Every finding on record at Monument Hill Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 2 residents (Resident #3) reviewed for medication errors. The facility failed to ensure nursing staff administered 7 doses of Rytary Oral Capsule Extended Release 48.75-195MG and Rytary Oral Capsule Extended Release 61.25-245 MG (Carbidopa-Levodopa) at the scheduled time for Resident #3. These failures could place residents at risk of their medications not being administered according to Physician's orders, getting their medications late, or not receiving the intended therapeutic benefits of their medications. Findings included: Record review of Resident #3 's face sheet, dated 08/06/2026, revealed a 75-years-old female admitted on [DATE] with diagnoses of Parkinson's disease (a slow brain disorder that affects movement), essential (primary) hypertension (high blood pressure with no known single cause), and fracture of right pubis (with subsequent encounter for fracture in the front part of pelvis [a basin-shaped ring of bones located at the base of the spine. It connects the upper body and spine to the legs, supports body weight, helps you walk and balance]) with routine healing. Record review of Resident #3's admission MDS assessment, dated 07/27/2026, revealed BIMS score of 15, intact cognition. Record review of Resident #3's order summary report, dated 08/05/2026, indicated Resident #3 had an order for Rytary Oral Capsule Extended Release 48.75-195MG (Carbidopa-Levodopa) Give 1 capsule by mouth three times a day Rytary Oral Capsule Extended Release 61.25-245 MG (Carbidopa-Levodopa) Give 1 capsule by mouth three times a day related to Parkinson's disease with start date 07/23/2026. Record review of Resident #3's Medication Administration Record, dated 08/01/2026-08/31/2026, indicated the following scheduled time for administration of Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) Give 1 capsule by mouth three times a day and Rytary Oral Capsule Extended Release 61.25-245 MG (Carbidopa-Levodopa) Give 1 capsule by mouth three times a day: 9:00 a.m., 3:00 p.m., and 9:00 p.m. with signatures of staff administered this medication without specific time of administration. Record review of Resident #3's Medication Administration Audit Report, dated 08/05/2026 for schedule dates 07/24/2026-08/05/2026 revealed Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) Give 1 capsule by mouth three times a day and Rytary Oral Capsule Extended Release 61.25-245 MG (Carbidopa-Levodopa) Give 1 capsule by mouth three times a day for Parkinson's disease: One dose - scheduled time at 09:00 a.m. on 07/29/2026 was administered at 10:48 a.m.One dose - schedule time at 9:00 a.m. on 08/01/2026 was administered at 10:14 a.m.One dose - schedule time at 9:00 a.m. on 08/02/2026 was administered at 10:35 a.m.One dose - schedule time at 9:00 a.m. on 08/03/2026 was administered at 10:57 a.m.One dose - schedule time at 9:00 p.m. on 07/27/2026 was administered at 10:26 p.m.One dose - schedule time at 9:00 p.m. on 07/29/2026 was administered at 10:50 p.m.One dose - schedule time at 9:00 p.m. on 08/01/2026 was administered at 10:24 p.m. During an interview with Resident #3 on 08/05/2026 at 3:25 p.m., she stated her Parkinson's medications ordered three times daily administered frequently an hour or more late. She stated that the doctor told her that consistent timing was critical for managing her Parkinson's symptoms. She stated the delay with administration of Parkinson's medications have not had any negative effect yet, but she was concerned it could happen in the future if facility continue to delay the administration of her Parkinson's medication. During an interview with the ADM on 08/05/2026 at 4:29 p.m., he stated that nursing staff, charge nurses and medication aides were responsible for administering medications timely. He stated that the DON was responsible for overseeing medication administration provided according to physician orders. He stated that the potential risk for not administering medications according to the physician's orders could be not treating residents' diagnoses properly. During an interview with the DON on 08/06/2026 at 10:22 a.m., she stated medication should be administered timely. She stated while most medications were on liberated schedule, certain medications such as those for Parkinson's disease do not and must be administered within a strict time window of scheduled time. She stated the failure to administer Parkinson's medications on time could dramatically exacerbate symptoms and cause serious health complications. She stated that she was responsible for periodically spot-checking medication administration times in PCC to ensure compliance. She stated that nursing staff received medication administration training on annual basis. Record review of the facility's Medication Administration, revised 10/01/2019, revealed Medications are administered as prescribed in accordance with good nursing principles. D. 10 Rights of Medication Administration - 5. Right time. The time a medication is given is important. Check the frequency of ordered medication. Double check that you are giving the ordered dose at the correct time. L. Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders,. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

Based on interviews and record review facility failed to ensure all alleged violations involving of mistreatment, neglect, abuse or misappropriation of resident property were reported immediately, but not later than 24 hours after the allegation was made to the administrator of the facility and to other officials (including to the State Agency) for 2 of 3 residents (Resident #1 and Resident #2) reviewed for misappropriation of resident property. Facility failed to immediately report an allegation of misappropriation of resident property involving Resident #1 to the State Agency.Facility failed to report immediately, or withing 24 hours, an allegation that Resident #2's recliner was not on site anymore to the State Agency. This failure could place residents at risk of misappropriation of property and emotional distress.Findings included: 1.Record review of Resident #1's face sheet, dated 08/05/2026, revealed an 81-years-old female admitted on [DATE] with diagnosis included blindness, one eye, depression (a common and serious medical illness with persistent feeling of sadness, emptiness, and a loss of interest in life that lasts for weeks or longer and affects how you think, feel, and act), and chronic pain (ongoing pain that lasts longer than three to six months). Record review of Resident #1's quarterly MDS assessment, dated 07/10/2026, revealed a BIMS score of 9, which indicated moderate cognitive impairment and substantial assistance required with ADLs. During an interview with Resident #1's family member on 08/05/2026, she stated she complained to different administrators since Resident #1 was admitted to this facility. Resident #1 experienced multiple incidents of missing personal property items during her stay here. She stated that she reported the complaint regarding missing laptop computers to current administrator and his superior several times in last couple of months through e-mail and phone communication. She stated last report was made on 08/03/2025. She reported two laptop computers missing and a heater along with multiple small items like a brand-new robe and snacks. She stated that it was very frustrating that those items were not located and not used for Resident #1 as was intended when purchased. One of the laptops was valued at $349.00 and the other valued at $250. She stated that a heater was missing that was about $100. 2.Record review of Resident #2 's face sheet, dated 08/05/2026, revealed an 78-years-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses of epilepsy (a common brain disorder that causes repeated, unprovoked seizures), hemiplegia affecting left nondominant side (a medical condition that causes total paralysis on one side of the body, affecting the arm, leg, and face), and major depressive disorder (a common mental health condition. It causes ongoing sadness, hopelessness, and a loss of interest in activities that lasts for at least two weeks). Record review of Resident #2's quarterly MDS assessment, dated 05/21/2026, revealed a BIMS score of 9, indicating moderate cognitive impairment and substantial/maximum assistance required with ADLs. During an interview with Resident #2's FM on 08/05/2026 at 3:11 p.m., she stated she purchased a power lift recliner for Resident #2 for about $1500. She stated that when they bought that recliner three years ago for Resident #2 and she could not use it and when Resident #2 got a roommate, facility staff put a chair out of the way. She stated when Resident #2 was moved over to a different room, the chair was placed in the storage on a different hall with her permission. She stated that it was supposed to be stored inside the facility and now no one can find it. She stated she was waiting for a return email from the business manager who could not explain where the recliner was and she also talked to ADM this morning. She stated that the MND said that the administrator told him to throw it away. She stated that it was a brand-new chair when they brought it to the facility. She stated that she decided to take it home now and sell it. She stated that facility staff never told her to pick it up or take it home. She stated that her brother saw this recliner used by another resident and when he told a former ADM about that, he put it back in the storage. During an attempt to interview Resident #2 on 08/05/2026 at 3:19 p.m., she was unable to respond comprehensively to questions. During an interview with the ADM on 08/06/2026 at 8:04 a.m., he stated that misappropriation of property was supposed to be reported according to facility's ANA policy within 24 hours. He stated that he filled out grievances for Resident #1 and Resident #2 reported by their family members immediately and started looking for the reported items immediately as that what he does first in order to find the missing items. After he completes investigation, he decides if it needed to be reported to state or not. He demonstrated a grievance filled out for Resident #1's FM reported to him missing items on 8/3/2026 and Resident #2's family member reported on 08/05/2025 to him about the recliner missing. He stated he remembered a message from a business office manager regarding a missing recliner for Resident #2 a day before that he did not have time to review closely. He stated that he contacted a previous administrator to inquire about situation with the recliner for Resident #2 and was informed that it was placed in the outside shed and got rotten and eaten by rats, so told MND to throw it away. He stated that it was before his time as he started in May 2026 and he did not know anything about the recliner just a few days ago. The ADM stated he initiated the search for Resident #1's two computers and located one iPad which he currently had in his office and was going to show to Resident #1's FM to verify if it was one of the missing computers. During an interview with the MND on 08/06/2026 at 11:44 a.m., he stated when Resident #2 moved rooms on 09/08/2025 the former ADM told him Resident #2's family will pick up a recliner, so he had it ready to be picked up on three occasions and finally the former ADM told him to put it in the outside shed to store where rodents and snakes were common occurrence. He stated that he spoke to Resident #2's family member himself on the day of the supposed pick up and Resident #2's family member told him that she will bring a bigger car more suitable for pick up. He stated that the recliner was in a good working condition and he could store it inside the building as there was plenty of inside storage space available, but former ADM told him to put it in the outside shed as Resident #2's family would be picking it up. He stated that it was destroyed by the rodents and thrown away about a year ago. He stated he was not sure if Resident #2's family were notified about that. Record review of a grievance, dated 08/03/2026, revealed the nature of complaint: Resident #1's FM requested all items available when she picks them up, including 2 laptops. They have not been located and have not been visualized since before ADM started and an investigation was still ongoing. Record review of e-mail correspondence between Resident #1's family member and ADM, dated 06/05/2026 at 8:08 a.m. and communication with former administrators revealed: Someone stole the brand-new heater that they took out of Resident #1's room and put in ADM office. During an interview with Resident #1's FM on 08/06/2026 at 4:11 p.m., she stated that she received one computer that she was missing from the ADM today, but she was still missing one computer and a heater. Record review of facility policy Abuse, Neglect, and Exploitation, implemented 7/11/2025, revealed Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. VII. Reporting/Response The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The facility's resident roster, dated 08/05/2026, reflected the census was 60.

Based on observation, interview, and record review, the facility failed to ensure that residents receive the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish for 2 of 7 residents (Resident #3 and Resident #4) reviewed for quality of life. The facility failed to ensure nursing staff provided scheduled showers and incontinent care for Resident #3 according to her ADL care plan goal. The facility failed to ensure Resident #4 was provided with incontinent care according to her ADL care plan goals. These failures could place residents at risk of decline in physical, mental, and psychosocial well-being. The findings included: Record review of Resident #3 's face sheet, dated 08/06/2026, revealed a 75-years-old female admitted on [DATE] with diagnosis of Parkinson's disease (a slow brain disorder that affects movement), essential (primary) hypertension (high blood pressure with no known single cause), and fracture of right pubis (with subsequent encounter for fracture in the front part of pelvis [a basin-shaped ring of bones located at the base of the spine. It connects the upper body and spine to the legs, supports body weight, helps you walk and balance]) with routine healing. Record review of Resident #3's admission MDS assessment, dated 07/27/2026, revealed BIMS score of 15, intact cognition, and required partial/moderate assistance (helper does less than half the effort) for showers, toileting hygiene, toilet transfer, and chair/bed-to-chair transfer. Record review of Resident #3's care plan, dated 07/28/2026, revealed a care focus Resident #3 has an ADL self-care performance deficit related to fatigue, impaired balance, limited mobility, musculoskeletal impairment, pubis rami (a break in the superior or inferior pubic bones that form the front part of the pelvis) fracture with interventions in place: Bathing/showering: provide sponge bath when a full bath or shower cannot be tolerated. The resident requires (limited to extensive assistance) by staff with showering. and Toileting use: the resident requires (extensive assistance) by (1) staff for toileting and transfer, and Discuss with resident/family/POA care any concerns related to loss of independence, decline in function. Resident #3's care focus She has bladder incontinence with interventions in place: Clean peri-area with each incontinence episode. During an interview with Resident #3 on 08/05/2026 at 3:25 p.m., she stated she was supposed to get 3 showers per week scheduled on Mondays, Wednesday, and Friday mornings, but she only received 3 showers between July 23rd and August 5th. She stated that she did not refuse her showers, only when she wanted to go play Bingo, but she still wanted that shower be given to her later that day. She stated that call lights consistently go unanswered for up to 4 hours when assistance was required to get out of bed or receive necessary changing/hygiene care. She stated that due to an excessive wait time for assistance to use the bathroom, she had an incontinence episode immediately upon standing up during physical therapy session. Waiting hours for essential personal care caused her to feel upset. She stated staff told her to urinate in her incontinent brief when she called for assistance to use a female urinal. She stated she requested to eat all meals in the main dining room and had communicated this directly to the DON and other staff members, but staff continued to bring food trays to her room instead which delayed her going to the dining room to eat. She stated that the DON assured her that she will get assistance with showers, incontinent care and eating in dining room promptly, however no meaningful improvement has occurred. She stated that she did not file a grievance. During an interview with Resident #3's family member on 08/05/2026 at 5:15 p.m., she stated Resident #3 experienced routine, 3-4 hours, delay when requesting assistance with toileting, showers and incontinence care. She stated that staff instructed Resident #3 to utilize her incontinent brief rather than assisting her to the toilet. She stated that Resident #3 wanted to become independent and not rely on using incontinent brief. She stated on 08/01/2026 she came to visit with Resident #3 and sat on her made bed, which was saturated with urine through the sheets to the mattress and covered with a dry cover, causing her clothes to become wet upon sitting down. She stated, Resident #3 called her on 07/05/2026 at 8:20 a.m. stating she was waiting to be changed and by 10:20 a.m. (2 hours later), no staff had responded. She stated when she called the facility at 11:59 to check on the delay, staff told her that Resident #3 was at physical therapy, and she assumed that she was changed before going there. She stated that Resident #3 asked facility staff on 07/31/2026 at 7:06 a.m. to eat breakfast in the dining room, but staff did not provide assistance and took her breakfast to her room. She stated that she spoke to the DON regarding these issues and the DON stated she will assist with Resident #3's concerns, but she did not notice a lot of difference in care for Resident #3. Record review of Resident #3's ADL - Bathing for 14 days (07/23/2026 - 08/05/2026), revealed Resident #3 received two showers on 07/26/2026 and 08/05/2026 and documented refusals on 07/24/2026 and 07/27/2026 with no documentation for other 3 showers. (07/28/2026, 07/31/2026, and 08/03/2026). Record review of Resident #3's ADL - toilet use for 14 days (07/23/2026 - 08/05/2026), revealed Resident #3 was assisted with toileting task: On 7/23/26 - 1 time at 3:38 p.m.On 7/24/26 - 2 times/day at 5:59 p.m. and 10:23 p.m.On 7/25/2026 - 1 time at 5:59 pm.On 7/26/2026 - 2 times at 00:17 a.m. and 5:59 p.m.On 7/27/2026 - 2 times at 00:30 a.m. and 2:22 p.m.On 7/28/2026 - 1 time at 8:44 a.m.On 7/29/26 - 1 time at 5:59 p.m.On 7/30/26 - 2 times at 00:42 a.m. and 11:30 p.m.On 7/31/2026 - 1 time at 3:16 p.m.On 8/01/2026 - 0On 08/02/2026 - 1 time at 2:28 a.m.On 08/03/2026 - 1 time at 2:18 a.m.On 08/04/2026 - 1 time at 00:01 a.m.On 08/05/2026 - 2 times at 01:45 a.m. and 12:45 p.m. 2. Record review of Resident #4 's face sheet, dated 08/06/2026, revealed a 90-years-old female originally admitted on [DATE] and readmitted on [DATE] with pathological fracture of hip with routine healing (a broken bone that happens because an underlying disease or condition has weakened the bone tissue), unspecified dementia without behavioral disturbance (cognitive decline, memory loss, or confusion, but the exact underlying subtype is not identified and there are no disruptive behavioral, psychotic, or mood symptoms), and repeated falls. Record review of Resident #4's quarterly MDS assessment, dated 07/02/2026, revealed BIMS score of 2, severe cognitive impairment, and always incontinent for urine and bowel (no episodes of continent voiding). Record review of Resident #4's care plan, dated 01/22/2026, revealed Resident #4's care focus ADL self-care performance deficit related to dementia, unsteady gait with interventions in place: Toileting use: the resident requires (extensive assistance) by (1) staff for toileting and transfer and Resident #4's care focus she has infection of the integumentary system (skin) related to prolonged moisture content with interventions, initiated on 01/23/2026, administer antibiotics as per medical doctor's orders and monitor/document/report for signs of UTI. Another care focus for Resident #4 was bladder incontinence with interventions: Clean perineal area (the diamond-shaped region at the base of the pelvis located between the thighs) with each incontinence episode. Record review of nursing progress notes for Resident #4, dated 08/05/2026, revealed no skin issues identified. During an interview with CNA B on 08/05/2026 at 2:32 p.m., she stated that scheduled showers were provided to Resident #3, however residents sometimes refuse showers. She stated staff do not have time to re-offer showers because one CNA was responsible for 22 residents making it difficult to provide timely assistance during busy periods. CNA B stated if residents did not receive timely showers and incontinent care, it could negatively impact their skin, increase the risk of infection and cause discomfort. During an interview with ADM on 08/05/2026 at 4:29 p.m., he stated that all nursing staff shared responsibility for answering call lights promptly and delivering required personal care residents including showers and incontinent care. He stated that his expectations were that staff must answer call lights promptly to meet residents' needs and provide timely incontinent care to prevent skin issues. He stated that the facility did not employ a dedicated shower aide, however they recently implemented a floating staff position assigned to assisting with care and showers to residents. He stated that shower schedules and administration procedures must be clearly documented in each resident's POC. He stated that if residents refused a shower or incontinent care, staff should still attempt to circle back and ensure showers were provided even on non-scheduled days if required. He stated that potential consequences of failing to provide timely incontinence care include skin breakdown, hygiene issues, and psychological distress for residents. During an interview with DON on 08/06/2026 at 10:22 a.m., she stated all nursing staff, including charge nurses, CNAs, ADON and DON are responsible for assisting with residents' showers. She stated that showers were scheduled 3 times a week on MWF or TThF morning or afternoon depending on room location. She stated 2 showers in two weeks was not acceptable practice that could cause skin breakdown and dehydration, risk of infection, and reduce residents' well-being. She stated nursing staff were required to attempt offering a shower three times before notifying the charge nurse of a refusal, and all attempts and refusals must be documented in POC and Point Click Care (residents' medical record) and on designated shower sheets. She stated staff were expected to check on residents every two hours and as needed. She stated a delay in assistance and incontinent brief changes could cause skin breakdown.She stated nursing staff was expected to assist residents with toileting and not tell them to use their incontinent briefs. During an interview with Resident #4's family member on 08/06/2026 at 12:31 p.m., he stated that Resident #4 did not get assisted with changing her incontinent brief for few hours in a time and he reported that to nursing staff but it did not help. He stated that Resident #4 did not remember to push a call light and tried to transfer to the toilet sometimes by herself and had a fall in the past few months because of that. He stated that he did not think she had any skin issues due to not being assisted with cleaning or changing incontinent briefs. He stated he was told by CNA, who worked at nights, that when she came at 6 p.m., Resident #4 was soaking wet on multiple occasions. During an attempt to interview Resident #4 on 08/06/2026 at 12:43 p.m., she was unable to respond comprehensively to questions. During an interview with CNA A on 08/06/2026 at 5:21 p.m., she stated that she rounded on residents every two hours, answer call lights promptly, and changed incontinence briefs as needed. She stated that she worked on different halls on day shifts 6 a.m. - 6 p.m. and recently switched to night shifts 6 p.m. - 6 a.m. She stated when she comes to the beginning of her shifts she frequently finds multiple residents who have not been changed and were soaking wet with urine. She stated some unidentified CNAs, she did not feel comfortable telling their names, failed to provide adequate care for the residents at this facility. She stated that she reported this issue to DON. Policy Review Activity of Daily Living, implemented 5/26/23, revealed the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living:Bathing, dressing, .Toileting.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; for all medication carts reviewed for controlled drug reconciliation. The facility failed to ensure they stored and labeled 34 tablets of 5-325 Norco for Resident #1 13 tablets of 5-325 for Resident #2 and 2 tablets of Oxycodone 5mg for Resident #3. This failure could place residents who receive medications at risk of not receiving the intended therapeutic effects of their prescribed medications.Findings included: Record review of facility self-report dated [DATE] reflected on [DATE] the facility conducted a narcotics count audit for discontinued medication. During the count they identified 2 individual Resident Controlled Substances Record Sheets of discontinued medication that did not have the corresponding medication. One Resident Controlled Substances Record Sheet was for Resident #1 and reflected 34 tablets of Norco 5-325 (a prescription medication combining 5 mg of hydrocodone (a narcotic opioid) and 325 mg of acetaminophen (the active ingredient in Tylenol) were missing and One Resident Controlled Substances Record Sheet for Resident #2 reflected 13 tablets of Norco 5-325 were missing. The facility conducted a full audit of narcotics for all carts in the building and identified a 3rd Resident Controlled Substances Record sheet for Resident #3 for Oxycodone 5mg tablets that reflected a count showed 5 tablets were present, but the medication blister pack contained 3 tablets. Record review of Resident #1, #2, and #3s' MAR reflected residents received all prescribed medications. Resident #1 and Resident #3 are deceased . Resident #2 was assessed for pain, and she denied having pain and stated her pain medications are controlling her pain. The facility conducted a search of all medication carts, the drug destruction waste bin and other locations throughout the facility and were unable to locate the missing narcotics. The facility reviewed the pharmacy destruction log, and the medications were not present. After a thorough investigation the facility had been unable to locate the 34 tablets of 5-325 Norco, the 13 tablets of 5-325, and the 2 tablets of Oxycodone 5mg. Record review of Resident #1's Individual Resident's Controlled Substance Record undated reflected a count of 34 tablets of 5-325 Norco with no signatures indicating a count of the narcotics. Record review of Resident #2's Individual Resident's Controlled Substance Record undated reflected a count of 13 tablets of 5-325 Norco with one illegible signature next to the number 13. Record review of Resident #3's Individual Narcotic Record reflected a count of 5 Oxycodone 5mg with the word expired and two illegible signatures. Record review of report by the CP, undated, to the facility reflected, On [DATE] I was notified of a controlled substance count discrepancy at [facility name] in [location]. The outgoing DON did not do a chain of custody med count upon resigning. The controlled substances for destruction were not logged and were kept under 2 locks in the DON office. The incoming (interim) DON did a med count with another employee when she became the sitting DON. The counts were not accurate according to the log sheets. A report was filed with HHSC and with the local police. An internal investigation was carried out. Discrepant quantities were noted on the drug destruction log. During an interview on [DATE] at 10:53 AM with the Administrator he said the IDON conducted an audit of discontinued medication when the FDON left. The Administrator said the audit was conducted because the FDON had left the day prior and the IDON decided to do an audit. The Administrator said the FDON did not do a narcotics count when she left the facility. The Administrator said when the FDON left, a narcotic count should have been done to make sure the narcotics count was correct before the IDON began working. The Administrator said the Resident Controlled Substances Record Sheets along with the discontinued medication should have gone together in the double lock cabinet located in the facility DON office. During an interview on [DATE] at 12:18 PM with the FDON she said when she was the DON, she was the only person with a key to the discontinued narcotics double locked medication box. She said she did not remember receiving the discontinued pills. The FDON said normally, there were two signatures on the discontinued Resident Controlled Substances Record Sheets, the signature of the nurse or MA who gave her the retired or discontinued medication and her signature. The FDON said she had no idea what happened with any of those pills. She said the pills should have been there and if they were not, she did not know what happened to them. During an interview on [DATE] at 1:00 PM with Resident #2 she said received all her pain medications and she was not in pain. Resident #2 said she did not have any concerns. During an interview on [DATE] at 1:14 PM with the IDON she said she was now a Charge Nurse but was the IDON from [DATE] until [DATE], before the current DON was hired. The IDON said on [DATE] she went into the FDONs office and found it in disarray. She said she began pairing the Resident Controlled Substances Record Sheets with the narcotic medication located in the facility DON lock box. She said she could not locate the narcotics for Resident #1's Controlled Substances Record Sheets that reflected 34 tablets of Norco 5-325 or the narcotics for Resident #2's Controlled Substances Record Sheets that reflected 13 tablets of Norco 5-325 were missing. The IDON said when facility conducted a full audit of narcotics for all carts in the building, they identified a 3rd Resident Controlled Substances Record Sheet for Resident #3 for Oxycodone 5mg tablets that reflected the count showed 5 tablets were present, but the medication blister pack contained 3 tablets. She said she did not think that the FDON took the narcotics because if she was going to take the medication, she would have disposed of the Controlled Substances Record Sheets. The IDON said that the Resident Controlled Substances Record Sheet should be rubberbanded together with the corresponding narcotics that were to be disposed of and there should have been a log listing all the Resident Controlled Substances Record Sheets. The IDON said she could not locate a log of the discontinued narcotics. The IDON said the FDON should have kept a log of the narcotics the FDON collected. The IDON said that both Resident #2 and Resident #3's medications were discontinued because the residents died. The IDON said Residents #1, Resident #2, and Resident #3 received all their prescribed medication as reflected in their MAR. The IDON said that Resident #2's Oxycodone 5mg prescription was changed and the 5mg tablets should have been removed from the cart and given to the FDON and placed in the facility DON lock box for destruction by the consultant pharmacist. The IDON said CMA A told her that she remembered she gave the FDON the discontinued medication for Resident #2, but MA A said that the FDON did not ask her to sign that she gave the medication to her. The IDON said it was not in the facility policy to have two signatures when counting discontinued narcotics to be given to the DON for the pharmacist's disposal. The IDON said in the past, the nurse or MA and the DON would sign the Resident Controlled Substance Record Sheets indicating that the count of the narcotics was correct. There would be two signatures on the Resident Controlled Substance Record Sheet when it was placed in the facility DON lock box for disposal. The IDON said the FDON was disorganized and because she was disorganized, she made an error with the medication. The IDON said it was the responsibility of the DON to make sure the narcotics to be disposed of were accounted for and placed in the facility DON lock box with the correct documentation. The IDON said the DON was responsible for the narcotics to be logged and locked. The IDON said a possible negative effect of the Resident Controlled Substance Record Sheet count being present with remaining pills, but no pills was a drug diversion. During an interview on [DATE] at 2:38 PM with CMA A she said she was the last person to give Resident #1 his medication before he died. She said when she returned to the facility for her next shift (date unknown) his Norco 5-325 tablets were still in the medication cart. CMA A said the FDON was not at the facility so they could not give Resident #1's unused narcotics to the FDON so she left a note on the medication to give it to the FDON. CMA A said when she next returned to the facility the Norco 5-325 tablets were not in the medication cart and she figured either a CMA or a nurse gave Resident #1's narcotics to the FDON. CMA A said when a resident died any leftover narcotics not taken by the resident must be turned over the to the facility DON immediately. CMA A said when Resident #2 received a change in the dosage for her narcotics she took Resident #2's pills with the old dosage to the FDON and handed them to her. The CMA said she stood in front of the FDON for a minute and thought the FDON was going to ask her to sign something regarding Resident #2's narcotics. CMA A said the FDON started talking to another staff member and told CMA A she was good to go and did not request her to count and sign she gave the FDON the medication and she did not see the FDON sign that she counted and received the medication. CMA A said two months ago when she was hired at the facility, she did not get any training on what to do concerning discontinued narcotics. CMA A said she received training since the incident. CMA A said the possible negative effect of not having the number of narcotics to match the Resident Controlled Substance Record Sheet was a drug diversion. During an interview by phone on [DATE] at 3:08 PM with the PC she said she was contacted about the discrepancy between the Controlled Substance Record Sheet and the narcotic count for Residents #1, #2, and #3. The PC said that if narcotics were not logged or counted, there could be a drug diversion. The PC said she did not think someone was intentionally trying to steal drugs. The PC said she thought the situation was an oversight. The PC said it was common sense that when discontinued narcotics were taken from the medication cart that the DON and the CMA or nurse both count and sign their names confirming that the narcotic count was correct. She said the signing off for the narcotics was a chain of custody for the narcotics. The PC said it was not a rule to sign that the count was accurate when it was given to the DON, but if there was not a count and signatures confirming the count and receipt of the medication, it was hard to deter theft of narcotics. During an interview by phone on [DATE] at 3:18 PM the ADON said she worked with the IDON to match the Controlled Substance Record Sheets with the residents' narcotics. The ADON said she and the IDON discovered that there were Controlled Substance Record Sheets that indicated there were remaining narcotics, but the narcotics were not present. The ADON said she did not know what happened but that the FDON was very sloppy and unorganized. The ADON said the FDON did not make sure there were double signatures on that indicated that two people counted the medication and confirmed the accuracy of the count and receipt of the pills. The ADON said the facility DON was responsible for making sure discontinued medications were double locked in the facility DON lock box to be destroyed. The ADON said the DON was responsible for confirming what was on the Controlled Substance Record Sheets was accurate then put the Controlled Substance Record Sheets and the pills into the locked box. During an interview on [DATE] at 5:18 PM with the Administrator he said the facility policy was that discontinued controlled substances were placed by the DON in a double locked box. The Administrator said it was his expectation that two licensed nurses or two CMAs complete the count of all controlled substances. He said it was his expectation that there were two signatures on the Controlled Substance Record Sheet indicating that discontinued narcotics were counted and received by the DON to put in the facility DON lock box. The Administrator said these two signatures represented the change of custody for the narcotics. The Administrator said there was not a negative outcome in this situation because the MAR reflected that Resident #1, #2, and #3 received all their pain medication but a situation like this could be a potential drug diversion. Record review of facility policy Medication Storage and Disposal dated [DATE] reflected Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. Disposition is documented on the individual controlled substance accountability record/book. For emergency kit controlled substances disposal, the bottom portion of the accountability record is completed.

