Every finding on record at Mountain View Health & Rehabilitation

Based on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 187 beds, failed to employ a qualified social worker on a full-time basis since 05/30/2026.This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included:Review of the Facility's Summary Report revealed the facility was licensed for 187 beds.During an interview and record review on 07/02/26 at 5:25 p.m. with the Administrator, revealed employee list provided to the surveyor on 07/01/26 by the Administrator revealed Social Worker R was listed as Social Worker unlicensed. He said he hired Social Worker R on 04/03/26, who was unlicensed, to assist the previously licensed Social Worker that had resigned on 05/30/26. He said he was in the process of interviewing potential applicants to hire a licensed Social Worker as soon as possible.Record review of the facility's undated policy Social Services revealed, the following is a non-exhaustive criterion that related to the job of a Social Worker, and it is consistent with the business needs of the facility. Knowledge Base: A bachelor's degree in social work or secondary education in social services and certification as a social worker may be substituted as appropriate. Social Worker Responsibilities: Purpose: To outline the role of the social worker in discharge planning to ensure safe transitions of care, regulatory compliance, and adequate coordination with residents, families, and the interdisciplinary team. Scope: This procedure applies to social workers managing the psychosocial and coordination aspects of resident discharges. Other duties as assigned.

Based on interviews, and record review, the facility failed to conduct assessments that accurately reflected the resident's status for 1 of 4 residents (Residents #2) reviewed for resident assessments.The facility failed to ensure Resident #2's Annual MDS Assessment accurately reflected resident's behaviors exhibited ongoing basis when daily care was provided.The failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.The findings included:Review of Resident #2's admission Record, dated 7/01/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE].Review of Resident #2's History & Physical dated 12/22/25, revealed Major Depression (is a serious mood disorder causing persistent sadness, hopelessness and loss of interest in activities, significantly affecting daily life, sleep, appetite and concentration), Anxiety Disorder (mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), and Diabetes Mellitus with Neuropathy (is nerve damage caused by prolonged high blood sugar).Review of Resident #2's Annual MDS dated [DATE] revealed, unclear speech, usually understood, usually understands others; BIMs Score 03 (cognition severely impaired). No Behavioral symptoms. Overall Presence of Behavioral Symptoms reflected none. Active Diagnoses: Non-Alzheimer's Dementia Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), Anxiety Disorder(mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations) , Adjustment Disorder with Anxiety (a stress related mental health condition) and Depression (a serious mood disorder causing persistent sadness, loss of interest, and lack of motivation, affecting how the person feels, think, and act, differing from normal sadness by lasting long periods and interfering with daily life).Review of the CNA Documentation Record dated June 2026, only document 16 episodes of behaviors on 6/08/26, 06/10/276, 06/11/26, 06/12, and 06/29/26 on the evening shift but did not specify the behaviors exhibited by Resident #2 when daily care was provided. Review of the Nurses Medication Administration Record dated June 2026 did not have any documentation of the resident's behaviors reported by the CNAs when daily personal care was provided. Review of Resident #2's Care Plan reviewed on 6/23/26 revealed:-The care plan did not address Resident #2 2 resisted care, and screamed when touched to provide care, pushed and hit staff when attempts to change briefs and to turn and reposition in bed were, attempted to bite while being transferred from the bed to the wheelchair, cursed at and insulted the staff, called them whores and told them they were stupid when they attempted to provide daily care.-Adverse medication effect and behavior monitoring. Interventions: Continually monitor for behaviors and medication adverse and notify the MD, LVN or NP as required. In addition, note any behaviors and adverse effects on the weekly summary. Each shift, monitor for and report any potential side effects or behaviors in the kiosk. If noted, also verbally report to a licensed nurse. Monitoring an accurate documentation of the resident's response to any treatments (such as lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regime review) is essential to evaluate the ongoing effectiveness benefits, as well as risk. For nonpharmacological approaches and medications.During a telephone interview on 7/02/26 at 4:25 p.m. with Resident #2's family member revealed CNA K had asked the family members on 06/21/26 to come in the resident's room so they could see how Resident #2 screamed when touched to provide care, cursed, hit, resisted care, scratched and attempted to bite the staff when care was provided or being transferred from the bed to the wheelchair. The family member reported that the resident would call the staff whores and told them that they were stupid. One of the family members said she was the resident's care giver for Resident #2 while she was living at home and she exhibited the same behaviors at home when she attempted to assist her with her personal care and would throw them out of her house.During a telephone interview on 7/02/26 at 4:38 p.m. with CNA K revealed Resident #2 was oriented to person, recognized familiar faces, required total assistance of one person with ADLs. She said Resident #2 resisted care, and screamed when touched to provide care, pushed and hit staff when attempts to change briefs and to turn and reposition in bed were, attempted to bite while being transferred from the bed to the wheelchair, cursed at and insulted the staff, called them whores and told them they were stupid when they attempted to provide daily care. She said the resident's body was very stiff and the resident did not make any efforts to assist with personal care. She said the resident would yell loudly when they touched her to turn & reposition, change soiled briefs, during transfers, and when personal care was provided. During an interview and record review on 07/02/26 at 5:07 p.m. with RN MDS Nurse M revealed that she was not aware that Resident #2 had behaviors. She said she gathered information to complete the MDS assessment from IDT progress notes, and history and physical. She said that she did not interview the nursing staff when she completed MDS Assessment. She said that she did not review the CNAs documentation Care Reports or the Nurses Medication Administration Records for behaviors.During an interview on 7/02/26 at 5:21 p.m. the facility's Regional Compliance Nurse R said that the facility did not have a policy and procedure on Completing MDS assessment and they followed the Resident Assessment Instrument 3.0 Manual to complete MDS assessments. The Compliance Nurse said the nurses and CNAs were not documenting in Resident #2's clinical record that resident exhibited behaviors anytime that direct care was provided. She said the nursing staff had been trained to document the behaviors in the IDT Notes, Medication Administration Records and CNA Documentation Sheets. She said the MDS should conduct interviews with the nursing staff and other disciplines as needed when completing MDS assessments.During an interview on 7/02/26 at 7:13 p.m. with CNA O said he started working on 02/26/26 on the 2 PM to 10 PM shift and that the CNAs rotate assigned sections daily and was frequently assigned to care for Resident #2. He said Resident #2 was only oriented to person, was able to verbalize needs, required total assistance of one person with ADLs. He said Resident #2 would become anxious when daily care was provided and would bite, hit, cuss, and scream. He said the resident's body was very stiff and her back was not straight. He said the nurses were aware that Resident #2 exhibited these behaviors when daily care was provided.During an interview on 7/02/26 at 7:15 p.m. with LVN Charge Nurse P said on the 2 PM to 10 PM shift revealed Resident #2 was confused, required total assistance of one person with ADLS, incontinent of bowel & bladder, had on-going behaviors and would cuss, bite, hit, and resisted care. She said the resident did not like for the staff to touch her and screamed when moved to provide the needed personal care. She said that the CNAs reported to her that Resident #2 would become anxious when daily care was provided and would bite, hit, cuss, and scream. She said that she could not remember if she had documented the behaviors in the resident's clinical record. She said that they had been trained to document the behaviors in the Medication Administration Records on every shift.

Based on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure behaviors were addressed in Resident #2's Care Plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included:Review of Resident #2's admission Record, dated 7/01/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE].Review of Resident #2's History & Physical dated 12/22/25, revealed Major Depression (is a serious mood disorder causing persistent sadness, hopelessness and loss of interest in activities, significantly affecting daily life, sleep, appetite and concentration), Anxiety Disorder (mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), and Diabetes Mellitus with Neuropathy (nerve damaged caused by prolonged high blood sugar and high blood fats).Review of Resident #2's Annual MDS dated [DATE] revealed, unclear speech, usually understood, usually understands others; BIMs Score 03 (cognition severely impaired). No Behavioral symptoms. Overall Presence of Behavioral Symptoms none. Active Diagnoses: Non-Alzheimer's Dementia, Anxiety Disorder, Adjustment Disorder with Anxiety and Depression.Review of Resident #2's Care Plan reviewed on 6/23/26 revealed:-The care plan did not address Resident #2 2 resisted care, and screamed when touched to provide care, pushed and hit staff when attempts to change briefs and to turn and reposition in bed were, attempted to bite while being transferred from the bed to the wheelchair, cursed at and insulted the staff, called them whores and told them they were stupid when they attempted to provide daily care.-Adverse medication effect and behavior monitoring. Interventions: Continually monitor for behaviors and medication adverse and notify the MD, LVN or NP as required. In addition, note any behaviors and adverse effects on the weekly summary. Each shift, monitor for and report any potential side effects or behaviors in the kiosk. If noted, also verbally report to a licensed nurse. Monitoring an accurate documentation of the resident's response to any treatments (such as lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regime review) is essential to evaluate the ongoing effectiveness benefits, as well as risk. For nonpharmacological approaches and medications.During a telephone interview on 7/02/26 at 4:25 p.m. with Resident #2's family member revealed CNA K had asked the family members on 06/21/26 to come in the resident's room so they could see how Resident #2 screamed when touched to provide care, cursed, hit, resisted care, scratched and attempted to bite the staff when care was provided or being transferred from the bed to the wheelchair. The family member reported that the resident would call the staff whores and told them that they were stupid. One of the family members said she was the resident's care giver for Resident #2 while she was living at home and she exhibited the same behaviors at home when she attempted to assist her with her personal care and would throw them out of her house.During a telephone interview on 7/02/26 at 4:38 p.m. with CNA K revealed Resident #2 was oriented to person, recognized familiar faces, required total assistance of one person with ADLs. She said Resident #2 resisted care, and screamed when touched to provide care, pushed and hit staff when attempts to change briefs and to turn and reposition in bed were, attempted to bite while being transferred from the bed to the wheelchair, cursed at and insulted the staff, called them whores and told them they were stupid when they attempted to provide daily care. She said the resident's body was very stiff and the resident did not make any efforts to assist with personal care. She said the resident would yell loudly when they touched her to turn & reposition, change soiled briefs, during transfers, and when personal care was provided. During an interview and record review on 07/02/26 at 5:07 p.m. with RN MDS Nurse M revealed that she was not aware that Resident #2 had behaviors. She said she gathered information to complete the MDS assessment from IDT progress notes, and history and physical. She said that she did not interview the nursing staff when she completed MDS Assessment. She said that she did not review the CNAs documentation Care Reports or the Nurses Medication Administration Records for behaviors.During an interview on 7/02/26 at 5:21 p.m. the facility's Regional Compliance Nurse R said that the facility did not have a policy and procedure on Completing MDS assessment and they followed the Resident Assessment Instrument 3.0 Manual to complete MDS assessments. The Compliance Nurse said the nurses and CNAs were not documenting in Resident #2's clinical record that resident exhibited behaviors anytime that direct care was provided. She said the nursing staff had been trained to document the behaviors in the IDT Notes, Medication Administration Records and CNA Documentation Sheets. She said the MDS should conduct interviews with the nursing staff and other disciplines as needed when completing MDS assessments.During an interview on 7/02/26 at 7:13 p.m. with CNA O said he started working on 02/26/26 on the 2 PM to 10 PM shift and that the CNAs rotate assigned sections daily and was frequently assigned to care for Resident #2. He said Resident #2 was only oriented to person, was able to verbalize needs, required total assistance of one person with ADLs. He said Resident #2 would become anxious when daily care was provided and would bite, hit, cuss, and scream. He said the resident's body was very stiff and her back was not straight. He said the nurses were aware that Resident #2 exhibited these behaviors when daily care was provided.During an interview on 7/02/26 at 7:15 p.m. with LVN Charge Nurse P said on the 2 PM to 10 PM shift revealed Resident #2 was confused, required total assistance of one person with ADLS, incontinent of bowel & bladder, had on-going behaviors and would cuss, bite, hit, and resisted care. She said the resident did not like for the staff to touch her and screamed when moved to provide the needed personal care. She said that the CNAs reported to her that Resident #2 would become anxious when daily care was provided and would bite, hit, cuss, and scream. She said that she could not remember if she had documented the behaviors in the resident's clinical record. She said that they had been trained to document the behaviors in the Medication Administration Records on every shift.Review of facility's undated policy and procedure on Comprehensive Care Planning revealed: The facility will develop and implement A comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being. Each resident will have a person-centered, comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set to assess the resident's, clinical condition, cognitive and the functional status and use of services.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #4) reviewed for quality of care in that:The facility failed to ensure CNA I and CNA J correctly applied the gait belt to transfer Resident #4 from the wheelchair to the bed.The failure could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.Findings included:Review of Resident #4's admission Record, dated 7/02/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE].Review of Resident #4's History & Physical dated 3/16/26, revealed Debility and immobility. Mobility device wheelchair. Substantial/maximal assistance with Sit to lying, sit to stand, chair/bed-to-chair transfer; Non-Alzheimer's Dementia, CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), unsteadiness on feet, lack of coordination.Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMs Score of 03 (cognition severely impaired).Review of Resident #4's Care Plan reviewed on 4/20/26 revealed: Resident #4 has ADL Self-Care Deficit. Interventions: transfer requires assistance x 1 person.Review of the facility's In-Service Training Record dated 03/29/24 presented by the ADONs provided by the ADON B on 07/02/26 revealed: Topic: Transfer-Kardex must be followed for transfer. No training information was attached to the Training Record. During an observation and interview on 07/02/26 at 3:36 p.m. with CNA I and CNA J accompanied by LVN ADON B revealed Resident #4 was sitting in a wheelchair by the right side of the bed waiting to be transferred from the wheelchair to the bed. The CNAs said that they used a gait belt to transfer residents that did not need a mechanical device to transfer. CNA I, handed the gait belt to the CNA J who was standing directly in front of the resident. CNA J asked CNA I to show her how to buckle the gait belt prior to placing the gait belt on the resident. It was observed that the CNAs asked the resident to sit forward to place the gait belt. It was observed that CNA J who was standing directly in front of the resident placed the gait belt around the resident's upper back directly over the resident's breasts and the CNAs were getting ready to move the resident. The state surveyor stopped the CNAs from moving the resident and asked the CNAs how they had been trained to place the gait belt to transfer the resident. The CNAs said they had been trained to place the gait belt just above the hips. The CNAs loosened the gait belt and placed the gait belt just above Resident #4's hips and they demonstrated that the gait belt was tight enough to provide support but loose enough to fit two fingers between the belt and the resident's body. The CNAs locked the wheelchair brakes, asked the resident to sit upright with feet flat on the floor and assisted the resident to a standing position by firmly placing their hands under the gait belt. The CNAs guided the resident in a controlled pivot towards the edge of the bed, maintaining a firm grip on the gait belt until they sat the resident at the edge of the bed. One CNA placed her arm under the resident's head and the other arm under the resident's knees and slightly turned the resident to the side, lifted her legs and the other CNA assisted in positioning the resident to the middle of the bed. The CNAs said it was important to place the gait belt around the waist to prevent injury to the resident when moving the resident from the wheelchair to the bed. The CNAs said they could not remember the last time that they were trained on use of the gait belt.During an observation and interview on 07/02/26 at 3:50 p.m. with PTA S in the presence of RN Regional Compliance Nurse R demonstrated how they had trained the CNAs to do a transfer using a gait belt. He said the resident was seated upright in the wheelchair with feet flat and arms at their sides. It was observed that the gait [NAME] was placed around the staff member's waist over the clothing just above the hip bones. The buckle in front was secured. The gait belt was pulled snug enough to allow two fingers to fit between the belt and the staff member. The PTA placed the wheelchair close to the side of the bed and locked the wheelchair brakes. He grasped the side of the gait belt withs his hands and assisted the staff member to a standing position and turned the staff member and sat the staff member at the edge of the bed. He placed a hand on the shoulder blade and with the other hand raised the legs and gently put the staff member in bed. The gait belt was removed. The RN Regional Compliance Nurse R said that the facility did not have a policy and procedure on the use of a gait belt. She said that she did not remember when the last time was the staff were trained on the use of the gait belts.Review of the facility's policy and procedure dated 2003 on Moving a Resident, Bed to chair/Chair to Bed revealed: This procedure may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Purpose: The purpose of this procedure are to allow the resident to be out of his bed. Or her men as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: this procedure may require 2 persons. Nor the height of the bed to the lowest position. If moving a resident from chair to bed. Place the chair stored. It touches the side of the bed and faces the foot of the bed. Have the chair on the resident strongest side. If transferring the resident from a wheelchair: Be sure the wheels are locked. Fold the footrest and or the leg rest out of the way. And place the residence feet Firmly on the floor. Turn the bed covers down. Instruct the resident to place both hands on the arms of the chair and waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable. If the resident requires 2 persons. One on each side should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed. Move the resident. Instruct their resident to raise his or her legs on the bed. Assist as necessary. Assist the resident to undress as necessary and remove the gate belt.

Based on observation, interview and Record review, the facility failed to ensure food was maintained and served in a palatable manner for 1 of 1 Kitchen observations reviewed for food temperatures. The facility failed to store thawed waffles under appropriate cold holding temperatures on 04/09/2026. This failure could affect food quality, safety and resident consumption. Findings include: In an observation and interview on 04/09/2026 at 11:45 am, with the Dietary Manager revealed a Ziploc bag containing defrosted waffles was observed sitting on a bread rack at room temperature. The Ziploc bag was dated 04/09/2026. The Dietary Manager was asked if the waffles should be refrigerated after thawing. The Dietary Manager stated, No as they could be left outside for use tomorrow, we will be using them tomorrow that's why they are left out. When asked if there is any risk of them being left out, the Dietary Manager stated No it is like bread which is why it is in the bread rack In an interview on 04/09/2026 at 01:04 pm, Administrator stated thawed food items should be maintained at the appropriate temperature and perishable food should be stored correctly in the refrigerator. The Administrator stated, The waffles should be refrigerated after use. In an interview on 04/09/2026 at 01:55pm, Assistant Manager stated thawed food items left out should be discarded due to the risk of bacterial growth and food spoilage. Record Review facility's Dietary Services Policy & Procedure Manual dated 2012 revealed: 8) On Perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stores at the proper temperature, spoilage bacteria can grow faster then anticipated and food becomes spoiled and should not be served.

Based on observations, interviews, and record review the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage.-The facility failed to ensure dietary staff followed proper food safety practices for hand hygiene after contamination on 03/24/2026.This failure had the potential to place residents at risk for foodborne illness.Findings included:During an observation on 3/24/2026 at 11:58 AM, it was observed that [NAME] F collected all the used sanitizing towelettes and wrappers and discarded them in the trash without practicing hand hygiene before returning to work. At 12:10 PM [NAME] F was filling a bowl of pozole (Mexican pork stew) that overflowed and wet her left hand with dripping falling back into the steam table pozole insert, she proceeded to work without practicing hand hygiene. At 12:13 PM [NAME] F was filling another bowl of pozole that overflowed and wet her left hand with dripping falling back into the steam table pozole insert, she proceeded to work without practicing hand hygiene. No hand hygiene was observed to taken place for the next 10 minutes, before surveyor exited kitchen. Pozole was still served to residents following the observed cross-contamination.During an interview on 03/26/2026 at 2:18 PM with Dietary Aide D, she stated she worked the steam table serving food sometimes. She stated that she washed her hands throughout the day, after restroom, after breaks, and when reentering the kitchen. She stated that staff needed to wash their hands if it was exposed to the food during serving. She stated that staff should have stopped and washed their hands because it was potential for cross contamination if they didn't. She stated all staff were responsible for recognizing cross contamination and washing hands when soiled. She stated there was a system in place that provided the opportunity for the serving to continue and the staff member to wash their hands. She stated that the last in-service for hand washing was within the past week. During an interview on 03/26/2026 at 2:27 PM with [NAME] E, he stated you practice hand hygiene before beginning work, every time you move from the cooking area, whenever you touch an article that was not part of the cooking process (for example a door handle, the walk-in refrigerator), and when you grab a residents cup or plate. He stated he had worked the steam table line before, and if his hands were exposed to food, he would stop and wash his hands. He stated it was considered cross contamination if staff did not wash their hands. He stated he would wash hands immediately and would wash his hands if it happened again. He stated staff not washing their hands after contamination was not appropriate. He stated that the supervisors were responsible for ensuring staff were washing their hands when contaminated. He stated the last in-service for hand hygiene was a couple of weeks ago. He explained the hand-washing procedure included washing the nails, fingers, hand, and a little above you wrist for 20 seconds. During an interview on 03/26/2026 at 2:39 PM with The Dietary Supervisor, she stated hand hygiene needed to be practiced for every kitchen reentry, when staff grabbed an ingredient or meat, and was an ongoing task staff needed to complete. She explained that the hand-washing procedure included washing the exposed area below the wrists for 40 seconds each time. She stated that anyone in the kitchen could tell another staff member to wash their hands if a potential contamination was observed. She stated that she had worked at the steam table during serving before and added she had experienced food touching her before. She stated in all instances she stopped what she was doing immediately to wash her hands. She stated this needed to be done because there was a potential for cross contamination of food. She stated that staff should wash their hands immediately to prevent a cross contamination and she needed to ask the cook for a replacement dish if the dripping landed back in the food. She stated the last in-service for hand hygiene was yesterday.During an interview on 03/26/2026 at 2:56 PM with the Dietary Director, he stated that staff needed to complete hand hygiene whenever they reenter the kitchen, encountered a raw ingredient or fridge handle, and before beginning a new task. He stated this needed to be adhered to because it could be considered cross contamination. He stated it would be an infection control issue if staff had a contaminant on their hands and continued meal service. He stated that staff should have stopped and completed hand hygiene if they encountered food while serving during mealtime. He stated everyone was responsible for completing hand hygiene and supervisors were responsible for providing in service and training on hand hygiene. He stated that residents could be exposed to symptoms related to food-borne illnesses if hand hygiene was not adhered to. He stated the last in service for hand hygiene was within the last month. He explained that the hand-washing procedure included washing palms, wrists, fingers, and back of hands for a minimum of 20 seconds. During an interview on 03/26/2026 at 3:43 PM with The Administrator, he stated dietary staff should be practicing hand hygiene at all times because it was a universal precaution. He stated proper hand hygiene provided infection control during meal service by minimizing cross contaminations for residents. He stated that the dietary manager, supervisors, and all staff could address hand hygiene concerns in the kitchen. He stated that if food came in contact during line service, staff needed to stop immediately and wash their hands to prevent cross contamination. He stated it affected residents by exposing them to cross contaminated food and added it messed up the quality of food. He stated that [NAME] F and any staff member who saw the mishandling should have instructed [NAME] F to practice hand hygiene. He stated there was no issue with staff stepping away from the meal service line to complete hand hygiene. Record review of the facility's policy titled, Fundamentals of Infection Control Precautions undated read in part, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility (Hand Hygiene section) Hand hygiene continue to be the primary means of preventing the transmission of infection, The following is a list of some situations that require hand hygiene: -When coming on duty - When hands are visibly soiled . -Before and after or handling food

Based on observation, interview, and record review the facility failed to maintain an infection prevention program designed to provide safe, sanitary, and prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #8 and Resident #77) reviewed for transmission-based precautions.- The facility failed on 03/24/2026 to ensure an unattended IV saline syringe flush was not left on Resident #77' nightstand.- The facility failed on 03/24/2026 and 03/25/2026 to ensure Resident #8's Eternal Feeding Syringe was not uncovered on his nightstand or in his dresser.The failures placed residents at risk for developing a preventable infection during patient care.Findings Included:Findings Included: 1.Resident #8 Record review of Resident #8 face sheet dated 03/26/2026 revealed an [AGE] year-old male with an admission date on 08/11/2025. Record review of Resident #8 Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating he was cognitively intact. Under Section K-swallowing/nutritional status revealed the resident had a feeding tube in place. Record review of Resident #8's care plan dated 11/20/2025 revealed the resident had an enhanced barrier precaution in place. The care plan revealed a focus for tube feeding with interventions to check for tube placement and gastric contents/residual volume per facility protocol and record and a goal for Resident #8 to remain free of side effects or complications related to tube feeding. Record review of Resident #8 health and physical dated 07/24/2025 revealed the resident was at the hospital emergency room with expressed concerns for swallowing and progressive weight loss ongoing for 2 weeks. Resident #8 was diagnoses with dysphagia (difficulty swallowing) with a PEG tube placement and Lewy body Dementia (causing cognitive decline, visual hallucinations, movement issues, and fluctuating alertness). During an observation on 3/24/2026 at 3:49 PM, it was observed that Resident #8's external feeding syringe was placed on his nightstand only partially sealed with the original packaging the syringe came in but still exposed by the piston and half of the syringe. During a follow up observation on 03/25/2026 at 11:08 AM, an external feeding syringe was stored inside Resident #8's dresser unsealed and exposed to all the contents of the dresser. During an interview on 03/25/2026 at 8:23 AM with Resident #8, he stated he had a gastric tube in place that staff used to provide feeding and hydration through. He stated they used a big purple syringe to assist in-between feedings and hydration. He stated staff provided feeding at a frequency of 3 times and quantity of 2 bottles per session. He added for hydration they came at a frequency of 5 times. 2.Resident #77 Record review of Resident #77 face sheet dated 03/26/2026 revealed a [AGE] year-old female with an admission date on 03/12/2026. Record review of Resident #77 MDS dated [DATE] revealed the resident had a diagnosis of Sepsis (the body's extreme, overwhelming response to an infection, leading to tissue damage and organ failure). Under Section O-Special treatments, procedures, and programs the resident was coded for having a peripheral IV access site on admission Record review of Resident #77 care plan dated 03/12/2026 revealed the resident was on enhanced barrier precautions with a goal to be free of transmission of infection from or to the resident. Further review revealed the resident had a focus are for the IV access site with interventions to flush the ports/lines as ordered and monitor for signs and symptoms of infection. Record review of Resident #77 health and physical dated 3/12/2026 revealed the resident was diagnoses with Coronary Artery Disease (buildup of plaque in the arteries), Urological cancer post chemotherapy (cancer of the urinary excretion system post treatment). During an observation on 3/24/2026 at 9:48 AM, it was observed a saline flush syringe was left unattended out of its package on Resident #77's nightstand. During an interview and observations on 3/24/2026 at 10:50 AM with Resident #77, she stated she had just returned from PT. She stated she had not noticed the saline flush syringe on her nightstand and does not remember what staff member had provided it or when. She added she did not know what it was used for. She stated she did have an IV access site on her hand but it had been discontinued. She was unable to recite for how long the IV therapy had been discontinued. During an interview on 03/26/2026 at 8:52 AM with CNA A, he stated if he found an unattended syringe out of its package, he would report it to the nurse immediately. He stated he did not know if it was okay to leave saline syringe flushes and external feeding syringe in the resident's room. He stated there was a hazard for leaving syringes in residents' rooms. He added it was an infection control issue because there was a possibility the syringe had encountered a resident's bodily fluids. He stated that the supervisors were responsible for ensuring staff were following infection prevention practices. During an interview on 03/26/2026 at 9:14 AM with RN C, she stated that the saline syringe was used to flush an IV line and the big purple syringes were external feeding syringes used for feeding and flushing water for residents with PEG tubes. She stated the saline syringe was disposable after it was out of its package and the external feeding syringe could be reused up to 24 hours, but it had to be stored in a Ziplock bag to seal it off from contaminants when not in use. She stated it was not okay for the external feeding syringe to be stored on top of the dresser or in the resident's dresser. She started the saline syringe needed to be discarded if it was removed from its package but not used. She stated it was an infection control issue if the resident syringes were left out because they could develop mold, dust, bodily fluids, medication, or old feeding shakes. She stated the nurse would be responsible for upholding infection prevention, but anyone could report or address it if they observed it in a residents' room. She stated that the last in service she received for infection control was last week. During an interview on 03/26/2026 at 3:47 PM with the Administrator, he stated that the external feeding syringe and saline syringes should not be stored in a resident's room when not in use. He stated if it was used, it should be discarded after. He stated that the external feeding syringe for Resident #8 should have stored and sealed away so that there was no potential for cross contamination and added it was not appropriate for it to be left in the Resident #8's dresser. He stated that the saline syringe left in Resident #77's room out of the package needed to be discarded. He stated every staff member could dispose of used medical equipment but typically it was nurse's responsibility. He stated the DON was the infection control specialist. He added it was expected the ADONs and nurses should adhere to infection control and prevention practices. He stated it affected residents by exposing them to other infections. In an interview on 03/26/2026 at 3:48 p.m., with the DON revealed the feeding syringe needed to be placed back in the packaging after use to prevent contamination and to prevent bacteria from entering the PEG tube. She stated that the saline flush needed to be discarded after each use to prevent cross contamination that could possibly enter the residents blood stream through the IV. She stated that it was the responsibility of the nurses to ensure that all equipment was stored, discarded, and sanitized properly along with the DON and ADONs. Record review of the facility's policy titled Eternal Nutrition undated, read in part, . (Procedure Section) The Nursing Services Department is responsible for all feeding equipment and the administration of tube feedings Problems with administration of the tube feeding are monitored and corrected by nursing Record review of the facility's policy titled, Fundamentals of Infection Control Precautions undated read in part, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility (Resident Care Equipment and Articles Section) Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant A documentation system will be maintained of the cleaning Any resident care equipment/article that is visibly contaminated with blood or body fluids will be immediately be cleaned with an approved disinfectant

Based on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents ( Resident #40) reviewed for ADL care.- The facility failed on 3/24/2026 to ensure Resident #40's fingernails were trimmedThis failure could place residents who required assistance with ADLs at risk for unmet care needs.Findings include:Resident #40Record Review of Resident #40's admission Record dated 03/26/2026 revealed a [AGE] year-old female with an initial admission date of 01/12/2023 and a readmission date of 10/13/2025.Record review of Resident #40's History and Physical dated 03/05/2026 revealed a diagnosis of a cerebral vascular accident (blood flow to a part of the brain is interrupted or reduced) and chronic vegetative state.Record review of Resident #40's Quarterly MDS dated [DATE] revealed no BIMs score. Section GG revealed personal hygiene tasks were not attempted due to medical condition or safety concerns.Record review of Resident #40's care plan revised on 03/18/2026 revealed Resident #40 had an ADL self-care deficit; interventions included resident required total assistance with personal hygiene care.An observation on 03/24/2026 at 10:13 a.m., revealed Resident #40's right hand fingers to be contracted with fingernails digging into the palm of the hand, and fingernails were observed to be long. Resident was awake but not alert or oriented, and she was not able to answer questionsDuring an interview on 03/26/2026 at 8:41 AM with CNA B, he stated if he saw a resident with long toenails, he would consult with the nurse to see if the resident was diabetic or scheduled with the podiatrist already. He stated that he was restorative CNA so he did not have a routine to look at the toenails in his responsibilities but would notify the nurse for any concerns he observed or heard. He stated when he was on the floor staff would review the toenails every day when providing care and ADLs. He stated if a resident requested nail service, then he would inform the nurse and gain clarification to see if it was a service he could provide based on the resident's condition. He stated that residents could be affected by infection, fungus development, and ingrown nails if they did not receive routine nail care. He stated it was all nursing staffs' responsibility to ensure residents' nails were regularly groomed. He stated the last in-service he received for ADLs was in February 2026.In an interview on 03/26/2026 at 1:40 p.m., with CNA I revealed fingernails were trimmed on Sundays and as needed. She stated that CNAs and nurses were responsible for ensuring that nails were trimmed. She stated a possible risk of long fingernails was injury due to scratching and could possibly be an infection control issue.In an interview on 03/26/2026 at 2:00pm with RN H revealed fingernails were trimmed as needed, when they were observed to be long or when the resident asked for a trimming. He stated that a potential risk would be injury by scratching or cutting themselves. He stated that the nurses were responsible for cutting the fingernails and ensuring that the residents had trimmed nails.During an Interview on 3/26/2026 at 3:28 PM with the Administrator, he stated that podiatry visited the facility 1 to 2 times a month. He added if a resident was requesting toenail trimming beyond the scope of nurses, it should be reported to the nurse to contact podiatry. He stated that the podiatrist had a list of residents they saw during their visits. He stated it affected residents who did not receive toenail care because they could experience pain and ingrown nails. He stated that the ADON, DON, and floor nurses were responsible for following up on toenail care. He stated fingernails were trimmed as needed. He stated that nurses and CNAs were responsible for trimming the fingernails. He stated that the nurses, DON and ADONs were responsible for ensuring that residents' fingernails were being trimmed. He stated that long nails were a potential risk of injury due to scratching. He stated he was not aware of a monitoring/tracking system in place for residents that required podiatry and referred to DON for further information. During an interview on 03/26/2026 at 4:24 PM with the DON, she stated that during showers staff recorded the conditions of the toenails and fingernails and reported it to the Podiatrist to provide services to the residents. She stated that it could be uncomfortable for a resident because there could be infections from ingrown nails and fungus. She stated that the nursing staff and supervisors monitored and tracked the condition of residents' toes and fingernails daily with rounds and assessments throughout the day. She stated that when the resident was diabetic or had a bleeding disorder, they would be referred to the podiatrist. She stated that the podiatrist comes as needed and once a month on routine. She stated there was a list that the facility kept of residents serviced when podiatry came; podiatry service census documentation was provided before exit on 3/26/2026. She stated that fingernails were trimmed during shower days. She stated that fingernails were trimmed by CNAs and nurses and it was the responsibility of the nurses and CNAs to ensure that fingernails were kept trimmed and clean.Record review of the facility's documents titled podiatry list dated on 12/09/2025, 02/03/2026, and 03/06/2026 revealed Residents #40 and #119 were not on the list of residents who received services through podiatry for the past 3 months.Record review of the facility's policy titled Nail care undated, read in part, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity issues, to prevent infection, and injury from scratching by fingernails and pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath NAIL CARE, ESPEECIALLY TRIMMING IS PERFORMED BY A PODIATRIST IN THOSE WITH DIABETES AND PERIPHERAL VASCULAR DISEASE (Goals section) Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions (Procedure section) . Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Report conditions immediately to the primary nurse. The nurse will ensure a referral to the podiatrist.

