 and the Central Supply person is helping me on gathering all the staff. I can't do it by myself. Observation on 1/31/2017 at 11:40 a.m. during incontinent care to Resident #1 revealed that 6 staff members came to assist with incontinent care. CNA J, CNA W and CNA X supported Resident #1's abdominal fold up while CNA I and CNA Y each held open one leg. The Central Supply person (who is also a CNA) cleaned Resident #1's abdominal fold and front perineal area. Further observation at that time revealed Resident #1 had a rectangular moisture sheet approx. 6 inches by 14 inches, under her abdominal area and one between her upper thighs. The moisture sheet that was between Resident #1's upper thighs was completely soaked and was dark brown in color. Continued observation at that time revealed a very strong urine and stool odor in the room. Further observation during incontinent care, while Resident #1 was turned to her side, revealed 3 staff were needed to turned Resident #1 to her side and other 3 staff were needed to support Resident #1 on the other side of the bed while she was being turned to her side. Continued observation revealed Resident #1's brief was completely soiled up the back of the brief. The brief was dark yellow in color and had stool on it. There was stool also on the buttocks of Resident #1. Resident #1 was lying on 2 pads that had a large dark brown colored ring where Resident #1 was lying, spreading from the buttocks area to her mid thighs. Under the pads there was a sling (staff used sling to move Resident #1 up in bed) that also had a large circular wet area where Resident #1 was lying. While Resident #1 was on her side, she required 3 staff to hold her on her side and 2 staff to hold Resident #1's back while the other staff was providing the incontinent care. Continued observation on 1/31/2017 at 12:23 p.m. at the end of the incontinent care, Resident #1 was assisted up in her bed. Three staff were on one side and three other staff were on the other side. Further observation at that time revealed it took 6 staff members to provide incontinent care and took 43 minutes to complete the procedure. In an interview on 2/1/2017 at 10:32 p.m. CNA V, stated she was the aide taking care of Resident #1 and it was her first time in the facility. She further said she was told Resident #1 required 6 people to do incontinent care and the staff from 2:00 p.m. to 10:00 p.m. had just cleaned Resident #1. In an interview on 2/1/2017 at 10:36 p.m. with Resident #1, she stated she was cleaned only twice during the day, at 2:15 p.m. and 9:00 p.m. In an interview on 2/1/2017 at 11:00 p.m. LVN B, stated there were 3 CNA's and 2 nurses for the night shift at the facility. She further said she was the charge nurse for Resident #1. She said during the night shift, they would only go to Resident #1 room if she put her light on and then said Resident #1 gets her incontinent care during the pm shift when there is more staff. If she had a bowel movement during the night shift and she would want to have incontinent care, it would take all the staff in the facility. All 5 staff working in the facility would have to do it . In an interview on 2/1/2017 at 11:05 p.m. LVN S, stated she was a full time nurse on the 10:00 p.m. to 6:00 a.m. shift and if Resident #1 would need any care during the nights shift, they would have to use all the staff present at the facility because it would take 6 to 7 people just to turn Resident #1 in bed. In an interview on 2/1/2017 at 11:13 p.m. CNA U, stated she was a full time CNA working on the night shift. She further said it would take 5 to 6 people to move Resident #1 and if Resident #1 needed incontinent care the 3 aides and the 2 nurses in the facility would have to assist with her care. In an interview on 2/1/2017 at 11:20 p.m. CNA T, stated she was a full time CNA working on the night shift and said I don't think we are equipped for Resident #1. We usually work 3 aides and 2 nurses on the night shift and it takes about 6 people to do incontinent care for her. If we needed to clean her, the whole building of staff would have to go and care for her and it would take 35 to 40 minutes. In an interview on 2/2/2017 at 11:03 a.m. the Administrator, stated the night shift usually works together on helping Resident #1 with her care and further said I was under the impression that Resident #1 had incontinent care every morning at 6:00 a.m. Resident #1 gets care at certain times only because she does not want to be bothered. The Administrator further said she had not heard any concerns related to the care of Resident #1. In an interview on 2/2/2017 at 2:40 p.m. Resident #1, stated she never requested only certain times and she had not refused any care or that staff not check on her during the night time. She further said Like this morning, I did not get cleaned until 12:00 p.m. It makes me want to cry. I have a history of getting skin infections. Last night they cleaned me around 9:00 p.m. and I did not get incontinent care again until 12:00 p.m. today. Since 8:00 a.m. I had been waiting for somebody to come but they did not come until 12:00 p.m. I have urinated and defecated on myself since early morning. The pad underneath me is always so wet because I urinate and urinate and urinate on it. I cry and get so frustrated because I know I smell. I smell my urine. I have not refused any care. I was told I was going to be bathed every other day and I don't get baths. In an interview on 2/2/2017 at 3:08 p.m. Central Supply, stated she was assigned with Resident #1 during the day shift and she was scheduled for a shower and said she was going to stay over to bathe Resident #1. Central Supply further said she did not give incontinent care to Resident #1 earlier on the shift because Resident #1 was eating breakfast. The Administrator stated on 2/3/2017 at 3:20 p.m. the facility did not have a policy and procedure for staffing. Record review of the facility's undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health . Dignity and respect . You have the right to live in safe, decent, and clean conditions, be free from neglect . be treated with dignity, consideration and respect .Make your own choices regarding personal care . Record review of the facility policy and procedure Incontinent Care revised 5/2007 revealed in part: .It is the policy of this facility to remove urine or feces from skin Further record review revealed no information on how often the facility provided incontinent care to the residents. Record review of the facility policy and procedure ADL, Services to carry out revised 11/2007 revealed in part: .It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .2.- Residents who are unable to carry out activities of daily living will receive necessary services to maintain: grooming, personal hygiene . Record review of the facility policy and procedure Turning rounds revised 11/2007 revealed in part; .It is the policy of this facility to 1.- Cleanse, refresh and reposition bedfast residents on a regular basis . The CMS form 672 revealed 56 residents who were occasionally or frequently incontinent of bladder or bowel.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. -The facility failed to transfer Resident #1 using two person transfer, resulting in a fall with fractures to the resident's both lower extremities, resulting in hospitalization . -MA #1 and an unnamed CNA put Resident #1 back into bed after a fall and did not notify a nurse until the next day. These failures affected one resident and had the potential to place 10 current residents on 100 hall who require two person transfers at risk of physical harm, pain, and/or hospitalization . Findings include: Incident Intake # 2/TX 563 Resident #1 Record review of Resident #1's admission face sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE]. Record review of Resident #1's incident report dated 12/30/16 revealed that on 12/29/16, Resident #1 reported knee pain to the nurse. There was swelling. The nurse reported it to the doctor who ordered an X ray and pain medication. On 12/30/16, the X ray results indicated there was a fracture of the left femur and right knee. Record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 14 out of 15 which indicted her cognition was intact. The resident required extensive assistance from two staff for her transfers. She required extensive assistance from one staff for bed mobility, dressing, toilet use and personal hygiene. Continued review of the MDS revealed the resident did not have limitations in her range of motion. Record review of Resident #1's electronic care plan date initiated 10/27/2016 revealed the following: -Focus Area: At risk for activities of daily living (ADL) self-care performance deficit related to limited mobility; -Interventions: Transfers: Requires (2) staff participation with transfers. Record review of Resident #1's electronic consolidated physician orders revealed the order dated 12/29/2016 X-Ray of both bilateral knees related to swelling and pain. Record review of Resident #1's electronic clinical nurses' note dated 12/29/2016 revealed, X-ray ordered for bilateral knee swelling and pain. Record review of Resident #1's clinical notes dated 12/30/2016 revealed resident complained of knee pain. The X-ray results were received and showed a right knee fracture and left femur fracture. Resident #1 was being transferred to a local hospital. Record review of the facility Radiology Report for Resident #1 dated 12/30/2016 revealed, - Conclusion: Supracondylar fracture left femur . Supracondylar fracture right knee. In an interview on 1/10/2017 at 8:35 a.m. the Administrator stated that on 12/28/2016 MA #1 attempted to transfer Resident #1 in to bed without help because she was unable to locate someone to help her. MA #1 was unable transfer the resident and had to lower the resident to the floor mat. The Administrator stated, according to MA #1, she looked in the hall for a nurse but she was unable to find one and MA #1 asked a CNA to help her. They lifted Resident #1 back to bed. MA #1 left the room to tell the nurse about what happened, but she got pulled away and started to give medications. MA #1 forgot to tell anyone until the next day. The Administrator stated the resident had chronic knee pain but had increase complaint of pain along with swelling on 12/29/2016. Observation and interview on 1/10/2017 at 10:30 a.m. revealed Resident #1 in bed on her left side. She was alert and oriented. Resident #1 had soft ace wrap splints on both of her lower extremities from her thighs to her ankles. Resident #1 said that it normally took two staff to transfer her, but this time the staff tried it alone. Resident #1 stated she went down to the floor. Then a second person came and put her into bed. In an interview on 1/10/2017 at 11:20 a.m., the DON stated that during the facility investigation, MA #1 stated she was passing medications when the resident asked her to help her to bed. Then the resident started yelling out and crying to go back to bed. The DON said that MA #1 should have gotten help but, according to what MA #1 reported, she felt she could help the resident into bed. MA #1 had to lower the resident to the floor mat. MA #1 looked for the nurse but she was unable to find her. She asked a CNA to help her put the resident into bed. After the resident was in bed, MA #1 left the room to tell the nurse, but residents asked her for medications and she forgot. According to MA #1, the next morning she heard the nurse say the resident had knee pain and swelling and that was when MA #1 remembered and notified them of the incident. Resident #1 had rheumatoid arthritis and always had pain and swelling that was why the X-Ray was not done stat. In an interview on 1/10/2017 at 2:00 p.m., MA #1 stated she went into Resident #1's room to give her routine scheduled pain medication. Resident #1 asked to go back to bed then she started yelling to go back to bed. MA #1 stated she looked in the hall and could not find help then she looked at the resident and felt she was small and would be able to transfer her. MA #1 stated Resident #1 was really yelling to go back to bed and she was trying to help her. MA #1 stated she began to transfer the resident and she had to lower the resident to the floor mat. She found a CNA who helped put Resident#1 back to bed. MA #1 stated she went to get the nurse but the other residents were asking for their medications and she got involved it passing medications. She forgot to notify the nurse until the next morning when she heard the resident had more pain and swelling in her knees. Record review of the facility policy titled, Quality of Care Transfer of a Resident, Safe Revision dated 05/2007 revealed, . It is the policy of this facility to transfer a resident in a safe manner . A transfer is the safe movement of a resident from one surface to another . The facility roster identified 11 residents on 100 hall who require two person transfer.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for one of nine residents (CR #2) reviewed for unecessary medications. -The facility failed to consult and report to CR #2's physician timely abnormal blood clotting laboratory values including panic high values. The facility continuously administered [MEDICATION NAME] (blood thinner medication) without checking the blood clotting laboratory values and without consulting with the MD on several occasions. CR#2 started a new antibiotic on 9/13/2016 that affected the resident's blood clotting values. -The facility failed to monitor CR #2's blood glucose while at the facility which led CR#2 to experience signs and symptoms of [MEDICAL CONDITION]. The facility also failed to recognize and thoroughly assess for signs and symptoms of [MEDICAL CONDITION] when CR #2 had a change in condition. An IJ was identified on 09/23/16. While the IJ was removed on 09/26/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected one CR and could place 5 residents at the facility receiving [MEDICATION NAME] medication and 29 residents who were identified diabetic at risk of not receiving adequate assessments, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings included: Intake # 8 Record review of the facility face sheet revealed CR# 2 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was sent to the hospital on [DATE] per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Record review of CR #2's hospital discharge packet printed on September 1, 2016 at 9:11 a.m. revealed in part Active medications as of August 31, 2016: Insulin [MEDICATION NAME] (rapid), low dose correction scale, give before meals subcutaneous. -0 units if blood glucose 70-140 -1 unit if blood glucose 141 - 220 -2 units if blood glucose 221-260 -3 units if blood glucose 261-280 -4 units if blood glucose 281 - 300 -5 units and call MD if blood glucose is above 300. Other discharge instructions: Diabetes Mellitus: Keep your blood sugars in the near normal range, Test your blood sugar regularly Record review of CR #2's admitting MD orders dated 9/1/2016 at 5:30 p.m. revealed no orders for insulin or blood sugar monitoring. Further record review revealed the following orders: -9/1/2016, [MEDICATION NAME] tablet 10 mg one tablet by mouth two times a day for diabetes. -9/2/2016, [MEDICATION NAME] sodium ([MEDICATION NAME]) tablet 4 mg, give 1 tablet by mouth in the evening for blood thinner. Record review of CR#2's telephone order dated 9/5/2016 revealed in part: -PT/INR on Wednesday and Fridays. (blood test that measures how long it takes blood to clot) Record review of the admission MDS dated [DATE] revealed CR #2 had severe cognitive impairment with a BIMS score of 2 out of a possible 15. She required extensive assistance for all her activities of daily living. She was always incontinent of bowel and bladder. CR #2 had received anticoagulant therapy on 4 of the last 7 days prior to assessment. Record review of CR #2's care plan revealed there was no care plan until 9/16/2016 and read in part: -Focus: CR#2 has diabetes mellitus. Goal: Will have no complications related to diabetes through the review date. Target date 9/23/2016. -Interventions: Diabetes medication as ordered by MD. Monitor/document for side effects and effectiveness. Record review of CR #2's care plan revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Continued record review revealed that CR #2's care plan for anticoagulant therapy was created on 9/21/2016 (after CR #2 was discharged from facility) revealed in part: -Focus: Anticoagulant therapy related to [MEDICAL CONDITION]. [MEDICATION NAME] (blood thinner). -Goal: will be free from adverse reactions related to anticoagulant use through the review date of 9/23/2016. -Interventions: Laboratory as ordered. Report abnormal laboratory results to the MD. Monitor/document/report to MD as needed sign and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, short of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Record review of CR #2's telephone MD orders dated 9/13/2016 at 1:46 p.m. revealed orders in part; -[MEDICATION NAME] (antibiotic) tablet 500 mg, give one tablet by mouth one time a day for right lower lobe pneumonia for 7 days. Further record review revealed that CR #2's care plan for antibiotic therapy was also created on 9/21/2016 (after CR#2's discharge) and revealed in part: -CR#2 has pneumonia. On [MEDICATION NAME] (antibiotic) 500 mg. every day for 7 days as of 9/13/2016. The care plan did not mention information related to effects of [MEDICATION NAME] and [MEDICATION NAME] with interventions in place. Record review of http://www.online.factsandcomparison.com.Drug/Interaction revealed that [MEDICATION NAME] and [MEDICATION NAME] had a drug interaction. Further record review revealed in part; -Effects: [MEDICATION NAME] (blood condition that results in impaired blood clotting, leading to increased risk for bleeding) effects of [MEDICATION NAME] Oral may be increased by [MEDICATION NAME] Oral. Dosage reduction of [MEDICATION NAME] Oral may be required.MECHANISM: Unknown.MANAGEMENT: Dosage reduction of [MEDICATION NAME] Oral may be needed during concurrent administration of [MEDICATION NAME] Oral. Coagulation status should be monitored, at least during the initial period of concomitant use, and the anticoagulant dose should be adjusted, if needed, accordingly. An alternative antimicrobial agent should be considered. Potentially severe or life-threatening reaction/interaction. Record review of CR #2's progress/nursing notes revealed in part; -9/3/2016 at 12:02 p.m. .RP stated concern that CR #2 very sleepy for therapy. Encouraged to let resident get adjusted to facility. CR #2 awakens easily to verbal stimuli and has no sign and symptoms of sedation at this time. Will continued to monitor Note signed by LVN C. In an interview on 9/25/2016 at 12:05 p.m. with LVN C, she stated that there were days that CR #2 appeared tired or sleepy but was easily arousable. When asked if she knew CR#2 was diabetic, LVN C responded yes. When asked if she ever thought about checking CR #2's blood glucose levels, LVN C stated that CR #2 did not have orders for her blood glucose to be checked. Further record review of CR #2's progress/nursing notes revealed in part; -9/8/2016 at 3:31 p.m. .Spoke with RP via phone. Concern that she noticed CR#2 very sleepy and not eating her dinner when visited Note signed by DON. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Record review of CR#2's laboratory report revealed in part; -9/9/2016 at 10:30 a.m. and faxed to the facility on [DATE] at 1:52 p.m. [MEDICATION NAME] Time of 46.1 seconds, High, Reference range (9.5 - 13.70)(measures in seconds the time that take for your plasma to clot). INR Ratio 3.81, High, Reference range (0.8 - 1.2) (INR- international normalized ratio index of blood coagulability). Further record review revealed hand written note MD notified. New order for [MEDICATION NAME] 3 mg . Continued record review of CR#2's phone orders revealed in part; -9/9/2016 at 8:22 p.m. Discontinue [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 4mg. [MEDICATION NAME] Sodium tablet 3 mg, one tablet by mouth in the evening for blood thinner. Order obtained by LVN A. Record review of CR #2's MAR indicated [REDACTED] -9/9/2016 [MEDICATION NAME] Sodium tablet 4 mg by mouth in the evening for blood thinner was administered at 5 p.m. In an interview on 9/23/2016 at 2:10 p.m. with LVN A, who was the 2 to 10 p.m. charge nurse, she said that on 9/9/2016 she was not able to contact CR #2's MD to notify the abnormal INR laboratory results until after 6:00 p.m. and that CR #2 had already received the [MEDICATION NAME] medication at 5:00 p.m. Record review of CR#2's laboratory report revealed in part; -9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m. [MEDICATION NAME] Time of 39.7 seconds, High, Reference range (9.5 - 13.70) INR Ratio 3.30, High, Reference range (0.8 - 1.2) Further record review revealed that MD was not consulted about laboratory report until the next day. Report had a hand written note 9/14/2016 completed. Changed dose to 2 mg. Record review of progress/nursing notes dated 9/14/2016 at 12:15 p.m. signed by LVN B revealed in part MD changed [MEDICATION NAME] order from 3 mg to 2 mg daily . Record review of CR #2's progress/nursing notes dated for 9/13/2016 revealed no information that MD was contacted on abnormal laboratory values of 9/13/2016. Record review of CR #2's MAR indicated [REDACTED] -9/13/2016 [MEDICATION NAME] Sodium tablet 3 mg by mouth in the evening for blood thinner was administered at 5 p.m. Further interview on 9/23/2016 at 2:10 p.m. with LVN A, When asked if she was able to follow up on CR #2's abnormal laboratory report dated 9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m., LVN A stated every shift is supposed to collect their laboratory reports from the fax machine and follow up on their shifts. Record review of CR #2's Medication Administration Record [REDACTED]. Record review of CR#2's Order Summary Report revealed in part: -9/14/2016, [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 2 mg by mouth in the evening for blood thinner. Record review of CR#2's laboratory report revealed in part; -9/14/2016 at 6:35 a.m. and faxed to the facility on [DATE] at 2:00 p.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Report contains Panic values. Critical results referred to client service. Call was made to facility on 9/14/2016 at 1:55 p.m., left on hold until 2:00 p.m; no answer, will try again later. Called at 3:17 p.m., left on hold until 3:22 p.m; no answer, will fax results. Call was made on 9/14/2016 at 3:37 p.m. No answer. Further record review revealed a hand written note by LVN A that read Per MD hold [MEDICATION NAME]. Record review of CR #2's phone order dated 9/14/2016 at 5:33 p.m. by LVN A revealed order to hold [MEDICATION NAME] 2 mg tablet from 9/14/2016 thru 9/16/2016. Record review of CR #2's MAR indicated [REDACTED] -9/14/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN A. Record review of CR #2's progress/nursing notes dated 9/14/2016 at 7:24 p.m. and signed by LVN A revealed in part; CR #2 laboratory INR level > 9, MD notified and aware. New order to hold [MEDICATION NAME] . Continued interview with LVN A on 9/23/2016 at 2:10 p.m. stated that on 9/14/2016 she did not remember what time she got the critical INR results of CR#2 and further said I believe I texted to the MD and he said to hold [MEDICATION NAME]. I think it was around 7:00 p.m. I had already administered her schedule [MEDICATION NAME] LVN A further said that she was supposed to check the laboratory INR results before administering [MEDICATION NAME]. Record review of CR#2's laboratory report revealed in part; -9/15/2016 at 9:35 p.m. and faxed to the facility on [DATE] at 3:34 a.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Further record review revealed no information on laboratory report that the MD was made aware of results. Record review of CR #2's progress/nursing notes dated 9/16/2016 at 10:41 a.m. and signed by LVN B revealed in part: .[MEDICATION NAME] is on hold due to increase INR levels 9.0. MD notified In an interview on 9/23/2016 at 12:42 p.m. with LVN B, who was the 6:00 a.m. to 2:00 p.m. charge nurse, he stated that he did not talk to MD on 9/16/2016 regarding the laboratory results of CR #2 dated 9/15/2016. He further said that he wrote the note on CR #2's nursing/progress notes on 9/16/2016 at 10:41 a.m. because the MD had been notified on 9/14/2016 of the previous abnormal laboratory results and that he saw the laboratory report dated 9/15/2016 and that he did not notify the MD because the MD had been already notified the previous day and that the results were the same so he believe that he did not need to notify the MD again. Record review of CR #2's MAR for September 2016 revealed in part; -9/17/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN C (weekend nurse). In a phone interview on 9/23/2016 at 12:53 p.m. with LVN C, who was the weekend nurse, she stated that CR #2 was complaining of abdominal pain on 9/17/2016 before going to the hospital and that the daughter was very concerned for the condition of CR#2 and requested to send her to the hospital. When asked if CR #2 was assessed for sign and symptoms of hyper/[DIAGNOSES REDACTED] or bleeding, LVN C stated CR #2 only spoke Spanish. It was until the daughter that came to the facility that told me that CR #2 was having abdominal and flank pain. When asked if she thought about checking blood glucose levels for CR #2 during her assessment, LVN C stated that she did not think it was necessary and that there were no orders to check for blood glucose levels. Further interview with LVN C at that time, she stated that she signed CR #2's MAR indicated [REDACTED]we are supposed to monitor the PT/INR levels before [MEDICATION NAME] is given. Record review of CR #2's progress/nurses notes revealed in part; -9/17/2016 at 6:44 p.m. .RP requested CR #2 to be sent to a local hospital due to increase trouble swallowing and severe abdominal pain. MD made aware and gave orders to send to ER to evaluate. Blood pressure 135/67, pulse 79, temperature 96.8, respirations 18 .Ambulance notified of transfer to a local hospital. Pick up time will be 7:30 p.m Further record review revealed no assessments for hyper/[DIAGNOSES REDACTED] or for signs of bleeding. -9/17/2016 at 7:59 p.m. ambulance here to transport CR #2 to a local hospital Note signed by LVN C. Record review of CR #2's Change in Condition Evaluation dated 9/17/2016 at 7:25 p.m. revealed in part: The change in condition, symptoms or signs I am calling about is/are: . abdominal pain. This started on 9/17/2016 in the afternoon. Additional Diagnoses: [REDACTED].? Yes. Results of last INR: 9.0 dated 9/15/2016. Most recent blood glucose: No information written. Mental Status Evaluation (compared to baseline) No changes observed . Record review of CR #2's hospital emergency room report dated 9/17/2016 at 8:33 p.m. read in part; XXX[AGE] years old hispanic female presents to ED via EMS with complaints of altered mental status. EMS reports that CR #2's sugar was over 600 when it was checked. RP reports that CR #2 hasn't been eating or drinking for the past 2 days. RP reported that she tried to give water to CR #2 and she was not able to swallow. No insulin since CR #2 being moved to facility on the 1st of September Exam: CR #2 appears sleepy but arousable to painful stimulus, dry mucous membranes. She has diffuse extremity bruising, in particular her right leg and left arm. Decreased mental status. Vital signs: blood pressure 85/57, pulse 60, respirations 16 and temperature 98.5. INR 11.8 (Reference range 0.8 - 1.2) and blood sugar 734 mg/dL (reference range is 65-99 mg/dL). Medical Decision Making: Diabetic ketoacidosis, very elevated INR. I have ordered Vitamin K and fresh frozen plasma for her [MEDICATION NAME] toxicity. Will arrange for an ICU bed. Will continue insulin drip. Right sidewall hematoma Record review of CR #2 hospital history and physical dated 9/18/2016 revealed in part; .CR #2 is a [AGE] year old female, came in after worsening mental status and was noted to be in diabetic ketoacidosis and admitted for the same. CR #2 is in the ICU at this point. According to the RP, CR #2 has not been eating for the last few days. She was found to have INR of 11.8 and vitamin K was given. -Laboratory data: Blood sugar is 191 today. The blood sugar was initially 734 with an anion gap of 15 (Reference range is 3-11 mEq/L). (Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis). -Impression: diabetic ketoacidosis, [MEDICAL CONDITION], [MEDICATION NAME] toxicity, nonketotic hyperosmolar coma. -Plan: CR #2 is in ICU getting insulin. Blood sugar was improved to 179. As she already received vitamin K, we are going to follow her INR. We are going to continue insulin . Record review of CR #2 hospital history and physical dated 9/20/2016 revealed in part; .Came to the ER due to complaints of worsening mentation. RP stated that she noted CR #2's mentation significantly changed. CR #2 appeared extremely agitated, unable to follow commands and noticed a decline in CR #2's oral intake. INR was 11 upon arrival to the ER. CR #2's glucose was greater than 600 upon arrival and was started on insulin drip. CR #2 received vitamin K. CR #2 was admitted to intensive care unit for further evaluation and workup. Assessment: coagulopathy, acute [MEDICAL CONDITION] and diabetic ketoacidosis. Glucose has improved and INR remains subtherapeutic. Prognosis remains poor and guarded . Record review of CR#2's hospital CT scan dated 9/18/2016 revealed in part: .Clinical history: Left flank pain. Conclusion: pelvic sidewall hematoma . In an interview on 9/23/2016 at 10:15 a.m. with the ADON, she stated that the facility had just input all the INR readings on the MAR indicated [REDACTED]. She further said that she was responsible to monitor the INR levels and [MEDICATION NAME] administration on the residents and that nurses were responsible to check the fax machine daily on their shifts to monitor the laboratory reports faxed from the laboratory and that they were supposed to call the MD for abnormal reports as soon as possible. ADON then said that when the facility received critical laboratory values, the nurses were supposed to notify the MD as soon as possible. She continued saying that INR levels above 3 needed to be given to the MD timely. When asked regarding laboratory reports being faxed to the facility between 12 p.m. and 3:00 p.m. and the MD not being made aware until after the scheduled [MEDICATION NAME] had been administered to residents, the ADON stated there could be a lot of dynamics because we can call the MD and by the time the MD calls back. ADON then said that any attempt to call the MD should be written on the nurses notes. Further interview with the ADON at that time, when asked if she was aware that CR #2 had received her scheduled [MEDICATION NAME] on 9/9/2016 and 9/13/2016 before MD was made aware of abnormal results, ADON at that time reviewed CR #2's information on the computer and said I can't speak for somebody else. When asked if the MD was made aware CR #2's abnormal laboratory results dated [DATE] on 9/13/2016, the ADON stated as she looked at the computer I don't see it, but the panic INR levels on 9/14/2016 the MD was notified at 7:24 p.m. When asked at what time the panic INR levels arrived via fax to the facility on [DATE], the ADON said the report reads at 2:00 p.m. ADON then said as she looked at CR #2's MAR CR #2 had 2 mg of [MEDICATION NAME] on 9/14/2016. When asked why it took too long to make the MD aware of the panic INR level of CR #2 on 9/14/2016, the ADON stated I did not know that the MD was notified late but I knew that the [MEDICATION NAME] was held for 2 days due to INR 9.0. When asked if CR #2 received [MEDICATION NAME] on 9/17/2016 before she went to the hospital, the ADON stated as she read CR #2's MAR it has a check mark, it means that the [MEDICATION NAME] was given. The last laboratory report for CR #2 was on 9/15/2016 and still indicated that her INR levels were critical. The nurse was supposed to check at the laboratory reports before given the [MEDICATION NAME]. Continued interview with the ADON on 9/23/2016 at 11:03 a.m. she stated that CR #2 did not come with insulin orders from the hospital or orders to check the blood glucose. When asked if someone had checked the hospital records to find out if CR #2 was using insulin at the hospital, the ADON stated facility follows the orders sent from the hospital. There was information that CR #2 was on insulin before on the information we received before but when CR #2 was admitted to the facility, she did not come with insulin orders. Facility does not have standard protocol to check blood sugar on residents who are diabetic and do not have orders for insulin. ADON then said that she did not see that CR #2 was assessed for [MEDICAL CONDITION] symptoms or bleeding on 9/17/2016 before going to hospital and further said I see what you are saying, CR #2 had abdominal pain and had a change on her level of consciousness. In an interview on 9/23/2016 at 11:55 a.m. with LVN B, he stated that before, the ADON would get the laboratory reports from the fax machine and would distributed them to the nurses, but that now, the nurses were responsible for getting their own faxed reports from the fax machine. He then said that he usually checked the fax machine once at the beginning of the shift and then said, I don't check for faxes more often or at the end of the shift because there is no protocol to tell us when to check the fax machine for laboratory reports. When asked how did he know which residents had laboratory work so he can look for those reports, LVN B stated you go by what comes on the fax machine. There is no way to know who gets what. When asked regarding CR #2's fax report dated 9/13/2016 and faxed to the facility on [DATE] at 12:50 p.m., LVN B said that on 9/13/2016 he only checked the fax machine once at the beginning of the shift and that when he came back to work the next day on 9/14/2016 nobody had followed up with the MD so he notified the MD on 9/14/2016 and the MD gave orders to decrease the [MEDICATION NAME] from 3mg to 2 mg. and further said I don't know what happened on the p.m. shift, don't know why LVN A did not call the MD. Further interview with LVN B at that time, when asked if he was aware of CR #2's critical laboratory INR results on 9/14/2016, LVN B stated I did not get any calls from the laboratory and the fax did not come until 2 p.m. on 9/14/2016, that was the responsibility of LVN A. I check my faxes only once a day, at 6:00 a.m. and will not do it anymore. In an interview on 9/23/2016 at 1:12 p.m. with the DON, she stated that nurses were supposed to get their laboratory reports from the fax machine at least once a shift. When asked if she knew that MD was made aware of abnormal INR levels after nurses had administered the [MEDICATION NAME] dose, the DON stated We don't know, nurses come at 2 p.m. they get report. I am only speculating. Nobody knows where the laboratory report was. If orders were obtained after [MEDICATION NAME] was given, it means that the nurse was not aware of the INR results but as soon as the nurse was aware, the nurse called the MD and got orders. Nurses are not sitting by the fax machine. Further interview with the DON at that time, she stated that critical laboratory results were supposed to be called by the laboratory and that nurses were supposed to notify the MD as soon as possible. When asked if she was made aware of CR #2's critical INR levels on 9/14/2016. The DON stated as she looked the computer telephone order was obtained at 8:22 p.m. on 9/14/2016 and the MD gave orders to hold [MEDICATION NAME]. When asked to see the time the fax report arrived to the facility, the DON said fax says 2:00 p.m. Nobody knows where the report was. As soon as the nurse was made aware, she called the MD. Do I think the nurse notified the MD after she gave the [MEDICATION NAME]? yes. DON continued saying On 9/17/2016, LVN C informed ADON that CR #2 had [MEDICATION NAME] on 9/17/2016 at 5:00 p.m. and LVN C got an order for [REDACTED]. In a second interview on 9/23/2016 at 1:50 p.m. with the ADON, she stated that she found out that CR #2 got her [MEDICATION NAME] 2mg on 9/17/2016 at 5:00 p.m. because she was at her house and was monitoring in her computer the medications that were being administered by the facility staff, and that she noted that LVN C had signed for CR #2's [MEDICATION NAME] at 5:00 p.m. and that she texted her and asked her to call the MD and get orders for STAT PT/INR because she knew that CR #2's last INR was 9.0 and CR #2 had orders to hold the [MEDICATION NAME]. ADON then said that CR #2 went out to the hospital before having her blood drawn. Observation on 9/23/2016 at 4:13 p.m. revealed CR #2 was at a local hospital. CR #2 was lying on an air mattress and was non-verbal. CR #2 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes)AC. CR #2 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with [MEDICATION NAME] (antibiotic) 500mg/100mg at 100 ml per hour. In continued observation, CR #2 was noted to have a foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. CR#2 had oxygen at 5 liters per minute via nasal cannula. Continued observation at that time revealed that CR #2 had dark purple bruising to her right upper and left entire arms. When tried to talk to CR #2, she would moan. Interview on 9/23/2016 at 4:19 p.m. with the hospital RN, she stated that CR#2 came to the hospital with super high blood sugar levels and abnormally high INR levels and further said [MEDICATION NAME] is still on hold. CR#2 is on a sliding scale insulin and we are checking her blood glucose every 4 hours. In an interview on 9/25/2016 at 11:05 a.m. with the DON, she stated that the facility had IDT meetings with all new residents within 72 hours of admission and that during those meetings the staff would go over the plan of care and the goals with the family, would review the medications and the food preferences with the resident and the family. When asked if the facility had an IDT meeting with CR #2 and her family. The DON looked at the computer and said I can't find any IDT meeting for CR #2. I would need to find out with the MDS nurse. MDS nurse is not here today but she is in charge of coordinating the meetings. When asked if the facility staff was aware of the effects of [MEDICATION NAME] on residents who were on [MEDICATION NAME], the DON stated [MEDICATION NAME] affects the laboratory values, not sure if anyone alerted the MD. Further interview at that time, the DON stated that the MDS nurse was in charge of updating the care plans. DON then said that she did not know if the care plan for CR#2 was further updated after the patient went to the hospital and said I will go and check with the nurse consultant. She is the one that updated the care plan on 9/21/2016. In a second interview on 9/25/2016 at 11:35 a.m. with LVN C, she stated that CR#2 was on [MEDICATION NAME] (antibiotic) for pneumonia and that she did not know if there were any effects between [MEDICATION NAME] and [MEDICATION NAME]. Further interview at that time, LVN C stated that on 9/17/2016 nobody gave her report that CR#2's INR levels were critical high until the ADON texted her at 5:30 p.m. and asked her to get STAT orders for PT/INR for CR#2. In a phone interview on 9/28/2016 at 3:01 p.m. with CR #2's RP, she stated that CR#2 was diabetic and had always being on insulin. She further said that at home, CR#2 was on oral medications for diabetes and insulin as well. RP continued saying that on 9/17/2016 when she visited CR#2 at around 5:30 p.m. she was trying to wake her up because CR#2 was very sleepy, very weak and couldn't hold herself up. She then said that she had noticed before that CR#2 was lethargic and having difficulties staying awake. However, that on 9/17/2016, RP was very scared because CR#2 was very pale and started shaking so bad and her mouth was so dry but couldn't swallow anything and was complaining of abdominal pain. RP further said that at that moment she believed CR#2 probably had another stroke and that she requested the nurse send CR#2 to the hospital. RP then said that the nurse at the facility (LVN C) told her that she should wait one more day that CR#2 probably was constipated. RP further said that she insisted on sending CR#2 to the hospital and that the facility finally helped her to send CR#2 to the hospital. The RP then stated that the facility never invited her for any meeting to discuss the medications or the care that CR#2 required and that she was under the impression that CR#2 was receiving insulin at the facility and her blood sugar was being monitored. Record review of the facility policy and procedure Laboratory Test Protocol revised 9/2016 revealed in part: .10.