Based on observation, interview, and record review the facility failed to ensure residents remained free of any significant errors for 1 of 3 residents (Resident # 1) reviewed for medication error. The facility failed to ensure Resident #1 received the correct dosage of Primidone required for treating tremors. Resident #1 was given Primidone 50 mg oral tablet 1 tablet by mouth 2 times a day from 12/11/2025 until 01/07/2026. The order from the hospital discharge was written as Primidone 50 mg oral tablet 2 tablet by mouth 2 times a day. The failure could place residents at risk of complications such as increased tremors. The findings included: Review of Resident #1 face sheet, dated 01/28/2026, revealed he was initially admitted to the facility 12/11/2025 with diagnosis including, type 2 diabetes (body does not produce enough insulin), kidney disease (kidneys are not filtering correctly), urinary tract infection (bladder infection) and Essential tremor (shaking you can't control) Review of Resident #1's quarterly MDS assessment, dated 12/02/2025 revealed his BIMS score was 08 out of 15 reflective of moderate cognitive impairment Review of Resident #1's Care Plan, dated 12/11/2025, and revised 01/07/2026 revealed: Resident 1 had a medication error related to Primidone. Review of hospital report dated 12/11/2025 revealed order of Primidone (primidone 50 mg oral tablet) 2-tab Oral (given by mouth) 2 times a day. This medicine is given for his tremors Record review of Resident #1's orders on the EMR revealed:Primidone Oral Tablet 50 MG Give 1 tablet by mouth 2 times a day. Start date 12/11/2025 End date 01/07/2026.Primidone Oral Tablet 50 MG Give 2 tablet by mouth 2 times a day. Start date 01/07/2026. Record review on the MAR for the month of December and January revealed that Resident #1 was administered Primidone, 50mg, 1 tablet by mouth 2 times a day starting on 12/11/2025 through 01/07/2026. Record review on the MAR for the month of January 2026 revealed that Resident #1 was administered Primidone, 50 mg, 2 tablets by mouth 2 times a day starting 01/07/2026. Observation and interview on 01/28/2026 at 11:00am revealed Resident #1 lying in his bed watching tv. Resident # 1 engaged in conversation but was watching a tv show and did not want to talk much. He told me he has no concerns with his care. He wishes the food tasted more like home cooking. I did not observe any tremors during our conversation. Observation of medication pass on 01/28/2026 at 11:30 am revealed no concern with administering correct medications. Interview on 01/28/2026 at 10:00am with resident's family member revealed that the facility had called her because of Resident #1's increased tremors. The family member asked about how much Primidone was being administered and that was when the discrepancy was found. Interview with Admin on 01/28/2026 at 11:00am revealed that once they became that the order being written incorrectly in the MAR the facility had an interim director of nurses, who immediately spoke with the doctor, and corrected the order in Resident #1s MAR. Interview with DON 01/28/2026 at 11:00am who stated that the medication Primidone was used to treat Resident #1 tremors. Surveyor asked her what could happen if he did not receive the correct dose and she revealed the tremors could increase. DON told me the facility has a new system in place for when a resident was admitted and 2 nurses enter the medication and check it off. The DON then comes after and checks if it is in the system and makes sure all medicines have been transcribed correctly. Record review of staff in services on medication errors and putting orders into the MAR. Record review of a facility policy Medication Administration implemented: 10/24/2022. Policy: Medications are administered by licensed nurses, or other staff wo are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines:10. Review of MAR to identify medication to be administered.11. Compare medication source with MAR to verify resident name, medication name, form, dose, route and time. 20. Correct any discrepancies and report to nurse manager. Record Review of a facility policy Medication Monitoring- Preventing Adverse Consequences and Med Errors implemented 01/01/2019. Procedure 2. When a resident receives a new medication, the medication order is evaluated for the following: A. The route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturers specification for use. 3. Facility staff monitor the residents for possible medication-related adverse consequences, including mental status and level of consciousness with the following conditions:C. Change in doseF. Medication error, e.g., wrong or expired medication.

Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 3 of 5 residents who were reviewed for immunizations. (Residents #14, #28 and #5) The facility failed to document in Resident #14, #28 and #5's medical records for having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings include: Review of Resident #14's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), cognitive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), and diabetes mullites type II (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #14's quarterly MDS dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #14's MDS did not address her current COVID-19 status. Review of Resident #14's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #14's EMR on 09/11/2025 reflected under the immunizations tab in PCC that Resident #14 received the influenza vaccination on 09/29/2024, no other immunizations were recorded. Review of Resident #14's admission paperwork dated 12/18/2023 reflected no informed consent or vaccination information sheet (VIS) for the COVID-19 vaccination. Review of Resident #28's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), PVD (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and aphasia(A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.). Review of Resident #28's quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #28 MDS did not address her current COVID-19 status. Review of Resident #28's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #28's resident admission agreement dated 09/07/2023 reflected no entry regarding the COVID-19 vaccination. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP the COVID-19 vaccination. Review of Resident #5's face sheet dated 09/11/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion.) and malignant neoplasm of pancreas (cancer). Review of Resident #5's Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #5's MDS did not address her current COVID-19 status. Review of Resident #5's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #5's resident admission agreement dated 09/03/2024 reflected no entries related to COVID-19 vaccinations. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP the COVID-19 vaccination. In an interview on 09/11/2025 at 1:02 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. She stated the facility did not have a policy for immunizations that they used the CDC guidelines. In an interview on 09/11/2024 at 1:15 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the IP but since the current IP is not yet certified the DON who is certified is doing it and had not yet come up with a system to keep track of the immunizations. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the CDC guidelines on the www.cdc.gov website reflected CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 and older. Parents of children ages 6 months to 17 years should discuss the benefits of vaccination with a healthcare provider.

Based on interviews and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 3 of 5 residents reviewed for immunizations. (Residents #14, #28 and #5) A) The facility failed to document in Resident #14's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. B) The facility failed to document in Resident #28's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects (VIS-Vaccine information sheet), for the influenza immunization and the pneumococcal immunization. C) The facility failed to document in Resident #5's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, for the influenza immunization and the pneumococcal immunization. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings include: A) Review of Resident #14's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), cognitive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), and diabetes mullites type II (A condition results from insufficient production of insulin, causing high blood sugar.). Review of Resident #14's quarterly MDS dated [DATE] reflected Resident #14 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Resident #14 was further assessed to receive the influenza vaccine on 09/29/2024. Resident #14 was assessed to not have the pneumococcal vaccination with stated reason offered and declined. Review of Resident #14's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #14's EMR on 09/11/2025 reflected under the immunizations tab in PCC that Resident #14 received the influenza vaccination on 09/29/2024, no other immunizations were recorded. Review of Resident #14's admission paperwork dated 12/18/2023 reflected no informed consent or vaccination information sheet (VIS) for the pneumonia vaccination. B) Review of Resident #28's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), peripheral vascular disease (is a common condition in which narrowed arteries reduce blood flow to the arms or legs.) and aphasia(A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain.). Review of Resident #28's quarterly MDS dated [DATE] reflected Resident #28 was assessed to have a BIMS score of 3 indicating severe cognitive impairment. Resident #28 was assessed to have the influenza vaccine dated 09/29/2024. Resident #28 was assessed to not be up to date on the pneumococcal. Review of Resident #28's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #28's resident admission agreement dated 09/07/2023 reflected Resident #28 refused the influenza and pneumococcal. Review of Resident #28's EMR on 09/11/2025 reflected no VIS were given to the resident or RP regarding influenza and pneumococcal vaccinations. C) Review of Resident #5's face sheet dated 09/11/2025 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), encephalopathy (a disease that affects brain structure or function. It causes altered mental state and confusion.) and malignant neoplasm of pancreas (cancer). Review of Resident #5's Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 2 indicating severe cognitive impairment. Resident #5 was assessed to not receive influenza, pneumococcal, offered and declined. Review of Resident #5's comprehensive care plan reviewed on 09/11/2025 reflected no entries related to immunizations. Review of Resident #5's resident admission agreement dated 09/03/2024 reflected last known pneumococcal vaccination question was blank. Review of the consent reflected the RP wanted the resident to receive the pneumococcal and influenza vaccinations. Review of Resident #5's resident informed consent for influenza immunization dated 09/29/2024 reflected Resident #5 refused the influenza immunization. The consent was signed by the resident. In an interview on 09/11/2025 at 1:02 PM the RNC stated immunizations should be done and verified on admission. She stated if consent was not given then the facility should provide education regarding the benefits and potential side effects of the immunization. She stated the facility did not have a policy for immunizations that they used the CDC guidelines. In an interview on 09/11/2024 at 1:15 PM the DON stated immunization should be done and verify on admission and consent and history should be done at that time. She stated immunizations were done by the IP but since the current IP was not yet certified the DON who is certified was doing it and had not yet come up with a system to keep track of the immunizations. The DON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. Review of the CDC guidelines on the www.cdc.gov website reflected Pneumococcal conjugate vaccine helps protect against bacteria that cause pneumococcal disease. There are several pneumococcal conjugate vaccines (PCVs). The specific PCV and number of doses recommended are based on a person's age, vaccination history, and medical status. Adults 50 years or older who have not previously received PCV should receive a PCV vaccine. Some adults in this group who have already received PCV might be recommended to receive another dose. CDC recommends everyone 6 months and older get vaccinated every flu season. Children 6 months through 8 years of age may need 2 doses during a single flu season. Everyone else needs only 1 dose each flu season.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents reviewed for during medication passMA B failed to wash her hands prior or during medication administration to Resident #21and Resident #43.These failures could place residents at risk for developing wounds, upper respiratory infections and risk for healthcare associated cross-contamination and infections. Findings include: Review of Resident #21's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: coronary heart disease (term for the buildup of plaque in the heart's arteries that could lead to heart attack or ischemic stroke), hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.), Diabetes Mellitus Type 2, (A condition results from insufficient production of insulin, causing high blood sugar.) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Review of Resident #43's face sheet dated 09/11/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body)., Hyperlipidemia (is an excess of lipids or fats in your blood) and dementia (A group of symptoms that affects memory, thinking and interferes with daily life.). Observation on 09/11/2025 at 10:14 am revealed MA B at her medication cart in the 200 hallway. MA B prepared Resident #43's medication and took them to Resident #43. MA B did not perform hand hygiene before or after medication administration to Resident #43. MA B then went down the hall. Observation on 09/11/2025 at 10:25 AM revealed MA B preparing Resident #21's medications. MA B administered Resident #21's medications. MA B did not perform hand hygiene before or after Resident #21's medication administration. In an interview on 09/09/2025 at 10:30 am MA B stated she did not perform hand hygiene before, during or after administering medications to Resident #21 or Resident #43 and should have. She stated she should wash her hands between each resident to prevent cross contamination. In an interview on 09/11/2025 at 11:13 AM the DON stated it was her expectations that MA B wash her hands during medication pass before and between residents. She stated she provided the staff member with Inservice training after being made aware of the situation. She stated failure to perform hand hygiene during medication administration could lead to cross contamination or infections. Review of the facility's policy Hand Hygiene dated 10/24/2022 reflected All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.

Based on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for 1 of 3 discharged residents (Resident #29) reviewed for closed records. The facility failed to complete and transmit a discharge MDS assessment for Resident #29, who discharged on [DATE], within 14 days of the discharge date . This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings included: Record review of Resident # 29's admission face sheet undated reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, hypertension (high blood pressure), hyperlipidemia (fat particles in the blood), major depressive disorder, adjustment disorder, dehydration, insomnia, shortness of breath, hypokalemia, anxiety disorder, edema, muscle wasting and atrophy, dysphagia, acute upper respiratory infection, edema, dyspnea, and cognitive communication deficit. Record review of Resident # 29's nursing progress note dated [DATE] reflected Resident # 29 expired on [DATE] at 7:52 AM. Record review of Resident # 29's MDS list in PCC on [DATE] reflected Resident # 29's last transmitted MDS was her Annual MDS dated [DATE]. Review of the warnings associated with Resident # 29's MDS transmission reflected Death-ARD complete by [DATE]-93 days overdue. Interview on [DATE] at 11:39 AM with LVN A, when asked who was responsible for completing the resident MDS assessment LVN A stated they were responsible for completing the resident MDS assessment. LVN A stated each resident should have a discharge MDS assessment completed upon discharge. LVN A stated it was important for residents to have discharge MDS assessments conducted because it was a record keeping tool for the state, and it was a cut off or end Date for CMS purposes. LVN A stated there was not a reason that the discharge MDS assessment was not completed for Resident # 29 other than it was just overlooked and missed, and it was a mistake. LVN A stated it was her expectation that MDS assessments were to be completed on time and accurately. Interview on [DATE] at 11:45 AM with the DON revealed LVN A was responsible for completing resident MDS assessments. The DON stated all residents discharged should have discharge MDS completed. The DON stated it was important to complete a discharge MDS, so the plan of care is documented of who the providers are, what services are provided to the resident, and any upcoming appointments. The DON stated for a death MDS it was important those were completed to be able to know where the resident discharged to and what they expired from and to let CMS know to stop any payments to the facility. The DON stated it was their expectation that MDS assessments were completed timely and accurately. Interview on [DATE] at 11:50 AM with the ADM revealed that LVN A was responsible for completing resident MDS assessments. The ADM stated all residents discharged should have a discharge MDS completed. The ADM stated it was important to have a discharge MDS completed so documentation can be shown that a safe discharge was provided to the family. The ADM stated in the event of death he was unsure if a MDS assessment was needed. The ADM stated he was also unsure if not having a death MDS completed could affect CMS funding. The ADM stated it was his expectation that MDS assessments are completed timely and accurately to protect resident care and overall well-being.Attempted record review of facility MDS policy reflected policy requested from ADM on [DATE] at 5:15 PM. The ADM replied on [DATE] at 10:17 AM that the facility follows the RAI manual.Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated [DATE], revealed OBRA Discharge assessments -Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days.

Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. On 04/08/2025, Resident #1 eloped from the facility through a side door and was later found by a neighbor in a grassy area approximately 219 feet away from the facility. This failure placed the resident at risk for serious harm.The non-compliance was identified as past non-compliance. The immediate jeopardy began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance prior to the start of the survey. The facility had implemented corrective actions and returned to compliance before the investigation began.This failure had the potential to affect other residents and could result in residents not receiving appropriate supervision, placing them at risk for serious injury, harm, or death. Upon entry to the facility, on 07/01/2025 an observation was conducted on all exit doors. The observations revealed that all doors were locked and equipped with functioning alarms. Additionally, it was observed that the side door in the activity room provided access to the area where Resident #1 had eloped. Resident #1 walked/used her wheelchair to ambulate to a grassy area across the way from the facility. Resident #1 is believed to have crossed a side driveway to the facility and then a street entering a neighborhood.Record Review of Resident #1's electronic facility face sheet dated 07/01/2025, revealed she was a [AGE] year-old female admitted to the facility originally on 08/08/2022 with the most recent admission on [DATE]. Her diagnoses included Cognitive communication Deficit(thinking and speaking difficulty), Repeated Falls, Unspecified Dementia with agitation(memory decline with acting out), Hypertension(high blood pressure), and Hypothyroidism unspecified(underactive thyroid).Record Review of Resident #1's MDS Assessment, dated 04/14/2025, reflected Resident #1 was unable to complete brief interview for mental status. Resident #1 had poor short-term memory recall. Her decision-making ability was severely impaired. Record review of Resident #1's care plan with a closed date of 04/25/2025 due to discharge indicated: Resident had an actual elopement: Fall occurred on 4/8/2025 during elopement attempt interventions included: Monitor 1:1 until resident is stable, Psychiatric NP will complete a medication review. Make recommendations as needed, and UA and Labs collected .Record review of Resident #1's wandering risk assessment dated [DATE] indicated a wander score of 05 which was a low wandering risk category.Record review of Resident #1's wandering risk assessment dated [DATE] indicated not a wandering risk category.Record review of Resident #1's wandering risk assessment dated [DATE] indicated Resident was a wandering risk. The assessment indicated an intervention of : Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of hospital discharge records dated 04/9/2025 indicated Resident #1 fell out of her wheelchair. There was no injury to head or neck. There were no fractures noted anywhere. They put an Ace wrap on her right wrist for comfort and support.Interview with ex-maintenance director, 07/01/2025 revealed he was terminated when the door to the exterior in the activities room was left unlocked and Resident #1 was able to elope from the facility. He stated the door was unlocked and the alarm did not sound from what he heard from staff. He stated he worked earlier that day and was not at the facility when resident eloped. He stated he locked the door in the Activity room that leads to the courtyard and left the activity room from the door that led to the hallway. He stated another staff member must have left the door unlocked. He stated the resident was found at night in a grassy area next to the facility by a neighbor who then called EMS and the administrator of the facility. Ex-maintenance director stated the facility blamed him for this incident, but he was not working nor in charge of the resident.Interview with AD, 07/01/2025 revealed she was not working when Resident #1 eloped from the facility. AD just returned to work 2 days ago. AD stated the activity room door stayed locked when there was no activity. She stated the door leading to the courtyard, locked automatically from the outside. AD could not recall when the alar was installed on the activity room door.Interview with MA, 07/01/2025, revealed she was working the night Resident #1 eloped from the facility. She reported she administered Resident #1's nighttime medications at 8:30 PM. She stated she later heard Resident #1 had been found across the facility driveway in a grassy area outside the nearby neighborhood. She stated Resident #1 typically only walked when agitated so staff were surprised by the location where Resident #1 was found with her wheelchair beside her.Interview with LVN , 07/01/2025 revealed she last saw around 9:00 PM on hall 200 (which is not Resident #1's hallway). She stated Resident #1 was sundowning and disturbing two residents on the hallway. She redirected Resident #1 back to Resident #1's hallway at that time. She said Resident #1 was not exit seeking at that time. She stated the next thing she heard was that Resident #1 was outside thefacility and had exited through the activity room exterior door. She stated she did not hear any alarms sound to indicate a resident was outside. She stated she immediately grabbed resident roster to ensure everyone else was in the building. Interview with CNA A, 07/01/2025 revealed she worked with Resident #1 the night she eloped. CNA A stated she was working the night Resident #1 eloped from the facility. She last observed the resident around 9:00 p.m. in the hallway. CNA A reported that the resident was attempting to enter and exit multiple rooms, and she redirected the resident several times. She described the night as very busy, noting that she was assisting with bedtime routines for multiple residents and that there was an actively dying resident on the same hallway.According to CNA A, the resident did not allow staff to place her in bed that evening. She explained that it typically takes two staff members to assist the resident into bed when she is active. She stated that another CNA performed one round with her, then left. CNA A noted that the resident tends to be active at night and does not usually sleep through the night. She recalled that the resident often sat near the front door during nighttime hours. CNA A stated she provided her statement to the charge nurse on duty.Attempted interview with Resident #1's hallway CNA C, 07/01/2025, called twice and received no response.Interview with Administrator, 07/01/2025 revealed he was contacted by a neighbor of the facility on 4/8/25 that Resident #1 was outside the facility near the entrance to the neighbor's neighborhood. He spoke to LVN D, the charge nurse, over the phone and had her check the doors and alarms. He stated the only door unlocked and alarm not working was the activity room exterior door. He did not know why the alarm was malfunctioning on the door. He stated the maintenance director was held responsible for the door being unlocked and the alarm malfunctioning and was terminated as a result. He stated the resident was placed on 1:1 supervision immediately and then transferred to a secure facility. He stated he made rounds with all residents to ensure they felt safe. He stated new elopement assessments were completed on 4/9/25 on all residents with no other residents at high risk. He stated they conducted in-services with all staff regarding elopements, securing doors/alarms, supervision, and abuse and neglect. Elopement drills were completed on all shifts on 4/9/25. He stated an ad hoc QAPI meeting was held on 4/9/25 with the medical director. He stated they also added a coded lock onto the activity room interior door so that a wandering resident would not be able to enter the room and use exit. He stated all doors, locks and alarms were evaluated on 4/9/25 and none were malfunctioning. Record Review of facility incident report dated 04/08/2025, revealed that Resident #1 eloped from the facility on that date. The facility ADM was notified by a neighbor of the facility that Resident #1 was observed outside in a grassy area left of the facility. Upon investigation, it was determined that the activity room door had been left unlocked, and the gate leading to the driveway area was open, which may have led to the resident's exit from the premises. Emergency Medical Services (EMS) assessed Resident #1 at the scene, after which the resident was transported to the hospital for further evaluation. The resident's physician and responsible party (RP) were notified on April 8, 2025. Following the incident and upon the resident's return to the facility, Resident #1 was placed on 1:1 supervision to ensure safety and prevent further incidents.Record Review of EMS report dated, 04/09/2025 reflected Resident #1 was found lying on the ground at 10:25 PM, 3 bystanders were with Resident #1 when EMS arrived. The report further stated, the bystanders stated they found Resident #1 lying in the grass, they noted Resident #1's wheelchair was found sitting upright a few feet away from resident and the resident possibly wandered outside the nursing home and then fell from her wheelchair into the grass. The resident was transferred to hospital.Attempted interview with Charge Nurse 07/02/2025, received no response.Interview with CNA B, 07/02/2025 revealed she was working the night Resident #1 eloped from the facility. She stated the administrator contacted the facility and spoke with the charge nurse. Upon noticing a concerning expression on the charge nurse's face during the call, CNA B stated she immediately exited through the front door. She observed EMS personnel near the facility and ran over to assist them in helping Resident #1 stand up. CNA B stated the resident was found on the ground in a grassy area, with her wheelchair positioned against a fence. She reported that she was unsure how the resident exited the facility. Although staff believe Resident #1 may have left through the activity room door, CNA B noted that the door is typically locked. She also stated that no door alarms sounded that night. CNA B recalled that Resident #1 was able to tell EMS her name and age. Interview with Resident #1 RP revealed Resident #1 was supervised with 1:1 staff prior to Resident #1 being transferred to secure facility. RP stated he had no concerns regarding Resident #1 care while at the facility. RP stated Resident #1 is doing well at the new facility.Record Review of Elopement Assessments dated 04/09/2025, revealed all current residents were assessed for elopement /wandering risk. No new residents were identified to be at high risk.On 07/02/2025 at 3:45 PM, the acting Administrator was informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 04/08/2025 and ended on 04/14/2025. The facility had corrected the noncompliance before the investigation began. The interventions and plan for correction included:Review of Resident #1 discharge paperwork revealed she was discharged on 04/14/25 to a secure facility.Review of Resident #1 EMR revealed Resident #1 was on 1:1 supervision with a caregiver until she was transferred to the new facility.Review of facility in-services dated 04/09/25 revealed all staff were educated regarding elopements, securing doors and activating alarms, abuse and neglect and supervision of residents. Staff were instructed to notify DON, Admin regarding any attempts of elopement or resident who may have increased confusion and attempt to exit. Staff were to ensure all exit gates are closed.Review of Elopement drills dated 04/09/25-04/11/25 revealed a drill was completed on all shifts. Review of Ad Hoc QAPI meeting held on 4/9/25 revealed an QAPI meeting was held to discuss the elopement of Resident #1.Review of Elopement Assessments dated 4/9/25 revealed current residents were assessed for elopement/wandering risk. No newresidents were identified to be at high risk.Observations at facility on 7/1/25 did not reveal observations of exit seeking or wandering residents.Interviews with facility staff on 7/1/25-7/2/25 revealed they were educated on elopements, securing doors and alarms, supervision ofresidents, abuse and neglect, and reinforcement of monitoring procedures.Interview with the facility's new maintenance supervisor revealed he is checking the locks and alarms each day to ensure they are working properly.