Based on observations, interview, and record review, the facility failed to ensure that resident receive proper treatment and care to maintain mobility and good foot health for 1 of 1 residents (Resident #119) reviewed for foot care.The facility failed on 3/24/2026 to ensure Resident #119's toenails were trimmedThis failure could place residents who required specialized foot care at risk for unmet care needs, infections, and health complications.Resident #119Record review of Resident #119's face sheet dated 3/26/2026 revealed a [AGE] year-old female with an original admission date on 04/01/2020 and a readmission date on 11/13/2023.Record review of Resident #119's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Section GG - Functional Abilities revealed the resident could not complete lower body dressing, personal hygiene, oral hygiene, upper body dressing, putting on/removing footwear, and transfers due to medical conditions or safety concerns.Record review of Resident #119's care plan dated 01/13/2026 revealed the resident needed assistance with ADLs and mobility due to hemiplegia/hemiparesis (A neurological condition causing one-sided body weakness) to the right side of her body. Further review revealed Resident #119 had an age-related physical debility (a state of general weakness or lack of stamina) and required extensive assistance with ADLs with intervention for 1 person to assist with personal hygiene.Record review of Resident #119's Physical and Health dated 3/19/2026 revealed the resident had diagnoses of peripheral vascular disease (progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels outside the heart and brain, most commonly in the legs and feet), Parkinsons (disease is a progressive neurodegenerative movement disorder), legally blind, and type 2 diabetes mellitus with hyperglycemia (chronic metabolic disease where the body becomes resistant to insulin).Record review of Resident #119's Orders revealed the resident had an active order from the Physician dated 02/26/2024 for, podiatrist consultation for foot care.During an observation and interview on 03/24/2026 at 3:36 PM with Resident #119 she stated she did not like the length of her toenails and would like someone to cut them. She stated that she had asked the direct care staff already but was unable to recall when and who she asked. Observation of Resident #119's exposed right foot revealed long and thickened toenails with a yellow hue under the nail.During an interview on 03/26/2026 at 8:41 AM with CNA B, he stated that he was restorative CNA so he did not have a routine to look at the toenails in his responsibilities but would notify the nurse for any concerns he observed or heard. He stated when he was on the floor staff would review the toenails every day when providing care and ADLs. He stated if a resident requested nail service, then he would inform the nurse and gain clarification to see if it was a service he could provide based on the resident's condition. He stated that residents could be affected by infection, fungus development, and ingrown nails if they did not receive routine foot care. He stated it was all nursing staffs' responsibility to ensure residents' nails were regularly groomed. He stated the last in-service he received for ADLs was in February 2026.During an interview on 03/26/2026 at 9:02 AM with RN C, she stated she would review with the resident to see if she can cut their toenails and any related diagnosis like diabetes and vascular circulation. She stated if a resident had fungus and diabetes they would be referred to podiatry for further care. She stated that the toenails should be reviewed every shift by the charge nurse and CNAs. She added a resident could potentially be reviewed minimum of 3 times by 3-6 different people. She stated the nurse would be responsible for completing the nail assessment. She stated residents could develop an ingrown nail, could result in infection, and fungus development. She stated if a resident vocalized wanting their toenails cut and there was no underlying condition she would do it immediately. She added if she was not able to she would consult with DON for podiatry as the alternative or contact the nurse practitioner to see if she could provide nail trimming services. She stated the last in-service for ADLs was 1 to 2 weeks ago.During an Interview on 3/26/2026 at 3:28 PM with the Administrator, he stated that podiatry visited the facility 1 to 2 times a month. He added if a resident was requesting toenail trimming beyond the scope of nurses, it should be reported to the nurse to contact podiatry. He stated that the podiatrist had a list of residents they saw during their visits. He stated it affected residents who did not receive toenail care because they could experience pain and ingrown nails. He stated that the ADON, DON, and floor nurses were responsible for following up on toenail care. He stated fingernails were trimmed as needed. He stated that nurses and CNAs were responsible for trimming the fingernails. He stated that the nurses, DON and ADONs were responsible for ensuring that residents' fingernails were being trimmed. He stated that long nails were a potential risk of injury due to scratching. He stated he was not aware of a monitoring/tracking system in place for residents that required podiatry and referred to DON for further information. During an interview on 03/26/2026 at 4:24 PM with the DON, she stated that during showers staff recorded the conditions of the toenails and fingernails and reported it to the Podiatrist to provide services to the residents. She stated that it could be uncomfortable for a resident because there could be infections from ingrown nails and fungus. She stated that the nursing staff and supervisors monitored and tracked the condition of residents' toes and fingernails daily with rounds and assessments throughout the day. She stated that when the resident was diabetic or had a bleeding disorder, they would be referred to the podiatrist. She stated that the podiatrist comes as needed and once a month on routine. She stated there was a list that the facility kept of residents serviced when podiatry came; podiatry service census documentation was provided before exit on 3/26/2026. She stated that fingernails were trimmed during shower days. She stated that fingernails were trimmed by CNAs and nurses and it was the responsibility of the nurses and CNAs to ensure that fingernails were kept trimmed and clean.Record review of the facility's documents titled podiatry list dated on 12/09/2025, 02/03/2026, and 03/06/2026 revealed Residents #40 and #119 were not on the list of residents who received services through podiatry for the past 3 months.Record review of the facility's policy titled Nail care undated, read in part, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity issues, to prevent infection, and injury from scratching by fingernails and pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath NAIL CARE, ESPEECIALLY TRIMMING IS PERFORMED BY A PODIATRIST IN THOSE WITH DIABETES AND PERIPHERAL VASCULAR DISEASE (Goals section) Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions (Procedure section) . Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Report conditions immediately to the primary nurse. The nurse will ensure a referral to the podiatrist.

Based on observations, interviews and record review the facility failed to ensure the resident's environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #123) reviewed for Accidents-the facility failed from 03/24/2026 to 03/26/2026 to ensure Resident #123 did not have a mini fridge resting on top of a wobbly table.This failure placed the resident at risk for injury from a foreseeable and avoidable hazard.Findings include:Record review of Resident #123's face sheet dated 03/26/2026 revealed a [AGE] year-old female with an original admission date on 08/03/2021 and a readmission date on 02/16/2023.Record review of Resident #123's Quarterly MDS dated [DATE] revealed BIMS score of 14 indicating cognitively intact. Revealed under Section GG-Functional Abilities the resident utilized a manual wheelchair for mobility needs. Under section I- Active Diagnoses, the resident was coded for muscle wasting and atrophy in multiple sites, unsteadiness on feet, and other abnormalities of gait and mobility.Record review of Resident #123's care plan dated 02/03/2026 revealed the resident had a focus area to treat ADL self-care performance deficits with interventions to receive 1 person assist for all ADLs. Resident #119 also had interventions to keep furniture in a locked position to address the risk of falls.Record review of Resident #123's Health and Physical dated 01/15/2026 revealed the resident had diagnoses of Transient Ischemic Attack (a temporary blockage of blood flow to the brain that causes stroke-like symptoms-such as weakness, confusion, or vision changes), Degenerative Joint Disease (when cartilage in joints breaks down over time, causing pain, stiffness, and decreased mobility), Peripheral Artery Disease (chronic circulatory condition where narrowed arteries reduce blood flow to the limbs), and Autonomic Neuropathy (nerve damage affecting involuntary bodily functions like blood pressure, heart rate, digestion, and bladder control).During an observation and interview on 03/24/2026 at 4:13 PM, Resident #123 was sitting in her wheelchair in front of her mini-fridge and TV, approximately 2-3 feet away. It was observed that the table (approximately 3 feet tall) her mini fridge was resting on had a wobbly front left leg that rendered the table uneven; tucked underneath the left leg was a folded cardboard. She stated the table was hers that she brought into the facility. She stated that the table was not always wobbly and staff had fixed the table by placing the folded cardboard under the front left leg. She was unable to recall when and what staff member placed the cardboard under the left leg. She stated she had not notified the facility of the condition of her table. A photo was captured of the mini fridge resting on top of the table with the cardboard support under the front left leg. Follow-up observations completed on 03/25/2026 at 9:00 AM and 03/26/2026 at 10:31 AM, revealed the mini-fridge was still resting on the wobbly table with folded cardboard supporting the front left leg. During an interview on 03/26/2026 at 8:45 AM with CNA B, he stated that a hazard could be furniture not in the right place, cluttered floor, or privacy curtain obstructing passage. He stated all the furniture needed to be in proper and good use condition. He stated if a resident brought in their own furniture that was not in proper condition, it needed to be reported to the nurse immediately. In reference to the photo captured, he stated it needed to be reported because the table could fall on the resident or their roommate. He stated that when residents provided their own furniture, the nurse would review the furniture first to ensure it was not a hazard. He stated it was a hazard for the mini fridge to sit on a table with an uneven table and added it needed to be reported immediately. He stated it affected residents if staff was not reviewing the environment for hazards because there could be potential for injuries. He stated the last in-service he received for environmental hazards was in February 2026.During an interview on 3/26/2026 at 9:08 AM with RN C, she stated to identify hazards in the room she would look for extra electrical cords not approved by the facility, tripping hazards in the form of clutter on the floor, or unnecessary equipment in place like a wheelchair properly stored. She stated the integrity of the furniture was the housekeeping team's responsibility because they would inspect the furniture daily during cleaning chores. She stated they moved the furniture around daily. She stated that a table with cardboard support on a wobbly leg with a mini fridge on top was a hazard. She stated that she estimated a mini fridge to weigh 20 pounds at minimum and would affect the resident by injury if it fell on them. She stated that every employee was responsible for addressing the environmental hazards in resident's rooms. She stated that the maintenance director was responsible for reviewing the integrity of furniture brought in by residents. She stated she does not recall when the last in-service was for identifying environmental hazards.During an interview on 3/26/2026 at 1:58 PM with the Maintenance Supervisor, he stated the process for when a resident provided their own furniture was to enter it through the front entrance for maintenance to log it in their system and complete a brief review of the furniture. He stated any staff member can move furniture around the room with the resident's permission. He stated he had not declined any furniture due to safety concerns. He stated furniture could be removed for the resident in the event it possessed a potential hazard to the resident. He stated putting a cardboard under a wobbly table was not an approved solution by the facility. In reference to the photo captured of the mini fridge on top of a wobbly table, he stated that this was a potential risk for the resident. He stated any staff member could have notified him, and there were QR codes throughout the facility for anyone to report concerns to him. He stated he had not provided an in-service for identifying environmental hazards. He stated he was the one who set up the table for Resident #123 when she brought it in. He added it was not wobbly at the time of installation, and the cardboard was added later by an unknown staff member. During an interview on 03/26/2026 at 3:32 PM with The Administrator, he stated he could not remember the last in-service training for environmental hazards. He stated that environmental hazards needed to be reported to maintenance immediately with a QR code. He stated that the QR codes are located throughout the facility. He identified examples of environmental hazards could be a loose cord, water on the floor, exposed electricity, air conditioning malfunction, or anything that affected a resident in a negative way. He stated that the only restrictions on resident's furniture were that it couldn't take up their neighbor's space or if a chair wasn't fire retardant. He stated the Maintenance Supervisor needed to review the furniture to ensure the article would not place residents in danger. He stated that the facility would provide notice to the family or resident if there was a concern or repair the furniture if it was possible. He stated that the mini fridge on the wobbly table was a hazard because it was unstable surface. He stated any resident who attempted to open the refrigerator would be at risk for the mini fridge falling on them. He stated there was potential for injury and staff needed to address it immediately. During an interview on 3/26/2026 at 4:30 PM with the DON, she stated she was not familiar with the review process for resident's personal furniture but suspected it was maintenance supervisor who would review furniture. She stated an example of environmental hazard would be clutter, rugs, and cords on the floor. She added having multiple things plugged into an outlet or a chair in the passageway. She stated that residents had dressers, tables, mini fridges, and closets in their room. She stated it was not appropriate for the fridge to be on top of a wobbly table because the support could be dislodged and affected the residents or staff in the room. She stated it needed to be reported immediately, and it could be reported by anyone who utilized the QR codes located throughout the building. She stated that it was not appropriate for a staff member to resolve a wobbly table with a folded cardboard under a table leg. She stated there was potential for injury for anyone in front of the fridge. A policy for environmental hazards was requested at the end of day on 03/25/2026. The policy provided on 03/26/2026 was titled Communication of Hazards to Employees undated, and focused on biological hazards, bodily fluids, and soiled linens. The policy did not provide insight to concerns about compromised furniture.

Based on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (500 Hall nurse cart) reviewed for cleanliness.The facility failed to ensure bottles of liquid medication (milk of magnesia and lactulose), stored in medication cart on the 500 hall did not have dried drippings on the sides of the bottles.This failure could affect residents by placing them at risk of cross contamination. The findings included:An observation of the medication cart in the 500 hall and interview on 03/26/2026 at 11:50p.m., with LVN I revealed medication 1 bottle of lactulose, and one bottle of milk of magnesia to have dried drippings on the side of the bottles. [NAME] colored spots were observed on the side of the medication drawer and on the lids of one bottle of MiraLAX, and 3 bottles of lactulose. LVN I stated that medication bottles were to be cleaned after each use. He stated the bottles could be wiped down with the wipes available in the cart. He stated that it was the nurses responsibility to ensure the bottles were clean after each use. He stated that there could be a possible risk of cross contamination and drippings/ stains did not give off a good look.In an interview on 3/26/2026 at 3:48 p.m., with the DON revealed medication bottles were to be cleaned after every use to prevent cross contamination and from bacteria forming on the dried drippings. She stated that it was the responsibility of the nurses to ensure all bottles were cleaned.In an interview on 03/26/2026 at 4:21 p.m., with the Administrator revealed all medication bottles were to be cleaned after every use to prevent cross contamination. He stated there was a possible risk of infection to the resident if medication was poured out of dirty bottles. He stated that the nurse pouring the medication was responsible for ensuring the bottles were cleaned. He stated that it was also the responsibility of all nurses to ensure medication cart and bottles were kept clean.Review of facility policy titled Medication Storage in the Facility dated 2025 read in part . outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediatly removed from stock,disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if current order exists. Medication storage areas are kept clean, well-lit and free of clutter.

Based on observations, interviews, and record reviews 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 devices when consuming meals for 1 of 8 (Residents #12) residents reviewed for special eating equipment.-The facility failed to provide Resident #12's physician ordered cup with lid for drinking fluids on 03/24/2026, 03/25/2026 and 03/26/2026.This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.Findings included:Record review of Resident #12's admission Record dated 03/26/2026 revealed a [AGE] year-old male with an original admit date of 06/03/2021 and a readmission date of 12/08/2025.Record review of Resident #12's History and Physical dated 12/08/2025 revealed a diagnosis of chronic schizophrenia (mental disorder characterized by disruptions in though process), and polyneuropathy(neurological condition characterized by numbness, tingling weakness and burning pain).Record review of Resident #12's Psychiatric Subsequent assessment dated [DATE] revealed a diagnosis of drug induced subacute dyskinesia (involuntary repetitive movements to include tremors appearing days to weeks after starting antipsychotic medications).Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Section GG- Functional Abilities revealed Resident #12 needed supervision or touching assistance while eating meaning helper provided verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.Record Review of Resident #12's Care plan revised on 11/14/2025 revealed Resident #12 had a regular diet. Interventions included the use of a sippy cup with meals.Record review of Resident #12's Physician Orders revealed an active order for a sippy cup to drink dated 12/08/2025. An observation on 03/24/2026 at 12:15 p.m. revealed Resident #12 drinking coffee from a cup without a lid with his lunch meal. He was noted to have a mild tremor to upper extremity. An observation on 03/25/2026 at 12:25 p.m. revealed Resident #12 drinking coffee from a cup without a lid with his lunch meal, he was observed to spill coffee on his left hand and on the table.An observation on 03/26/2026 at 12:17 p.m. revealed Resident #12 drinking coffee from a cup without a lid with his lunch meal.In an interview on 03/26/2026 at 1:46 p.m. with CNA G revealed that the purpose of a sippy cup was to prevent the resident from spilling liquids, on themselves, and to make it easier for residents to drink their liquids. She stated that the risk of the residents not using the sippy cup would be possible injury due to spilling hot liquids on themselves. She stated it was the responsibility of the staff supervising dining to ensure that all residents were using adequate drinkware.In an interview on 03/26/2026 at 2:00 p.m. with RN H revealed the purpose of the sippy cup was for safety reasons so that residents would not burn themselves with hot liquids. He stated that the CNAs observing the dining room were responsible for ensuring that the residents had adequate drinkware. He stated that a risk would be the possibility of a burn if it was a hot liquid. In an interview on 03/26/2026 at 3:48 p.m. With the DON revealed the purpose of a sippy cup was to protect the residents from spilling liquids on themselves. She stated that it was the responsibility of all staff members to ensure that all residents were using the correct drinkware as ordered. She stated a possible risk would be the resident getting burned if drinking a hot liquid.In an interview on 03/26/2026 at 4:21 p.m., with the Administrator revealed the purpose of the sippy cup was an adaptive aid that residents used to prevent liquid from spilling on them, especially hot liquids. He staed that it was the responsibility of all staff members to ensure that all residents were provided with the adequate aids needed.The facility did not provide a policy regarding adaptive aids before exit.

Based on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 28 residents (Residents #13, #56 and #87) reviewed for call lights. The facility failed to ensure resident call lights were within reach for Residents #13, #56 and #87 on 03/24/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.Findings include:Resident #13Record review of Resident #13's face sheet dated 3/26/2026, revealed a [AGE] year-old female with an admission date of 1/13/2023.Record review of Resident #13's quarterly MDS dated [DATE] revealed BIMS score of 14 indicating cognitively intact. Section GG-Functional Abilities notated Resident #13 was unable to complete oral hygiene, bathing, upper/lower body dressing, rolling to side, and bed/toilet/wheelchair transfers due to medical conditions. Resident was dependent meaning the helper does all the effort required to complete activities for daily living.Record review of Resident #13's care plan dated 1/29/2026 revealed the resident was at risk for falls with an intervention in place to ensure the call light was within reach. The care plan had a focus to address Resident #13's uncontrolled pain with interventions in place to monitor and anticipate the resident's need for pain relief.Record review of Resident #13's Health and Physical dated 3/3/2026 revealed the resident had diagnoses of cerebral palsy (a group of permanent movement and posture disorders), quadriplegic with chronic lower extremity contractures (a person with paralysis or severe weakness in all four limbs), and seizure disorder (unprovoked seizures caused by abnormal electrical activity in the brain).During an observation and interview on 3/24/2026 at 4:22 PM, Resident #13 was sitting in her wheelchair while the call light touch pad was on her bed. Resident #13 stated that she was dependent on staff for everything she needed and added the call light was not accessible to her because she could not move her wheelchair herself to obtain the call light. Resident #13 was approximately 6 feet away from her call light touch pad.Resident #56Record review of Resident #56's admission Record dated 03/26/2026 revealed a [AGE] year-old male with an admission date of 05/23/2024.Record review of Resident # 56's History and Physical dated 03/19/2026 revealed a diagnosis of generalized muscle weakness.Record review of Resident #56's comprehensive MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognitive function. Section GG indicated Resident needed partial/moderate assistance meaning the helper does less than half the effort. Helper lifts or holds, or supports trunk or limbs, but provides less than half the effort when going from sitting to standing position.Record review of Resident #56's care plan revised 03/17/2026 revealed Resident # 56 was a risk for falls. Interventions included to ensure the residents call light was within reach and encouraging the resident to use it for assistance as needed.An observation on 03/24/2026 at 3:38 p.m., revealed Resident #56 asleep in bed. The call light was hanging on a sharps container that was to the right of the resident's bed above the head of the bed.Resident #87Record review of Resident #87's admission Record dated 03/26/2026, revealed a [AGE] year-old female with admission date 05/17/2019.Record review of Resident #87's History and Physical dated 03/26/2026 revealed a medical history of Dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), muscle wasting and atrophy (muscle atrophy is when muscles appear smaller than usual due to a lack of muscle tissue), and Muscle Weakness. Record review of Resident #87's Quarterly MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment.Record review of Resident #87's care plan with revision date 09/30/2021, revealed Resident #87 had a cognitive communication problem with staff intervention to ensure a safe environment including providing the call light within resident reach.An observation was made on 03/24/2026 at 10:08 AM of Resident #87's call light on the floor under the resident's bed and out of her reach. Resident #87 did not answer any of the surveyor's questions.In an interview on 03/26/2026 at 2:47 PM with RN H, he stated the purpose of call lights was for residents to call staff for their needs. He stated the nursing staff rounded on residents every 2 hours which included ensuring the call light was within the residents' reach. He stated the risks for residents not having their call light within reach, included possible falls or not having their needs met. RN H stated residents not having their call light within reach was not safe for the resident.During an interview on 3/26/2026 at 3:24 PM with The Administrator, he stated that a call light was used for residents to contact the staff to provide customer service and care. He stated the call light needed to be within reach for the resident to utilize. He stated everybody in the facility can place a call light within reach for the resident. He added any staff member could respond to an illuminated call light but would be dependent on the staff member's position for what services they could provide . He stated that it affected residents who needed assistance by not having their needs met like a brief change and delayed time response from staff. He was unable to recall the last in service for call lights and did not provide documentation before exiting on 3/26/2026 at 5:45 PM.In an interview on 03/26/2026 at 3:43 PM with the DON, she stated all staff were responsible for ensuring the call light was within the residents' reach. She stated CNAs and Nurses round on residents throughout their shifts. She stated ADONs round on residents 3-4 times on their shift to ensure residents have call lights within reach. The DON stated the potential risk of residents not having the call light within reach included residents being unable to call for help or not having their needs met.On 03/26/2026 at 9 AM, the Administrator stated there was no call light policy.

ased on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 8 residents reviewed for MDS assessments. (Resident #63).-The facility did not accurately code Resident #63's MDSs for a pressure ulcer on the Sacrum that had resolved 11/30/2026. This failure could place the census of 133 residents at risk of not receiving adequate care and services to meet their needs. Findings include:Record review of Resident #63's admission Record dated 03/26/2026 revealed a [AGE] year-old female with admission date 11/07/2025.Record review of Resident #63's History and Physical dated 03/06/2026 revealed a medical history of Type II Diabetes Mellitus (a chronic condition that happens when the body cannot use insulin correctly and sugar builds up in the blood).Record review of Resident #63's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section M- Skin Conditions noted Resident #87 had a Stage II pressure ulcer and had pressure ulcer/injury care.Record review of Resident #63's Care plan revised 11/12/2025, and resolved date 03/26/2026 after surveyor intervention, revealed the resident had a pressure ulcer or potential for pressure ulcer development: Stage 3 to Sacrum (just above the buttocks and at the base of the spine). The staff interventions included Administering treatments as ordered and monitored for effectiveness.Record review of Resident #63's Weekly Skin assessment dated [DATE] noted Resident #63 did not have any pressure, venous, arterial, or diabetic ulcers during assessment. It noted Resident #63 did not have any bruising, skin tears, abrasions (scrape or graze), lacerations (a rip or tear in or on the body), rashes, or moisture-associated skin damage.In an interview on 03/26/2026 at 1:00 PM with Resident #63 revealed she was admitted to the nursing facility last year with a wound which was resolved in the facility months ago. She denied having any wounds at the moment.In an interview on 03/26/2026 at 1:05 PM with MDS Nurse L, he stated Resident #63 had her pressure ulcer to her Sacrum resolved since 11/30/2025. He stated he did not believe there was a potential risk of the resident's MDS having resolved Resident #87's wound as active in the MDS but it was his mistake as the MDS Nurse. He stated that MDS Nursing was responsible for monitoring and confirming that the MDS was updated with resident's information correctly. MDS Nurse L stated MDS Nursing monitored on a quarterly basis and as needed for significant changes.In an interview on 03/26/2026 at 3:37 PM with the DON, she stated floor nursing staff initiated the initial or baseline MDS upon admission. She stated MDS Nursing composed the comprehensive MDS and were responsible for the MDS. She stated she did not believe there was a potential risk for residents having an active wound and wound care noted in the MDS.Record review of the facility's policy Resident Assessment, with no date, read in part: A comprehensive assessment will be completed within 14 days of admission and annually on each resident. It continued to read, 4. The facility will examine each resident and review the minimum data set expanded core elements specified in RAI no less than once every three (3) months and as appropriate. Results must be recorded to assure continued accuracy of the assessment. 5. The results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care.