- All laboratory reports with abnormal results will be called to the MD immediately and document in the progress note. 11.- Fax machine is located in the main nurses station. Fax machine are to be checked every shift, every 2 hours for laboratory reports. 12.- DON/designee will conduct daily audit of the laboratory with the date of the test, the date returned, time of MD notification and documentation in place If lab is abnormal you are required to do the following: 1.- Notify the MD and RP 2.- Be specific what is going on Ex. Follow up day 2/3 PT/INR 6.31. [MEDICATION NAME] remains on hold. No signs/symptoms of bleeding noted. Place patient in follow up and chart on patient every shift . Record review of the facility policy and procedure revised December 2005 revealed in part: The facility will implement a medication management program that incorporates systems with established goals to meet each patient's needs as well as our regulatory requirements. Preparation for Medication pass: 3.- Licensed staff must understand: A. Reason for therapy B. Effectiveness of the therapeutic goal. C. Drug actions D. The seven rights for administering medication . Further record review revealed no information on therapeutic drug monitoring prior to administration on medications that require laboratory monitoring to measure the effect on the residents' body such as [MEDICATION NAME]. Record review of the facility policy and procedure Change of condition reporting revised 5/2007 re

Based on interview and record review, the Administration failed to oversee the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for one of nine residents (CR#2) reviewed for [MEDICATION NAME] administration, abnormal laboratory reports, diabetes management and MD notification. -The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect when CR #2 was administered [MEDICATION NAME] (blood thinner medication) without checking the blood clotting laboratory values and without consulting with the MD on several occasions. -The Administrator failed to develop a system of communication between the facility and the laboratory to notify abnormal laboratory values and a communication system between nurses and the MD related to abnormal laboratory values and [MEDICATION NAME] administration. --The Administrator failed to supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessment and monitoring of medical conditions, such as sign and symptoms of hypo/[MEDICAL CONDITION] including MD notifications. --The DON failed to train all staff to monitor, thoroughly assess, and consult with physicians concerning critical laboratory values, [MEDICATION NAME] administration and identifying changes in resident condition related to signs and symptoms of hypo/[MEDICAL CONDITION]. --The DON failed to supervise the nursing staff regarding consulting with the physician prior to medication administration of [MEDICATION NAME] when residents' laboratory values were abnormal and ensure that nursing staff would monitor laboratory reports in a timely manner to report to the MD. -The DON failed to have a system in place for reviewing hospital medications to medications ordered by the facility on new admitted residents. -CR #2 was sent to the hospital per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. An IJ was identified on 09/23/16. While the IJ was removed on 09/26/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected one CR and could place 5 residents at the facility receiving [MEDICATION NAME] medication and 29 residents who were identified diabetic at risk of not receiving adequate assessments, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings included: Intake # 8 In an interview on 9/25/2016 at 12:10 p.m. with the DON, when asked how did she think this incident of IJ came about, the DON stated that in both instances there was a failure to follow the nursing practice from the nurses part. She further said that nurses did not follow protocols to check the laboratory values prior to administering [MEDICATION NAME]. DON then said that if a resident was lethargic and had [DIAGNOSES REDACTED]. This was a failure to identify and assess CR#2 for signs and symptoms of [MEDICAL CONDITION]. In an interview on 9/26/2016 at 1:25 p.m. with the Administrator, he stated that he was not aware of the IJ situation. He further said that he believed it was just oversight and that he believed that more validations and staff to do more rounds with the residents was needed. He then said that the facility did daily rounds on selected residents where they review the residents' diagnoses, orders and that having people checking behind each other was a way to monitor that the care of the residents were provided. Administrator further said that due to the latest changes in the facility, he was not participating much on daily rounds but that after this situation, he was going to make sure he was there on daily rounds to monitor the care of the residents. Record review of the facility face sheet revealed CR# 2 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was sent to the hospital on [DATE] per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Record review of CR #2's hospital discharge packet printed on September 1, 2016 at 9:11 a.m. revealed in part Active medications as of August 31, 2016: Insulin [MEDICATION NAME] (rapid), low dose correction scale, give before meals subcutaneous. -0 units if blood glucose 70-140 -1 unit if blood glucose 141 - 220 -2 units if blood glucose 221-260 -3 units if blood glucose 261-280 -4 units if blood glucose 281 - 300 -5 units and call MD if blood glucose is above 300. Other discharge instructions: Diabetes Mellitus: Keep your blood sugars in the near normal range, Test your blood sugar regularly Record review of CR #2's admitting MD orders dated 9/1/2016 at 5:30 p.m. revealed no orders for insulin or blood sugar monitoring. Further record review revealed the following orders: -9/1/2016, [MEDICATION NAME] tablet 10 mg one tablet by mouth two times a day for diabetes. -9/2/2016, [MEDICATION NAME] sodium ([MEDICATION NAME]) tablet 4 mg, give 1 tablet by mouth in the evening for blood thinner. Record review of CR#2's telephone order dated 9/5/2016 revealed in part: -PT/INR on Wednesday and Fridays. (blood test that measures how long it takes blood to clot) Record review of the admission MDS dated [DATE] revealed CR #2 had severe cognitive impairment with a BIMS score of 2 out of a possible 15. She required extensive assistance for all her activities of daily living. She was always incontinent of bowel and bladder. CR #2 had received anticoagulant therapy on 4 of the last 7 days prior to assessment. Record review of CR #2's care plan revealed there was no care plan until 9/16/2016 and read in part: -Focus: CR#2 has diabetes mellitus. Goal: Will have no complications related to diabetes through the review date. Target date 9/23/2016. -Interventions: Diabetes medication as ordered by MD. Monitor/document for side effects and effectiveness. Record review of CR #2's care plan revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Continued record review revealed that CR #2's care plan for anticoagulant therapy was created on 9/21/2016 (after CR #2 was discharged from facility) revealed in part: -Focus: Anticoagulant therapy related to [MEDICAL CONDITION]. [MEDICATION NAME] (blood thinner). -Goal: will be free from adverse reactions related to anticoagulant use through the review date of 9/23/2016. -Interventions: Laboratory as ordered. Report abnormal laboratory results to the MD. Monitor/document/report to MD as needed sign and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, short of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Record review of CR #2's telephone MD orders dated 9/13/2016 at 1:46 p.m. revealed orders in part; -[MEDICATION NAME] (antibiotic) tablet 500 mg, give one tablet by mouth one time a day for right lower lobe pneumonia for 7 days. Further record review revealed that CR #2's care plan for antibiotic therapy was also created on 9/21/2016 (after CR#2's discharge) and revealed in part: -CR#2 has pneumonia. On [MEDICATION NAME] (antibiotic) 500 mg. every day for 7 days as of 9/13/2016. The care plan did not mention information related to effects of [MEDICATION NAME] and [MEDICATION NAME] with interventions in place. Record review of http://www.online.factsandcomparison.com.Drug/Interaction revealed that [MEDICATION NAME] and [MEDICATION NAME] had a drug interaction. Further record review revealed in part; -Effects: [MEDICATION NAME] (blood condition that results in impaired blood clotting, leading to increased risk for bleeding) effects of [MEDICATION NAME] Oral may be increased by [MEDICATION NAME] Oral. Dosage reduction of [MEDICATION NAME] Oral may be required.MECHANISM: Unknown.MANAGEMENT: Dosage reduction of [MEDICATION NAME] Oral may be needed during concurrent administration of [MEDICATION NAME] Oral. Coagulation status should be monitored, at least during the initial period of concomitant use, and the anticoagulant dose should be adjusted, if needed, accordingly. An alternative antimicrobial agent should be considered. Potentially severe or life-threatening reaction/interaction. Record review of CR #2's progress/nursing notes revealed in part; -9/3/2016 at 12:02 p.m. .RP stated concern that CR #2 very sleepy for therapy. Encouraged to let resident get adjusted to facility. CR #2 awakens easily to verbal stimuli and has no sign and symptoms of sedation at this time. Will continued to monitor Note signed by LVN C. In an interview on 9/25/2016 at 12:05 p.m. with LVN C, she stated that there were days that CR #2 appeared tired or sleepy but was easily arousable. When asked if she knew CR#2 was diabetic, LVN C responded yes. When asked if she ever thought about checking CR #2's blood glucose levels, LVN C stated that CR #2 did not have orders for her blood glucose to be checked. Further record review of CR #2's progress/nursing notes revealed in part; -9/8/2016 at 3:31 p.m. .Spoke with RP via phone. Concern that she noticed CR#2 very sleepy and not eating her dinner when visited Note signed by DON. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Record review of CR#2's laboratory report revealed in part; -9/9/2016 at 10:30 a.m. and faxed to the facility on [DATE] at 1:52 p.m. [MEDICATION NAME] Time of 46.1 seconds, High, Reference range (9.5 - 13.70)(measures in seconds the time that take for your plasma to clot). INR Ratio 3.81, High, Reference range (0.8 - 1.2) (INR- international normalized ratio index of blood coagulability). Further record review revealed hand written note MD notified. New order for [MEDICATION NAME] 3 mg . Continued record review of CR#2's phone orders revealed in part; -9/9/2016 at 8:22 p.m. Discontinue [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 4mg. [MEDICATION NAME] Sodium tablet 3 mg, one tablet by mouth in the evening for blood thinner. Order obtained by LVN A. Record review of CR #2's MAR indicated [REDACTED] -9/9/2016 [MEDICATION NAME] Sodium tablet 4 mg by mouth in the evening for blood thinner was administered at 5 p.m. In an interview on 9/23/2016 at 2:10 p.m. with LVN A, who was the 2 to 10 p.m. charge nurse, she said that on 9/9/2016 she was not able to contact CR #2's MD to notify the abnormal INR laboratory results until after 6:00 p.m. and that CR #2 had already received the [MEDICATION NAME] medication at 5:00 p.m. Record review of CR#2's laboratory report revealed in part; -9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m. [MEDICATION NAME] Time of 39.7 seconds, High, Reference range (9.5 - 13.70) INR Ratio 3.30, High, Reference range (0.8 - 1.2) Further record review revealed that MD was not consulted about laboratory report until the next day. Report had a hand written note 9/14/2016 completed. Changed dose to 2 mg. Record review of progress/nursing notes dated 9/14/2016 at 12:15 p.m. signed by LVN B revealed in part MD changed [MEDICATION NAME] order from 3 mg to 2 mg daily . Record review of CR #2's progress/nursing notes dated for 9/13/2016 revealed no information that MD was contacted on abnormal laboratory values of 9/13/2016. Record review of CR #2's MAR indicated [REDACTED] -9/13/2016 [MEDICATION NAME] Sodium tablet 3 mg by mouth in the evening for blood thinner was administered at 5 p.m. Further interview on 9/23/2016 at 2:10 p.m. with LVN A, When asked if she was able to follow up on CR #2's abnormal laboratory report dated 9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m., LVN A stated every shift is supposed to collect their laboratory reports from the fax machine and follow up on their shifts. Record review of CR #2's Medication Administration Record [REDACTED]. Record review of CR#2's Order Summary Report revealed in part: -9/14/2016, [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 2 mg by mouth in the evening for blood thinner. Record review of CR#2's laboratory report revealed in part; -9/14/2016 at 6:35 a.m. and faxed to the facility on [DATE] at 2:00 p.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Report contains Panic values. Critical results referred to client service. Call was made to facility on 9/14/2016 at 1:55 p.m., left on hold until 2:00 p.m; no answer, will try again later. Called at 3:17 p.m., left on hold until 3:22 p.m; no answer, will fax results. Call was made on 9/14/2016 at 3:37 p.m. No answer. Further record review revealed a hand written note by LVN A that read Per MD hold [MEDICATION NAME]. Record review of CR #2's phone order dated 9/14/2016 at 5:33 p.m. by LVN A revealed order to hold [MEDICATION NAME] 2 mg tablet from 9/14/2016 thru 9/16/2016. Record review of CR #2's MAR indicated [REDACTED] -9/14/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN A. Record review of CR #2's progress/nursing notes dated 9/14/2016 at 7:24 p.m. and signed by LVN A revealed in part; CR #2 laboratory INR level > 9, MD notified and aware. New order to hold [MEDICATION NAME] . Continued interview with LVN A on 9/23/2016 at 2:10 p.m. stated that on 9/14/2016 she did not remember what time she got the critical INR results of CR#2 and further said I believe I texted to the MD and he said to hold [MEDICATION NAME]. I think it was around 7:00 p.m. I had already administered her schedule [MEDICATION NAME] LVN A further said that she was supposed to check the laboratory INR results before administering [MEDICATION NAME]. Record review of CR#2's laboratory report revealed in part; -9/15/2016 at 9:35 p.m. and faxed to the facility on [DATE] at 3:34 a.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Further record review revealed no information on laboratory report that the MD was made aware of results. Record review of CR #2's progress/nursing notes dated 9/16/2016 at 10:41 a.m. and signed by LVN B revealed in part: .[MEDICATION NAME] is on hold due to increase INR levels 9.0. MD notified In an interview on 9/23/2016 at 12:42 p.m. with LVN B, who was the 6:00 a.m. to 2:00 p.m. charge nurse, he stated that he did not talk to MD on 9/16/2016 regarding the laboratory results of CR #2 dated 9/15/2016. He further said that he wrote the note on CR #2's nursing/progress notes on 9/16/2016 at 10:41 a.m. because the MD had been notified on 9/14/2016 of the previous abnormal laboratory results and that he saw the laboratory report dated 9/15/2016 and that he did not notify the MD because the MD had been already notified the previous day and that the results were the same so he believe that he did not need to notify the MD again. Record review of CR #2's MAR for September 2016 revealed in part; -9/17/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN C (weekend nurse). In a phone interview on 9/23/2016 at 12:53 p.m. with LVN C, who was the weekend nurse, she stated that CR #2 was complaining of abdominal pain on 9/17/2016 before going to the hospital and that the daughter was very concerned for the condition of CR#2 and requested to send her to the hospital. When asked if CR #2 was assessed for sign and symptoms of hyper/[DIAGNOSES REDACTED] or bleeding, LVN C stated CR #2 only spoke Spanish. It was until the daughter that came to the facility that told me that CR #2 was having abdominal and flank pain. When asked if she thought about checking blood glucose levels for CR #2 during her assessment, LVN C stated that she did not think it was necessary and that there were no orders to check for blood glucose levels. Further interview with LVN C at that time, she stated that she signed CR #2's MAR indicated [REDACTED]we are supposed to monitor the PT/INR levels before [MEDICATION NAME] is given. Record review of CR #2's progress/nurses notes revealed in part; -9/17/2016 at 6:44 p.m. .RP requested CR #2 to be sent to a local hospital due to increase trouble swallowing and severe abdominal pain. MD made aware and gave orders to send to ER to evaluate. Blood pressure 135/67, pulse 79, temperature 96.8, respirations 18 .Ambulance notified of transfer to a local hospital. Pick up time will be 7:30 p.m Further record review revealed no assessments for hyper/[DIAGNOSES REDACTED] or for signs of bleeding. -9/17/2016 at 7:59 p.m. ambulance here to transport CR #2 to a local hospital Note signed by LVN C. Record review of CR #2's Change in Condition Evaluation dated 9/17/2016 at 7:25 p.m. revealed in part: The change in condition, symptoms or signs I am calling about is/are: . abdominal pain. This started on 9/17/2016 in the afternoon. Additional Diagnoses: [REDACTED].? Yes. Results of last INR: 9.0 dated 9/15/2016. Most recent blood glucose: No information written. Mental Status Evaluation (compared to baseline) No changes observed . Record review of CR #2's hospital emergency room report dated 9/17/2016 at 8:33 p.m. read in part; XXX[AGE] years old hispanic female presents to ED via EMS with complaints of altered mental status. EMS reports that CR #2's sugar was over 600 when it was checked. RP reports that CR #2 hasn't been eating or drinking for the past 2 days. RP reported that she tried to give water to CR #2 and she was not able to swallow. No insulin since CR #2 being moved to facility on the 1st of September Exam: CR #2 appears sleepy but arousable to painful stimulus, dry mucous membranes. She has diffuse extremity bruising, in particular her right leg and left arm. Decreased mental status. Vital signs: blood pressure 85/57, pulse 60, respirations 16 and temperature 98.5. INR 11.8 (Reference range 0.8 - 1.2) and blood sugar 734 mg/dL (reference range is 65-99 mg/dL). Medical Decision Making: Diabetic ketoacidosis, very elevated INR. I have ordered Vitamin K and fresh frozen plasma for her [MEDICATION NAME] toxicity. Will arrange for an ICU bed. Will continue insulin drip. Right sidewall hematoma Record review of CR #2 hospital history and physical dated 9/18/2016 revealed in part; .CR #2 is a [AGE] year old female, came in after worsening mental status and was noted to be in diabetic ketoacidosis and admitted for the same. CR #2 is in the ICU at this point. According to the RP, CR #2 has not been eating for the last few days. She was found to have INR of 11.8 and vitamin K was given. -Laboratory data: Blood sugar is 191 today. The blood sugar was initially 734 with an anion gap of 15 (Reference range is 3-11 mEq/L). (Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis). -Impression: diabetic ketoacidosis, [MEDICAL CONDITION], [MEDICATION NAME] toxicity, nonketotic hyperosmolar coma. -Plan: CR #2 is in ICU getting insulin. Blood sugar was improved to 179. As she already received vitamin K, we are going to follow her INR. We are going to continue insulin . Record review of CR #2 hospital history and physical dated 9/20/2016 revealed in part; .Came to the ER due to complaints of worsening mentation. RP stated that she noted CR #2's mentation significantly changed. CR #2 appeared extremely agitated, unable to follow commands and noticed a decline in CR #2's oral intake. INR was 11 upon arrival to the ER. CR #2's glucose was greater than 600 upon arrival and was started on insulin drip. CR #2 received vitamin K. CR #2 was admitted to intensive care unit for further evaluation and workup. Assessment: coagulopathy, acute [MEDICAL CONDITION] and diabetic ketoacidosis. Glucose has improved and INR remains subtherapeutic. Prognosis remains poor and guarded . Record review of CR#2's hospital CT scan dated 9/18/2016 revealed in part: .Clinical history: Left flank pain. Conclusion: pelvic sidewall hematoma . In an interview on 9/23/2016 at 10:15 a.m. with the ADON, she stated that the facility had just input all the INR readings on the MAR indicated [REDACTED]. She further said that she was responsible to monitor the INR levels and [MEDICATION NAME] administration on the residents and that nurses were responsible to check the fax machine daily on their shifts to monitor the laboratory reports faxed from the laboratory and that they were supposed to call the MD for abnormal reports as soon as possible. ADON then said that when the facility received critical laboratory values, the nurses were supposed to notify the MD as soon as possible. She continued saying that INR levels above 3 needed to be given to the MD timely. When asked regarding laboratory reports being faxed to the facility between 12 p.m. and 3:00 p.m. and the MD not being made aware until after the scheduled [MEDICATION NAME] had been administered to residents, the ADON stated there could be a lot of dynamics because we can call the MD and by the time the MD calls back. ADON then said that any attempt to call the MD should be written on the nurses notes. Further interview with the ADON at that time, when asked if she was aware that CR #2 had received her scheduled [MEDICATION NAME] on 9/9/2016 and 9/13/2016 before MD was made aware of abnormal results, ADON at that time reviewed CR #2's information on the computer and said I can't speak for somebody else. When asked if the MD was made aware CR #2's abnormal laboratory results dated [DATE] on 9/13/2016, the ADON stated as she looked at the computer I don't see it, but the panic INR levels on 9/14/2016 the MD was notified at 7:24 p.m. When asked at what time the panic INR levels arrived via fax to the facility on [DATE], the ADON said the report reads at 2:00 p.m. ADON then said as she looked at CR #2's MAR CR #2 had 2 mg of [MEDICATION NAME] on 9/14/2016. When asked why it took too long to make the MD aware of the panic INR level of CR #2 on 9/14/2016, the ADON stated I did not know that the MD was notified late but I knew that the [MEDICATION NAME] was held for 2 days due to INR 9.0. When asked if CR #2 received [MEDICATION NAME] on 9/17/2016 before she went to the hospital, the ADON stated as she read CR #2's MAR it has a check mark, it means that the [MEDICATION NAME] was given. The last laboratory report for CR #2 was on 9/15/2016 and still indicated that her INR levels were critical. The nurse was supposed to check at the laboratory reports before given the [MEDICATION NAME]. Continued interview with the ADON on 9/23/2016 at 11:03 a.m. she stated that CR #2 did not come with insulin orders from the hospital or orders to check the blood glucose. When asked if someone had checked the hospital records to find out if CR #2 was using insulin at the hospital, the ADON stated facility follows the orders sent from the hospital. There was information that CR #2 was on insulin before on the information we received before but when CR #2 was admitted to the facility, she did not come with insulin orders. Facility does not have standard protocol to check blood sugar on residents who are diabetic and do not have orders for insulin. ADON then said that she did not see that CR #2 was assessed for [MEDICAL CONDITION] symptoms or bleeding on 9/17/2016 before going to hospital and further said I see what you are saying, CR #2 had abdominal pain and had a change on her level of consciousness. In an interview on 9/23/2016 at 11:55 a.m. with LVN B, he stated that before, the ADON would get the laboratory reports from the fax machine and would distributed them to the nurses, but that now, the nurses were responsible for getting their own faxed reports from the fax machine. He then said that he usually checked the fax machine once at the beginning of the shift and then said, I don't check for faxes more often or at the end of the shift because there is no protocol to tell us when to check the fax machine for laboratory reports. When asked how did he know which residents had laboratory work so he can look for those reports, LVN B stated you go by what comes on the fax machine. There is no way to know who gets what. When asked regarding CR #2's fax report dated 9/13/2016 and faxed to the facility on [DATE] at 12:50 p.m., LVN B said that on 9/13/2016 he only checked the fax machine once at the beginning of the shift and that when he came back to work the next day on 9/14/2016 nobody had followed up with the MD so he notified the MD on 9/14/2016 and the MD gave orders to decrease the [MEDICATION NAME] from 3mg to 2 mg. and further said I don't know what happened on the p.m. shift, don't know why LVN A did not call the MD. Further interview with LVN B at that time, when asked if he was aware of CR #2's critical laboratory INR results on 9/14/2016, LVN B stated I did not get any calls from the laboratory and the fax did not come until 2 p.m. on 9/14/2016, that was the responsibility of LVN A. I check my faxes only once a day, at 6:00 a.m. and will not do it anymore. In an interview on 9/23/2016 at 1:12 p.m. with the DON, she stated that nurses were supposed to get their laboratory reports from the fax machine at least once a shift. When asked if she knew that MD was made aware of abnormal INR levels after nurses had administered the [MEDICATION NAME] dose, the DON stated We don't know, nurses come at 2 p.m. they get report. I am only speculating. Nobody knows where the laboratory report was. If orders were obtained after [MEDICATION NAME] was given, it means that the nurse was not aware of the INR results but as soon as the nurse was aware, the nurse called the MD and got orders. Nurses are not sitting by the fax machine. Further interview with the DON at that time, she stated that critical laboratory results were supposed to be called by the laboratory and that nurses were supposed to notify the MD as soon as possible. When asked if she was made aware of CR #2's critical INR levels on 9/14/2016. The DON stated as she looked the computer telephone order was obtained at 8:22 p.m. on 9/14/2016 and the MD gave orders to hold [MEDICATION NAME]. When asked to see the time the fax report arrived to the facility, the DON said fax says 2:00 p.m. Nobody knows where the report was. As soon as the nurse was made aware, she called the MD. Do I think the nurse notified the MD after she gave the [MEDICATION NAME]? yes. DON continued saying On 9/17/2016, LVN C informed ADON that CR #2 had [MEDICATION NAME] on 9/17/2016 at 5:00 p.m. and LVN C got an order for [REDACTED]. In a second interview on 9/23/2016 at 1:50 p.m. with the ADON, she stated that she found out that CR #2 got her [MEDICATION NAME] 2mg on 9/17/2016 at 5:00 p.m. because she was at her house and was monitoring in her computer the medications that were being administered by the facility staff, and that she noted that LVN C had signed for CR #2's [MEDICATION NAME] at 5:00 p.m. and that she texted her and asked her to call the MD and get orders for STAT PT/INR because she knew that CR #2's last INR was 9.0 and CR #2 had orders to hold the [MEDICATION NAME]. ADON then said that CR #2 went out to the hospital before having her blood drawn. Observation on 9/23/2016 at 4:13 p.m. revealed CR #2 was at a local hospital. CR #2 was lying on an air mattress and was non-verbal. CR #2 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes)AC. CR #2 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with [MEDICATION NAME] (antibiotic) 500mg/100mg at 100 ml per hour. In continued observation, CR #2 was noted to have a foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. CR#2 had oxygen at 5 liters per minute via nasal cannula. Continued observation at that time revealed that CR #2 had dark purple bruising to her right upper and left entire arms. When tried to talk to CR #2, she would moan. Interview on 9/23/2016 at 4:19 p.m. with the hospital RN, she stated that CR#2 came to the hospital with super high blood sugar levels and abnormally high INR levels and further said [MEDICATION NAME] is still on hold. CR#2 is on a sliding scale insulin and we are checking her blood glucose every 4 hours. In an interview on 9/25/2016 at 11:05 a.m. with the DON, she stated that the facility had IDT meetings with all new residents within 72 hours of admission and that during those meetings the staff would go over the plan of care and the goals with the family, would review the medications and the food preferences with the resident and the family. When asked if the facility had an IDT meeting with CR #2 and her family. The DON looked at the computer and said I can't find any IDT meeting for CR #2. I would need to find out with the MDS nurse. MDS nurse is not here today but she is in charge of coordinating the meetings. When asked if the facility staff was aware of the effects of [MEDICATION NAME] on residents who were on [MEDICATION NAME], the DON stated [MEDICATION NAME] affects the laboratory values, not sure if anyone alerted the MD. Further interview at that time, the DON stated that the MDS nurse was in charge of updating the care plans. DON then said that she did not know if the care plan for CR#2 was further updated after the patient went to the hospital and said I will go and check with the nurse consultant. She is the one that updated the care plan on 9/21/2016. In a second interview on 9/25/2016 at 11:35 a.m. with LVN C, she stated that CR#2 was on [MEDICATION NAME] (antibiotic) for pneumonia and that she did not know if there were any effects between [MEDICATION NAME] and [MEDICATION NAME]. Further interview at that time, LVN C stated that on 9/17/2016 nobody gave her report that CR#2's INR levels were critical high until the ADON texted her at 5:30 p.m. and asked her to get STAT orders for PT/INR for CR#2. In a phone interview on 9/28/2016 at 3:01 p.m. with CR #2's RP, she stated that CR#2 was diabetic and had always being on insulin. She further said that at home, CR#2 was on oral medications for diabetes and insulin as well. RP continued saying that on 9/17/2016 when she visited CR#2 at around 5:30 p.m. she was trying to wake her up because CR#2 was very sleepy, very weak and couldn't hold herself up. She then said that she had