Based on observations, interviews, and record review, the facility failed to maintain an infection control prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 (Resident #2, Resident #11, Resident #19 and Resident #44) residents reviewed for infection control practices. 1. Business Office Manager failed to don PPE according to the facility protocol prior to entering COVID isolation. 2. The CNAs serving food trays failed to ensure Resident #44 was served his meal under safe sanitary conditions. 3. Activity Director observed assisting Resident # 11 in dining room with meal set up touching ready to eat food items with ungloved hands and without performing hand hygiene in between residents. 4. CNA A observed passing hall tray for Resident # 2 and assisting Resident # 2 with meal tray set up with ungloved hands and without performing hand hygiene between residents. These failures could lead to the spread of infection to residents, residents' illness, and/ or distress. Findings included: 1. Observation on 07/30/2024 at 12:40 PM the BOM was in the dining room and volunteered to take Resident # 19 meal tray to her room on 400 hall. Business Office Manager exited the dining room with the meal tray and carried it to COVID Resident # Business Office Manager donned N95 mask ( personal protective equipment that are used to protect the wearer from particles of liquid from contaminating the face) and did not sanitize her hands. She entered Resident #19's room with meal tray. She exited Resident #19's room approximately nine minutes after entering the room. Observation on 07/30/2024 at 12:46 PM revealed the protocol of donning and doffing PPE was on the door of Resident #19's room and had instructions of the proper PPE to wear prior to entering the room. Observation on 07/30/2024 at 12:46 PM revealed the following was the protocol of PPE by CDC guidelines prior to entering Resident #19's room: 1. Use Personal Protective Equipment : PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). 2. Preferred PPE use N95 or higher respirator , face shield or googles, one pair of clean, non-sterile gloves, and isolation gown. 3. Acceptable Alternative PPE- use face mask, face shield or goggles, face mask N95 or higher respirators are preferred but facemasks are an acceptable alternative. One pair of clean , non-sterile gloves, and an isolation gown. Observation on 07/30/2024 at 12:46 PM revealed the following form on Resident #19's room, everyone must clean their hands, including before entering and leaving the room. In an interview on 07/30/2024 at 12:48 PM the BOM stated she did not sanitize her hands, place gloves on her hands, or wear a gown prior to entering Resident #19's room . She stated this was a COVID isolation room. She stated she thought she only needed to wear a mask and not anything else when entering an isolation room. She stated she did not sanitize or wash her hands prior to leaving the room. She was standing by Resident #19's room and stated she did not read the signs on the door and if she had read the signs she would have known the proper protocol she was to follow with wearing gloves, gowns, and sanitizing her hands. She stated she did bring cellophane and other container lids from the residents' meal tray out of the room. The BOM stated she was not to bring anything out of the room, and she did not discard these items prior to leaving the room. She stated she had been in-serviced on PPE, but she misunderstood the difference when it was COVID isolation and Non-COVID isolation. She stated she needed to read the signs or ask a nurse to ensure she was using the proper PPE. The BOM stated she did not follow facility protocol on wearing the proper PPE when she entered Resident #19's room . She stated both Residents in that room did have COVID. Observation on 07/30/2024 at 12:53 PM the BOM did not sanitize her hands when she exited Resident #19's room and during the interview. She walked down the end of the 400 hall to the front of the 400 hall and entered the therapy room, went into the restroom, washed her hands, and threw away the items she had in her hands when she exited Resident #19's room in the trash in the therapy bathroom. In an interview on 07/30/2024 at 1:15 PM the BOM stated she did enter the therapy room, wash her hands, and disposed of the lids and cellophane off of the meal tray she delivered to the COVID room Resident #19's room . She stated she was required to sanitize her hands prior to leaving the room and she should have sanitized her hands as soon as she exited the room. She stated there was a potential she could have contaminated her clothes and hands while around residents with COVID. The BOM apologized for touching the state surveyors' clothes and arm after she exited Resident #19's room . She stated, I was not to touch anyone or anything until I washed my hands. She stated there was a possibility she could contaminate other residents, staff, or visitors with COVID if she was not wearing the proper PPE when she entered a COVID isolation room. She stated there was protocol in place of the correct PPE to wear, to sanitize hands, and she did not follow the facility protocol. The BOM stated she had been in-service on the facility protocol of wearing the proper PPE. She stated it was recently but did not recall the date. In an interview on 07/31/2024 at 9:08 AM the Administrator stated the staff were expected to follow facility protocol for PPE when entering COVID isolation rooms. He stated the staff were expected to wear gown, face mask, face shield or goggles, and sanitize hands prior to donning gloves. He stated they had recent in-services for all staff on wearing PPE in COVID isolation rooms. The Administrator stated the forms on Resident #19 was the facilities protocol of what to wear prior to entering the room. He stated the BOM did not follow the facility protocol/policy on PPE when entering or exiting a COVID positive resident room. He did not reply when asked if there was a potential when a staff did not wear proper PPE in COVID room, that it could be spread to other staff or residents. In an interview on 07/31/2024 at 11:09 AM the DON stated the infection control forms on Resident #19's door was the facility protocol for the proper use of PPE and hand sanitation. She stated the facility was following CDC recommendations. The DON stated anyone including non- nursing staff were expected to sanitize their hands prior to donning gloves. The staff were required to Donn gown, N95 face mask, and face shield prior to entering any COVID isolation room. She stated all of the information of what to wear and how to Donn PPE was on the door of Resident #19's room . She stated if anyone did not follow the facility protocol of wearing PPE in a COVID isolation room there was a potential the person may contaminate other staff, residents, or visitors. She stated when someone exits a COVID isolation room the person was expected to wash their hands in the room prior to exiting. The DON also stated if the person did not wash their hands or sanitize their hands prior to exiting the COVID isolation room they were to sanitize their hands immediately after exiting the room. The DON stated both residents in Resident #19's room did have COVID. 2. Review of the Face Sheet for Resident #44 reflected he was admitted on [DATE] with diagnoses of: malignant neoplasm of renal pelvis ( the area at the center of the kidney), dementia with psychotic disturbance and anxiety, UTI ( infection in any part of the urinary system, pain to right arm/wrist, history of falling, high blood pressure, anemia, malignant skin cancer, and atrial fibrillation (irregular heart beat). Review of the quarterly MDS assessment dated [DATE] reflected: a BIMS score of 7 indicated severe cognitive impairment. His physical assessment reflected he was independent in eating and some oral hygiene, but needed at least one to two person assist for dressing, bathing, and other ADLs. He was assessed as occasionally incontinent of bladder and always continent of bowels. Review of the Care Plan for Resident #44 reflected interventions were in place for: DNR status, high risk of fractures or injuries r/t renal cancer untreated, ADL performance deficit r/t cancer and weakness, impulsive behavior problem, impaired cognitive function, lower extremity weakness, terminal prognosis r/t renal cancer, and the resident elected to be on palliative care. Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnoses of: hemiplegia to left side ( paralysis of limbs) , metabolic encephalopathy ( a problem of the brain) , history of traumatic brain injury ( happens when a sudden , external, physical assault damages the brain, muscle wasting and atrophy, epilepsy, unspecified convulsions, and need for personal care. Review of the quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene, and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 reflected interventions were in place for: full code status, ADL performance deficit, history of falls/hemiplegia, antidepressant medication, anticoagulant (inhibiting the coagulation of the blood) medication, chronic pain r/t pelvic fracture, and vertebrae fractures. Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: myopathy , morbid obesity, hypothyroidism, congestive heart failure , muscle wasting and atrophy, and peripheral vascular disease . Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming, and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self-performance deficit, a history of falls, a UTI, chronic back pain, psych history related to sexual assault. In an interview on 7/30/24 at 8:20 am Resident #21 stated no one had ever cleaned the surface of her bedside table as far back as she could remember. She stated no one cleaned the table in between meals and incontinence care. She stated no one cleaned the table before setting her meal tray on it and no one helped to wash her hands. 3. A record review of Residents # 11's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking, and interferes with daily life.), traumatic subarachnoid hemorrhage (bleeding on the brain), wedge compression fracture of the T5-T6 vertebra (spinal fracture), hypertension (high blood pressure), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), major depressive disorder ( a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life.), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone.), cervicalgia (neck pain), bullous pemphigoid (a rare skin condition causing large, fluid-filled blisters.), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) A record review of Resident # 11's care plan last revised on 5/09/2024 reflected she had an ADL self-care performance deficit related to dementia, limited mobility, and terminal illness. Resident # 11's interventions reflected she needed total assistance by 1 staff to eat. 4. A record review of Residents # 2's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture.), intellectual disabilities (a neurodevelopmental condition that affects a person's intellectual functioning and adaptive behavior.), pain in left leg, muscle wasting and atrophy (the loss of muscle mass and strength), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus.), ataxia (impaired balance or coordination can be due to damage to the brain), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood.), major depressive disorder ( a mental health disorder characterized by persistently depressed mood or loss of interest in activities also called major depression or clinical depression), hypertension ( high blood pressure), need for assistance with personal care, type 2 diabetes ( adult onset diabetes a group of diseases that result in too much sugar in the blood), cognitive communication deficit (a communication problem that's caused by a cognitive deficit rather than a language or speech deficit), age related physical debility, and bilateral feet deformity. A record review of Resident # 2's care plan last revised on 5/10/2023 reflected she had an ADL self-care performance deficit related to impaired balance, cerebral palsy, ataxia, pain in left leg, age related physical debility, and bilateral feet deformity. Resident # 2's interventions reflected she needed supervision with setup assist of 1 staff to eat. Observation on 7/29/24 at 12:30 pm of the Activity Director in the dining room assisting Resident # 11 in setting up meal trays including touching ready to eat food of soft tacos without gloved hands and without performing hand hygiene in between residents. Observation of Activity Director providing clothing protectors to residents and touching residents' clothes without performing hand hygiene in between each resident. Observation of Activity Director getting residents in dining room, getting residents drinks, and straws without performing hand hygiene between residents. Observation on 7/29/2024 at 7:48 am of CNA A passing breakfast hall trays for 200 hall. CNA A went to pass tray to Resident # 2, assisting with meal tray set up with ungloved hands, and without performing hand hygiene between residents. The facility protocol/policy for following infection control prevention of wearing PPE was the CDC guidelines (not dated) listed during observations of the signs on the door of . Review of the facility policy Promoting Resident Dignity dated 1/13/23 reflected the employees were to protect and promote Resident rights and treat each resident with respect and dignity. Resident requests will be responded to in a timely manner. Residents personal space is to be respected and maintained in a clean sanitary manner. Record review of dietary hand washing policy dated 10/1/2018 reflected under heading policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will practice good hand washing practices to minimize the risk of infection and food borne illness. Under heading procedure: 2. Hands should be washed after the following occurrences: l. Assisting residents. Record review of hand hygiene policy dated 10/24/2022 reflected under heading policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under heading definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub also known as alcohol-based hand rub. Review of the facility policy Infection Prevention and Control Program dated 5/13/24 reflected the facility has established and maintained a safe, sanitary, and comfortable environment to help prevent the spread and development of communicable diseases and infection per accepted national standards and guidelines. All staff are responsible for following policy and guidelines. Hand Hygiene shall be performed in accordance with established hand hygiene procedures. Environmental cleaning and disinfection shall be performed according to facility policy. 48917

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure all items were labeled and dated. 2. The facility failed to ensure all items were covered and stored properly. 3. The facility failed to ensure sanitation practices were occurring in kitchen. 4. The facility failed to ensure temperature logs were being completed. These failures placed residents at risk of foodborne illness. Findings included: Observation of the kitchen's ice machine on 7/29/24 at 7:00 am revealed the inside of the machine to have black debris and growth growing on the upper inside of the machine near the door. Observation of ice scoop receptacle on wall next to ice machine on 7/29/24 at 7:05 am revealed inside of receptacle to have dried brown appearing substance at the bottom of the receptacle. Observation of kitchen prep area worktable on 7/29/24 at 7:08 am revealed a staff member had a Styrofoam cup of coffee uncovered in work prep area near toaster, robot coupe blender, and block of butter unwrapped with butcher knife on wrapper next to it. Observation on 7/29/24 at 7:10 am in the clean dish storage area, there were steam table lids with dried particles on them. The lids were stored in bin with other clean steam table lids. Observation of walk-in refrigerator on 7/29/24 at 7:13 am revealed the following: *A cut unwrapped undated cucumber sitting on a tray with health shakes and chocolate syrup bottles. *A thawing brisket on bottom shelf on sheet pan undated. Observation of walk-in freezer on 7/29/24 at 7:16 am revealed the following: *A bag of frozen chicken breast that had been torn open with 1 single chicken breast remaining undated and unsealed. *A steam table pan of mixed vegetable blend with red peppers, green beans, broccoli, and mushrooms uncovered and undated on shelf. *A package with half of an angel food cake undated and unsealed. Observation of dry storage area on 7/229/24 at 7:20 am revealed the following: *A container of brown sugar with the lid sitting on top of container with a gap of approximately 2-centimeter opening. *A container of flour with lid sitting on top of container with a gap of approximately 1-centimeter. *A gallon Ziploc bag with penne pasta inside unlabeled and undated. *An open storage bin with individually wrapped saltine crackers unlabeled and undated on bin. *An open storage bin with individually packaged ketchup packets with a label stating contents were flour and date of 10/20/23. *An opened storage bin with individually packaged mustard packets undated and unlabeled. *An opened box of tea bags undated unlabeled and with box partially torn open with part of box missing. *An undated container of unopened oatmeal. *An undated container of parsley flakes. Observation of kitchen prep drink station on 7/29/24 at 7:30 am revealed the following: *An undated gallon container of orange juice without lid approximately 1/4 full. *6 juice glasses full of orange juice without lids on table. A stack of lids were present next to glasses that had been filled. Observation of temperature logs on 7/29/24 at 7:33 am revealed the following: *The daily dish machine temperature and sanitizer log had not been completed for lunch on 7/10/24, breakfast on 7/25/24, and breakfast and lunch on 7/26/24. *The walk-in freezer temperature log had not been completed for 4/30/24, 7/27/24, and 7/28/24. *The walk-in refrigerator temperature log had not been completed for 7/27/24 and 7/28/24. *The pot/sink sanitizer test strip log had not been completed for dinner 7/25/24, breakfast 7/26/24, and lunch 7/26/24. *The daily meal/ food temperature log had not been completed for dinner 7/21/24 and breakfast 6/10/24. Observation of three-compartment sink on 7/29/24 at 7:38 am revealed dried particles, dirt, grime, and a single hair black in color on the dish drain side of the sink. Observation of dish machine rack storage dolly on 7/29/24 at 7:40 am revealed dirt, grime, dried particles, and paper scraps on storage dolly surface where dish machine racks are stored. Observation of lunch tray line on 7/29/24 at 12:15 pm revealed the 400 hall cart trays being loaded into meal cart with charro beans in bowls uncovered and bowls of soup uncovered. Observation of breakfast meal cart on 7/30/24 at 7:50 am revealed the 200 hall meal cart doors open in hallway with bowls of oatmeal on resident trays uncovered. Meal cart unattended at time of observation. Observation on 7/30/24 at 9:15 am Dietary Aide I was in kitchen with his beard guard down under chin not covering beard. Observation on 7/30/24 at 9:22 am of kitchen revealed large 55-gallon trash can in kitchen without lid. Observation on 7/30/24 at 12:05 pm Dietary Aide I was in kitchen working the lunch tray line with beard guard under chin not covering beard. Observation on 7/31/24 at 9:20 am of kitchen revealed large 55-gallon trash can in kitchen without lid. Observation on 7/31/24 at 9:21 am of kitchen revealed spatula hanging in clean utensil storage area with dried particles on surface. Observation on 7/31/24 at 9:24 am of kitchen revealed inside of juice dispenser nozzle to be caked with red and orange slimy buildup. Observation on 7/31/24 at 12:19 pm of Dietary Aide J in kitchen prepping mayonnaise cups for lunch meal service. Observation further revealed mayonnaise cups to be put on meal trays uncovered and loaded onto meal cart. Interview on 7/29/24 at 9:00 am the Dietary Director said the cleaning logs are posted on the cooler and each staff member has different parts of the kitchen they are responsible for cleaning. The Dietary Director said the cleaning schedule was posted on the cooler right next to the cleaning logs. The Dietary Director said all staff are trained in kitchen sanitation in part of their new hire onboarding training. The Dietary Director said everyone who comes into the kitchen was required to wear hair restraints and beard restraints for the males. The Dietary Director said when items are received, they are dated with the receipt date and stored using the First In First Out method. DD said once items are opened or prepared, they are dated with the open/preparation date and the discard date. Record review of dietary cleaning schedule posted for week of 6/24/24 revealed the following: *cleaning task of toaster completed 6/24/24, *cleaning task of microwave completed 6/24/24 by Dietary Aide K, *cleaning task of can opener completed 6/24/24 by Dietary Director and 6/25/24 by Dietary Aide K, *cleaning task of cook shelves and steam table completed by [NAME] F undated, *cleaning task of storeroom completed by [NAME] F undated, and *cleaning task of dish machine completed by [NAME] F undated. Record review of weekly dietary cleaning schedule posted for week of 7/1/24-7/8/24 with cleaning task of: *dry storage completed 7/1/24 by Dietary Aide I, *cleaning task of walk-in freezer completed on 7/1/24 by [NAME] E, * cleaning task of walk-in cooler completed on 7/1/24 by Dietary Director, *cleaning task of reach-in cooler completed 7/10/24 by Dietary Director, *cleaning task of mop under/between ovens, fryer and steamer completed on 7/1/24 by Dietary Director, and on 7/2/24 by Dietary Aide I, and *cleaning task of dish room completed on 7/1/24 and 7/2/24 by [NAME] F. Record review of general kitchen sanitation policy dated 10/1/2018 reflected under heading policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US food codes to minimize the risk of infection and food borne illness. Under heading procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all food-contact surfaces of equipment. 4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 5. After cleaning and until use, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the dietary food handling policy undated under heading purpose: The purpose of this procedure is to provide guidelines for the d=safe preparation, handling, and storage of perishable food and proper environmental cleaning. Under heading general guidelines 13. Clean uniforms, hairnets or caps should be worn daily. All facial hair should be covered.

Based on observations, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 8, Resident #18, Resident #34, and Resident #50). 1. The facility failed to ensure Resident #18 and Resident #50's facial hair was removed. 2. The facility failed to ensure Resident # 8, and Resident # 34's nails were cleaned and did not have any rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 18's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle wasting and atrophy, not elsewhere classified, multiple sites ( thinning or loss of muscle tissue), lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), age-related physical debility (frail patients often present with symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), and type 2 diabetes mellitus without complications (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high). Record review of Resident #18's Quarterly MDS Assessment, dated 06/21/2024, reflected the resident had a BIMS score of 1 indicating her cognition was severely impaired. Resident #18 did not reject care. She did require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, and required maximum assistance with personal hygiene. Record review of Resident #18's Comprehensive Care Plan , dated 06/25/2024, reflected Resident #18 had ADL self -care performance deficit related to dementia (impairment of memory and abstract thinking, and often with personality change). Intervention: Resident #1 required limited assistance by one staff with personal hygiene and oral care. Observation on 07/29/2024 at 11:01 AM Resident #18 was sitting in her room. She had facial hair above her upper lip and had hair on the right side of her chin. The hair was approximately 1-2 inches long. Interview on 07/29/2024 at 11:03 AM Resident #18 was not interview able. Record review of Resident #50's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle wasting and atrophy, not elsewhere classified, multiple sites ( thinning or loss of muscle tissue), unspecified dementia, mild , with anxiety (impairment of memory and abstract thinking, and often with personality change and anxiety is often related to worries about coping with the condition and what the future holds). Record review of Resident #50's Quarterly MDS Assessment, dated 05/21/2024, reflected Resident #50 had a BIMS score of 7 indicating her cognition was severely impaired. Resident #50 required ADL assistance with eating, oral hygiene, toileting, upper and lower body dressing, putting on/ taking off footwear, and personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 06/07/2024, reflected Resident #50 had an ADL self-care performance deficit related to dementia. Intervention: Resident #50 required assistance with personal hygiene. Observation on 07/29/2024 at 11:13 AM Resident #50 entered her room and was standing at the side of her bed. She had facial hair on the right and left side of her chin. The hair was approximately 1-2 inches long. Interview on 07/29/2024 at 11:14 AM Resident # 50 stated she was so embarrassed when asked if anyone had offered to remove hair on her chin. She stated she did not realize she had hair on her chin and if she did, she would have asked someone to remove it for her. She stated she was not able to remove hair from her chin anymore and needed help. She stated she had been visiting people and did not realize she had hair on her chin. She stated she never let anyone see her with hair on her chin. She stated it worried her. She stated she always wanted to look nice. Resident #50 stated she was worried other people would believe she did not take care of herself and it was embarrassing. 2. Record review of Resident #8's Face Sheet , dated 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of other lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), age-related physical debility ( frail patients often present with symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (impairment of memory). Record review of Resident #8's Quarterly MDS Assessment, dated 05/22/2024, reflected the resident was not capable of completing BIMS assessment. The staff completed the Assessment for Mental Status. Resident #8 had poor short- and long-term memory recall, she did not know the current season, location of own room, staff names and faces, or that she was residing in a nursing facility. Her decision-making ability was severely impaired. She was also assessed to require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower body dressing, and personal hygiene. Record review of Resident #8's Comprehensive Care Plan, dated 06/21/2024, reflected Resident #8 had an ADL self- care performance deficit related to dementia. Intervention: Resident required assistance with personal hygiene. She was at risk for signs/symptoms of depression related to dementia. Observation on 07/29/2024 at 8:59 AM Resident #8 was in her room sitting in her wheelchair. Her middle finger and ring fingernails were rough around the edges on her right hand. Resident #8 also had blackish/ brownish hard substance underneath the forefinger, ring finger and middle fingernails on her right hand. Interview on 07/29/2024 at 9:02 AM Resident #8 was not interview able. Record review of Resident # 34's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), type 2 diabetes mellitus with diabetic neuropathy, unspecified (nerve damage caused by high blood sugar levels over time, leading to various complications in different parts of the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (impairment of memory), and chronic angle -closure glaucoma, unspecified eye, stage unspecified ( occurs when a portion of the angle is intermittently obstructed, resulting in scarring). Record review of Resident #34's Quarterly MDS Assessment, dated 04/30/2024, reflected the resident had a BIMS score of 11 indicating his cognition was moderately impaired. Resident #34 required assistance with personal hygiene, showers, and putting on and taking off footwear. Record review of Resident #34's Comprehensive Care Plan dated, 06/21/2024, reflected Resident #34 had an ADL self-care performance deficit. Intervention: Bathing/Showering: check nail length and clean on bath day and as needed. Report any changes to the nurse. Resident required assistance with bathing/showering. Resident was assessed to refuse showers and to be shaved. Record review of Resident #34's Shower record dated 07/02/2024 - 07/31/2024 reflected Resident #34 did not refuse shower from 07/12/2024 thru -7/31/2024. Observation on 07/29/2024 at 9:39 AM Resident #34 was sitting in his wheelchair in his room watching television. Resident #34 had blackish hard substance underneath the forefinger and middle fingernails on his right hand. His middle and right fingernails were rough around the edges. There was an odor of bowel movement on his right hand. Interview on 07/29/2024 at 9:42 AM Resident # 34 stated he asked someone to clean and trim his nails two or three days ago. The person stated she would report it to a nurse to clean and trim his nails because he was a diabetic. He stated a nurse never came to his room. Resident #34 stated he would try to clean and trim his nails, but with his vision issues he was reluctant due to being a diabetic and did not want to cut his finger and get it infected. He stated he did this one time, his finger became infected, and he quit doing his own nail care. Resident #34 stated he thought he had bowel movement in his fingernails and did not know how it got into his nails. In an interview on 06/27/2024 at 11:20 AM LVN P stated the nurses and the CNAs were responsible for nail care. He stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN P stated it was the CNAs responsibility to clean and trim all other residents' nails. He stated if anyone refused nail care it would be documented on their shower record. He stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. He also stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea. He stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear. LVN P stated he was not aware of anyone refusing nail care. He stated he would need to refer to the shower record to know for certain if Resident # 8 or Resident #34 refused nail care. He stated if a female resident had facial hair on their chin there was a possibility the resident may become embarrassed with their appearance and may isolate themselves in their room. In an interview on 06/27/2024 at 11:09 AM the DON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin was impaired). The DON stated nail care was given during showers and as needed. She stated if a resident had blackish substance underneath their nails there was a possibility the substance may be some type of bacteria. The DON stated if the scent of feces was noticed underneath the residents' fingernails there was a potential this may be bacteria. She stated it was a possibility a resident may become physically ill such as vomiting or diarrhea if they ingested bacteria. She stated if a resident had rough fingernails there was a possibility the resident may scratch themselves and develop a skin tear. The DON stated if the female residents had facial hair on their chin or around the top lip of their mouth, it was a dignity issue. She stated the resident may become embarrassed and there was a possibility the resident may not want to interact with other residents. In an interview on 06/27/2024 at 11:30 AM CNA B stated the nurses completed all diabetic fingernails and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails. CNA B stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day the staff were expected to do any type of nail care as needed. She stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements. She stated if a resident swallowed bacteria it was a potential the resident may become ill with E. coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) and may develop major stomach problems such as diarrhea. She stated she worked with Resident #8 and Resident #34, and she was not aware of them refusing nail care. CNA B stated sometimes Resident #34 would refuse to shave but she was not aware of him refusing nail care. She stated if a resident's nails were rough there was a possibility the resident may scratch themselves and develop a skin tear, or possibly scratch their eye and cause a tear on their eyeball. CNA B stated if a female resident had facial hair on their chin, a resident may become embarrassed over their appearance. She stated it would be a dignity issue and it was a possibility a resident may isolate themselves if they did not want anyone to see them with facial hair. CNA B stated it was the CNAs or nurses' responsibility to remove facial hair from the female's chin in the resident's room or during showers. She stated she was not aware of any female resident refusing to allow staff to remove unwanted facial hair from their face. Record review of the Facilities Policy on ADLs dated 05/26/2023 reflected A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene.