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 of 7 (Resident #149) residents reviewed for PASRR services.-The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting from 12/18/2025This failure placed the PASRR residents at risk from not receiving services identified by the IDT in a timely manner.Findings include:Record review of Resident #149's face sheet dated 3/26/2026 revealed a [AGE] year-old female with an admission date of 07/08/2025 and a discharge date of 02/25/2026.Record review of Resident #149's Quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed the resident did not have a BIMS score because the resident was rarely/never understood. Section GG-Functional Abilities notated Resident #149 was unable to complete oral hygiene, bathing, upper/lower body dressing, rolling to side, and bed/toilet/wheelchair transfers due to medical conditions. Resident was dependent, meaning the helper does all the effort required to complete activities for daily living.Record review of Resident #149's Care plan dated 12/18/2025 revealed a focus for Resident #149's Parkinson diagnosis with interventions of PT, OT treatment as ordered. An additional focus area was identified for PASRR services with interventions of providing specialized services will be provided per IDT recommendations: PT/OT/ST 3X WEEK and Habilitation Coordination.Record review of Resident #149's Health and Physical dated 2/24/2026 revealed the resident had diagnoses of volvulus of sigmoid colon (a serious condition where the sigmoid colon twists around its stomach fold causing closed-loop bowel obstruction,), large bowel obstruction (blockage of the colon preventing waste passage), advance Parkinson disease (characterized by severe, disabling symptoms-including extreme rigidity, significant balance issues, freezing, and cognitive decline), and debilitated (general weakness, lack of stamina, and functional decline, often linked to advanced age or multiple comorbidities).Record review of the complaint intake dated 3/10/2026 read in part, Attached is the spreadsheet of nursing facilities (NFs) that have been contacted. These NFs were informed that per 26 TAC Chapter 554, Subchapter BB S554.2704 (i)(7). The resident has not received a Medicaid service because of the following: The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident (Resident #149).Record review of Resident #149's PCSP dated 12/18/2025 revealed the meeting was a Local Authority update due to a change in service (Section: A0900) and Resident #149 was Medicaid confirmed payer source (Section A0810). Under Section A2800-Nursing Facility Specialized Services, it was identified as a new finding that Resident #149 required a PT and OT assessment and therapy services.Record review of Resident #149's PCSP dated 01/15/2026 revealed under Section A2800- Nursing Facility Specialized Services, it was identified the findings for related for PT and OT assessment and therapy services was still coded as new. At the time, Resident #149 had a new identified need for ST assessment and therapy services.Record review of the documents titled NFSS Therapist, Referring Physician and NF Administrator Therapy Signature page for Resident #149, revealed the Physical Therapist, Occupational Therapist, Physician, and Administrator signed their portion of the document on 1/15/2026.During an interview on 3/25/2026 at 2:13 PM with the Director of Rehabilitation, she stated she was aware of Resident #149 was PASRR positive (an individual who was identified for having a mental health or intellectual and developmental disorder who required additional screening and services upon entry into a nursing facility) and was present during her care plan meetings. She stated the resident was PASRR 1 positive before admission and transferred from skilled nursing services, then to long term care, then into Hospice. She stated that MDS would provide her with the paperwork and the therapists and herself would complete the assessments in 20 days. She stated the specialized services were PT, OT and ST. She stated the services were initiated on 1/15/2026 following the therapists' signatures. She stated that for PASRR, the authorization from the state had to be provided before providing the services and treatment. She added, once approval came in then the services could begin and authorization was good for 6 months. She stated it was shared responsibility amongst the whole team to meet the NFSS deadlines. She stated if services were delayed, the resident would not see improvement in their condition and would cause a restart after a delay. She stated she recalled a delay in Resident #149's therapy services but could not remember the cause of delay and did not recall being aware of the conditions being vocalized on 12/18/2025 during the PCSP meeting.During an interview on 3/25/2026 at 2:29 PM with the DON, she stated she remembered Resident #149 but was not aware of her PASRR situation and was not aware of any delay in services. She stated that PASRR was comprised of PT, OT, ST, Director of Rehabilitation, The LMHA/LIDDA, Social Worker, and the MDS Nurses. She stated that MDS typically coordinated the PASRR. She stated she could not recall completion of the PASRR 1 or 2 (an individual who was identified for having a mental health or intellectual and developmental disorder who required additional screening and services upon entry into a nursing facility) for Resident #149. She stated she could not recall the specialized services she required for Resident #149. She stated that MDS completed all the documentation in the health record software and conversed with LMHA/LIDDA. She stated she would be notified by MDS if there was any participation required on her part. She stated she was not aware of the timelines for NFSS. She stated that herself, ADON, MDS needed to adhere to the timelines and monitor to ensure they were completed before required deadlines. She stated the delay in services would negatively affect the resident and added she could not elaborate based on limited clinical knowledge on therapy. During an interview on 3/25/2026 at 2:42 PM with MDS Nurse A, she stated she recalled Resident #149 and her PASRR situation. She stated Resident #149 was screened PASRR 1 positive on 7/18/2025. She stated that the resident was screened for PASRR 2 on 7/14/2025 and was positive by LMHA/LIDDA under the IDD portion of the PASRR assessment. She stated Resident #149 did not have any specialized services identified because she was Medicaid pending. She stated that PASRR services stopped when Medicaid was pending. She stated that PASRR specialized services were only for individuals on Medicaid. She stated the family was indecisive on continuing or stopping PASRR for therapy services or admitting Resident #149 into Hospice. She stated that she was confused with the LMHA/LIDDA representative because during the care plan meeting on 12/18/2025 they had clarified with LMHA/LIDDA representative that all specialized services were not going to be provided until January 2026 during the next care plan meeting. She stated that the specialized services for PT and OT were not provided from 12/18/2025 to 01/15/2026. She stated that the therapy department completed notes in their system. She stated that when LMHA/LIDDA provided services, it was documented in an external program. She stated that therapy department, MDS, and clinical team had access to the external program. She identified herself as the individual who was responsible for meeting the NFSS timelines. She stated that the state needed to know within 20 days of specialized services being identified. She stated that the timeline for Resident #149's specialized services identification and therapists' signature was not within the 20-day NFSS requirement. She stated it affected residents who received a delay in services that they would not receive the physical, occupational, and speech therapy needed for improvement. She stated there could be a decline in a resident's wellbeing. During an interview on 3/26/2026 at 10:43 AM with the Physical Therapist, she stated she evaluated Resident #149 on 1/6/2026. She stated the resident was very fragile and required total assistance for bed mobility, had a PEG tube in place, contracture on her right knee, contracture hip abductor bilaterally (both sides), left plantar flexion (downward movement of the foot and ankle) contractions, bilateral (both sides) hand contractions, chronic contractions to the neck. She stated that the findings on 7/29/2025 evaluation had the same findings as those in 1/6/2026. She stated the contractures were too severe for Resident #149 to participate in a PT restoration program and was more focused on providing maintenance for Resident #149. She stated her portion of the PASRR was to complete a document when requested and clarified she did not participate in the care plan meetings. She stated that the Director of Rehabilitation would present the PASRR documents to her when a resident needed to have one completed for specialized services. She stated that the NFSS form came after the 6 of January and was not signed until 1/15/2026. She stated she was not familiar with the PASRR process. She stated she recommended stretching for physical therapy for passive range of motion and tolerate semi-upright in bed with head elevated for Resident #149. She stated she documented her service delivery in an external program and added she did not know who else had access to the external program. She stated that services delayed could result in worsening conditions for residents. During an interview on 3/26/2026 at 3:55 PM with The Administrator, he stated he was familiar with Resident #149 and was aware she was a skilled nursing resident and transferred to LTC with Medicaid pending, then entered Hospice care. He stated when a resident was Medicaid pending, it was difficult to get new services approved. He stated that there was a possibility the facility failed to start PASRR services due to human error from payor source. He stated that there was a pending signature from the Hospice RN that resulted in the delay of care. He stated that he was not familiar when Resident #149 was PASRR 1 positive. He stated he did not know when Resident #149 was screened for PASRR 2. He stated he was not aware of any specialized services Resident #149 required under PASRR. He stated that the MDS reviewed delivery of services for PASRR on a daily and quarterly basis. He stated that the IDT team and MDS were responsible for ensuring the NFSS timelines were met. He stated that ADLs could decline during the period of no service provided. He stated that the IDT needed to report it within 20 days and was unaware if the facility met the requirement for specialized services for Resident #149.Record review of Resident #149's document titled PASRR Level 1 Screening revealed it was completed on 07/08/2025 and that the facility had identified evidence in the resident for a mental illness and a developmental disability.Record review of Resident #149's document titled PASRR Evaluation revealed it was completed on 07/14/2025 by the LMHA/LIDDA representative. Further review revealed Resident #149 presented positive screening for findings under Section B for IDD with identified assistance for nutritional support. coordinating medical treatments. ADLs. development to include social/recreational activities and relationships with othersA policy for PASRR care and treatment was requested at end of day on 3/25/2026 and was not fulfilled before exit on 3/26/2026.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Residents #63) of 6 residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #63 by showing a resolved wound as active.These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Record review of Resident #63's admission Record dated 03/26/2026 revealed a [AGE] year-old female with admission date 11/07/2025.Record review of Resident #63's History and Physical dated 03/06/2026 revealed a medical history of Type II Diabetes Mellitus (a chronic condition that happens when the body cannot use insulin correctly and sugar builds up in the blood).Record review of Resident #63's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section M- Skin Conditions noted Resident #87 had a Stage II pressure ulcer and had pressure ulcer/injury care.Record review of Resident #63's Care plan revised 11/12/2025, and resolved date 03/26/2026 which was during survey, revealed the resident had a pressure ulcer or potential for pressure ulcer development: Stage 3 to Sacrum (just above the buttocks and at the base of the spine). The staff interventions included Administering treatments as ordered and monitored for effectiveness.Record review of Resident #63's Weekly Skin assessment dated [DATE] noted Resident #63 did not have any pressure, venous, arterial, or diabetic ulcers during assessment. It noted Resident #63 did not have any bruising, skin tears, abrasions (scrape or graze), lacerations (a rip or tear in or on the body), rashes, or moisture-associated skin damage.In an interview on 03/26/2026 at 1:00 PM with Resident #63 revealed she was admitted to the nursing facility last year with a wound which was resolved in the facility months ago. She denied having any wounds at the moment.In an interview on 03/26/2026 at 1:04 PM with MDS Nurse L, he stated Resident #63 had her pressure ulcer to her Sacrum resolved since 11/30/2025. He stated there was no potential risk to the resident having an active Pressure Wound diagnosis in the care plan, though it was an error and his mistake. He stated that MDS Nursing was responsible for monitoring and confirming that the care plan was updated correctly. MDS Nurse L stated MDS Nursing monitored on a quarterly basis and as needed for significant changes.In an interview on 03/26/2026 at 2:43 PM with RN H, he stated care plans were started by floor nursing staff and the MDS Nursing were responsible for monitoring the care plan. He stated that MDS Nursing monitored the care plan quarterly. RN H stated potential risks of care plans not reflecting accurate resident information, would include the risk of utilizing or supplying equipment that were no longer needed if the intial issue was resolved.He stated that the ADONs and the DON monitored care plans, but unsure how often.In an interview on 03/26/2026 at 3:36 PM with the DON, she stated floor nurses were responsible for composing the baseline care plan and as needed for acute changes. She stated the comprehensive care plan was monitored every 3 months by MDS Nursing. The DON stated she did not think there was a potential risk of having resolved diagnosis included in the care plan as active, including the care plan noting a resident had a wound and required wound care when they did not.Record review of the facility's policy Comprehensive Care Planning, with no date, read in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. It also read, The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.

Based on observation, interview and record review, the facility failed to develop and implement a care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for 6 (Residents #1, #2, #3, #7, #8 and #9) of 14 residents reviewed for care plans and assessments. -The facility failed to conduct a safety smoking assessment for Residents 1, 2, 3 and 8. -The facility failed to update Residents 1, 2, 3 and 8's care plans to include they smoked and were able to safely smoke. These failures could place residents at risk of not having care needs met regarding smoking supervision which could result in health complications.Findings included: 1. Record review of Resident #1's face sheet, dated 02/13/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE]. Record review of Resident #1's history and physical, dated 01/26/2026, revealed a social history of daily tobacco use. The assessment included osteomyelitis with amputation of 3rd toe right foot (bone infection requiring removal of toe), hypertension (high blood pressure), dyslipidemia (abnormal cholesterol levels), peripheral arterial disease (narrowing of leg arteries reducing blood flow), peripheral vascular disease (poor circulation), benign prostatic hyperplasia (enlarged prostate), coronary artery disease (blocked heart arteries), type 2 diabetes mellitus (high blood sugar), pain (physical discomfort), impaired mobility (difficulty moving independently), and protein calorie malnutrition (poor nutrition). The documentation reflected chronic tobacco use. Record review of Resident #1's admission MDS assessment, dated 01/27/2026, revealed diagnoses including Nicotine Dependence (addiction to tobacco), cognitive communication deficit (difficulty processing or expressing thoughts), muscle Weakness (reduced strength), unsteadiness on Feet (impaired balance), and Impaired Mobility (difficulty ambulating). The MDS reflected physical limitations including left below-knee amputation and toe amputations, which impaired mobility and safe ambulation to and from designated smoking areas. The MDS revealed Resident # 1 required substantial to maximal assistance (staff does more than [NAME] the effort) for upper body dressing (the ability to dress and undress above the waist; including fasteners, if applicable) Record review of Resident #1's care plan, dated 01/26/2026, revealed focus areas including Hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), Anticoagulant Therapy (blood thinning medication increasing bleeding risk), Impaired Cognitive Function (difficulty thinking clearly), ADL Self Care Deficit (difficulty performing daily activities), and Enhanced Barrier Precautions (infection control measures requiring gown and gloves). The care plan included education regarding the adverse effects of tobacco. Further record review revealed care plans did not reflect specific smoking supervision interventions, designated smoking area assistance, lighter control measures, fire prevention strategies, or individualized hazard mitigation despite the residents' nicotine dependence and impaired mobility. During an interview on 02/13/2026 at 2:38 p.m., Resident #1 stated he smoked outside in the designated smoking area. Resident #1 stated he started smoking about a week after his admission into the facility and stated he did not know if the facility evaluated him for smoking safety. Resident #1 stated he requested a staff member take him outside to. Resident #1 stated he did not remember if he was educated on the facility's policies and procedures regarding smoking and said he did not know he needed to let the facility staff know he wished to start smoking. 2. Record review of Resident #2's face sheet, dated 11/26/2025, revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #2's history and physical, dated 02/20/2025, revealed diagnoses including congestive heart failure (chf) (a condition where the heart does not pump blood effectively), chronic kidney disease (ckd) (long-term damage to the kidneys that reduces their ability to filter waste), pleural effusion (fluid buildup around the lungs), depression (persistent feelings of sadness), anxiety (excessive worry or nervousness), nicotine dependence (addiction to tobacco products), atherosclerotic heart disease (hardening and narrowing of the heart arteries), hypokalemia (low potassium levels in the blood), muscle wasting (loss of muscle mass and strength), dysphagia (difficulty swallowing), gait abnormalities (problems with walking or balance), protein calorie malnutrition (lack of proper nutrition causing weight and muscle loss), acute pulmonary edema (sudden fluid buildup in the lungs), respiratory failure with hypoxia (inability to breathe adequately with low oxygen levels), pneumonia (lung infection), hypertension (high blood pressure), anemia (low red blood cell count), and schizophrenia (chronic mental disorder affecting thinking and behavior).Record review of Resident #2's MDS quarterly assessment, dated 01/06/2026, revealed completion by the RN Assessment Coordinator and included evaluation of medications, high-risk drug classes, and clinical status indicators.Record review of Resident #2's care plan, dated 02/21/2025 with revisions through 01/29/2026, revealed interventions for congestive heart failure (CHF) (a condition where the heart does not pump blood effectively) and COPD (chronic obstructive pulmonary disease) (a chronic lung disease that makes breathing difficult) including oxygen therapy (use of supplemental oxygen to assist breathing), monitoring for respiratory distress (watching for signs of trouble breathing), lab monitoring (regular blood testing to check health status), fall precautions (measures to prevent falls), skin integrity interventions for pressure ulcer prevention (steps to prevent skin breakdown and bedsores), antidepressant medication monitoring, and pain. Record review of Resident #3's face sheet, dated 02/03/2026, revealed a [AGE] year-old female with an admission date of 01/07/2026. Record review of Resident #3's admission MDS assessment, dated 01/13/2026, revealed intact cognition with a BIMS score of 15, indicating she was able to make daily decisions independently. Record review of Resident #3's care plan dated 01/07/2026 revealed the care plan was updated on 02/13/2026. The revised care plan revealed the resident was a smoker and that she would be able to smoke without causing injuries calling for interventions including for staff to ensure smoking occurred in the designated smoking area, to ensure there was no oxygen located in the smoking area while the resident was smoking, to ensure Resident #3 was made aware of the facility smoking policy, that no smoking materials were stored in the resident's room and that a safe smoking assessment was conducted every month. The care plan revealed that Resident #3 needed to be always supervised by a visitor or a facility staff member. In an interview on 02/13/2026 at 10:44 AM with Resident #3, stated she smoked, knew where the smoking area was and staff kept her cigarettes and lighter. Resident # 3 stated staff were responsible for lighting her cigarettes as well. 4. Record Review of Resident #8's face sheet 02/03/2026revealed a [AGE] year-old female with an original admission date of 06/28/2024 and a readmission date of 02/05/2022. Record Review of Resident #8's history and physical, dated 06/06/2025, revealed Resident #8 was a [AGE] year-old with diagnoses including seizure disorder (condition causing episodes of abnormal electrical activity in the brain resulting in seizures), essential hypertension (high blood pressure), hypothyroidism (underactive thyroid gland), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), bipolar disorder (mental health condition causing mood swings), metabolic encephalopathy (brain dysfunction caused by metabolic imbalance), anxiety disorder (persistent excessive worry), diabetic neuropathy (nerve damage caused by diabetes), chronic pain (long-lasting pain), obesity (excess body weight), pulmonary nodule (small growth in the lung), GERD (acid reflux disease), diabetic retinopathy (eye damage caused by diabetes), acute respiratory failure with hypoxia (inability to get enough oxygen into the blood), and altered mental status (change in awareness or thinking). The record indicated the resident denied tobacco use. There was no documentation identifying the resident as a smoker. Record review of Resident #8's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 12 (indicating moderately impaired cognition). The MDS indicated the resident required supervision with eating, transfers, and toileting. The resident was noted to have impaired vision (difficulty seeing regular print) and required corrective lenses. There was no documentation within the MDS identifying the resident as a smoker. There was no smoking status documented, and no smoking assessment completed. Resident #8 had seizure disorder (condition causing sudden uncontrolled electrical disturbances in the brain), which increased risk for sudden episodes of loss of awareness and injury. Additionally, the resident had diabetic neuropathy (nerve damage resulting in decreased sensation), impaired vision (reduced ability to see clearly), and chronic pain (persistent pain lasting longer than expected healing time), all of which increased risk for accidents and injury. Record review of Resident #8's care plan, dated 02/03/2026, revealed focus areas for hypertension (high blood pressure), diabetes (high blood sugar), diuretic therapy related to edema (fluid swelling), impaired visual function related to diabetic retinopathy (eye damage from diabetes), depression (persistent sadness), and ADL self-care deficit (difficulty performing daily activities). The care plan included education regarding the adverse effects of tobacco; however, there was no specific problem statement identifying the resident as a smoker, no documented smoking risk assessment, and no interventions addressing supervision, safe smoking location, or monitoring for smoking-related hazards. In an observation and interview on 02/13/2026 at 10:04 AM, Resident #7 was lying on bed watching TV. Resident #7 admitted to be a smoker and showed this investigator he had a pack of cigarettes in the pocket of his jacket. Resident #7 stated he had just got the pack of cigarettes from a family member and that he was to turn it into the facility for safekeeping. Resident #7 stated he did not had a lighter or matches in his possession and said he was aware of the policies and procedures from the facility which stated resident should not keep these items with them and to turn them into the facility upon buying them for safety purposes. In an observation and interview on 02/13/2026 at 10:15 AM, Resident #9 was on his bed watching TV. Resident #9 stated he did not know he needed to let the facility know that he smoked and that to his knowledge, he had not been evacuated to safely smoke. Stated that he knew that he could not smoke inside the facility and that he needed to go outside to the designated smoking area to be able to smoke. Resident #9 had a pack of cigarettes in his nightstand drawer, and he had a lighter inside the pack of cigarettes. Resident #9 stated he knew he needed to give the smoking equipment to the facility staff and said the pack of cigarettes and lighter he had on him was because a family member had given them to him the previous day. During an interview on 02/13/2026 at 10:44 a.m., Resident #3 revealed she smoked, knew where the smoking area was and staff kept her cigarettes and lighter. Resident # 3 stated staff were responsible for lighting her cigarettes as well. In an observation and interview on 02/13/2026 at 11:37 a.m., Resident #8 was observed in the smoking area sitting on a bench with other residents who were smoking. Resident #8 stated she started smoking about two weeks ago and she had just gone to the smoking area and was given cigarettes by other residents. Resident #8 said she did not know if she was evaluated by the facility to safely smoke and stated she did not know the facility's rules for smoking, other than she needed to go outside the facility to the smoking area and that she was not allowed to smoke inside the facility.Resident #1 was observed smoking sitting close to Resident #8. It was observed that CNA A lit Resident #1's cigarette and asked him if he needed help to smoke because his hand was shaking. Resident #1 said he could do it on his own and CNA A said ok, just be careful. In an interview on 02/13/2026 at 1:54 PM with Resident #2, he stated he smoked and had no problems with smoking, holding a cigarette and disposing of ashes. He stated he smoked outside the facility at the designated smoking area and that staff provided his cigarettes and they would light them up for him. Resident #2 stated he did not know if he was assessed to safely smoke at the facility. During an interview on 02/13/2026 at 12:13 p.m., CNA A stated she assisted with overseeing residents during designated smoking times and reported that nursing informed staff which residents were permitted to smoke. She stated cigarettes and lighters were kept in a locked box and staff handed out cigarettes and supervised residents while smoking. CNA A stated she did not know which residents completed smoking assessments and who had not, and she stated she was concerned that some Resident #1 may not have appropriate or safe smoking assessments in place. She stated she was concerned about residents with tremors and poor hand control while smoking and feared the risk of burns or potential fire hazards. CNA A indicated she had informed nursing of her concerns and emphasized that smoking safety remained an ongoing concern among staff due to the potential for injury or fire.During an interview on 02/13/2026 at 3:51 p.m., the Activities Director stated the facility was not following its policies and procedures for the resident's safety and that residents with smoking equipment, such as lighters, in their rooms could potentially result in fire hazards or burns. The Activities Director stated all staff in the facility were responsible for checking the safety of the residents and to immediately report to the administrator if they saw a resident having a lighter or cigarettes in their rooms to prevent fire hazards. Record review of the facility's Nursing Policy and Procedure Manual titled, Comprehensive Care Planning, not dated, stated in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings.The comprehensive care plan will describe the following:Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 7 (Residents #1, #2, #3, #5, #7, #8 and #9) of 14 residents reviewed for quality of care. The facility failed on 02/12/2026 to ensure CNA C communicated to the Charge Nurse or DON of Resident #5's fall.This failure could place residents at risk of not having care needs met, which could result in health complications.Findings included: Resident #1: Record review of Resident #1's face sheet dated 02/13/2026 revealed a [AGE] year-old male with an initial admission date of 03/31/2022 and readmitted on [DATE]. Record review of Resident #1's history and physical dated 01/26/2026 revealed a social history of daily tobacco use. The assessment included Osteomyelitis with Amputation of 3rd Toe Right Foot (bone infection requiring removal of toe), Hypertension (high blood pressure), Dyslipidemia (abnormal cholesterol levels), Peripheral Arterial Disease (narrowing of leg arteries reducing blood flow), Peripheral Vascular Disease (poor circulation), Benign Prostatic Hyperplasia (enlarged prostate), Coronary Artery Disease (blocked heart arteries), Type 2 Diabetes Mellitus (high blood sugar), Pain (physical discomfort), Impaired Mobility (difficulty moving independently), and Protein Calorie Malnutrition (poor nutrition). The documentation reflected chronic tobacco use. Record review of Resident #1's admission MDS assessment dated [DATE] revealed diagnoses including Nicotine Dependence (addiction to tobacco), Cognitive Communication Deficit (difficulty processing or expressing thoughts), Muscle Weakness (reduced strength), Unsteadiness on Feet (impaired balance), and Impaired Mobility (difficulty ambulating). The MDS reflected physical limitations including left below-knee amputation and toe amputations, which impaired mobility and safe ambulation to and from designated smoking areas. Record review of Resident #1's care plan dated 01/26/2026 revealed focus areas including Hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), Anticoagulant Therapy (blood thinning medication increasing bleeding risk), Impaired Cognitive Function (difficulty thinking clearly), ADL Self Care Deficit (difficulty performing daily activities), and Enhanced Barrier Precautions (infection control measures requiring gown and gloves). The care plan included education regarding the adverse effects of tobacco; however, the documentation did not clearly reflect specific smoking supervision interventions, designated smoking area assistance, lighter control measures, fire prevention strategies, or individualized hazard mitigation despite the residents' nicotine dependence and impaired mobility. Resident #2 Record review of Resident #2's face sheet dated 11/26/2025 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #2's History and Physical dated 02/21/2025 revealed diagnoses including Nicotine Dependence (tobacco addiction), COPD (chronic lung disease causing breathing difficulty), Respiratory Failure with Hypoxia (inadequate oxygen levels in the blood), Pneumonia (lung infection), Pulmonary Edema (fluid in the lungs), Pleural Effusion (fluid around the lungs), Chronic Kidney Disease Stage 5 (advanced kidney failure), Anemia (low red blood cell count), and Bipolar Disorder (mood disorder with mood swings). Although Nicotine Dependence was listed as a diagnosis, the H&P documented under Social History that the resident denied tobacco use, creating inconsistency in smoking documentation. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognition with mild recall difficulty. The MDS section I - Active Diagnoses revealed Resident #2 had debility, cardiorespiratory conditions (medical problems that affect breathing and blood circulation). Record review of Resident #2's Care Plan dated 01/29/2026 revealed a problem area addressing coronary artery disease (condition where the blood vessels that supply blood to the heart, called coronary arteries, become narrowed or blocked due to buildup of plaque (fat, cholesterol, and other substances) and included an intervention to 'encourage resident to refrain from smoking.' However, the care plan did not include a specific smoking supervision plan, designated smoking area guidance, staff supervision requirements, smoking safety precautions, lighter control procedures, or fire risk mitigation interventions. No individualized smoking safety assessment was identified despite the documented diagnosis of Nicotine Dependence. Record review of Resident #2's assessments revealed the facility did not have a safe smoking assessment on their electronic records. Resident #3 Record review of Resident #3's face sheet dated revealed a [AGE] year-old female with an admission date of 01/07/2026. Record review of Resident #3's History and Physical dated 01/07/2026 revealed a Resident #3 was a [AGE] year-old female with a history of chronic smoking, lung nodule (small abnormal lung growth), physical debility (overall body weakness), anxiety (excessive worry), and insomnia (sleep disturbance). The history and physical revealed a history of respiratory health issues, substance use disorder, and smoking safety. Record review of Resident #3's admission assessment MDS dated [DATE] revealed intact cognition with a BIMS score of 15, indicating she was able to make daily decisions independently. However, the MDS did not clearly document smoking behaviors or specify supervision requirements related to tobacco use. The absence of detailed smoking risk documentation contrasted with the Safe Smoking Assessment indicating supervision was required. Record review of Resident #3's care plan dated 01/07/2026 revealed the care plan was updated on 02/13/2026. The revised care plan revealed the resident was a smoker and that she would be able to smoke without causing injuries calling for interventions including for staff to ensure smoking occurred in the designated smoking area, to ensure there was no oxygen located in the smoking area while the resident was smoking, to ensure Resident #3 was made aware of the facility smoking policy, that no smoking materials were stored in the resident's room and that a safe smoking assessment was conducted every month. The care plan revealed that Resident #3 needed to be always supervised by a visitor or a facility staff member.Resident #5Record review of Resident #5's admission Record, 09/12/2026 revealed Resident #5 was a [AGE] year-old male, admitted [DATE], and readmitted [DATE] from an acute (a sudden change in a resident's condition that is severe, new, or rapidly worsening and requires immediate medical attention) care hospital.Record review of Resident #5's History and Physical, dated 01/02/2026, revealed diagnoses of nondisplaced intertrochanteric fracture of the left femur (a break in the upper part of the thigh bone near the hip that did not shift out of place), atrial fibrillation (an irregular and often rapid heart rhythm), altered mental status (a change in awareness, thinking, or alertness), legal blindness (severe vision loss meeting legal criteria), repeated falls (a history of falling multiple times), mild dementia (cognitive decline affecting memory and judgment), type 2 diabetes mellitus (a chronic condition causing elevated blood sugar), hypokalemia (low potassium levels in the blood), and essential hypertension (high blood pressure).Record review of Resident #5's significant change in status MDS assessment, dated 01/08/2026, revealed a BIMS score of 01, indicating severe cognitive impairment and impaired decision-making ability. Record review of Section GG, Functional Abilities and Goals, revealed the resident required assistance with bed mobility, transfers, and ambulation. The MDS revealed Resident # 5 required staff assistance for sit-to-lying, lying-to-sitting, sit-to-stand, chair/bed-to-chair transfers, and walking activities.Record review of Resident #5's Care Plan, dated 12/02/2025, revealed the resident was identified as at risk for falls. The care plan included goals that the resident would be free of falls and would not sustain serious injury. Resident #5's care plan revealed listed interventions included ensuring the call light was within reach and encouraging its use, providing education regarding safety measures and actions to take if a fall occurred, encouraging participation in activities to promote strengthening and improved mobility, ensuring appropriate footwear during ambulation, keeping furniture locked and needed items within reach, and providing staff assistance with transfers (staff x1). Resident #8 Record Review of Resident #8's face sheet revealed a [AGE] year-old female with an original admission date of 06/28/2024 and a readmission date of 02/05/2022. Record Review of Resident #8's history and physical dated 06/06/2025 revealed Resident #8 was a [AGE] year-old long-term care resident with diagnoses including seizure disorder (condition causing episodes of abnormal electrical activity in the brain resulting in seizures), essential hypertension (high blood pressure), hypothyroidism (underactive thyroid gland), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), bipolar disorder (mental health condition causing mood swings), metabolic encephalopathy (brain dysfunction caused by metabolic imbalance), anxiety disorder (persistent excessive worry), diabetic neuropathy (nerve damage caused by diabetes), chronic pain (long-lasting pain), obesity (excess body weight), pulmonary nodule (small growth in the lung), GERD (acid reflux disease), diabetic retinopathy (eye damage caused by diabetes), acute respiratory failure with hypoxia (inability to get enough oxygen into the blood), and altered mental status (change in awareness or thinking). The record indicated that the resident denied tobacco use. There was no documentation identifying the resident as a smoker. There was no evidence of a smoking assessment completed. Record review of Resident #8's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12 (indicating moderately impaired cognition). The MDS indicated the resident required supervision with eating, transfers, and toileting. The resident was noted to have impaired vision (difficulty seeing regular print) and required corrective lenses. There was no documentation within the MDS identifying the resident as a smoker. There was no smoking status documented, and no smoking assessment completed. Resident #8's had seizure disorder (condition causing sudden uncontrolled electrical disturbances in the brain), which increased risk for sudden episodes of loss of awareness and injury. Additionally, the resident had diabetic neuropathy (nerve damage resulting in decreased sensation), impaired vision (reduced ability to see clearly), and chronic pain (persistent pain lasting longer than expected healing time), all of which increased risk for accidents and injury. Record review of Resident #8's care plan dated 02/03/2026 revealed focus areas for hypertension (high blood pressure), diabetes (high blood sugar), diuretic therapy related to edema (fluid swelling), impaired visual function related to diabetic retinopathy (eye damage from diabetes), depression (persistent sadness), and ADL self-care deficit (difficulty performing daily activities). The care plan included education regarding the adverse effects of tobacco; however, there was no specific problem statement identifying the resident as a smoker, no documented smoking risk assessment, and no interventions addressing supervision, safe smoking location, or monitoring for smoking-related hazards. Record review on 2/13/26 at 2:38 PM of Resident #8's assessment conducted by the facility revealed the facility did not have records for this resident on safely smoking assessments. Resident # 9Record review of Resident #9's admission Record, 02/02/2026 revealed he was a [AGE] year-old male admitted on [DATE]. Record review of Resident #9's History and Physical, dated 10/01/2025, revealed a past medical history significant for dementia (a decline in memory and reasoning abilities), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol levels), diabetes mellitus type 2 (high blood sugar due to insulin resistance), arthritis (joint inflammation and pain), atrial fibrillation (irregular heartbeat that increases stroke risk), gastroesophageal reflux disease (chronic acid reflux), and cognitive communication deficit (difficulty processing or expressing language). The social history section documented that he denied smoking at the time of admission. Record review of Resident #9's MDS Quarterly Assessment, dated 01/05/2026, revealed a BIMS score of 12, which indicated moderate cognitive impairment. The MDS reflected he was generally understood and able to understand others. Under Section I, Active Diagnoses, the MDS revealed Resident #9 had diabetes and non-Alzheimer's dementia. Under section J, Health Conditions, the MDS revealed Resident #9 had shortness of breath. Record review of Resident #9's Care Plan on 02/13/2026 at 1:32 PM revealed Resident #9 had hypertension (high blood pressure), diabetes mellitus type 2 (high blood sugar levels), anticoagulant therapy (blood thinning medication used to prevent clots), GERD (acid reflux), arthritis (joint pain and stiffness), and cognitive impairment (reduced memory and judgment). The care plan included education encouraging avoidance of smoking in relation to GERD management. The care plan indicated smoking materials were kept at the nurses' station. The documentation did not clearly describe supervision frequency, monitoring for burns, or risk mitigation in relation to his dementia (impaired judgment), atrial fibrillation (heart rhythm disorder), or anticoagulant therapy (blood thinning medication increasing bleeding risk if injured). Record review of Resident #9's Safe Smoking Assessment, dated 02/13/2026, revealed he knew the designated smoking areas and could independently access them. He was able to independently light smoking materials safely, extinguish them appropriately, and dispose of ashes properly. The assessment documented that he did not have tremors (involuntary shaking), did not fall asleep while smoking, had no prior smoking-related incidents, had no visible burn marks, and did not have finger dexterity problems (difficulty using his hands or fingers). The summary indicated he was safe to smoke unsupervised at that time. All smoking materials were kept at the nurses' station. The evaluation had been discussed with the resident and family responsible. The smoking assessment was conducted at the date of entrance to the facility by this investigator. In an observation and interview on 02/13/2026 at 10:04 AM, Resident #7 was lying on bed watching TV. Resident #7 admitted to be a smoker and showed this investigator he had a pack of cigarettes in the pocket of his jacket. Resident #7 stated he had just got the pack of cigarettes from a family member and that he was to turn it into the facility for safekeeping. Resident #7 stated he did not had a lighter or matches in his possession and said he was aware of the policies and procedures from the facility which stated resident should not keep these items with them and to turn them into the facility upon buying them for safety purposes. In an observation and interview on 02/13/2026 at 10:15 AM, Resident #9 was on his bed watching TV. Resident #9 stated he did not know he needed to let the facility know that he smoked and that to his knowledge, he had not been evaluated to safely smoke. Resident #9 stated that he knew that he could not smoke inside the facility and that he needed to go outside to the designated smoking area to be able to smoke. Resident #9 had a pack of cigarettes in his nightstand drawer, and he had a lighter inside the pack of cigarettes. Resident #9 stated he knew he needed to give the smoking equipment to the facility staff and said the pack of cigarettes and lighter he had on him was because a family member had given them to him the previous day. In an interview on 02/13/2026 at 10:44 AM with Resident #3, it revealed she was a smoker and the Resident stated she knew where the smoking area was and that staff kept her cigarettes and lighter. Resident # 3 stated that staff were responsible for lighting her cigarettes as well. In an observation and interview on 02/13/2026 at 11:37 AM, Resident #8 was observed in the smoking area sitting on a bench at proximity to other residents who were smoking. Resident #8 stated she had started smoking about two weeks ago and she had just gone to the smoking area and was given cigarettes by other residents. Resident #8 said she did not know if she had been evaluated by the facility so she could safely smoke and stated she did not know the facility's rules for smoking, other than she needed to go outside the facility to the smoking area and that she was not allowed to smoke inside the facility.Resident #1 was observed smoking sitting close to Resident #8. It was observed that CNA A lit Resident #1's cigarette and asked him if he needed help to smoke because his hand was shaking. Resident #1 said he could do it on his own and CNA A said ok, just be careful. In an interview on 02/13/2026 at 1:54 PM with Resident #2, he stated that he was a smoker and said he had no problems smoking, holding a cigarette and disposing of ashes. He stated he smoked outside the facility at the designated smoking area and that staff provided his cigarettes and they would light them up for him. Resident #2 stated he did not know if he was assessed to safely smoke in the facility. In an interview on 02/13/2026 at 12:13 PM with CNA A revealed she assisted with overseeing residents during designated smoking times and reported that nursing informed staff which residents were permitted to smoke. She explained that cigarettes and lighters were kept in a locked box and that staff handed out cigarettes and supervised residents while smoking. CNA A expressed concern that she did not know which residents from the facility had completed smoking assessments and who had not, which made her worried that some residents may not have had appropriate or safe smoking assessments in place. She reported concerns about residents with tremors and poor hand control while smoking and feared the risk of burns or potential fire hazards. CNA A stated that residents were allowed to engage in smoking activities without clear confirmation that individualized safety needs had been evaluated and implemented, potentially compromising the provision of necessary care and supervision to prevent avoidable harm. In an interview on 02/13/2026 at 12:54 PM with the DON revealed the facility had a smoking policy and that residents who identified as smokers upon admission were to receive a nursing smoking assessment to determine if they were cognitively appropriate and safe to smoke. She explained that smoking without an assessment was not permitted and that staff were expected to stop any residents from smoking until the required assessment was completed. The DON stated that failure to ensure individualized assessments and implementation of appropriate supervision could affect the facility's ability to provide care and services necessary to maintain residents' highest practicable physical health and safety. In an interview on 02/13/2026 at 2:38 PM, with Resident #1 revealed he had been smoking outside in the designated smoking area. Resident #1 stated he had started smoking about a week after his admission into the facility and stated he did not know if the facility had evaluated him for smoking. Resident #1 stated he requested a staff member to take him outside to smoke and he had been cigarettes by the staff who were outside looking after him. Resident #1 stated he did not remember if he was educated on the facility's policies and procedures regarding smoking and said he did not know he needed to let the facility staff know he wished to start smoking. In an interview on 02/13/2026 at 3:01 PM with ADON B, she stated smoking assessments should be completed immediately once a resident wished to participate in smoking. ADON B stated failure to complete assessments timely may create safety risks for residents, staff, and visitors, including potential burns or fire hazards. ADON B stated that without prompt evaluation and implementation of appropriate supervision and safety measures, residents may be exposed to avoidable harm. In an interview on 02/13/2026 at 3:09 PM with the Administrator, he stated all residents who wished to participate in smoking needed to be assessed to ensure their safety and the safety of others. He stated that if residents possessed smoking equipment without proper assessment, it could result in burns or injuries. The Administrator stated that individualized safety measures were necessary to prevent accidents and ensure residents received adequate supervision and services consistent with their needs. In an interview on 02/13/2026 at 3:51 PM with the Activities Director she stated the facility was not consistently following its policies and procedures related to resident smoking safety. She said that residents having smoking equipment such as lighters in their rooms could result in fire hazards or burns. The Activities director stated the facility failed to consistently implement safety measures necessary to prevent accidents and ensure residents received care and supervision sufficient to maintain their highest practicable well-being. During an interview on 02/17/2026 at 10:12 a.m., CNA C stated Resident #5 lost balance during a transfer from his wheelchair to his bed and fell on his buttocks to his left side to the floor on the floormat. CNA C stated she knew she was required to report the fall to the charge nurse or DON immediately but forgot to do so. CNA C stated that upon assisting the resident, he did not complain of any pain. CNA C stated she understood that failing to report the fall was not acceptable and falls not reported in a timely manner could result in injuries not being noticed, which could make the resident's health conditions worsen. CNA C stated she was wrong by not immediately reporting the resident's fall. During an interview on 02/17/2026 at 10:34 a.m., CNA K stated all staff who had contact with the residents at the facility were responsible for their safety and that all falls needed to be reported immediately to the charge nurse or the DON. CNA K stated that failing to report a fall immediately could result in injuries not being treated in a timely manner and stated it was not acceptable not to report any resident's fall or injury. During an interview on 02/17/2026 at 10:54 a.m., LVN E stated CNAs, LVNs, and RNs in the facility were trained on fall prevention and reporting and all staff were required to immediately report any fall or injury to the charge nurses and the DON. LVN E stated it was not acceptable for a CNA not to report a fall because the resident could have unseen injuries. LVN E stated not reporting a fall put residents at risk of further injury or needing to go to the hospital, if left untreated. In an interview on 02/17/2026 at 11:10 a.m., CNA D stated he assisted CNA C with Resident #5 after the resident fell in his room during a transfer. CNA D stated that when he assisted CNA C with Resident #5 to his bed, he did not complain of pain. CNA D reported that CNA C informed him she would notify the charge nurse of the fall. CNA D stated that facility expectations required falls to be reported immediately to a licensed nurse. He stated that failure to report a fall could result in the residents not being timely assessed by nursing staff, potentially leading to unidentified injuries and further harm. During an interview on 02/17/2026 at 2:30 p.m., the DON stated CNAs were required to immediately report any fall to a licensed nurse for assessment. The DON stated it was not within a CNAs scope of practice to determine whether a resident could be repositioned after a fall without nursing evaluation. She stated that failure to report a fall timely could result in the resident not being properly assessed, potentially leading to unidentified injuries and further harm. During an interview on 02/17/2026 at 3:25 p.m., the Administrator stated the CNA should have immediately reported the fall to the charge nurse so the resident could be assessed prior to being repositioned. He stated it was not appropriate for a CNA to independently determine the resident's condition after a fall. He further stated that failure to report the fall timely could result in delayed medical evaluation, worsening of injuries, or additional traumaRecord review of the facility's policy and procedures titled Uniform Smoke Free Policy, not dated, stated in part: Residents and employees are prohibited from smoking in any of the facility's buildings except in the designated smoking area. The designated smoking areas will be environmentally separate from all resident care areas and equipped with exhaust fans. The restrictions are intended to restrict smoking to a minimum and reduce risks to residents who smoke, including possible adverse effects on treatment; reduce risks of passive smoking for others; and reduce the risk of fire. The resident and responsible party, if applicable, will be informed of the smoking policy upon admission and in conjunction with care plan meetings thereafter.Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel. Smoking will be permitted only in designated areas of the facility. Smoking is prohibited in resident rooms.Employees, medical staff, residents, and visitors are expected to adhere to the no smoking policy. Employees, medical staff, residents, and visitors must smoke in the designated outdoor area only. Employees, medical staff, and visitors will receive instructions as needed. It will be the responsibility of the management personnel to enforce the no smoking policy. A resident, who is assessed safe to smoke unsupervised, will be instructed to obtain their smoking paraphernalia from a designated, secured area. The resident will be instructed to return the smoking paraphernalia following the smoking session. The resident may smoke at their request, unless the time interferes with resident care. A resident, who is assessed unsafe to smoke without supervision, will be notified of the facilities site specific smoking times, at which time the resident will have supervision and assistance as needed. A resident who is assessed unsafe to smoke unsupervised must be in direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor, must be aware of these responsibilities. Record review of the facility's Nursing Policy and Procedure Manual titled Comprehensive Care Planning, not dated, stated in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings.The comprehensive care plan will describe the following:Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Record review of the facility's Policy and Procedures titled Fall Risk Manual, not dated, revealed in part: Fall Policy (MM FR 03-4.0):In instances where fall risk measures do not prevent a fall, the residents will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. The nurse will complete an event fall nurses note after each fall. Falls resulting in serious injury will be reported to the DON and/or Administrator. The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as required. Event Reporting; Completion Of (QA 03-2.0):1. The facility will complete an Event report on variances that occur within the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others.2. All Events that result in treatment beyond immediate first aid must be reported immediately to the Administrator and/or DON. The supervisor of the shift on which the Event occurred will be responsible for notifying the Administrator and/or DON.3. All Events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident. Documentation of the notification and subsequent interventions and comments must be recorded in the resident's clinical record and/or on the Event Note. Any physician order should be followed.4. The Administrator and/or DON will be responsible for ensuring completion of documentation and notification of the physician and the family member as well as notification to the home office and the Tx DADS as applicable.7. Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events of the reported Event including persons, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form.8. Interventions: Include and care plan any required interventions or supervision to help prevent further occurrence of the event.