Based on observation, interview and record review, it was determined the facility failed to implement its written policy and procedures that prohibit neglect for one of nine residents (CR #2) reviewed for neglect. -The facility failed to consult and report to CR #2's physician timely abnormal blood clotting laboratory values including panic high values. The facility continuously administered [MEDICATION NAME] (blood thinner medication) without checking the blood clotting laboratory values and without consulting with the MD on several occasions. CR#2 started a new antibiotic on 9/13/2016 that affected the resident's blood clotting values. -The facility failed to monitor CR #2's blood glucose while at the facility which led CR#2 to experience signs and symptoms of [MEDICAL CONDITION]. The facility also failed to recognize and thoroughly assess for signs and symptoms of [MEDICAL CONDITION] when CR #2 had a change in condition. -The facility failed to compare CR#2's medications she was receiving at the hospital prior to admission to the facility that included daily insulin and daily blood glucose monitoring, to the medications ordered by the MD at the facility. CR#2 blood glucose was never monitored while at the facility which led CR#2 to experience signs and symptoms of [MEDICAL CONDITION]. The facility failed to recognize and thoroughly assess for signs and symptoms of [MEDICAL CONDITION] when CR #2 had a change in condition. An IJ was identified on 09/23/16. While the IJ was removed on 09/26/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected one former resident (CR #2) and could place the 98 residents at the facility at risk of not receiving adequate assessments, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings included: Intake # 8 In an interview on 9/26/2016 at 1:25 p.m. with the Administrator, who was the abuse coordinator, he stated that he was not aware of the IJ situation. He further said that he believed it was just oversight and that he believed that more validations and staff to do more rounds with the residents was needed. He then said that the facility did daily rounds on selected residents where they review the residents' diagnoses, orders and that having people checking behind each other was a way to monitor that the care of the residents were provided. Administrator further said that due to the latest changes in the facility, he was not participating much on daily rounds but that after this situation, he was going to make sure he was there on daily rounds to monitor the care of the residents. Record review of the facility face sheet revealed CR# 2 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was sent to the hospital on [DATE] per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Record review of CR #2's hospital discharge packet printed on September 1, 2016 at 9:11 a.m. revealed in part Active medications as of August 31, 2016: Insulin [MEDICATION NAME] (rapid), low dose correction scale, give before meals subcutaneous. -0 units if blood glucose 70-140 -1 unit if blood glucose 141 - 220 -2 units if blood glucose 221-260 -3 units if blood glucose 261-280 -4 units if blood glucose 281 - 300 -5 units and call MD if blood glucose is above 300. Other discharge instructions: Diabetes Mellitus: Keep your blood sugars in the near normal range, Test your blood sugar regularly Record review of CR #2's admitting MD orders dated 9/1/2016 at 5:30 p.m. revealed no orders for insulin or blood sugar monitoring. Further record review revealed the following orders: -9/1/2016, [MEDICATION NAME] tablet 10 mg one tablet by mouth two times a day for diabetes. -9/2/2016, [MEDICATION NAME] sodium ([MEDICATION NAME]) tablet 4 mg, give 1 tablet by mouth in the evening for blood thinner. Record review of CR#2's telephone order dated 9/5/2016 revealed in part: -PT/INR on Wednesday and Fridays. (blood test that measures how long it takes blood to clot) Record review of the admission MDS dated [DATE] revealed CR #2 had severe cognitive impairment with a BIMS score of 2 out of a possible 15. She required extensive assistance for all her activities of daily living. She was always incontinent of bowel and bladder. CR #2 had received anticoagulant therapy on 4 of the last 7 days prior to assessment. Record review of CR #2's care plan revealed there was no care plan until 9/16/2016 and read in part: -Focus: CR#2 has diabetes mellitus. Goal: Will have no complications related to diabetes through the review date. Target date 9/23/2016. -Interventions: Diabetes medication as ordered by MD. Monitor/document for side effects and effectiveness. Record review of CR #2's care plan revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Continued record review revealed that CR #2's care plan for anticoagulant therapy was created on 9/21/2016 (after CR #2 was discharged from facility) revealed in part: -Focus: Anticoagulant therapy related to [MEDICAL CONDITION]. [MEDICATION NAME] (blood thinner). -Goal: will be free from adverse reactions related to anticoagulant use through the review date of 9/23/2016. -Interventions: Laboratory as ordered. Report abnormal laboratory results to the MD. Monitor/document/report to MD as needed sign and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, short of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Record review of CR #2's telephone MD orders dated 9/13/2016 at 1:46 p.m. revealed orders in part; -[MEDICATION NAME] (antibiotic) tablet 500 mg, give one tablet by mouth one time a day for right lower lobe pneumonia for 7 days. Further record review revealed that CR #2's care plan for antibiotic therapy was also created on 9/21/2016 (after CR#2's discharge) and revealed in part: -CR#2 has pneumonia. On [MEDICATION NAME] (antibiotic) 500 mg. every day for 7 days as of 9/13/2016. The care plan did not mention information related to effects of [MEDICATION NAME] and [MEDICATION NAME] with interventions in place. Record review of http://www.online.factsandcomparison.com.Drug/Interaction revealed that [MEDICATION NAME] and [MEDICATION NAME] had a drug interaction. Further record review revealed in part; -Effects: [MEDICATION NAME] (blood condition that results in impaired blood clotting, leading to increased risk for bleeding) effects of [MEDICATION NAME] Oral may be increased by [MEDICATION NAME] Oral. Dosage reduction of [MEDICATION NAME] Oral may be required.MECHANISM: Unknown.MANAGEMENT: Dosage reduction of [MEDICATION NAME] Oral may be needed during concurrent administration of [MEDICATION NAME] Oral. Coagulation status should be monitored, at least during the initial period of concomitant use, and the anticoagulant dose should be adjusted, if needed, accordingly. An alternative antimicrobial agent should be considered. Potentially severe or life-threatening reaction/interaction. Record review of CR #2's progress/nursing notes revealed in part; -9/3/2016 at 12:02 p.m. .RP stated concern that CR #2 very sleepy for therapy. Encouraged to let resident get adjusted to facility. CR #2 awakens easily to verbal stimuli and has no sign and symptoms of sedation at this time. Will continued to monitor Note signed by LVN C. In an interview on 9/25/2016 at 12:05 p.m. with LVN C, she stated that there were days that CR #2 appeared tired or sleepy but was easily arousable. When asked if she knew CR#2 was diabetic, LVN C responded yes. When asked if she ever thought about checking CR #2's blood glucose levels, LVN C stated that CR #2 did not have orders for her blood glucose to be checked. Further record review of CR #2's progress/nursing notes revealed in part; -9/8/2016 at 3:31 p.m. .Spoke with RP via phone. Concern that she noticed CR#2 very sleepy and not eating her dinner when visited Note signed by DON. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Record review of CR#2's laboratory report revealed in part; -9/9/2016 at 10:30 a.m. and faxed to the facility on [DATE] at 1:52 p.m. [MEDICATION NAME] Time of 46.1 seconds, High, Reference range (9.5 - 13.70)(measures in seconds the time that take for your plasma to clot). INR Ratio 3.81, High, Reference range (0.8 - 1.2) (INR- international normalized ratio index of blood coagulability). Further record review revealed hand written note MD notified. New order for [MEDICATION NAME] 3 mg . Continued record review of CR#2's phone orders revealed in part; -9/9/2016 at 8:22 p.m. Discontinue [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 4mg. [MEDICATION NAME] Sodium tablet 3 mg, one tablet by mouth in the evening for blood thinner. Order obtained by LVN A. Record review of CR #2's MAR indicated [REDACTED] -9/9/2016 [MEDICATION NAME] Sodium tablet 4 mg by mouth in the evening for blood thinner was administered at 5 p.m. In an interview on 9/23/2016 at 2:10 p.m. with LVN A, who was the 2 to 10 p.m. charge nurse, she said that on 9/9/2016 she was not able to contact CR #2's MD to notify the abnormal INR laboratory results until after 6:00 p.m. and that CR #2 had already received the [MEDICATION NAME] medication at 5:00 p.m. Record review of CR#2's laboratory report revealed in part; -9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m. [MEDICATION NAME] Time of 39.7 seconds, High, Reference range (9.5 - 13.70) INR Ratio 3.30, High, Reference range (0.8 - 1.2) Further record review revealed that MD was not consulted about laboratory report until the next day. Report had a hand written note 9/14/2016 completed. Changed dose to 2 mg. Record review of progress/nursing notes dated 9/14/2016 at 12:15 p.m. signed by LVN B revealed in part MD changed [MEDICATION NAME] order from 3 mg to 2 mg daily . Record review of CR #2's progress/nursing notes dated for 9/13/2016 revealed no information that MD was contacted on abnormal laboratory values of 9/13/2016. Record review of CR #2's MAR indicated [REDACTED] -9/13/2016 [MEDICATION NAME] Sodium tablet 3 mg by mouth in the evening for blood thinner was administered at 5 p.m. Further interview on 9/23/2016 at 2:10 p.m. with LVN A, When asked if she was able to follow up on CR #2's abnormal laboratory report dated 9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m., LVN A stated every shift is supposed to collect their laboratory reports from the fax machine and follow up on their shifts. Record review of CR #2's Medication Administration Record [REDACTED]. Record review of CR#2's Order Summary Report revealed in part: -9/14/2016, [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 2 mg by mouth in the evening for blood thinner. Record review of CR#2's laboratory report revealed in part; -9/14/2016 at 6:35 a.m. and faxed to the facility on [DATE] at 2:00 p.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Report contains Panic values. Critical results referred to client service. Call was made to facility on 9/14/2016 at 1:55 p.m., left on hold until 2:00 p.m; no answer, will try again later. Called at 3:17 p.m., left on hold until 3:22 p.m; no answer, will fax results. Call was made on 9/14/2016 at 3:37 p.m. No answer. Further record review revealed a hand written note by LVN A that read Per MD hold [MEDICATION NAME]. Record review of CR #2's phone order dated 9/14/2016 at 5:33 p.m. by LVN A revealed order to hold [MEDICATION NAME] 2 mg tablet from 9/14/2016 thru 9/16/2016. Record review of CR #2's MAR indicated [REDACTED] -9/14/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN A. Record review of CR #2's progress/nursing notes dated 9/14/2016 at 7:24 p.m. and signed by LVN A revealed in part; CR #2 laboratory INR level > 9, MD notified and aware. New order to hold [MEDICATION NAME] . Continued interview with LVN A on 9/23/2016 at 2:10 p.m. stated that on 9/14/2016 she did not remember what time she got the critical INR results of CR#2 and further said I believe I texted to the MD and he said to hold [MEDICATION NAME]. I think it was around 7:00 p.m. I had already administered her schedule [MEDICATION NAME] LVN A further said that she was supposed to check the laboratory INR results before administering [MEDICATION NAME]. Record review of CR#2's laboratory report revealed in part; -9/15/2016 at 9:35 p.m. and faxed to the facility on [DATE] at 3:34 a.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Further record review revealed no information on laboratory report that the MD was made aware of results. Record review of CR #2's progress/nursing notes dated 9/16/2016 at 10:41 a.m. and signed by LVN B revealed in part: .[MEDICATION NAME] is on hold due to increase INR levels 9.0. MD notified In an interview on 9/23/2016 at 12:42 p.m. with LVN B, who was the 6:00 a.m. to 2:00 p.m. charge nurse, he stated that he did not talk to MD on 9/16/2016 regarding the laboratory results of CR #2 dated 9/15/2016. He further said that he wrote the note on CR #2's nursing/progress notes on 9/16/2016 at 10:41 a.m. because the MD had been notified on 9/14/2016 of the previous abnormal laboratory results and that he saw the laboratory report dated 9/15/2016 and that he did not notify the MD because the MD had been already notified the previous day and that the results were the same so he believe that he did not need to notify the MD again. Record review of CR #2's MAR for September 2016 revealed in part; -9/17/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN C (weekend nurse). In a phone interview on 9/23/2016 at 12:53 p.m. with LVN C, who was the weekend nurse, she stated that CR #2 was complaining of abdominal pain on 9/17/2016 before going to the hospital and that the daughter was very concerned for the condition of CR#2 and requested to send her to the hospital. When asked if CR #2 was assessed for sign and symptoms of hyper/[DIAGNOSES REDACTED] or bleeding, LVN C stated CR #2 only spoke Spanish. It was until the daughter that came to the facility that told me that CR #2 was having abdominal and flank pain. When asked if she thought about checking blood glucose levels for CR #2 during her assessment, LVN C stated that she did not think it was necessary and that there were no orders to check for blood glucose levels. Further interview with LVN C at that time, she stated that she signed CR #2's MAR indicated [REDACTED]we are supposed to monitor the PT/INR levels before [MEDICATION NAME] is given. Record review of CR #2's progress/nurses notes revealed in part; -9/17/2016 at 6:44 p.m. .RP requested CR #2 to be sent to a local hospital due to increase trouble swallowing and severe abdominal pain. MD made aware and gave orders to send to ER to evaluate. Blood pressure 135/67, pulse 79, temperature 96.8, respirations 18 .Ambulance notified of transfer to a local hospital. Pick up time will be 7:30 p.m Further record review revealed no assessments for hyper/[DIAGNOSES REDACTED] or for signs of bleeding. -9/17/2016 at 7:59 p.m. ambulance here to transport CR #2 to a local hospital Note signed by LVN C. Record review of CR #2's Change in Condition Evaluation dated 9/17/2016 at 7:25 p.m. revealed in part: The change in condition, symptoms or signs I am calling about is/are: . abdominal pain. This started on 9/17/2016 in the afternoon. Additional Diagnoses: [REDACTED].? Yes. Results of last INR: 9.0 dated 9/15/2016. Most recent blood glucose: No information written. Mental Status Evaluation (compared to baseline) No changes observed . Record review of CR #2's hospital emergency room report dated 9/17/2016 at 8:33 p.m. read in part; XXX[AGE] years old hispanic female presents to ED via EMS with complaints of altered mental status. EMS reports that CR #2's sugar was over 600 when it was checked. RP reports that CR #2 hasn't been eating or drinking for the past 2 days. RP reported that she tried to give water to CR #2 and she was not able to swallow. No insulin since CR #2 being moved to facility on the 1st of September Exam: CR #2 appears sleepy but arousable to painful stimulus, dry mucous membranes. She has diffuse extremity bruising, in particular her right leg and left arm. Decreased mental status. Vital signs: blood pressure 85/57, pulse 60, respirations 16 and temperature 98.5. INR 11.8 (Reference range 0.8 - 1.2) and blood sugar 734 mg/dL (reference range is 65-99 mg/dL). Medical Decision Making: Diabetic ketoacidosis, very elevated INR. I have ordered Vitamin K and fresh frozen plasma for her [MEDICATION NAME] toxicity. Will arrange for an ICU bed. Will continue insulin drip. Right sidewall hematoma Record review of CR #2 hospital history and physical dated 9/18/2016 revealed in part; .CR #2 is a [AGE] year old female, came in after worsening mental status and was noted to be in diabetic ketoacidosis and admitted for the same. CR #2 is in the ICU at this point. According to the RP, CR #2 has not been eating for the last few days. She was found to have INR of 11.8 and vitamin K was given. -Laboratory data: Blood sugar is 191 today. The blood sugar was initially 734 with an anion gap of 15 (Reference range is 3-11 mEq/L). (Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis). -Impression: diabetic ketoacidosis, [MEDICAL CONDITION], [MEDICATION NAME] toxicity, nonketotic hyperosmolar coma. -Plan: CR #2 is in ICU getting insulin. Blood sugar was improved to 179. As she already received vitamin K, we are going to follow her INR. We are going to continue insulin . Record review of CR #2 hospital history and physical dated 9/20/2016 revealed in part; .Came to the ER due to complaints of worsening mentation. RP stated that she noted CR #2's mentation significantly changed. CR #2 appeared extremely agitated, unable to follow commands and noticed a decline in CR #2's oral intake. INR was 11 upon arrival to the ER. CR #2's glucose was greater than 600 upon arrival and was started on insulin drip. CR #2 received vitamin K. CR #2 was admitted to intensive care unit for further evaluation and workup. Assessment: coagulopathy, acute [MEDICAL CONDITION] and diabetic ketoacidosis. Glucose has improved and INR remains subtherapeutic. Prognosis remains poor and guarded . Record review of CR#2's hospital CT scan dated 9/18/2016 revealed in part: .Clinical history: Left flank pain. Conclusion: pelvic sidewall hematoma . In an interview on 9/23/2016 at 10:15 a.m. with the ADON, she stated that the facility had just input all the INR readings on the MAR indicated [REDACTED]. She further said that she was responsible to monitor the INR levels and [MEDICATION NAME] administration on the residents and that nurses were responsible to check the fax machine daily on their shifts to monitor the laboratory reports faxed from the laboratory and that they were supposed to call the MD for abnormal reports as soon as possible. ADON then said that when the facility received critical laboratory values, the nurses were supposed to notify the MD as soon as possible. She continued saying that INR levels above 3 needed to be given to the MD timely. When asked regarding laboratory reports being faxed to the facility between 12 p.m. and 3:00 p.m. and the MD not being made aware until after the scheduled [MEDICATION NAME] had been administered to residents, the ADON stated there could be a lot of dynamics because we can call the MD and by the time the MD calls back. ADON then said that any attempt to call the MD should be written on the nurses notes. Further interview with the ADON at that time, when asked if she was aware that CR #2 had received her scheduled [MEDICATION NAME] on 9/9/2016 and 9/13/2016 before MD was made aware of abnormal results, ADON at that time reviewed CR #2's information on the computer and said I can't speak for somebody else. When asked if the MD was made aware CR #2's abnormal laboratory results dated [DATE] on 9/13/2016, the ADON stated as she looked at the computer I don't see it, but the panic INR levels on 9/14/2016 the MD was notified at 7:24 p.m. When asked at what time the panic INR levels arrived via fax to the facility on [DATE], the ADON said the report reads at 2:00 p.m. ADON then said as she looked at CR #2's MAR CR #2 had 2 mg of [MEDICATION NAME] on 9/14/2016. When asked why it took too long to make the MD aware of the panic INR level of CR #2 on 9/14/2016, the ADON stated I did not know that the MD was notified late but I knew that the [MEDICATION NAME] was held for 2 days due to INR 9.0. When asked if CR #2 received [MEDICATION NAME] on 9/17/2016 before she went to the hospital, the ADON stated as she read CR #2's MAR it has a check mark, it means that the [MEDICATION NAME] was given. The last laboratory report for CR #2 was on 9/15/2016 and still indicated that her INR levels were critical. The nurse was supposed to check at the laboratory reports before given the [MEDICATION NAME]. Continued interview with the ADON on 9/23/2016 at 11:03 a.m. she stated that CR #2 did not come with insulin orders from the hospital or orders to check the blood glucose. When asked if someone had checked the hospital records to find out if CR #2 was using insulin at the hospital, the ADON stated facility follows the orders sent from the hospital. There was information that CR #2 was on insulin before on the information we received before but when CR #2 was admitted to the facility, she did not come with insulin orders. Facility does not have standard protocol to check blood sugar on residents who are diabetic and do not have orders for insulin. ADON then said that she did not see that CR #2 was assessed for [MEDICAL CONDITION] symptoms or bleeding on 9/17/2016 before going to hospital and further said I see what you are saying, CR #2 had abdominal pain and had a change on her level of consciousness. In an interview on 9/23/2016 at 11:55 a.m. with LVN B, he stated that before, the ADON would get the laboratory reports from the fax machine and would distributed them to the nurses, but that now, the nurses were responsible for getting their own faxed reports from the fax machine. He then said that he usually checked the fax machine once at the beginning of the shift and then said, I don't check for faxes more often or at the end of the shift because there is no protocol to tell us when to check the fax machine for laboratory reports. When asked how did he know which residents had laboratory work so he can look for those reports, LVN B stated you go by what comes on the fax machine. There is no way to know who gets what. When asked regarding CR #2's fax report dated 9/13/2016 and faxed to the facility on [DATE] at 12:50 p.m., LVN B said that on 9/13/2016 he only checked the fax machine once at the beginning of the shift and that when he came back to work the next day on 9/14/2016 nobody had followed up with the MD so he notified the MD on 9/14/2016 and the MD gave orders to decrease the [MEDICATION NAME] from 3mg to 2 mg. and further said I don't know what happened on the p.m. shift, don't know why LVN A did not call the MD. Further interview with LVN B at that time, when asked if he was aware of CR #2's critical laboratory INR results on 9/14/2016, LVN B stated I did not get any calls from the laboratory and the fax did not come until 2 p.m. on 9/14/2016, that was the responsibility of LVN A. I check my faxes only once a day, at 6:00 a.m. and will not do it anymore. In an interview on 9/23/2016 at 1:12 p.m. with the DON, she stated that nurses were supposed to get their laboratory reports from the fax machine at least once a shift. When asked if she knew that MD was made aware of abnormal INR levels after nurses had administered the [MEDICATION NAME] dose, the DON stated We don't know, nurses come at 2 p.m. they get report. I am only speculating. Nobody knows where the laboratory report was. If orders were obtained after [MEDICATION NAME] was given, it means that the nurse was not aware of the INR results but as soon as the nurse was aware, the nurse called the MD and got orders. Nurses are not sitting by the fax machine. Further interview with the DON at that time, she stated that critical laboratory results were supposed to be called by the laboratory and that nurses were supposed to notify the MD as soon as possible. When asked if she was made aware of CR #2's critical INR levels on 9/14/2016. The DON stated as she looked the computer telephone order was obtained at 8:22 p.m. on 9/14/2016 and the MD gave orders to hold [MEDICATION NAME]. When asked to see the time the fax report arrived to the facility, the DON said fax says 2:00 p.m. Nobody knows where the report was. As soon as the nurse was made aware, she called the MD. Do I think the nurse notified the MD after she gave the [MEDICATION NAME]? yes. DON continued saying On 9/17/2016, LVN C informed ADON that CR #2 had [MEDICATION NAME] on 9/17/2016 at 5:00 p.m. and LVN C got an order for [REDACTED]. In a second interview on 9/23/2016 at 1:50 p.m. with the ADON, she stated that she found out that CR #2 got her [MEDICATION NAME] 2mg on 9/17/2016 at 5:00 p.m. because she was at her house and was monitoring in her computer the medications that were being administered by the facility staff, and that she noted that LVN C had signed for CR #2's [MEDICATION NAME] at 5:00 p.m. and that she texted her and asked her to call the MD and get orders for STAT PT/INR because she knew that CR #2's last INR was 9.0 and CR #2 had orders to hold the [MEDICATION NAME]. ADON then said that CR #2 went out to the hospital before having her blood drawn. Observation on 9/23/2016 at 4:13 p.m. revealed CR #2 was at a local hospital. CR #2 was lying on an air mattress and was non-verbal. CR #2 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes)AC. CR #2 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with [MEDICATION NAME] (antibiotic) 500mg/100mg at 100 ml per hour. In continued observation, CR #2 was noted to have a foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. CR#2 had oxygen at 5 liters per minute via nasal cannula. Continued observation at that time revealed that CR #2 had dark purple bruising to her right upper and left entire arms. When tried to talk to CR #2, she would moan. Interview on 9/23/2016 at 4:19 p.m. with the hospital RN, she stated that CR#2 came to the hospital with super high blood sugar levels and abnormally high INR levels and further said [MEDICATION NAME] is still on hold. CR#2 is on a sliding scale insulin and we are checking her blood glucose every 4 hours. In an interview on 9/25/2016 at 11:05 a.m. with the DON, she stated that the facility had IDT meetings with all new residents within 72 hours of admission and that during those meetings the staff would go over the plan of care and the goals with the family, would review the medications and the food preferences with the resident and the family. When asked if the facility had an IDT meeting with CR #2 and her family. The DON looked at the computer and said I can't find any IDT meeting for CR #2. I would need to find out with the MDS nurse. MDS nurse is not here today but she is in charge of coordinating the meetings. When asked if the facility staff was aware of the effects of [MEDICATION NAME] on residents who were on [MEDICATION NAME], the DON stated [MEDICATION NAME] affects the laboratory values, not sure if anyone alerted the MD. Further interview at that time, the DON stated that the MDS nurse was in charge of updating the care plans. DON then said that she did not know if the care plan for CR#2 was further updated after the patient went to the hospital and said I will go and check with the nurse consultant. She is the one that updated the care plan on 9/21/2016. In a second interview on 9/25/2016 at 11:35 a.m. with LVN C, she stated that CR#2 was on [MEDICATION NAME] (antibiotic) for pneumonia and that she did not know if there were any effects between [MEDICATION NAME] and [MEDICATION NAME]. Further interview at that time, LVN C stated that on 9/17/2016 nobody gave her report that CR#2's INR levels were critical high until the ADON texted her at 5:30 p.m. and asked her to get STAT orders for PT/INR for CR#2. In a phone interview on 9/28/2016 at 3:01 p.m. with CR #2's RP, she stated that CR#2 was diabetic and had always being on insulin. She further said that at home, CR#2 was on oral medications for diabetes and insulin as well. RP continued saying that on 9/17/2016 when she visited CR#2 at around 5:30 p.m. she was trying to wake her up because CR#2 was very sleepy, very weak and couldn't hold herself up. She then said that she had noticed before that CR#2 was lethargic and having difficulties staying awake. However, that on 9/17/2016, RP was very scared because CR#2 was very pale and started shaking so bad and her mouth was so dry but couldn't swallow anything and was complaining of abdominal pain. RP further said that at that moment she believed CR#2 probably had another stroke and that she requested the nurse send CR#2 to the hospital. RP then said that the nurse at the facility (LVN C) told her that she should wait one more day that CR#2 probably was constipated. RP further said that she insisted on sending CR#2 to the hospital and that the facility finally helped her to send CR#2 to the hospital. The RP then stated that the facility never invited her for any meeting to discuss the medications or the care that CR#2 required and that she was under the impression that CR#2 was receiving insulin at the facility and her blood sugar was being monitored. Record review of the facility policy and procedure Laboratory Test Protocol revised 9/2016 revealed in part: .10.- All laboratory reports with abnormal results will be called to the MD immediately and document in the progress note. 11.- Fax machine is located in the main nurses station. Fax machine are to be checked every shift, every 2 hours for laboratory reports. 12.- DON/designee will conduct daily audit of the laboratory with the date of the test, the date returned, time of MD notification and documentation in place If lab is a

Based on observation, interview and record review, the facility failed to consult with the physician when there was a significant change in the resident's physical, mental, or psychosocial status for one of nine residents (CR #2) reviewed for [MEDICATION NAME] administration and diabetes as evidenced by: -The facility failed to consult with CR #2's physician timely regarding abnormal blood clotting laboratory values including high panic levels. The facility administered [MEDICATION NAME] (blood thinner medication) without checking the blood clotting laboratory values and without consulting with the MD on several occasions. -The facility failed to recognize and thoroughly assess for signs and symptoms of [MEDICAL CONDITION] when CR #2 had a change in her condition. The physician was not notified when CR #2 showed signs and symptoms of [MEDICAL CONDITION] including being weak, tired and abdominal pain. An IJ was identified on 09/23/16. While the IJ was removed on 09/26/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These deficient practices affected one CR and could place five (5) Residents in the facility receiving [MEDICATION NAME] and 29 residents who are diabetic at risk for their physicians and/or family members not being notified resulting in a delay in appropriate medical treatment, the development of new or worsening medical conditions, diminished quality of life and hospitalization . Findings include: Intake # 8 Record review of the facility face sheet revealed CR# 2 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was sent to the hospital on [DATE] per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Record review of CR #2's hospital discharge packet printed on September 1, 2016 at 9:11 a.m. revealed in part Active medications as of August 31, 2016: Insulin [MEDICATION NAME] (rapid), low dose correction scale, give before meals subcutaneous. -0 units if blood glucose 70-140 -1 unit if blood glucose 141 - 220 -2 units if blood glucose 221-260 -3 units if blood glucose 261-280 -4 units if blood glucose 281 - 300 -5 units and call MD if blood glucose is above 300. Other discharge instructions: Diabetes Mellitus: Keep your blood sugars in the near normal range, Test your blood sugar regularly Record review of CR #2's admitting MD orders dated 9/1/2016 at 5:30 p.m. revealed no orders for insulin or blood sugar monitoring. Further record review revealed the following orders: -9/1/2016, [MEDICATION NAME] tablet 10 mg one tablet by mouth two times a day for diabetes. -9/2/2016, [MEDICATION NAME] sodium ([MEDICATION NAME]) tablet 4 mg, give 1 tablet by mouth in the evening for blood thinner. Record review of CR#2's telephone order dated 9/5/2016 revealed in part: -PT/INR on Wednesday and Fridays. (blood test that measures how long it takes blood to clot) Record review of the admission MDS dated [DATE] revealed CR #2 had severe cognitive impairment with a BIMS score of 2 out of a possible 15. She required extensive assistance for all her activities of daily living. She was always incontinent of bowel and bladder. CR #2 had received anticoagulant therapy on 4 of the last 7 days prior to assessment. Record review of CR #2's care plan revealed there was no care plan until 9/16/2016 and read in part: -Focus: CR#2 has diabetes mellitus. Goal: Will have no complications related to diabetes through the review date. Target date 9/23/2016. -Interventions: Diabetes medication as ordered by MD. Monitor/document for side effects and effectiveness. Record review of CR #2's care plan revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Continued record review revealed that CR #2's care plan for anticoagulant therapy was created on 9/21/2016 (after CR #2 was discharged from facility) revealed in part: -Focus: Anticoagulant therapy related to [MEDICAL CONDITION]. [MEDICATION NAME] (blood thinner). -Goal: will be free from adverse reactions related to anticoagulant use through the review date of 9/23/2016. -Interventions: Laboratory as ordered. Report abnormal laboratory results to the MD. Monitor/document/report to MD as needed sign and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, short of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Record review of CR #2's telephone MD orders dated 9/13/2016 at 1:46 p.m. revealed orders in part; -[MEDICATION NAME] (antibiotic) tablet 500 mg, give one tablet by mouth one time a day for right lower lobe pneumonia for 7 days. Further record review revealed that CR #2's care plan for antibiotic therapy was also created on 9/21/2016 (after CR#2's discharge) and revealed in part: -CR#2 has pneumonia. On [MEDICATION NAME] (antibiotic) 500 mg. every day for 7 days as of 9/13/2016. The care plan did not mention information related to effects of [MEDICATION NAME] and [MEDICATION NAME] with interventions in place. Record review of http://www.online.factsandcomparison.com.Drug/Interaction revealed that [MEDICATION NAME] and [MEDICATION NAME] had a drug interaction. Further record review revealed in part; -Effects: [MEDICATION NAME] (blood condition that results in impaired blood clotting, leading to increased risk for bleeding) effects of [MEDICATION NAME] Oral may be increased by [MEDICATION NAME] Oral. Dosage reduction of [MEDICATION NAME] Oral may be required.MECHANISM: Unknown.MANAGEMENT: Dosage reduction of [MEDICATION NAME] Oral may be needed during concurrent administration of [MEDICATION NAME] Oral. Coagulation status should be monitored, at least during the initial period of concomitant use, and the anticoagulant dose should be adjusted, if needed, accordingly. An alternative antimicrobial agent should be considered. Potentially severe or life-threatening reaction/interaction. Record review of CR #2's progress/nursing notes revealed in part; -9/3/2016 at 12:02 p.m. .RP stated concern that CR #2 very sleepy for therapy. Encouraged to let resident get adjusted to facility. CR #2 awakens easily to verbal stimuli and has no sign and symptoms of sedation at this time. Will continued to monitor Note signed by LVN C. In an interview on 9/25/2016 at 12:05 p.m. with LVN C, she stated that there were days that CR #2 appeared tired or sleepy but was easily arousable. When asked if she knew CR#2 was diabetic, LVN C responded yes. When asked if she ever thought about checking CR #2's blood glucose levels, LVN C stated that CR #2 did not have orders for her blood glucose to be checked. Further record review of CR #2's progress/nursing notes revealed in part; -9/8/2016 at 3:31 p.m. .Spoke with RP via phone. Concern that she noticed CR#2 very sleepy and not eating her dinner when visited Note signed by DON. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Record review of CR#2's laboratory report revealed in part; -9/9/2016 at 10:30 a.m. and faxed to the facility on [DATE] at 1:52 p.m. [MEDICATION NAME] Time of 46.1 seconds, High, Reference range (9.5 - 13.70)(measures in seconds the time that take for your plasma to clot). INR Ratio 3.81, High, Reference range (0.8 - 1.2) (INR- international normalized ratio index of blood coagulability). Further record review revealed hand written note MD notified. New order for [MEDICATION NAME] 3 mg . Continued record review of CR#2's phone orders revealed in part; -9/9/2016 at 8:22 p.m. Discontinue [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 4mg. [MEDICATION NAME] Sodium tablet 3 mg, one tablet by mouth in the evening for blood thinner. Order obtained by LVN A. Record review of CR #2's MAR indicated [REDACTED] -9/9/2016 [MEDICATION NAME] Sodium tablet 4 mg by mouth in the evening for blood thinner was administered at 5 p.m. In an interview on 9/23/2016 at 2:10 p.m. with LVN A, who was the 2 to 10 p.m. charge nurse, she said that on 9/9/2016 she was not able to contact CR #2's MD to notify the abnormal INR laboratory results until after 6:00 p.m. and that CR #2 had already received the [MEDICATION NAME] medication at 5:00 p.m. Record review of CR#2's laboratory report revealed in part; -9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m. [MEDICATION NAME] Time of 39.7 seconds, High, Reference range (9.5 - 13.70) INR Ratio 3.30, High, Reference range (0.8 - 1.2) Further record review revealed that MD was not consulted about laboratory report until the next day. Report had a hand written note 9/14/2016 completed. Changed dose to 2 mg. Record review of progress/nursing notes dated 9/14/2016 at 12:15 p.m. signed by LVN B revealed in part MD changed [MEDICATION NAME] order from 3 mg to 2 mg daily . Record review of CR #2's progress/nursing notes dated for 9/13/2016 revealed no information that MD was contacted on abnormal laboratory values of 9/13/2016. Record review of CR #2's MAR indicated [REDACTED] -9/13/2016 [MEDICATION NAME] Sodium tablet 3 mg by mouth in the evening for blood thinner was administered at 5 p.m. Further interview on 9/23/2016 at 2:10 p.m. with LVN A, When asked if she was able to follow up on CR #2's abnormal laboratory report dated 9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m., LVN A stated every shift is supposed to collect their laboratory reports from the fax machine and follow up on their shifts. Record review of CR #2's Medication Administration Record [REDACTED]. Record review of CR#2's Order Summary Report revealed in part: -9/14/2016, [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 2 mg by mouth in the evening for blood thinner. Record review of CR#2's laboratory report revealed in part; -9/14/2016 at 6:35 a.m. and faxed to the facility on [DATE] at 2:00 p.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Report contains Panic values. Critical results referred to client service. Call was made to facility on 9/14/2016 at 1:55 p.m., left on hold until 2:00 p.m; no answer, will try again later. Called at 3:17 p.m., left on hold until 3:22 p.m; no answer, will fax results. Call was made on 9/14/2016 at 3:37 p.m. No answer. Further record review revealed a hand written note by LVN A that read Per MD hold [MEDICATION NAME]. Record review of CR #2's phone order dated 9/14/2016 at 5:33 p.m. by LVN A revealed order to hold [MEDICATION NAME] 2 mg tablet from 9/14/2016 thru 9/16/2016. Record review of CR #2's MAR indicated [REDACTED] -9/14/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN A. Record review of CR #2's progress/nursing notes dated 9/14/2016 at 7:24 p.m. and signed by LVN A revealed in part; CR #2 laboratory INR level > 9, MD notified and aware. New order to hold [MEDICATION NAME] . Continued interview with LVN A on 9/23/2016 at 2:10 p.m. stated that on 9/14/2016 she did not remember what time she got the critical INR results of CR#2 and further said I believe I texted to the MD and he said to hold [MEDICATION NAME]. I think it was around 7:00 p.m. I had already administered her schedule [MEDICATION NAME] LVN A further said that she was supposed to check the laboratory INR results before administering [MEDICATION NAME]. Record review of CR#2's laboratory report revealed in part; -9/15/2016 at 9:35 p.m. and faxed to the facility on [DATE] at 3:34 a.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Further record review revealed no information on laboratory report that the MD was made aware of results. Record review of CR #2's progress/nursing notes dated 9/16/2016 at 10:41 a.m. and signed by LVN B revealed in part: .[MEDICATION NAME] is on hold due to increase INR levels 9.0. MD notified In an interview on 9/23/2016 at 12:42 p.m. with LVN B, who was the 6:00 a.m. to 2:00 p.m. charge nurse, he stated that he did not talk to MD on 9/16/2016 regarding the laboratory results of CR #2 dated 9/15/2016. He further said that he wrote the note on CR #2's nursing/progress notes on 9/16/2016 at 10:41 a.m. because the MD had been notified on 9/14/2016 of the previous abnormal laboratory results and that he saw the laboratory report dated 9/15/2016 and that he did not notify the MD because the MD had been already notified the previous day and that the results were the same so he believe that he did not need to notify the MD again. Record review of CR #2's MAR for September 2016 revealed in part; -9/17/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN C (weekend nurse). In a phone interview on 9/23/2016 at 12:53 p.m. with LVN C, who was the weekend nurse, she stated that CR #2 was complaining of abdominal pain on 9/17/2016 before going to the hospital and that the daughter was very concerned for the condition of CR#2 and requested to send her to the hospital. When asked if CR #2 was assessed for sign and symptoms of hyper/[DIAGNOSES REDACTED] or bleeding, LVN C stated CR #2 only spoke Spanish. It was until the daughter that came to the facility that told me that CR #2 was having abdominal and flank pain. When asked if she thought about checking blood glucose levels for CR #2 during her assessment, LVN C stated that she did not think it was necessary and that there were no orders to check for blood glucose levels. Further interview with LVN C at that time, she stated that she signed CR #2's MAR indicated [REDACTED]we are supposed to monitor the PT/INR levels before [MEDICATION NAME] is given. Record review of CR #2's progress/nurses notes revealed in part; -9/17/2016 at 6:44 p.m. .RP requested CR #2 to be sent to a local hospital due to increase trouble swallowing and severe abdominal pain. MD made aware and gave orders to send to ER to evaluate. Blood pressure 135/67, pulse 79, temperature 96.8, respirations 18 .Ambulance notified of transfer to a local hospital. Pick up time will be 7:30 p.m Further record review revealed no assessments for hyper/[DIAGNOSES REDACTED] or for signs of bleeding. -9/17/2016 at 7:59 p.m. ambulance here to transport CR #2 to a local hospital Note signed by LVN C. Record review of CR #2's Change in Condition Evaluation dated 9/17/2016 at 7:25 p.m. revealed in part: The change in condition, symptoms or signs I am calling about is/are: . abdominal pain. This started on 9/17/2016 in the afternoon. Additional Diagnoses: [REDACTED].? Yes. Results of last INR: 9.0 dated 9/15/2016. Most recent blood glucose: No information written. Mental Status Evaluation (compared to baseline) No changes observed . Record review of CR #2's hospital emergency room report dated 9/17/2016 at 8:33 p.m. read in part; XXX[AGE] years old hispanic female presents to ED via EMS with complaints of altered mental status. EMS reports that CR #2's sugar was over 600 when it was checked. RP reports that CR #2 hasn't been eating or drinking for the past 2 days. RP reported that she tried to give water to CR #2 and she was not able to swallow. No insulin since CR #2 being moved to facility on the 1st of September Exam: CR #2 appears sleepy but arousable to painful stimulus, dry mucous membranes. She has diffuse extremity bruising, in particular her right leg and left arm. Decreased mental status. Vital signs: blood pressure 85/57, pulse 60, respirations 16 and temperature 98.5. INR 11.8 (Reference range 0.8 - 1.2) and blood sugar 734 mg/dL (reference range is 65-99 mg/dL). Medical Decision Making: Diabetic ketoacidosis, very elevated INR. I have ordered Vitamin K and fresh frozen plasma for her [MEDICATION NAME] toxicity. Will arrange for an ICU bed. Will continue insulin drip. Right sidewall hematoma Record review of CR #2 hospital history and physical dated 9/18/2016 revealed in part; .CR #2 is a [AGE] year old female, came in after worsening mental status and was noted to be in diabetic ketoacidosis and admitted for the same. CR #2 is in the ICU at this point. According to the RP, CR #2 has not been eating for the last few days. She was found to have INR of 11.8 and vitamin K was given. -Laboratory data: Blood sugar is 191 today. The blood sugar was initially 734 with an anion gap of 15 (Reference range is 3-11 mEq/L). (Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis). -Impression: diabetic ketoacidosis, [MEDICAL CONDITION], [MEDICATION NAME] toxicity, nonketotic hyperosmolar coma. -Plan: CR #2 is in ICU getting insulin. Blood sugar was improved to 179. As she already received vitamin K, we are going to follow her INR. We are going to continue insulin . Record review of CR #2 hospital history and physical dated 9/20/2016 revealed in part; .Came to the ER due to complaints of worsening mentation. RP stated that she noted CR #2's mentation significantly changed. CR #2 appeared extremely agitated, unable to follow commands and noticed a decline in CR #2's oral intake. INR was 11 upon arrival to the ER. CR #2's glucose was greater than 600 upon arrival and was started on insulin drip. CR #2 received vitamin K. CR #2 was admitted to intensive care unit for further evaluation and workup. Assessment: coagulopathy, acute [MEDICAL CONDITION] and diabetic ketoacidosis. Glucose has improved and INR remains subtherapeutic. Prognosis remains poor and guarded . Record review of CR#2's hospital CT scan dated 9/18/2016 revealed in part: .Clinical history: Left flank pain. Conclusion: pelvic sidewall hematoma . In an interview on 9/23/2016 at 10:15 a.m. with the ADON, she stated that the facility had just input all the INR readings on the MAR indicated [REDACTED]. She further said that she was responsible to monitor the INR levels and [MEDICATION NAME] administration on the residents and that nurses were responsible to check the fax machine daily on their shifts to monitor the laboratory reports faxed from the laboratory and that they were supposed to call the MD for abnormal reports as soon as possible. ADON then said that when the facility received critical laboratory values, the nurses were supposed to notify the MD as soon as possible. She continued saying that INR levels above 3 needed to be given to the MD timely. When asked regarding laboratory reports being faxed to the facility between 12 p.m. and 3:00 p.m. and the MD not being made aware until after the scheduled [MEDICATION NAME] had been administered to residents, the ADON stated there could be a lot of dynamics because we can call the MD and by the time the MD calls back. ADON then said that any attempt to call the MD should be written on the nurses notes. Further interview with the ADON at that time, when asked if she was aware that CR #2 had received her scheduled [MEDICATION NAME] on 9/9/2016 and 9/13/2016 before MD was made aware of abnormal results, ADON at that time reviewed CR #2's information on the computer and said I can't speak for somebody else. When asked if the MD was made aware CR #2's abnormal laboratory results dated [DATE] on 9/13/2016, the ADON stated as she looked at the computer I don't see it, but the panic INR levels on 9/14/2016 the MD was notified at 7:24 p.m. When asked at what time the panic INR levels arrived via fax to the facility on [DATE], the ADON said the report reads at 2:00 p.m. ADON then said as she looked at CR #2's MAR CR #2 had 2 mg of [MEDICATION NAME] on 9/14/2016. When asked why it took too long to make the MD aware of the panic INR level of CR #2 on 9/14/2016, the ADON stated I did not know that the MD was notified late but I knew that the [MEDICATION NAME] was held for 2 days due to INR 9.0. When asked if CR #2 received [MEDICATION NAME] on 9/17/2016 before she went to the hospital, the ADON stated as she read CR #2's MAR it has a check mark, it means that the [MEDICATION NAME] was given. The last laboratory report for CR #2 was on 9/15/2016 and still indicated that her INR levels were critical. The nurse was supposed to check at the laboratory reports before given the [MEDICATION NAME]. Continued interview with the ADON on 9/23/2016 at 11:03 a.m. she stated that CR #2 did not come with insulin orders from the hospital or orders to check the blood glucose. When asked if someone had checked the hospital records to find out if CR #2 was using insulin at the hospital, the ADON stated facility follows the orders sent from the hospital. There was information that CR #2 was on insulin before on the information we received before but when CR #2 was admitted to the facility, she did not come with insulin orders. Facility does not have standard protocol to check blood sugar on residents who are diabetic and do not have orders for insulin. ADON then said that she did not see that CR #2 was assessed for [MEDICAL CONDITION] symptoms or bleeding on 9/17/2016 before going to hospital and further said I see what you are saying, CR #2 had abdominal pain and had a change on her level of consciousness. In an interview on 9/23/2016 at 11:55 a.m. with LVN B, he stated that before, the ADON would get the laboratory reports from the fax machine and would distributed them to the nurses, but that now, the nurses were responsible for getting their own faxed reports from the fax machine. He then said that he usually checked the fax machine once at the beginning of the shift and then said, I don't check for faxes more often or at the end of the shift because there is no protocol to tell us when to check the fax machine for laboratory reports. When asked how did he know which residents had laboratory work so he can look for those reports, LVN B stated you go by what comes on the fax machine. There is no way to know who gets what. When asked regarding CR #2's fax report dated 9/13/2016 and faxed to the facility on [DATE] at 12:50 p.m., LVN B said that on 9/13/2016 he only checked the fax machine once at the beginning of the shift and that when he came back to work the next day on 9/14/2016 nobody had followed up with the MD so he notified the MD on 9/14/2016 and the MD gave orders to decrease the [MEDICATION NAME] from 3mg to 2 mg. and further said I don't know what happened on the p.m. shift, don't know why LVN A did not call the MD. Further interview with LVN B at that time, when asked if he was aware of CR #2's critical laboratory INR results on 9/14/2016, LVN B stated I did not get any calls from the laboratory and the fax did not come until 2 p.m. on 9/14/2016, that was the responsibility of LVN A. I check my faxes only once a day, at 6:00 a.m. and will not do it anymore. In an interview on 9/23/2016 at 1:12 p.m. with the DON, she stated that nurses were supposed to get their laboratory reports from the fax machine at least once a shift. When asked if she knew that MD was made aware of abnormal INR levels after nurses had administered the [MEDICATION NAME] dose, the DON stated We don't know, nurses come at 2 p.m. they get report. I am only speculating. Nobody knows where the laboratory report was. If orders were obtained after [MEDICATION NAME] was given, it means that the nurse was not aware of the INR results but as soon as the nurse was aware, the nurse called the MD and got orders. Nurses are not sitting by the fax machine. Further interview with the DON at that time, she stated that critical laboratory results were supposed to be called by the laboratory and that nurses were supposed to notify the MD as soon as possible. When asked if she was made aware of CR #2's critical INR levels on 9/14/2016. The DON stated as she looked the computer telephone order was obtained at 8:22 p.m. on 9/14/2016 and the MD gave orders to hold [MEDICATION NAME]. When asked to see the time the fax report arrived to the facility, the DON said fax says 2:00 p.m. Nobody knows where the report was. As soon as the nurse was made aware, she called the MD. Do I think the nurse notified the MD after she gave the [MEDICATION NAME]? yes. DON continued saying On 9/17/2016, LVN C informed ADON that CR #2 had [MEDICATION NAME] on 9/17/2016 at 5:00 p.m. and LVN C got an order for [REDACTED]. In a second interview on 9/23/2016 at 1:50 p.m. with the ADON, she stated that she found out that CR #2 got her [MEDICATION NAME] 2mg on 9/17/2016 at 5:00 p.m. because she was at her house and was monitoring in her computer the medications that were being administered by the facility staff, and that she noted that LVN C had signed for CR #2's [MEDICATION NAME] at 5:00 p.m. and that she texted her and asked her to call the MD and get orders for STAT PT/INR because she knew that CR #2's last INR was 9.0 and CR #2 had orders to hold the [MEDICATION NAME]. ADON then said that CR #2 went out to the hospital before having her blood drawn. Observation on 9/23/2016 at 4:13 p.m. revealed CR #2 was at a local hospital. CR #2 was lying on an air mattress and was non-verbal. CR #2 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes)AC. CR #2 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with [MEDICATION NAME] (antibiotic) 500mg/100mg at 100 ml per hour. In continued observation, CR #2 was noted to have a foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. CR#2 had oxygen at 5 liters per minute via nasal cannula. Continued observation at that time revealed that CR #2 had dark purple bruising to her right upper and left entire arms. When tried to talk to CR #2, she would moan. Interview on 9/23/2016 at 4:19 p.m. with the hospital RN, she stated that CR#2 came to the hospital with super high blood sugar levels and abnormally high INR levels and further said [MEDICATION NAME] is still on hold. CR#2 is on a sliding scale insulin and we are checking her blood glucose every 4 hours. In an interview on 9/25/2016 at 11:05 a.m. with the DON, she stated that the facility had IDT meetings with all new residents within 72 hours of admission and that during those meetings the staff would go over the plan of care and the goals with the family, would review the medications and the food preferences with the resident and the family. When asked if the facility had an IDT meeting with CR #2 and her family. The DON looked at the computer and said I can't find any IDT meeting for CR #2. I would need to find out with the MDS nurse. MDS nurse is not here today but she is in charge of coordinating the meetings. When asked if the facility staff was aware of the effects of [MEDICATION NAME] on residents who were on [MEDICATION NAME], the DON stated [MEDICATION NAME] affects the laboratory values, not sure if anyone alerted the MD. Further interview at that time, the DON stated that the MDS nurse was in charge of updating the care plans. DON then said that she did not know if the care plan for CR#2 was further updated after the patient went to the hospital and said I will go and check with the nurse consultant. She is the one that updated the care plan on 9/21/2016. In a second interview on 9/25/2016 at 11:35 a.m. with LVN C, she stated that CR#2 was on [MEDICATION NAME] (antibiotic) for pneumonia and that she did not know if there were any effects between [MEDICATION NAME] and [MEDICATION NAME]. Further interview at that time, LVN C stated that on 9/17/2016 nobody gave her report that CR#2's INR levels were critical high until the ADON texted her at 5:30 p.m. and asked her to get STAT orders for PT/INR for CR#2. In a phone interview on 9/28/2016 at 3:01 p.m. with CR #2's RP, she stated that CR#2 was diabetic and had always being on insulin. She further said that at home, CR#2 was on oral medications for diabetes and insulin as well. RP continued saying that on 9/17/2016 when she visited CR#2 at around 5:30 p.m. she was trying to wake her up because CR#2 was very sleepy, very weak and couldn't hold herself up. She then said that she had noticed before that CR#2 was lethargic and having difficulties staying awake. However, that on 9/17/2016, RP was very scared because CR#2 was very pale and started shaking so bad and her mouth was so dry but couldn't swallow anything and was complaining of abdominal pain. RP further said that at that moment she believed CR#2 probably had another stroke and that she requested the nurse send CR#2 to the hospital. RP then said that the nurse at the facility (LVN C) told her that she should wait one more day that CR#2 probably was constipated. RP further said that she insisted on sending CR#2 to the hospital and that the facility finally helped her to send CR#2 to the hospital. The RP then stated that the facility never invited her for any meeting to discuss the medications or the care that CR#2 required and that she was under the impression that CR#2 was receiving insulin at the facility and her blood sugar was being monitored. Record review of the facility policy and procedure Laboratory Test Protocol revised 9/2016 revealed in part: .10.- All laboratory reports with abnormal results will be called to the MD immediately and document in the progress note. 11.- Fax machine is located in the main nurses station. Fax machine are to be checked every shift, every 2 hours for laboratory reports. 12.- DON/designee will conduct daily audit of the laboratory with the date of the test, the date returned, time of MD notification and documentation in place If lab is abnormal you are required to do the following: 1.- Notify the MD and RP 2.- Be specific what is going on Ex. Follow up day 2/3 PT/INR 6.31. [MEDICATION NAME] remains on hold. No signs/symptoms of bleeding noted. Place patient in follow up and chart on patient every shift . Record review of the facility policy and procedure revised December 2005 revealed in part: The facility will implement a medication management program that incorporates systems with established goals to meet each patient's needs as well as our regulatory requirements. Preparation for Medication pass: 3.- Licensed staff must understand: A. Reason for therapy B. Effectiveness of the therapeutic goal. C. Drug actions D. The seven rights for administering medication . Further record review revealed no information on therapeutic drug monitoring prior to administration on medications that require laboratory monitoring to measure the effect on the residents' body such as [MEDICATION NAME]. Record review of the facility policy and procedure Change of condition reporting revised 5/2007 revealed in part: It is the policy of this facility that all changes in resident condition will be communicated to the physic

Based on interview and record review, it was determined the facility failed to notify the attending physician of abnormal lab results for one (CR #2) of nine residents reviewed for lab results. -The facility failed to consult and report to CR #2's physician timely abnormal blood clotting laboratory values including panic high values. The facility continuously administered [MEDICATION NAME] (blood thinner medication) without checking the blood clotting laboratory values and without consulting with the MD on several occasions. CR#2 started a new antibiotic on 9/13/2016 that affected the resident's blood clotting values. -The facility failed to monitor CR #2's blood glucose while at the facility which led CR#2 to experience signs and symptoms of [MEDICAL CONDITION]. The facility also failed to recognize and thoroughly assess for signs and symptoms of [MEDICAL CONDITION] when CR #2 had a change in condition. An IJ was identified on 09/23/16. While the IJ was removed on 09/26/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected one (CR #2) and has the potential to affect the 98 residents at the facility and placed them at risk for the potential of having abnormal labs and not having their physician notified, resulting in a delay in medical intervention necessary to stabilize the residents. Findings included: Intake # 8 Record review of the facility face sheet revealed CR# 2 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was sent to the hospital on [DATE] per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Record review of CR #2's admitting MD orders dated 9/1/2016 at 5:30 p.m. revealed orders in part; -9/2/2016, [MEDICATION NAME] sodium ([MEDICATION NAME]) tablet 4 mg, give 1 tablet by mouth in the evening for blood thinner. Record review of CR#2's telephone order dated 9/5/2016 revealed in part: -PT/INR on Wednesday and Fridays. (blood test that measures how long it takes blood to clot) Record review of the admission MDS dated [DATE] revealed CR #2 had severe cognitive impairment with a BIMS score of 2 out of a possible 15. She required extensive assistance for all her activities of daily living. She was always incontinent of bowel and bladder. CR #2 had received anticoagulant therapy on 4 of the last 7 days prior to assessment. Record review revealed that CR #2's care plan for anticoagulant therapy was created on 9/21/2016 (after CR #2 was discharged from facility) revealed in part: -Focus: Anticoagulant therapy related to [MEDICAL CONDITION]. [MEDICATION NAME] (blood thinner). -Goal: will be free from adverse reactions related to anticoagulant use through the review date of 9/23/2016. -Interventions: Laboratory as ordered. Report abnormal laboratory results to the MD. Monitor/document/report to MD as needed sign and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, short of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Further record review revealed that CR #2's care plan for antibiotic therapy was also created on 9/21/2016 (after CR#2's discharge) and revealed in part: -CR#2 has pneumonia. On [MEDICATION NAME] (antibiotic) 500 mg. every day for 7 days as of 9/13/2016. The care plan did not mention information related to effects of [MEDICATION NAME] and [MEDICATION NAME] with interventions in place. Record review of http://www.online.factsandcomparison.com.Drug/Interaction revealed that [MEDICATION NAME] and [MEDICATION NAME] had a drug interaction. Further record review revealed in part; -Effects: [MEDICATION NAME] (blood condition that results in impaired blood clotting, leading to increased risk for bleeding) effects of [MEDICATION NAME] Oral may be increased by [MEDICATION NAME] Oral. Dosage reduction of [MEDICATION NAME] Oral may be required.MECHANISM: Unknown.MANAGEMENT: Dosage reduction of [MEDICATION NAME] Oral may be needed during concurrent administration of [MEDICATION NAME] Oral. Coagulation status should be monitored, at least during the initial period of concomitant use, and the anticoagulant dose should be adjusted, if needed, accordingly. An alternative antimicrobial agent should be considered. Potentially severe or life-threatening reaction/interaction. Record review of CR#2's laboratory report revealed in part; -9/9/2016 at 10:30 a.m. and faxed to the facility on [DATE] at 1:52 p.m. [MEDICATION NAME] Time of 46.1 seconds, High, Reference range (9.5 - 13.70)(measures in seconds the time that take for your plasma to clot). INR Ratio 3.81, High, Reference range (0.8 - 1.2) (INR- international normalized ratio index of blood coagulability). Further record review revealed hand written note MD notified. New order for [MEDICATION NAME] 3 mg . Continued record review of CR#2's phone orders revealed in part; -9/9/2016 at 8:22 p.m. Discontinue [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 4mg. [MEDICATION NAME] Sodium tablet 3 mg, one tablet by mouth in the evening for blood thinner. Order obtained by LVN A. Record review of CR #2's MAR indicated [REDACTED] -9/9/2016 [MEDICATION NAME] Sodium tablet 4 mg by mouth in the evening for blood thinner was administered at 5 p.m. In an interview on 9/23/2016 at 2:10 p.m. with LVN A, who was the 2 to 10 p.m. charge nurse, she said that on 9/9/2016 she was not able to contact CR #2's MD to notify the abnormal INR laboratory results until after 6:00 p.m. and that CR #2 had already received the [MEDICATION NAME] medication at 5:00 p.m. Record review of CR#2's laboratory report revealed in part; -9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m. [MEDICATION NAME] Time of 39.7 seconds, High, Reference range (9.5 - 13.70) INR Ratio 3.30, High, Reference range (0.8 - 1.2) Further record review revealed that MD was not consulted about laboratory report until the next day. Report had a hand written note 9/14/2016 completed. Changed dose to 2 mg. Record review of CR #2's progress/nursing notes dated for 9/13/2016 revealed no information that MD was contacted on abnormal laboratory values of 9/13/2016. Record review of CR #2's MAR indicated [REDACTED] -9/13/2016 [MEDICATION NAME] Sodium tablet 3 mg by mouth in the evening for blood thinner was administered at 5 p.m. Further interview on 9/23/2016 at 2:10 p.m. with LVN A, When asked if she was able to follow up on CR #2's abnormal laboratory report dated 9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m., LVN A stated every shift is supposed to collect their laboratory reports from the fax machine and follow up on their shifts. Record review of CR #2's telephone MD orders dated 9/13/2016 at 1:46 p.m. revealed orders in part; -[MEDICATION NAME] (antibiotic) tablet 500 mg, give one tablet by mouth one time a day for right lower lobe pneumonia for 7 days. Record review of CR #2's Medication Administration Record [REDACTED]. Record review of progress/nursing notes dated 9/14/2016 at 12:15 p.m. signed by LVN B revealed in part MD changed [MEDICATION NAME] order from 3 mg to 2 mg daily . Record review of CR#2's Order Summary Report revealed in part: -9/14/2016, [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 2 mg by mouth in the evening for blood thinner. Record review of CR#2's laboratory report revealed in part; -9/14/2016 at 6:35 a.m. and faxed to the facility on [DATE] at 2:00 p.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Report contains Panic values. Critical results referred to client service. Call was made to facility on 9/14/2016 at 1:55 p.m., left on hold until 2:00 p.m; no answer, will try again later. Called at 3:17 p.m., left on hold until 3:22 p.m; no answer, will fax results. Call was made on 9/14/2016 at 3:37 p.m. No answer. Further record review revealed a hand written note by LVN A that read Per MD hold [MEDICATION NAME]. Record review of CR #2's phone order dated 9/14/2016 at 5:33 p.m. by LVN A revealed order to hold [MEDICATION NAME] 2 mg tablet from 9/14/2016 thru 9/16/2016. Record review of CR #2's MAR indicated [REDACTED] -9/14/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN A. Record review of CR #2's progress/nursing notes dated 9/14/2016 at 7:24 p.m. and signed by LVN A revealed in part; CR #2 laboratory INR level > 9, MD notified and aware. New order to hold [MEDICATION NAME] . Continued interview with LVN A on 9/23/2016 at 2:10 p.m. stated that on 9/14/2016 she did not remember what time she got the critical INR results of CR#2 and further said I believe I texted to the MD and he said to hold [MEDICATION NAME]. I think it was around 7:00 p.m. I had already administered her schedule [MEDICATION NAME] LVN A further said that she was supposed to check the laboratory INR results before administering [MEDICATION NAME]. Record review of CR#2's laboratory report revealed in part; -9/15/2016 at 9:35 p.m. and faxed to the facility on [DATE] at 3:34 a.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Further record review revealed no information on laboratory report that the MD was made aware of results. Record review of CR #2's progress/nursing notes dated 9/16/2016 at 10:41 a.m. and signed by LVN B revealed in part: .