Based on observations, interviews, and record review, the facility failed to provide the physician prescribed therapeutic diet to 11 of 13 residents (Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207) reviewed for therapeutic diets, in that: Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207did not receive a mechanical soft diet as ordered. This failure could place residents at risk for choking and causing further health issues. Findings included: A record review of Resident # 3's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 9's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # !0's diet order dated 7/10/24 reflected an order for Regular diet mechanical sift texture, regular liquids consistency. A record review of Resident # 12's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 13's diet order dated 12/14/23 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 22's diet order dated 3/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 23's diet order dated 4/22/24 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 25's diet order dated 9/25/23 reflected an order for Reduced Concentrated Sweets mechanical soft texture, regular liquids consistency. A record review of Resident # 36's diet order dated 8/10/23 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 156's diet order dated 7/16/24 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 207's diet order dated 7/16/24 reflected and order for Renal-Liberalized diet mechanical soft texture, regular liquids consistency. Observation of kitchen lunch preparation on 7/29/24 at 11:00 am revealed tray line to be set up with chopped lettuce for beef soft tacos. Observation of lunch tray line service on 7/29/24 at 12:00 pm revealed mechanical soft diets receiving chopped lettuce on meal trays. Observation of lunch meal tray on 7/29/24 at 12:45 pm of Resident # 13's meal tray and meal ticket with order of Regular diet mechanical soft texture. Resident # 13's meal tray consisted of ground beef and tortilla mixture with shredded cheese as garnish on top of beef mixture with a side of chopped lettuce. Observation of Resident # 13 to be eating some of the lettuce. Record review of week 2-day 8 recipe for soft beef taco reflected under notes: 3. For ground and puree texture modifications, omit lettuce and tomatoes. Record review of week 2-day 8 production records signed by Dietary Director and RD reflected mechanical soft texture to receive 1/2 cup of shredded lettuce. Interview on 7/29/24 at 12:33 pm the Dietary Director said the cooks follow the production records when preparing the meals and the production records stated mechanical soft diets can have chopped lettuce. The Dietary Director was asked about the recipe for soft beef tacos indicating to omit the lettuce and tomato and modify with substitution, the Dietary Director reiterated the staff follow the production records for meal preparation. The Dietary Director was unsure about the policy concerning diet texture modifications and stated they would ask the RD and Administrator about the policy. Interview on 7/30/24 at 9:22 am reflected the Registered Dietician (RD) said the company and the facility followed the National Dysphasia Diet Level 3: Advanced protocol for their mechanical soft diets. The RD said this protocol allowed for residents to receive shredded lettuce. The RD said this protocol was the policy the facility follows. The RD said the recipes come from their grocery supplier and the facility follows the facility procedure/protocol if the recipe has a discrepancy and states differently than the facility policy/protocol. Interview with Dietary Director on 7/31/24 at 9:15 am reflected Dietary Director said the facility received whole heads of lettuce and they chop it themselves as receiving pre-shredded lettuce in was more expensive and usually does not have a long shelf life. Record review of mechanical soft diet textures in-service dated 6/3/24 presented by Dietary Director reflected 5 staff members signatures of attendance. In-service training documentation reflected Under heading What is a Mechanical Soft diet texture? An altered diet texture for residents who cannot safely chew or swallow regular/hard food textures but may still chew softer foods. Foods should be soft, moist. Meats are ground or minced, moist, and no larger than 1/4 inch pieces. Under heading Not approved foods: raw vegetables Record review of National Dysphagia Diet Level 3: Advanced policy provided by facility RD undated reflected mech soft to be handwritten in parenthesis at the top of the document next to the word advanced. Under heading considerations for specific food items: Raw fruits and vegetables-shredded lettuce is underlined, sliced tomatoes, and finely chopped tomatoes/salads as tolerated.

Based on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive device when consuming meals and snacks for 1 resident (Resident # 2) of 8 residents reviewed for assistive devices. The facility failed to provide Residents# 2's physician ordered handled cup with lid for lunch. This failure put resident at risk for decreased fluid intake, dehydration, and decreased quality of life. Findings included: A record review of Residents # 2's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (A congenital disorder of movement, muscle tone, or posture.), intellectual disabilities (A neurodevelopmental condition that affects a person's intellectual functioning and adaptive behavior.), muscle wasting and atrophy (The loss of muscle mass and strength), dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus.), ataxia (Impaired balance or coordination can be due to damage to the brain), need for assistance with personal care,, cognitive communication deficit (A communication problem that's caused by a cognitive deficit rather than a language or speech deficit), and age related physical debility. A record review of Resident # 2's care plan last revised on 1/26/2024 reflected she has potential nutritional problems related to cerebral palsy. Diet order RCS diet, mech soft, regular liquids consistency, Handled cup. Interventions reflected Resident # 2 will get a no spill handled cup with her meals to help aid with her drinking abilities. Provide serve diet as ordered. Monitor intake and record meal. A record review of Resident # 2's diet order dated 1/25/2024 reflected Reduced Concentrated Sweets diet, Mechanical Soft texture, Regular liquid consistency, handled cup with lid, divided plate, built up utensils, can have salads per speech therapy. Observation on 7/29/24 at 12:40 pm the Activity Director in dining room assisting Resident # 2 with their drink. Resident # 2 had a diet coke being poured into handled cup with lid by the Activity Director. The drink foamed over cup lid was applied to cup and given to Resident # 2. Cup slipped from Resident # 2's hands onto floor and spilled contents on floor. The Activity Director put Resident # 2 handled cup in the dirty dish area of dining room. The Activity Director went to Resident # 2's room got Resident # 2 another diet coke opened it then went to get straw to put inside can for Resident # 2. The Activity Director gave Resident # 2 the can of Diet coke with straw. A new clean handled spill proof cup was never provided to Resident # 2 during lunch meal service. Interview and observation on 7/29/24 at 2:00 pm with the Dietary Director reflected Resident # 2 has an order for a handled spill proof cup with all meals. The Dietary Director showed the kitchen had a quantity of 2 handled cups in the clean dish storage area that Resident# 2 used. Record review of Meal Service policy dated 10/1/2018 reflected under heading policy: The facility believes that all residents should be always treated with dignity and respect. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. 8. Assistive devices will be provided as ordered and documented in residents' care plans.

Based on observation, interview, and record review, the facility failed to have sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for one cook (Cook G) of three dietary cooks reviewed for qualified dietary staff in that: Cook G had not received onboarding training with the appropriate competencies and skills to carry out the functions of the food and nutrition services department. This failure could place residents at risk of not having their nutritional needs met and place them at risk of food borne illness. Findings included: During an interview on 7/29/24 at 9:00 am the DD said all her staff including herself had the Texas Food Handlers License except for [NAME] G who was new and just started in the early part of July 2024. The DD said [NAME] G will be coming in to take her Texas Food Handlers course this week and get their food handlers license . The DD said [NAME] G had recently transitioned from the housekeeping department to dietary department. The DD said [NAME] G has worked several shifts since starting and was being trained by the DD, [NAME] E, and [NAME] F. The DD said [NAME] G has never prepared a meal by themselves and they have never been left in the kitchen without a team member present who has their Texas Food Handlers certification. During an observation and interview on 7/31/24 at 12:30 pm revealed [NAME] G to be in the DD office taking the Texas Food Handler online course. [NAME] G said they started in the dietary department on 7/11/24. [NAME] G said their normal shift was 12:00 pm-8:00 pm. [NAME] G said they have been receiving training from the DD, [NAME] E, and [NAME] F. [NAME] G said they have never worked in food service prior to this position. [NAME] G said they do not have a Texas Food Handlers certification, and which was why the DD requested they come in early today to be able to take the course today. [NAME] G said they have received Hands on training from the DD and the other cooks. [NAME] G said they have been allowed to assist in preparing the resident meals, wash dishes independently, serve tray line independently. [NAME] G said they have been trained on the different types of diets offered, menus and alternate meal options available. [NAME] G said they have not received or were unsure if they had received training on cross contamination, infection control, time temperature control, HACCP , recipes, and production records. [NAME] G said they had never received a job description to sign or nay other paperwork documents for this current position. Record review of dietary schedule for 7/15/24 - 8/12/24, revealed [NAME] G had worked 11 shifts in the dietary department as a cook. Record review of [NAME] G personnel file revealed a hire date of 3/1/24 with a job title of housekeeper signed by [NAME] G on 3/4/24. Job description of housekeeper in employee file dated 3/4/24. Interview on 7/29/24 at 9:00 am, DD was asked for the training documentation for [NAME] G. No training documents for [NAME] G provided prior to exit. Record review of the cook job description undated revealed under Licensing requirements: Texas Food Handler Certificate And under Experience requirements: Knowledge of food preparation, sanitation, and hygienic methods. Knowledge of Universal Precautions and rules that govern hazardous waste. Previous experience in skilled nursing facility is preferred. Ability to follow oral and written directions.

Based on observations, interviews, and record review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (1) of five (5) residents reviewed for abuse. The facility failed to protect Resident #1 from abuse when staff yelled at her when asking for assistance via call light. The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of experiencing and enduring abuse by facility staff causing decreased quality of life. Findings Included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: Hemiplegia to left side, Metabolic encephalopathy, Hx of Traumatic Brain Injury, Muscle wasting and atrophy, epilepsy, Unspecified convulsions, need for personal care. Review of the quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 reflected interventions were in place for: Full Code status, ADL performance deficit, History of Falls/Hemiplegia, Antidepressant medication, Anticoagulant medication, Chronic Pain r/t pelvic fracture and vertebrae fractures. Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: Myopathy, Morbid Obesity, Hypothyroidism, Congestive Heart Failure, Muscle wasting and atrophy and Peripheral Vascular disease. Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self performance deficit, a history of falls, a UTI, Chronic back pain, Psych history related to sexual assault. In an interview on 7/29/24 at 9:10 am Resident #1 stated she felt fine, and she got along well with facility staff. She stated the one aide was the only one that had ever spoken badly to her. She stated she did not like to discuss the matter because the aide was disrespectful to her and talked to her like a child. In an interview on 7/29/24 at 9:15 am Resident #21 stated she had overheard the conversation between the CNA and Resident #1. She stated when Resident #1 first pushed her call light it was for assistance to the toilet. She stated the aide came in and said she would be right back. Resident #21 stated Resident #1 then pushed the call light about five more times. She stated the aide came back and yelled and cussed at Resident #1. She stated she didn't hear everything, but the aide was mean and warned Resident #1 not to push the call light anymore. In an interview on 7/30/24 at 1:36 pm the Administrator stated the employee named in the Abuse/Neglect allegation involving Resident #1 and her roommate Resident #21. The Administrator stated the employee was terminated for inappropriate behavior towards a resident. He stated he interviewed Resident #1, and she confirmed the staff was rude. The Administrator stated the Resident's room-mate Resident #21 stated she overheard and felt the aide had a bad attitude and was disrespectful. The Administrator stated no other reports of bad behavior were found in interviews with other residents. He stated in his interview with the can she denied speaking inappropriately or using cuss words. The Administrator stated no harm was assessed to either resident. In an interview on 7/30/24 at 3:15 pm the DON stated the incident involving Resident #1 and #21 had been investigated. She stated the facility had an aide who was not always polite with residents. She stated Resident #1 informed her the aide talked down to her like she was a child. The DON stated the roommate, Resident #21, confirmed the aide was grouchy with Resident #1. The DON stated no psychological harm was assessed. The DON stated the social worker did a Harm Survey with all able residents and no other residents had any complaints related to the allegations. In an interview on 7/30/24 at 4:00 pm LVN L stated neither Residents #1 nor #21, had any changes in behavior after the incident involving the aide. LVN L stated Resident #21 had complained about the aide stating she yelled at Resident #1 and cussed at her to stop using her call light. Review of the investigation report by the facility completed on 7/29/24 reflected the facility had substantiated the CNA was verbally inappropriate or abusive. The investigation started on 7/22/24 when Resident #1's family member reported via telephone that the Resident was treated ugly and disrespectfully by the CNA. The aide was suspended, and the physician, RP, and Sheriff department were notified. A head-to-toe assessment reflected no new injuries. Resident #1 denied any psychological stress. Interviews with other residents were conducted. Residents #1 and her roommate, Resident #21, were interviewed by the administrator. The interviews reflected the CNA was loud, inappropriate, and yelled at Resident #1 for putting her call light on too many times. The Administrator interviewed the alleged perpetrator who denied doing anything wrong. She stated Resident #1 put on her call light multiple times and she told her after getting her up she was going to keep her in her wheelchair. She stated she did not yell, the resident took it wrong. Review of the CNA's written statement dated 7/22/24 reflected she went to answer Resident #1's call light and she asked for a pain pill. She stated she would inform the nurse, and the nurse stated it would be 45 more minutes before she could have a pain pill per her physician's orders. The CNA stated Resident #1 put on the call light five more times asking for a pain pill. The CNA stated she took Resident #1 to the bathroom and placed her in a regular wheelchair as Resident #1's electric chair was still charging. Her statement also reflected she had informed Resident #1 the nurse wanted her to sit up in the wheelchair for a while after her lunch. Review of the Abuse Neglect and Exploitation Policy dated 8/15/22 reflected a definition of Verbal Abuse which included the use of disparaging or derogatory terms to residents. The CNA had completed training on abuse neglect at the time of her employment. Review of the facility policy Promoting Resident Dignity dated 1/13/23 reflected the employees were to protect and promote Resident rights and treat each resident with respect and dignity. Resident requests will be responded to in a timely manner. Staff were to speak respectfully to residents, discussions should not be overheard by others. The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began.

Based on observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment; including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Resident #1) of 8 residents reviewed for homelike environment. The facility failed to ensure two bedside tables were cleaned daily for three days observed during annual survey. This failure placed residents at risk for infections, injuries, and demoralization. The findings included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: hemiplegia to left side ( paralysis of limbs on the left side of body), metabolic encephalopathy (problem of the brain, history of traumatic brain injury (disruption in the normal function of the brain, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), epilepsy, unspecified convulsions ( a group of disorders marked by problems in the normal functioning of the brain), and need for personal care. Review of the Quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene, and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 reflected interventions were in place for: full code status, ADL performance deficit, history of falls/hemiplegia, antidepressant medication, anticoagulant medication, chronic pain r/t pelvic fracture, and vertebrae fractures. Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: myopathy (disorder of the skeletal muscles), morbid obesity, hypothyroidism ( when the thyroid gland does not make enough thyroid hormones to meet your body's needs), congestive heart failure ( weakened heart condition that causes fluid buildup in the feet, arms, lungs and other organs), muscle wasting and atrophy ( decrease in size of muscles) and peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel. Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming, and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self- performance deficit, a history of falls, a urinary tract infection( infection in any part of the urinary system), Chronic back pain, and psych history related to sexual assault. In an interview on 7/30/24 at 8:20 am Resident #21 stated no one had ever cleaned the surface of her bedside table as far back as she could remember. She stated no one cleaned the table in between meals and incontinence care. She stated no one cleaned the table before setting her meal tray on it and no one helped to wash her hands. Observation of lunch service on 7/30/24, starting at 12:10 pm. At 12:15 pm Resident #21 stated her tray table or bedside table had not been cleaned. She also stated she had not been assisted to wash her hands. At 12:20 pm trays for 500 Hall exited the dining room and were checked by a nurse. At 12:22 pm trays were served to the first two rooms, Resident #10 and Resident #50 by Aides CNA M and CNA N. Neither resident was observed to be assisted with handwashing or cleaning their table. At 12:30 pm Resident #21 was not assisted to wash her hands and her tray table was not cleaned prior to being served her lunch tray. At 12:35 Resident #44 was served his lunch tray with a urinal containing approximately 300 mls of clear yellow urine sitting on the bedside table and left behind alongside his food. In an interview on 7/30/24 at 3:25 pm Housekeeper P stated each room in the facility was to be cleaned daily. He stated all touch surfaces were to be cleaned daily. He stated staff should be sure to follow policy during the current increase in Covid-19 infections in the facility . He stated there was a possibility if residents' rooms were not sanitized a resident may become ill with some type of virus. In an interview on 7/30/24 at 4:00 pm LVN L stated Residents should be assisted to wash their hands multiple times a day by aides and nurses. She stated caregivers should be wearing PPE when in Covid-19 rooms. She stated housekeeping was responsible for wiping down high touch surfaces once a day . She stated if not sanitized a resident may become ill. In an interview on 7/31/24 at 8:12 am Resident #21 stated no one cleaned her bedside table or helped her wash her hands before breakfast today. In an interview on 7/31/24 at 8:50am Resident #1 stated the staff did not help her wash her hands before breakfast today and did not help her wash her hands after getting up to the bathroom at 8:30 am. In an interview on 7/31/24 at 12:20 pm CNA A stated she assisted all the residents on 500 Hall to wash their hands this morning. She stated she can't speak for other aides, but she made sure everyone got help when they needed it. She stated tabletops and bedside tables were to be cleaned by housekeeping each day . She stated if a room was not sanitized a resident may become ill with breathing problems.

Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 9 and Resident #47) out of 8 residents reviewed for call lights. The facility failed to ensure Resident #9 and Resident #47's call light was within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #9's Face Sheet, dated 07/31/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of history of falling (balance issues or other health conditions that increase the risk of falling), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), and abnormal posture ( rigid body movements and chronic abnormal positions of the body.). Record review of Resident #9's Annual MDS Assessment, dated 06/04/2024, reflected the Resident had a BIMS score of a 6 indicating her cognition was severely impaired. Resident #9 was assessed to require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, putting on /taking off footwear, and personal hygiene. She also required assistance with transfers. Record review of Resident #9's Comprehensive Care Plan, dated 06/17/2024 reflected Resident #9 had an ADL self-care deficit related to cognitive loss and limited mobility. Intervention: Resident #9 required assistance with transfers, bed mobility, dressing, eating, toileting, dressing, and grooming. Resident #9 had actual falls with no injury related to poor balance and unsteady gait. Intervention: keep in highly visible areas. Record review of Resident # 47's face sheet dated 7/31/24 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of respiratory failure ( a condition that occurs when the lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the body), traumatic brain injury ( brain dysfunction caused by an outside force, usually a violent blow to the head), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), quadriplegia (a type of paralysis that causes severe or complete loss of motor function in all four limbs and the body from the neck down), altered mental status (a general term for a change in mental function that can range from slight confusion to coma), chronic pain syndrome (persistent pain that lasts weeks to years), need for assistance with personal care, hypertension (high blood pressure), contracture to both left and right hands ( a permanent tightening of the muscles, tendons, skin, and surrounding tissue that causes the joints to shorten and stiffen and a decrease in ROM in both hands), muscle wasting and atrophy (the loss of muscle mass and strength), neuromuscular dysfunction of bladder (a urinary tract condition that occurs when the nerves and muscles of the urinary system don't work together properly due to damage to the nervous system), cognitive communication deficit (a communication problem that's caused by a cognitive deficit rather than a language or speech deficit), aphasia ( a comprehension and communication (reading, speaking, writing) disorder resulting from damage or injury to a specific area in the brain), complete amputation at right hip joint, and gastronomy status (the presence of a gastrostomy, which is a surgical opening into the stomach for nutritional support or gastric decompression) Record review of Resident # 47's care plan revised on 1/4/24 reflected the resident was a high risk for falls related to spasticity and traumatic brain injury interventions reflect to be sure resident's call light was within reach and encourage resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. The care plan also reflected the resident had a communication problem related to head injury. Resident was nonverbal most of the time but will occasionally speak to staff and family. Will blink eyes yes and no and nod head no in response to questions. Interventions included anticipate and meet needs revised 5/6/24. Care plan reflected the resident has oxygen therapy PRN related to respiratory distress, decreased oxygen level revised 4/1/24 with interventions to include provide reassurance and allay anxiety. Have an agreed upon method for the resident to call for assistance (e.g. call light, bell). Stay with resident during episode of respiratory distress. Care plan reflected the resident had an ADL self-care performance deficit related to TBI interventions include resident to be totally dependent on staff for all aspects of ADL's revision on 2/16/24. Observation on 07/29/2024 at 9:41 AM to 9:47 AM Resident #9 was in her room sitting in her wheelchair. She had both feet propped up on her recliner. She had an overhead rolling table approximately 3 feet from where she was sitting. On the rolling table her call light was hanging over the table and the call button was not near her. The call button was hanging from the rolling table on the right side of the table and Resident #9 was sitting on the left side of the rolling table. Resident #9 attempted to reach for the call light. She was not able to reach the call light from where she was sitting in her wheelchair. Observation on 07/29/2024 at 9:45 AM Resident #9 attempted to reach for the call light and she was not able to reach it from where she was sitting in her wheelchair. Observation on 7/30/24 at 4:02 pm of Resident # 47's room revealed Resident # 47 to be in bed resting looking out the window. Further observation revealed Resident # 47's call light and soft pad call device both to be hung on the opposite wall not within reach of Resident # 47. Resident # 47 asked if he needed any assistance. Resident # 47 shook his head no. Resident # 47 asked if he was ok currently and Resident # 47 shook head yes as Resident # 47 is primarily nonverbal and this is his primary way to communicate. Interview on 07/29/2024 at 9:43 to 9:47 AM Resident #9 stated no when she was asked if she knew where her call light was located. She began to look for the call light in her wheelchair and she looked around the room and saw it on the overhead rolling table. She stated she could not reach it but she saw it on the table ( she pointed to the overhead rolling table and to the call light). Resident #9 stated she did use her light when she needed help. In an interview on 07/29/2024 at 9:50 AM CNA Q entered Resident #9's room and stated the call light was not within reach of Resident #9. She stated the resident would not be able to use the call light if she had an emergency or needed anything from the staff. CNA Q stated Resident #9 had fallen in the past attempting to get out of her chair. She stated there was a possibility Resident #9 could fall or have an emergency and would not be able to call out for help. She stated she had been in-serviced on call lights and to place the call light near the resident when in their room. She stated she did not recall when she received the in-service. Interview on 7/30/24 at 1:00 pm with CNA A revealed that residents should have their call lights within reach so they could have their needs met. CNA A said most residents have a regular call light except Resident # 47 who has a soft pad call device that he used be he has contractures of both arms. CNA A said Resident # 47 was mainly nonverbal so he needed frequent checks to make sure his needs were met. In an interview on 07/31/2024 at 9:08 AM the Administrator stated all call lights were expected to be within reach of the resident when the resident was in their room. He stated there was a possibility if the call light were not in reach the resident may need nursing assistance and would not be able to call out for help. In an interview on 07/31/2024 at 10:06 AM LVN P stated if a resident's call light was not within reach of the resident there was a possibility a resident may fall and break a hip or hit their head on the floor attempting to reach the call light. He stated if the resident had an emergency, the resident may be able to yell for help but there were some residents that would not be able to yell very loud. It would be difficult to hear those residents. LVN P stated Resident #9 would be difficult to hear if staff were not near their rooms. He stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached where the residents had easy access to use the call light. He stated he had been in-serviced on call lights and placing the call light within reach of the resident when they were in their room. LVN P did not recall the last time he received the in-service. In an interview on 07/31/2024 at 11:09 AM the DON stated it was all the staff's responsibility when they entered a resident room to ensure the call light was within reach of the resident. She stated if the call light were not within reach, it would be difficult for a resident to obtain the help they may need in a timely manner. She stated some residents were able to yell for help and some residents would not be able to yell loud enough. She stated a resident had a potential to fall if the resident attempted to reach for their call light. She stated a resident may fracture their hip, break their leg, or arm. The DON stated it was safe practice for all staff to ensure call lights were within reach of all residents. She stated an in-service had been given to all staff on call light placement. She stated she did not recall the date when the in-service was given to the staff. In an interview on 07/31/2024 at 11:40 AM CNA B stated all staff were responsible to check call lights when they entered a resident's room. She stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. CNA B stated a resident may break a bone or gain a laceration on their head if they fell . She stated all call lights were expected to be within reach of all residents when they were in their room. CNA B stated it would be difficult to hear Resident #9 if she attempted to yell for help and the staff were not standing near her room. She stated she had been in-serviced on call lights and attach call lights where residents can reach it when in their room. CNA B did not recall the date of the last in-service she had on call lights. Record review of the Facilities Policy on Call Lights: Accessibility and Timely Response, dated 10/13/2022 reflected the following: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 2. Staff will ensure the call light is within reach of resident and secured, as needed. 3. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 4. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 5. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 6. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for one (Resident # 11) of eight residents reviewed for dignity. Resident # 11 waited 14 minutes staring at her meal tray before a staff member set down to assist with feeding Resident # 11. This failure placed residents at risk of not being treated with dignity. Findings included: A record review of Residents # 11's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), traumatic subarachnoid hemorrhage (bleeding on the brain), wedge compression fracture of the T5-T6 vertebra (spinal fracture), major depressive disorder ( A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life.), cervicalgia (Neck pain),and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) A record review of Resident # 11's care plan last revised on 5/09/2024 reflected she had ADL self-care performance deficit related to dementia, limited mobility, and terminal illness. Resident # 11's interventions reflected she needed total assistance by 1 staff to eat. An observation of meal service on 7/29/2024 at 1:00 pm revealed Resident # 11 lunch meal tray was sat in front of her. The Activity director came over and set up Resident # 11 meal tray without performing hand hygiene prior to touching meal tray and food items. After meal tray was set up the Activity Director walked away. Resident # 11 sat staring at her meal tray for 14 minutes before a staff member came over and sat down to assist with feeding Resident # 11 her meal tray. Interview with the Dietary Director on 7/29/2024 at 2:00 pm reflected the dining room trays are served after the hall trays go out. The Dietary Director said the meal tickets are in the order they are printed but they try to serve all residents at one table at a time. The Dietary Director said as for the trays of residents who need assistance those are not separated, they just come out in the normal order as they are printed. Record review of Meal Service policy dated 10/1/2018 reflected under heading policy: The facility believes that all residents should be always treated with dignity and respect. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. 7.Residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining.