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 5 (Resident #1, Resident #2, , Resident #8, Resident #7 and Resident #9) of 14 residents reviewed for smoking safety. -The facility failed to conduct a safe smoking assessment for Resident #1.-The facility failed to update Resident #2's care plan for smoking.-The facility failed to ensure Resident #7 had cigarettes in his room. -The facility failed to ensure Resident #8 had a safe smoking assessment and a care plan for smoking.-The facility failed to ensure Resident #9 had a cigarette lighter in his room.-The facility failed to assess and supervise residents who smoked.Findings included: Record review of Resident #1's face sheet, dated 02/13/2026, revealed a [AGE] year-old male with an initial admission date of 03/31/2022 and readmitted on [DATE]. Record review of Resident #1's history and physical, dated 01/26/2026, revealed a social history of daily tobacco use. The assessment included Osteomyelitis with Amputation of 3rd Toe Right Foot (bone infection requiring removal of toe), Hypertension (high blood pressure), Dyslipidemia (abnormal cholesterol levels), Peripheral Arterial Disease (narrowing of leg arteries reducing blood flow), Peripheral Vascular Disease (poor circulation), Benign Prostatic Hyperplasia (enlarged prostate), Coronary Artery Disease (blocked heart arteries), Type 2 Diabetes Mellitus (high blood sugar), Pain (physical discomfort), Impaired Mobility (difficulty moving independently), and Protein Calorie Malnutrition (poor nutrition). The documentation reflected chronic tobacco use. Record review of Resident #1's admission MDS assessment dated [DATE] revealed diagnoses including Nicotine Dependence (addiction to tobacco), Cognitive Communication Deficit (difficulty processing or expressing thoughts), Muscle Weakness (reduced strength), Unsteadiness on Feet (impaired balance), and Impaired Mobility (difficulty ambulating). The MDS reflected physical limitations including left below-knee amputation and toe amputations, which impaired mobility and safe ambulation to and from designated smoking areas. Record review of Resident #1's care plan dated 01/26/2026 revealed focus areas including Hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), Anticoagulant Therapy (blood thinning medication increasing bleeding risk), Impaired Cognitive Function (difficulty thinking clearly), ADL Self Care Deficit (difficulty performing daily activities), and Enhanced Barrier Precautions (infection control measures requiring gown and gloves). The care plan included education regarding the adverse effects of tobacco; however, the documentation did not clearly reflect specific smoking supervision interventions, designated smoking area assistance, lighter control measures, fire prevention strategies, or individualized hazard mitigation despite the residents' nicotine dependence and impaired mobility. Record review of Resident #2's face sheet dated 11/26/2025 revealed a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #2's History and Physical dated 02/21/2025 revealed diagnoses including Nicotine Dependence (tobacco addiction), COPD (chronic lung disease causing breathing difficulty), Respiratory Failure with Hypoxia (inadequate oxygen levels in the blood), Pneumonia (lung infection), Pulmonary Edema (fluid in the lungs), Pleural Effusion (fluid around the lungs), Chronic Kidney Disease Stage 5 (advanced kidney failure), Anemia (low red blood cell count), and Bipolar Disorder (mood disorder with mood swings). Although Nicotine Dependence was listed as a diagnosis, the H&P documented under Social History that the resident denied tobacco use, creating inconsistency in smoking documentation. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognition with mild recall difficulty. The MDS section I - Active Diagnoses revealed Resident #2 had debility, cardiorespiratory conditions (medical problems that affect breathing and blood circulation). Record review of Resident #2's Care Plan dated 01/29/2026 revealed a problem area addressing coronary artery disease (condition where the blood vessels that supply blood to the heart, called coronary arteries, become narrowed or blocked due to buildup of plaque (fat, cholesterol, and other substances) and included an intervention to 'encourage resident to refrain from smoking.' However, the care plan did not include a specific smoking supervision plan, designated smoking area guidance, staff supervision requirements, smoking safety precautions, lighter control procedures, or fire risk mitigation interventions. No individualized smoking safety assessment was identified despite the documented diagnosis of Nicotine Dependence. Record review of Resident #2's assessments revealed the facility did not have a safe smoking assessment on their electronic records. Record review of Resident #7's face sheet, dated 01/16/2026, revealed the resident was admitted on [DATE]. Record review of Resident #7's history and physical, dated 01/16/2026, revealed he was admitted with multiple diagnoses including other acute osteomyelitis, left ankle and foot (bone infection in the left ankle and foot), type 2 diabetes mellitus with hyperglycemia (high blood sugar), Typical atrial flutter (irregular heart rhythm), Cellulitis of the left lower limb (skin infection of the left leg), muscle wasting and atrophy (loss of muscle mass), generalized muscle weakness (overall decreased strength), dysphagia (difficulty swallowing), unsteadiness on feet (poor balance), other abnormalities of gait and mobility (difficulty walking), age-related cognitive decline (memory and thinking decline associated with aging), major depressive disorder (ongoing depression), and anxiety disorder (persistent worry). The record revealed the resident had bilateral below-knee amputations (both legs surgically removed below the knees) and infections of the amputation stumps (infection at the surgical site of removed limbs). Record review of Resident #7's admission MDS assessment, dated 01/22/2026, revealed a BIMS score of 15 (indicating intact cognition). Resident #7 was coded as unsteady on feet (poor balance) and required assistance with ADLs. The MDS revealed Resident #7 required staff assistance for dressing, eating, toileting, and transfers. The resident utilized a wheelchair (mobility device for individuals unable to ambulate independently) for ambulation. Further review revealed the resident was on anticoagulant therapy related to typical atrial flutter (blood thinning medication used for irregular heart rhythm), which increased the risk of excessive bleeding if injured. The resident was also on diuretic therapy (medication that increases urination and may cause dizziness). Record review of Resident #7's Care Plan, dated 01/19/2026 and revised on 01/29/2026, revealed a focus area identifying the resident smoked. The stated goal was Resident #7 would be able to smoke without causing injury. Interventions included ensuring smoking occurred in designated smoking areas, ensuring no oxygen was located in the smoking area while the resident was smoking, ensuring the resident and/or responsible party was made aware of the facility smoking policy, prohibiting smoking materials or igniters from being stored in the resident's room, completing a Safe Smoking Assessment every month. Further record review of the care plan further revealed the resident was considered safe to smoke unsupervised. Record review of Resident #7's safe smoking assessment dated [DATE], revealed the resident knew of the location designated for smoking, that he could get to the area independently, that he was able to light, extinguish and dispose of ashes and smoking materials safely. 5. Record Review of Resident #8's face sheet revealed a [AGE] year-old female with an original admission date of 06/28/2024 and a readmission date of 02/05/2022. Record Review of Resident #8's history and physical dated 06/06/2025 revealed Resident #8 was a [AGE] year-old long-term care resident with diagnoses including seizure disorder (condition causing episodes of abnormal electrical activity in the brain resulting in seizures), essential hypertension (high blood pressure), hypothyroidism (underactive thyroid gland), Type 2 diabetes mellitus with hyperglycemia (high blood sugar), bipolar disorder (mental health condition causing mood swings), metabolic encephalopathy (brain dysfunction caused by metabolic imbalance), anxiety disorder (persistent excessive worry), diabetic neuropathy (nerve damage caused by diabetes), chronic pain (long-lasting pain), obesity (excess body weight), pulmonary nodule (small growth in the lung), GERD (acid reflux disease), diabetic retinopathy (eye damage caused by diabetes), acute respiratory failure with hypoxia (inability to get enough oxygen into the blood), and altered mental status (change in awareness or thinking). The record indicated that the resident denied tobacco use. There was no documentation identifying the resident as a smoker. There was no evidence of a smoking assessment completed. Record review of Resident #8's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12 (indicating moderately impaired cognition). The MDS indicated the resident required supervision with eating, transfers, and toileting. The resident was noted to have impaired vision (difficulty seeing regular print) and required corrective lenses. There was no documentation within the MDS identifying the resident as a smoker. There was no smoking status documented, and no smoking assessment completed. Resident #8's had seizure disorder (condition causing sudden uncontrolled electrical disturbances in the brain), which increased risk for sudden episodes of loss of awareness and injury. Additionally, the resident had diabetic neuropathy (nerve damage resulting in decreased sensation), impaired vision (reduced ability to see clearly), and chronic pain (persistent pain lasting longer than expected healing time), all of which increased risk for accidents and injury. Record review of Resident #8's care plan dated 02/03/2026 revealed focus areas for hypertension (high blood pressure), diabetes (high blood sugar), diuretic therapy related to edema (fluid swelling), impaired visual function related to diabetic retinopathy (eye damage from diabetes), depression (persistent sadness), and ADL self-care deficit (difficulty performing daily activities). The care plan included education regarding the adverse effects of tobacco; however, there was no specific problem statement identifying the resident as a smoker, no documented smoking risk assessment, and no interventions addressing supervision, safe smoking location, or monitoring for smoking-related hazards. Record review on 2/13/26 at 2:38 PM of Resident #8's assessment conducted by the facility revealed the facility did not have records for this resident on safely smoking assessments. 6. Record review of Resident #9's admission Record revealed he was a [AGE] year-old male admitted on [DATE]. Record review of Resident #9's History and Physical dated 10/01/2025 revealed a past medical history significant for dementia (a decline in memory and reasoning abilities), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol levels), diabetes mellitus type 2 (high blood sugar due to insulin resistance), arthritis (joint inflammation and pain), atrial fibrillation (irregular heartbeat that increases stroke risk), gastroesophageal reflux disease (chronic acid reflux), and cognitive communication deficit (difficulty processing or expressing language). The social history section documented that he denied smoking at the time of admission. Record review of Resident #9's MDS Quarterly assessment dated [DATE] revealed a BIMS score of 12, which indicated moderate cognitive impairment. The MDS reflected he was generally understood and able to understand others. Under Section I - Active Diagnoses, the MDS revealed Resident #9 had diabetes and non-Alzheimer's dementia. Under section J - Health Conditions, the MDS revealed Resident #9 had shortness of breath. Record review of Resident #9's Care Plan on 02/13/2026 at 1:32 PM revealed interventions addressing hypertension (high blood pressure), diabetes mellitus type 2 (high blood sugar levels), anticoagulant therapy (blood thinning medication used to prevent clots), GERD (acid reflux), arthritis (joint pain and stiffness), and cognitive impairment (reduced memory and judgment). The care plan included education encouraging avoidance of smoking in relation to GERD management. The care plan indicated smoking materials were kept at the nurses' station. The documentation did not clearly describe supervision frequency, monitoring for burns, or risk mitigation in relation to his dementia (impaired judgment), atrial fibrillation (heart rhythm disorder), or anticoagulant therapy (blood thinning medication increasing bleeding risk if injured). The care plan was updated on the date of the investigations as it did not have indications prior to the date of entrance to the facility. Record review of Resident #9's Safe Smoking assessment dated [DATE] revealed he knew the designated smoking areas and could independently access them. He was able to independently light smoking materials safely, extinguish them appropriately, and dispose of ashes properly. The assessment documented that he did not have tremors (involuntary shaking), did not fall asleep while smoking, had no prior smoking-related incidents, had no visible burn marks, and did not have finger dexterity problems (difficulty using his hands or fingers). The summary indicated he was safe to smoke unsupervised at that time. All smoking materials were kept at the nurses' station. The evaluation had been discussed with the resident and family responsible. The smoking assessment was conducted at the date of entrance to the facility by this investigator. During an observation and interview on 02/13/2026 at 10:04 a.m., Resident #7 was lying on bed watching TV. Resident #7 said he smoked and was observed with a pack of cigarettes in the pocket of his jacket. Resident #7 stated he just got the pack of cigarettes from a family member and he was to turn it into the facility for safekeeping. Resident #7 stated he did not have a lighter or matches in his possession and said he was aware of the policies and procedures from the facility which stated a resident could not keep such items with them and was required to give them into the facility for safety purposes. During an observation and interview on 02/13/2026 at 10:15 a.m., Resident #9 was on his bed watching TV. Resident #9 stated he did not know he needed to let the facility know he smoked and, to his knowledge, he was not evaluated to safely smoke. Resident #9 stated that he knew that he could not smoke inside the facility and that he needed to go outside to the designated smoking area to smoke. Resident #9 was observed with a pack of cigarettes in his nightstand drawer and a lighter inside the pack of cigarettes. Resident #9 stated he knew he needed to give the smoking equipment to the facility staff and said the pack of cigarettes and lighter he had on him was because a family member had given them to him the previous day. During an observation and interview on 02/13/2026 at 11:37 AM, Resident #8 was observed in the smoking area sitting on a bench at proximity to other residents who were smoking. CNA A remained in the smoking area with all residents throughout the smoking break. Resident #8 did not smoked during this observation. Resident #8 stated she had started smoking about two weeks ago and she had just gone to the smoking area and was given cigarettes by other residents. Resident #8 said she did not know if she had been evaluated by the facility so she could safely smoke and stated she did not know the facility's rules for smoking, other than she needed to go outside the facility to the smoking area and that she was not allowed to smoke inside the facility. Resident #1 was observed smoking sitting close to Resident #8. It was observed that CNA A lit Resident #1's cigarette and asked him if he needed help to smoke because his hand was shaking. Resident #1 said he could do it on his own and CNA A said ok, just be careful. CNA A remained in the smoking area with all residents throughout the smoking break. Resident # 1's was able to smoke on his own during the observation and was observed dropping ashes into the ash tray. In an interview on 02/13/2026 at 1:54 PM with Resident #2, he stated that he was a smoker and said he had no problems smoking, holding a cigarette and disposing of ashes. He stated he smoked outside the facility at the designated smoking area and that staff provided his cigarettes and they would light them up for him. Resident #2 stated he did not know if he was assessed to safely smoke in the facility. During an interview on 02/13/2026 at 12:13 p.m., CNA A stated she assisted with overseeing residents during designated smoking times and reported that nursing informed staff which residents were permitted to smoke. She stated cigarettes and lighters were kept in a locked box and staff handed out cigarettes and supervised residents while smoking. CNA A stated she did not know which residents completed smoking assessments and who had not, and she stated she was concerned that some residents may not have appropriate or safe smoking assessments in place. She stated she was concerned about residents with tremors and poor hand control while smoking and feared the risk of burns or potential fire hazards. CNA A indicated she had informed nursing of her concerns and emphasized that smoking safety remained an ongoing concern among staff due to the potential for injury or fire. In an interview on 02/13/2026 at 12:54 PM with the DON revealed the facility had a smoking policy and that residents who identified as smokers upon admission were to receive a nursing smoking assessment to determine if they were cognitively appropriate and safe to smoke. She explained that smoking without an assessment was not permitted and that staff were expected to stop any residents from smoking until the required assessment was completed. The DON stated that staff often relied on routine, familiarity, and smoking schedules to determine who was allowed to smoke, rather than verifying completion of a current assessment. The DON stated that not having smoking assessment conducted on the resident placed them at risk of fire hazards as well as compromising the resident's health and safety if there was no proper assessment conducted. In an interview on 02/13/2026 at 2:38 PM, Resident #1 revealed he had been smoking outside in the designated smoking area. Resident #1 stated he had started smoking about a week after his admission into the facility and stated he did not know if the facility had evaluated him for smoking. Resident #1 stated he requested a staff member to take him outside to smoke and he had been cigarettes by the staff who were outside looking after him. Resident #1 stated he did not remember if he was educated on the facility's policies and procedures regarding smoking and said he did not know he needed to let the facility staff know he wished to start smoking. In an interview on 02/13/2026 at 3:01 PM with ADON B, she stated smoking assessments should be completed immediately once a resident initiates smoking. ADON B stated that failure to complete assessments timely may create safety risks for residents, staff, and visitors which could potentially cause harm to the residents and make their health worse. ADON B stated that residents having lighters in their rooms could potentially create a fire hazard which could result in injuries to the resident, visitors and staff from the facility. In an interview on 02/13/2026 at 3:09 PM with the Administrator, he stated that all residents in the facility who wished to participate in smoking needed to be assessed to ensure their safety and the safety of all residents and staff from the facility. He stated that if a resident had a lighter in their possession and not locked away by staff, could potentially result in fire hazards for the residents. The Administrator stated that if a resident has smoking equipment such as lighters and they have not been properly assessed, could result in them getting burned or injured. In an interview on 02/13/2026 at 3:51 PM with the Activities Director she stated that the facility was not following its policies and procedures for the resident's safety and that residents who had smoking equipment such as lighters in their rooms could potentially result in fire hazards or burns. The Activities Director stated that all staff in the facility were responsible for checking the safety of the residents and to immediately report to the administrator if they saw a resident having a lighter or cigarettes in their rooms to prevent fire hazards. Record review of the facility's policy and procedures titled, Uniform Smoke Free Policy, not dated, stated in part: Residents and employees are prohibited from smoking in any of the facility's buildings except in the designated smoking area. The designated smoking areas will be environmentally separate from all resident care areas and equipped with exhaust fans. The restrictions are intended to restrict smoking to a minimum and reduce risks to residents who smoke, including possible adverse effects on treatment; reduce risks of passive smoking for others; and reduce the risk of fire. The resident and responsible party, if applicable, will be informed of the smoking policy upon admission and in conjunction with care plan meetings thereafter. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel. Smoking will be permitted only in designated areas of the facility. Smoking is prohibited in resident rooms. Employees, medical staff, residents, and visitors are expected to adhere to the no smoking policy. Employees, medical staff, residents, and visitors must smoke in the designated outdoor area only. Employees, medical staff, and visitors will receive instructions as needed. It will be the responsibility of the management personnel to enforce the no smoking policy. A resident, who is assessed safe to smoke unsupervised, will be instructed to obtain their smoking paraphernalia from a designated, secured area. The resident will be instructed to return the smoking paraphernalia following the smoking session. The resident may smoke at their request, unless the time interferes with resident care. A resident, who is assessed unsafe to smoke without supervision, will be notified of the facilities site specific smoking times, at which time the resident will have supervision and assistance as needed. A resident who is assessed unsafe to smoke unsupervised must be in direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor, must be aware of these responsibilities.