[MEDICATION NAME] is on hold due to increase INR levels 9.0. MD notified In an interview on 9/23/2016 at 12:42 p.m. with LVN B, who was the 6:00 a.m. to 2:00 p.m. charge nurse, he stated that he did not talk to MD on 9/16/2016 regarding the laboratory results of CR #2 dated 9/15/2016. He further said that he wrote the note on CR #2's nursing/progress notes on 9/16/2016 at 10:41 a.m. because the MD had been notified on 9/14/2016 of the previous abnormal laboratory results and that he saw the laboratory report dated 9/15/2016 and that he did not notify the MD because the MD had been already notified the previous day and that the results were the same so he believe that he did not need to notify the MD again. Record review of CR #2's MAR for September 2016 revealed in part; -9/17/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN C (weekend nurse). In a phone interview on 9/23/2016 at 12:53 p.m. with LVN C, who was the weekend nurse, she stated that CR #2 was complaining of abdominal pain on 9/17/2016 before going to the hospital and that the daughter was very concerned for the condition of CR#2 and requested to send her to the hospital. When asked if CR #2 was assessed for sign and symptoms of hyper/[DIAGNOSES REDACTED] or bleeding, LVN C stated CR #2 only spoke Spanish. It was until the daughter that came to the facility that told me that CR #2 was having abdominal and flank pain. When asked if she thought about checking blood glucose levels for CR #2 during her assessment, LVN C stated that she did not think it was necessary and that there were no orders to check for blood glucose levels. Further interview with LVN C at that time, she stated that she signed CR #2's MAR indicated [REDACTED]we are supposed to monitor the PT/INR levels before [MEDICATION NAME] is given. Record review of CR #2's progress/nurses notes revealed in part; -9/17/2016 at 6:44 p.m. .RP requested CR #2 to be sent to a local hospital due to increase trouble swallowing and severe abdominal pain. MD made aware and gave orders to send to ER to evaluate. Blood pressure 135/67, pulse 79, temperature 96.8, respirations 18 .Ambulance notified of transfer to a local hospital. Pick up time will be 7:30 p.m Further record review revealed no assessments for hyper/[DIAGNOSES REDACTED] or for signs of bleeding. -9/17/2016 at 7:59 p.m. ambulance here to transport CR #2 to a local hospital Note signed by LVN C. Record review of CR #2's Change in Condition Evaluation dated 9/17/2016 at 7:25 p.m. revealed in part: The change in condition, symptoms or signs I am calling about is/are: . abdominal pain. This started on 9/17/2016 in the afternoon. Additional Diagnoses: [REDACTED].? Yes. Results of last INR: 9.0 dated 9/15/2016. Most recent blood glucose: No information written. Mental Status Evaluation (compared to baseline) No changes observed . Record review of CR #2's hospital emergency room report dated 9/17/2016 at 8:33 p.m. read in part; XXX[AGE] years old hispanic female presents to ED via EMS with complaints of altered mental status. EMS reports that CR #2's sugar was over 600 when it was checked. RP reports that CR #2 hasn't been eating or drinking for the past 2 days. RP reported that she tried to give water to CR #2 and she was not able to swallow. No insulin since CR #2 being moved to facility on the 1st of September Exam: CR #2 appears sleepy but arousable to painful stimulus, dry mucous membranes. She has diffuse extremity bruising, in particular her right leg and left arm. Decreased mental status. Vital signs: blood pressure 85/57, pulse 60, respirations 16 and temperature 98.5. INR 11.8 (Reference range 0.8 - 1.2) and blood sugar 734 mg/dL (reference range is 65-99 mg/dL). Medical Decision Making: Diabetic ketoacidosis, very elevated INR. I have ordered Vitamin K and fresh frozen plasma for her [MEDICATION NAME] toxicity. Will arrange for an ICU bed. Will continue insulin drip. Right sidewall hematoma Record review of CR #2 hospital history and physical dated 9/18/2016 revealed in part; .CR #2 is a [AGE] year old female, came in after worsening mental status and was noted to be in diabetic ketoacidosis and admitted for the same. CR #2 is in the ICU at this point. According to the RP, CR #2 has not been eating for the last few days. She was found to have INR of 11.8 and vitamin K was given. -Laboratory data: Blood sugar is 191 today. The blood sugar was initially 734 with an anion gap of 15 (Reference range is 3-11 mEq/L). (Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis). -Impression: diabetic ketoacidosis, [MEDICAL CONDITION], [MEDICATION NAME] toxicity, nonketotic hyperosmolar coma. -Plan: CR #2 is in ICU getting insulin. Blood sugar was improved to 179. As she already received vitamin K, we are going to follow her INR. We are going to continue insulin . Record review of CR #2 hospital history and physical dated 9/20/2016 revealed in part; .Came to the ER due to complaints of worsening mentation. RP stated that she noted CR #2's mentation significantly changed. CR #2 appeared extremely agitated, unable to follow commands and noticed a decline in CR #2's oral intake. INR was 11 upon arrival to the ER. CR #2's glucose was greater than 600 upon arrival and was started on insulin drip. CR #2 received vitamin K. CR #2 was admitted to intensive care unit for further evaluation and workup. Assessment: coagulopathy, acute [MEDICAL CONDITION] and diabetic ketoacidosis. Glucose has improved and INR remains subtherapeutic. Prognosis remains poor and guarded . Record review of CR#2's hospital CT scan dated 9/18/2016 revealed in part: .Clinical history: Left flank pain. Conclusion: pelvic sidewall hematoma . In an interview on 9/23/2016 at 10:15 a.m. with the ADON, she stated that the facility had just input all the INR readings on the MAR indicated [REDACTED]. She further said that she was responsible to monitor the INR levels and [MEDICATION NAME] administration on the residents and that nurses were responsible to check the fax machine daily on their shifts to monitor the laboratory reports faxed from the laboratory and that they were supposed to call the MD for abnormal reports as soon as possible. ADON then said that when the facility received critical laboratory values, the nurses were supposed to notify the MD as soon as possible. She continued saying that INR levels above 3 needed to be given to the MD timely. When asked regarding laboratory reports being faxed to the facility between 12 p.m. and 3:00 p.m. and the MD not being made aware until after the scheduled [MEDICATION NAME] had been administered to residents, the ADON stated there could be a lot of dynamics because we can call the MD and by the time the MD calls back. ADON then said that any attempt to call the MD should be written on the nurses notes. Further interview with the ADON at that time, when asked if she was aware that CR #2 had received her scheduled [MEDICATION NAME] on 9/9/2016 and 9/13/2016 before MD was made aware of abnormal results, ADON at that time reviewed CR #2's information on the computer and said I can't speak for somebody else. When asked if the MD was made aware CR #2's abnormal laboratory results dated [DATE] on 9/13/2016, the ADON stated as she looked at the computer I don't see it, but the panic INR levels on 9/14/2016 the MD was notified at 7:24 p.m. When asked at what time the panic INR levels arrived via fax to the facility on [DATE], the ADON said the report reads at 2:00 p.m. ADON then said as she looked at CR #2's MAR CR #2 had 2 mg of [MEDICATION NAME] on 9/14/2016. When asked why it took too long to make the MD aware of the panic INR level of CR #2 on 9/14/2016, the ADON stated I did not know that the MD was notified late but I knew that the [MEDICATION NAME] was held for 2 days due to INR 9.0. When asked if CR #2 received [MEDICATION NAME] on 9/17/2016 before she went to the hospital, the ADON stated as she read CR #2's MAR it has a check mark, it means that the [MEDICATION NAME] was given. The last laboratory report for CR #2 was on 9/15/2016 and still indicated that her INR levels were critical. The nurse was supposed to check at the laboratory reports before given the [MEDICATION NAME]. In an interview on 9/23/2016 at 11:55 a.m. with LVN B, he stated that before, the ADON would get the laboratory reports from the fax machine and would distributed them to the nurses, but that now, the nurses were responsible for getting their own faxed reports from the fax machine. He then said that he usually checked the fax machine once at the beginning of the shift and then said, I don't check for faxes more often or at the end of the shift because there is no protocol to tell us when to check the fax machine for laboratory reports. When asked how did he know which residents had laboratory work so he can look for those reports, LVN B stated you go by what comes on the fax machine. There is no way to know who gets what. When asked regarding CR #2's fax report dated 9/13/2016 and faxed to the facility on [DATE] at 12:50 p.m., LVN B said that on 9/13/2016 he only checked the fax machine once at the beginning of the shift and that when he came back to work the next day on 9/14/2016 nobody had followed up with the MD so he notified the MD on 9/14/2016 and the MD gave orders to decrease the [MEDICATION NAME] from 3mg to 2 mg. and further said I don't know what happened on the p.m. shift, don't know why LVN A did not call the MD. Further interview with LVN B at that time, when asked if he was aware of CR #2's critical laboratory INR results on 9/14/2016, LVN B stated I did not get any calls from the laboratory and the fax did not come until 2 p.m. on 9/14/2016, that was the responsibility of LVN A. I check my faxes only once a day, at 6:00 a.m. and will not do it anymore. In an interview on 9/23/2016 at 1:12 p.m. with the DON, she stated that nurses were supposed to get their laboratory reports from the fax machine at least once a shift. When asked if she knew that MD was made aware of abnormal INR levels after nurses had administered the [MEDICATION NAME] dose, the DON stated We don't know, nurses come at 2 p.m. they get report. I am only speculating. Nobody knows where the laboratory report was. If orders were obtained after [MEDICATION NAME] was given, it means that the nurse was not aware of the INR results but as soon as the nurse was aware, the nurse called the MD and got orders. Nurses are not sitting by the fax machine. Further interview with the DON at that time, she stated that critical laboratory results were supposed to be called by the laboratory and that nurses were supposed to notify the MD as soon as possible. When asked if she was made aware of CR #2's critical INR levels on 9/14/2016. The DON stated as she looked the computer telephone order was obtained at 8:22 p.m. on 9/14/2016 and the MD gave orders to hold [MEDICATION NAME]. When asked to see the time the fax report arrived to the facility, the DON said fax says 2:00 p.m. Nobody knows where the report was. As soon as the nurse was made aware, she called the MD. Do I think the nurse notified the MD after she gave the [MEDICATION NAME]? yes. DON continued saying On 9/17/2016, LVN C informed ADON that CR #2 had [MEDICATION NAME] on 9/17/2016 at 5:00 p.m. and LVN C got an order for [REDACTED]. In a second interview on 9/23/2016 at 1:50 p.m. with the ADON, she stated that she found out that CR #2 got her [MEDICATION NAME] 2mg on 9/17/2016 at 5:00 p.m. because she was at her house and was monitoring in her computer the medications that were being administered by the facility staff, and that she noted that LVN C had signed for CR #2's [MEDICATION NAME] at 5:00 p.m. and that she texted her and asked her to call the MD and get orders for STAT PT/INR because she knew that CR #2's last INR was 9.0 and CR #2 had orders to hold the [MEDICATION NAME]. ADON then said that CR #2 went out to the hospital before having her blood drawn. Observation on 9/23/2016 at 4:13 p.m. revealed CR #2 was at a local hospital. CR #2 was lying on an air mattress and was non-verbal. CR #2 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes)AC. CR #2 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with [MEDICATION NAME] (antibiotic) 500mg/100mg at 100 ml per hour. In continued observation, CR #2 was noted to have a foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. CR#2 had oxygen at 5 liters per minute via nasal cannula. Continued observation at that time revealed that CR #2 had dark purple bruising to her right upper and left entire arms. When tried to talk to CR #2, she would moan. Interview on 9/23/2016 at 4:19 p.m. with the hospital RN, she stated that CR#2 came to the hospital with super high blood sugar levels and abnormally high INR levels and further said [MEDICATION NAME] is still on hold. CR#2 is on a sliding scale insulin and we are checking her blood glucose every 4 hours. In an interview on 9/25/2016 at 11:05 a.m. with the DON, she stated that the facility had IDT meetings with all new residents within 72 hours of admission and that during those meetings the staff would go over the plan of care and the goals with the family, would review the medications and the food preferences with the resident and the family. When asked if the facility had an IDT meeting with CR #2 and her family. The DON looked at the computer and said I can't find any IDT meeting for CR #2. I would need to find out with the MDS nurse. MDS nurse is not here today but she is in charge of coordinating the meetings. When asked if the facility staff was aware of the effects of [MEDICATION NAME] on residents who were on [MEDICATION NAME], the DON stated [MEDICATION NAME] affects the laboratory values, not sure if anyone alerted the MD. Further interview at that time, the DON stated that the MDS nurse was in charge of updating the care plans. DON then said that she did not know if the care plan for CR#2 was further updated after the patient went to the hospital and said I will go and check with the nurse consultant. She is the one that updated the care plan on 9/21/2016. In a second interview on 9/25/2016 at 11:35 a.m. with LVN C, she stated that CR#2 was on [MEDICATION NAME] (antibiotic) for pneumonia and that she did not know if there were any effects between [MEDICATION NAME] and [MEDICATION NAME]. Further interview at that time, LVN C stated that on 9/17/2016 nobody gave her report that CR#2's INR levels were critical high until the ADON texted her at 5:30 p.m. and asked her to get STAT orders for PT/INR for CR#2. In a phone interview on 9/28/2016 at 3:01 p.m. with CR #2's RP, she stated that CR#2 was diabetic and had always being on insulin. She further said that at home, CR#2 was on oral medications for diabetes and insulin as well. RP continued saying that on 9/17/2016 when she visited CR#2 at around 5:30 p.m. she was trying to wake her up because CR#2 was very sleepy, very weak and couldn't hold herself up. She then said that she had noticed before that CR#2 was lethargic and having difficulties staying awake. However, that on 9/17/2016, RP was very scared because CR#2 was very pale and started shaking so bad and her mouth was so dry but couldn't swallow anything and was complaining of abdominal pain. RP further said that at that moment she believed CR#2 probably had another stroke and that she requested the nurse send CR#2 to the hospital. RP then said that the nurse at the facility (LVN C) told her that she should wait one more day that CR#2 probably was constipated. RP further said that she insisted on sending CR#2 to the hospital and that the facility finally helped her to send CR#2 to the hospital. The RP then stated that the facility never invited her for any meeting to discuss the medications or the care that CR#2 required and that she was under the impression that CR#2 was receiving insulin at the facility and her blood sugar was being monitored. Record review of the facility policy and procedure Laboratory Test Protocol revised 9/2016 revealed in part: .10.- All laboratory reports with abnormal results will be called to the MD immediately and document in the progress note. 11.- Fax machine is located in the main nurses station. Fax machine are to be checked every shift, every 2 hours for laboratory reports. 12.- DON/designee will conduct daily audit of the laboratory with the date of the test, the date returned, time of MD notification and documentation in place If lab is abnormal you are required to do the following: 1.- Notify the MD and RP 2.- Be specific what is going on Ex. Follow up day 2/3 PT/INR 6.31. [MEDICATION NAME] remains on hold. No signs/symptoms of bleeding noted. Place patient in follow up and chart on patient every shift . Record review of the facility policy and procedure revised December 2005 revealed in part: The facility will implement a medication management program that incorporates systems with established goals to meet each patient's needs as well as our regulatory requirements. Preparation for Medication pass: 3.- Licensed staff must understand: A. Reason for therapy B. Effectiveness of the therapeutic goal. C. Drug actions D. The seven rights for administering medication . Further record review revealed no information on therapeutic drug monitoring prior to administration on medications that require laboratory monitoring to measure the effect on the residents' body such as [MEDICATION NAME]. Record review of the facility policy and procedure Change of condition reporting revised 5/2007 revealed in part: It is the policy of this facility that all changes in resident condition will be communicated to the physician. Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation . Record review of the facility policy and procedure undated Statement of Resident Rights revealed in part: .You have the right to (1) all care necessary for you to have the highest possible level of health;(10) participate in developing a plan of care . Record review of the facility policy and procedure revised 5/2007 Care and treatment/Care Planning revealed in part: It is the policy of this facility that the IDT (interdisciplinary team) shall develop a comprehensive care plan for each resident. 3.- To the extent possible, the resident, the resident's family and / or responsible party should participate in the development of the care plan . The website, http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm, accessed 11/5/12, indicated diabetic ketoacidosis was a medical emergency and could lead to severe illness or death. An IJ was identified on 09/23/16 at 2:47 pm and the Administrator and DON were informed at that time. The POR was accepted on 09/26/16 at ¿¿¿¿¿¿10:00 a.m. The POR included: 1.- Resident affected by the deficient practice on failure to monitor the blood sugar and PR/INR levels is currently in the hospital. 2.- Nursing department leadership currently changed. Clinical resource assigned to run the nursing department at the facility. 3.- Nurse who gave the [MEDICATION NAME] with INR 9.0 received the disciplinary action. 4.- Nurse who did not notify the MD with the INR 9.0 received the disciplinary action. 5.- Clinical Resource/designee will review the new admissions for the last 2 weeks to ensure we are not missing any discharge orders that may potentially affect he resident such as drug level monitoring. Reviewed 22 admission charts for the last 2 weeks and have not identified any concerns related to reconciliation of the physician orders comparing from the hospital orders to facility admitting orders. 7.- Clinical Resource/designee will review all the residents on [MEDICATION NAME] to ensure that PR/INR levels are being monitored and MD notification and order changes have been made as appropriate and implemented per MD order. -Reviewed the 5 residents on [MEDICATION NAME] and addressed current PT/INR levels. MD had been notified with PT/INR results on 9/23/2016. One resident had MD order to increase the [MEDICATION NAME] according to the level. The 2 residents had no new orders according to the PT/INR levels. One resident had an order for [REDACTED]. 8.- Clinical Resource/designee will review the facility practice in making follow ups on laboratory orders and timeliness of carrying out the order and notification of MD for critical results. Clinical Resource/designee conducted the In-service on lab results follow-ups and notification of MD for critical lab values. Nurse instructed if attending MD not responding the medical director will be notified. If Medical director does not respond, the nurse to call the DON and Administrator for further instructions. 10.- Clinical Resource/designee will in-service nurses on STAT orders to follow up within 4 hours of completion and results received. If results are not received within 4 hours, the nurse is to call the lab and notify administrator/DON. Clinical resource h

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for one of nine residents (CR #2) reviewed for neglect. -The facility failed to consult and report to CR #2's physician timely abnormal blood clotting laboratory values including panic high values. The facility administered [MEDICATION NAME] (blood thinner medication) without checking the blood clotting laboratory values and without consulting with the MD on several occasions. -CR#2 started a new antibiotic on 9/13/2016 that affected the resident's blood clotting values. CR#2 s blood clotting laboratory values were panic high on 9/14/2016 and the MD was not notified in a timely manner. CR #2 received her scheduled [MEDICATION NAME] medication without the staff monitoring the laboratory values. -The facility failed to compare CR#2's medications she was receiving at the hospital prior to admission to the facility that included daily insulin and daily blood glucose monitoring, to the medications ordered by the MD at the facility. CR#2 blood glucose was never monitored while at the facility which led CR#2 to experience signs and symptoms of [MEDICAL CONDITION]. The facility failed to recognize and thoroughly assess for signs and symptoms of [MEDICAL CONDITION] when CR #2 had a change in her condition. -CR #2 was sent to the hospital per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. An IJ was identified on 09/23/16. While the IJ was removed on 09/26/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility needing more time to monitor the plan of removal for effectiveness. These failures affected one CR and could place the 98 residents at the facility at risk of not receiving adequate assessments, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings included: Intake # 8 Record review of the facility policy and procedure Abuse Prevention Manual revised June 2009 revealed in part: .The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of neglet and to treat all patients at the facility with dignity and respect at all times. Neglect is the failure to provide goods and services necessary to avoid harm '' In an interview on 9/26/2016 at 1:25 p.m. with the Administrator, who was the abuse coordinator, he stated that he was not aware of the IJ situation. He further said that he believed it was just oversight and that he believed that more validations and staff to do more rounds with the residents was needed. He then said that the facility did daily rounds on selected residents where they review the residents' diagnoses, orders and that having people checking behind each other was a way to monitor that the care of the residents were provided. Administrator further said that due to the latest changes in the facility, he was not participating much on daily rounds but that after this situation, he was going to make sure he was there on daily rounds to monitor the care of the residents. Record review of the facility face sheet revealed CR# 2 was a [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #2 was sent to the hospital on [DATE] per RP request and she was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Record review of CR #2's hospital discharge packet printed on September 1, 2016 at 9:11 a.m. revealed in part Active medications as of August 31, 2016: Insulin [MEDICATION NAME] (rapid), low dose correction scale, give before meals subcutaneous. -0 units if blood glucose 70-140 -1 unit if blood glucose 141 - 220 -2 units if blood glucose 221-260 -3 units if blood glucose 261-280 -4 units if blood glucose 281 - 300 -5 units and call MD if blood glucose is above 300. Other discharge instructions: Diabetes Mellitus: Keep your blood sugars in the near normal range, Test your blood sugar regularly Record review of CR #2's admitting MD orders dated 9/1/2016 at 5:30 p.m. revealed no orders for insulin or blood sugar monitoring. Further record review revealed the following orders: -9/1/2016, [MEDICATION NAME] tablet 10 mg one tablet by mouth two times a day for diabetes. -9/2/2016, [MEDICATION NAME] sodium ([MEDICATION NAME]) tablet 4 mg, give 1 tablet by mouth in the evening for blood thinner. Record review of CR#2's telephone order dated 9/5/2016 revealed in part: -PT/INR on Wednesday and Fridays. (blood test that measures how long it takes blood to clot) Record review of the admission MDS dated [DATE] revealed CR #2 had severe cognitive impairment with a BIMS score of 2 out of a possible 15. She required extensive assistance for all her activities of daily living. She was always incontinent of bowel and bladder. CR #2 had received anticoagulant therapy on 4 of the last 7 days prior to assessment. Record review of CR #2's care plan revealed there was no care plan until 9/16/2016 and read in part: -Focus: CR#2 has diabetes mellitus. Goal: Will have no complications related to diabetes through the review date. Target date 9/23/2016. -Interventions: Diabetes medication as ordered by MD. Monitor/document for side effects and effectiveness. Record review of CR #2's care plan revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Continued record review revealed that CR #2's care plan for anticoagulant therapy was created on 9/21/2016 (after CR #2 was discharged from facility) revealed in part: -Focus: Anticoagulant therapy related to [MEDICAL CONDITION]. [MEDICATION NAME] (blood thinner). -Goal: will be free from adverse reactions related to anticoagulant use through the review date of 9/23/2016. -Interventions: Laboratory as ordered. Report abnormal laboratory results to the MD. Monitor/document/report to MD as needed sign and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, short of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Record review of CR #2's telephone MD orders dated 9/13/2016 at 1:46 p.m. revealed orders in part; -[MEDICATION NAME] (antibiotic) tablet 500 mg, give one tablet by mouth one time a day for right lower lobe pneumonia for 7 days. Further record review revealed that CR #2's care plan for antibiotic therapy was also created on 9/21/2016 (after CR#2's discharge) and revealed in part: -CR#2 has pneumonia. On [MEDICATION NAME] (antibiotic) 500 mg. every day for 7 days as of 9/13/2016. The care plan did not mention information related to effects of [MEDICATION NAME] and [MEDICATION NAME] with interventions in place. Record review of http://www.online.factsandcomparison.com.Drug/Interaction revealed that [MEDICATION NAME] and [MEDICATION NAME] had a drug interaction. Further record review revealed in part; -Effects: [MEDICATION NAME] (blood condition that results in impaired blood clotting, leading to increased risk for bleeding) effects of [MEDICATION NAME] Oral may be increased by [MEDICATION NAME] Oral. Dosage reduction of [MEDICATION NAME] Oral may be required.MECHANISM: Unknown.MANAGEMENT: Dosage reduction of [MEDICATION NAME] Oral may be needed during concurrent administration of [MEDICATION NAME] Oral. Coagulation status should be monitored, at least during the initial period of concomitant use, and the anticoagulant dose should be adjusted, if needed, accordingly. An alternative antimicrobial agent should be considered. Potentially severe or life-threatening reaction/interaction. Record review of CR #2's progress/nursing notes revealed in part; -9/3/2016 at 12:02 p.m. .RP stated concern that CR #2 very sleepy for therapy. Encouraged to let resident get adjusted to facility. CR #2 awakens easily to verbal stimuli and has no sign and symptoms of sedation at this time. Will continued to monitor Note signed by LVN C. In an interview on 9/25/2016 at 12:05 p.m. with LVN C, she stated that there were days that CR #2 appeared tired or sleepy but was easily arousable. When asked if she knew CR#2 was diabetic, LVN C responded yes. When asked if she ever thought about checking CR #2's blood glucose levels, LVN C stated that CR #2 did not have orders for her blood glucose to be checked. Further record review of CR #2's progress/nursing notes revealed in part; -9/8/2016 at 3:31 p.m. .Spoke with RP via phone. Concern that she noticed CR#2 very sleepy and not eating her dinner when visited Note signed by DON. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Record review of CR#2's laboratory report revealed in part; -9/9/2016 at 10:30 a.m. and faxed to the facility on [DATE] at 1:52 p.m. [MEDICATION NAME] Time of 46.1 seconds, High, Reference range (9.5 - 13.70)(measures in seconds the time that take for your plasma to clot). INR Ratio 3.81, High, Reference range (0.8 - 1.2) (INR- international normalized ratio index of blood coagulability). Further record review revealed hand written note MD notified. New order for [MEDICATION NAME] 3 mg . Continued record review of CR#2's phone orders revealed in part; -9/9/2016 at 8:22 p.m. Discontinue [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 4mg. [MEDICATION NAME] Sodium tablet 3 mg, one tablet by mouth in the evening for blood thinner. Order obtained by LVN A. Record review of CR #2's MAR indicated [REDACTED] -9/9/2016 [MEDICATION NAME] Sodium tablet 4 mg by mouth in the evening for blood thinner was administered at 5 p.m. In an interview on 9/23/2016 at 2:10 p.m. with LVN A, who was the 2 to 10 p.m. charge nurse, she said that on 9/9/2016 she was not able to contact CR #2's MD to notify the abnormal INR laboratory results until after 6:00 p.m. and that CR #2 had already received the [MEDICATION NAME] medication at 5:00 p.m. Record review of CR#2's laboratory report revealed in part; -9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m. [MEDICATION NAME] Time of 39.7 seconds, High, Reference range (9.5 - 13.70) INR Ratio 3.30, High, Reference range (0.8 - 1.2) Further record review revealed that MD was not consulted about laboratory report until the next day. Report had a hand written note 9/14/2016 completed. Changed dose to 2 mg. Record review of progress/nursing notes dated 9/14/2016 at 12:15 p.m. signed by LVN B revealed in part MD changed [MEDICATION NAME] order from 3 mg to 2 mg daily . Record review of CR #2's progress/nursing notes dated for 9/13/2016 revealed no information that MD was contacted on abnormal laboratory values of 9/13/2016. Record review of CR #2's MAR indicated [REDACTED] -9/13/2016 [MEDICATION NAME] Sodium tablet 3 mg by mouth in the evening for blood thinner was administered at 5 p.m. Further interview on 9/23/2016 at 2:10 p.m. with LVN A, When asked if she was able to follow up on CR #2's abnormal laboratory report dated 9/13/2016 at 3:50 a.m. and faxed to the facility on [DATE] at 12:50 p.m., LVN A stated every shift is supposed to collect their laboratory reports from the fax machine and follow up on their shifts. Record review of CR #2's Medication Administration Record [REDACTED]. Record review of CR#2's Order Summary Report revealed in part: -9/14/2016, [MEDICATION NAME] Sodium ([MEDICATION NAME]) tablet 2 mg by mouth in the evening for blood thinner. Record review of CR#2's laboratory report revealed in part; -9/14/2016 at 6:35 a.m. and faxed to the facility on [DATE] at 2:00 p.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Report contains Panic values. Critical results referred to client service. Call was made to facility on 9/14/2016 at 1:55 p.m., left on hold until 2:00 p.m; no answer, will try again later. Called at 3:17 p.m., left on hold until 3:22 p.m; no answer, will fax results. Call was made on 9/14/2016 at 3:37 p.m. No answer. Further record review revealed a hand written note by LVN A that read Per MD hold [MEDICATION NAME]. Record review of CR #2's phone order dated 9/14/2016 at 5:33 p.m. by LVN A revealed order to hold [MEDICATION NAME] 2 mg tablet from 9/14/2016 thru 9/16/2016. Record review of CR #2's MAR indicated [REDACTED] -9/14/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN A. Record review of CR #2's progress/nursing notes dated 9/14/2016 at 7:24 p.m. and signed by LVN A revealed in part; CR #2 laboratory INR level > 9, MD notified and aware. New order to hold [MEDICATION NAME] . Continued interview with LVN A on 9/23/2016 at 2:10 p.m. stated that on 9/14/2016 she did not remember what time she got the critical INR results of CR#2 and further said I believe I texted to the MD and he said to hold [MEDICATION NAME]. I think it was around 7:00 p.m. I had already administered her schedule [MEDICATION NAME] LVN A further said that she was supposed to check the laboratory INR results before administering [MEDICATION NAME]. Record review of CR#2's laboratory report revealed in part; -9/15/2016 at 9:35 p.m. and faxed to the facility on [DATE] at 3:34 a.m. [MEDICATION NAME] Time of > 84.0 seconds, High, Reference range (9.5 - 13.70) INR Ratio > 9.0, High, Reference range (0.8 - 1.2). Further record review revealed no information on laboratory report that the MD was made aware of results. Record review of CR #2's progress/nursing notes dated 9/16/2016 at 10:41 a.m. and signed by LVN B revealed in part: .