Based on observations, interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to investigate to determine the causative factors of falls to help prevent and/or reduce risk for falls and implement new fall interventions, if needed; and failed to ensure fall interventions were implemented to help prevent falls. This affected three (3) of three (3) residents reviewed for falls (Resident #1, Resident #3, and Resident #10), The facility also failed to complete post-fall neurological checks for one (1) of three (3) residents reviewed for falls (Resident #3). It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of K. The Immediate Jeopardy (IJ) began on 04/17/2020 when Resident #1 had a fall in the facility that resulted in a right femur fracture due to the facility not identifying causative factors or interventions after numerous previous falls. The Nursing Home Administrator (NHA), Interim Director of Nursing (DON) and Nurse Consultant were notified of the IJ on 09/10/2021 at 5:25 PM and provided the IJ Template on 09/10/2021 at 5:40 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 09/11/2021 at 6:18 PM. The IJ was removed on 09/11/2021 at 7:42 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy for F689. Findings included: A review of the facility's policy, titled, Lippincott Nursing Procedure, Seventh Edition 2013, revealed perform a fall risk assessment after a change in the patient's condition, perform a post fall assessment to determine root cause, and update the patient's risk profile. 1. Resident #1 was readmitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], repeated falls, age-related physical disability, muscle wasting, other lack of coordination, hypertensive [CONDITION(S)], abnormal posture, difficulty in walking, other abnormalities of gait and mobility, and chronic obstructive pulmonary disease ([CONDITION(S)]). A review of the discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated significant cognitive impairment. Resident #1 required extensive assistance of two persons with bed mobility, dressing, and toileting. Resident #1 required limited assistance of one person with eating. A review of the care plan, initiated on 09/04/2019, revealed the resident was at risk for falls related to dementia, unsteady gait, lack of coordination, poor balance, and mobility impairment. A further review of the care plan revealed the last update to the care plan was on 09/04/2019. A review of the falls risk assessment completed on 12/14/2019 revealed the resident scored an 18, meaning the resident was considered a high fall risk. A review of an incident report, dated 01/30/2020, revealed staff observed the resident with a skin tear to the left knee at bedtime. When asked by staff how it happened, the resident stated the resident fell on their knees on the prior shift at 2:30 PM. A further review revealed no incident report related to the fall was completed, and no causal factors related to the fall or appropriate interventions were identified. A review of an incident report, dated 01/30/2020, revealed staff found the resident awake and confused, on the resident's knees, out of bed, on the floor mat, and the resident was unable to say what happened. There were no causal factors related to the fall identified or appropriate interventions put into place. A review of an incident report, dated 03/10/2020, revealed staff found the resident sitting on the floor mat next to the bed with a small abrasion noted to the right forearm. The resident stated they had fallen and hit their arm. There were no causal factors related to the fall identified or appropriate interventions put into place. A review of an incident report, dated 03/11/2020, revealed staff found the resident lying on their left side on the floor in the front lobby. Another resident stated seeing the resident stand from the wheelchair and sit back down, but the wheelchair rolled, and the resident went to the floor. Staff observed a new skin tear to the right elbow. There were no causal factors related to the fall identified or appropriate interventions put into place. A review of an incident report, dated 03/25/2020, revealed the resident had an unwitnessed fall in the dining room. Staff observed a very small bump to the posterior of the resident's head. There were no causal factors related to the fall identified or appropriate interventions put into place. A review of a progress note dated 04/06/2020 revealed the resident was alert and up in the wheelchair that afternoon and was noted to be sliding down in the wheelchair. The resident was repositioned by 2 staff, with no acute distress noted. A review of an incident report, dated 04/15/2020, revealed staff found the resident sitting on the floor in front of their wheelchair, and the resident stated it was a result of a fall. The resident complained of right leg pain that subsided after the resident was assisted into bed. There were no causal factors related to the fall identified or appropriate interventions put into place. A review of an incident report, dated 04/17/2020, revealed staff found the resident out of the wheelchair and on the floor. Staff stated the resident was sitting up in the wheelchair by the nurse's station and tried to get up out of the wheelchair and fell . The resident was found lying on their right side. Staff observed a skin tear to the right elbow and the resident complained of right hip pain. There were no causal factors related to the fall identified or appropriate interventions put into place. A record review of Roadrunner Radiology interpretation report, dated 04/17/2020, revealed a right hip x-ray with 2-3 views of pelvis. There was no fracture or dislocation seen. A further review revealed a report dated 04/20/2020, of a right hip x-ray with 2-3 views of pelvis. It showed a displaced right femoral neck fracture was now visible. A review of a progress note, dated 04/20/2020, revealed, At this time spoke with Physician and made aware of Displaced R (right) femoral fracture, responsible party (RP) notified, A further review revealed staff received verbal orders to send the resident out to emergency room (ER). A review of a progress note, dated 04/24/2020, revealed staff at the facility called and spoke with staff at the hospital to check on the status of the resident, and they were informed that the resident had been placed on Hospice. During an interview on 09/09/2021 at 10:55 AM, Registered Nurse (RN) #2 stated that when a fall occurred, staff would first assess the resident for injuries and assist the resident back to where they were prior to the fall if it was safe to do so. Staff would then notify the physician and family. RN #2 stated staff should document the details of the fall on the incident report and not in progress notes. If it was an unwitnessed fall, the staff started neurological checks every shift for 72 hours. RN #2 stated staff should complete an incident/accident report. The information in the report should include a description of the incident, what the resident said happened, and witnesses, if there were any. RN #2 stated staff take the resident's vital signs, assess for injuries, conduct a pain scale, and look at environmental factors. Staff completed communication in the electronic medical record, and all nursing staff have access to this. RN #2 stated that was how all nursing staff, including the DON, became aware that a fall had occurred. RN #2 stated the floor nurse completing the incident report did not complete root cause analysis or update the care plan with interventions. RN #2 stated if an immediate intervention was put into place, it would be stated in the communication but would not actually be updated on the care plan. RN #2 stated that nursing staff would have to verbally communicate the updated intervention to CNA staff, so they were aware. He assumed that all staff would do this for the following shifts. RN #2 stated if neurological checks were completed, they were documented on paper and then given to medical records to be filed. RN #2 stated he remembered Resident #1 was on the locked dementia unit, and there were usually 2 CNA staff back there for all the residents. RN #2 stated Resident #1 would always try to get up unassisted, and staff would try to sit near by and watch the resident closely. During a phone interview on 09/10/2021 at 5:30 AM, Licensed Vocational Nurse (LVN) #1 stated that when a resident had a fall, nursing staff should first assess the resident for injuries and ask the resident what happened if the resident was cognitively intact and able to tell staff what occurred. Next, the resident's vitals were taken, and staff notified the family and doctor. LVN #1 stated that the nurse completed an incident report/risk management assessment related to the fall. The DON reviewed the incident reports and identified root cause and any appropriate interventions and updated the care plan. LVN #1 stated she did not know why there were not any updates to the resident's care plan. She figured the DON had a meeting to discuss the falls and at that time she would identify root cause/causal factors and any appropriate interventions, and that the care plan would have been updated then. LVN #1 stated she knew Resident #1 had a low bed and fall mat and that staff played games with the resident. She was not sure why interventions related to Resident #1's wheelchair was not explored after the resident had numerous falls from the wheelchair. LVN #1 stated she did not recall any specific details about the fall incident forms she completed for Resident #1 or why she did not complete an incident report for the fall that occurred on 01/30/2020. During an interview on 09/10/2021 at 9:58 AM, the Director of Nursing (DON) stated that when a resident had a fall, it was the floor nurse's responsibility to assess the resident. It was also their responsibility to complete a risk assessment and get witness statements from any staff or other residents who may have seen the fall occur. The DON stated that when the fall is unwitnessed, the floor nurse still needed to figure out how the fall may have occurred and put an appropriate intervention in place and update the care plan. The DON stated that after the floor nurse completed the fall incident report/risk management assessment, it was submitted electronically. This allowed the DON to pull an incident report each morning related to falls so the interdisciplinary team (IDT) could review that information to ensure falls investigations were completed accurately and that appropriate interventions were identified. The DON stated it was the responsibility of the clinical supervisor, i.e., Assistant Director of Nursing (ADON) or DON, to ensure the fall incident reports were completed correctly and thoroughly, and that the care plan had been updated with appropriate interventions. The DON reviewed all seven (7) of Resident #1's incident reports related to falls and stated that none of the incident reports had causal factors identified, new interventions weren't being explored, and the care plan was not updated after any of the falls. The DON stated that after each fall occurred, she would have expected nursing staff to interview other staff and cognitive residents that may have witnessed the fall to try and determine causal factors and look at patterns and trends related to the falls. The DON stated that she noticed most of Resident #3's falls occurred after 6:00 PM and staff should have been looking at those patterns as far as the time of day and location of all of Resident #3's falls. The DON stated she would have expected staff to look at that to try and see what needed to be done to ensure continued safety of the resident and reduce the likelihood of additional falls. The DON agreed that staff were not completing investigations after falls and were not looking at patterns or trends; therefore, staff were not identifying appropriate interventions. The DON stated that the Risk Management Assessment guided the process to compete the investigation, and nurses were not completing it correctly. The DON also stated the IDT was not monitoring the incident logs and ensuring falls were being investigated and that care plans were being updated with appropriate interventions. The DON stated an in-service should be completed for all nurses related to the falls process to ensure they were completed correctly. During an interview on 09/10/2021 at 4:15 PM, the Administrator stated he was not aware that causal factors or appropriate interventions were not being identified and that care plans were not being updated after falls occurred in the facility. The Administrator stated he was not sure if the falls process was discussed with any of the nursing staff to ensure they were aware of the expectations when a fall occurred. The floor nurse should have been identifying casual factors and implementing appropriate interventions each time a fall occurred. The Administrator stated the IDT, which consisted of therapy, MDS, DON and ADON, should have been reviewing incident reports daily. He was not sure how the falls process was being missed. The Administrator stated he would expect nurses to initiate interventions and identify causal factors after each fall. He would expect that the IDT was monitoring and there was follow-through by them to ensure the falls process was being followed. During an interview on 09/11/2021 at 3:22 PM, the ADON stated that when a fall occurred, the nursing staff would first assess the resident for injury, get vitals, and return the resident safely to their prior location, if possible. The ADON stated the nurse would then start neurological checks and document these checks for 72 hours. The nurse would notify the responsible party (RP) via phone and the physician via fax. They would call the physician if it was emergent. The ADON stated nurses would initiate orders if any were given after notifying the physician. The ADON stated that nurses should ensure the fall was care planned and that appropriate interventions were identified. The care plan should reflect that an actual fall occurred, along with the date of the fall, if the fall was witnessed or unwitnessed, and a list of new interventions. The ADON stated that after a fall occurred, nursing staff should be getting information from the resident, if possible, along with other witness statements about what occurred. The nursing staff should complete a risk management/incident report related to the fall. The ADON stated it was the responsibility of the nurses on the floor to identify causal factors. Once a risk management/incident report was initiated in the system it remained open until the DON reviewed it and closed it after ensuring that the root cause and appropriate interventions had been identified. The ADON stated the incident reports should be reviewed by the DON and closed within three days of being initiated. The incident report was signed off by the licensed nurse, the DON and the Administrator. The ADON reviewed all seven (7) incident reports for Resident #1 and confirmed that root cause was not identified for any of the falls, the care plans were not updated, and the facilities fall protocol was not followed. The ADON stated the falls risk assessment should be completed on admission, quarterly, and after each fall. The ADON also stated that the oversight by the DON did not appear to have been done since there were not any causal factors or interventions identified after any of the falls. During an interview on 09/11/2021 at 4:45 PM, Certified Nurse Aide (CNA) #2 stated she remembered that Resident #1 had a couple of falls in the facility. Resident #1 did have some minor injuries as a result of falling in the facility but did not remember if the resident suffered any major injuries. CNA #2 stated Resident #1 had a low bed and fall mat, and staff would monitor the resident more often, but CNA #2 could not remember any interventions related to Resident #1's wheelchair use. During an interview on 09/11/2021 at 6:34 PM, RN #1 stated Resident #1 was a high fall risk. RN #1 stated Resident #1 had floor mats, a bed in low position, and staff often had to redirect the resident. It was the floor nurses' responsibility to initiate the falls incident report for the DON to complete. RN #1 stated the nurse completing the incident report would identify root cause if possible and put in interventions. The fall incident reports that she completed on 03/10/2020 and 04/12/2020 did not have a root cause analysis or causal factors identified, and there were no care plan interventions identified. RN #1 stated she was not sure if she reviewed prior falls that Resident #1 had to look for patterns or trends. When completing fall incident reports, she might look back at previous falls, but that was not her general practice. RN #1 stated it made sense to look at all that information, like previous falls, to try and identify casual factors. 2. A record review of progress notes revealed Resident #3 was originally admitted to the facility on [DATE] and was discharged from the facility on 11/03/2020. The resident had diagnoses of lack of coordination, abnormalities of gait and mobility, muscle wasting, dementia, muscle weakness, repeated falls, and a history of falls. The annual Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status to be a 0 out of 15, which indicated the resident was severely cognitively impaired, and the resident had two non-injury falls since the prior assessment. A record review of Resident #3's fall risk assessments from January 2020 through September 2020 was conducted. The assessment completed on 01/13/2020 documented the resident was a High Risk for falls and had 1-2 falls in the past 3 months. On 09/07/2020, the assessment indicated the resident was a High Risk for falls and documented 1-2 falls within the last 3 months. There were no fall risk assessments completed between 01/14/2020 and 09/06/2020 in the resident's medical record. A record review of Resident #3's care plan, reviewed on 08/12/2020, indicated Resident #3, has had an actual fall with injury [related to] poor balance, poor communication/comprehension, psychoactive drug use, unsteady gait, [and] non-Compliance with using Walker It listed the resident had the following falls: - on 11/14/19; - on 5/12/20, the resident did not have any injuries; and - on 5/15/20, the resident had two falls with no injuries. The initiated date of the care plan problem was 11/21/2018 with interventions listed to monitor resident's room for wet floor, with an initiated date of 05/01/2019; to remind the resident to always use their walker, with an initiated date of 11/21/2018; to remind the resident to lock the wheelchair with transfers, with an initiated date of 11/14/2019; and therapy to screen after a fall, with an initiated date of 05/01/2019. There were no interventions listed for 2020. A record review of Resident #3's progress notes on 01/12/2020 at 1:30 AM revealed LVN #1 indicated, Resident was heard by staff yelling found resident sitting up on floor alert able to respond verbally, with [Resident #3's] back against the dresser, resident facing closet with legs straight out in front of [them] next to bed with [their] pants pulled down & with [their] shoes on, resident states [they were] getting out of bed going to the bath room getting [their] walker and fell resident assessed for injuries c/o [complained of] right arm pain to elbow and upper arm and bruising red, purple with skin tear noted 2cm [centimeters] linear, no visible head injury noted no other c/o pain voiced able to move BLE [bilateral lower extremity] w/o [without] difficulty NVS [neurological vital signs] started [.] [To] have X-ray of right elbow and humerus, resident medicated for pain with prn [as needed] apap [acetaminophen] WCTM [will continue to monitor] for changes and pain. A record review of Resident #3's injury and accident report dated 01/12/2020 at 1:30 AM indicated the resident had a fall in the resident's room. The report documented that the resident stated the resident was getting out of bed, going to the bathroom, and was getting the walker and fell . Injuries at the time of the incident were a bruise and a skin tear to the right elbow. The family member was notified on 01/13/2020 at 7:04 AM. There was no documentation that the resident's doctor was notified. The Notes section documented that the incident reviewed, will refer to rehab and anticipate needs, assist with toileting. A record review of Resident #3's progress notes on 01/24/2020 at 7:25 PM revealed that LVN #1 indicated she Heard a resident, yelling out help, this resident [Resident #3] was found on floor in walkway/bathroom area in [their] room lying on [their] left side back against the sink and [they were] facing bathroom door, [their] legs where [straight] out into bathroom area, resident alert eyes open assessed for injuries noted with skin tear top right hand, old bruising to right elbow no other injuries noted resident denies pain at present states going to bathroom I turned & fell , resident was able to move all extremities w/o c/o pain NVS started will continue to monitor for changes and pain . A record review of Resident #3 injury and accident report dated 01/24/2020 indicated the resident had an unwitnessed fall in the resident's bathroom, which resulted in a skin tear to the right hand. The resident had stated that they were going to the bathroom, turned, and fell . The resident's restroom noted with wet floor and wet towels by the toilet, resident was wearing house shoes . The resident's family and doctor were notified. There were no interventions listed. A record review of Resident #3's progress notes on 05/12/2020 at 6:00 PM revealed LVN #1 Called [responsible party] to notify of resident with fall and head injury and resident being sent to [emergency room for evaluation and treatment] . At 6:05 PM, LVN #1 indicated that the ambulance arrived, the resident was confused, hard of hearing, and unable to answer questions. The .resident had to be shook on shoulder by [ambulance driver] to get a response, eyes opened resident holding head and with facial grimacing and c/o pain to hematoma site . At 6:45 PM, LVN #1 revealed that the resident was found on the floor, lying flat on their back with their legs extended out and their head by the corner of the sink. The resident's wheelchair was next to the closet and there was coffee noted on the floor by the resident's bed. The resident had stated that they were walking with the coffee, dropped the coffee on the floor, and fell . The resident was assessed for injuries, and there was a right forehead/temporal closed hematoma. The resident complained of severe pain to the head. There was no bleeding, and the resident denied pain in the legs or hips. The resident was sent to the emergency room . A record review of Resident #3's injury and accident report dated 05/12/2020 at 6:45 PM revealed LVN #1 indicated the resident had a fall in the resident's room and staff states resident is on the floor resident found lying flat on [their] back in [their] room with [their] legs extended out[, their] head was by the corner of the sink when walking in to room, [their] w/c was by the closet[,] coffee noted to be spelt on floor by [the] bed . states [Resident #3] was up walking with coffee, dropped coffee on floor & fell . Injuries listed were a hematoma to the top of the scalp. The doctor and family member were notified on 05/12/2020, and the resident was sent to the hospital. Other info indicated the resident was on antibiotics for a urinary tract infection and that the resident was wearing shoes during the fall. There were no interventions listed. A record review of Resident #3's progress notes on 05/15/2020 at 4:05 AM revealed that RN #1 indicated a resident who resided across the hall from Resident #3 notified RN #1 that Resident #3 had fallen. Upon entry to the resident's room, RN #1 found that Resident #3 was on floor by bathroom door lying on back. Stated that [they] had finished on toilet and was sitting down in w/c [wheelchair] when it rolled away and . fell in sitting position onto floor. C/o low back pain which subsided once [they were] lying down in the bed . The doctor and family were notified. At the end of the progress note, RN #1 revealed that the fall occurred at 5/14/20 2045 [8:45 PM]. On 05/15/2020 at 6:44 AM, RN #1 indicated that Resident #3 was walking in their room and fell , hitting their head on the door, which resulted in a laceration to the posterior head and two small skin tears to the right elbow. The resident was assisted to bed. Bleeding to head has stopped. Resident alert, responds to verbal stimuli. Fax to MD [medical doctor], notified [family] . A record review of Resident #3's injury and accident report dated 05/15/2020 at 3:56 AM, completed by RN #1, revealed Resident across hall called nurse because resident had fallen on floor. Resident lying on back by bathroom. Stated that [they] had sat on w/c but it had pulled away and [they] landed on sitting position. Resident stated that [they were] going from toilet to w/c and w/c rolled back. [Resident #3] sat on floor, then laid back . C/o low back pain upon movement which subsided after resting in bed. NVS begun. The doctor and family member were notified. There were no fall interventions listed. A record review of Resident #3's progress notes on 05/15/2020 at 11:21 AM, revealed RN #2 indicated that certified nursing assistants got the resident up and into a wheelchair, and they observed a laceration to the back of the resident's head from the fall from that morning on 05/15/2020 at 6:44 AM. The doctor was notified, and an order was received to send the resident to the hospital. At 7:10 PM, LVN #1 indicated that the resident had returned from the hospital, was alert and confused, and had dark purple bruising to right side of [the resident's] face[;] back of head laceration with staples intact, no drainage noted at present . A record review of Resident #3's progress notes on 05/18/2020 at 3:55 PM revealed that LVN #2 documented there were 6 staples in place on the top of the resident's head, and on 05/26/2020 at 11:25 AM, RN #2 indicated that the 6 staples were removed. In an interview on 09/11/2021 at 10:16 AM, the ADON stated that neurological checks are done on paper and the only document she could find was for the fall on 05/12/2020. She was not able to verify the neurological checks were completed after unwitnessed falls and/or falls in which the resident hit their head. In an interview on 09/09/2021 at 10:12 AM, RN #2 was asked to recall the resident's falls in January and May 2020, and he stated that the resident wanted to be very independent and attempted to go to the bathroom unassisted. He stated that the resident had a stroke with weakness to one side. He stated, I remember a bump on [their] head. I don't remember the fall at all . He stated that they tried to keep the resident near the nurse's desk so they could watch the resident and if the resident went to their room, they would put the resident to bed. He stated, A lot of times, [the resident] get up on her own, without asking for help and go to the bathroom. He was asked if the resident had numerous falls in May 2020 and he stated, I don't remember. He was asked if RN #1 had given him report of the resident falling and if the resident had any injuries and he stated, I don't remember. He was asked if the resident had a laceration or was ever sent out to the hospital after a fall and he stated, I don't remember. He was asked what CNAs brought it to his attention that the resident had a laceration to the back of their head, and he stated that he could not remember. In an interview on 09/09/2021 at 10:56 AM, RN #2 was asked about the process they should follow after a fall has taken place and he stated, Assess for injuries and either help them back in bed . Depending on the circumstances. Then, we notify the doctor, then the family. He stated that he puts the fall information in the incident report in the electronic health record. He stated, I think that [documentation] carries over to the nursing note in risk management. If it's unwitnessed, we do neuro checks. It's all listed in the incident and accident report . It has a description of incident, what the resident states, any witnesses, any injuries, the pain scale, the description on injuries, environmental factors like if the floor is wet. The progress note is in there and it carries over. It goes into the system and the DON does the investigative report. I don't notify anyone else unless the doctor tells me. I assume the DON looks at it. The following day, they'll [the DON] ask about it. We have to follow up for 72 hours after the incident. We do a communication in the computer and all of the nursing staff can see it. The DON does the root cause and updates the care plan. He was asked if he is responsible for identifying immediate interventions and he stated, We start doing that right away. We know what their habits are. It [intervention] doesn't always work. I do not update the care plan. The CNAs are typically the ones that let us know when they have one [a fall] . We put the intervention in the communication [on the computer] and we inform the CNAs [of the intervention]. I'm not part of the morning meeting, that's just department heads. He stated he does not do anything with the follow-up portion of the incident report. He was asked how neurological checks are completed and he stated, Neuro checks are on paper, and we give it to medical records, and they file them. There is a place on the computer [to complete them electronically], but we do them on paper. We give them [the neurological checks] to medical records and she files it. In an interview on 09/09/2021 at 10:36 AM, the DON was interviewed regarding the resident's falls in January and May 2020. Regarding the fall on 01/12/2020 and 01/24/2020, she was asked if there were any long-term interventions to ensure those falls would not happen again. She reviewed the injury and accident reports, as well as the resident's care plan and she stated, There are not any . The falls get transferred over to the I and A log, which is a binder that documents all of the falls throughout the facility. She was asked if any of the resident's falls were listed in the log and she stated, No. For the fall on 05/12/2020, she stated [The resident's] intervention was to be sent to the hospital. You want to see it in writing where the intervention is? I will have to look. She verified all falls in January and May 2020 did not have any documented interventions and were also not in the I and A logbook. She stated each injury and accident report should have interventions documented on the report and should be followed up on. She stated she was not aware they were not being done at that time since she had only been at the facility for two weeks. When asked if interventions should be put on the care plan after each fall, she stated, Yes. In an interview on 09/09/2021 at 11:25 AM, the resident's neurological checks were requested by the ADON. In a phone interview on 09/10/2021 at 8:58 AM, RN #1 was asked to recall Resident #3's falls in January and May 2020 and she stated, I know that [the resident] had fallen; I don't know the time frame. I don't remember particulars . [Resident #3] had some dementia. I th [TRUNCATED]