Based on interview and record review, the facility failed to ensure the resident's right to make choices regarding aspects of his daily life, including beverage preference, for 1 of 6 residents reviewed for resident rights (Resident #6). The facility failed to honor Resident #6's wishes by not providing him with the beverage of his choice.Findings included: Record review of Resident #6's admission Record, dated 05/24/2025, revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE]. Record review of Resident #6's History and Physical, dated 05/27/2025, revealed diagnoses including vascular dementia (decline in thinking ability due to reduced blood flow to the brain), type 2 diabetes mellitus (chronic condition affecting blood sugar control), hypertension (high blood pressure), chronic systolic congestive heart failure (condition where the heart does not pump blood effectively), chronic obstructive pulmonary disease (long-term lung disease causing breathing difficulty), seizure disorder (episodes of abnormal electrical activity in the brain), and left-sided hemiparesis (weakness on one side of the body). Record review of Resident #6's quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderately impaired cognition. The MDS revealed under Section C, Cognitive Patterns, Resident #6's cognitive skills for daily decision-making were independent. Record review of Resident #6's Care Plan, dated 02/06/2026, revealed congestive heart failure (a condition where the heart does not pump blood effectively, causing fluid buildup), chronic obstructive pulmonary disease (a long-term lung disease that makes breathing difficult), seizure disorder (a condition causing episodes of abnormal electrical activity in the brain resulting in seizures), diabetes mellitus (a chronic condition affecting the body's ability to regulate blood sugar), vascular dementia (decline in thinking ability caused by reduced blood flow to the brain), hemiplegia (paralysis or severe weakness on one side of the body), and peripheral vascular disease (poor blood circulation to the limbs due to narrowed blood vessels). The care plan included no restriction related to soda, caffeine, or beverages. Record review of Resident #6's Psychological Services Progress Note , dated 02/05/2026 at 12:40 p.m., revealed the resident reported being denied a soda at midnight by a staff member who pointed her finger close to his face. During an observation and interview on 02/17/2026 at 12:40 p.m., Resident #6 was alert, seated in his room. Resident #6 stated he remembered a previous night he requested a soda from a female staff. He stated he did not know the name of the staff but that it was a female CNA. Resident #6 said the staff told him it was too late for a soda and she could give him water instead. Resident #6 stated he felt angry and told her he could make his own decisions and it was not her job to tell him what he could drink. Resident #6 stated the staff ignored him and walked away. He stated the incident had made him feel like the facility did not care about his preferences. During a telephone interview on 02/17/2026 at 1:20 p.m., Resident #6's relative stated his family installed video cameras in the resident's room. Resident #6's relative stated they reviewed the footage after Resident #6 told them about the interaction with the unidentified female CNA. Resident #6's relative stated she heard the CNA offer him water instead of soda. Resident #6's relative stated Resident #6's family was upset because they felt the facility was not respecting the resident's wishes. During an interview on 02/17/2026 at 1:40 p.m., CNA G stated she was trained on abuse, neglect, and resident rights and understood the facility was Resident #6's home. CNA G stated she knew the resident already had a soda and thought it would be best for her to offer him water. She stated she should have provided the soda and recognized the resident had the right to request and receive it. She stated she acted on her own judgment at the time. CNA G stated she should have consulted with the charge nurse to get directions regarding resident requests. During an interview on 02/17/2026 at 1:49 p.m., CNA H stated he was with CNA G when Resident # 6 requested a soda and CNA G did not provide it. CNA H stated he felt it was wrong of CNA G for not asking a supervisor if the resident could have a soda and said that it could cause the resident to get upset and feel his choices were not being taken into consideration. During an interview on 02/17/2026 at 2:30 p.m., the DON stated residents had the right to make choices regarding food and beverage preferences unless medically contraindicated. The DON stated there were no indications in Resident # 6's care plan that he was not able to have a soda at night and stated the facility was Resident #6's home and it was their right to have a soda or a snack, even in the middle of the night, unless it was contraindicated by the doctor for a medical reason. The DON stated CNA G should have respected Resident #6's wishes and requests. During an interview on 02/17/2026 at 3:20 p.m., the Administrator stated Resident #6 should have been given his soda if he wished one at night. The Administrator stated if a resident had no health-related condition and, if not indicated on their care plan, all staff were responsible for respecting the resident's wishes. The Administrator stated it was possible the resident could feel frustrated. The Administrator stated it was wrong for a CNA to make a decision without consulting a charge nurse or the resident's care plan. Record review of the facility's policies and procedures titled Resident Rights, not dated, mentioned in part: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.The facility will provide the Resident Rights to each newly admitted resident and upon any revision to the Resident Rights to each resident and/or resident representatives.Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. Self-determination - The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part.The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. Food and Nutrition services as required.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs for 1 of 7 residents (Resident #1) reviewed for care plans.The facility failed to implement Resident #1's comprehensive person-centered care plan for repositioning assistance by two staff members. On 11/11/25, CNA A repositioned the resident alone. During the process, the resident rolled off the bed and struck his head on the suctioning machine suffering from a brain bleed, sustaining a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The noncompliance was identified as PNC. The IJ began on 11/11/25 and ended 11/11/25. The facility had corrected the noncompliance before the investigation began. This failure places the resident at risk of inappropriate repositioning with resulting injury. The findings included:Record review of Resident #1's face sheet dated 11/13/25 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's History and Physical dated 6/3/25 revealed a [AGE] year-old male with a history of long-standing alcohol use disorder, alcoholic encephalopathy (Brain damage and confusion caused by long-term heavy alcohol use), and chronic complications including cirrhosis (Severe scarring of the liver that prevents it from working properly), pancreatitis (Long-term inflammation and damage of the pancreas that affects digestion and causes pain), GI bleed (gastrointestinal bleed, bleeding somewhere in the stomach or intestines), and hypertension (High blood pressure). He was admitted to skilled nursing for medical management, nutrition, and ADL support following a seizure due to alcohol intoxication (A condition where a person has repeated seizures and being severely impaired or poisoned by drinking too much alcohol), acute respiratory failure (a serious condition where the lungs cannot provide enough oxygen to the body), and anoxic brain injury (brain damage caused by lack of oxygen) requiring tracheostomy (A breathing tube placed through the neck into the windpipe) and gastrostomy placement (A feeding tube placed directly into the stomach through the abdomen). Resident #1 was nonverbal and unable to follow commands. He required total care and repositioning every two hours. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 0, indicating his cognition was severely impaired. Under section GG0115 for Functional Limitation in Range of Motion, Resident #1's MDS revealed he was impaired in his upper and lower extremities. Resident #1 was totally dependent on staff for all activities due to vegetative state. Record review of Resident #1's care plan dated 9/24/25 revealed focus area for ADLs stating he had a Self-Care Performance Deficit Limited Mobility, had a diagnosis of anoxic brain injury. It stated that Resident #1 was totally dependent (meaning the helper or staff does all of the effort and the resident does none of the effort to complete the activity and the assistance of two or more helpers is required for the resident to complete the activity) on staff for bathing, bed mobility, requiring two staff for assistance.Record review of Resident #1's progress notes dated 11/11/25 at 7:14 AM by LVN B stated CNA A assisted the resident with ADLs (assistance with daily personal care). The resident was positioned on his left side. CNA A attempted to stabilize the resident by holding his RUE (right upper extremity - right arm) to prevent a fall; however, the resident fell from the bed to the floor, landing face-down on a floor mat. The resident was observed with a laceration (skin cut) to the right eyebrow. The resident was assessed and assisted back to bed by nursing staff and CNA A. The wound was cleansed with NS solution (sterile saline solution) and sterile strips (adhesive wound closure strips) were applied. Hospice was notified and the resident was transferred to the emergency room for further evaluation.Record review of Resident #1's progress notes dated 11/11/25 at 2:02 PM by the DON stated that An in-person conference was held with the resident's family members. Present were the Facility Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON). The purpose of the meeting was to discuss the resident's recent fall that occurred during care, which resulted in an orbital fracture (broken bone around the eye socket) and brain bleed (bleeding in the brain), as confirmed by the attending physician. The Medical Director anticipated the resident's discharge back to the facility with an expected return date of 11/11/25. The family was informed that a self-report to the state had been initiated and that the facility was conducting a thorough internal investigation to identify contributing factors and implement appropriate corrective measures, to include clinical staff in servicing.The resident's care plan was updated to include bed bolsters (supportive cushions placed on the bed) and enhanced safety interventions during care to minimize the risk of future falls. Record review of Resident #1's progress notes dated 11/11/25 at 8:11 PM by LVN P revealed Resident #1 returned to the facility from the hospital via EMS (Emergency Medical Services - ambulance transport) following a fall and was observed to have a sutured laceration (stitched cut) to the right eyebrow and an abrasion (scrape) to the right shoulder. The injury sites were assessed and noted to be clean, dry, and free of infection. Vital signs were obtained and were within acceptable limits, and Resident #1 was maintained on supplemental oxygen. Family and facility leadership were notified of the residents' return. No new orders were received. Resident #1 was continued monitoring, with instructions to notify the provider of any change in conditionRecord review of Resident #1's CT Scan hospital records dated 11/11/25 revealed Resident #1 sustained a fall which resulted in acute subarachnoid hemorrhage (bleeding in the space around the brain) along the medial right frontal lobe (the inner front right part of the brain) and comminuted fractures (a bone broken into several pieces) of the right orbital floor (the bottom part of the eye socket) and inferior lateral orbital wall (the lower outer wall of the eye socket) with mild depression (slight sinking of the broken bone), and additional nondisplaced fracture (a crack in the bone without movement) of the anterior wall (front wall) of the right maxillary sinus (air-filled space behind the cheek), no intra orbital hematoma (no collection of blood inside the eye socket) or displacement of orbital contents (no movement of the structures of the eye).Resident #1 was observed laying in bed in the lowest position, he had fall mats to both sides of his bed. He appeared clean and the room had no smells. CNA N and CNA O assisted the resident with repositioning successfully.In an interview on 11/13/25 at 11:33 AM, Resident # 1's family member stated she had been contacted by the facility staff early in the morning the date of the incident and was told Resident # 1 was transported to the ER because he had sustained a fall. Resident # 1's family member said she appreciated the facility communicated with her and stated she was upset that Resident # 1 got injured and stated she understood it was an accident, but staff should have been paying attention and asked for help to clean Resident # 1 with two staff members instead of doing it on her own. In an interview on 11/13/25 at 11:58 AM, RN G stated CNAs had access to the facility's electronic records containing all the resident's care plans and all CNAs, LVNs and RNs were trained on how to look for the residents' care plans. RN G stated CNA A should have checked Resident #1's care plan and Kardex before trying to reposition the resident on her own. RN G stated that it was not acceptable not to follow a resident's care plan because it could result in injuries to both the residents and the staff members.In an interview on 11/13/25 at 12:40 PM, the DON stated Resident #1 was a total care (means the resident is completely dependent on staff for all daily activities and cannot safely perform them on their own), non-verbal individual with a tracheostomy who required oxygen as needed and was care-planned for two-person repositioning and peri-care. The DON stated while CNA A attempted to perform peri-care, she did not wait for a second staff member and proceeded alone, despite being aware that the resident required two staff for repositioning per the care plan. The DON reported during this one-person repositioning attempt, Resident #1 fell and struck his head on a suctioning machine, sustaining a laceration, swelling, and facial injuries. The DON confirmed CNA A acknowledged knowing the resident required two-person assistance as stated on Resident #1's care plan. The DON stated the incident was preventable and resulted from CNA A's failure to follow the care plan and use required two-person assistance during repositioning. The DON confirmed that CNA A was counseled, re-educated on Nurse Aide Incontinence Care and two staff repositioned, and suspended following the incident on 11/11/25.In an interview on 11/13/25 at 1:21 PM, LVN B said she was the charge nurse for Resident #1's hallway during the date of the incident and stated Resident #1 required two-person assistance for repositioning per the care plan. She reported that CNA A attempted to reposition Resident #1 alone and did not call for assistance as required and instructed per Resident #1's care plan. The LVN stated CNA A acknowledged she was unable to explain why she did not request help. The LVN stated the fall occurred due to CNA A's failure to follow Resident #1's care plan.In an interview on 11/13/25 at 2:02 PM, LVN D reported CNA A admitted to her after an interview to repositioning Resident #1 alone despite the care plan requiring two staff. LVN D stated CNA A reported no assistance was available, although the LVN B was nearby. LVN D stated CNA A failed to follow the care plan for Resident #1 and was counseled regarding noncompliance and instructed to always follow the resident's care plans.In an interview on 11/13/2025 at 3:22 PM, CNA A stated she was performing peri-care and repositioning when Resident #1 fell from the bed. She reported the air mattress shifted and Resident #1 fell off his bed and struck his head on the suction pump located next to the bed while falling. CNA A described Resident #1 landing on the fall mat that was at bedside and sustaining a laceration near the eye in between his eye lid and the eyebrow. She stated she called for help, and LVN B responded immediately. She acknowledged the fall could have been avoided if she had followed Resident #1's care plan and repositioned him with the help of additional staff. CNA A stated she thought she would be able to reposition the resident on her own and acknowledged that the accident happened due to her actions. CNA A stated she had been trained on Resident #1's care plan and on proper techniques for repositioning a resident when they required two staff for repositioning before the incident. CNA A stated she knew Resident #1 required two-person assistance for repositioning but chose to perform the task alone. CNA A stated she did not request help and that she failed to follow the care plan. CNA A acknowledged her actions resulted in Resident #1's fall and injury. She admitted she failed to follow the required care plan interventions. CNA A stated that she had been suspended that same date on 11/11/25 when she was called back to the facility to provide a written statement regarding Resident #1's fall and she was told she would not be able to go back to work until the facility investigated. CNA A stated she was in-serviced on 11/13/24 by LVN D on two-people repositioning of residents. In an interview on 11/14/2025 at 10:48 AM, the Administrator reported learning of the fall around 7:00 AM on 11/11/25 and Resident #1 was transported to the hospital to be evaluated. The Administrator stated the incident was reported to the state after the fracture was confirmed. The Administrator stated CNA A was instructed to follow the Kardex and Resident #1's care plan. The Administrator reported CNA A failed to request assistance despite knowledge that Resident #1 required two-person transfers. The Administrator stated CNA A failed to follow established protocols.Record review of the facility's policy and procedures, not dated, titled How to Use the Kardex in PCC read in part: The Kardex is used to communicate a ton of resident information and needs to the C.N.A.s. This is a very helpful tool that can save us time and be very informative to the direct care staff. The Kardex can be accessed through the each kiosk in the facility. While in a resident's chart in the kiosk, the staff member simply touches here and the Kardex will open in a new window for review. You may also view the entire Care plan of a resident. The care plan button is to the right of the Kardex Button. Click the care plan button to see the entire care plan. Accessing the Kardex via Kiosk via Normal PCC. Go to the residents chart and click the care plan tab. Click to the far right of the screen. Record review of the facility's policy and procedures, not dated, titled Comprehensive Care Planning read in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents' medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the residents preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the residents goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the residents life before coming to reside in the nursing home. Residents goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the residents goals, and can be measured, quantified, and/or verified. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Facility staff will assist residents to engage in the care planning process, e.g., helping residents and resident representatives, if applicable understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision making; encouraging a resident's representative to participate in care planning and attend care planning conferences. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. The facility will ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required.The facility completed the following corrective actions to address the non-compliance after the incident occurred and prior to the surveyor entering on 11/13/25.Record review- In-services conducted for:Residents on air mattresses requiring two staff assistance dated 11/11/25 signed by all staff including CNA A.How to access Kardex in hospice binder and in the facility's electronic system, dated 11/11/25, signed by all staff.Training in Compliance: Following the Kardex orders without exceptions related to two-person repositioning assistance, dated 11/11/25 signed by all staff.Proficiency Assessment for Incontinence Care and repositioning dated 11/11/25, was signed by all staff. Interviews on 11/13/25: RN G on 11/13/25 at 11:54 AM, CNA E on 11/13/25 at 11:40 AM, CNA F on 11/13/25 at 11:42 AM, CNA H on 11/13/25 at 12:01 PM and CNA I on 11/13/25 at 12:03 PM, LVN B on 11/13/25 at 1:21 PM, reflected they had received in-service on following the resident's care plans and on two-person repositioning; on 11/11/25, these staff members all verbalized they needed to ask for assistance from another staff member and review and follow the Kardex or care plan in PCC (Point Click Care, the facility's electronic health record software) for the residents at the facility. In an interview on 11/13/25 at 11:53 AM, CNA E stated all staff had been in-serviced on 11/11/25 on repositioning and how to look for information in the Kardex (a quick-reference summary sheet that gives staff a snapshot of a resident's key care information. It's used to help nurses and CNAs quickly understand what a resident needs without having to dig through the full medical chart) in the residents' care plans. CNA E said if a resident required two staff members for repositioning, they always needed to request help from a coworker. CNA E said the potential outcome for not following a resident's care plan could result in the residents not receiving the proper treatment or care they needed. In an interview on 11/13/25 at 11:55 AM, CNA F reported all staff had received in-service on 11/11/25 regarding residents' care plans, where to find them in the system and how to read them. CNA F stated all staff from the facility were expected to always follow the residents' care plans. CNA F explained not following a resident's care plan could result in neglecting their needs or even physical injury if staff did not familiarize themselves with the residents' care plans.In an interview on 11/13/25 at 12:01 PM, CNA H said staff have been trained on 11/11/25 on how to find the residents' care plans and Kardex in the facility's system. CNA H stated it was important for all staff to be familiarized with the residents' care plans to ensure they were providing the care the residents needed and to avoid any potential hazards or injuries to residents by not properly following the care plans developed for each resident.In an interview on 11/13/25 at 12:05 PM, CNA I explained the staff were taught how to check for care pans and the residents' charts and Kardex. CNA I stated when a resident was listed as needing two staff for repositioning, the information would be documented in the resident's care plans. CNA I said not following the care plans developed for each resident was not acceptable because it could lead to neglecting the residents with the care they needed which could result in injuries to both residents and staff in the facility.Observations: In an observation on 11/13/25 at 11:40 AM, CNAs E and F demonstrated repositioning procedures with Resident #2. Both CNAs followed repositioning procedures successfully and explained to the resident what they were doing, ensuring the resident understood. CNAs placed call light within reach. No distress noted on Resident #2. In an observation on 11/13/25 at 12:00 PM, CNAs H and I demonstrated repositioning procedures with Resident #3. Both CNAs followed repositioning procedures successfully and explained to the resident what they were doing, ensuring the resident understood. No distress noted on Resident #3. Call light was placed within reach.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 7 residents reviewed for accidents and supervision.Resident #1 required two-person assistance for peri care and repositioning. On 11/11/25, CNA A repositioned the resident alone. During the process, the resident rolled off the bed and struck his head on the suctioning machine, causing for him to suffer a brain bleed, sustaining a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The noncompliance was identified as PNC. The IJ began on 11/11/25 and ended 11/11/25. The facility had corrected the noncompliance before the survey began.These failures placed residents at risk of injuries, hospitalization, and death. The findings included:Record review of Resident #1's face sheet dated 11/13/25 revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's History and Physical dated 6/3/25 revealed a [AGE] year-old male with a history of long-standing alcohol use disorder, alcoholic encephalopathy (Brain damage and confusion caused by long-term heavy alcohol use), and chronic complications including cirrhosis (Severe scarring of the liver that prevents it from working properly), pancreatitis (Long-term inflammation and damage of the pancreas that affects digestion and causes pain), GI bleed (gastrointestinal bleed, bleeding somewhere in the stomach or intestines), and hypertension (High blood pressure). He was admitted to skilled nursing for medical management, nutrition, and ADL support following a seizure due to alcohol intoxication (A condition where a person has repeated seizures and being severely impaired or poisoned by drinking too much alcohol), acute respiratory failure (a serious condition where the lungs cannot provide enough oxygen to the body), and anoxic brain injury (brain damage caused by lack of oxygen) requiring tracheostomy (A breathing tube placed through the neck into the windpipe) and gastrostomy placement (A feeding tube placed directly into the stomach through the abdomen). Resident #1 was nonverbal and unable to follow commands. He required total care and repositioning every two hours. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 0, indicating his cognition was severely impaired. Under section GG0115 for Functional Limitation in Range of Motion, Resident #1's MDS revealed he was impaired in his upper and lower extremities. Resident #1 was totally dependent on staff for all activities due to vegetative state. Record review of Resident #1's care plan dated 9/24/25 revealed focus area for ADLs stating he had a Self-Care Performance Deficit Limited Mobility, had a diagnosis of anoxic brain injury. It stated that Resident #1 was totally dependent (meaning the helper or staff does all of the effort and the resident does none of the effort to complete the activity and the assistance of two or more helpers is required for the resident to complete the activity) on staff for bathing, bed mobility, requiring two staff for assistance.Record review of Resident #1's progress notes dated 11/11/25 at 7:14 AM by LVN B stated CNA A assisted the resident with ADLs (assistance with daily personal care). The resident was positioned on his left side. CNA A attempted to stabilize the resident by holding his RUE (right upper extremity - right arm) to prevent a fall; however, the resident fell from the bed to the floor, landing face-down on a floor mat. The resident was observed with a laceration (skin cut) to the right eyebrow. The resident was assessed and assisted back to bed by nursing staff and CNA A. The wound was cleansed with NS solution (sterile saline solution) and sterile strips (adhesive wound closure strips) were applied. Hospice was notified and the resident was transferred to the emergency room for further evaluation.Record review of Resident #1's progress notes dated 11/11/25 at 2:02 PM by the DON stated that An in-person conference was held with the resident's family members. Present were the Facility Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON). The purpose of the meeting was to discuss the resident's recent fall that occurred during care, which resulted in an orbital fracture (broken bone around the eye socket) and brain bleed (bleeding in the brain), as confirmed by the attending physician. The Medical Director anticipated the resident's discharge back to the facility with an expected return date of 11/11/25. The family was informed that a self-report to the state had been initiated and that the facility was conducting a thorough internal investigation to identify contributing factors and implement appropriate corrective measures, to include clinical staff in servicing.The resident's care plan was updated to include bed bolsters (supportive cushions placed on the bed) and enhanced safety interventions during care to minimize the risk of future falls. Record review of Resident #1's progress notes dated 11/11/25 at 8:11 PM by LVN P revealed Resident #1 returned to the facility from the hospital via EMS (Emergency Medical Services - ambulance transport) following a fall and was observed to have a sutured laceration (stitched cut) to the right eyebrow and an abrasion (scrape) to the right shoulder. The injury sites were assessed and noted to be clean, dry, and free of infection. Vital signs were obtained and were within acceptable limits, and Resident #1 was maintained on supplemental oxygen. Family and facility leadership were notified of the residents' return. No new orders were received. Resident #1 was continued monitoring, with instructions to notify the provider of any change in conditionRecord review of Resident #1's CT Scan hospital records dated 11/11/25 revealed Resident #1 sustained a fall which resulted in acute subarachnoid hemorrhage (bleeding in the space around the brain) along the medial right frontal lobe (the inner front right part of the brain) and comminuted fractures (a bone broken into several pieces) of the right orbital floor (the bottom part of the eye socket) and inferior lateral orbital wall (the lower outer wall of the eye socket) with mild depression (slight sinking of the broken bone), and additional nondisplaced fracture (a crack in the bone without movement) of the anterior wall (front wall) of the right maxillary sinus (air-filled space behind the cheek), no intra orbital hematoma (no collection of blood inside the eye socket) or displacement of orbital contents (no movement of the structures of the eye).Resident #1 was observed laying in bed in the lowest position, he had fall mats to both sides of his bed. He appeared clean and the room had no smells. CNA N and CNA O assisted the resident with repositioning successfully.In an interview on 11/13/25 at 11:33 AM, Resident # 1's family member stated she had been contacted by the facility staff early in the morning the date of the incident and was told Resident # 1 was transported to the ER because he had sustained a fall. Resident # 1's family member said she appreciated the facility communicated with her and stated she was upset that Resident # 1 got injured and stated she understood it was an accident, but staff should have been paying attention and asked for help to clean Resident # 1 with two staff members instead of doing it on her own. In an interview on 11/13/25 at 11:58 AM, RN G stated CNAs had access to the facility's electronic records containing all the resident's care plans and all CNAs, LVNs and RNs were trained on how to look for the residents' care plans. RN G stated CNA A should have checked Resident #1's care plan and Kardex before trying to reposition the resident on her own. RN G stated that it was not acceptable not to follow a resident's care plan because it could result in injuries to both the residents and the staff members.In an interview on 11/13/25 at 12:40 PM, the DON stated Resident #1 was a total care (means the resident is completely dependent on staff for all daily activities and cannot safely perform them on their own), non-verbal individual with a tracheostomy who required oxygen as needed and was care-planned for two-person repositioning and peri-care. The DON stated while CNA A attempted to perform peri-care, she did not wait for a second staff member and proceeded alone, despite being aware that the resident required two staff for repositioning per the care plan. The DON reported during this one-person repositioning attempt, Resident #1 fell and struck his head on a suctioning machine, sustaining a laceration, swelling, and facial injuries. The DON confirmed CNA A acknowledged knowing the resident required two-person assistance as stated on Resident #1's care plan. The DON stated the incident was preventable and resulted from CNA A's failure to follow the care plan and use required two-person assistance during repositioning. The DON confirmed that CNA A was counseled, re-educated on Nurse Aide Incontinence Care and two staff repositioned, and suspended following the incident on 11/11/25.In an interview on 11/13/25 at 1:21 PM, LVN B said she was the charge nurse for Resident #1's hallway during the date of the incident and stated Resident #1 required two-person assistance for repositioning per the care plan. She reported that CNA A attempted to reposition Resident #1 alone and did not call for assistance as required and instructed per Resident #1's care plan. The LVN stated CNA A acknowledged she was unable to explain why she did not request help. The LVN stated the fall occurred due to CNA A's failure to follow Resident #1's care plan.In an interview on 11/13/25 at 2:02 PM, LVN D reported CNA A admitted to her after an interview to repositioning Resident #1 alone despite the care plan requiring two staff. LVN D stated CNA A reported no assistance was available, although the LVN B was nearby. LVN D stated CNA A failed to follow the care plan for Resident #1 and was counseled regarding noncompliance and instructed to always follow the resident's care plans.In an interview on 11/13/2025 at 3:22 PM, CNA A stated she was performing peri-care and repositioning when Resident #1 fell from the bed. She reported the air mattress shifted and Resident #1 fell off his bed and struck his head on the suction pump located next to the bed while falling. CNA A described Resident #1 landing on the fall mat that was at bedside and sustaining a laceration near the eye in between his eye lid and the eyebrow. She stated she called for help, and LVN B responded immediately. She acknowledged the fall could have been avoided if she had followed Resident #1's care plan and repositioned him with the help of additional staff. CNA A stated she thought she would be able to reposition the resident on her own and acknowledged that the accident happened due to her actions. CNA A stated she had been trained on Resident #1's care plan and on proper techniques for repositioning a resident when they required two staff for repositioning before the incident. CNA A stated she knew Resident #1 required two-person assistance for repositioning but chose to perform the task alone. CNA A stated she did not request help and that she failed to follow the care plan. CNA A acknowledged her actions resulted in Resident #1's fall and injury. She admitted she failed to follow the required care plan interventions. CNA A stated that she had been suspended that same date on 11/11/25 when she was called back to the facility to provide a written statement regarding Resident #1's fall and she was told she would not be able to go back to work until the facility investigated. CNA A stated she was in-serviced on 11/13/24 by LVN D on two-people repositioning of residents. In an interview on 11/14/2025 at 10:48 AM, the Administrator reported learning of the fall around 7:00 AM on 11/11/25 and Resident #1 was transported to the hospital to be evaluated. The Administrator stated the incident was reported to the state after the fracture was confirmed. The Administrator stated CNA A was instructed to follow the Kardex and Resident #1's care plan. The Administrator reported CNA A failed to request assistance despite knowledge that Resident #1 required two-person transfers. The Administrator stated CNA A failed to follow established protocols.Record review of the facility's policy and procedures, not dated, titled How to Use the Kardex in PCC read in part: The Kardex is used to communicate a ton of resident information and needs to the C.N.A.s. This is a very helpful tool that can save us time and be very informative to the direct care staff. The Kardex can be accessed through the each kiosk in the facility. While in a resident's chart in the kiosk, the staff member simply touches here and the Kardex will open in a new window for review. You may also view the entire Care plan of a resident. The care plan button is to the right of the Kardex Button. Click the care plan button to see the entire care plan. Accessing the Kardex via Kiosk via Normal PCC. Go to the residents chart and click the care plan tab. Click to the far right of the screen. Record review of the facility's policy and procedures, not dated, titled Comprehensive Care Planning read in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the residents' medical, physical, mental and psychosocial needs. Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the residents preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the residents goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the residents life before coming to reside in the nursing home. Residents goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the residents goals, and can be measured, quantified, and/or verified. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Facility staff will assist residents to engage in the care planning process, e.g., helping residents and resident representatives, if applicable understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision making; encouraging a resident's representative to participate in care planning and attend care planning conferences. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. The facility will ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required.The facility completed the following corrective actions to address the non-compliance after the incident occurred and prior to the surveyor entering on 11/13/25.Record review- In-services conducted for:Residents on air mattresses requiring two staff assistance dated 11/11/25 signed by all staff including CNA A.How to access Kardex in hospice binder and in the facility's electronic system, dated 11/11/25, signed by all staff.Training in Compliance: Following the Kardex orders without exceptions related to two-person repositioning assistance, dated 11/11/25 signed by all staff.Proficiency Assessment for Incontinence Care and repositioning dated 11/11/25, was signed by all staff. Interviews on 11/13/25: RN G on 11/13/25 at 11:54 AM, CNA E on 11/13/25 at 11:40 AM, CNA F on 11/13/25 at 11:42 AM, CNA H on 11/13/25 at 12:01 PM and CNA I on 11/13/25 at 12:03 PM, LVN B on 11/13/25 at 1:21 PM, reflected they had received in-service on following the resident's care plans and on two-person repositioning; on 11/11/25, these staff members all verbalized they needed to ask for assistance from another staff member and review and follow the Kardex or care plan in PCC (Point Click Care, the facility's electronic health record software) for the residents at the facility. In an interview on 11/13/25 at 11:53 AM, CNA E stated all staff had been in-serviced on 11/11/25 on repositioning and how to look for information in the Kardex[KS1] (a quick-reference summary sheet that gives staff a snapshot of a resident's key care information. It's used to help nurses and CNAs quickly understand what a resident needs without having to dig through the full medical chart) in the residents' care plans. CNA E said if a resident required two staff members for repositioning, they always needed to request help from a coworker. CNA E said the potential outcome for not following a resident's care plan could result in the residents not receiving the proper treatment or care they needed. In an interview on 11/13/25 at 11:55 AM, CNA F reported all staff had received in-service on 11/11/25 regarding residents' care plans, where to find them in the system and how to read them. CNA F stated all staff from the facility were expected to always follow the residents' care plans. CNA F explained not following a resident's care plan could result in neglecting their needs or even physical injury if staff did not familiarize themselves with the residents' care plans.In an interview on 11/13/25 at 12:01 PM, CNA H said staff have been trained on 11/11/25 on how to find the residents' care plans and Kardex in the facility's system. CNA H stated it was important for all staff to be familiarized with the residents' care plans to ensure they were providing the care the residents needed and to avoid any potential hazards or injuries to residents by not properly following the care plans developed for each resident.In an interview on 11/13/25 at 12:05 PM, CNA I explained the staff were taught how to check for care pans and the residents' charts and Kardex. CNA I stated when a resident was listed as needing two staff for repositioning, the information would be documented in the resident's care plans. CNA I said not following the care plans developed for each resident was not acceptable because it could lead to neglecting the residents with the care they needed which could result in injuries to both residents and staff in the facility.Observations: In an observation on 11/13/25 at 11:40 AM, CNAs E and F demonstrated repositioning procedures with Resident #2. Both CNAs followed repositioning procedures successfully and explained to the resident what they were doing, ensuring the resident understood. CNAs placed call light within reach. No distress noted on Resident #2. In an observation on 11/13/25 at 12:00 PM, CNAs H and I demonstrated repositioning procedures with Resident #3. Both CNAs followed repositioning procedures successfully and explained to the resident what they were doing, ensuring the resident understood. No distress noted on Resident #3. Call light was placed within reach.