[MEDICATION NAME] is on hold due to increase INR levels 9.0. MD notified In an interview on 9/23/2016 at 12:42 p.m. with LVN B, who was the 6:00 a.m. to 2:00 p.m. charge nurse, he stated that he did not talk to MD on 9/16/2016 regarding the laboratory results of CR #2 dated 9/15/2016. He further said that he wrote the note on CR #2's nursing/progress notes on 9/16/2016 at 10:41 a.m. because the MD had been notified on 9/14/2016 of the previous abnormal laboratory results and that he saw the laboratory report dated 9/15/2016 and that he did not notify the MD because the MD had been already notified the previous day and that the results were the same so he believe that he did not need to notify the MD again. Record review of CR #2's MAR for September 2016 revealed in part; -9/17/2016 [MEDICATION NAME] Sodium tablet 2 mg by mouth in the evening for blood thinner was administered at 5 p.m. by LVN C (weekend nurse). In a phone interview on 9/23/2016 at 12:53 p.m. with LVN C, who was the weekend nurse, she stated that CR #2 was complaining of abdominal pain on 9/17/2016 before going to the hospital and that the daughter was very concerned for the condition of CR#2 and requested to send her to the hospital. When asked if CR #2 was assessed for sign and symptoms of hyper/[DIAGNOSES REDACTED] or bleeding, LVN C stated CR #2 only spoke Spanish. It was until the daughter that came to the facility that told me that CR #2 was having abdominal and flank pain. When asked if she thought about checking blood glucose levels for CR #2 during her assessment, LVN C stated that she did not think it was necessary and that there were no orders to check for blood glucose levels. Further interview with LVN C at that time, she stated that she signed CR #2's MAR indicated [REDACTED]we are supposed to monitor the PT/INR levels before [MEDICATION NAME] is given. Record review of CR #2's progress/nurses notes revealed in part; -9/17/2016 at 6:44 p.m. .RP requested CR #2 to be sent to a local hospital due to increase trouble swallowing and severe abdominal pain. MD made aware and gave orders to send to ER to evaluate. Blood pressure 135/67, pulse 79, temperature 96.8, respirations 18 .Ambulance notified of transfer to a local hospital. Pick up time will be 7:30 p.m Further record review revealed no assessments for hyper/[DIAGNOSES REDACTED] or for signs of bleeding. -9/17/2016 at 7:59 p.m. ambulance here to transport CR #2 to a local hospital Note signed by LVN C. Record review of CR #2's Change in Condition Evaluation dated 9/17/2016 at 7:25 p.m. revealed in part: The change in condition, symptoms or signs I am calling about is/are: . abdominal pain. This started on 9/17/2016 in the afternoon. Additional Diagnoses: [REDACTED].? Yes. Results of last INR: 9.0 dated 9/15/2016. Most recent blood glucose: No information written. Mental Status Evaluation (compared to baseline) No changes observed . Record review of CR #2's hospital emergency room report dated 9/17/2016 at 8:33 p.m. read in part; XXX[AGE] years old hispanic female presents to ED via EMS with complaints of altered mental status. EMS reports that CR #2's sugar was over 600 when it was checked. RP reports that CR #2 hasn't been eating or drinking for the past 2 days. RP reported that she tried to give water to CR #2 and she was not able to swallow. No insulin since CR #2 being moved to facility on the 1st of September Exam: CR #2 appears sleepy but arousable to painful stimulus, dry mucous membranes. She has diffuse extremity bruising, in particular her right leg and left arm. Decreased mental status. Vital signs: blood pressure 85/57, pulse 60, respirations 16 and temperature 98.5. INR 11.8 (Reference range 0.8 - 1.2) and blood sugar 734 mg/dL (reference range is 65-99 mg/dL). Medical Decision Making: Diabetic ketoacidosis, very elevated INR. I have ordered Vitamin K and fresh frozen plasma for her [MEDICATION NAME] toxicity. Will arrange for an ICU bed. Will continue insulin drip. Right sidewall hematoma Record review of CR #2 hospital history and physical dated 9/18/2016 revealed in part; .CR #2 is a [AGE] year old female, came in after worsening mental status and was noted to be in diabetic ketoacidosis and admitted for the same. CR #2 is in the ICU at this point. According to the RP, CR #2 has not been eating for the last few days. She was found to have INR of 11.8 and vitamin K was given. -Laboratory data: Blood sugar is 191 today. The blood sugar was initially 734 with an anion gap of 15 (Reference range is 3-11 mEq/L). (Anion gap (AG or AGAP) is a value calculated using the results of an electrolyte panel. It is used to help distinguish between anion-gap and non-anion-gap metabolic acidosis). -Impression: diabetic ketoacidosis, [MEDICAL CONDITION], [MEDICATION NAME] toxicity, nonketotic hyperosmolar coma. -Plan: CR #2 is in ICU getting insulin. Blood sugar was improved to 179. As she already received vitamin K, we are going to follow her INR. We are going to continue insulin . Record review of CR #2 hospital history and physical dated 9/20/2016 revealed in part; .Came to the ER due to complaints of worsening mentation. RP stated that she noted CR #2's mentation significantly changed. CR #2 appeared extremely agitated, unable to follow commands and noticed a decline in CR #2's oral intake. INR was 11 upon arrival to the ER. CR #2's glucose was greater than 600 upon arrival and was started on insulin drip. CR #2 received vitamin K. CR #2 was admitted to intensive care unit for further evaluation and workup. Assessment: coagulopathy, acute [MEDICAL CONDITION] and diabetic ketoacidosis. Glucose has improved and INR remains subtherapeutic. Prognosis remains poor and guarded . Record review of CR#2's hospital CT scan dated 9/18/2016 revealed in part: .Clinical history: Left flank pain. Conclusion: pelvic sidewall hematoma . In an interview on 9/23/2016 at 10:15 a.m. with the ADON, she stated that the facility had just input all the INR readings on the MAR indicated [REDACTED]. She further said that she was responsible to monitor the INR levels and [MEDICATION NAME] administration on the residents and that nurses were responsible to check the fax machine daily on their shifts to monitor the laboratory reports faxed from the laboratory and that they were supposed to call the MD for abnormal reports as soon as possible. ADON then said that when the facility received critical laboratory values, the nurses were supposed to notify the MD as soon as possible. She continued saying that INR levels above 3 needed to be given to the MD timely. When asked regarding laboratory reports being faxed to the facility between 12 p.m. and 3:00 p.m. and the MD not being made aware until after the scheduled [MEDICATION NAME] had been administered to residents, the ADON stated there could be a lot of dynamics because we can call the MD and by the time the MD calls back. ADON then said that any attempt to call the MD should be written on the nurses notes. Further interview with the ADON at that time, when asked if she was aware that CR #2 had received her scheduled [MEDICATION NAME] on 9/9/2016 and 9/13/2016 before MD was made aware of abnormal results, ADON at that time reviewed CR #2's information on the computer and said I can't speak for somebody else. When asked if the MD was made aware CR #2's abnormal laboratory results dated [DATE] on 9/13/2016, the ADON stated as she looked at the computer I don't see it, but the panic INR levels on 9/14/2016 the MD was notified at 7:24 p.m. When asked at what time the panic INR levels arrived via fax to the facility on [DATE], the ADON said the report reads at 2:00 p.m. ADON then said as she looked at CR #2's MAR CR #2 had 2 mg of [MEDICATION NAME] on 9/14/2016. When asked why it took too long to make the MD aware of the panic INR level of CR #2 on 9/14/2016, the ADON stated I did not know that the MD was notified late but I knew that the [MEDICATION NAME] was held for 2 days due to INR 9.0. When asked if CR #2 received [MEDICATION NAME] on 9/17/2016 before she went to the hospital, the ADON stated as she read CR #2's MAR it has a check mark, it means that the [MEDICATION NAME] was given. The last laboratory report for CR #2 was on 9/15/2016 and still indicated that her INR levels were critical. The nurse was supposed to check at the laboratory reports before given the [MEDICATION NAME]. Continued interview with the ADON on 9/23/2016 at 11:03 a.m. she stated that CR #2 did not come with insulin orders from the hospital or orders to check the blood glucose. When asked if someone had checked the hospital records to find out if CR #2 was using insulin at the hospital, the ADON stated facility follows the orders sent from the hospital. There was information that CR #2 was on insulin before on the information we received before but when CR #2 was admitted to the facility, she did not come with insulin orders. Facility does not have standard protocol to check blood sugar on residents who are diabetic and do not have orders for insulin. ADON then said that she did not see that CR #2 was assessed for [MEDICAL CONDITION] symptoms or bleeding on 9/17/2016 before going to hospital and further said I see what you are saying, CR #2 had abdominal pain and had a change on her level of consciousness. In an interview on 9/23/2016 at 11:55 a.m. with LVN B, he stated that before, the ADON would get the laboratory reports from the fax machine and would distributed them to the nurses, but that now, the nurses were responsible for getting their own faxed reports from the fax machine. He then said that he usually checked the fax machine once at the beginning of the shift and then said, I don't check for faxes more often or at the end of the shift because there is no protocol to tell us when to check the fax machine for laboratory reports. When asked how did he know which residents had laboratory work so he can look for those reports, LVN B stated you go by what comes on the fax machine. There is no way to know who gets what. When asked regarding CR #2's fax report dated 9/13/2016 and faxed to the facility on [DATE] at 12:50 p.m., LVN B said that on 9/13/2016 he only checked the fax machine once at the beginning of the shift and that when he came back to work the next day on 9/14/2016 nobody had followed up with the MD so he notified the MD on 9/14/2016 and the MD gave orders to decrease the [MEDICATION NAME] from 3mg to 2 mg. and further said I don't know what happened on the p.m. shift, don't know why LVN A did not call the MD. Further interview with LVN B at that time, when asked if he was aware of CR #2's critical laboratory INR results on 9/14/2016, LVN B stated I did not get any calls from the laboratory and the fax did not come until 2 p.m. on 9/14/2016, that was the responsibility of LVN A. I check my faxes only once a day, at 6:00 a.m. and will not do it anymore. In an interview on 9/23/2016 at 1:12 p.m. with the DON, she stated that nurses were supposed to get their laboratory reports from the fax machine at least once a shift. When asked if she knew that MD was made aware of abnormal INR levels after nurses had administered the [MEDICATION NAME] dose, the DON stated We don't know, nurses come at 2 p.m. they get report. I am only speculating. Nobody knows where the laboratory report was. If orders were obtained after [MEDICATION NAME] was given, it means that the nurse was not aware of the INR results but as soon as the nurse was aware, the nurse called the MD and got orders. Nurses are not sitting by the fax machine. Further interview with the DON at that time, she stated that critical laboratory results were supposed to be called by the laboratory and that nurses were supposed to notify the MD as soon as possible. When asked if she was made aware of CR #2's critical INR levels on 9/14/2016. The DON stated as she looked the computer telephone order was obtained at 8:22 p.m. on 9/14/2016 and the MD gave orders to hold [MEDICATION NAME]. When asked to see the time the fax report arrived to the facility, the DON said fax says 2:00 p.m. Nobody knows where the report was. As soon as the nurse was made aware, she called the MD. Do I think the nurse notified the MD after she gave the [MEDICATION NAME]? yes. DON continued saying On 9/17/2016, LVN C informed ADON that CR #2 had [MEDICATION NAME] on 9/17/2016 at 5:00 p.m. and LVN C got an order for [REDACTED]. In a second interview on 9/23/2016 at 1:50 p.m. with the ADON, she stated that she found out that CR #2 got her [MEDICATION NAME] 2mg on 9/17/2016 at 5:00 p.m. because she was at her house and was monitoring in her computer the medications that were being administered by the facility staff, and that she noted that LVN C had signed for CR #2's [MEDICATION NAME] at 5:00 p.m. and that she texted her and asked her to call the MD and get orders for STAT PT/INR because she knew that CR #2's last INR was 9.0 and CR #2 had orders to hold the [MEDICATION NAME]. ADON then said that CR #2 went out to the hospital before having her blood drawn. Observation on 9/23/2016 at 4:13 p.m. revealed CR #2 was at a local hospital. CR #2 was lying on an air mattress and was non-verbal. CR #2 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of Diabetisource (nutritional formula for patients with Diabetes)AC. CR #2 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with [MEDICATION NAME] (antibiotic) 500mg/100mg at 100 ml per hour. In continued observation, CR #2 was noted to have a foley catheter that had approx. 200 cc of amber colored urine on the collection drainage bag. CR#2 had oxygen at 5 liters per minute via nasal cannula. Continued observation at that time revealed that CR #2 had dark purple bruising to her right upper and left entire arms. When tried to talk to CR #2, she would moan. Interview on 9/23/2016 at 4:19 p.m. with the hospital RN, she stated that CR#2 came to the hospital with super high blood sugar levels and abnormally high INR levels and further said [MEDICATION NAME] is still on hold. CR#2 is on a sliding scale insulin and we are checking her blood glucose every 4 hours. In an interview on 9/25/2016 at 11:05 a.m. with the DON, she stated that the facility had IDT meetings with all new residents within 72 hours of admission and that during those meetings the staff would go over the plan of care and the goals with the family, would review the medications and the food preferences with the resident and the family. When asked if the facility had an IDT meeting with CR #2 and her family. The DON looked at the computer and said I can't find any IDT meeting for CR #2. I would need to find out with the MDS nurse. MDS nurse is not here today but she is in charge of coordinating the meetings. When asked if the facility staff was aware of the effects of [MEDICATION NAME] on residents who were on [MEDICATION NAME], the DON stated [MEDICATION NAME] affects the laboratory values, not sure if anyone alerted the MD. Further interview at that time, the DON stated that the MDS nurse was in charge of updating the care plans. DON then said that she did not know if the care plan for CR#2 was further updated after the patient went to the hospital and said I will go and check with the nurse consultant. She is the one that updated the care plan on 9/21/2016. In a second interview on 9/25/2016 at 11:35 a.m. with LVN C, she stated that CR#2 was on [MEDICATION NAME] (antibiotic) for pneumonia and that she did not know if there were any effects between [MEDICATION NAME] and [MEDICATION NAME]. Further interview at that time, LVN C stated that on 9/17/2016 nobody gave her report that CR#2's INR levels were critical high until the ADON texted her at 5:30 p.m. and asked her to get STAT orders for PT/INR for CR#2. In a phone interview on 9/28/2016 at 3:01 p.m. with CR #2's RP, she stated that CR#2 was diabetic and had always being on insulin. She further said that at home, CR#2 was on oral medications for diabetes and insulin as well. RP continued saying that on 9/17/2016 when she visited CR#2 at around 5:30 p.m. she was trying to wake her up because CR#2 was very sleepy, very weak and couldn't hold herself up. She then said that she had noticed before that CR#2 was lethargic and having difficulties staying awake. However, that on 9/17/2016, RP was very scared because CR#2 was very pale and started shaking so bad and her mouth was so dry but couldn't swallow anything and was complaining of abdominal pain. RP further said that at that moment she believed CR#2 probably had another stroke and that she requested the nurse send CR#2 to the hospital. RP then said that the nurse at the facility (LVN C) told her that she should wait one more day that CR#2 probably was constipated. RP further said that she insisted on sending CR#2 to the hospital and that the facility finally helped her to send CR#2 to the hospital. The RP then stated that the facility never invited her for any meeting to discuss the medications or the care that CR#2 required and that she was under the impression that CR#2 was receiving insulin at the facility and her blood sugar was being monitored. Record review

Based on observation, interview, record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of seven residents (CR #7) reviewed for quality of care. -The facility failed to follow on the MD orders to do a urinalysis for CR #7. The facility failed to notify the MD that the urinalysis was not completed as ordered. CR #7 was admitted to a local hospital 20 days later when RP brought her to the hospital and CR #7 was diagnosed with [REDACTED]. - CR #7 acquired a pressure sore to bilateral buttocks and nine days later she acquired a deep tissue injury to bilateral heels. -The facility failed to accurately or consistently assess CR#7's skin integrity per MD orders and failed to follow on the wound MD recommendations to treat a stage 3 pressure sore to her right heel. CR #7 was admitted to a local hospital with pressure sores and wounds not identified by the facility. These failures affected one former resident and had the potential to place 25 residents on Hall 300 at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Findings include: Record review of CR #7's face sheet revealed she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR #7 was brought to the hospital by her RP on 8/22/2016 and did not return to the facility. Record review of CR #7's Initial Admission Record dated 6/18/2016 revealed in part: Skin integrity - A1. Any skin problems on admission: No. Record review of CR #7's Braden Scale for Predicting Pressure Sore Risk signed 6/19/2016 revealed a score of 11 indicating high risk. Further record review revealed no interventions in place to prevent pressure sore development. Record review of Skin Assessment/Evaluation dated 6/20/2016 revealed in part -Pressure Ulcer review Site 1. Onset date: 6/20/2016. Bilateral buttocks. Stage 2. Measures in cm: 7x5x0.2 (LWD). Wound base pink. Comments: New admission assessment shows CR#7 with stage 2 pressure ulcer to bilateral buttocks. Wound bed with bright red granulation tissue and small amount of odorless drainage seen. Peri wound with reddish discoloration seen. Will apply moisture barrier for incontinence and protection and speak with nursing about strict turn and reposition every 2 hours and offload with pillows. Record review of CR #7's MD orders revealed orders dated 6/21/2016 in part: -Venelex ointment (Balsam Peru-Castor oil) apply to bilateral buttocks topically every day shift for stage 2 pressure ulcer. -Weekly skin evaluation. Every day shift on Wednesday. Further record review of CR #7's Treatment Administration Record for June 2016 revealed that wound care orders to bilateral buttocks were not initiated as ordered on [DATE], 6/23/2016 and 6/24/2016. Continued record review revealed no explanation why wound care orders were not followed as ordered on those dates. Record review of CR#7's Braden Scale for Predicting Pressure Sore Risk signed 6/21/2016 revealed a score of 16 indicating low risk. Record review of CR #7's Admission Assessment MDS dated [DATE] revealed CR #7 had moderate cognitive impairment with a BIMS score of 9 out of a possible 15. She required extensive assistance of two persons for transfer and extensive assistance of one person for bed mobility, locomotion, dressing and toilet use and walked in corridor and in room once or twice with assistance of one person during assessment. CR #7 was always incontinent of bowel and bladder. CR #7 was assessed not at risk of developing pressure ulcers, had one unhealed stage 2 pressure ulcer that was present upon admission/entry or reentry. CR #7 was not on a pressure reducing device for chair or bed and she was not on a turning/repositioning program. Record review of CR #7's care plan initiated 6/28/2016 in part: -Focus: CR#7 has Unstageable pressure ulcer to bilateral heels and stage 2 ulcer to bilateral buttocks related to immobility. -Goal: Pressure ulcer will show signs of healing and remain free from infection by review date. -Interventions: Administer treatments as ordered and monitor for effectiveness, Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested, requires foam wedge for bed offloading and seat cushion for wheelchair, Weekly head to toe skin at risk assessment. Further record review of CR#7's Braden Scale for Predicting Pressure Sore Risk signed 6/28/2016 revealed a score of 18 indicating low risk. Continued record review revealed no further assessments for CR #7's level of risk for pressure ulcer development per facility's policy. Record review of Skin Assessment/Evaluation dated 6/29/2016 revealed in part: -Pressure Ulcer review Site 1. Onset date: 6/29/2016. Left heel. Stage: Suspected Deep Tissue Injury. Measures: 3x5xunable to determinate. (LWD). Wound Bed: Black/brown (Eschar). -Pressure Ulcer review Site 2. Onset date: No date written. Right heel. Stage: Suspected Deep Tissue Injury. Measures in cm: 2x5xunable to determinate. (LWD). Wound Bed: Black/brown (Eschar). Comments: New Deep Tissue Injuries to bilateral heels. Both with no open areas or drainage noted. Wound beds soft and deep purple in coloration. Encouraged CR#7 to keep heel floated off bed. Further record review revealed no weekly skin assessment for stage 2 pressure sore to bilateral buttocks. Record review of CR#7's MD orders revealed that orders to treat Deep Tissue Injuries to bilateral heels were not obtained until 7/8/2016 with orders that read in part: -Order dated 7/8/2016 Cleanse bilateral heel Deep Tissue Injuries with Normal Saline, pat dry, paint both with iodine (prevents and treats infections in wounds), pad with foam and wrap feet with kerlix every day shift. Record review of CR #7's Treatment Administration Record for July 2016 revealed that wound care orders were to bilateral heels Deep Tissue Injuries were not done as ordered on [DATE] and 7/17/2016. Continued record review of Treatment Administration Record revealed that wound care orders to bilateral buttocks stage 2 pressure ulcer was not done as ordered on [DATE], 7/15/2016, 7/17/2016, 7/19/2016 and 7/23/2016. Further record review revealed no explanation why wound care orders were not followed on those dates. Record review of Skin Assessment/Evaluation dated 7/05/2016 revealed in part: -Pressure Ulcer review Site 1. Left heel. Stage: Suspected Deep Tissue Injury. Measures in c.m.: 2.5x3.5xunable to determinate. (LWD). Wound Bed: clean nongranulating tissue. -Pressure Ulcer review Site 2. Right heel. Stage: Unstageable (Slough/Eschar). Measures in cm: 2x3xunable to determinate. (LWD). Wound Bed: Black/brown (Eschar). -Pressure Ulcer review Site 3. Sacrum. Stage: 2. Measures in c.m.: 3x3x0.1 (LWD). Further record review of Skin Assessment/Evaluation dated 7/13/2016 revealed in part: -Pressure Ulcer review Site 1. Left heel. Stage: Stage 4. Measures in c.m.: 3x4xunable to determinate. (LWD). Wound Bed: Black/Brown (Eschar). -Pressure Ulcer review Site 2. Right heel. Stage: Unstageable (Slough/Eschar). Measures in cm: 1 x 0.6 x unable to determinate. (LWD). Wound Bed: Black/brown (Eschar). -Pressure Ulcer review Site 3. Sacrum. Stage: 2. Measures in c.m.: 5x6x0.1 (LWD). Surrounding site: [DIAGNOSES REDACTED]. Further record review revealed no information that MD was immediately notified that left heel pressure sore had increased in size and had a change on stage. Record review of CR #7's MD progress note dated 7/17/2016 revealed in part: .Skin: Ulcers. Left heel ulcer with eschar form and necrotic tissues/tender to touch. Surrounding necrosis with inflammation. Assessment plan: 1.- Infected Pressure ulcers. [MEDICAL CONDITION]. Start Keflex (antibiotic) 500 mg every 6 hours for 10 days . Further record review of CR #7 MD orders dated 7/19/2016 revealed orders in part: -discontinue wound care orders to bilateral heel deep tissue injuries. -Cleanse right heel with normal saline, pat dry. Paint with iodine, pad with foam and wrap foot with kerlix. -Cleanse left heel with normal saline, pat dry. Apply nickel thick layer of santyl ointment to wound bed, cover with moistened gauze and wrap foot with kerlix. Record review of CR #7's Skin Assessment/Evaluation dated 7/20/2016 revealed no skin assessments for that date. Record review of CR#7's nursing/progress note revealed in part: -7/30/2016 at 1:31 p.m. .RP here and requested to notify MD about changes in CR #7 ' s condition. CR#7 with paranoia according to RP . -8/2/2016 at 9:31 p.m. .New order for urine specimen for a.m. CR #7 aware to call for help for collection Continuous record review of nursing/progress notes revealed no further information related to the urine specimen. Record review of CR#7's electronic Physician Orders revealed an order dated 8/2/2016 that read in part: .Urine Analysis . In an interview on 8/24/2016 at 3:20 p.m. with ADON C, she stated that she was unable to find any laboratory results for CR #7 ' s urinalysis and that she did not know what happened or why CR#7 was supposed to have urinalysis in the first place. She then said that she was going to call the laboratory. Further record review of CR#7's Skin Assessment/Evaluation revealed in part: Effective date: 8/3/2016. Document all Ulcers, Wound, and other skin problems: - Site: Left heel, Type: Pressure. Measure in centimeters: 4.2x2.4x0.4 (LWD). Stage: Unstageable. - Site: Sacrum, Type: Pressure. Measure in centimeters: 0.6x0.4x0.1 (LWD). Stage:2. Continued record review revealed no assessment to right heel Unstageable pressure ulcer. Record review of MD wound assessment notes dated 8/8/2016 revealed in part: -Location: Right heel: 0.4x0.5 c.m. (LxW) 100% necrosis. Unstageable Recommendations: [MEDICATION NAME] (prevent and treat infections in wounds) every day. -Location: left heel: 4.0x2.3x0.4 c.m. (LWD). 50% Slough. Unstageable. Recommendations: Santyl every day. -Location: Buttocks: closed. -Left anterior lower leg open area. Measurements: 3.7x1.1x0.3 c.m. Recommendations: Xeroform everyday. (wound dressing to maintain a moist wound environment.) Record review of CR #7's Skin Assessment/Evaluation dated 8/10/2016 revealed in part: Site: Left heel. Type: Pressure. Measurements: 4.0x2.3x0.4 c.m. (LWD) Stage: Unstageable. Further record review revealed no further assessments of any other wounds. Further record review of wound MD wound assessment notes dated 8/15/2016 revealed in part: -Location: Right heel: 0.4x0.5x0.2c.m. (LxWxD) 100% slough. Stage: 3. Recommendations: Santyl (wound debridment ointment) every day. -Location: left heel: 4.0x2.5x0.4 c.m. (LWD). 20% Slough. Stage: Unstageable. Recommendations: Santyl every day. -Left anterior lower leg open area. Measurements: 2.9x1.2x0.2 c.m. -Right lower leg. Measurements: 11.5x2.9x0.3 (LWD). Wound type: tear. Recommendations: [MEDICATION NAME] everyday. (wound care dressing) Record review of CR #7's MD orders for August 2016 revealed orders in part: -7/19/2016. Cleanse right heel with Normal Saline, pat dry. Paint with iodine, pad with foam and wrap foot with kerlix every day. -8/18/2016. Cleanse skin tear to right lateral leg with normal saline, pat dry. Apply medi-honey to proximal wound area, cover approximated skin with xeroform gauze, top with abdominal pad, wrap with kerlix every day. -7/19/2016. Cleanse left heel with normal saline, pat dry. Apply nickel thick layer of santyl to wound bed, cover with moistened gauze and wrap foot with kerlix. Continued record review revealed that wound MD recommendations were not followed to right heel. Stage 3 pressure ulcer and left anterior lower leg open area did not have wound care orders. Further record review of CR #7's nursing Skin Assessment/Evaluation dated 8/17/2016 revealed in part: -Site: Left heel. Type: Pressure ulcer. Measurements: 4.0x2.5x0.4 c.m. (LWD). -Site: Right leg. Type: Skin tear. Measurement: 11.5x2.9x0.3 c.m. Continued record review revealed no assessments for open areas to left anterior lower leg and right heel pressure sore. Record review of CR #7's nursing/progress notes revealed in part: -8/22/2016 at 2:15 p.m. .CR #7 went to an eye MD appointment. RP sent CR #7 to a local hospital -8/23/2016 at 10:03 a.m. IDT Plans for this week: CR #7 discharged to a local hospital on [DATE]. RP insisted that CR #7 needed to go to the hospital . Record review of CR #7's hospital History and Physical dated 8/23/2016 at 1:54 p.m. revealed in part: . Condition present on admission: Pressure ulcer Stage 3-4. Wheelchair bound with multiple decubitus ulcers on the heel and sacral area. Dermatology history: Multi wounds on admit. RP reported CR#7 to be somewhat confused and had requested to the facility to do a urinalysis but was not done. CR #7 was found to have a urinary tract infection. Problem: 1.- [MEDICAL CONDITION]. Status: Acute. Assessment and plan: Suspected secondary to urinary tract infection. Continue [MEDICATION NAME] (antibiotic) I gm every 24 hours. Acute Urinary Tract Infection. Assessment and plan: Multiple decubitus ulcers. Sacral stage 2, bilateral heel. Left heel: unstageable. Right heel: stage 2. Bilateral leg lacerations. Problem: Pressure sore on heels. Assessment and Plan: Painful wound care. Pain management Record review of CR #7's hospital's urine culture dated 8/24/2016 revealed in part: .Collection date: 8/22/2016 at 5:25 p.m. -Urine appearance: slight cloudy. Reference (clear). -Urine Bacteria: Moderate. Reference (none). -Urine WBC: Too numerous to count. High. Reference (3.0 - 3.5) /hpf. -Organism: Yeast. Bud Yeast with hyphae. Greater than 100,000 CFU/ML. Reference ( none) Record review of CR #7's hospital Wound Specialist Notes dated 8/23/2016 at 11:26 a.m. revealed in part: Multi wound on legs and heels. 1.- Left lower leg has abrasion/laceration that measures 3.0x1.0x0.3 c.m. (LWD). Periwound is [DIAGNOSES REDACTED]tous (skin redness). 2.- Right lateral lower leg has laceration that measures 12.4x2.0x0.5 c.m. (LWD). 3.- Left heel has unstageable pressure ulcer measuring 4.0x1.5x0.5 .m. (LWD). Wound bed is 85% yellow slough. Periwound is extremely [DIAGNOSES REDACTED]tous. 4.- Right heel has Stage 2 pressure ulcer measuring 0.4x0.4x0.2 c.m. (LWD). Wound bed is 100% dark prink tissue. Periwound is extremely [DIAGNOSES REDACTED]tous. Serosanguineous drainage noted. PolyMem Ag foam applied over heel for antimicrobial properties and protection. 5.- Sacrum/coccyx Stage 2 pressure ulcer measuring 8.0x10.0x0.1 c.m. (LWD). Serous drainage noted. Periwound is [DIAGNOSES REDACTED]tous. Braden scale=12 (High risk). Possible sharp debridement if necrotic tissue to left heel wound not responsive to Santyl ointment Observation and interview on 8/24/2016 at 11:38 a.m. revealed that CR #7 was in a local hospital. She was lying on her side with her heels off loaded. CR #7 stated I am in a lot of pain. My legs and my rear end. I have several holes in my rear end that hurt a lot. Further observation at that moment, Hospital RN stated CR #7 came to the hospital on [DATE] and was found with pressure sores to her sacrum, heels and open areas to both of her lower legs. I will give her pain medication. She is here for antibiotic treatment for [REDACTED]. Further interview at that time, CR #7 stated I was in the facility because I couldn't walk and I needed help. Continued observation and interview at that time revealed that CR #7 had dressings to her lower extremities and the hospital RN stated CR #7 just had wound care to her sacral pressure sore and lower legs and heels. In an interview on 8/24/2016 at 4:05 p.m. ADON C stated that the laboratory did not collect the specimen for CR#7's urinalysis and she did not know what had happened. She then read the nursing notes and said no information is there . When asked if the MD was notified that the urinalysis was not completed, ADON C said as she looked at the nursing notes Nothing is there. In an interview on 8/24/2016 at 4:22 p.m. with the DON, she stated that she did not know what happened with CR #7's order for urinalysis and that the nurse that had obtained the order was no longer in the facility. DON stated that she did not know why the order was obtained. In an interview on 8/24/2016 at 4:30 p.m. with ADON A, she stated that she was the wound care nurse since last part of July 2016. She further said that nurses admitting the residents were responsible for doing the skin assessments upon admission. She then said that according to the initial skin assessment of CR #7 her skin was intact. She continued saying that on 6/20/2016 RN B who was the wound care nurse at that time, saw CR #7 for skin assessment and that according to the assessment, CR #7 was found with a stage 2 pressure sore to her buttocks. ADON A then said that Braden Scale for Predicting Pressure Sore Risk had different readings on different dates was because they were done by different nurses and that the wound care nurse was responsible for completing the Braden Scale for Predicting Pressure Sore Risk and that the facility had found that some of the wound assessments were missing for some of the residents and that it was the reason that the facility changed wound care nurse. ADON A continued saying that Braden Scale for Predicting Pressure Sore Risk assessments were supposed to be completed upon admission then weekly times 3, then quarterly. Further interview at that time, ADON A stated that she did not know why the wound care orders were not initiated as ordered to CR #7's buttocks pressure sore and why wound care orders were not immediately obtained for CR #7's heel pressure sores. ADON A also did not know what happened on the several dates of missing wound care to CR #7's buttocks and heels on July 2016 and August 2016 and then said I started doing wound care on 7/20/2016. Continued interview with the ADON A, she stated that CR#7 did not have pressure sores to her buttocks or the right heel anymore before she went to the hospital. When asked about the wound MD recommendations dated 8/15/2016 where the MD was recommending Santyl treatment to CR #7's right heel Stage 3 pressure sore, ADON A stated that the wound care MD recommendations were not followed because CR#7 did not have pressure sores to her right heel and that probably the wound care MD wrote the recommendations by mistake. She said There was nothing on her right heel. I don't know why the MD wrote Stage 3 to the heel and I did not get to ask him why he wrote it. She then said that CR #7 buttocks pressure sore healed on 8/8/2016 and that she did not see CR #7's buttocks anymore after 8/8/2016 and that nobody reported to her any open areas to CR #7's buttocks or right heel and then said CR#7 only had a facility acquired pressure sore that was Unstageable to her left heel and open wounds to her right leg. Further interview on 8/24/2016 at 4:45 p.m. with ADON A, when asked what interventions were put into place when CR #7 was first assessed at high risk for pressure ulcer development, ADON A stated there is usually an interim care plan that is first placed on the resident's file then the MDS updates the care plan. Requested copies of the interim care plan for CR#7. Copies were not provided to surveyor by the time of exit. In an interview on 8/24/2016 at 5:30 p.m. with the DON and ADON A, the DON stated that the wound care MD comes once a week and gives recommendations but that those recommendations were only recommendations that the facility does not need to follow them because the facility still had to call the primary MD. When asked if the primary MD was made aware of the recommendations given to CR #7's right heel, the ADON A stated It was a mistake of the wound MD. That's why we did not get orders. Further interview at that time, the DON stated If a resident has a new open area, C.N.A ' s would complete a paper or will notify the nurse or the wound care nurse and there was no report that CR #7 had any wounds to her buttocks or right heel. Continued interview on 8/24/2016 at 5:40 p.m. with the DON and ADON C, ADON C stated that nurses on the floor where supposed to follow on the laboratory orders and write the orders on requisition forms for the laboratory personnel. Further interview and record review at that time with the DON and ADON C of CR #7's nursing notes and MD orders revealed no information that MD was made aware that urinalysis was not obtained as ordered. There were no MD orders to discontinued orders as well. Continued interview at that time, the DON stated that she was going to start in-service training with the staff. In an interview on 8/24/2016 at 5:45 p.m. with RN B, she stated that she was the previous wound care nurse and that she assessed CR #7 two days after her admission because CR#7 was admitted on a weekend and she did not get to see her until two days later which was a Monday or a Tuesday. RN B continued saying that CR #7 had wounds to her buttocks areas during the first assessment she did. RN B then said that she tried to do the Braden Scale assessments and skin assessments timely but that on the old computer system she would get the alerts whenever an assessment was due and that on the current system, she was not getting those alerts anymore. Further interview at that time, RN B stated that she did not know why there were missing wound care treatments for CR #7 and that she believed that all wound care orders were started timely for CR#7. RN B stated that she did not remember the condition of CR#7's skin before she stopped working as a wound care nurse at the facility. Further interview at at that time, RN B stated that she was not aware that CR #7 was assessed high risk for pressure sores upon admission and that when she assessed CR#7, she was low risk. In a phone interview on 8/29/2016 at 9:30 a.m. with CR #7 ' s RP, she stated that she requested to the facility to call the MD and request a urinalysis to CR#7 since 7/30/2016 because she was having some changes on her mental status and CR #7 just did not look well at all. RP stated that CR #7 appeared more weak and wasn ' t herself and she was concerned that CR#7 might be having a urinary tract infection. CR #7 further said that she tried to talk to different facility staff regarding getting a urinalysis for CR#7 but that staff would often ignored her. Further interview at that time, RP stated that on 8/22/2016 while at the eye MD appointment, CR#7 started complaining of pain to the wounds on the legs and buttocks, was complaining of SOB and that CR#7 just did not look well at all and that she called 911 while at the MD office and asked for CR #7 to be sent to the hospital. RP stated that CR#7 was immediately admitted to the hospital and was still at the hospital at this time receiving antibiotics for the urinary tract infection, wound care and pain control to the wounds. Record review of the facility policy and procedure with title Skin revised January 2016 revealed in part: 1.- A Braden Scale must be completed the day of admission, then weekly for three additional weeks. 4.- A Weekly Head-to-Toe Assessment must be completed the day of admission, once weekly Further record review of the policy and procedure revealed no information related to wound care. Record review of the facility policy and procedure dated 2016 with title Laboratory management revealed in part: .Policy: The facility is expected to monitor carrying orders for laboratory services and ensure that laboratory results are printed and communicated to the attending physician for review. Facility ' s census dated 8/24/2016 revealed a census of 25 on the 300 hall.