Based on interview and record review the facility failed to ensure that a physician approved in writing that an individual be admitted to the facility, and provide orders for the resident's immediate care needs, in that Resident #1 was admitted to the facility on [DATE] without consulting or notifying the physician of his admission or obtaining physician orders [REDACTED]. On 08/06/2020 Resident #1 reported pain, burning and discomfort related to his Foley catheter and it was noted his urine was amber colored. No orders for treatment were received prior to Resident #1 removal from the facility on 08/08/2020 by his family due to lack of care and treatment of [REDACTED].#1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 Foley was noted to be clogged and Resident #1 had more than a liter of urine in his bladder. These failures could place residents with indwelling urinary catheters at risk [MEDICAL CONDITIONS], pain or death. Finding include: Review of Resident #1's Face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's 5-Day MDS (still in process) reflected Resident #1 was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #1 was assessed to require extensive to dependent assist with ADL's and supervision for eating. Resident #1 was assessed to have an indwelling urinary catheter. Review of Resident #1's Initial Baseline Care Plan dated 08/04/2020 reflected Resident #1 had a Foley catheter but did not indicate any interventions for the care or monitoring of the Foley catheter. Review of Resident #1's Initial Nursing Evaluation dated 08/04/2020 reflected Foley catheter intact, patent, draining yellow urine to bedside drainage bag. Further review of the Nursing Evaluation reflected the Catheter [DIAGNOSES REDACTED]. Review of Resident #1's MAR and TAR dated 08/04/2020 through 08/08/2020 reflected no entries for his Foley Catheter or care of the Foley Catheter. Review of Resident #1's Nurisng Progress notes dated 08/05/2020 through 08/08/2020 reflected no entries for his Foley Catheter or care of the Foley Catheter. Review of Resident #1's Hospital Discharge orders dated 08/04/2020 reflected a list of medication. No orders for the Foley Catheter were listed. Review of Resident #1's Consolidated Physician order [REDACTED]. In an interview on 08/10/2020 at 3:45 PM LVN A stated she was Resident #1's nurse on 08/06/2020 and 08/08/2020. LVN A stated Resident #1's family called on 08/08/2020 and stated they were taking Resident #1 out of the facility because he wasn't getting care. LVN A stated they told her his Foley had not been changed and they asked for a UA. LVN A stated she faxed Resident #1's doctor about the UA on 08/06/2020 and the office told her they did not know who he was and needed admission paperwork and she faxed it to the doctor's office. When asked if it was common to admit a resident without contacting the doctor she stated No. When asked if Resident #1 had orders for the care of his Foley Catheter, she looked at the EMR and stated No. LVN A stated Resident #1 should've had orders for the care and monitoring of his Foley. LVN A stated she did not receive orders from the doctor's office for Resident #1 prior to his family taking him home on the morning 08/08/2020 AMA. Review of Resident #1's Medical Fax Referral to the physician dated 08/06/2020 at 1:00 PM reflected Resident admitted on [DATE] with Foley catheter for [MEDICAL CONDITION]. Voicing pain, burning and discomfort, urine amber color and clear in drain bag. Family would like to know when Foley catheter will be discontinued. May we have order for UA C&S and would you like to do voiding trial? Please Advise. Documented under New orders/ treatment No record of patient in our system, we have no paperwork on him. Where was he admitted from and who gave admit orders? We need admission paperwork. In an interview on 08/11/2020 at 12:08 PM Resident #1's Physician stated the facility did send a fax on 08/06/2020 regarding Resident #1 and that the resident was having [MEDICAL CONDITION] and voicing pain, but he did not now who the resident was and had not been made aware of his admission and he requested the facility fax over more information on the resident. Resident #1's Physician stated by the time his office had gotten all the information the resident had already been removed from the facility. Resident #1 stated the facility was usually pretty good about notifications of admission. Resident #1's Physician stated Resident #1 should've had orders for his Foley catheter and the nurses should monitor for changes in output. In an interview on 08/11/2020 at 2:00 PM the DON stated Resident #1 should've had orders for his Foley Catheter that included catheter care every shift, irrigation every shift if needed for clogging, to check placement and securement of the Catheter and for the catheter to be changed as needed. The DON stated the physician should have been notified prior to admission of the Resident. The DON was asked how the facility failed to ensure Resident #1 had orders for his admission and Foley catheter she stated the facility did chart audits on all new admits to ensure all care areas are addressed after admission. She stated it just took longer with this resident. She stated it was her expectation that residents admitted to the facility have their physician notified and Residents with a Foley catheter have a complete assessment and orders are obtained for the care of the Foley catheter at the time of admission. Review of the facility's Admission/ Readmission Checklist dated 04/2015 provided as a policy reflected .admission orders [REDACTED].Vendor has been notified of needed enteral products .(i.e. Foley Cath) .

Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services for one (1) of four (4) residents reviewed for indwelling urinary catheters (Foley), in that Resident #1 was admitted to the facility on [DATE] with a Foley catheter for [MEDICAL CONDITION] without physician orders for care and monitoring of his Foley catheter. On 08/06/2020 Resident #1 reported pain, burning and discomfort related to his Foley catheter and it was noted his urine was amber colored. No physician orders for treatment were received and Resident #1's family removed Resident #1 from the facility on 08/08/2020 due to lack of care and treatment. Resident #1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 Foley was noted to be clogged and Resident #1 had more than a liter of urine in his bladder. These failures could place residents with indwelling urinary catheters at risk [MEDICAL CONDITIONS], pain or death. Finding Include: In an interview on 08/10/2020 at 10:16 AM Resident #1's FM stated she was a Nurse Practitioner. She stated her dad was brought to the facility on [DATE] to complete 20 more days of rehabilitation. Resident #1's FM stated during a window visit on 08/06/2020 it was noted Resident #1's urine was dark brown and appeared infected. She stated on 08/06/2020 family had requested a UA, but nothing had been done. The FM stated on 08/08/2020 the family decided to remove Resident #1 from the facility because they felt he was not getting the care he needed. The FM stated Resident #1 was taken to the hospital on [DATE]. The FM stated the resident was very confused and could no longer speak. The FM stated in the ER his Foley was changed and the hospital staff stated Resident #1's Foley had not been changed in sometime and had not been draining. The FM stated Resident #1 was admitted [MEDICAL CONDITION] and UTI. Review of Resident #1's Face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's 5-Day MDS (still in process) reflected Resident #1 was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #1 was assessed to require extensive to dependent assist with ADL's and supervision for eating. Resident #1 was assessed to have an indwelling urinary catheter. Review of Resident #1's Initial Baseline Care Plan dated 08/04/2020 reflected Resident #1 had a Foley catheter but did not indicate any interventions for the care or monitoring of the Foley catheter. Review of Resident #1's Initial Nursing Evaluation dated 08/04/2020 reflected Foley catheter intact, patent, draining yellow urine to bedside drainage bag. Further review of the Nursing Evaluation reflected the Catheter [DIAGNOSES REDACTED]. Review of Resident #1's MAR and TAR for 08/04/2020 through 08/08/2020 reflected no entries for his Foley Catheter or care of the Foley Catheter. Review of Resident #1's Nursing progress notes for 08/05/2020 through 08/08/2020 reflected no entries for his Foley Catheter or care of the Foley Catheter. Review of Resident #1's Hospital Discharge orders dated 08/04/2020 reflected a list of medication. No orders for the Foley Catheter were listed. Review of Resident #1's Consolidated Physician Orders from 08/04/2020 through 08/08/2020 reflected no orders for the Foley catheter or the care and monitoring of the catheter. Review of Resident #1's Medical Fax Referral to the physician dated 08/06/2020 at 1:00 PM reflected Resident admitted on [DATE] with Foley Catheter for [MEDICAL CONDITION]. Voicing pain, burning and discomfort, urine amber color and clear in drain bag. Family would like to know when Foley Catheter will be discontinued. May we have order for UA C&S and would you like to do voiding trial? Please Advise. Documented under New orders/ treatment No record of patient in our system, we have no paperwork on him. Where was he admitted from and who gave admit orders? We need admission paperwork. In an interview on 08/10/2020 at 3:45 PM LVN A stated she was Resident #1's nurse on 08/06/2020 and 08/08/2020. LVN A stated Resident #1's family called on 08/08/2020 and stated they were taking Resident #1 out of the facility because he wasn't getting care. LVN A stated they told her his Foley had not been changed and they asked for a UA. LVN A stated she faxed Resident #1's doctor about the UA on 08/06/2020 and the office told her they did not know who he was and needed admission paperwork and she faxed it to the doctor's office. When asked if it was common to admit a resident without contacting the doctor she stated No. When asked if Resident #1 had orders for the care of his Foley Catheter, she looked a the EMR and stated No. LVN A stated Resident #1 should've had orders for the care and monitoring of his Foley. LVN A stated she did not receive orders from the doctor's office for Resident #1 prior to his family taking him home on the morning 08/08/2020 AMA. Review of Resident #1's Hospital Records dated 08/09/2020 reflected Patient is a [AGE] year-old male with history of [MEDICAL CONDITION], he was apparently staying in a nursing home but was taken home recently by his daughter, today brought to the hospital for AMS. In the ER he was noted to be septic with UTI. He was noted to be in [MEDICAL CONDITION], a Foley was placed, and he had more than a liter of urine output, he is extremely confused at the time of exam and unable to provide any history. [DIAGNOSES REDACTED]. In an interview on 08/11/2020 at 3:30 PM Resident #1 FM stated Resident #1 did have dementia and would probably not talk with surveyor since he did not know her. Resident #1's FM did provide Resident #1's hospital room phone number. Multiple attempts to contact Resident #1 via phone at the hospital were unsuccessful. In an interview on 08/11/2020 at 12:08 PM Resident #1's Physician stated the facility did send a fax on 08/06/2020 regarding Resident #1 and the resident was having [MEDICAL CONDITION] and voicing pain, but he did not now who the resident was and had not been made aware of his admission and he requested the facility fax over more information on the resident. Resident #1's Physician stated by the time his office had gotten all the information the resident had already been removed from the facility.Resident #1's Physician stated Resident #1 should've had orders for his Foley catheter and the nurses should monitor for changes in output. In an interview on 08/11/2020 at 2:00 PM the DON stated Resident #1 should've had orders for his Foley catheter that included catheter care every shift, irrigation every shift if needed for clogging, to check placement and securement of the catheter and for the catheter to be changed as needed. When asked if Resident #1's admission assessments should have included condition of the Foley Catheter on admission she stated yes. The DON stated the physician should have been notified prior to admission of the Resident. The DON was asked how the facility failed to ensure Resident #1 had orders for his admission and Foley catheter she stated the facility did chart audits on all new admits to ensure all care areas are addressed after admission. She stated it just took longer with this resident. She stated it was her expectation that residents admitted to the facility have their physician notified and Residents with a Foley catheter have a complete assessment and orders are obtained for the care of the Foley catheter at the time of admission. Review of the facility's Admission/ Readmission Checklist dated 04/2015 provided as a policy reflected .admission orders [REDACTED].Vendor has been notified of needed enteral products .(i.e. Foley Cath) .

Based on interview and record review the facility failed to ensure that residents were free from neglect for one (1) of five (5) residents reviewed for neglect, in that Resident #1 was admitted to the facility on [DATE] without consulting or notifying the physician of his admission or obtaining physician orders [REDACTED]. The facility failed to provide a complete assessment of Resident #1's Foley catheter on admission or develop a plan of care for his Foley catheter. On 08/06/2020 Resident #1 reported pain, burning and discomfort related to his Foley catheter and it was noted his urine was amber colored. No orders for treatment were received prior to Resident #1's removal from the facility on 08/08/2020 by his family due to lack of care and treatment of [REDACTED].#1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 Foley was noted to be clogged and Resident #1 had more than a liter of urine in his bladder. These failures could place residents with indwelling urinary catheters at risk [MEDICAL CONDITIONS], pain or death. Finding Include: In an interview on 08/10/2020 at 10:16 AM Resident #1's FM stated she was a Nurse Practitioner. She stated her dad was brought to the facility on [DATE] to complete 20 more days of rehab. Resident #1's FM stated during a window visit on 08/06/2020 it was noted Resident #1's urine was dark brown and appeared infected. She stated on 08/06/2020 family had requested a UA, but nothing had been done. The FM stated on 08/08/2020 the family decided to remove Resident #1 from the facility because they felt he was not getting the care he needed. The FM stated Resident #1 was taken to the hospital on [DATE]. The FM stated the resident was very confused and could no longer speak. The FM stated in the ER his Foley was changed and the hospital staff stated Resident #1's Foley had not been changed in sometime and had not been draining. The FM stated Resident #1 was admitted [MEDICAL CONDITION] and UTI. Review of Resident #1's Face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's 5-Day MDS (still in process) reflected Resident #1 was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #1 was assessed to require extensive to dependent assist with ADL's and supervision for eating. Resident #1 was assessed to have an indwelling urinary catheter. Review of Resident #1's Initial Baseline Care Plan dated 08/04/2020 reflected Resident #1 had a Foley catheter but did not indicate any interventions for the care or monitoring of the Foley catheter. Review of Resident #1's Initial Nursing Evaluation dated 08/04/2020 reflected Foley catheter intact, patent, draining yellow urine to bedside drainage bag. Further review of the Nursing Evaluation reflected the Catheter [DIAGNOSES REDACTED]. Review of Resident #1's MAR and TAR for 08/04/2020 through 08/08/2020 reflected no entries for his Foley Catheter or care of the Foley Catheter. Review of Resident #1's Nursing progress notes for 08/05/2020 through 08/08/2020 reflected no entries for this Foley catheter or care of the Foley Catheter. Review of Resident #1's Hospital Discharge orders dated 08/04/2020 reflected a list of medication. No orders for the Foley Catheter were listed. Review of Resident #1's Consolidated Physician order [REDACTED]. Review of Resident #1's Medical Fax Referral to the physician dated 08/06/2020 at 1:00 PM reflected Resident admitted on [DATE] with Foley Catheter for [MEDICAL CONDITION]. Voicing pain, burning and discomfort, urine amber color and clear in drain bag. Family would like to know when Foley Catheter will be discontinued. May we have order for UA C&S and would you like to do voiding trial? Please Advise. Documented under New orders/ treatment No record of patient in our system, we have no paperwork on him. Where was he admitted from and who gave admit orders? We need admission paperwork. In an interview on 08/10/2020 at 3:45 PM LVN A stated she was Resident #1's nurse on 08/06/2020 and 08/08/2020. LVN A stated Resident #1's family called on 08/08/2020 and stated they were taking Resident #1 out of the facility because he wasn't getting care. LVN A stated they told her his Foley had not been changed and they asked for a UA. LVN A stated she faxed Resident #1's doctor about the UA on 08/06/2020 and the office told her they did not know who he was and needed admission paperwork and she faxed it to the doctor's office. When asked if it was common to admit a resident without contacting the doctor she stated No. When asked if Resident #1 had orders for the care of his Foley Catheter, she looked at the EMR and stated No. LVN A stated Resident #1 should've had orders for the care and monitoring of his Foley. LVN A stated she did not receive orders from the doctor's office for Resident #1 prior to his family taking him home on the morning 08/08/2020 AMA. Review of Resident #1's Hospital Records dated 08/09/2020 reflected Patient is a [AGE] year-old male with history of [MEDICAL CONDITION], he was apparently staying in a nursing home but was taken home recently by his daughter, today brought to the hospital for AMS. In the ER he was noted to be septic with UTI. He was noted to be in [MEDICAL CONDITION], a Foley was placed, and he had more than a liter of urine output, he is extremely confused at the time of exam and unable to provide any history. [DIAGNOSES REDACTED]. In an interview on 08/11/2020 at 3:30 PM Resident #1 FM stated Resident #1 did have dementia and would probably not talk with surveyor since he did not know her. Resident #1's FM did provide Resident #1's hospital room phone number. Multiple attempts to contact Resident #1 via phone at the hospital were unsuccessful. In an interview on 08/11/2020 at 12:08 PM Resident #1's Physician stated the facility did send a fax on 08/06/2020 regarding Resident #1 and the resident was having [MEDICAL CONDITION] and voicing pain, but he did not know who the resident was and had not been made aware of his admission and he requested the facility fax over more information on the resident. Resident #1's Physician stated by the time his office had gotten all the information the resident had already been removed from the facility. Resident #1's Physician stated Resident #1 should've had orders for his Foley catheter and the nurses should monitor for changes in output. In an interview on 08/11/2020 at 2:00 PM the DON stated Resident #1 should've had orders for his Foley catheter that included catheter care every shift, irrigation every shift if needed for clogging, to check placement and securement of the catheter and for the catheter to be changed as needed. When asked if Resident #1's admission assessments should have included condition of the Foley catheter on admission she stated yes. The DON stated the physician should have been notified prior to admission of the Resident. The DON was asked how the facility failed to ensure Resident #1 had orders for his admission and Foley catheter she stated the facility did chart audits on all new admits to ensure all care areas are addressed after admission. She stated it just took longer with this resident. She stated it was her expectation that residents admitted to the facility have their physician notified and Residents with a Foley catheter have a complete assessment and orders are obtained for the care of the Foley catheter at the time of admission. Review of the facility's Admission/ Readmission Checklist dated 04/2015 provided as a policy reflected .admission orders [REDACTED].Vendor has been notified of needed enteral products .(i.e. Foley Cath) . Review of the facility's policy Abuse Prevention Program dated September 2018 reflected Our residents have the right to be free from abuse, neglect .Comprehensive polices and procedures have been developed to aid our facility in preventing abuse, neglect .Mandated staff training/ orientation programs .