Based on observation, interview, and record review the facility failed to ensure coordination of care to ensure hospice services were provided according to the services the LTC facility provided based on resident's care plan for 1 of 9 residents (Residents #1) reviewed for hospice services. The facility failed to coordinate with hospice interdiciplinary team to coordinate care to the resident provided by facility staff and hospice staff for those residents receiving these services. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base) resulting in placement in the hospital ICU. An Immediate Jeopardy (IJ) situation was identified on 05/02/25. While the IJ was removed on 05/05/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falls, injury, or death. Findings include: Record review of Resident #1's Admission Record, dated 04/29/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: cerebral infraction (a condition where blood flow to the brain is interrupted, causing brain cell to die), altered mental status (there's a change in how your brain is working affecting your ability to think, be aware of your surroundings, and react normally), abnormal gait and mobility (issues with how someone walks or moves, often due to underlying medical conditions or injuries), Alzheimer's disease (is a brain disorder that leads to memory loss and other cognitive decline, eventually impacting a person's ability to perform daily tasks), history of falling, anxiety disorder (mental health conditions characterized by excessive and persistent worry and fear, often leading to physical symptoms and difficulties in daily life), atrial fibrillation (an irregular and often rapid heartbeat that occurs when the electrical signals in the heart's upper chambers (atrial) fire out at the same speed). Review of Hospital ED notes dated 04/26/25 at 8:20 a.m., for Resident #1 revealed, Chief Complaint: Pt. presents to the ED s/p fall sustained on Wednesday with head strike per EMS. Patient was being showered by hospice nurse when he fell . Patient is bedbound, left-sided hemiparesis (impairment on the left side of the body). Presented from nursing home apparently had fallen out of bed on Wednesday, did not seek any attention till today. Was brought in today complaining of pain. Patient is non-verbal and does not follow commands. Contracture (a permanent tightening of the muscle, tendons, skin, and nearby tissues that cause the joints shorten and become very stiff) to left upper extremity and contractures of both lower extremities. Physical Exam: 2 cm laceration with steri-strips to forehead. Impression and Plan: Neurosurgeon reported he will not operate and wants to keep the patient at the hospital to treat conservatively. Patient in ICU under trauma services. Medical Decision Making: Patient very cachectic (weakness and wasting of the body) and would not withstand any kind of surgical intervention and place in a hard collar for life. Assessment: C2 dens type II fracture displacement nonoperative. Record review of Resident #1's Hospital Discharge Summary dated 04/28/25, revealed admitted [DATE] and discharge date [DATE]. Resident was admitted to the hospital on 04/26/25 at 11:36 a.m. History of Present Illness: [AGE] year-old male that resident at nursing home. On 04/23/25 he sustained a fall while being showered when he fell forward from the shower chair causing a laceration to the right side of his forehead requiring steri- strips. CT cervical spine revealed an acute unstable type II dens fracture of C1 on C2. Discharge Diagnosis 04/28/25: Type II dens fracture of second cervical vertebra, atrial fibrillation, advanced dementia. Record review of Resident #1's History & Physical dated 01/14/25 for Resident #1 revealed, Patient readmitted under hospice care after a massive cerebrovascular accident. Hemiplegia to left side, dementia, comfort care under Hospice, repeated falls. Neurological: Non-ambulatory, terminally demented, unable to follow commands. Unable to stand or walk. Record review of Physician's Progress Noted dated 04/24/25 written by attending physician revealed, resident seen today due to charge nurse reporting a fall. Recent fall from shower chair and sustained a laceration to the right side of forehead requiring steri-stips. Skull x-ray was obtained which was negative for fracture. Continue comfort care and pain management. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed BIMS was not conducted due to Resident #1's inability to answer questions. Short-term and Long-term Memory Problems. Section C1000. Cognitive Skills for Daily Decision Making - Severely Impaired. Section GG - Functional Abilities revealed Resident #1 required substantial/maximal assistance with toileting hygiene, shower/bathing, sit to stand and chair/bed transfer; partial/moderate assistance with upper body dressing and personal hygiene. Wheelchair for mobility. Functional Limitation in Range of Motion - Impairment on one side to upper extremity; incontinent of bowel & bladder. Active diagnoses - Alzheimer's disease, stroke, cerebral infarction, altered mental status, unsteadiness on feet, abnormal gait, and mobility. Record review of Resident #1's Care Plan, dated 03/17/2025, revealed Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Transfer: The resident requires total assistance with transfer. Mechanical lift for all transfers with 2 staff for assistance. Contractures to all extremities. Risk for falls. Mechanical lift for all transfers with 2 staff for assistance. Resident has a terminal prognosis and is receiving hospice services. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Hospice staff (nurse, CNA, SW, Chaplin) to assist with resident care. Record review of Hospice Plan of Care Effective 4/02/25 for Resident #1 revealed, Last Updated: 04/01/25. Problem: Patient at risk for experiencing inability to perform care related to cognitive deficits, functional limitations, weakness, debility, deconditioning, altered mental status, environmental/logistical limitations, lack of supervision. Problem: Patient at risk for/experiencing falls with injury related to deconditioning, altered mental status cognitive decline, neurological deficit, altered gait or balance, medication effects/side effects, functional alterations, other. Goal: Patient will have no fall with injury. Interventions: RN and/or SN will assess fall risk on admission, at recertification, change in level or location of care. SN will identify appropriate DME and collaborate with MD to order as indicated and will train/model how to safely use assistive devices during visits. The Hospice Care Plan did not document resident #1 needed a Mechanical lift and two-person assistance with transfers. Review of Physician's Order dated 02/16/2025 for Resident #1 revealed, Resident a Mechanical Lift with 2-person transfer. Review of Physician Order Summary undated for Resident #1 revealed, Hospice Mechanical Lift for all transfers. Review of Hospice Admission Orders revealed Resident #1 was admitted to Hospice on 01/14/25, and did not document resident needed a Mechanical Lift with two-person assist for transfers. Review of the Nursing Progress Note dated 04/23/25 at 12:28 p.m., written by LVN A revealed, Resident #1 had a fall in his room. Hospice CNA gave a shower to resident, and during the transfer back to bed the resident fell on the floor and hit his head. Fall information: Hit head, bending over. The fall caused a laceration to right side of the head 3 cm with bleeding. Physician and responsible party were notified. Ordered skull x-rays. Review of the facility's Event Report dated 04/23/25 at 11:00 a.m., revealed, Incident Location: Resident #1's Room. Incident Description: Hospice CNA gave a shower to resident, and during transfer back to bed, the CNA could not hold the resident strongly and fell to the floor. Resident has a laceration on right side of the forehead. Immediate Action Taken: Ordered skull x-rays. Pending results. Interventions in place prior to fall: Floor mat, Low bed. Record review of Resident #1's Event Nurses' Note - Fall dated 04/23/25, revealed, Unwitnessed fall in resident's room. Bending over. Laceration to right side of forehead measuring 3 cm. Nursing description of the event: Hospice CNA gave a shower to resident, and during transfer back to bed the resident fell to the floor. Record review of Hospice Note dated 04/23/25 at 1:50 p.m., written by Hospice Case Manager RN F revealed, Received a call from LVN A from nursing facility, patient sustained a fall while getting showered. Resident sustained a laceration on right side of head. Record review of Resident #1's x-ray report dated 04/23/25 revealed, exam of skull. Unremarkable skull series without obvious evidence of fracture. Record review of Nursing Progress Notes dated 04/26/25 at 7:30 a.m., for Resident #1 revealed Head CT scan pending. Record review of Nursing Progress Notes dated 04/26/25 at 7:36 a.m., revealed Resident #1 was picked up by transport ambulance and taken to hospital. Family member at bedside. Record review of Nursing Progress Notes dated 04/26/25 at 9:45 p.m., for Resident #1 revealed, placed a telephone call to follow up on resident and was informed by hospital RN, the resident had been admitted for cervical fx and would be discharged back to nursing home pending discharge orders from physician. Record review of Nursing Progress Notes dated 04/28/25 at 9:19 p.m., for Resident #1 revealed, Admission Note: Arrived by EMS via stretcher. Current diagnoses/conditions: Dementia/Alzheimer's, Cervical Fx. Lethargic, unclear speech, sometimes understood, sometimes understands. Wheelchair. No balance issues. Assistance required for the following ADLs: Bed Mobility: 2 persons assist. Transferring: Mechanical lift. Toileting assistance. Briefs/pads one person assist. Hygiene/bathing: one person assist. Record review of Hospice Physician Telephone Order dated 04/28/25 for Resident #1 revealed, admit to Hospice. DX: Cerebral infarction, unspecified. Review of Witness Statement dated 05/05/25, written by LVN A revealed, he was sitting at the nurses' station working on documentation, when suddenly hospice CNA C, was standing by the entrance to the room, waving and calling him. He went to Resident #1's room and found the resident on the floor. The shower chair was positioned directly in front of the middle to the bed facing the wall and the resident was next to the chair, with his face on the floor. The CNA C said she could not hold him, and he fell . She did not call for assistance. They were not aware that she was at the facility providing care to the resident. She had been instructed prior to the incident to ask for help with all transfers. Review of Hospice Care Services Agreement dated 09/05/2024, revealed Plans of Care means a written care plan established, maintained, reviewed, and modified, as necessary, at regular intervals, by the IDG. The Plan of Care should reflect the participation of the Hospice, Facility, to the extent possible, which includes identification of the Hospice Services, including interventions and identification of the services to be provided by Facility; and coordinating the Plan of Care to meet the needs of the Hospice patient; and the IDG's documentation of Hospice representative's level of understanding, involvement, and agreement with the Plan of Care. During an interview on 04/30/25 at 10:16 a.m., with LVN A, revealed, Hospice CNA C had not asked the facility staff for assistance on 04/23/25 to transfer Resident #1 from the bed to the shower chair to bathe the resident or after the shower was completed. He said CNA C had transferred the resident from the shower chair to the bed without assistance and had not used the Mechanical lift. He said the resident required a two-person assistance and a Mechanical lift for all transfers. He said that the nurses and the CNAs were always available to help the Hospice CNAs with transfers and use of the Mechanical Lifts as needed. He said that on the day of the incident the Hospice CNA C was standing by the entrance to the resident's room and had called him to the room. He said, When I got to the resident's room, CNA C said that she needed assistance because Resident #1 had fallen off the bed when she had turned to get a diaper. Upon entering the resident's room, the resident was lying on the floor on his left side and his face was planted on the floor and blood was coming out of resident's right side of his head. He said he had assisted CNA C to pick up the resident from the floor and put the resident in bed. He said the attending physician was notified and gave an order for an x-ray of the skull. He said the skull x-ray results were negative for fractures. During a telephone interview on 04/30/25 at 11:15 a.m., with RN B Hospice Director of Clinical Services, revealed the Hospice CNAs had been trained to always ask for help if they could not transfer the patient alone. She said that CNA C had reported to them, that LVN A had helped her on 04/23/25 to do a two-person transfer to sit the resident on the shower chair to bathe him without using the Mechanical lift. She said CNA C, did report that once the resident was bathe, she had not asked LVN A again for assistance to put the resident back in bed and had transferred the resident without assistance. CNA C reported that when she had laid down the resident in the bed, she had turned her back to get a diaper and that is when the resident had rolled off from the bed and fell on the floor. CNA C said that she had asked LVN A for assistance to put the resident in bed, after resident had fallen to the floor. CNA C, reported that sometimes she did not use the Mechanical lift and would ask the CNAs for assistance do a two-person transfer to move the resident from the bed to the shower chair to give him a shower. RN B said, Either way Resident #1 required a two-patient transfer. She said CNA C had not explained to them why she had not asked her help to transfer the resident to the bed on that day. During a telephone interview on 04/30/25 at 4:25 p.m., with Hospice CNA C revealed, that she had asked LVN A on 04/23/25 to assist her to transfer Resident #1 from the bed to the shower chair without using a Mechanical lift. She said that after the shower was completed LVN A had assisted her to transfer the resident from the shower chair to the bed without using the Mechanical lift. She said, the resident was lying in bed, and I turned to grab a diaper from a drawer that was approximately 6 feet from the bed and that is when resident fell off the bed. She said that she had called LVN A to help her put the resident on the bed. She said that she had reported the accident to the hospice nurse. She said, I didn't mean it, it just happened so fast. She said that she was aware that Resident #1 needed a Mechanical lift and required a two-person transfer. She said, It was my fault for not using the Mechanical lift. On that day, I could not find the sling to use the Mechanical lift. When I informed LVN A that I could not find the sling to use the Mechanical lift, he said that it was okay, and he would help me to transfer Resident #1. Sometimes I do transfer him without assistance because I cannot find anyone to help me with the two-person transfer. She said that she had been re-trained on 04/28/25 by the hospice staff on how to use of the Mechanical lift and with a two-person transfer. During a second telephone interview on 05/01/25 at 12:07 p.m., with RN B Hospice Director of Clinical Services, revealed, that CNA C had reported to hospice staff in the past, that the facility did not always have the Mechanical sling available, so the facility staff would assist her to do a two-person transfer to move Resident #1 from the bed to the shower chair. She said that CNA C, had reported that on the day of the incident on 04/23/25, it was close to lunch time, and no one had come to help her to transfer Resident #1 from the shower chair to the bed, so she had transferred Resident #1 on her own without using the Mechanical lift. CNA C also reported that the bed was on the lowest position when the resident had rolled off the bed. She said that after the incident involving Resident #1, the hospice staff had been retrained including CNA C on the use of the mechanical lift with two-person assistance and had also completed a competence skills checklist on CNA C. She said that the hospice staff did not attend the facility's care plan meetings because they were never invited. During an interview on 05/01/25 at 12:18 p.m., with RN F Hospice Case Manager who was assigned to Resident #1 revealed that the Hospice CNAs were expected to follow the Hospice care plans, and that he verified that the care plan was being followed by the Hospice CNAs when he went to see the resident. He said, after the fall, they would be working with the nursing home to compare their care plans to make sure that everyone is on the same page because the hospice and the nursing facility have their own care plans. We keep a copy of the hospice care plan in the hospice binder that is provided to the nursing facility. I was aware that Resident #1 required a two-person transfer because when the resident was admitted to hospice, he was bedbound and automatically that will require a two-person transfer. I did not know that Resident #1 required a lift for transfers, because it was not on the hospice care plan. During an interview on 05/01/25 at 12:45 p.m., with the Administrator, DON, and ADON revealed, that prior to the incident with Resident #1, the facility and the hospice staff did not share a copy of the care plans to coordinate the care and services provided to the resident. The DON said, the hospice staff would give a verbal report to the facility staff of what care was provided to the resident when they came to see the resident at the facility. During an interview on 05/01/25 at 1:40 p.m., with the DON revealed the hospice providers did not attend the IDT care plan meetings at the facility and did not know if the facility's Social Worker was inviting the hospice providers to attend the IDT care plan meetings, since the Social Worker was responsible for scheduling the IDT care plan meetings. During an interview on 05/01/25 at 1:44 p.m., with the facility's Social Worker V revealed that she was not aware that she needed to invite the hospice providers to the facility's IDT care plan meetings. During an interview on 05/01/25 at 5:05 p.m., with the Administrator revealed, he was not aware that the hospice aide had transferred Resident #1 on 04/23/25 without using a Hoyer lift, until the hospice staff came to the facility on [DATE] to apologize for not using the Hoyer lift. He said, I did not know hospice had made a mistake until they came. He said that he knew about the fall but did not start the investigation process to determine what had caused the fall. Review of the facility's on Hospice Services dated 02/13/2007, revealed, As an end-of-life measure. The resident or responsible family member may choose to use Hospice services within the facility. Procedures: The facility may have a legally binding written agreement with the provision of arranged services with a recognized Hospice provider. Authorized representatives of the nursing facility and Hospice provider must sign the agreement. A copy of the agreement will be maintained by the facility. The identification of the services to be provided. The manner in which the contracted services are coordinated, supervised and evaluated by the hospice and nursing facility. The delineation of the roles of the hospice and the nursing facility in the admission process, recipient and family assessment and the interdisciplinary team case conferences. The hospice facility will be responsible for appropriately training healthcare personnel to care for the resident is outlined in the State Practice Act. The hospice employees will be responsible for complying with the standards of care for environmental, safety, and infection control practices while employed under contract in the nursing facility. The nursing facility and hospice provider must ensure that a coordinated plan of care reflects the participation of hospice, nursing facility, the recipient, and the legal representative to the extent possible. This was determined to be an Immediate Jeopardy (IJ) on 05/02/2025 at 3:55 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/02/2025 at 3:55 p.m. The following Plan of Removal submitted by the facility was accepted on 5/03/2025 at 8:29 p.m.: Interventions: -The alleged perpetrator will not be returning to the facility. Completed on 4/23/2025. -Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan. Completed 5/2/2025. -The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required in the for transfer and mechanical devices required in the kiosk. Completed on 5/2/2025. -Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment. Completed on 5/1/2025. -Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex. Completed on 5/2/2025. -Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries. Completed on 5/2/2025. -The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON. Completed on 5/2/2025. -100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team. This was completed on 5/2/2025. In-services: -Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above. Completed on 5/3/2025. -05/03/25 Subject: Hospice sign-in and Kardex review process; Summary: Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station. -Inservice dated 5/3/2025 revealed, Subject: All hospice staff must report to charge nurse and review Kardex; Summary: All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex. -Inservice dated 5/3/2025 revealed, Subject: Hospice staff - Abuse, Neglect and Exploitation; Summary: In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff. -Inservice dated 5/4/2025 revealed, Subject: Abuse, neglect, and exploitation; Summary: Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting. Monitoring of the facility's plan of removal included the following: During an interview on 05/04/25 at 11:42 a.m., with CNA H assigned to the second floor revealed, she had been trained on 05/02/25 on how to use the lift with two-person assist. She said, The hospice staff report to the charge nurse who is assigned to the hospice resident, and they will review the hospice binder that is kept at the nurses' station to review the Kardex and the facility's care plan to verify if the resident needs a Mechanical lift with a two-person transfer. The charge nurse will assign a CNA to help the hospice aide with transfers as needed. She said that the charge nurses are also available to assist the CNAs with transfers. She said the Mechanical lifts have a bright orange sign posted on the Mechanical lift to remind staff that all Mechanical lift transfers require a two-person to transfer the resident. The CNAs were also trained to remind the hospice CNAs to sign in at the nurses' station and get report from the charge nurse prior to providing care to the hospice resident. She said that this process was implemented to communicate with the hospice staff on an on-going basis to ensure that hospice residents receive the necessary care and services according to the facility's care plan approaches. During an interview on 05/04/25 at 11:43 a.m., with CNA I assigned to the first floor in hall 500, revealed the facility staff and hospice staff had been trained on 05/02/25, on the new process for the hospice staff to report to the charge nurse to review the Kardex before providing care to the resident to ensure that hospice staff are following the care plan approaches related to the use of mechanical lifts and two-person transfers. She said there is a binder at the nurses' station that contains the Kardex and copy of facility care plan to verify if the resident needs to be transferred with a Mechanical lift and two-person transfer. The charge nurse will assign a CNA to help the hospice aide with transfers as needed. She said that the charge nurses are also available to assist the CNAs with transfers. She said the Mechanical lifts have a bright orange sign posted on the Mechanical lift to remind staff that all Mechanical lift transfers require a two-person to transfer the resident. The CNAs were also trained to remind the hospice CNAs to sign in at the nurses' station and get report from the charge nurse prior to providing care to the hospice resident. She said that this process was implemented to communicate with the hospice staff on an on-going basis to ensure that hospice residents receive the necessary care and services according to the facility's care plan approaches. During a telephone interview on 05/04/25 at 12:56 p.m., with Hospice Liaison J revealed, the facility had provided in-service training on 05/02/25. She said, the whole team assigned to the nursing facility attended the training. We were informed by the nursing facility staff, that without this training the hospice staff would not be able to enter the facility to perform any clinical duties with their contracted residents. The Hospice Liaison was not able to provide any other specifics regarding the training and advised the state surveyor to contact the hospice Director of Clinical Services RN B who could tell her who had attended the training. During a telephone interview on 05/04/25 at 12:58 p.m., with Hospice Care Consultant/Director of Admissions K revealed, hospice staff had attended an in-service training at the nursing facility on proper use of a Mechanical lift. It was explained that when hospice staff arrives to the facility they are to report and be cleared by the charge nurse before any care is provided to the resident and sign the form in acknowledgment that care plans and Kardex have been reviewed. She said that the hospice staff were scheduled to attend and IDT care plan meeting at the nursing facility to review the care plan approaches and coordinate the care and services provided to the resident. During an interview on 05/04/25 at 1:00 p.m., with family member revealed that she was visiting a resident. She stated that she has never had any issues with the care that is provided to the resident. The family member reported that transfers were always done with two-persons. Observation on 05/04/25 at 1:15 p.m., revealed that the Mechanical lifts were tagged with a bright orange sign that stated, Two-people required to operate the lift. During an interview on 05/04/25 at 1:15 p.m., with the Administrator revealed there was always at least eight CNAs available in the facility to help with transfers as well as the charge nurses and the activities director who is also a CNA. Observation and interview on 05/04/25 at 1:15 PM, revealed CNA M and CNA I were transferring Resident #7 with a Mechanical lift from the bed to the wheelchair. Resident #7 said that the CNAs always completed two-persons when they transferred him with the Mechanical lift. CNAs reported that they had checked the Kardex prior to transfer and had confirmed that Resident #7 required a Mechanical lift with two-persons transfer. Record Review on 05/04/25 at 1:30 p.m., revealed Hospice binders were kept at the nurses' stations on the first and second floor that had the Kardex, copy of facility care plan, Kardex and Sign-In Sheets for hospice staff to acknowledge if the resident required a Mechanical lift and two-person transfer. During an interview on 05/04/25 at 1:55 p.m., with the facility's Social Worker V revealed that she had been in-serviced by the Administrator, DON, and ADON to invite the hospice providers to the IDT care plan meetings. During a telephone interview on 05/04/25 at 3:00 p.m., with RN L Hospice Administrator of Operations revealed that she was present on 05/02/25 to observe the training on how to complete a Mechanical lift transfer with two-persons. The staff were also trained to check in with the charge nurse prior to providing care to the hospice resident to review the Kardex and facility care plan to verify if the resident needed a Mechanical lift transfer with two-persons. Observation and interview on 05/04/25 at 3:35 p.m., revealed CNA H and CNA N were preparing to transfer Resident #9 with a Mechanical lift from the bed to the wheelchair. The CNAs said that they always checked the Kardex prior to transfer to verify if Resident #9 still required a Mechanical lift transfer with two-persons assistance. Observation and interview on 05/04/25 at 3:58 p.m., revealed Hospice CNA P was being assisted by the CNA O to transfer Resident #9, from the wheelchair to the bed using a Mechanical lift. Both CNAs said that checked the Kardex prior to transfer to verify if Resident #9 still required a Mechanical lift transfer with two-persons assistance. The CNA S said they would get the Hospice binder to check the Kardex and facility care plan with the charge nurse and then signed the Kardex Sign-In Sheet to acknowledge if the resident required a Mechanical lift and two-person transfer. During a telephone interview on 05/04/25 at 5:06 p.m., with RN L Hospice Administrator of Operations revealed, in-service training had been provided on 05/02/25, to all the hospice staff by the facility's administrative staff on complete a transfer with a Mechanical lift with two-persons assistance. The hospice staff will review the care plan and Kardex that are kept in the hospice binder with the charge nurse prior to providing care to the resident to make sure that the information is the same on the hospice plan o [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to coordinate care and services with the hospice provider to ensure the written plans of care included both the most recent hospice plan of care and a description of the services furnished by the nursing facility to prevent neglect. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). An Immediate Jeopardy (IJ) situation was identified on 05/02/25. While the IJ was removed on 05/05/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falls, injury, or death. Findings include: Record review of Resident #1's Admission Record, dated 04/29/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: cerebral infraction (a condition where blood flow to the brain is interrupted, causing brain cell to die), altered mental status (there's a change in how your brain is working affecting your ability to think, be aware of your surroundings, and react normally), abnormal gait and mobility (issues with how someone walks or moves, often due to underlying medical conditions or injuries), Alzheimer's disease (is a brain disorder that leads to memory loss and other cognitive decline, eventually impacting a person's ability to perform daily tasks), history of falling, anxiety disorder (mental health conditions characterized by excessive and persistent worry and fear, often leading to physical symptoms and difficulties in daily life), atrial fibrillation (an irregular and often rapid heartbeat that occurs when the electrical signals in the heart's upper chambers (atrial) fire out at the same speed). Review of Hospital ED notes dated 04/26/25 at 8:20 a.m., for Resident #1 revealed, Chief Complaint: Pt. presents to the ED s/p fall sustained on Wednesday with head strike per EMS. Patient was being showered by hospice nurse when he fell . Patient is bedbound, left-sided hemiparesis (impairment on the left side of the body). Presented from nursing home apparently had fallen out of bed on Wednesday, did not seek any attention till today. Was brought in today complaining of pain. Patient is non-verbal and does not follow commands. Contracture (a permanent tightening of the muscle, tendons, skin, and nearby tissues that cause the joints shorten and become very stiff) to left upper extremity and contractures of both lower extremities. Physical Exam: 2 cm laceration with steri-strips to forehead. Impression and Plan: Neurosurgeon reported he will not operate and wants to keep the patient at the hospital to treat conservatively. Patient in ICU under trauma services. Medical Decision Making: Patient very cachectic (weakness and wasting of the body) and would not withstand any kind of surgical intervention and place in a hard collar for life. Assessment: C2 dens type II fracture displacement nonoperative. Record review of Resident #1's Hospital Discharge Summary dated 04/28/25, revealed admitted [DATE] and discharge date [DATE]. Resident was admitted to the hospital on 04/26/25 at 11:36 a.m. History of Present Illness: [AGE] year-old male that resident at nursing home. On 04/23/25 he sustained a fall while being showered when he fell forward from the shower chair causing a laceration to the right side of his forehead requiring steri- strips. CT cervical spine revealed an acute unstable type II dens fracture of C1 on C2. Discharge Diagnosis 04/28/25: Type II dens fracture of second cervical vertebra, atrial fibrillation, advanced dementia. Record review of Resident #1's History & Physical dated 01/14/25 for Resident #1 revealed, Patient readmitted under hospice care after a massive cerebrovascular accident. Hemiplegia to left side, dementia, comfort care under Hospice, repeated falls. Neurological: Non-ambulatory, terminally demented, unable to follow commands. Unable to stand or walk. Record review of Physician's Progress Noted dated 04/24/25 written by attending physician revealed, resident seen today due to charge nurse reporting a fall. Recent fall from shower chair and sustained a laceration to the right side of forehead requiring steri-stips. Skull x-ray was obtained which was negative for fracture. Continue comfort care and pain management. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed BIMS was not conducted due to Resident #1's inability to answer questions. Short-term and Long-term Memory Problems. Section C1000. Cognitive Skills for Daily Decision Making - Severely Impaired. Section GG - Functional Abilities revealed Resident #1 required substantial/maximal assistance with toileting hygiene, shower/bathing, sit to stand and chair/bed transfer; partial/moderate assistance with upper body dressing and personal hygiene. Wheelchair for mobility. Functional Limitation in Range of Motion - Impairment on one side to upper extremity; incontinent of bowel & bladder. Active diagnoses - Alzheimer's disease, stroke, cerebral infarction, altered mental status, unsteadiness on feet, abnormal gait, and mobility. Record review of Resident #1's Care Plan, dated 03/17/2025, revealed Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Transfer: The resident requires total assistance with transfer. Mechanical lift for all transfers with 2 staff for assistance. Contractures to all extremities. Risk for falls. Mechanical lift for all transfers with 2 staff for assistance. Resident has a terminal prognosis and is receiving hospice services. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Hospice staff (nurse, CNA, SW, Chaplin) to assist with resident care. Record review of Hospice Plan of Care Effective 4/02/25 for Resident #1 revealed, Last Updated: 04/01/25. Problem: Patient at risk for experiencing inability to perform care related to cognitive deficits, functional limitations, weakness, debility, deconditioning, altered mental status, environmental/logistical limitations, lack of supervision. Problem: Patient at risk for/experiencing falls with injury related to deconditioning, altered mental status cognitive decline, neurological deficit, altered gait or balance, medication effects/side effects, functional alterations, other. Goal: Patient will have no fall with injury. Interventions: RN and/or SN will assess fall risk on admission, at recertification, change in level or location of care. SN will identify appropriate DME and collaborate with MD to order as indicated and will train/model how to safely use assistive devices during visits. The Hospice Care Plan did not document resident #1 needed a Mechanical lift and two-person assistance with transfers. Review of Physician's Order dated 02/16/2025 for Resident #1 revealed, Resident a Mechanical Lift with 2-person transfer. Review of Physician Order Summary undated for Resident #1 revealed, Hospice Mechanical Lift for all transfers. Review of Hospice Admission Orders revealed Resident #1 was admitted to Hospice on 01/14/25, and did not document resident needed a Mechanical Lift with two-person assist for transfers. Review of the Nursing Progress Note dated 04/23/25 at 12:28 p.m., written by LVN A revealed, Resident #1 had a fall in his room. Hospice CNA gave a shower to resident, and during the transfer back to bed the resident fell on the floor and hit his head. Fall information: Hit head, bending over. The fall caused a laceration to right side of the head 3 cm with bleeding. Physician and responsible party were notified. Ordered skull x-rays. Review of the facility's Event Report dated 04/23/25 at 11:00 a.m., revealed, Incident Location: Resident #1's Room. Incident Description: Hospice CNA gave a shower to resident, and during transfer back to bed, the CNA could not hold the resident strongly and fell to the floor. Resident has a laceration on right side of the forehead. Immediate Action Taken: Ordered skull x-rays. Pending results. Interventions in place prior to fall: Floor mat, Low bed. Record review of Resident #1's Event Nurses' Note - Fall dated 04/23/25, revealed, Unwitnessed fall in resident's room. Bending over. Laceration to right side of forehead measuring 3 cm. Nursing description of the event: Hospice CNA gave a shower to resident, and during transfer back to bed the resident fell to the floor. Record review of Hospice Note dated 04/23/25 at 1:50 p.m., written by Hospice Case Manager RN F revealed, Received a call from LVN A from nursing facility, patient sustained a fall while getting showered. Resident sustained a laceration on right side of head. Record review of Resident #1's x-ray report dated 04/23/25 revealed, exam of skull. Unremarkable skull series without obvious evidence of fracture. Record review of Nursing Progress Notes dated 04/26/25 at 7:30 a.m., for Resident #1 revealed Head CT scan pending. Record review of Nursing Progress Notes dated 04/26/25 at 7:36 a.m., revealed Resident #1 was picked up by transport ambulance and taken to hospital. Family member at bedside. Record review of Nursing Progress Notes dated 04/26/25 at 9:45 p.m., for Resident #1 revealed, placed a telephone call to follow up on resident and was informed by hospital RN, the resident had been admitted for cervical fx and would be discharged back to nursing home pending discharge orders from physician. Record review of Nursing Progress Notes dated 04/28/25 at 9:19 p.m., for Resident #1 revealed, Admission Note: Arrived by EMS via stretcher. Current diagnoses/conditions: Dementia/Alzheimer's, Cervical Fx. Lethargic, unclear speech, sometimes understood, sometimes understands. Wheelchair. No balance issues. Assistance required for the following ADLs: Bed Mobility: 2 persons assist. Transferring: Mechanical lift. Toileting assistance. Briefs/pads one person assist. Hygiene/bathing: one person assist. Record review of Hospice Physician Telephone Order dated 04/28/25 for Resident #1 revealed, admit to Hospice. DX: Cerebral infarction, unspecified. Record review of Bedside Kardex dated 04/28/25 for Resident #1 revealed, Transferring: The resident required total assistance with transfers. Mechanical lift for all transfers with 2 staff for assistance. Mobility: Bed Mobility requires extensive assist x 2 staff to reposition and turn in bed. Review of Witness Statement dated 05/05/25, written by LVN A revealed, he was sitting at the nurses' station working on documentation, when suddenly hospice CNA C, was standing by the entrance to the room, waving and calling him. He went to Resident #1's room and found the resident on the floor. The shower chair was positioned directly in front of the middle to the bed facing the wall and the resident was next to the chair, with his face on the floor. The CNA C said she could not hold him, and he fell . She did not call for assistance. They were not aware that she was at the facility providing care to the resident. She had been instructed prior to the incident to ask for help with all transfers. Review of Hospice Care Services Agreement dated 09/05/2024, revealed Plans of Care means a written care plan established, maintained, reviewed, and modified, as necessary, at regular intervals, by the IDG. The Plan of Care should reflect the participation of the Hospice, Facility, to the extent possible, which includes identification of the Hospice Services, including interventions and identification of the services to be provided by Facility; and coordinating the Plan of Care to meet the needs of the Hospice patient; and the IDG's documentation of Hospice representative's level of understanding, involvement, and agreement with the Plan of Care. During a telephone interview on 04/30/25 at 8:45 a.m., with Resident #1's family member, revealed LVN A had called on 04/23/25 to report that resident had sustained a fall in the shower. The family member reported that two days after the incident, family member had requested to have resident transferred to the hospital to get an MRI, to see what was wrong with him since he was declining and was no longer was eating, and no longer was able to talk because he was just sleeping. During an interview on 04/30/25 at 10:16 a.m., with LVN A, revealed, Hospice CNA C had not asked the facility staff for assistance on 04/23/25 to transfer Resident #1 from the bed to the shower chair to bathe the resident or after the shower was completed. He said CNA C had transferred the resident from the shower chair to the bed without assistance and had not used the Mechanical lift. He said the resident required a two-person assistance and a Mechanical lift for all transfers. He said that the nurses and the CNAs were always available to help the Hospice CNAs with transfers and use of the Mechanical Lifts as needed. He said that on the day of the incident the Hospice CNA C was standing by the entrance to the resident's room and had called him to the room. He said, When I got to the resident's room, CNA C said that she needed assistance because Resident #1 had fallen off the bed when she had turned to get a diaper. Upon entering the resident's room, the resident was lying on the floor on his left side and his face was planted on the floor and blood was coming out of resident's right side of his head. He said he had assisted CNA C to pick up the resident from the floor and put the resident in bed. He said the attending physician was notified and gave an order for an x-ray of the skull. He said the skull x-ray results were negative for fractures. During a telephone interview on 04/30/25 at 11:15 a.m., with RN B Hospice Director of Clinical Services, revealed the Hospice CNAs had been trained to always ask for help if they could not transfer the patient alone. She said that CNA C had reported to them, that LVN A had helped her on 04/23/25 to do a two-person transfer to sit the resident on the shower chair to bathe him without using the Mechanical lift. She said CNA C, did report that once the resident was bathe, she had not asked LVN A again for assistance to put the resident back in bed and had transferred the resident without assistance. CNA C reported that when she had laid down the resident in the bed, she had turned her back to get a diaper and that is when the resident had rolled off from the bed and fell on the floor. CNA C said that she had asked LVN A for assistance to put the resident in bed, after resident had fallen to the floor. CNA C, reported that sometimes she did not use the Mechanical lift and would ask the CNAs for assistance do a two-person transfer to move the resident from the bed to the shower chair to give him a shower. RN B said, Either way Resident #1 required a two-patient transfer. She said CNA C had not explained to them why she had not asked her help to transfer the resident to the bed on that day. During a telephone interview on 04/30/25 at 1:24 p.m., with Nurse Practitioner D, revealed that she was notified on 04/23/25 that Resident #1 had sustained a fall on 04/23/25 and had come to the facility the next day, to assess the resident. She said that she was not aware that the resident had been transferred without a Mechanical Lift and a two-person transfer. She said that she could not recall the resident's diagnosis but did remember that the resident was [AGE] year-old male and was very fragile. She stated that the cervical fractures could have been related to the fall. During an interview on 04/30/25 at 3:12 p.m., with the DON revealed, I believed that we found out on Sunday 04/27/25, from the hospital paperwork that Resident #1 had a cervical fracture. He had a diagnosis of osteoporosis, so his injuries could have resulted from the fall on 04/23/25. During an interview on 04/30/25 at 4:00 p.m., with the Administrator revealed that he did not know that Resident #1 had sustained a cervical fracture until 04/28/25, when they had received the hospital paperwork upon resident's readmission to the nursing facility. During a telephone interview on 04/30/25 at 4:25 p.m., with Hospice CNA C revealed, that she had asked LVN A on 04/23/25 to assist her to transfer Resident #1 from the bed to the shower chair without using a Mechanical lift. She said that after the shower was completed LVN A had assisted her to transfer the resident from the shower chair to the bed without using the Mechanical lift. She said, the resident was lying in bed, and I turned to grab a diaper from a drawer that was approximately 6 feet from the bed and that is when resident fell off the bed. She said that she had called LVN A to help her put the resident on the bed. She said that she had reported the accident to the hospice nurse. She said, I didn't mean it, it just happened so fast. She said that she was aware that Resident #1 needed a Mechanical lift and required a two-person transfer. She said, It was my fault for not using the Mechanical lift. On that day, I could not find the sling to use the Mechanical lift. When I informed LVN A that I could not find the sling to use the Mechanical lift, he said that it was okay, and he would help me to transfer Resident #1. Sometimes I do transfer him without assistance because I cannot find anyone to help me with the two-person transfer. She said that she had been re-trained on 04/28/25 by the hospice staff on how to use of the Mechanical lift and with a two-person transfer. Observation on 04/30/25 at 4:50 p.m., revealed Resident #1's bed was approximately 7 feet from the drawer where the disposable briefs were stored. The resident had a high/low bed and floor mat by the side of the bed. During an interview on 04/30/25 at 5:20 p.m., with CNA G revealed, the facility had provided an in-service training on 04/28/25 on how to use the Mechanical lifts with a two-person transfer. During a second telephone interview on 04/30/25 at 5:29 PM, with LVN A revealed that he had only assisted the hospice CNA C, to lift Resident #1 from the floor after he fell , to put him in bed. LVN A denied assisting CNA C to transfer resident on 04/23/25. He said that when he entered the resident's room, to put the resident in bed, he had not seen the Mechanical lift in the room. He said staff had been trained to always use a Mechanical lift with two-person assistance to transfer Resident #1. During an interview on 04/30/25 at 5:30 p.m., with ADON revealed, that she had done an in-service training on 04/29/25 for all facility nursing staff and Hospice staff on the use of a Mechanical lift with a two-person transfer. During an interview on 05/01/25 at 11:24 a.m., with the Administrator revealed the facility did not have a Fall Prevention policy & procedure. During a second telephone interview on 05/01/25 at 12:07 p.m., with RN B Hospice Director of Clinical Services, revealed, that CNA C had reported to hospice staff in the past, that the facility did not always have the Mechanical sling available, so the facility staff would assist her to do a two-person transfer to move Resident #1 from the bed to the shower chair. She said that CNA C, had reported that on the day of the incident on 04/23/25, it was close to lunch time, and no one had come to help her to transfer Resident #1 from the shower chair to the bed, so she had transferred Resident #1 on her own without using the Mechanical lift. CNA C also reported that the bed was on the lowest position when the resident had rolled off the bed. She said that after the incident involving Resident #1, the hospice staff had been retrained including CNA C on the use of the mechanical lift with two-person assistance and had also completed a competence skills checklist on CNA C. She said that the hospice staff did not attend the facility's care plan meetings because they were never invited. During an interview on 05/01/25 at 12:18 p.m., with RN F Hospice Case Manager who was assigned to Resident #1 revealed that the Hospice CNAs were expected to follow the Hospice care plans, and that he verified that the care plan was being followed by the Hospice CNAs when he went to see the resident. He said, after the fall, they would be working with the nursing home to compare their care plans to make sure that everyone is on the same page because the hospice and the nursing facility have their own care plans. We keep a copy of the hospice care plan in the hospice binder that is provided to the nursing facility. I was aware that Resident #1 required a two-person transfer because when the resident was admitted to hospice, he was bedbound and automatically that will require a two-person transfer. I did not know that Resident #1 required a lift for transfers, because it was not on the hospice care plan. During an interview on 05/01/25 at 12:45 p.m., with the Administrator, DON, and ADON revealed, that prior to the incident with Resident #1, the facility and the hospice staff did not share a copy of the care plans to coordinate the care and services provided to the resident. The DON said, the hospice staff would give a verbal report to the facility staff of what care was provided to the resident when they came to see the resident at the facility. During an interview on 05/01/25 at 5:05 p.m., with the Administrator revealed, he was not aware that the hospice aide had transferred Resident #1 on 04/23/25 without using a Mechanical lift and a two-person transfer, until the hospice staff came to the facility on [DATE] to apologize for not using the Mechanical lift. He said, I did not know hospice had made a mistake until they came. He said that he knew about the fall but did not start the investigation process to determine what had caused the fall. Review of In-Service Training Attendance Roster dated 04/29/25 revealed, all facility staff were trained on Reporting Abuse, Neglect, Exploitation Review of In-Service Training Attendance Roster dated 04/30/25 revealed, all facility staff were trained on Abuse, Neglect, and Exploitation or Sexual Abuse immediately to the Abuse Coordinator - Facility Administrator. Review of the facility's Policy & Procedure on Abuse/Neglect revised on 09/09/24 revealed, the resident has the right to be free from abuse, neglect, misappropriation of property and exploitation. Residents should not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members and legal guardians, friends, and other individuals. The facility will provide an ensure their promotion and protection of resident rights. Definitions: Neglect: Is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Training: The facility will train through orientation and ongoing in-services on issues related to abuse, neglect, prohibition practices regularly. Prevention.: The facility will provide the residents, families, and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect will be investigated as per facility protocol. The facility will be responsible to identify, correct and intervene in situations of possible abuse/neglect. Protection.: The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents, or misappropriation of a resident's property. Review of the facility's policy on Resident Rights dated 11/28/26 revealed, The right to exercise his or her rights as a resident of the Facility and as a citizen or resident of the United States. Patient has a right to a safe, clean, comfortable, and home like environment including but not limited to receiving treatment and supports for daily living safely. The right to reside and receive services in the facility with reasonable accommodations and resident needs and preferences, except. When to do so would endanger the health or safety of the resident or other residents. This was determined to be an Immediate Jeopardy (IJ) on 05/02/2025 at 3:55 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/02/2025 at 3:55 p.m. The following Plan of Removal submitted by the facility was accepted on 5/03/2025 at 8:29 p.m.: Interventions: -The alleged perpetrator will not be returning to the facility. Completed on 4/23/2025. -Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan. Completed 5/2/2025. -The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required in the for transfer and mechanical devices required in the kiosk. Completed on 5/2/2025. -Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment. Completed on 5/1/2025. -Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex. Completed on 5/2/2025. -Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries. Completed on 5/2/2025. -The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON. Completed on 5/2/2025. -100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team. This was completed on 5/2/2025. In-services: -Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above. Completed on 5/3/2025. -05/03/25 Subject: Hospice sign-in and Kardex review process; Summary: Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station. -Inservice dated 5/3/2025 revealed, Subject: All hospice staff must report to charge nurse and review Kardex; Summary: All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex. -Inservice dated 5/3/2025 revealed, Subject: Hospice staff - Abuse, Neglect and Exploitation; Summary: In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff. -Inservice dated 5/4/2025 revealed, Subject: Abuse, neglect, and exploitation; Summary: Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting. Monitoring of the facility's plan of removal included the following: During an interview on 05/04/25 at 11:42 a.m., with CNA H assigned to the second floor revealed, she had been trained on 05/02/25 on how to use the lift with two-person assist. She said, The hospice staff report to the charge nurse who is assigned to the hospice resident, and they will review the hospice binder that is kept at the nurses' station to review the Kardex and the facility's care plan to verify if the resident needs a Mechanical lift with a two-person transfer. The charge nurse will assign a CNA to help the hospice aide with transfers as needed. She said that the charge nurses are also available to assist the CNAs with transfers. She said the Mechanical lifts have a bright orange sign posted on the Mechanical lift to remind staff that all Mechanical lift transfers require a two-person to transfer the resident. The CNAs were also trained to remind the hospice CNAs to sign in at the nurses' station and get report from the charge nurse prior to providing care to the hospice resident. She said that this process was implemented to communicate with the hospice staff on an on-going basis to ensure that hospice residents receive the necessary care and services according to the facility's care plan approaches. During an interview on 05/04/25 at 11:43 a.m., with CNA I assigned to the first floor in hall 500, revealed the facility staff and hospice staff had been trained on 05/02/25, on the new process for the hospice staff to report to the charge nurse to review the Kardex before providing care to the resident to ensure that hospice staff are following the care plan approaches related to the use of mechanical lifts and two-person transfers. She said there is a binder at the nurses' station that contains the Kardex and copy of facility care plan to verify if the resident needs to be transferred with a Mechanical lift and two-person transfer. The charge nurse will assign a CNA to help the hospice aide with transfers as needed. She said that the charge nurses are also available to assist the CNAs with transfers. She said the Mechanical lifts have a bright orange sign posted on the Mechanical lift to remind staff that all Mechanical lift transfers require a two-person to transfer the resident. The CNAs were also trained to remind the hospice CNAs to sign in at the nurses' station and get report from the charge nurse prior to providing care to the hospice resident. She said that this process was implemented to communicate with the hospice staff on an on-going basis to ensure that hospice residents receive the necessary care and services according to the facility's care plan approaches. During a telephone interview on 05/04/25 at 12:56 p.m., with Hospice Liaison J revealed, the facility had provided in-service training on 05/02/25. She said, the whole team assigned to the nursing facility attended the training. We were informed by the nursing facility staff, that without this training the hospice staff would not be able to enter the facility to perform any clinical duties with their contracted residents. The Hospice Liaison was not able to provide any other specifics regarding the training and advised the state surveyor to contact the hospice Director of Clinical Services RN B who could tell her who had attended the training. During a telephone interview on 05/04/25 at 12:58 p.m., with Hospice Care Consultant/Director of Admissions K revealed, hospice staff had attended an in-service training at the nursing facility on proper use of a Mechanical lift. It was explained that when hospice staff arrives to the facility they are to report and be cleared by the charge nurse before any care is provided to the resident and sign the form in acknowledgment that care plans and Kardex have been reviewed. She said that the hospice staff were scheduled to attend and IDT care plan meeting at the nursing [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent for 1 of 9 residents (Residents #1) reviewed for accidents. The facility failed to ensure the Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). An Immediate Jeopardy (IJ) situation was identified on 05/02/25. While the IJ was removed on 05/05/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falls, injury, or death. Findings include: Record review of Resident #1's Admission Record, dated 04/29/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: cerebral infraction (a condition where blood flow to the brain is interrupted, causing brain cell to die), altered mental status (there's a change in how your brain is working affecting your ability to think, be aware of your surroundings, and react normally), abnormal gait and mobility (issues with how someone walks or moves, often due to underlying medical conditions or injuries), Alzheimer's disease (is a brain disorder that leads to memory loss and other cognitive decline, eventually impacting a person's ability to perform daily tasks), history of falling, anxiety disorder (mental health conditions characterized by excessive and persistent worry and fear, often leading to physical symptoms and difficulties in daily life), atrial fibrillation (an irregular and often rapid heartbeat that occurs when the electrical signals in the heart's upper chambers (atrial) fire out at the same speed). Review of Hospital ED notes dated 04/26/25 at 8:20 a.m., for Resident #1 revealed, Chief Complaint: Pt. presents to the ED s/p fall sustained on Wednesday with head strike per EMS. Patient was being showered by hospice nurse when he fell . Patient is bedbound, left-sided hemiparesis (impairment on the left side of the body). Presented from nursing home apparently had fallen out of bed on Wednesday, did not seek any attention till today. Was brought in today complaining of pain. Patient is non-verbal and does not follow commands. Contracture (a permanent tightening of the muscle, tendons, skin, and nearby tissues that cause the joints shorten and become very stiff) to left upper extremity and contractures of both lower extremities. Physical Exam: 2 cm laceration with steri-strips to forehead. Impression and Plan: Neurosurgeon reported he will not operate and wants to keep the patient at the hospital to treat conservatively. Patient in ICU under trauma services. Medical Decision Making: Patient very cachectic (weakness and wasting of the body) and would not withstand any kind of surgical intervention and place in a hard collar for life. Assessment: C2 dens type II fracture displacement nonoperative. Record review of Resident #1's Hospital Discharge Summary dated 04/28/25, revealed admitted [DATE] and discharge date [DATE]. Resident was admitted to the hospital on 04/26/25 at 11:36 a.m. History of Present Illness: [AGE] year-old male that resident at nursing home. On 04/23/25 he sustained a fall while being showered when he fell forward from the shower chair causing a laceration to the right side of his forehead requiring steri- strips. CT cervical spine revealed an acute unstable type II dens fracture of C1 on C2. Discharge Diagnosis 04/28/25: Type II dens fracture of second cervical vertebra, atrial fibrillation, advanced dementia. Record review of Resident #1's History & Physical dated 01/14/25 for Resident #1 revealed, Patient readmitted under hospice care after a massive cerebrovascular accident. Hemiplegia to left side, dementia, comfort care under Hospice, repeated falls. Neurological: Non-ambulatory, terminally demented, unable to follow commands. Unable to stand or walk. Record review of Physician's Progress Noted dated 04/24/25 written by attending physician revealed, resident seen today due to charge nurse reporting a fall. Recent fall from shower chair and sustained a laceration to the right side of forehead requiring steri-stips. Skull x-ray was obtained which was negative for fracture. Continue comfort care and pain management. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed BIMS was not conducted due to Resident #1's inability to answer questions. Short-term and Long-term Memory Problems. Section C1000. Cognitive Skills for Daily Decision Making - Severely Impaired. Section GG - Functional Abilities revealed Resident #1 required substantial/maximal assistance with toileting hygiene, shower/bathing, sit to stand and chair/bed transfer; partial/moderate assistance with upper body dressing and personal hygiene. Wheelchair for mobility. Functional Limitation in Range of Motion - Impairment on one side to upper extremity; incontinent of bowel & bladder. Active diagnoses - Alzheimer's disease, stroke, cerebral infarction, altered mental status, unsteadiness on feet, abnormal gait, and mobility. Record review of Resident #1's Care Plan, dated 03/17/2025, revealed Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Transfer: The resident requires total assistance with transfer. Mechanical lift for all transfers with 2 staff for assistance. Contractures to all extremities. Risk for falls. Mechanical lift for all transfers with 2 staff for assistance. Resident has a terminal prognosis and is receiving hospice services. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Hospice staff (nurse, CNA, SW, Chaplin) to assist with resident care. Record review of Hospice Plan of Care Effective 4/02/25 for Resident #1 revealed, Last Updated: 04/01/25. Problem: Patient at risk for experiencing inability to perform care related to cognitive deficits, functional limitations, weakness, debility, deconditioning, altered mental status, environmental/logistical limitations, lack of supervision. Problem: Patient at risk for/experiencing falls with injury related to deconditioning, altered mental status cognitive decline, neurological deficit, altered gait or balance, medication effects/side effects, functional alterations, other. Goal: Patient will have no fall with injury. Interventions: RN and/or SN will assess fall risk on admission, at recertification, change in level or location of care. SN will identify appropriate DME and collaborate with MD to order as indicated and will train/model how to safely use assistive devices during visits. The Hospice Care Plan did not document resident #1 needed a Mechanical lift and two-person assistance with transfers. Review of Physician's Order dated 02/16/2025 for Resident #1 revealed, Resident a Mechanical Lift with 2-person transfer. Review of Physician Order Summary undated for Resident #1 revealed, Hospice Mechanical Lift for all transfers. Review of Hospice Admission Orders revealed Resident #1 was admitted to Hospice on 01/14/25, and did not document resident needed a Mechanical Lift with two-person assist for transfers. Review of the Nursing Progress Note dated 04/23/25 at 12:28 p.m., written by LVN A revealed, Resident #1 had a fall in his room. Hospice CNA gave a shower to resident, and during the transfer back to bed the resident fell on the floor and hit his head. Fall information: Hit head, bending over. The fall caused a laceration to right side of the head 3 cm with bleeding. Physician and responsible party were notified. Ordered skull x-rays. Review of the facility's Event Report dated 04/23/25 at 11:00 a.m., revealed, Incident Location: Resident #1's Room. Incident Description: Hospice CNA gave a shower to resident, and during transfer back to bed, the CNA could not hold the resident strongly and fell to the floor. Resident has a laceration on right side of the forehead. Immediate Action Taken: Ordered skull x-rays. Pending results. Interventions in place prior to fall: Floor mat, Low bed. Record review of Resident #1's Event Nurses' Note - Fall dated 04/23/25, revealed, Unwitnessed fall in resident's room. Bending over. Laceration to right side of forehead measuring 3 cm. Nursing description of the event: Hospice CNA gave a shower to resident, and during transfer back to bed the resident fell to the floor. Record review of Hospice Note dated 04/23/25 at 1:50 p.m., written by Hospice Case Manager RN F revealed, Received a call from LVN A from nursing facility, patient sustained a fall while getting showered. Resident sustained a laceration on right side of head. Record review of Resident #1's x-ray report dated 04/23/25 revealed, exam of skull. Unremarkable skull series without obvious evidence of fracture. Record review of Nursing Progress Notes dated 04/26/25 at 7:30 a.m., for Resident #1 revealed Head CT scan pending. Record review of Nursing Progress Notes dated 04/26/25 at 7:36 a.m., revealed Resident #1 was picked up by transport ambulance and taken to hospital. Family member at bedside. Record review of Nursing Progress Notes dated 04/26/25 at 9:45 p.m., for Resident #1 revealed, placed a telephone call to follow up on resident and was informed by hospital RN, the resident had been admitted for cervical fx and would be discharged back to nursing home pending discharge orders from physician. Record review of Nursing Progress Notes dated 04/28/25 at 9:19 p.m., for Resident #1 revealed, Admission Note: Arrived by EMS via stretcher. Current diagnoses/conditions: Dementia/Alzheimer's, Cervical Fx. Lethargic, unclear speech, sometimes understood, sometimes understands. Wheelchair. No balance issues. Assistance required for the following ADLs: Bed Mobility: 2 persons assist. Transferring: Mechanical lift. Toileting assistance. Briefs/pads one person assist. Hygiene/bathing: one person assist. Record review of Hospice Physician Telephone Order dated 04/28/25 for Resident #1 revealed, admit to Hospice. DX: Cerebral infarction, unspecified. Record review of Bedside Kardex dated 04/28/25 for Resident #1 revealed, Transferring: The resident required total assistance with transfers. Mechanical lift for all transfers with 2 staff for assistance. Mobility: Bed Mobility requires extensive assist x 2 staff to reposition and turn in bed. Review of Witness Statement dated 05/05/25, written by LVN A revealed, he was sitting at the nurses' station working on documentation, when suddenly hospice CNA C, was standing by the entrance to the room, waving and calling him. He went to Resident #1's room and found the resident on the floor. The shower chair was positioned directly in front of the middle to the bed facing the wall and the resident was next to the chair, with his face on the floor. The CNA C said she could not hold him, and he fell . She did not call for assistance. They were not aware that she was at the facility providing care to the resident. She had been instructed prior to the incident to ask for help with all transfers. During a telephone interview on 04/30/25 at 8:45 a.m., with Resident #1's family member, revealed LVN A had called on 04/23/25 to report that resident had sustained a fall in the shower. The family member reported that two days after the incident, family member had requested to have resident transferred to the hospital to get an MRI, to see what was wrong with him since he was declining and was no longer was eating, and no longer was able to talk because he was just sleeping. During an interview on 04/30/25 at 10:16 a.m., with LVN A, revealed, Hospice CNA C had not asked the facility staff for assistance on 04/23/25 to transfer Resident #1 from the bed to the shower chair to bathe the resident or after the shower was completed. He said CNA C had transferred the resident from the shower chair to the bed without assistance and had not used the Mechanical lift. He said the resident required a two-person assistance and a Mechanical lift for all transfers. He said that the nurses and the CNAs were always available to help the Hospice CNAs with transfers and use of the Mechanical Lifts as needed. He said that on the day of the incident the Hospice CNA C was standing by the entrance to the resident's room and had called him to the room. He said, When I got to the resident's room, CNA C said that she needed assistance because Resident #1 had fallen off the bed when she had turned to get a diaper. Upon entering the resident's room, the resident was lying on the floor on his left side and his face was planted on the floor and blood was coming out of resident's right side of his head. He said he had assisted CNA C to pick up the resident from the floor and put the resident in bed. He said the attending physician was notified and gave an order for an x-ray of the skull. He said the skull x-ray results were negative for fractures. During a telephone interview on 04/30/25 at 11:15 a.m., with RN B Hospice Director of Clinical Services, revealed the Hospice CNAs had been trained to always ask for help if they could not transfer the patient alone. She said that CNA C had reported to them, that LVN A had helped her on 04/23/25 to do a two-person transfer to sit the resident on the shower chair to bathe him without using the Mechanical lift. She said CNA C, did report that once the resident was bathe, she had not asked LVN A again for assistance to put the resident back in bed and had transferred the resident without assistance. CNA C reported that when she had laid down the resident in the bed, she had turned her back to get a diaper and that is when the resident had rolled off from the bed and fell on the floor. CNA C said that she had asked LVN A for assistance to put the resident in bed, after resident had fallen to the floor. CNA C, reported that sometimes she did not use the Mechanical lift and would ask the CNAs for assistance do a two-person transfer to move the resident from the bed to the shower chair to give him a shower. RN B said, Either way Resident #1 required a two-patient transfer. She said CNA C had not explained to them why she had not asked her help to transfer the resident to the bed on that day. During a telephone interview on 04/30/25 at 1:24 p.m., with Nurse Practitioner D, revealed that she was notified on 04/23/25 that Resident #1 had sustained a fall on 04/23/25 and had come to the facility the next day, to assess the resident. She said that she was not aware that the resident had been transferred without a Mechanical Lift and a two-person transfer. She said that she could not recall the resident's diagnosis but did remember that the resident was [AGE] year-old male and was very fragile. She stated that the cervical fractures could have been related to the fall. During an interview on 04/30/25 at 3:12 p.m., with the DON revealed, I believed that we found out on Sunday 04/27/25, from the hospital paperwork that Resident #1 had a cervical fracture. He had a diagnosis of osteoporosis, so his injuries could have resulted from the fall on 04/23/25. During an interview on 04/30/25 at 4:00 p.m., with the Administrator revealed that he did not know that Resident #1 had sustained a cervical fracture until 04/28/25, when they had received the hospital paperwork upon resident's readmission to the nursing facility. During a telephone interview on 04/30/25 at 4:25 p.m., with Hospice CNA C revealed, that she had asked LVN A on 04/23/25 to assist her to transfer Resident #1 from the bed to the shower chair without using a Mechanical lift. She said that after the shower was completed LVN A had assisted her to transfer the resident from the shower chair to the bed without using the Mechanical lift. She said, the resident was lying in bed, and I turned to grab a diaper from a drawer that was approximately 6 feet from the bed and that is when resident fell off the bed. She said that she had called LVN A to help her put the resident on the bed. She said that she had reported the accident to the hospice nurse. She said, I didn't mean it, it just happened so fast. She said that she was aware that Resident #1 needed a Mechanical lift and required a two-person transfer. She said, It was my fault for not using the Mechanical lift. On that day, I could not find the sling to use the Mechanical lift. When I informed LVN A that I could not find the sling to use the Mechanical lift, he said that it was okay, and he would help me to transfer Resident #1. Sometimes I do transfer him without assistance because I cannot find anyone to help me with the two-person transfer. She said that she had been re-trained on 04/28/25 by the hospice staff on how to use of the Mechanical lift and with a two-person transfer. Observation on 04/30/25 at 4:50 p.m., revealed Resident #1's bed was approximately 7 feet from the drawer where the disposable briefs were stored. The resident had a high/low bed and floor mat by the side of the bed. During an interview on 04/30/25 at 5:20 p.m., with CNA G revealed, the facility had provided an in-service training on 04/28/25 on how to use the Mechanical lifts with a two-person transfer. During a second telephone interview on 04/30/25 at 5:29 PM, with LVN A revealed that he had only assisted the hospice CNA C, to lift Resident #1 from the floor after he fell , to put him in bed. LVN A denied assisting CNA C to transfer resident on 04/23/25. He said that when he entered the resident's room, to put the resident in bed, he had not seen the Mechanical lift in the room. He said staff had been trained to always use a Mechanical lift with two-person assistance to transfer Resident #1. During an interview on 04/30/25 at 5:30 p.m., with ADON revealed, that she had done an in-service training on 04/29/25 for all facility nursing staff and Hospice staff on the use of a Mechanical lift with a two-person transfer. During an interview on 05/01/25 at 11:24 a.m., with the Administrator revealed the facility did not have a Fall Prevention policy & procedure. During a second telephone interview on 05/01/25 at 12:07 p.m., with RN B Hospice Director of Clinical Services, revealed, that CNA C had reported to hospice staff in the past, that the facility did not always have the Mechanical sling available, so the facility staff would assist her to do a two-person transfer to move Resident #1 from the bed to the shower chair. She said that CNA C, had reported that on the day of the incident on 04/23/25, it was close to lunch time, and no one had come to help her to transfer Resident #1 from the shower chair to the bed, so she had transferred Resident #1 on her own without using the Mechanical lift. CNA C also reported that the bed was on the lowest position when the resident had rolled off the bed. She said that after the incident involving Resident #1, the hospice