Based on observation, interview and record review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable, for one of 7 residents (CR #7) reviewed for pressure ulcers. - CR #7 acquired a pressure sore to bilateral buttocks and nine days later she acquired a deep tissue injury to bilateral heels. -The facility failed to accurately or consistently assess CR#7's skin integrity per MD orders and failed to follow up on the wound MD recommendations to treat a stage 3 pressure sore to her right heel. CR #7 was admitted to a local hospital with pressure sores and wounds not identified by the facility. These failures affected one former resident and placed all 6 residents with pressure ulcers at risk for developing new pressure ulcers and a decline in existing pressure ulcers due to the delayed discovery and treatment. Findings included: Record review of CR #7's face sheet revealed CR #7 was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR #7 was brought to the hospital by her RP on 8/22/2016 and did not return to the facility. Record review of CR #7's Initial Admission Record dated 6/18/2016 revealed in part: Skin integrity - A1. Any skin problems on admission: No. Record review of CR #7's Braden Scale for Predicting Pressure Sore Risk signed 6/19/2016 revealed a score of 11 indicating high risk. Further record review revealed no interventions in place to prevent pressure sore development. Record review of Skin Assessment/Evaluation dated 6/20/2016 revealed in part -Pressure Ulcer review Site 1. Onset date: 6/20/2016. Bilateral buttocks. Stage 2. Measures in cm: 7x5x0.2 (LWD). Wound base pink. Comments: New admission assessment shows CR#7 with stage 2 pressure ulcer to bilateral buttocks. Wound bed with bright red granulation tissue and small amount of odorless drainage seen. Peri wound with reddish discoloration seen. Will apply moisture barrier for incontinence and protection and speak with nursing about strict turn and reposition every 2 hours and offload with pillows. Record review of CR #7's MD orders revealed orders dated 6/21/2016 in part: -Venelex ointment (Balsam Peru-Castor oil) apply to bilateral buttocks topically every day shift for stage 2 pressure ulcer. -Weekly skin evaluation. Every day shift on Wednesday. Further record review of CR #7's Treatment Administration Record for June 2016 revealed that wound care orders to bilateral buttocks were not initiated as ordered on [DATE], 6/23/2016 and 6/24/2016. Continued record review revealed no explanation why wound care orders were not followed as ordered on those dates. Record review of CR#7's Braden Scale for Predicting Pressure Sore Risk signed 6/21/2016 revealed a score of 16 indicating low risk. Record review of CR #7's Admission Assessment MDS dated [DATE] revealed CR #7 had moderate cognitive impairment with a BIMS score of 9 out of a possible 15. She required extensive assistance of two persons for transfer and extensive assistance of one person for bed mobility, locomotion, dressing and toilet use and walked in corridor and in room once or twice with assistance of one person during assessment. CR #7 was always incontinent of bowel and bladder. CR #7 was assessed not at risk of developing pressure ulcers, had one unhealed stage 2 pressure ulcer that was present upon admission/entry or reentry. CR #7 was not on a pressure reducing device for chair or bed and she was not on a turning/repositioning program. Record review of CR #7's care plan initiated 6/28/2016 in part: -Focus: CR#7 has Unstageable pressure ulcer to bilateral heels and stage 2 ulcer to bilateral buttocks related to immobility. -Goal: Pressure ulcer will show signs of healing and remain free from infection by review date. -Interventions: Administer treatments as ordered and monitor for effectiveness, Needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested, requires foam wedge for bed offloading and seat cushion for wheelchair, Weekly head to toe skin at risk assessment. Further record review of CR#7's Braden Scale for Predicting Pressure Sore Risk signed 6/28/2016 revealed a score of 18 indicating low risk. Continued record review revealed no further assessments for CR #7's level of risk for pressure ulcer development per facility's policy. Record review of Skin Assessment/Evaluation dated 6/29/2016 revealed in part: -Pressure Ulcer review Site 1. Onset date: 6/29/2016. Left heel. Stage: Suspected Deep Tissue Injury. Measures: 3x5xunable to determinate. (LWD). Wound Bed: Black/brown (Eschar). -Pressure Ulcer review Site 2. Onset date: No date written. Right heel. Stage: Suspected Deep Tissue Injury. Measures in cm: 2x5xunable to determinate. (LWD). Wound Bed: Black/brown (Eschar). Comments: New Deep Tissue Injuries to bilateral heels. Both with no open areas or drainage noted. Wound beds soft and deep purple in coloration. Encouraged CR#7 to keep heel floated off bed. Further record review revealed no weekly skin assessment for stage 2 pressure sore to bilateral buttocks. Record review of CR#7's MD orders revealed that orders to treat Deep Tissue Injuries to bilateral heels were not obtained until 7/8/2016 with orders that read in part: -Order dated 7/8/2016 Cleanse bilateral heel Deep Tissue Injuries with Normal Saline, pat dry, paint both with iodine (prevents and treats infections in wounds), pad with foam and wrap feet with kerlix every day shift. Record review of CR #7's Treatment Administration Record for July 2016 revealed that wound care orders were to bilateral heels Deep Tissue Injuries were not done as ordered on [DATE] and 7/17/2016. Continued record review of Treatment Administration Record revealed that wound care orders to bilateral buttocks stage 2 pressure ulcer was not done as ordered on [DATE], 7/15/2016, 7/17/2016, 7/19/2016 and 7/23/2016. Further record review revealed no explanation why wound care orders were not followed on those dates. Record review of Skin Assessment/Evaluation dated 7/05/2016 revealed in part: -Pressure Ulcer review Site 1. Left heel. Stage: Suspected Deep Tissue Injury. Measures in c.m.: 2.5x3.5xunable to determinate. (LWD). Wound Bed: clean nongranulating tissue. -Pressure Ulcer review Site 2. Right heel. Stage: Unstageable (Slough/Eschar). Measures in cm: 2x3xunable to determinate. (LWD). Wound Bed: Black/brown (Eschar). -Pressure Ulcer review Site 3. Sacrum. Stage: 2. Measures in c.m.: 3x3x0.1 (LWD). Further record review of Skin Assessment/Evaluation dated 7/13/2016 revealed in part: -Pressure Ulcer review Site 1. Left heel. Stage: Stage 4. Measures in c.m.: 3x4xunable to determinate. (LWD). Wound Bed: Black/Brown (Eschar). -Pressure Ulcer review Site 2. Right heel. Stage: Unstageable (Slough/Eschar). Measures in cm: 1 x 0.6 x unable to determinate. (LWD). Wound Bed: Black/brown (Eschar). -Pressure Ulcer review Site 3. Sacrum. Stage: 2. Measures in c.m.: 5x6x0.1 (LWD). Surrounding site: [DIAGNOSES REDACTED]. Further record review revealed no information that MD was immediately notified that left heel pressure sore had increased in size and had a change on stage. Record review of CR #7's MD progress note dated 7/17/2016 revealed in part: .Skin: Ulcers. Left heel ulcer with eschar form and necrotic tissues/tender to touch. Surrounding necrosis with inflammation. Assessment plan: 1.- Infected Pressure ulcers. [MEDICAL CONDITION]. Start Keflex (antibiotic) 500 mg every 6 hours for 10 days . Further record review of CR #7 MD orders dated 7/19/2016 revealed orders in part: -discontinue wound care orders to bilateral heel deep tissue injuries. -Cleanse right heel with normal saline, pat dry. Paint with iodine, pad with foam and wrap foot with kerlix. -Cleanse left heel with normal saline, pat dry. Apply nickel thick layer of santyl ointment to wound bed, cover with moistened gauze and wrap foot with kerlix. Record review of CR #7's Skin Assessment/Evaluation dated 7/20/2016 revealed no skin assessments for that date. Further record review of CR#7's Skin Assessment/Evaluation revealed in part: Effective date: 8/3/2016. Document all Ulcers, Wound, and other skin problems: - Site: Left heel, Type: Pressure. Measure in centimeters: 4.2x2.4x0.4 (LWD). Stage: Unstageable. - Site: Sacrum, Type: Pressure. Measure in centimeters: 0.6x0.4x0.1 (LWD). Stage:2. Continued record review revealed no assessment to right heel Unstageable pressure ulcer. Record review of wound MD wound assessment notes dated 8/8/2016 revealed in part: -Location: Right heel: 0.4x0.5 c.m. (LxW) 100% necrosis. Unstageable Recommendations: [MEDICATION NAME] (prevent and treat infections in wounds) every day. -Location: left heel: 4.0x2.3x0.4 c.m. (LWD). 50% Slough. Unstageable. Recommendations: Santyl every day. -Location: Buttocks: closed. -Left anterior lower leg open area. Measurements: 3.7x1.1x0.3 c.m. Recommendations: Xeroform everyday. (wound dressing to maintain a moist wound environment.) Record review of CR #7's Skin Assessment/Evaluation dated 8/10/2016 revealed in part: Site: Left heel. Type: Pressure. Measurements: 4.0x2.3x0.4 c.m. (LWD) Stage: Unstageable. Further record review revealed no further assessments of any other wounds. Further record review of wound MD wound assessment notes dated 8/15/2016 revealed in part: -Location: Right heel: 0.4x0.5x0.2c.m. (LxWxD) 100% slough. Stage: 3. Recommendations: Santyl (wound debridment ointment) every day. -Location: left heel: 4.0x2.5x0.4 c.m. (LWD). 20% Slough. Stage: Unstageable. Recommendations: Santyl every day. -Left anterior lower leg open area. Measurements: 2.9x1.2x0.2 c.m. -Right lower leg. Measurements: 11.5x2.9x0.3 (LWD). Wound type: tear. Recommendations: [MEDICATION NAME] everyday. (wound care dressing) Record review of CR #7's MD orders for August 2016 revealed orders in part: -7/19/2016. Cleanse right heel with Normal Saline, pat dry. Paint with iodine, pad with foam and wrap foot with kerlix every day. -8/18/2016. Cleanse skin tear to right lateral leg with normal saline, pat dry. Apply medi-honey to proximal wound area, cover approximated skin with xeroform gauze, top with abdominal pad, wrap with kerlix every day. -7/19/2016. Cleanse left heel with normal saline, pat dry. Apply nickel thick layer of santyl to wound bed, cover with moistened gauze and wrap foot with kerlix. Continued record review revealed that wound MD recommendations were not followed to right heel Stage 3 pressure ulcer and left anterior lower leg open area did not have wound care orders. Further record review of CR #7's nursing Skin Assessment/Evaluation dated 8/17/2016 revealed in part: -Site: Left heel. Type: Pressure ulcer. Measurements: 4.0x2.5x0.4 c.m. (LWD). -Site: Right leg. Type: Skin tear. Measurement: 11.5x2.9x0.3 c.m. Continued record review revealed no assessments for open areas to left anterior lower leg and right heel pressure sore. Record review of CR #7's nursing/progress notes revealed in part: -8/22/2016 at 2:15 p.m. .CR #7 went to an eye MD appointment. RP sent CR #7 to a local hospital -8/23/2016 at 10:03 a.m. IDT Plans for this week: CR #7 discharged to a local hospital on [DATE]. RP insisted that CR #7 needed to go to the hospital . Record review of CR #7's hospital History and Physical dated 8/23/2016 at 1:54 p.m. revealed in part: . Condition present on admission: Pressure ulcer Stage 3-4. Wheelchair bound with multiple decubitus ulcers on the heel and sacral area. Dermatology history: Multi wounds on admit. Assessment and plan: Multiple decubitus ulcers. Sacral stage 2, bilateral heel. Left heel: unstageable. Right heel: stage 2. Bilateral leg lacerations. Problem: Pressure sore on heels. Assessment and Plan: Painful wound care. Pain management Record review of CR #7's hospital Wound Specialist Notes dated 8/23/2016 at 11:26 a.m. revealed in part: Multi wound on legs and heels. 1.- Left lower leg has abrasion/laceration that measures 3.0x1.0x0.3 c.m. (LWD). Periwound is [DIAGNOSES REDACTED]tous (skin redness). 2.- Right lateral lower leg has laceration that measures 12.4x2.0x0.5 c.m. (LWD). 3.- Left heel has unstageable pressure ulcer measuring 4.0x1.5x0.5 .m. (LWD). Wound bed is 85% yellow slough. Periwound is extremely [DIAGNOSES REDACTED]tous. 4.- Right heel has Stage 2 pressure ulcer measuring 0.4x0.4x0.2 c.m. (LWD). Wound bed is 100% dark prink tissue. Periwound is extremely [DIAGNOSES REDACTED]tous. Serosanguineous drainage noted. PolyMem Ag foam applied over heel for antimicrobial properties and protection. 5.- Sacrum/coccyx Stage 2 pressure ulcer measuring 8.0x10.0x0.1 c.m. (LWD). Serous drainage noted. Periwound is [DIAGNOSES REDACTED]tous. Braden scale=12 (High risk). Possible sharp debridement if necrotic tissue to left heel wound not responsive to Santyl ointment Observation and interview on 8/24/2016 at 11:38 a.m. revealed that CR #7 was in a local hospital. She was lying on her side with her heels off loaded. CR #7 stated I am in a lot of pain. My legs and my rear end. I have several holes in my rear end that hurt a lot . Further observation at that moment, Hospital RN stated CR #7 came to the hospital on [DATE] and was found with pressure sores to her sacrum, heels and open areas to both of her lower legs. I will give her pain medication. She is here for antibiotic treatment for [REDACTED]. Further interview at that time, CR #7 stated I was in the facility because I couldn't walk and I needed help. Continued observation and interview at that time revealed that CR #7's had dressings to her lower extremities and the hospital RN stated CR #7 just had wound care to her sacral pressure sore and lower legs and heels. In an interview on 8/24/2016 at 4:30 p.m. with ADON A, she stated that she was the wound care since last part of July 2016. She further said that nurses admitting the residents were responsible for doing the skin assessments upon admission. She then said that according to the initial skin assessment of CR #7 her skin was intact. She continued saying that on 6/20/2016 RN B who was the wound care nurse at that time, saw CR #7 for skin assessment and that according to the assessment, CR #7 was found with a stage 2 pressure sore to her buttocks. ADON A then said that Braden Scale for Predicting Pressure Sore Risk had different readings on different dates was because were done by different nurses and that the wound care nurse was responsible for completing the Braden Scale for Predicting Pressure Sore Risk and that the facility had found that some of the wound assessments were missing for some of the residents and that it was the reason that the facility changed wound care nurse. ADON A continued saying that Braden Scale for Predicting Pressure Sore Risk assessments were supposed to be completed upon admission then weekly times 3, then quarterly. Further interview at that time, ADON A stated that she did not know why the wound care orders were not initiated as ordered to CR #7's buttocks pressure sore and why wound care orders were not immediately obtained for CR #7's heel pressure sores. ADON A also did not know what happened on the several dates of missing wound care to CR #7's buttocks and heels on July 2016 and August 2016 and then said I started doing wound care on 7/20/2016. Continued interview with the ADON A, she stated that CR#7 did not have pressure sores to her buttocks or the right heel anymore before she went to the hospital. When asked about the wound MD recommendations dated 8/15/2016 where the MD was recommending Santyl treatment to CR #7's right heel Stage 3 pressure sore, ADON A stated that the wound care MD recommendations were not followed because CR#7 did not have pressure sores to her right heel and that probably the wound care MD wrote the recommendations by mistake. She said There was nothing on her right heel. I don't know why the MD wrote Stage 3 to the heel and I did not get to ask him why he wrote it. She then said that CR #7 buttocks pressure sore healed on 8/8/2016 and that she did not see CR #7's buttocks anymore after 8/8/2016 and that nobody reported to her any open areas to CR #7's buttocks or right heel and then said CR#7 only had a facility acquired pressure sore that was Unstageable to her left heel and open wounds to her right leg. Further interview on 8/24/2016 at 4:45 p.m. with ADON A, when asked what interventions were put into place when CR #7 was first assessed at high risk for pressure ulcer development, ADON A stated there is usually an interim care plan that is first placed on the resident's file then the MDS updates the care plan. Requested copies of the interim care plan for CR#7. Copies were not provided to surveyor upon exit time. In an interview on 8/24/2016 at 5:30 p.m. with the DON and ADON A, the DON stated that the wound care MD comes once a week and gives recommendations but that those recommendations were only recommendations that the facility does not need to follow them because the facility still had to call the primary MD. When asked if the primary MD was made aware of the recommendations given to CR #7's right heel, the ADON A stated It was a mistake of the wound MD. That's why we did not get orders. Further interview at that time, the DON stated if a resident has a new open area, C.N.A's would complete a paper or will notify the nurse or the wound care nurse and there was no report that CR #7 had any wounds to her buttocks or right heel. In an interview on 8/24/2016 at 5:45 p.m. with RN B, she stated that she was the previous wound care nurse and that she assessed CR #7 two days after her admission because CR#7 was admitted on a weekend and she did not get to see her until two days later which was a Monday or a Tuesday. RN B continued saying that CR #7 had wounds to her buttocks areas during the first assessment she did. RN B then said that she tried to do the Braden Scale assessments and skin assessments timely but that on the old computer system she would get the alerts whenever an assessment was due and that on the current system, she was not getting those alerts anymore. Further interview at at that time, RN B stated that she was not aware that CR #7 was assessed high risk for pressure sores upon admission and that when she assessed CR#7, she was low risk. Further interview at that time, RN B stated that she did not know why there were missing wound care treatments for CR #7 and that she believed that all wound care orders were started timely for CR#7. RN B stated that she did not remember the condition of CR#7's skin before she stopped working as a wound care nurse at the facility. Record review of the facility policy and procedure with title Skin revised January 2016 revealed in part: 1.- A Braden Scale must be completed the day of admission, then weekly for three additional weeks. 4.- A Weekly Head-to-Toe Assessment must be completed the day of admission, once weekly Further record review of the policy and procedure revealed no information related to wound care. A sheet provided by the wound care nurse on 8/24/16 indicated 6 residents had pressure ulcers.

Based on observation, interview and record review the facility failed to ensure residents received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 24 residents, (Resident #19) reviewed for medication administration, as evidenced by: - Resident #19 ' s [MEDICATION NAME] 10-325mg prescription (a medication to treat pain) was not requested from the physician ' s office in a timely manner. Resident #19 was out of the medication starting on Sunday, March 15, 2015 at 6:00pm through Thursday March 19, 2015 at 12:00pm. This failure affected 1 resident and could place an additional 116 residents at risk of decline in health due to complications or an adverse reaction to medications not being administered per the physician's orders [REDACTED]. Findings Include: Record review of Resident #19 ' s medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years old. Record review of Resident #19 ' s quarterly MDS assessment dated [DATE] revealed that she had a BIMS of 15, indicating no cognitive impairment. It further revealed that she was receiving scheduled pain medications, she experienced frequent pain with a maximum intensity level of severe, and the pain limited her day-to-day activities. In an interview on 3/17/2015 at 1:15pm, Resident #19 said that she ran out of the [MEDICATION NAME] 10-325mg pain medication over the weekend, and it had not been delivered. She said that LVN E did not request a new prescription in time. She shared that she had pain rated at an 8 on a scale of 1-10 due to [MEDICAL CONDITION] that started after a closed-[MEDICAL CONDITION]. She said that she preferred to stay in her room due to a high-level of pain. Record review of Resident #19 ' s Physician order [REDACTED]. Z on 2/11/2015 revealed that she was prescribed [MEDICATION NAME] 10-325mg one tablet by mouth every 6 hours for pain management. Record review of Resident #19 ' s MAR indicated [REDACTED]" . Record review of Resident #19 ' s Care Plan revealed that she had chronic pai[DIAGNOSES REDACTED]. The goal read... " The resident, will not have discomfort related to side effects of [MEDICATION NAME] through the next review date. " The date initiated was 12/24/2014, and the target date was 5/13/2015. Record review of Resident #19 ' s Narcotic Record revealed that 120 tablets of [MEDICATION NAME] 10-325mg was delivered to the facility on [DATE]. The resident was administered the last tablet from this delivery on 3/15/2015 at 12:00pm. In an interview on 3/18/2015 at 10:45am, LVN E said that she had been calling the physician ' s office for a new [MEDICATION NAME] 10-325 mg prescription for Resident #19 since Monday, 3/16/2015. She said that she usually contacted the physician ' s office when there are 8 tablets left. She said that since she started requesting a new prescription, Dr. Z would not accept calls on his cell phone and the physician ' s office was not responding to her requests. In an interview on 3/18/2015 at 11:40am, LVN E said that on Friday, 3/13/2015, there were 8 tablets left of Resident #19 ' s [MEDICATION NAME] 10-325mg medication. She said that Dr. Z usually provided another prescription for this medication 3 to 4 days after a request was made. Record review of Resident #19 ' s Progress Notes revealed the following: - 3/15/2015 at 3:10pm: " LE 3/14/2015 called MD regarding needing a triplicate for [MEDICATION NAME] order since upon start of shift since a refill is needed, no response. Made sup aware. Called MD and text at 1030 am & 1pm, no response. Called again at 1510 and responsed (sic), indicating that staff will have to call his office on Monday to fill script for patient, sup made aware of status. " - 3/16/2015 at 11:15am: " [MEDICATION NAME] Tablet 10-325MG ...Need script waiting on MD. " - 3/16/2015 at 1:27pm: " Called MD (Dr. Z) regarding residents [MEDICATION NAME] Refill. MD stated do not call him, call his office. Informed him that his office was called no one answered the phone. MD stated call back in one hour. " - 3/16/2015 at 2:13pm: " Spoke with (staff member) from (Dr. Z) ' s office regarding residents [MEDICATION NAME] script. She stated no none (sic) was available at this time and took a message. " - 3/16/2015 at 7:04pm: " [MEDICATION NAME] Tablet 10-325MG ...not aviable (sic). " - 3/17/2015 at 12:45am: " [MEDICATION NAME] Tablet 10-325MG ...pending pharmacy delivery. " - 3/17/2015 at 11:07am: " Called Dr. Z ' s office regarding residents [MEDICATION NAME] script. Receptionist stated that MD assistant would return call. Residents info was given. " - 3/17/2015 at 5:10pm: " ...narco (sic) not given not aviable (sic) Tylenol #3 given " - 3/18/2015 at 6:15pm: [MEDICATION NAME] Tablet 10-325MG ...pending delivery. " - 3/18/2015 at 10:59am: " CALLED (Dr. Z) OFFICE SPOKE WITH (staff member). STATED SHE THOUGHT SHE FAXED IT OVER TO THE PHARMACY. (Staff member) CHECKED AND STATED SHE WAS WRONG. SHE STATED SHE IS ABOUT TO GET (Dr. Z) TO WRITE OUT SCRIPT AND SHE WILL FAX IT TO PHARMACY ... " - 3/19/2015 at 1:14pm: " [MEDICATION NAME] Tablet 10-325MG ...pending delivery " In an interview on 3/19/2015 at 1:30pm, the DON said that she has in-serviced the nursing staff regarding not waiting until the last minute to re-order prescription medications. She said that if a physician is not responding to requests, then nursing staff should call the medical director to notify him of the problem. She said that typically, medications are requested when there are 3 to 4 doses left. When asked about requesting a new prescription over the weekend, she said that was not standard protocol. She further stated that when Dr. Z does not have a prescription pad on the weekend it is " not an excuse " and he should send a prescription to the pharmacy. In an interview on 3/19/2015 at 3:15pm, Resident #19 said that she received a dose of the [MEDICATION NAME] 10-325mg medication at noon. She described the pain as stabbing or throbbing in the neck, back, and shoulders when she does not take her medication. When asked for a facility policy related to re-ordering medications, a copy of the Medication Management Program policy was provided, which read in part ... " The facility will implement a medication management program that incorporates systems with established goals to meet each patient ' s needs as well as our regulatory requirements. " According to the CMS 672 form, the census was 116.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 24 residents, (Resident #19) reviewed for medication administration, as evidenced by: - Resident #19 ' s Norco 10-325mg prescription (a medication to treat pain) was not requested from the physician ' s office in a timely manner. Resident #19 was out of the medication starting on Sunday, March 15, 2015 at 6:00pm through Thursday March 19, 2015 at 12:00pm. This failure affected 1 resident and could place an additional 116 residents at risk of decline in health due to complications or an adverse reaction to medications not being administered per the physician's orders [REDACTED]. Findings Include: Record review of Resident #19 ' s medical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was [AGE] years old. Record review of Resident #19 ' s quarterly MDS assessment dated [DATE] revealed that she had a BIMS of 15, indicating no cognitive impairment. It further revealed that she was receiving scheduled pain medications, she experienced frequent pain with a maximum intensity level of severe, and the pain limited her day-to-day activities. In an interview on 3/17/2015 at 1:15pm, Resident #19 said that she ran out of the Norco 10-325mg pain medication over the weekend, and it had not been delivered. She said that LVN E did not request a new prescription in time. She shared that she had pain rated at an 8 on a scale of 1-10 due to Fibromyalgia that started after a closed-brain injury. She said that she preferred to stay in her room due to a high-level of pain. Record review of Resident #19 ' s Physician order [REDACTED]. Z on 2/11/2015 revealed that she was prescribed Norco 10-325mg one tablet by mouth every 6 hours for pain management. Record review of Resident #19 ' s MAR indicated [REDACTED]" . Record review of Resident #19 ' s Care Plan revealed that she had chronic pai[DIAGNOSES REDACTED]. The goal read... " The resident, will not have discomfort related to side effects of analgesia through the next review date. " The date initiated was 12/24/2014, and the target date was 5/13/2015. Record review of Resident #19 ' s Narcotic Record revealed that 120 tablets of Norco 10-325mg was delivered to the facility on [DATE]. The resident was administered the last tablet from this delivery on 3/15/2015 at 12:00pm. In an interview on 3/18/2015 at 10:45am, LVN E said that she had been calling the physician ' s office for a new Norco 10-325 mg prescription for Resident #19 since Monday, 3/16/2015. She said that she usually contacted the physician ' s office when there are 8 tablets left. She said that since she started requesting a new prescription, Dr. Z would not accept calls on his cell phone and the physician ' s office was not responding to her requests. In an interview on 3/18/2015 at 11:40am, LVN E said that on Friday, 3/13/2015, there were 8 tablets left of Resident #19 ' s Norco 10-325mg medication. She said that Dr. Z usually provided another prescription for this medication 3 to 4 days after a request was made. Record review of Resident #19 ' s Progress Notes revealed the following: - 3/15/2015 at 3:10pm: " LE 3/14/2015 called MD regarding needing a triplicate for Norco order since upon start of shift since a refill is needed, no response. Made sup aware. Called MD and text at 1030 am & 1pm, no response. Called again at 1510 and responsed (sic), indicating that staff will have to call his office on Monday to fill script for patient, sup made aware of status. " - 3/16/2015 at 11:15am: " Norco Tablet 10-325MG ...Need script waiting on MD. " - 3/16/2015 at 1:27pm: " Called MD (Dr. Z) regarding residents Norco Refill. MD stated do not call him, call his office. Informed him that his office was called no one answered the phone. MD stated call back in one hour. " - 3/16/2015 at 2:13pm: " Spoke with (staff member) from (Dr. Z) ' s office regarding residents norco script. She stated no none (sic) was available at this time and took a message. " - 3/16/2015 at 7:04pm: " Norco Tablet 10-325MG ...not aviable (sic). " - 3/17/2015 at 12:45am: " Norco Tablet 10-325MG ...pending pharmacy delivery. " - 3/17/2015 at 11:07am: " Called Dr. Z's office regarding residents Norco script. Receptionist stated that MD assistant would return call. Residents info was given. " - 3/17/2015 at 5:10pm: " ...narco (sic) not given not aviable (sic) Tylenol #3 given " - 3/18/2015 at 6:15pm: Norco Tablet 10-325MG ...pending delivery. " - 3/18/2015 at 10:59am: " CALLED (Dr. Z) OFFICE SPOKE WITH (staff member). STATED SHE THOUGHT SHE FAXED IT OVER TO THE PHARMACY. (Staff member) CHECKED AND STATED SHE WAS WRONG. SHE STATED SHE IS ABOUT TO GET (Dr. Z) TO WRITE OUT SCRIPT AND SHE WILL FAX IT TO PHARMACY ... " - 3/19/2015 at 1:14pm: " Norco Tablet 10-325MG ...pending delivery " In an interview on 3/19/2015 at 1:30pm, the DON said that she has in-serviced the nursing staff regarding not waiting until the last minute to re-order prescription medications. She said that if a physician is not responding to requests, then nursing staff should call the medical director to notify him of the problem. She said that typically, medications are requested when there are 3 to 4 doses left. When asked about requesting a new prescription over the weekend, she said that was not standard protocol. She further stated that when Dr. Z does not have a prescription pad on the weekend it is " not an excuse " and he should send a prescription to the pharmacy. In an interview on 3/19/2015 at 3:15pm, Resident #19 said that she received a dose of the Norco 10-325mg medication at noon. She described the pain as stabbing or throbbing in the neck, back, and shoulders when she does not take her medication. When asked for a facility policy related to re-ordering medications, a copy of the Medication Management Program policy was provided, which read in part ... " The facility will implement a medication management program that incorporates systems with established goals to meet each patient ' s needs as well as our regulatory requirements. " According to the CMS 672 form, the census was 116.