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit neglect of residents for two (2) of 14 residents (Resident #1) reviewed for lab results and #5 reviewed for incidents and accidents)when: Resident #1's Hemoglobin (Hgb) and Hematocrit (Hct) lab test ordered on [DATE] that was drawn on 04/02/2014 included critical lab values and the results of the lab test were not accessed by the facility until 04/11/2014 even though the results were available on 04/03/14. As a result, the physician immediately sent Resident #1 to the Hospital after he was notified of the critical results on 04/11/14. Resident #1 received four (4) units of blood at the hospital due to the critically low Hgb and Hct lab values. An Immediate Jeopardy (IJ) was identified on 04/11/2014. While the IJ was removed on 04/11/2014 at exit, the facility remained out of compliance at a Severity level of Potential for More Than Minimal Harm that is not IJ with a Scope identified as Isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed 81 residents at risk for delayed changes in the course of medical treatment for [REDACTED]. Non Immediate Jeopardy B) The facility failed to thoroughly investigate and report an incident to the Administrator within five (5) working days when Resident #5 had a dark colored substance in her lap in the dining room. Resident #5 received injuries including blisters and red skin. This deficient practice placed 67 residents who required assistance of one to two staff to eat at risk for serious injury [MEDICAL CONDITION] to not investigating incidents. Findings Include: Review of facility's Abuse and Neglect Policy dated 10/30/2014 reflected the facility will follow the resident's right to be free from neglect and the physician will be notified of findings. Review of the facilities policy Abuse Prevention dated 07/01/2005 reflected "Investigation and review of incidents and allegations, complaints and incidents to include identifying the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities...7. Review of all events leading up to the incident to attempt to identify causative factors...Based upon the results of the investigation, a care plan will be initiated, as appropriate, if the residents's condition was affected or measures are needed to prevent recurrence." A) Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].#1 had her gallbaladder removed on 02/20/2014), Hypertension, Intellect Disability, [MEDICAL CONDITION] Arthritis, and [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] reflected Resident #1 had a BIMS score of three (3) which indicated the Resident had severe cognitive impairment. The MDS reflected Resident #1 was a one person assist with all activities of daily living. Review of the Comprehensive Care Plan dated 03/26/2014 for Resident #1 reflected a Problem/Need as "Resident requires a PEG (Percutaneous Endoscopic Gastrostomy) tube for adequate nutritional intake". The Care Plan reflected under Goal "Resident will maintain current weight" and "Resident will not experience adverse effects from placement of a PEG tube". The Care Plan also reflected under Approaches "all meds per tube; Dietician to evaluate resident's current nutritional status; Weigh resident monthly; Resident will not experience adverse effects from placement of a PEG tube; Refer resident to speech therapy for swallowing evaluation as needed; Maintain resident in an upright position during feeding HOB (head of bed) at 30 degrees; Site care of resident's G tube daily or as ordered; Check resident G tube placement before initiating feeding; Monitor for changes that may indicate worsening of resident's condition and notify the physician as indicated." Observation on 04/11/2014 at 9:30 AM of an ambulance stretcher with Resident #1 on board. Resident #1 was pale in color. In an interview on 04/11/2014 at 9:30 AM LVN A stated Resident #1 was being transferred to the emergency room due to a critical lab results the facility did not get because there was a "glitch" in their phone system on 4/2/2014 when the lab was drawn and the DON discovered it on 04/11/2014. In an interview on 04/11/2014 at 9:40 AM the DON stated she found out today, 4/11/2014 when she was completing her weekly lab audit that Resident #1 had critical lab values: Hgb was 5.9 and Hct was 18.5. The DON stated the charge nurse was supposed to check labs drawn daily and place the results on the charts. The DON stated that on 04/02/2014 when the labs were drawn, the facility experienced their phone system to go down, along with the physician offices. The DON stated the facility did not receive any faxes from the lab company. The DON stated she normally followed up every Friday for labs drawn that week but on 04/04/2014 she "did not check the labs" and "if I had it would have been caught". The DON stated she notified the physician today, 04/11/2014, and "he was mad" about not being notified. The DON stated "now the system has to be re-vamped" and that Resident #1 was being sent out to the ER. Review of the Lab Report dated 04/02/2014 reflected HGB 5.9 critical and HCT 18.5 critical. The Report's reference range-normal was HGB: 12.0-15.6 and HCT normal range was 35.0-46.0. The Report reflected a notation on the lab report sheet "(Physician) notified of the critical level Hgb and Hct by the DON at 8:40 AM 04/11/2014. Review of the Nurses' Notes dated 04/11/2014 reflected Resident #1 complained of abdominal pain at 8:00 AM and was medicated with [MEDICATION NAME] 10/325 mg (an [MEDICATION NAME] given for pain). Review of the Departmental Notes dated 03/26/2014 from Dietary for Resident #1 reflected "Resident returned from PEG placement, needs orders for tube feeding...Check CMP (Comprehensive Metabolic Panel) in 1 (one) week." Review of Dietician Recommendations Record dated 03/26/2014 reflected the dietician recommended a CMP lab work be done in one week if not already ordered and the physician responded "yes do it" and added a CBC. Review of ProLab Log Sheet dated 04/02/2014 reflected a CBC and CMP were drawn for Resident #1. The Sheet was initialed by the phlebotomist but the column for the nurse to initial blood drawn and results received were blank. In an interview on 04/11/2014 at 11:50 AM CNA H stated, when asked how Resident #1 had been feeling this week, Resident #1 seemed to be weak in her legs and did not want to get out of bed except when she had an appointment this week to see the physician. CNA H stated she agreed to get up into the wheelchair. In an interview on 04/11/2014 at 11:55 AM CNA I stated Resident #1 did not like to get out of bed much these days, Resident #1 "just wants to watch TV and stay in bed." In an interview on 04/11/2014 at 12:00 PM LVN A stated she as a charge nurse was supposed to check labs drawn by checking the fax machine in the medication room and the fax machine in the Administrator's office for labs in general. LVN A stated she did not know when a specific lab was due or when it should be reported. LVN A stated "I guess I screwed up, I signed the form to collect the blood for the CMP and CBC." Review of the Lab Request Form dated 04/02/2014 reflected a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel) was ordered on [DATE] and collected 04/02/2014. In an interview on 04/11/2014 at 1:50 PM the Lab Manager stated the procedure for notifying the facility was to call the nurse in charge of the resident and communicate the results of lab values with panic levels and fax the results of other labs. The Lab Manager stated that on 04/02/2014 the Lab tech "tried to call and notify the facility of lab values for ten minutes and could not get a hold of anyone." The Lab Manager stated that then the system used to fax the results was tried by sending notifications five times and failed, then tried five more times and failed. The Lab Manager stated that a note was placed on the lab results: Could not contact nurse for critical lab value. Labs are available via the Lab's website online . Review of the Lab Summary with a draw date of 4/2/14 and results delivery date of 4/11/14 reflected "Critical Value, Please call the lab as soon as possible to confirm you have received CRITICAL VALUES" and evidence of initialed by lab tech. In an interview on 04/11/2014 at 2:00 PM the Administrator stated she knew the facility had just identified and pulled off the computer the critical lab values on Resident #1. After attempt to contact the Physician in charge of Resident #1's care was unsuccessful, an interview was conducted with the Physician's Staff LVN on 04/11/2014 at 2:10 PM. The Physician's Staff LVN stated the physician was gone for the day. The Physician's Staff LVN stated the Physician was notified today of Resident #1's critical lab values of Hgb and Hct and orders received to transfer Resident #1 to the ER (emergency room ) for evaluation. The Physician's Staff LVN stated they would expect the facility to call the office immediately with critical lab results. The Physician's Staff LVN stated the office did experience the same phone issues on 04/02/2014 but expected the facility to call on 04/03/2014 with the results of any lab reports, especially critical labs. In a phone interview on 04/14/2014 at 9:40 AM Resident #1's Responsible Party (RP), which was the Guardian, stated Resident #1 was admitted to the hospital with [REDACTED]. Symptoms of [MEDICAL CONDITION] can include: fast heart beat; shortness of breath; trouble breathing when doing ADLs; dizziness; chest pain; swelling in the hands and/or feet; pale skin, nail beds, mouth and gums; and extreme tiredness or fatigue) and the RP was called by the hospital for permission to give Resident #1 a blood transfusion. The RP stated Resident #1 received four units of blood. Review of the facility's Lab Tracking Policy dated September 2003 reflected "Once the lab is drawn, the phlebotomist will initial the Laboratory Log form with the date drawn. Upon return of lab results, MD will be notified, lab results will be placed in medical records and results documented on nursing notes and CP (care plan) as indicated. The Laboratory Lob will be initialed with date reported, facilitating completion of the lab work. Periodic random audits of the Laboratory Log by the Charge Nurse will ensure timely results are obtained and followed up to the MD." The facility Administrator was notified on 04/11/2014 at 12:15 PM that an IJ situation had been identified due to above failures. The first Plan of Removal (POR) was submitted by the Administrator on 04/11/2014 at 2:20 PM. The following POR was accepted by the Survey Team and Program Manager on 04/11/2014 at 5:15 PM: (The Nursing Home) Plan of Removal (POR) for Immediate Jeopardy (IJ) on 04/11/2014 Related to Failure to Obtain Labs in a Timely manner and Failure to Notify Physicians in a Timely Manner 1. Resident #1 was sent to the emergency room (ER) on 04/11/2014 as the result of a critical lab which had been drawn on 04/02/2014. Resident #1's Physician had been contacted immediately upon receipt on the lab results on 04/11/2014. As per protocol with ProLab, the facility is notified via telephone and fax of critical labs, however, on 04/02/2014, the phone system to most of the city of (the town) and the Physician's location of (the town) had been disabled due to an 18-wheeler accident. (The lab company's) policy was to stop notification attempts after 6 hours. No follow-up by the facility occurred until 04/11/2014. 2. All residents with scheduled labs have the potential to be harmed when lab results are not obtained in a timely manner. 3. On April 11, 2014, Nursing Administration audited lab orders written April 1st thru current to lab results to ensure follow-up of labs where indicated and Physician notification. 4. As of 04/11/2014 at 2:00 PM, licensed nurses have been and will continue to be in-serviced by Nursing Administration on the process of ensuring the timely disposition of labs and Physician notification. Utilizing the (lab company name) Log Sheet, the DON or designee will review labs that had been drawn within the previous 24 hour period. As lab results are returned, licensed nursing staff will initial the lab's return, and results will be communicated to the Physician. 5. New procedure developed on 04/11/2014: Prior to the DON or designee leaving for the day, she will review the (the lab company's) Log Sheet and any labs from the previous day. Those that have not had results returned will be followed-up on and have their status determined. 6. In the remote circumstance (the lab company) is unable to notify the facility of a critical lab within a 6 hour time frame, the lab results will be forwarded to (the facility's lab) account manager who will continue to attempt to notify until successful. (The lab company) has been provided with the DON and Administrator's personal cell phone numbers. The Survey team monitored the current POR as follows: The Administrative Nursing staff reviewed the Lab Log Sheet from 04/01/2014 through 04/11/2014. The Administrative Nursing staff checked each resident that was on the log to verify that the lab results were sent to the facility, to the Physician, and if any orders were written. The Administrative Nursing staff then reviewed the orders to make sure they were carried out and checked to make sure that the residents or families were notified. The Administrative Nursing staff in-serviced the Charge Nurses on the Lab Monitoring Procedures as outlined in the POR. On 04/11/2014 the Survey Team monitored three (3) residents from the Lab Log Sheet to ensure the lab results were in the facility, that the Physician was notified, that any orders written were carried out, and that the families were notified. The Survey Team found no failures. The Survey Team interviewed two (2) LVNs and one (1) RN about the lab policy and procedures and the in-service. All three (3) nurses knew about the new policies and procedures on lab work for all residents. The IJ was lifted on 04/11/2014 at 7:10 PM at exit. On 04/11/2014 at 7:10 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a Severity of Actual Harm that is not IJ with a Scope identified as Widespread due to the facility's need to evaluate the effectiveness of the corrective systems. Non Immediate Jeopardy Findings include: B) Review of Resident #5's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's Significant Change (SC) MDS dated [DATE] reflected Resident #5 had a BIMS score of 10 indicating Resident #5 had moderate cognitive impairment. Resident #5 was coded as Limited Assistance of one staff with eating and drinking. Review of the 5-day and a Quarterly MDS dated [DATE] and 02/03/2014 reflected Resident #5 had a BIMS score of 10 indicating Resident #5 had moderate cognitive impairment. Both MDSs reflected Resident #5 needed supervision (oversight, encouragement, or cueing) with setup help only for eating and drinking. Review of Resident #5's Comprehensive Care Plan dated 02/25/2014 reflected Resident #5 was to be served a pureed diet with nectar thickened liquids. The Care Plan reflected under Approaches "...will be served diet as ordered...staff will monitor my intake". Review of the Care Plan dated 03/05/2014 for Resident #5 reflected under Approaches "Provide the resident daily assistance with ADLs..with meals..." Review of the Facsimile dated 01/27/2014 at 10:45 AM reflected the Treatment Nurse notified the Medical Director that Resident #5 "spilled coffee few days ago on self. Assessed 9.0 X 4.0 centimeter peeling, red, non-painful skin left abdomen and 8.0 X 3.0 centimeter red, enclosed skin (blister) to right abdomen. 1.0 X 8.0 centimeter enclosed fluid blisters with inner open blister to left upper anterior thigh. Will treat with normal saline, hydrogel and dressing every one to three days." Review of the Incident Reports and Log for the month of January 2014 and February 2014 reflected no record of the report of the incident of the coffee burn to Resident #5. In an interview on 04/11/2014 at 8:50 AM the DON stated, "I didn't even know about the burn. I never knew there was a burn." In an interview on 04/11/2014 at 9:00 AM the Treatment Nurse stated, "I saw blisters so I started asking questions. When I came in I said here's a problem so let's take care of it. I can't remember who told me. Someone told me it was a coffee burn. The blisters were on her lower abdomen and thighs." The Treatment Nurse stated she did not witness an incident, she just found the blisters. Review of the Physician Telephone Order dated 01/27/2014 at 4:00 PM reflected an order to cleanse left abdomen red area with normal saline, pat dry with gauze, apply hydrogel, cover with gauze pad, secure with tape every one (1) to three (3) days. Cleanse Right abdomen red area with normal saline, pat dry with gauze, apply hydrogel, cover with gauze pad, secure with tape every one (1) to three (3) days. Cleanse Left upper anterior thigh open blister with normal saline, pat dry with gauze, apply hydrogel, cover with gauze pad, secure with tape every one (1) to here (3) days. In an interview on 04/11/14 at 3:00 PM with the DON and ADON, the DON stated that when an incident occurred the charge nurse should write an incident report. The DON further stated the incident reports were reviewed in the morning by the ADON and all the staff who attend the morning meeting, including all the department heads. The ADON stated, "I make sure everyone is notified and we close it out. 72 hour monitoring and charting for 72 hours to make sure there are no delayed injuries. We talk to nurses and CNAs to find out what happened. We all do." In an interview on 04/12/2014 at 9:00 AM the Administrator was informed Resident #5 had a burn in January 2014 and there was no incident report of the event. The Administrator stated, "Well, I'll tell you that's news to me. I never heard about that before." The Surveyor informed the Administrator that the DON and the ADON were informed of the event on the morning of 04/11/2014 and had performed a full chart review and found one nurse note regarding the care of Resident #5 and the burn. In an interview on 04/12/2014 at 12:10 PM the Administrator returned to the surveyor team and stated, "I can't find anything else, it is what it is." In an interview on 04/12/2014 at 2:05 PM CNA K stated, "I witnessed her (Resident #5) in the dining room. We (CNA K and another CNA) went in to start serving and we said, 'what is that on her clothes?', and we discovered it was the thickened liquid coffee. CNA K stated that in the mornings the Social Worker was in the dining room getting them coffee. "She (Resident #5) was coming out of the dining room and I (CNA K) just saw it on her clothes. I would like to say (the other CNA) reported it." In an interview on 04/12/2014 at 2:15 PM the Social Worker stated he was unaware of the situation with Resident #5. The Social Worker stated he would not serve a dependent resident who cannot handle the coffee cup hot coffee. In an interview on 04/29/2014 at 1:03 PM LVN E stated she found Resident #5 holding a coffee cup turned sideways in her lap. LVN E stated that at the time of this incident Resident #5 was able to hold her own cup to drink. LVN E stated she propelled Resident #5 in her wheelchair into her room and assessed the area on her abdomen and thighs that was covered in dark colored liquid, "where the brief covers", and found no redness or blisters. LVN E stated she did not fill out an incident report and did not report this incident to the Administrator or DON. Attempted an interview with Resident #5 on 04/29/2014 at 1:15 PM. Resident #5 was unable to state or remember the possible coffee spill and of any skin issues. Observation on 04/29/2014 at 1:15 PM revealed Resident #5 lying in her bed. Resident #5 allowed the DON and this surveyor to assess her skin. Resident #5 had an old scarred area (area was slightly darker in color than the surrounding skin) to the top of her left thigh just below the brief that was approximately 1.5 cm x 5 cm. Resident #5 had approximately 1 cm of a lighter skin colored circle within the above scarred area on the inner most side of the scarring. The facility provided a CMS form 672 that reflected a census of 81 residents.

Based on observation, interview, and record review the facility failed to be responsible for the timeliness of the laboratory services for two (2) of 14 residents (Resident #1 and #4) reviewed for lab results when: A) Resident #1's Hemoglobin (Hgb) and Hematocrit (Hct) lab test ordered on [DATE] that was drawn on 04/02/2014 included critical lab values and the results of the lab test were not accessed by the facility until 04/11/2014 even though the results were available on 04/03/14. As a result, the physician immediately sent Resident #1 to the Hospital after he was notified of the critical results on 04/11/14. Resident #1 received four (4) units of blood at the hospital due to the critically low Hgb and Hct lab values. An Immediate Jeopardy (IJ) was identified on 04/11/2014. While the IJ was removed on 04/11/2014 at exit, the facility remained out of compliance at a Severity level of Actual Harm that is not IJ with a Scope identified as Isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could have affected 81 residents by delaying changes in the course of medical treatment for [REDACTED]. Non Immediate Jeopardy B) Resident #4 had a physician order [REDACTED]. Resident #4's labs were drawn on 02/27/2014. The facility failed to ensure Resident #4's lab results were communicated to Resident #4's physician. This deficient practice placed 81 residents at risk for delayed changes in the course of medical treatment and evaluation of residents health status for each resident with routine lab results. Findings Include: A) Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].#1 had her gallbaladder removed on 02/20/2014), Hypertension, Intellect Disability, [MEDICAL CONDITION] Arthritis, and [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] reflected Resident #1 had a BIMS score of three (3) which indicated the Resident had severe cognitive impairment. The MDS reflected Resident #1 was a one person assist with all activities of daily living. Review of the Comprehensive Care Plan dated 03/26/2014 for Resident #1 reflected a Problem/Need as "Resident requires a PEG (Percutaneous Endoscopic Gastrostomy) tube for adequate nutritional intake". The Care Plan reflected under Goal "Resident will maintain current weight" and "Resident will not experience adverse effects from placement of a PEG tube". The Care Plan also reflected under Approaches "all meds per tube; Dietician to evaluate resident's current nutritional status; Weigh resident monthly; Resident will not experience adverse effects from placement of a PEG tube; Refer resident to speech therapy for swallowing evaluation as needed; Maintain resident in an upright position during feeding HOB (head of bed) at 30 degrees; Site care of resident's G tube daily or as ordered; Check resident G tube placement before initiating feeding; Monitor for changes that may indicate worsening of resident's condition and notify the physician as indicated." Observation on 04/11/2014 at 9:30 AM of an ambulance stretcher with Resident #1 on board. Resident #1 was pale in color. In an interview on 04/11/2014 at 9:30 AM LVN A stated Resident #1 was being transferred to the emergency room due to a critical lab results the facility did not get because there was a "glitch" in their phone system on 4/2/2014 when the lab was drawn and the DON discovered it on 04/11/2014. In an interview on 04/11/2014 at 9:40 AM the DON stated she found out today, 4/11/2014 when she was completing her weekly lab audit that Resident #1 had critical lab values: Hgb was 5.9 and Hct was 18.5 (Hgb--a compound in the blood that carries oxygen to the cells from the lungs. Normal concentration of hemoglobin is 12-15.6 in women and Hct--the proportion of your total blood volume that is composed of red blood cells. Red blood cells transport oxygen throughout your body. The normal range is 35.0-46.0) . The DON stated the charge nurse was supposed to check labs drawn daily and place the results on the charts. The DON stated that on 04/02/2014 when the labs were drawn, the facility experienced their phone system to go down, along with the physician offices. The DON stated the facility did not receive any faxes from the lab company. The DON stated she normally followed up every Friday for labs drawn that week but on 04/04/2014 she "did not check the labs" and "if I had it would have been caught". The DON stated she notified the physician today, 04/11/2014, and "he was mad" about not being notified. The DON stated "now the system has to be re-vamped" and that Resident #1 was being sent out to the ER. Review of the Lab Report dated 04/02/2014 reflected HGB 5.9 critical and HCT 18.5 critical. The Report's reference range-normal was HGB: 12.0-15.6 and HCT normal range was 35.0-46.0. The Report reflected a notation on the lab report sheet "(Physician) notified of the critical level Hgb and Hct by the DON at 8:40 AM 04/11/2014. Review of the Nurses' Notes dated 04/11/2014 reflected Resident #1 complained of abdominal pain at 8:00 AM and was medicated with [MEDICATION NAME] 10/325 mg (an [MEDICATION NAME] given for pain). Review of the Departmental Notes dated 03/26/2014 from Dietary for Resident #1 reflected "Resident returned from PEG placement, needs orders for tube feeding...Check CMP (Comprehensive Metabolic Panel) in 1 (one) week." Review of Dietician Recommendations Record dated 03/26/2014 reflected the dietician recommended a CMP lab work be done in one week if not already ordered and the physician responded "yes do it" and added a CBC. Review of ProLab Log Sheet dated 04/02/2014 reflected a CBC and CMP were drawn for Resident #1. The Sheet was initialed by the phlebotomist but the column for the nurse to initial blood drawn and results received were blank. In an interview on 04/11/2014 at 11:50 AM CNA H stated, when asked how Resident #1 had been feeling this week, Resident #1 seemed to be weak in her legs and did not want to get out of bed except when she had an appointment this week to see the physician. CNA H stated she agreed to get up into the wheelchair. In an interview on 04/11/2014 at 11:55 AM CNA I stated Resident #1 did not like to get out of bed much these days, Resident #1 "just wants to watch TV and stay in bed." In an interview on 04/11/2014 at 12:00 PM LVN A stated she as a charge nurse was supposed to check labs drawn by checking the fax machine in the medication room and the fax machine in the Administrator's office for labs in general. LVN A stated she did not know when a specific lab was due or when it should be reported. LVN A stated "I guess I screwed up, I signed the form to collect the blood for the CMP and CBC." Review of the Lab Request Form dated 04/02/2014 reflected a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel) was ordered on [DATE] and collected 04/02/2014. In an interview on 04/11/2014 at 1:50 PM the Lab Manager stated the procedure for notifying the facility was to call the nurse in charge of the resident and communicate the results of lab values with panic levels and fax the results of other labs. The Lab Manager stated that on 04/02/2014 the Lab tech "tried to call and notify the facility of lab values for ten minutes and could not get a hold of anyone." The Lab Manager stated that then the system used to fax the results was tried by sending notifications five times and failed, then tried five more times and failed. The Lab Manager stated that a note was placed on the lab results: Could not contact nurse for critical lab value. Labs are available via the Lab's website online . Review of the Lab Summary with a draw date of 4/2/14 and results delivery date of 4/11/14 reflected "Critical Value, Please call the lab as soon as possible to confirm you have received CRITICAL VALUES" and evidence of initialed by lab tech. In an interview on 04/11/2014 at 2:00 PM the Administrator stated she knew the facility had just identified and pulled off the computer the critical lab values on Resident #1. After attempt to contact the Physician in charge of Resident #1's care was unsuccessful, an interview was conducted with the Physician's Staff LVN on 04/11/2014 at 2:10 PM. The Physician's Staff LVN stated the physician was gone for the day. The Physician's Staff LVN stated the Physician was notified today of Resident #1's critical lab values of Hgb and Hct and orders received to transfer Resident #1 to the ER (emergency room ) for evaluation. The Physician's Staff LVN stated they would expect the facility to call the office immediately with critical lab results. The Physician's Staff LVN stated the office did experience the same phone issues on 04/02/2014 but expected the facility to call on 04/03/2014 with the results of any lab reports, especially critical labs. In a phone interview on 04/14/2014 at 9:40 AM Resident #1's Responsible Party (RP), which was the Guardian, stated Resident #1 was admitted to the hospital with [REDACTED]. Symptoms of [MEDICAL CONDITION] can include: fast heart beat; shortness of breath; trouble breathing when doing ADLs; dizziness; chest pain; swelling in the hands and/or feet; pale skin, nail beds, mouth and gums; and extreme tiredness or fatigue) and the RP was called by the hospital for permission to give Resident #1 a blood transfusion. The RP stated Resident #1 received four units of blood. Review of the facility's Lab Tracking Policy dated September 2003 reflected "Once the lab is drawn, the phlebotomist will initial the Laboratory Log form with the date drawn. Upon return of lab results, MD will be notified, lab results will be placed in medical records and results documented on nursing notes and CP (care plan) as indicated. The Laboratory Lob will be initialed with date reported, facilitating completion of the lab work. Periodic random audits of the Laboratory Log by the Charge Nurse will ensure timely results are obtained and followed up to the MD." The facility Administrator was notified on 04/11/2014 at 12:15 PM that an IJ situation had been identified due to above failures. The first Plan of Removal (POR) was submitted by the Administrator on 04/11/2014 at 2:20 PM. The following POR was accepted by the Survey Team and Program Manager on 04/11/2014 at 5:15 PM: (The Nursing Home) Plan of Removal (POR) for Immediate Jeopardy (IJ) on 04/11/2014 Related to Failure to Obtain Labs in a Timely manner and Failure to Notify Physician's in a Timely Manner 1. Resident #1 was sent to the emergency room (ER) on 04/11/2014 as the result of a critical lab which had been drawn on 04/02/2014. Resident #1's Physician had been contacted immediately upon receipt on the lab results on 04/11/2014. As per protocol with ProLab, the facility is notified via telephone and fax of critical labs, however, on 04/02/2014, the phone system to most of the city of (the town) and the Physician's location of (the town) had been disabled due to an 18-wheeler accident. (The lab company's) policy was to stop notification attempts after 6 hours. No follow-up by the facility occurred until 04/11/2014. 2. All residents with scheduled labs have the potential to be harmed when lab results are not obtained in a timely manner. 3. On April 11, 2014, Nursing Administration audited lab orders written April 1st thru current to lab results to ensure follow-up of labs where indicated and Physician notification. 4. As of 04/11/2014 at 2:00 PM, licensed nurses have been and will continue to be in-serviced by Nursing Administration on the process of ensuring the timely disposition of labs and Physician notification. Utilizing the (lab company name) Log Sheet, the DON or designee will review labs that had been drawn within the previous 24 hour period. As lab results are returned, licensed nursing staff will initial the lab's return, and results will be communicated to the Physician. 5. New procedure developed on 04/11/2014: Prior to the DON or designee leaving for the day, she will review the (the lab company's) Log Sheet and any labs from the previous day. Those that have not had results returned will be followed-up on and have their status determined. 6. In the remote circumstance (the lab company) is unable to notify the facility of a critical lab within a 6 hour time frame, the lab results will be forwarded to (the facility's lab) account manager who will continue to attempt to notify until successful. (The lab company) has been provided with the DON and Administrator's personal cell phone numbers. The Survey team monitored the current POR as follows: The Administrative Nursing staff reviewed the Lab Log Sheet from 04/01/2014 through 04/11/2014. The Administrative Nursing staff checked each resident that was on the log to verify that the lab results were sent to the facility, to the Physician, and if any orders were written. The Administrative Nursing staff then reviewed the orders to make sure they were carried out and checked to make sure that the residents or families were notified. The Administrative Nursing staff in-serviced the Charge Nurses on the Lab Monitoring Procedures as outlined in the POR. On 04/11/2014 the Survey Team monitored three (3) residents from the Lab Log Sheet to ensure the lab results were in the facility, that the Physician was notified, that any orders written were carried out, and that the families were notified. The Survey Team found no failures. The Survey Team interviewed two (2) LVNs and one (1) RN about the lab policy and procedures and the in-service. All three (3) nurses knew about the new policies and procedures on lab work for all residents. The IJ was lifted on 04/11/2014 at 7:10 PM at exit. On 04/11/2014 at 7:10 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a Severity of Actual Harm that is not IJ with a Scope identified as Isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Non Immediate Jeopardy Findings include: B) Review of Resident #4's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] reflected Resident #4 had a BIMS score of 12 indicating Resident #4 had moderate cognitive impairment. Resident #4 was coded to require extensive assist with all ADL ' s. Resident #4 was coded to be incontinent of bowel and bladder. Resident #4 was coded to have pressure ulcers and venous ulcers. Resident #4 was coded to be on anticoagulant and diuretic medication. Review of Resident #4's Comprehensive Care Plan dated 01/29/2014 reflected "Problem: Resident has a history of [MEDICAL CONDITION] and is at risk for chest pains and irregular pulse due to having hypertension." Under approaches: "CBC as ordered." Observation on 04/09/2014 at 2:46 PM revealed Resident #4 in bed. Resident #4 was alert and able to communicate with surveyor. Resident #4 had a [DEVICE] attached to both her heels. Review of Resident #4's Physician Telephone orders dated 12/26/2013 reflected an order for [REDACTED].), Ferritin ( blood test is a test that measures the amount of iron stored in the body.), Folate (Testing the folate level, which is also known as folic acid and vitamin B9, is primarily used in the [DIAGNOSES REDACTED].), Lipid Profile ( is a panel of blood tests that serves as an initial broad medical screening tool for abnormalities in lipids, such as cholesterol and triglycerides.), Magnesium (checks the level of magnesium in the blood. Magnesium is an important electrolyte needed for proper muscle, nerve, and enzyme function. It also helps the body use energy and is needed to move other electrolytes (potassium and sodium) into and out of cells.), Vitamin B12 (measures the amount of B12 in your blood. B12 is an important vitamin for many basic bodily functions, such as brain health, blood cell production, and proper nerve functioning. Low B12 levels can lead to serious nerve damage and deteriorating brain functions.), Complete Blood Count ( gives important information about the kinds and numbers of cells in the blood, especially red blood cells,white blood cells and platelets. A CBC helps your doctor check any symptoms, such as weakness, fatigue, or bruising, you may have. A CBC also helps him or her diagnose conditions, such as [MEDICAL CONDITION], infection, and many other disorders.) every six (6) months. Review of Resident #4's Medical Record on 04/10/2014 reflected a CBC and a Vitamin B12 level in the chart with Resident #4's Physician signature. No other lab reports were noted. In an interview on 04/10/2014 at 10:00 AM the DON stated she would see if she could locate the missing lab reports ordered for Resident #4. Observation on 04/10/2014 at 2:30 PM revealed the DON handed the surveyor multiple labs for Resident #4. Review of Resident #4's Lab Results reflected a CMP, Ferritin, Folate, Iron and TIBC, Lipid Profile, and a Magnesium level completed on 02/28/2014. Printed on top of the lab reports was a date of 04/10/2014 at 10:57 AM as the time of delivery to the facility. The labs were not signed by a physician. The lab reports contained multiple results that were not within normal limits. In an interview on 04/10/2014 at 3:16 AM the DON stated she did not know what happen with Resident #4's labs. She stated she got the lab off the Lab's website because they were not at the facility. The DON stated the lab reports were not sent to the physician. The DON stated the nursing staff should ensure lab reports are received from the lab and the results faxed to the physician and check to ensure the labs are returned from the physician and note orders if any are given by the physician. Review of the facility's Lab Tracking Policy dated September 2013 reflected upon return of lab results, MD will be notified, lab results will be placed in medical records and the results are documented on the nursing notes. Periodic random audits of the Laboratory Log by the charge nurse will ensure timely results are obtained. The facility provided a CMS form 672 that reflected a census of 81 residents.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for one (1) of 14 residents (Resident #1) reviewed for lab results when: Resident #1's Hemoglobin (Hgb) and Hematocrit (Hct) lab test ordered on [DATE] that was drawn on 04/02/2014 included critical lab values and the results of the lab test were not accessed by the facility until 04/11/2014 even though the results were available on 04/03/14. As a result, the physician immediately sent Resident #1 to the Hospital after he was notified of the critical results on 04/11/14. Resident #1 received four (4) units of blood at the hospital due to the critically low Hgb and Hct lab values. An Immediate Jeopardy (IJ) was identified on 04/11/2014. While the IJ was removed on 04/11/2014 at exit, the facility remained out of compliance at a Severity level of Potential for More Than Minimal Harm that is not IJ with a Scope identified as Isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed 81 residents at risk of delayed changes in the course of medical treatment for [REDACTED]. Findings Include: Review of Resident #1's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].#1 had her gallbaladder removed on 02/20/2014), Hypertension, Intellect Disability, [MEDICAL CONDITION] Arthritis, and [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] reflected Resident #1 had a BIMS score of three (3) which indicated the Resident had severe cognitive impairment. The MDS reflected Resident #1 was a one person assist with all activities of daily living. Review of the Comprehensive Care Plan dated 03/26/2014 for Resident #1 reflected a Problem/Need as "Resident requires a PEG (Percutaneous Endoscopic Gastrostomy) tube for adequate nutritional intake". The Care Plan reflected under Goal "Resident will maintain current weight" and "Resident will not experience adverse effects from placement of a PEG tube". The Care Plan also reflected under Approaches "all meds per tube; Dietician to evaluate resident's current nutritional status; Weigh resident monthly; Resident will not experience adverse effects from placement of a PEG tube; Refer resident to speech therapy for swallowing evaluation as needed; Maintain resident in an upright position during feeding HOB (head of bed) at 30 degrees; Site care of resident's G tube daily or as ordered; Check resident G tube placement before initiating feeding; Monitor for changes that may indicate worsening of resident's condition and notify the physician as indicated." Observation on 04/11/2014 at 9:30 AM of an ambulance stretcher with Resident #1 on board. Resident #1 was pale in color. In an interview on 04/11/2014 at 9:30 AM LVN A stated Resident #1 was being transferred to the emergency room due to a critical lab results the facility did not get because there was a "glitch" in their phone system on 4/2/2014 when the lab was drawn and the DON discovered it on 04/11/2014. In an interview on 04/11/2014 at 9:40 AM the DON stated she found out today, 4/11/2014 when she was completing her weekly lab audit that Resident #1 had critical lab values: Hgb was 5.9 and Hct was 18.5 (Hgb--a compound in the blood that carries oxygen to the cells from the lungs. Normal concentration of hemoglobin is 12-15.6 in women and Hct--the proportion of your total blood volume that is composed of red blood cells. Red blood cells transport oxygen throughout your body. The normal range is 35.0-46.0) . The DON stated the charge nurse was supposed to check labs drawn daily and place the results on the charts. The DON stated that on 04/02/2014 when the labs were drawn, the facility experienced their phone system to go down, along with the physician offices. The DON stated the facility did not receive any faxes from the lab company. The DON stated she normally followed up every Friday for labs drawn that week but on 04/04/2014 she "did not check the labs" and "if I had it would have been caught". The DON stated she notified the physician today, 04/11/2014, and "he was mad" about not being notified. The DON stated "now the system has to be re-vamped" and that Resident #1 was being sent out to the ER. Review of the Lab Report dated 04/02/2014 reflected HGB 5.9 critical and HCT 18.5 critical. The Report's reference range-normal was HGB: 12.0-15.6 and HCT normal range was 35.0-46.0. The Report reflected a notation on the lab report sheet "(Physician) notified of the critical level Hgb and Hct by the DON at 8:40 AM 04/11/2014. Review of the Nurses' Notes dated 04/11/2014 reflected Resident #1 complained of abdominal pain at 8:00 AM and was medicated with [MEDICATION NAME] 10/325 mg (an [MEDICATION NAME] given for pain). Review of the Departmental Notes dated 03/26/2014 from Dietary for Resident #1 reflected "Resident returned from PEG placement, needs orders for tube feeding...Check CMP (Comprehensive Metabolic Panel) in 1 (one) week." Review of Dietician Recommendations Record dated 03/26/2014 reflected the dietician recommended a CMP lab work be done in one week if not already ordered and the physician responded "yes do it" and added a CBC. Review of ProLab Log Sheet dated 04/02/2014 reflected a CBC and CMP were drawn for Resident #1. The Sheet was initialed by the phlebotomist but the column for the nurse to initial blood drawn and results received were blank. In an interview on 04/11/2014 at 11:50 AM CNA H stated, when asked how Resident #1 had been feeling this week, Resident #1 seemed to be weak in her legs and did not want to get out of bed except when she had an appointment this week to see the physician. CNA H stated she agreed to get up into the wheelchair. In an interview on 04/11/2014 at 11:55 AM CNA I stated Resident #1 did not like to get out of bed much these days, Resident #1 "just wants to watch TV and stay in bed." In an interview on 04/11/2014 at 12:00 PM LVN A stated she as a charge nurse was supposed to check labs drawn by checking the fax machine in the medication room and the fax machine in the Administrator's office for labs in general. LVN A stated she did not know when a specific lab was due or when it should be reported. LVN A stated "I guess I screwed up, I signed the form to collect the blood for the CMP and CBC." Review of the Lab Request Form dated 04/02/2014 reflected a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel) was ordered on [DATE] and collected 04/02/2014. In an interview on 04/11/2014 at 1:50 PM the Lab Manager stated the procedure for notifying the facility was to call the nurse in charge of the resident and communicate the results of lab values with panic levels and fax the results of other labs. The Lab Manager stated that on 04/02/2014 the Lab tech "tried to call and notify the facility of lab values for ten minutes and could not get a hold of anyone." The Lab Manager stated that then the system used to fax the results was tried by sending notifications five times and failed, then tried five more times and failed. The Lab Manager stated that a note was placed on the lab results: Could not contact nurse for critical lab value. Labs are available via the Lab's website online . Review of the Lab Summary with a draw date of 4/2/14 and results delivery date of 4/11/14 reflected "Critical Value, Please call the lab as soon as possible to confirm you have received CRITICAL VALUES" and evidence of initialed by lab tech. In an interview on 04/11/2014 at 2:00 PM the Administrator stated she knew the facility had just identified and pulled off the computer the critical lab values on Resident #1. After attempt to contact the Physician in charge of Resident #1's care was unsuccessful, an interview was conducted with the Physician's Staff LVN on 04/11/2014 at 2:10 PM. The Physician's Staff LVN stated the physician was gone for the day. The Physician's Staff LVN stated the Physician was notified today of Resident #1's critical lab values of Hgb and Hct and orders received to transfer Resident #1 to the ER (emergency room ) for evaluation. The Physician's Staff LVN stated they would expect the facility to call the office immediately with critical lab results. The Physician's Staff LVN stated the office did experience the same phone issues on 04/02/2014 but expected the facility to call on 04/03/2014 with the results of any lab reports, especially critical labs. In a phone interview on 04/14/2014 at 9:40 AM Resident #1's Responsible Party (RP), which was the Guardian, stated Resident #1 was admitted to the hospital with [REDACTED]. Symptoms of [MEDICAL CONDITION] can include: fast heart beat; shortness of breath; trouble breathing when doing ADLs; dizziness; chest pain; swelling in the hands and/or feet; pale skin, nail beds, mouth and gums; and extreme tiredness or fatigue) and the RP was called by the hospital for permission to give Resident #1 a blood transfusion. The RP stated Resident #1 received four units of blood. Review of the facility's Lab Tracking Policy dated September 2003 reflected "Once the lab is drawn, the phlebotomist will initial the Laboratory Log form with the date drawn. Upon return of lab results, MD will be notified, lab results will be placed in medical records and results documented on nursing notes and CP (care plan) as indicated. The Laboratory Lob will be initialed with date reported, facilitating completion of the lab work. Periodic random audits of the Laboratory Log by the Charge Nurse will ensure timely results are obtained and followed up to the MD." Review of facility's Abuse and Neglect Policy dated 10/30/2014 reflected the facility will follow the resident's right to be free from neglect and the physician will be notified of findings. The facility Administrator was notified on 04/11/2014 at 12:15 PM that an IJ situation had been identified due to above failures. The first Plan of Removal (POR) was submitted by the Administrator on 04/11/2014 at 2:20 PM. The following POR was accepted by the Survey Team and Program Manager on 04/11/2014 at 5:15 PM: (The Nursing Home) Plan of Removal (POR) for Immediate Jeopardy (IJ) on 04/11/2014 Related to Failure to Obtain Labs in a Timely manner and Failure to Notify Physicians in a Timely Manner 1. Resident #1 was sent to the emergency room (ER) on 04/11/2014 as the result of a critical lab which had been drawn on 04/02/2014. Resident #1's Physician had been contacted immediately upon receipt on the lab results on 04/11/2014. As per protocol with ProLab, the facility is notified via telephone and fax of critical labs, however, on 04/02/2014, the phone system to most of the city of (the town) and the Physician's location of (the town) had been disabled due to an 18-wheeler accident. (The lab company's) policy was to stop notification attempts after 6 hours. No follow-up by the facility occurred until 04/11/2014. 2. All residents with scheduled labs have the potential to be harmed when lab results are not obtained in a timely manner. 3. On April 11, 2014, Nursing Administration audited lab orders written April 1st thru current to lab results to ensure follow-up of labs where indicated and Physician notification. 4. As of 04/11/2014 at 2:00 PM, licensed nurses have been and will continue to be in-serviced by Nursing Administration on the process of ensuring the timely disposition of labs and Physician notification. Utilizing the (lab company name) Log Sheet, the DON or designee will review labs that had been drawn within the previous 24 hour period. As lab results are returned, licensed nursing staff will initial the lab's return, and results will be communicated to the Physician. 5. New procedure developed on 04/11/2014: Prior to the DON or designee leaving for the day, she will review the (the lab company's) Log Sheet and any labs from the previous day. Those that have not had results returned will be followed-up on and have their status determined. 6. In the remote circumstance (the lab company) is unable to notify the facility of a critical lab within a 6 hour time frame, the lab results will be forwarded to (the facility's lab) account manager who will continue to attempt to notify until successful. (The lab company) has been provided with the DON and Administrator's personal cell phone numbers. The Survey team monitored the current POR as follows: The Administrative Nursing staff reviewed the Lab Log Sheet from 04/01/2014 through 04/11/2014. The Administrative Nursing staff checked each resident that was on the log to verify that the lab results were sent to the facility, to the Physician, and if any orders were written. The Administrative Nursing staff then reviewed the orders to make sure they were carried out and checked to make sure that the residents or families were notified. The Administrative Nursing staff in-serviced the Charge Nurses on the Lab Monitoring Procedures as outlined in the POR. On 04/11/2014 the Survey Team monitored three (3) residents from the Lab Log Sheet to ensure the lab results were in the facility, that the Physician was notified, that any orders written were carried out, and that the families were notified. The Survey Team found no failures. The Survey Team interviewed two (2) LVNs and one (1) RN about the lab policy and procedures and the in-service. All three (3) nurses knew about the new policies and procedures on lab work for all residents. The IJ was lifted on 04/11/2014 at 7:10 PM at exit. On 04/11/2014 at 7:10 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a Severity of Actual Harm that is not IJ with a Scope identified as Isolated due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided CMS Form 672 that reflected a census of 81.

Based on observation, interview and record review the facility failed to ensure 1 of 4 residents reviewed for pain (Resident # 8) received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordence with the comprehensive assessment and plan of care. Resident # 8's experienced severe abdominal pain on 01/17/2013. X-Ray results dated 01/16/2013 were received by the facility on 01/17/2013 and noted an 8.7 centimeter (cm) fecal impaction (a large lump of dry, hard stool that remains stuck in the rectum.) Licensed Vocational Nurse (LVN) E failed to read the complete report and did not notify Resident # 8's physician of the abdominal pain. The facility failed to monitor the resident's pain and provide care and services to Resident #8 This deficient practice placed one resident, who had a fecal impaction, at risk for unresolved pain that caused a decline in physical, mental and psychosocial condition. Findings include: Review of Resident # 8's Face Sheet reflected a [AGE] year old female who entered the facility on 06/30/2006 and was readmitted on [DATE]. Resident # 8's [DIAGNOSES REDACTED]. Observation made on 01/22/2013 at 11:00 AM revealed Resident # 8 sitting in the lobby in her wheel chair visiting with a family member. In an interview on 01/24/2013 at 9:30 AM Resident # 8 stated she did remember the abdominal pain she experienced on 01/17/2013 (Thursday)and stated the pain was very bad. Resident # 8 scored her pain level at a 9 on a scale of 1 - 10. Resident # 8 stated she was embarrassed because she doubled over in pain. Resident # 8 stated she doubled over because the pain was so bad and she "couldn't hardly stand it." Resident # 8 stated she was not completely free of pain until the following Sunday after it had time "to work itself out". Resident # 8 stated she did not get an enema or exam to check for fecal impaction from any nursing staff. Review of Resident # 8's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam which reflected the Resident is moderately cognitively impaired. The assessment reflected Resident # 8 is continent of bowel and bladder without constipation. The assessment reflected Resident # 8 was not on a scheduled pain medication regimen or did not receive pain medication as needed. Review of Resident #8's Comprehensive Plan of Care dated 11/26/2012 reflected the resident had a history of [REDACTED]. Approaches included give medications per order ([MEDICATION NAME]) per order. Monitor for effectiveness and report to Medical Doctor if the resident complains of increased abdominal distress. Review of Resident # 8's X-Ray of her hip loft performed on 01/16/2012 reflected the reason for the exam as "S/P (status [REDACTED]. The results reflected no fracture however there was an "8.7 cm fecal impaction noted in the rectum." The Impression included "No acute fracture or dislocation visible. Nonspecific [MEDICAL CONDITION] change of the lumbar spine, fecal impaction in the rectum and bone island of the right aliac bone are noted as incidental findings." This report was faxed to the facility on [DATE] and to the physician on 01//18/2013 by the Imaging Department. Review of Resident # 8's Nurses Notes dated 01/17/2013 reflected the resident was "Awake, up in wheel chair for breakfast. 50% of meal accepted Oral fluids encouraged, moaning, complained of abdominal cramps. Denies need to go to bathroom. Stated "just stretch me out and it will feel better". Resident assisted back to bed at this time. Will continue to monitor." There was no additional nurses notes documenting monitoring of Resident # 8 until 01/23/2013, after the facility was made aware of the fecal impaction by the survey team. Review of Resident # 8's Physician Orders reflected the resident had the following medication prescribed for pain: 01/28/2010 - APAP (Tylenol) 500 milligrams (mg) 1 tab every 4 hours as needed (prn) for pain and temperature. 01/28/2010 - APAP 500 mg 2 tabs every 4 hours prn for pain and temperature. Review of Resident # 8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on 01/23/2013 at 5:55 PM, LVN E stated she did see Resident # 8's X-Ray results that noted no fracture but did not read the complete report therefore did not see the resident had a fecal impaction. LVN E stated she did not notify Resident # 8's physician of her abdominal pain on 01/17/2013 as it was not abnormal for Resident # 8 to suffer from constipation. LVN E stated the aides had advised her Resident # 8 was having medium bowel movements and she had documented. LVN E stated Resident # 8 had been independent in toileting prior to an accident she had but now the aides assist her with toileting, unless Resident # 8 sneeks into the bathroom by herself. LVN E stated one day last week (date unknown) the Physical Therapist (PT) had advised her Resident # 8 "had a blow out" indicating the resident had a large bowel movement. LVN E stated she documented she had a medium bowel movement because sometimes PT exaggerates. LVN E stated Resident # 8 had advised her of the severe abdominal cramps on 01/17/2012 and she had assisted her to bed but did not think she had a fecal impaction. LVN E again stated she did not read the X-Ray report fully to acknowledge Resident # 8 had a fecal impaction. In an interview on 01/24/2012 at 9:00 AM Occupational Therapist (OT) Y stated she had evaluated Resident # 8 one day last week (date unknown at this time) when she had a bowel movement. OT Y stated Resident # 8 was not eating well and did not eat much lunch at all. OT Y stated Resident # 8 complained and stated "I need to go to the bathroom". OT Y described Resident # 8's bowel movement black, formed and approximately 1 1/2 inches long. Review of OT Evaluation and Plan of Treatment dated 01/14/2012 revealed an evaluation was completed on that date but there was no mention of Resident #8's bowel movement. The evaluation did note under Pain Analysis: Does pain limit patient's functional activities? = Yes (Resident # 8 basically wants to stay in bed, unless going to the bathroom, complain of pain low back, but not consistent on location)........What alleviates the pain? lying down in bed; What makes the pain worse?: transfers and standing up on left leg. Review of the Activities of Daily Living (ADL) Flow Sheet for January, 2013 reflected Resident # 8 required more assistance with eating during the night shift beginning 01/16/2013 through 01/22/2013. From 01/16/2013 through 01/22/2013 (last date documented) Resident # 8 required supervision-oversight,encouragement or cueing with eating. The day shift did not document. The evening shift remained approximately the same. The ADL Flow sheet did not document the amount of food intake for Resident # 8. In an interview on 01/23/2013 at 6:15 PM the Director of Nurses (DON) stated the Nursing Department should read the X-ray reports as they come in and should have assessed Resident # 8 to see if she needed an enema. The DON stated it was her expectation that nurses read the x-ray reports for all residents and report severe pain to the physician. In an interview on 01/24/2013 at 12:10 PM Doctor of Osteopathic Medication (DO) B stated he reviewed the X-Ray report for Resident # 8 that was transmitted to him from the Imaging Department at the hospital. DO B stated he was not concerned about the fecal impaction as he had not been notified of any symptoms Resident # 8 was experiencing and from past history he knew the resident suffered from constipation. DO B stated he was not notified of the abdominal pain Resident # 8 was experiencing on 01/17/2013 and that information could have possibly changed his course of action for Resident # 8. Review of the facility policy regarding Physician Notification of Change in Resident Condition reflected: Policy - It is the policy of this Center to notify the physician and inform the resident and resident's responsible party of a significant change in the resident's physical, mental, psychological status including accidents and when there is a need to alter treatments significantly. Purpose - To keep the physician, resident and resident's responsible party informed of changes in the resident's condition so that timely interventions can be obtained; and To ensure the resident receives prompt medical treatment in an emergency, when indicated. Definition - "Change of Condition" related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. Procedure: 2. The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. 3. The licensed nurse will be responsible for making all notifications of changes to physicians, the resident and the resident's representative. 4. Examples of changes may include, but not limited to: Gastrointestinal problems Abnormal lab studies....... Resident sample list identified one of one residents with a fecal impaction.

Based on observation, interview and record review the facility failed to consult with a resident's physician when 1 of 4 residents (Resident #8)reviewed for pain experienced a significant change in physical condition. Resident # 8's experienced severe abdominal pain on 01/17/2013. X-Ray results dated 01/16/2013 were received by the facility on 01/17/2013 and noted an 8.7 centimeter (cm) fecal impaction (a large lump of dry, hard stool that remains stuck in the rectum.) Licensed Vocational Nurse (LVN) E failed to read the complete report and did not notify Resident # 8's physician of the abdominal pain. This deficient practice placed one resident with a fecal impaction at risk of receiving necessary care and services of their physician. Findings include: Review of Resident # 8's Face Sheet reflected a [AGE] year old female who entered the facility on 06/30/2006 and was readmitted on [DATE]. Resident # 8's [DIAGNOSES REDACTED]. Observation made on 01/22/2013 at 11:00 AM revealed Resident # 8 sitting in the lobby in her wheel chair visiting with a family member. In an interview on 01/24/2013 at 9:30 AM Resident # 8 stated she did remember the abdominal pain she experienced on 01/17/2013 (Thursday)and stated the pain was very bad. Resident # 8 scored her pain level at a 9 on a scale of 1 - 10. Resident # 8 stated she was embarrassed because she doubled over in pain. Resident # 8 stated she doubled over because the pain was so bad and she "couldn't hardly stand it." Resident # 8 stated she was not completely free of pain until the following Sunday after it had time "to work itself out". Resident # 8 stated she did not get an enema or exam to check for fecal impaction from any nursing staff. Review of Resident # 8's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected the Resident scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam which reflected the Resident is moderately cognitively impaired. The assessment reflected Resident # 8 is continent of bowel and bladder without constipation. The assessment reflected Resident # 8 was not on a scheduled pain medication regimen or did not receive pain medication as needed. Review of Resident #8's Comprehensive Plan of Care dated 11/26/2012 reflected the resident had a history of [REDACTED]. Approaches included give medications per order ([MEDICATION NAME]) per order. Monitor for effectiveness and report to Medical Doctor if the resident complains of increased abdominal distress. Review of Resident # 8's X-Ray of her hip loft performed on 01/16/2012 reflected the reason for the exam as "S/P (status [REDACTED]. The results reflected no fracture however there was an "8.7 cm fecal impaction noted in the rectum." The Impression included "No acute fracture or dislocation visible. Nonspecific [MEDICAL CONDITION] change of the lumbar spine, fecal impaction in the rectum and bone island of the right aliac bone are noted as incidental findings." This report was faxed to the facility on [DATE] and to the physician on 01//18/2013 by the Imaging Department. Review of Resident # 8's Nurses Notes dated 01/17/2013 reflected the resident was "Awake, up in wheel chair for breakfast. 50% of meal accepted Oral fluids encouraged, moaning, complained of abdominal cramps. Denies need to go to bathroom. Stated "just stretch me out and it will feel better". Resident assisted back to bed at this time. Will continue to monitor." Review of Resident # 8's Physician Orders reflected the resident had the following medication prescribed for pain: 01/28/2010 - APAP (Tylenol) 500 milligrams (mg) 1 tab every 4 hours as needed (prn) for pain and temperature. 01/28/2010 - APAP 500 mg 2 tabs every 4 hours prn for pain and temperature. Review of Resident # 8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In an interview on 01/23/2013 at 5:55 PM, LVN E stated she did see Resident # 8's X-Ray results that noted no fracture but did not read the complete report therefore did not see the resident had a fecal impaction. LVN E stated she did not notify Resident # 8's physician of her abdominal pain on 01/17/2013 as it was not abnormal for Resident # 8 to suffer from constipation. LVN E stated the aides had advised her Resident # 8 was having medium bowel movements and she had documented. LVN E stated Resident # 8 had been independent in toileting prior to an accident she had but now the aides assist her with toileting, unless Resident # 8 sneeks into the bathroom by herself. LVN E stated one day last week (date unknown) the Physical Therapist (PT) had advised her Resident # 8 "had a blow out" indicating the resident had a large bowel movement. LVN E stated she documented she had a medium bowel movement because sometimes PT exaggerates. LVN E stated Resident # 8 had advised her of the severe abdominal cramps on 01/17/2012 and she had assisted her to bed but did not think she had a fecal impaction. LVN E again stated she did not read the X-Ray report fully to acknowledge Resident # 8 had a fecal impaction. In an interview on 01/24/2012 at 9:00 AM Occupational Therapist (OT) Y stated she had evaluated Resident # 8 one day last week (date unknown at this time) when she had a bowel movement. OT Y stated Resident # 8 was not eating well and did not eat much lunch at all. OT Y stated Resident # 8 complained and stated "I need to go to the bathroom". OT Y described Resident # 8's bowel movement black, formed and approximately 1 1/2 inches long. Review of OT Evaluation and Plan of Treatment dated 01/14/2012 revealed an evaluation was completed on that date but there was no mention of Resident # 8's bowel movement. The evaluation did note under Pain Analysis: Does pain limit patient's functional activities? = Yes (Resident # 8 basically wants to stay in bed, unless going to the bathroom, complain of pain low back, but not consistent on location)........What alleviates the pain? lying down in bed; What makes the pain worse?: transfers and standing up on left leg. Review of the Activities of Daily Living (ADL) Flow Sheet for January, 2013 reflected Resident #8 required more assistance with eating during the night shift beginning 01/16/2013 through 01/22/2013. From 01/16/2013 through 01/22/2013 (last date documented) Resident #8 required supervision-oversight,encouragement or cueing with eating. The day shift did not document. The evening shift remained approximately the same. The ADL Flow sheet did not document the amount of food intake for Resident #*. In an interview on 01/23/2013 at 6:15 PM the Director of Nurses (DON) stated the Nursing Department should read the X-ray reports as they come in and should have assessed Resident # 8 to see if she needed an enema. The DON stated it was her expectation that nurses read the x-ray reports for all residents and report severe pain to the physician. In an interview on 01/24/2013 at 12:10 PM Doctor of Osteopathic Medication (DO) B stated he reviewed the X-Ray report for Resident # 8 that was transmitted to him from the Imaging Department at the hospital. DO B stated he was not concerned about the fecal impaction as he had not been notified of any symptoms Resident # 8 was experiencing and from past history he knew the resident suffered from constipation. DO B stated he was not notified of the abdominal pain Resident # 8 was experiencing on 01/17/2013 and that information could have possibly changed his course of action for Resident # 8. Review of the facility policy regarding Physician Notification of Change in Resident Condition reflected: Policy - It is the policy of this Center to notify the physician and inform the resident and resident's responsible party of a significant change in the resident's physical, mental, psychological status including accidents and when there is a need to alter treatments significantly. Purpose - To keep the physician, resident and resident's responsible party informed of changes in the resident's condition so that timely interventions can be obtained; and To ensure the resident receives prompt medical treatment in an emergency, when indicated. Definition - "Change of Condition" related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. Procedure: 2. The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. 3. The licensed nurse will be responsible for making all notifications of changes to physicians, the resident and the resident's representative. 4. Examples of changes may include, but not limited to: Gastrointestinal problems Abnormal lab studies....... Resident sample list identified one of one residents with a fecal impaction.