Based on interview and record review the facility failed to implement their written policy and procedure that prohibit neglect for 1 of 8 residents reviewed for neglect. (Resident #8) The facility failed to recognize, assess and intervene in a timely manner: --- to assess nutritional needs of Resident # 8 when an initial weight loss was identified on 08/16/12 --- when Resident # 8 had a severe weight loss of 13% in 1month and a severe weight loss of 15% in 3 months, --- to ensure the PCP followed up on dietitian's recommendations in a timely manner, --- when Resident # 8 developed a sacral pressure ulcer in the facility. The wound worsened over a 45 day period, --- when Resident # 8 was transferred to another facility with a wound that was infected, required hospitalization and surgical debridement. Resident #8 ' s weight went from 136.3 pounds on admission to facility #1 on 05/24/2012 down to 92.4 pounds on admission to facility #2 on 09/12/2012. Resident #8 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident # 8 passed away on 09/24/2012 at facility #2. This failure affected 1 discharged resident and placed the 88 residents in the facility at risk of failure to provide services necessary to avoid physical harm. Complaint # 6 Findings Included: Record review of Resident #8 ' s clinical record revealed an [AGE] year old female that was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 was discharged to facility #2 on 09/12/12. She was admitted to the hospital on [DATE], returned to facility #2 09/20/2012 and passed away on 09/24/12. Pressure ulcer Issues: Record review of Resident #8 ' s Comprehensive Nursing Assessment on 05/24/2012 at 1:30 p.m. upon admission revealed that the resident had no pressure ulcers upon admission. Record review of Resident #8 ' s Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/31/2012 revealed resident weight was 133, she was not at risk of developing pressure ulcers, and she had no stage 1 or higher pressure ulcers. Record review of Resident #8 ' s Braden Scale-For predicting Pressure Sore Risk dated 05/31/12 revealed the resident ' s risk score was 13 (a total score of 12 or less represents High Risk). Record review of Resident #8 ' s Pressure Ulcer Care Plan revealed date initiation date of 07/29/2012 revealed deep tissue injury to right buttock, left buttocks and left heel; stage II pressure ulcers to right buttocks and left buttocks; and an unstageable pressure ulcer to the sacral area. Record review of Resident #8 ' s pressure ulcer report date 08/09/12 for sacral wound revealed wound stage was unstageable. Size was length 4.5 cm by width 5.5 cm. and depth was 0.3 cm. Exudate type was serosanguinous. Odor was none. Exudate amount was small. Record review of Resident #8 ' s physician progress notes [REDACTED]. No new complaints. Essentially stable. Per nurses, the patient is sleeping well and eating fairly normally in the dining hall. No recent fall ....denies anorexia, [MEDICAL CONDITION], depression. Denies skin ulcers ....Physical exam reveals skin was intact, dry, and without [MEDICAL CONDITION] .... Instructions printed and provided to patient: Patient is essentially stable in nursing home environment. No new complaints of complications. Discuss with the nursing staff about any change in conditions, falls, change in mental status, or behavior. The patient has been stable.". Record review of Resident #8 ' s pressure ulcer report dated 09/06/2012 revealed unstageable sacral wound; size in centimeters 3.5 length by 3.5 width; depth was UTD (unable to determine). Exudate type was serosanguinous, odor was moderate, exudate amount was small. Response to treatment, deteriorated was marked. treatment of [REDACTED]. Record review of Resident #8 ' s pressure ulcer report dated 09/12/2012 (date of discharge from facility #1) revealed: Stage was unstageable. Size was 3.5 cm by 3.5 cm with depth was unable to determine. Exudate type was purulent. Odor was moderate. Exudate amount was moderate. Comments revealed resident was discharged to another facility (#2) with unstageable sacral wound with 100% necrotic tissue. Record review of Resident #8's Weekly Pressure Ulcer Assessment from facility #2 revealed an assessment date of 09/13/2012 with " ...Additional Narrative Notes: (wound) is malodorous, (stage) 4 (with) red per 1 (wound) (by) 4 (centimeters) beyond (wound) margin, Temp 101. (charge) nurse contacted (doctor) (with) concerns-(Resident) sent to (hospital) " Record review of Resident #8's hospital record revealed the Initial Admission Record dated 09/13/2012 with an assessment of the wound to the sacrum was eschar, full thick/skin loss covered with slough; there was undermining and tunneling present; the wound base was black, brown eschar; wound drainage was moderate, thick brown; and odor was foul-smelling. Record review of Resident #8's hospital record revealed the History and Physical dated 09/13/2012 with "...Impression: 1.[MEDICAL CONDITION] secondary to urinary tract infection and infected sacral decubitus ...." Record review of Resident #8's hospital record revealed Consultation dated 09/14/2012 with " ...Assessment and Recommendations: ...2. Sacral decubitus ulcer, stage IV, which appears to be infected and with concern for underlying osteo[DIAGNOSES REDACTED] ...." During an interview on 09/24/2012 at 11:25 AM, DON at facility #2 stated that Resident #8 had passed away at their facility at 9:03 AM on 09/24/2012. The Surveyor was unable to observe the resident's wound. During an interview on 09/24/12 at 11:48 AM, Long Term Care Treatment Nurse at facility #2 stated that she assessed Resident #8 ' s wound the morning after her admission. She said she did not like the way it looked or smelled, so she sent the Resident to the hospital. She also stated that she did not get to work with the Resident long enough to determine if the wound was the result of the end-of-life process. During an interview on 09/24/12 at 4:30 PM, the Treatment Nurse at facility #1stated that she did not think there was a problem with Resident #8 ' s sacral wound on the day she was discharged to facility #2. She stated that there was serosanguinous tan-colored exudate. It had slight odor. She had no fever that could be felt. She also stated that family wanted her transferred to the other facility. During an interview on 09/26/12 at 9:58 AM, Treatment Nurse at facility #1 stated that the Wound Care Physician did not follow, assess or treat Resident #8 because she could not get a consult order from the primary care physician (PCP). Record review of Resident #8 ' s clinical chart revealed there was no documentation of the Medical Director being notified that facility #1was unable to obtain order from the PCP for wound consult for Resident #8. Weight Loss Issues: Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 05/25/12 that " Recommendation: Multivitamin with mineral. Medication pass 2.0 " . Signed by Registered Dietician A. " Response from attending physician: Agree " was not circled and signed until 08/15/12. Record review of Resident #8 ' s Dietary Progress notes revealed the Dietary manager ' s last entry was 06/07/2012 which included " Care plan update. Family attended, concerned about eating amount and resident feeding self. Resident on mechanical soft ground meat. Current weight: 134 " . No further documentation by the dietary manager. Record review of Resident #8 ' s Comprehensive Care Plan dated 08/17/12 for unplanned weight loss. Approach weight q (every) week until stable. Record review of Resident #8 ' s Dietary Assessment revealed an entry date of 08/31/12 with "Weight 112.4 pounds on weekly weights. Down 19.2 pounds, which is 14.6%. Weight loss significant. Resident depressed, crying, not eating. Recommendations: Appetite stimulant as appropriate, vitamin C, zinc x 14 days,[MEDICATION NAME] packet. Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 08/31/12 that " Problem and concern of decreased appetite. Weight loss is 19.2 pounds x1 month and wound healing. Recommendation: Appetite with stimulant is appropriate. If agree, please specify. Vitamin C, zinc sulfate, increased medication pass,[MEDICATION NAME] " signed by Registered Dietician B. Response from attending physician with " agree " was not signed until 09/06/12. Record review of Resident #8 ' s Dietary Assessment revealed an entry date of 09/07/12 with " Weight: 111.8 pounds. Down 22 pounds, 16.6% x3 months. Unstageable eschar to sacral per 09/05/12 skin log. Continues diet and medications and supplements. Registered Dietician recommendations 08/31/12 have not yet been addressed. Continues not to eat and cry and that she wants to die. No new labs. Recommendation: Weekly weights. Follow-up on Registered Dietician recommendation 08/31/12. Consider appetite stimulant " . Record review of Resident #8 ' s medication record for 09/01/2012 to 09/30/2012 revealed [MEDICATION NAME] 400 mg at 5 mL. Give 5 cc daily by mouth with a start date of 09/10/2012. First initial date was 09/12/2012 circled and no explanation why not given on 09/10/12 or 09/11/12. Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 09/07/12 which included "problem and concern: Not eating, weight down 22 pounds x 3 months. Recommendation: Consider appetite stimulant. If yes, please specify one " signed by Registered Dietician A. Response from attending physician with "agree" was not signed until 09/17/12.(Resident discharged from the facility on 09/12/2012). Record review of Resident #8's Resident Data Set v3.1 from the facility #2 revealed an assessment date of 09/12/2012 with " Vitals: ...Admission Weight: 92.4 ....Cognitive/Communication/ Mood/Behavior: ...Lethargic ..." Record review of Resident #8 ' s facility weight report revealed weight in May 2012 was 136.3, in June was 134.0, in July was 131.6, in August was 114.4, and in September was 111.8. Record review of Resident #8 ' s Weekly Weight Variance Log reveals 09/2012, the resident weighed 112 on 09/06/12 and on 09/13/12 discharge weight was 109.2. Record review of the hospital's nutritional status report completed on 09/17/12 revealed that Resident #8's total protein was 5.8 gm/dL (normal range is 6.0 to 8.3 g/dL), [MEDICATION NAME] was 2.0 (normal range is 3.5-6.0 g/dL) and pre-[MEDICATION NAME] was 7 g/dL (normal range 16-35 g/dl). Weight loss listed as 38 pounds in 4 months. Further review of the form revealed that severe [MEDICAL CONDITION] was checked and signed by a physician. During an interview on 09/26/12 at 10:40 AM, Registered Dietician A stated that dieticians are in the facility four times a month, that they receive a report after the 10th of the month on skin and weight issues. She did not know why it was so long for the other dietician to come to the facility in August to assess Resident #8 after the June visit but stated that she did notice that the doctor had not replied to recommendation made on 08/31/12 until she came out on 09/07/12. During an interview on 09/26/12 at 11:40 AM, ADON stated that staff were to document on meal intake, how much Resident ate, and if less than 75% how much of the alternative or supplement that was given was taken. When shown records on Resident #8 for meal intake, she acknowledged that the documentation was not done on her for the alternative and substitute. During an interview on 09/26/12 at 10:15 AM, Resident #8 ' s PCP stated he knew Resident #8 had weight loss and was going by the dietary recommendations. He said he thought she was eating fairly normal, according to the facility staff. When questioned about his Progress Note on 08/27/12 regarding the wound, he said he did not know about the wound and did not know there was a change in the wound prior to discharge. He stated he usually would turn the wound care over to the wound care physician. Record Review of the facility Abuse Prevention policy dated 06/2009 revealed in part: "The facility will prohibit abuse, neglect...abuse is defined in part as...deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being..." According to the CMS 672, the facility's census was 88.

Based on interview, and record review, the facility failed to ensure that a resident who entered the facility without a pressure sore did not develop a pressure sore and receive necessary treatment and services to promote healing, prevent infection for 1 of 3 residents reviewed for pressure ulcers (Resident #8). ---Resident #8 developed a sacral pressure ulcer in the facility. The wound worsened over a 45 day period. ---Resident #8 was transferred to another facility with a wound that was infected, required hospitalization and surgical debridement. These failures affected 1 discharged resident and placed 13 other resident with pressure ulcers at risk for pain, odors, further skin breakdown, infection, hospitalization and surgery. Complaint # 6 Findings included: Record review of Resident #8 ' s clinical record revealed an [AGE] year old female that was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 was discharged to facility #2 on 09/12/12. She was admitted to the hospital on [DATE], returned to facility #2 09/20/2012 and passed away on 09/24/12. Record review of Resident #8 ' s Comprehensive Nursing Assessment on 05/24/2012 at 1:30 p.m. upon admission revealed that the resident had no pressure ulcers upon admission. Record review of Resident #8 ' s Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/31/2012 revealed resident weight was 133, she was not at risk of developing pressure ulcers, and she had no stage 1 or higher pressure ulcers. Record review of Resident #8 ' s Braden Scale-For predicting Pressure Sore Risk dated 05/31/12 revealed the resident ' s risk score was 13 (a total score of 12 or less represents High Risk). Record review of Resident #8 ' s Braden Scale-For predicting Pressure Sore Risk dated 06/14/12 revealed the resident ' s risk score had decreased to a 12 (a total score of 12 or less represents High Risk). Record review of Resident #8 ' s Quarterly MDS with ARD of 07/01/2012 revealed resident weight was unchanged at 133, she was not at risk of developing pressure ulcers and she had no stage 1 or higher pressure ulcers. Record review of Resident #8 ' s Pressure Ulcer Care Plan revealed date initiation date of 07/29/2012 revealed deep tissue injury to right buttock, left buttocks and left heel; stage II pressure ulcers to right buttocks and left buttocks; and an unstageable pressure ulcer to the sacral area. Record review of Resident #8 ' s pressure ulcer report date 08/09/12 for sacral wound revealed wound stage was unstageable. Size was length 4.5 cm by width 5.5 cm. and depth was 0.3 cm. Exudate type was serosanguinous. Odor was none. Exudate amount was small. Wound bed granulation was red with slough. Surrounding skin color was dark red and purple. Surrounding tissue/wound edges were normal for skin. In the comments section " noted 60% yellow tan necrotic tissue mixed with 40% red beefy tissue." Record review of Resident #8 ' s physician progress notes [REDACTED]. No new complaints. Essentially stable. Per nurses, the patient is sleeping well and eating fairly normally in the dining hall. No recent fall ....denies anorexia, [MEDICAL CONDITION], depression. Denies skin ulcers ....Physical exam reveals skin was intact, dry, and without [MEDICAL CONDITION] .... Instructions printed and provided to patient: Patient is essentially stable in nursing home environment. No new complaints of complications. Discuss with the nursing staff about any change in conditions, falls, change in mental status, or behavior. The patient has been stable.". Record review of Resident #8 ' s pressure ulcer report dated 09/06/2012 revealed unstageable sacral wound; size in centimeters 3.5 length by 3.5 width; depth was UTD (unable to determine). Exudate type was serosanguinous, odor was moderate, exudate amount was small. Wound bed, slough, necrotic, surrounding skin color bright red and dark red-purple. Surrounding tissue/wound edges were maceration. Response to treatment, deteriorated was marked. In-house is also marked. treatment of [REDACTED]. Comment was noted that 100% tan-black necrotic tissue edges bright red with dark purple discoloration. Record review of Resident #8 ' s pressure ulcer report dated 09/12/2012 (date of discharge from facility#1) revealed: Stage was unstageable. Size was 3.5 cm by 3.5 cm with depth was unable to determine. Exudate type was purulent. Odor was moderate. Exudate amount was moderate. Wound bed had slough and was necrotic. Surrounding skin color was dark, red-purple to surrounding tissue. Wound edges were normal for skin. Handwritten on the form was an assessment of the wound that stated " 100% tan-black necrotic tissue. Edges, bright red and partly maroon-purple, something surrounding tissue " . Comments revealed resident was discharged to another facility (#2) with unstageable sacral wound with 100% necrotic tissue. Record review of Resident #8's Resident Data Set v3.1 from the facility #2 revealed an assessment date of 09/12/2012 with " Vitals: ...Admission Weight: 92.4 ....Cognitive/Communication/ Mood/Behavior: ...Lethargic ..." Record review of Resident #8's Weekly Pressure Ulcer Assessment from facility #2 revealed an assessment date of 09/13/2012 with " ...Additional Narrative Notes: (wound) is malodorous, (stage) 4 (with) red per 1 (wound) (by) 4 (centimeters) beyond (wound) margin, Temp 101. (charge) nurse contacted (doctor) (with) concerns-(Resident) sent to (hospital) " Record review of Resident #8's hospital record revealed the Initial Admission Record dated 09/13/2012 with an assessment of the wound to the sacrum was eschar, full thick/skin loss covered with slough; there was undermining and tunneling present; the wound base was black, brown eschar; wound drainage was moderate, thick brown; and odor was foul-smelling. Record review of Resident #8's hospital record revealed the History and Physical dated 09/13/2012 with "...Impression: 1.[MEDICAL CONDITION] secondary to urinary tract infection and infected sacral decubitus ...." Record review of Resident #8's hospital record revealed Consultation dated 09/14/2012 with " ...Assessment and Recommendations: ...2. Sacral decubitus ulcer, stage IV, which appears to be infected and with concern for underlying osteo[DIAGNOSES REDACTED] ...." Record review of Resident #8 ' s hospital record revealed Disclosure and Consent Medical and Surgical Procedures with date of September 14, 2012 revealed " To the patient: ...the recommended surgical, medical, or diagnostic procedure to be used ...I/we voluntarily request ...to treat my condition which has been explained to me as: " to clean out wound to sacral " ... " During an interview on 09/24/2012 at 11:25 AM, DON at facility #2 stated that Resident #8 had passed away at their facility at 9:03 AM on 09/24/2012. The Surveyor was unable to observe the resident ' s wound. During an interview on 09/24/12 at 11:35 AM with Acute Care Treatment Nurse at facility #2 she said that Resident #8 was transferred to their facility and when their Treatment Nurse observed Resident #8's wound and assessed it, that Resident was sent to the hospital. She also stated that when Resident #8 returned to their facility from the hospital, the wound on the sacral area had been debrided and it was a 7 cm x 6.5 cm x 4.3 cm deep wound. During an interview on 09/24/12 at 11:48 AM, Long Term Care Treatment Nurse at facility #2 stated that she assessed Resident #8 ' s wound the morning after her admission. She said she did not like the way it looked or smelled, so she sent the Resident to the hospital. She also stated that she did not get to work with the Resident long enough to determine if the wound was the result of the end-of-life process. During an interview on 09/24/12 at 4:30 PM, the Treatment Nurse at facility #1stated that she did not think there was a problem with Resident #8 ' s sacral wound on the day she was discharged to facility #2. She stated that there was serosanguinous tan-colored exudate. It had slight odor. She had no fever that could be felt. She also stated that family wanted her transferred to the other facility. During an interview on 09/26/12 at 9:58 AM, Treatment Nurse at facility #1 stated that the Wound Care Physician did not follow, assess or treat Resident #8 because she could not get a consult order from the primary care physician (PCP). Record review of Resident #8 ' s clinical chart revealed there was no documentation of the Medical Director being notified that facility #1was unable to obtain order from the PCP for wound consult for Resident #8. During an interview on 09/26/12 at 10:15 AM, Resident #8 ' s PCP stated he knew Resident #8 had weight loss and was going by the dietary recommendations. He said he thought she was eating fairly normal, according to the facility staff. When questioned about his Progress Note on 08/27/12 regarding the wound, he said he did not know about the wound and did not know there was a change in the wound prior to discharge. He stated he usually would turn the wound care over to the wound care physician. According to the CMS 672 form, the facility had 13 residents with pressure ulcers.

Based on interview and record review the facility failed to ensure that 1 of 8 residents reviewed for nutrition maintained acceptable parameters of nutritional status and body weight with adequate nutrients to assist in wound healing and failed to assess and thoroughly evaluate the nutritional needs. (Resident #8). The facility failed to: - assess Resident #8's nutritional needs in a timely manner when initial weight loss was identified on 08/16/12, - ensure the dietitian's recommendations for Resident #8 were communicated to the physician in a timely manner, - provide new nutritional interventions to prevent further weight loss and worsening of the pressure ulcers for Resident #8, - Resident #8 had a severe weight loss of 13% in 1month and a severe weight loss of 15% in 3 months. These failures affected 1 discharged resident and placed 88 residents at risk of continued weight loss, [MEDICAL CONDITION] and slow wound healing. Complaint # 6 Findings included: Record review of Resident #8 ' s clinical record revealed Resident was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8 ' s Admission MDS with Assessment Reference Date (ARD) of 05/31/2012 revealed resident weight was 133, and weight gain/loss was marked as NO. Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 05/25/12 that " Recommendation: Multivitamin with mineral. Medication pass 2.0 " . Signed by Registered Dietician A. " Response from attending physician: Agree " was not circled and signed until 08/15/12. Record review of Resident #8 ' s Dietary Assessment revealed an entry date 06/08/12 with " Weight 134 pounds. Treatment Nurse reports deep tissue injury to right heel and sacrum. Dietary evaluation ordered 05/25/12, the same day as Registered Dietician ' s assessment. Recommendation: Redraw BMP. Follow-up on Registered Dietician recommendation 05/25/12. Vitamin C 500 mg twice daily" . Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 06/08/12 that " Problem or concern: Deep tissue injury to right heel and sacrum, per Treatment Nurse and sodium level on 05/26/12 of 129, which is low. Resident is on a 1000 mL fluid restriction. At risk for dehydration. Recommendation: Vitamin C 500 mg, zinc sulfate. Redraw BMP and can we possibly liberalize fluid restriction " signed by Registered Dietician A. Response from attending physician, " agree " was circled and PCP signature with date of 06/15/12. Record review of Resident #8 ' s Dietary Progress notes revealed the Dietary manager ' s last entry was 06/07/2012 which included " Care plan update. Family attended, concerned about eating amount and resident feeding self. Resident on mechanical soft ground meat. Current weight: 134 " . No further documentation by the dietary manager. Record review of Resident #8 ' s Quarterly MDS with ARD of 07/01/2012 revealed resident weight was unchanged at 133, she was not at risk of developing pressure ulcers and she had no stage 1 or higher pressure ulcers. Record review of Resident #8 ' s Comprehensive Care Plan dated 08/17/12 for unplanned weight loss. Approach weight q (every) week until stable. Record review of Resident #8 ' s Dietary Assessment revealed an entry date of 08/31/12 with "Weight 112.4 pounds on weekly weights. Down 19.2 pounds, which is 14.6%. Weight loss significant. Resident depressed, crying, not eating. Recommendations: Appetite stimulant as appropriate, vitamin C, zinc x 14 days,[MEDICATION NAME] packet. Record review of Resident #8 ' s Dietary Assessment revealed an entry date of 08/31/12 with "addendum: Increase Med Pass (supplement) 2.0 to 3 times a day ". Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 08/31/12 that " Problem and concern of decreased appetite. Weight loss is 19.2 pounds x1 month and wound healing. Recommendation: Appetite with stimulant is appropriate. If agree, please specify. Vitamin C, zinc sulfate, increased medication pass,[MEDICATION NAME] " signed by Registered Dietician B. Response from attending physician with " agree " was not signed until 09/06/12. Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician revealed a second form dated 08/31/12 with had written [MEDICATION NAME] 400 mg/5 cc 5cc daily. PCP did not signed until 09/06/12. Record review of Resident #8 ' s Dietary Assessment revealed an entry date of 09/07/12 with " Weight: 111.8 pounds. Down 22 pounds, 16.6% x3 months. Unstageable eschar to sacral per 09/05/12 skin log. Continues diet and medications and supplements. Registered Dietician recommendations 08/31/12 have not yet been addressed. Continues not to eat and cry and that she wants to die. No new labs. Recommendation: Weekly weights. Follow-up on Registered Dietician recommendation 08/31/12. Consider appetite stimulant " . Record review of Resident #8 ' s clinic record revealed physician order [REDACTED]. Record review of Resident #8 ' s medication record for 09/01/2012 to 09/30/2012 revealed [MEDICATION NAME] 400 mg at 5 mL. Give 5 cc daily by mouth with a start date of 09/10/2012. First initial date was 09/12/2012 circled and no explanation why not given on 09/10/12 or 09/11/12. Record review of Resident #8 ' s clinical record revealed communication between dietician and attending physician dated 09/07/12 which included "problem and concern: Not eating, weight down 22 pounds x 3 months. Recommendation: Consider appetite stimulant. If yes, please specify one " signed by Registered Dietician A. Response from attending physician with "agree" was not signed until 09/17/12. Record review of Resident #8 ' s facility weight report revealed weight in May 2012 was 136.3, in June was 134.0, in July was 131.6, in August was 114.4, and in September was 111.8. Record review of Resident #8 ' s Weekly Weight Variance Log reveals 08/2012 the resident weighed 112.4 on 08/22/12, week 1 date 08/29/12 weight was 112.2 and on 09/06/12, weight was 111.8; Record review of Resident #8 ' s Weekly Weight Variance Log reveals 09/2012, the resident weighed 112 on 09/06/12 and on 09/13/12 discharge weight was 109.2. Record of Record review of Resident #8 ' s hospital record revealed Initial Admission Record with weight of 92.4 pounds on 09/13/2012 at 12:17. Record review of the hospital's nutritional status report completed on 09/17/12 revealed that Resident #8's total protein was 5.8 gm/dL (normal range is 6.0 to 8.3 g/dL), [MEDICATION NAME] was 2.0 (normal range is 3.5-6.0 g/dL) and pre-[MEDICATION NAME] was 7 g/dL (normal range 16-35 g/dl). Weight loss listed as 38 pounds in 4 months. Further review of the form revealed that severe [MEDICAL CONDITION] was checked and signed by a physician. During an interview on 09/26/12 at 10:25 AM, Dietary Manager stated that when a Resident had weight issues, they would have a care plan meeting and that the dietician followed the Resident for skin and weight issues. She said she placed the information received by staff in the report for the dietician to follow up the weights and skin issues reported to her. She had put the information on the report for Resident #8 ' s weight and skin issues. During an interview on 09/26/12 at 10:40 AM, Registered Dietician A stated that dieticians are in the facility four times a month, that they receive a report after the 10th of the month on skin and weight issues. She did not know why it was so long for the other dietician to come to the facility in August to assess Resident #8 after the June visit but stated that she did notice that the doctor had not replied to recommendation made on 08/31/12 until she came out on 09/07/12. During an interview at 11:30 AM on 09/26/12, RNA A, stated that if a Resident refused to eat, she was to offer an alternative or a substitute and report to the charge nurse and document it on the Meal Intake Record. During an interview on 09/26/12 at 11:40 AM, ADON stated that staff were to document on meal intake, how much Resident ate, and if less than 75% how much of the alternative or supplement that was given was taken. When shown records on Resident #8 for meal intake, she acknowledged that the documentation was not done on her for the alternative and substitute. During an interview on 09/26/12 at 12:00 PM, RNA B stated that if a Resident refused to eat, she lets the charge nurse know, offers a substitute or an alternate, and then she would document how much they ate of their meal, as well as the alternative or the substitute. According to the CMS 672, the facility's census was 88.

Based on interview and record review, the facility failed to ensure that one (1) of eleven (11) residents reviewed for adequate supervision (Resident # 8) received adequate supervision to prevent accidents. The facility failed to prevent Resident #8 from eloping and falling, resulting in a closed head injury and facial lacerations, as evidenced by: - Resident # 8 was not prevented from leaving the facility late at night, even though he had [DIAGNOSES REDACTED]. The facility was contacted by the local hospital emergency room staff after an ambulance had picked up Resident # 8 in the street where he had been lying, bleeding from his head. This deficient practice affected one resident and could affect 8 additional residents in the facility with Wanderguards by putting them at risk for elopement and injuries. Findings include: Complaint # 9 Resident #8 Record review of the facility's nurses' notes dated 3/31/2012 (this was incorrectly dated as the family member was actually there and the elopement occurred on 3/30/12) at 10:15 PM read in part "(family member) is trying to convince resident to stay and go to bed." Further review of the nurses' notes this same date revealed that Resident # 8 was given IM Haldol "for agitation" at 10:45 PM. Continued review of facility nurses' notes (incorrect date)3/31/2012 at 11:30 PM read that Resident was escorted to his room and encouraged to go to bed but was refusing. Continued review of the nurses' notes for Resident #8 dated 3/31/2012 (incorrect date) at 12 midnight, revealed that RN A had been asked by a CNA if she had seen the resident, and following notes revealed that after RN A had "completed doing resident care at 12:00 AM (midnight)" the resident was still missing. RN A ordered a search of the building and outside area. Nurses' notes dated 4/01/12 (incorrect date) at 12:34 AM revealed that RN A called the DON to notify her that the resident was missing. Nurse notes dated 4/1/12 (incorrect date) at 1:00 AM read that RN A received a call from the hospital emergency room asking if they were missing a patient. Record review of Houston Fire Department EMS notes dated 3/31/2012 0005 read that (Resident # 8) had "Right eye blunt trauma: symptoms - bleeding .....Notes - arrived on scene to find pt. lying in the street w/bystanders caring for pt. Bystanders stated that they found pt. on the ground bleeding from the head. Pt. was in pajama pants, t-shirt and a bath robe, stated that someone pushed him down and the right side of his head hurts. Pt. has a hematoma above his right eye, bleeding had stopped. Pt. was approx. 200 yards from a nursing home. Pt. is AAO x 2, pt. is unaware of where he is or where he lives .....With Pt. clothing and proximity to nursing home it is suspected that he may have walked out of facility and confusion is his baseline. Pt. transported to ER for evaluation ..." Record review of the hospital ER notes dated 3/31/12 at 0030 read in part "Altered mental status, right forehead laceration ....Closed head injury, Facial Laceration, Facial Contusion, Altered mental status ...." Record review of the hospital ER notes dated 3/31/12 at 0123 read in part "Right forehead laceration. Onset: The symptoms/episode began/occurred at an unknown time." Record review of the Physician's Documentation dated 3/31/12 at 0744 revealed that Resident #8 was admitted to the hospital. Record review of the Discharge Summary from the hospital dated 4/8/12 revealed that Resident #8 was discharged on [DATE]. Record review of the closed facility medical record for Resident # 8 revealed a face sheet documenting he had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of an EMS transfer narrative from a hospital to the facility dated 3/28/12 read in part "Homicidal ideation, aggressive behavior, AMS, A&O x 2 ...Arrived to find 81 y/o male A & O x 2 to self/place, sitting on side of bed in no apparent distress with a sitter in sight. Pt. was admitted to hospital for aggressive behavior, homicidal, AMS .... Pt. stable while en route." Record review of the previous hospital notes revealed that Resident # 8 had sitters with him constantly to prevent wandering and getting out of bed (Nurses' Notes from 3/23/2012 through discharge from hospital on [DATE]). Further review of the previous hospital notes in his facility medical record read that he was confused throughout his stay in the hospital. One of his [DIAGNOSES REDACTED]. Record review of the facility's nurses notes dated 3/28/2012 read in part "Resident arrived at the facility around 7:00 PM via a stretcher from (the hospital). A&O x 1 to person only. Abnormal gait noted." Record review of Resident #8's admission "Wandering Data Collection Tool" dated 3/29/12 read that he was positive for a history of wandering, was a new admission and not accepting the new situation, ambulated independently, verbally expressed the desire to go home, was seeking spouse/family, and that staff were aware of resident's wander risk. There was no physician's order for a Wanderguard. His admission orders Alzheimer's dementia and aggressive behavior." Record review of Resident #8's facility Care Plan dated 3/29/12, revealed a Care Plan for Wandering. Under the section titled "Approaches" it read in part " ...4) Place a Wanderguard bracelet on resident and monitor for attempts to leave facility. " An interview with the facility's Administrator on 4/05/12 at 3:30 PM revealed he knew about Resident #8's elopement and subsequent hospitalization . He stated that Resident #8 was supposed to have a Wanderguard put on him when he was admitted to the facility, but they did not have one available. When asked why a Wanderguard bracelet was not available, the Administrator stated the nurses had used the last Wanderguard, which had been designated for Resident #8, on another resident. He stated he had re-ordered Wanderguards but he was unable to get any more in the building from 3/28/12 when the resident was admitted to 3/30/12 when Resident #8 eloped. The Administrator further stated the "clinical liason" went to see potential residents prior to their being admitted to the facility and had OK'd Resident #8 to come to the facility. The Administrator stated that he was called by facility staff and told that Resident # 8 was missing "around midnight" on 3/31/12. He stated the staff told him that Resident #8 had been attempting to leave the facility several times with his (family member) on 3/30/12 at 11:15 PM. The Administrator further stated that he was told that staff was looking for Resident #8 at midnight to do peri-care. He said he later received a call that Resident #8 had been found in the street by strangers who called an ambulance. Resident #8 was taken by ambulance to the local hospital ER. He stated "The ER called here and asked if we were missing a resident. They said he was found with bruises and had a cut above his right eye" An interview with the facility's DON on 4/05/2012 at 3:45 PM revealed she had been called when Resident #8 had eloped "about midnight" by the facility nurse (RN A). She stated she went to the facility to help look for him. When asked if she read the reports about the residents prior to their being admitted to the facility, she stated that she did when she could. She stated that the facility had a clinical liason who went out to the hospitals to do pre-admission screenings. She stated she had read the hospital notes related to Resident #8. When asked if she knew about his hospital history of having to be restrained and prevented from wandering in the hospital, she stated she did not. The DON stated that staff were looking for Resident #8 for "about an hour" before the hospital called. She stated that none of the staff knew what door he went out of, stating that none of the alarms went off. She stated he was not wearing a Wanderguard. Record review of the facility's document titled "Performance Improvement Meeting" dated 4/03/12 revealed the following documentation: "A patient (Resident #8) admitted to the facility at 7:00 PM on March 28th., 2012. This patient had been in the hospital for Alzheimer's and Dementia with psychotic behaviors exhibited. During his stay at the hospital, he was under the care of a 1:4 sitter (1 staff member for 4 patients in one room). Medication was started to treat the psychotic behaviors. He admitted to the facility having just been relieved of his 1:4 sitter. His assessment was completed pre-admission by the liason, and he was again assessed upon admission. Wandering behavior was identified, and a bed and chair alarm initiated. He eloped from the facility on 3/30/2012 around midnight. He was found by someone other than the facility staff, and admitted to the hospital for treatment of [REDACTED]." During an interview with Resident #8's family member on 4/04/12 at 6:05 PM, he stated that even though he was the responsible party, the facility nurse called another family member when they found out Resident #8 was in the emergency room in the early morning hours of 3/31/12. He stated the other family member called him to let him know Resident #8 was at the ER. He said " I had a meeting with the Administrator. He told me (Resident #8) had only been gone about an hour. He said they should have had a security bracelet on him. He (Resident #8) isn't going back there." He stated that the family had chosen another nursing facility to send Resident #8 to when he was discharged from the hospital. According to the DON there were 8 residents with Wanderguards in the facility.