staff had been retrained including CNA C on the use of the mechanical lift with two-person assistance and had also completed a competence skills checklist on CNA C. She said that the hospice staff did not attend the facility's care plan meetings because they were never invited. During an interview on 05/01/25 at 12:18 p.m., with RN F Hospice Case Manager who was assigned to Resident #1 revealed that the Hospice CNAs were expected to follow the Hospice care plans, and that he verified that the care plan was being followed by the Hospice CNAs when he went to see the resident. He said, after the fall, they would be working with the nursing home to compare their care plans to make sure that everyone is on the same page because the hospice and the nursing facility have their own care plans. We keep a copy of the hospice care plan in the hospice binder that is provided to the nursing facility. I was aware that Resident #1 required a two-person transfer because when the resident was admitted to hospice, he was bedbound and automatically that will require a two-person transfer. I did not know that Resident #1 required a lift for transfers, because it was not on the hospice care plan. During an interview on 05/01/25 at 12:45 p.m., with the Administrator, DON, and ADON revealed, that prior to the incident with Resident #1, the facility and the hospice staff did not share a copy of the care plans to coordinate the care and services provided to the resident. The DON said, the hospice staff would give a verbal report to the facility staff of what care was provided to the resident when they came to see the resident at the facility. During an interview on 05/01/25 at 5:05 p.m., with the Administrator revealed, he was not aware that the hospice aide had transferred Resident #1 on 04/23/25 without using a Mechanical lift and a two-person transfer, until the hospice staff came to the facility on [DATE] to apologize for not using the Mechanical lift. He said, I did not know hospice had made a mistake until they came. He said that he knew about the fall but did not start the investigation process to determine what had caused the fall. This was determined to be an Immediate Jeopardy (IJ) on 05/02/2025 at 3:55 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/02/2025 at 3:55 p.m. The following Plan of Removal submitted by the facility was accepted on 5/03/2025 at 8:29 p.m.: Interventions: -The alleged perpetrator will not be returning to the facility. Completed on 4/23/2025. -Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan. Completed 5/2/2025. -The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required in the for transfer and mechanical devices required in the kiosk. Completed on 5/2/2025. -Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment. Completed on 5/1/2025. -Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex. Completed on 5/2/2025. -Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries. Completed on 5/2/2025. -The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON. Completed on 5/2/2025. -100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team. This was completed on 5/2/2025. In-services: -Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above. Completed on 5/3/2025. -05/03/25 Subject: Hospice sign-in and Kardex review process; Summary: Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station. -Inservice dated 5/3/2025 revealed, Subject: All hospice staff must report to charge nurse and review Kardex; Summary: All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex. -Inservice dated 5/3/2025 revealed, Subject: Hospice staff - Abuse, Neglect and Exploitation; Summary: In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff. -Inservice dated 5/4/2025 revealed, Subject: Abuse, neglect, and exploitation; Summary: Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting. Monitoring of the facility's plan of removal included the following: During an interview on 05/04/25 at 11:42 a.m., with CNA H assigned to the second floor revealed, she had been trained on 05/02/25 on how to use the lift with two-person assist. She said, The hospice staff report to the charge nurse who is assigned to the hospice resident, and they will review the hospice binder that is kept at the nurses' station to review the Kardex and the facility's care plan to verify if the resident needs a Mechanical lift with a two-person transfer. The charge nurse will assign a CNA to help the hospice aide with transfers as needed. She said that the charge nurses are also available to assist the CNAs with transfers. She said the Mechanical lifts have a bright orange sign posted on the Mechanical lift to remind staff that all Mechanical lift transfers require a two-person to transfer the resident. The CNAs were also trained to remind the hospice CNAs to sign in at the nurses' station and get report from the charge nurse prior to providing care to the hospice resident. She said that this process was implemented to communicate with the hospice staff on an on-going basis to ensure that hospice residents receive the necessary care and services according to the facility's care plan approaches. During an interview on 05/04/25 at 11:43 a.m., with CNA I assigned to the first floor in hall 500, revealed the facility staff and hospice staff had been trained on 05/02/25, on the new process for the hospice staff to report to the charge nurse to review the Kardex before providing care to the resident to ensure that hospice staff are following the care plan approaches related to the use of mechanical lifts and two-person transfers. She said there is a binder at the nurses' station that contains the Kardex and copy of facility care plan to verify if the resident needs to be transferred with a Mechanical lift and two-person transfer. The charge nurse will assign a CNA to help the hospice aide with transfers as needed. She said that the charge nurses are also available to assist the CNAs with transfers. She said the Mechanical lifts have a bright orange sign posted on the Mechanical lift to remind staff that all Mechanical lift transfers require a two-person to transfer the resident. The CNAs were also trained to remind the hospice CNAs to sign in at the nurses' station and get report from the charge nurse prior to providing care to the hospice resident. She said that this process was implemented to communicate with the hospice staff on an on-going basis to ensure that hospice residents receive the necessary care and services according to the facility's care plan approaches. During a telephone interview on 05/04/25 at 12:56 p.m., with Hospice Liaison J revealed, the facility had provided in-service training on 05/02/25. She said, the whole team assigned to the nursing facility attended the training. We were informed by the nursing facility staff, that without this training the hospice staff would not be able to enter the facility to perform any clinical duties with their contracted residents. The Hospice Liaison was not able to provide any other specifics regarding the training and advised the state surveyor to contact the hospice Director of Clinical Services RN B who could tell her who had attended the training. During a telephone interview on 05/04/25 at 12:58 p.m., with Hospice Care Consultant/Director of Admissions K revealed, hospice staff had attended an in-service training at the nursing facility on proper use of a Mechanical lift. It was explained that when hospice staff arrives to the facility they are to report and be cleared by the charge nurse before any care is provided to the resident and sign the form in acknowledgment that care plans and Kardex have been reviewed. She said that the hospice staff were scheduled to attend and IDT care plan meeting at the nursing facility to review the care plan approaches and coordinate the care and services provided to the resident. During an interview on 05/04/25 at 1:00 p.m., with family member revealed that she was visiting a resident. She stated that she has never had any issues with the care that is provided to the resident. The family member reported that transfers were always done with two-persons. Observation on 05/04/25 at 1:15 p.m., revealed that the Mechanical lifts were tagged with a bright orange sign that stated, Two-people required to operate the lift. During an interview on 05/04/25 at 1:15 p.m., with the Administrator revealed there was always at least eight CNAs available in the facility to help with transfers as well as the charge nurses and the activities director who is also a CNA. Observation and interview on 05/04/25 at 1:15 PM, revealed CNA M and CNA I were transferring Resident #7 with a Mechanical lift from the bed to the wheelchair. Resident #7 said that the CNAs always completed two-persons when they transferred him with the Mechanical lift. CNAs reported that they had checked the Kardex prior to transfer and had confirmed that Resident #7 required a Mechanical lift with two-persons transfer. Record Review on 05/04/25 at 1:30 p.m., revealed Hospice binders were kept at the nurses' stations on the first and second floor that had the Kardex, copy of facility care plan, Kardex and Sign-In Sheets for hospice staff to acknowledge if the resident required a Mechanical lift and two-person transfer. During an interview on 05/04/25 at 1:55 p.m., with the facility's Social Worker V revealed that she had been in-serviced by the Administrator, DON, and ADON to invite the hospice providers to the IDT care plan meetings. During a telephone interview on 05/04/25 at 3:00 p.m., with RN L Hospice Administrator of Operations revealed that she was present on 05/02/25 to observe the training on how to complete a Mechanical lift transfer with two-persons. The staff were also trained to check in with the charge nurse prior to providing care to the hospice resident to review the Kardex and facility care plan to verify if the resident needed a Mechanical lift transfer with two-persons. Observation and interview on 05/04/25 at 3:35 p.m., revealed CNA H and CNA N were preparing to transfer Resident #9 with a Mechanical lift from the bed to the wheelchair. The CNAs said that they always checked the Kardex prior to transfer to verify if Resident #9 still required a Mechanical lift transfer with two-persons assistance. Observation and interview on 05/04/25 at 3:58 p.m., revealed Hospice CNA P was being assisted by the CNA O to transfer Resident #9, from the wheelchair to the bed using a Mechanical lift. Both CNAs said that checked the Kardex prior to transfer to verify if Resident #9 still required a Mechanical lift transfer with two-persons assistance. The CNA S said they would get the Hospice binder to check the Kardex and facility care plan with the charge nurse and then signed the Kardex Sign-In Sheet to acknowledge if the resident required a Mechanical lift and two-person transfer. During a telephone interview on 05/04/25 at 5:06 p.m., with RN L Hospice Administrator of Operations revealed, in-service training had been provided on 05/02 [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure resident's drug regimen be free from unnecessary drugs for one (Resident #1) of 13 residents reviewed. The facility failed to ensure Resident #1's anticoagulant medication was not administered without adequate monitoring of lab results which resulted in resident #1 being sent to ER and diagnosed with a supratherapeutic INR of 11 (above thereapeutic level of blood thinning), [CONDITION(S)] from possible GI bleed, was hospitalized and received a plasma transfusion. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 1/18/22. While the IJ was removed on 1/19/22, the facility remained out of compliance at Actual Harm with a scope of Isolated. This failure put residents on anticoagulants at high risk of bleeding and possible death. Findings included: Record review of Resident #1 Face sheet (not dated) revealed Resident #1 was a [AGE] year-old female was admitted on [DATE]. Record review of Resident #1 History and Physical from local medical center dated 12/21/21 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1 MDS dated [DATE] revealed section N.0410 Medications received with the last 7 days included anticoagulant, antibiotic, and opioid. Record review of Resident #1 Care Plan dated 12/27/21 revealed Resident #1 is on anticoagulant therapy. Resident #1 will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN signs/symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising , blurred vision, Shortness of breath , Loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . Record review of electronic Progress Notes dated 01/08/22 revealed Nursing Progress Note. Note Text: resident had X2 hematemesis (blood in vomit) episodes. resident AAOX3 follow commands. denies pain. denies SOB. able to move all extremities. abdomen soft. BS present at 4 quadrants. VS 115/73-respirations 20. temp 98.8- pulse 90- sats 99%RA. call placed to MD answering service. left message. RP in facility requesting resident to be send to hospital for eval. DON notified agree to send resident to hospital. resident send to local medical center. Interview on 1/14/22 at 9:45 AM LVN A stated she worked on 1/8/22 the day Resident #1 was transferred to hospital for further evaluation due to having two episodes of emesis (vomit) with blood. LVN A stated there was no change in condition in Resident #1 prior to emesis incident. LVN A stated Resident #1 family member was at bedside when Resident #1 had emesis. LVN A stated during assessment blood was noted on bed sheets, vitals were taken and were within normal limit and Resident #1 was alert and oriented x4. LVN A stated Resident #1 was taking anticoagulants and was pending PT/INR results (prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results). LVN A stated she checked Q Med Lab Portal (electronic website) for results on 1/8/22 beginning of morning shift and stated there were no results available for Resident #1. LVN A stated she notified DON and NP on call of Resident #1 transfer to hospital. LVN A stated residents on [MEDICATION(S)] are monitored for bleeding i.e., bloody nose, bloody gums, bruising, blood in stool and emesis and require PT/INR lab for therapeutic level. LVN A stated if any indication of bleeding and abnormal lab results are to be reported to NP/MD immediately. LVN A stated she checks Q Med lab portal daily at least once during her shift. LVN A stated she is to review all lab results available to verify lab values are within normal range. Interview and record review on 1/14/22 at 10:50 AM DON stated she was notified of Resident #1 transfer to hospital on 1/8/22. DON stated Resident #1 was taking anticoagulant and pending PT/INR results. DON stated no reports of any type of bleeding had been reported prior to incident on 1/8/22. DON stated upon return to work on 1/10/22 when conducting internal investigation LVN's reported no critical lab results were called in by Q Med Lab and no critical lab results were posted in Q Med Portal. DON stated typically critical lab results are highlighted in red. DON stated when she opened Q Med lab results that were dated 1/7/22 and not marked as critical, she noticed the critical high INR lab level of 9.1 If the INR is too high there is a increased risk of bleeding. Surveyor asked for copy of admission labs done for Resident #1. DON gave copy of Resident #1 PT/INR lab results dated 12/29/21 and stated she was not aware of these results either until she printed them upon surveyor request. Record review of Resident #1 Clinical Pathology Laboratories dated 12/29/21 revealed INR lab level of 8.5 CH (critical high). DON stated INR lab results dated 12/29/21 had not been reported to her and more than likely not reported to NP. DON stated both INR lab results should have been reported to NP/MD due to being critically high. DON stated that anticoagulant had still been administered during stay until Resident #1 was sent to the hospital on 1/8/22. DON stated nurses are trained to check for any lab results as they become available to verify any abnormal/critical results. DON stated nurses should have been reviewing lab results and not relying on Q Med to highlight critical lab results. DON stated a high INR lab result could cause serious harm, high risk of bleeding, to any resident taking [MEDICATION(S)]/ [MEDICATION(S)]. Record review of Resident #1 Electronic Orders (not dated) revealed Resident was taking [MEDICATION(S)] Tablet 4 MG ([MEDICATION(S)] Sodium) 1 tablet by mouth one time a day for DVT until 01/20/2022 and Lab Order for PT/PTT/INR placed on 01/05/2022. Record review of Resident #1 Clinical Pathology Laboratories dated 12/29/21 revealed INR lab level of 8.5 CH (critical high). Record review of Resident #1 Clinical Pathology Laboratories dated 01/07/2022 revealed INR lab level of 9.1 CH (critical high). Record review of Resident #1 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's local hospital admission report revealed Upon evaluation at ER patient was found with [CONDITION(S)] having Hb on 7.4 g/dl (a normal hemoglobin level is 11 to 18 grams per deciliter, a 7.4 value was low) most probably from GI bleeding, supratherapeutic INR of 11 (need for rapid reversal), and [CONDITION(S)]. Admission has been decided got GI. Patient will receive plasma transfusion to help correcting INR. Interview on 1/14/22 at 12:10 PM NP B stated she does rounds at the facility once a week on Fridays. NP stated Resident #1 had history of valve replacement and was taking [MEDICATION(S)] prior to admission to facility. NP B stated she ordered a PT/INR lab to be done for Resident #1 on 12/22/21 and does not know when they were drawn. NP B stated since Resident #1 had history of valve replacement Resident #1's therapeutic INR goal would be 2-3 therapeutic level. Surveyor read INR results dated 12/29/21 with INR level of 8.4 and INR results dated 1/7/22 with INR level of 9.1. NP B stated this was the first time she was hearing these results. NP B stated the facility had not reported these INR lab results to her and had not been on Resident #1 chart in facility for her to review upon rounds. NP B stated both lab results were critically high and should have been reported to NP/MD to make adjustments to medication regimen. NP B stated she would have stopped Resident #1 [MEDICATION(S)] medication immediately. NP B stated a high INR level could result in internal bleeding. Interview on 1/14/22 at 1:05 PM NP C stated she does rounds at the facility once a week. NP C stated she got paged twice on 1/8/22 at 9:52 AM. NP C stated she returned call to facility twice and there was no answer. NP C stated she received a call on 1/8/22 at 11:45 AM notifying her that Resident #1 had been sent out to the hospital. Surveyor read Resident #1 INR lab results dated 12/29/21 with level 8.5 and INR lab results dated 1/7/22 with level 9.1, NP C stated both INR levels were extremely high, therapeutic INR range was 2-3. NP C stated both INR levels should have been reported to NP/MD immediately. NP C stated [MEDICATION(S)] would have been stopped temporarily and believed the internal bleeding from Resident #1 was due to the high INR level. Interview on 1/14/22 at 1:37 PM LVN D stated she was the nurse assigned to Resident #1 during morning shift. LVN D stated on 12/22/21 NP B gave orders for PT/INR due to Resident #1 taking an anticoagulant. LVN D stated she worked on 12/29/21 but does not remember if INR for Resident #1 were available in Q Med portal. LVN D stated she worked on 1/7/22 and stated she did not see any critical lab results on Q Med Portal and had not received a call from Q Med Lab to notify of critical INR results. LVN D stated she normally only opens flagged lab results to be able to report to NP/MD and will wait for the day that NP/MD does rounds to print out labs that were not flagged. LVN D stated she does not open labs that are not flagged and will see them the day she prints them for NP/MD to review. LVN D stated both INR results should have been reported to NP/MD due to being extremely high possible putting any resident on high risk of bleeding. LVN D stated residents who are taking [MEDICATION(S)]/ [MEDICATION(S)] are monitored for any signs of bleeding i.e., bruising, blood in stool, blood in urine, blood in emesis and require PT/INR lab as ordered by NP/MD for therapeutic range monitoring. LVN D stated she does not recall [MEDICATION(S)] being discontinued for Resident #1. LVN D stated a high INR could cause any resident on [MEDICATION(S)]/ [MEDICATION(S)] to be at high risk for bleeding. LVN D stated she had been trained to open and review all lab results when available and to check daily for lab results. LVN D stated she was trained to call Q Med Lab for follow up and any problems should have been reported to DON. Interview on 1/14/22 at 4:39 PM LVN E stated he worked the night of 1/7/22, the night prior to Resident #1 incident. LVN E stated there were no symptoms of bleeding. LVN E stated Resident #1 was taking an anticoagulant. LVN E stated he did not receive report from previous nurse stating there were pending PT/INR results for Resident #1. LVN E does not remember checking the Q Med Portal that night for results. LVN E stated monitoring for signs of bleeding is required for residents on [MEDICATION(S)]/ [MEDICATION(S)]. LVN E stated signs of bleeding include bloody gums, bruising, blood in urine, blood in stool, blood in emesis. LVN E stated residents taking [MEDICATION(S)]/ [MEDICATION(S)] required at least weekly PT/INR lab monitoring for therapeutic level. LVN E stated [MEDICATION(S)] had not been discontinued for Resident #1 and had last taken [MEDICATION(S)] medication the night prior to incident on 1/7/22 was scheduled to be administered during his shift. LVN E stated any PT/INR out of range would have to be immediately reported to NP/MD. LVN E stated he had been trained to open and review all lab results when available and to check daily for lab results. LVN E stated he was trained to call Q Med Lab for follow up and any problems should have been reported to DON. Interview on 1/14/22 at 4:48 PM LVN F stated she worked the evening prior to incident on 1/7/22 with Resident #1. LVN F stated no signs of bleeding for Resident #1 were reported. LVN F stated Resident #1 was taking an anticoagulant. LVN F stated she checked Q Med Portal for lab results and did not see any flagged lab results for that day. LVN F stated she does not recall seeing any lab results for Resident #1 on 1/7/22 and did not get a call from Q Med Lab reporting critical value. LVN F stated for any critical results Q Med Lab usually calls the facility to notify of critical values and will flag results by highlighting name of resident in red on Q Med portal. LVN F stated any resident taking [MEDICATION(S)]/ [MEDICATION(S)] needs to be monitored for any signs of bleeding and require PT/INR lab as ordered by NP/MD for INR therapeutic levels. LVN F stated any critical values need to be reported to NP/MD. LVN F stated she had been trained to open and review all lab results when available and to check daily for lab results. LVN F stated she was trained to call Q Med Lab for follow up and any problems should have been reported to DON. Interview on 1/17/22 at 9:57 AM Family Member stated Resident #1 was admitted to facility on 12/21/21. Family Member stated he notified nurse in charge at admission about Resident #1 needing PT/INR lab to be done weekly due to Resident #1 taking [MEDICATION(S)]/ [MEDICATION(S)]. Family Member does not remember name of nurse he spoke to but stated she made it known to several nurse's throughput the course of Resident #1 stay at facility. Family Member stated nurses never gave him updates on PT/INR lab orders or results. Family Member stated that if Resident #1 INR level was ever to be high it could potentially cause Resident #1 to bleed out which was the reason why Resident #1 needed weekly PT/INR labs to be completed. Family Member stated on 1/8/22 he visited Resident #1 in the morning and upon arrival he noticed blood in bed sheets. Family Member stated he reported to nurse and requested for Resident #1 to be transferred to hospital for further evaluation. Family Member stated when Resident #1 arrived at the hospital on 1/8/22 he was informed that INR level was extremely high. Family Member FM stated Resident #1 received blood transfusion to reverse the INR. Family Member stated if he had not gone to visit the morning of 1/8/22 he was afraid the outcome for Resident #1 would have been much worse due to nurses not monitoring PT/INR lab values because he never got updates on results if any lab orders were given to be completed. Interview on 1/17/22 at 11:24 AM DON stated nurses should be checking and reviewing lab results daily for any lab results available whether they be flagged or not. DON stated she checked Resident #1 chart and did not see any lab results for PT/INR dated 12/29/21 and 1/7/22 printed in Resident #1 chart, therefore critical INR levels were not available for NP's to review during their weekly rounds. Interview on 1/17/22 at 11:41 AM SRD stated facility keeps records with time stamps of when lab results are uploaded and reported. SRD stated facility has had issues in the past with not answering calls or leaving them on hold for 30 min to an hour at times. SRD stated they will keep trying to call until they get through with a nurse. SRD stated they have a out-of-town laboratory that assists with lab results as well. SRD stated the out-of-town lab uploaded Resident #1's critical lab results on 12/29/21 and 1/7/22, although they did not flag them in red indicating lab results were critical, both INR results were available in Q Med Portal for nurses to review. SRD stated the nurses need to have had opened the report in Q Med Portal and review lab results to have known they were critically high. SRD stated the out-of-town lab will usually call Q Med Lab to report any critical lab results in which Q Med Lab will be the ones to flag results in red. SRD stated Q Med Lab received a call on 1/10/22 from the out-of-town lab reporting Resident #1 critical INR results. SRD stated she uploaded Resident #1 INR results on 1/7/22 at 12:11 PM, at this time the results are available for the facility to obtain and time stamp are included in lab reports as well. SRD stated Resident #1 INR results dated 12/29/21 were uploaded on 12/29/21 at 1:29 PM, at this time the INR results were available for facility to review on Q Med Portal. The out-of-town lab stated she spoke to DON sometime last week, does not remember the exact date, and stated DON provided facility with personal cell phone number and email address in case Q Med lab had trouble getting answer from facility to reach her directly. Interview on 1/18/22 at 8:53 AM LVN G stated residents on anticoagulants require constant monitoring for any type of bleeding i.e., blood in urine, stool, emesis, gums, and/ or nose. LVN G stated residents taking [MEDICATION(S)]/ [MEDICATION(S)] require PT/INR level monitoring for therapeutic level as per NP/MD order. LVN G stated once labs are drawn, she normally checks Q Med lab portal the following day to see if any lab results are available to review. LVN G stated if no results are available, she will call Q Med lab to get an update on lab results. LVN G stated when labs become available in Q Med lab portal, she opens them whether flagged as critical or not to verify labs are within normal therapeutic range. LVN G stated any abnormal/critical level she has to report to NP/MD immediately. LVN G stated failure to report any abnormal PT/INR values could put the resident at high risk of bleeding. Interview on 1/18/22 at 9:03 AM Administrator stated all nurses are in charge of checking for lab results on Q Med lab portal on a daily basis. Administrator stated once lab results become available to review, nurses should be checking and reviewing all lab results are within normal range; any abnormal/ critical lab value need to be reported to NP/MD immediately. Administrator stated failure to report any abnormal/ critical lab value to NP/MD can potentially be very harmful for resident. Administrator could not give an answer for this failure. Interview on 1/18/22 at 11:30 AM DON and Administrator stated they had no policy on file related to lab results and anticoagulant monitoring. Record review of Notifying the Physician of Change in Status policy dated 3/11/13 revealed 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. On 1/18/22 at 2:02 PM Administrator and DON were notified that an IJ had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The facility's Plan of Removal was accepted on 1/19/22 at 1:34 PM. The Plan of Removal revealed the facility took or would take the following actions: 1. Director of nursing contacted the lab on 1/10/22 to follow up on why critical lab results had not been reported to the facility and they stated they called but no one answered, DON provided lab with personal cell phone number and email, instructions were given to contact DON if there was no answer to report critical lab values. 2. DON/designee in-serviced all licensed staff on 1/12/22 on checking and printing all lab results from portal at start of shift and end of shift for abnormal results. All abnormal labs will be reported to MD. All lab results will be placed in residents' chart for MD to review. DON, ADON/ weekend supervisor will check daily that labs are printed, reviewed, and reported to MD. DON will conduct random audits. 3. ADON's audited residents requiring anticoagulant therapy and any other medications requiring routine monitoring on 1/10/22. 4. DON/ ADON in-serviced all licensed nurses on 1/12/22 to review all lab reports, at the start and end of shift. Nurses will print and place lab results in resident chart, critical labs will be called to MD to prevent re-occurrence of missing values. 5. Compliance nurse in-serviced ADONs and DON on 1/12/22 on auditing daily PT/INR for residents that have order for [MEDICATION(S)]/ [MEDICATION(S)] and check the results to ensure that they are within the parameters. If not within the parameters, they will verify MD was notified. Compliance nurse in-serviced ADONs and DON on 1/12/22 on checking and printing all lab results from portal at start of shift and end of shift for abnormal results. All abnormal labs will be reported to MD. All lab results will be paced in residents' chart for MD to review. DON/ ADON and weekend supervisor will check daily that labs are printed, reviewed, and reported to MD. DON will conduct daily audits. 6. Administrator in-serviced receptionist on 1/18/22 to ensure call are delivered to the nurses, to maintain a call log of all calls to include date, time, name of caller, which nurse received the call. DON or designee need to be notified of call not answered. Administrator/ weekend supervisor will monitor log daily. 7. MD was notified on 1/18/22 at 3:00 PM.MD approved current recommendations. 8. To prevent reoccurrence of critical lab values, nursing new hire orientation will include checking and printing all lab results from portal at start of shift ad end of shift for abnormal results. All abnormal labs will be reported to the MD. All lab results will be placed in resident's chart for MS to review. 9. Anticoagulant monitoring will be discussed in the facilities monthly QA meetings. Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows: - Record review of in service: all anticoagulants receive monitoring for nurses and CNA upon initiation (not dated) - Record review of in-service: labs for medication that require therapeutic level are nurse's responsibility dated 1/12/22 - Record review of in-service: laboratory values, checking, reporting [MEDICATION(S)] therapy dated 1/12/22-1/18/22 - Record review of laboratory tracking form start date 1/11/22- 1/18/22 - Record review of in-service: lab calls maintain log, maintain log include date, time, name of caller, which nurse received call dated 1/18/22 - Record review of in-service: audit lab results daily, review results and verify MD was notified dated 1/12/22 - Record review of MD email confirming recommendations regarding plan of removal dated 1/19/22 - Interview on 1/19/22 at 2:43 PM LVN H stated he last received in-service anticoagulant monitoring, lab orders, lab results, lab follow up, and lab result reporting sometime last week. LVN H stated he was trained to check Q Med lab Portal daily during his shift, upon arrival and before end of shift. Nurses are to follow up with lab for pending lab results and report to on coming shift nurse if lab results are pending. LVN H stated once lab results are available in Q Med portal for review, they are to open report and verify labs are within normal range, any abnormal/ critical values are to be reported to NP/MD and ADON/ DON immediately. LVN H stated nurses will need to print lab report once reviewed and chart in residents' chart for NP/MD to have available for review upon weekly rounds. - Interview on 1/19/22 at 2:50 PM LVN I confirmed receiving training regarding anticoagulant monitoring and lab orders, lab results, lab follow up, and lab result reporting to NP/MD and ADON/MD. LVN I stated nurses need to print lab reports once they become available and chart them in resident's chart. - Interview on 1/19/22 at 2:57 PM Receptionist confirmed receiving in-service yesterday (1/18/22) regarding call log for incoming calls. Receptionist showed surveyor call log started on 1/18/22 there was only 1 entry; a call for Administrator with time call received, caller and message. Receptionist stated for Q Med lab calls she is to write down name of caller, time, the name of nurse call was transferred to, and if nurse is not able to take call, she is to forward the call to DON. Receptionist stated there has not been a call from Q Med lab since the log was started on 1/18/22. - Interview on 1/19/22 at 3:08 PM RN stated she received training regarding anticoagulant monitoring and lab orders, lab results, lab follow up, and lab result reporting to NP/MD and ADON/MD. RN stated nurses need to print lab reports once they become available and chart them in resident's chart. - Interview on 1/19/22 at 3:16 PM LVN G stated she received training regarding anticoagulant monitoring and lab orders, lab results, lab follow up, and lab result reporting to NP/MD and ADON/MD. LVN G stated nurses need to print lab reports once they become available and chart them in resident's chart. - Interview on 1/19/22 at 4:15 DON stated any staff out on PTO, Covid 19 related, and PRN received a over the phone in-service so they could be aware prior to return to work. The Administrator was notified on 1/19/22 at 4:00 PM that IJ was removed. However, the facility remained out of compliance at a severity of Actual Harm at a scope of isolated. The facility was continuing to monitor its plan for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 8 residents reviewed for accidents. Certified Nursing Assistant (CNA) A failed to supervise Resident #1, who was at high risk of falls, during toilteting. Resident #1 fell and sustained a Subdural Hematoma. This failure could place residents at risk for injury. Findings included: Review of Resident #1's face sheet dated 10/16/19 documented in part; Resident #1 was an [AGE] year-old female admitted to facility on 03/27/19. Review of Resident #1's Doctor's Progress Note dated 08/08/19 documented in part the following diagnoses; dementia, multiple falls, [MEDICAL CONDITIONS] with left [MEDICAL CONDITION], depression and [MEDICAL CONDITION] stage III. Review of Resident t#1's Minimum Data Set (MDS) assessment dated [DATE] documented in part; -The Brief Interview for Mental Status (BIMS) summary score was 6 which indicated at the time of the MDS the resident was severely impaired. -Functional Status- Toilet use requires extensive assistance of two persons physical assist. -Fall History since Admission/Entry indicates 1 fall Review of Resident #1's Care Plan dated revised on 04/15/19 documented in part; -At risk for falls related of being unaware of her safety needs. Resident #1 is not steady, only with staff assist. Resident #1 will not sustain serious injury. -Resident #1 has bowel and bladder incontinence. Requires extensive assistance with toileting needs. Review of Resident #1's Fall Risk assessment dated [DATE] documented in part; Resident #1 was a high risk for falls. Review of Resident #1's Physical Therapy Evaluation and Plan of Treatment dated 04/02/19 documented in part; reason for Referral- falls/fall risk, increased need for assistance from others, paralysis/paresis, and decrease in functional mobility. Review of Nurses Notes for Resident #1 dated 09/29/19 documented in part; Certified Nurse's Aide (CNA) A assisted resident to bathroom. CNA A left resident to go grab wipes and briefs. We heard a loud noise in the hallway. At 02:37 AM this nurse found resident laying on the bathroom floor on her left side. Bathroom light on. Call light in reach. Resident wearing shoes, briefs and pants down to ankles. Blood was found on the floor near face. Other nurse and I sat up the resident location spot of bleeding to left upper. Lip bleeding. Left cheek swollen. Left eye swollen shut. Resident was sent out to hospital at 5:05 AM. Review of hospital History and Physical Reports dated 09/29/19 at 11:59 AM documented in part; Diagnostic Results Subdural Hematoma. In an interview on 10/16/19 at 10:44 AM, CNA B stated a fall risk resident should not be left alone on the toilet. Staff are to stay with resident while toileting them and if they need wipes or briefs then the call light should be pulled to get another staff member to assist. She stated CNA's are to always prepare beforehand with the necessary supplies needed so that resident is not left alone. CNA B stated staff can see in the computer system the care needs for a resident and if they are fall risk residents. CNA B stated at shift change report is given and any changes in care are shared at that time. In an interview on 10/16/19 at 11:20 AM, CNA C stated he had assisted Resident #1 to the restroom. He stated he does not leave her alone and was aware she was a fall risk resident due to her stroke and left side weakness. He stated all staff have access to care of a resident in the computer and log in what activities of daily living have been performed. In an interview on 10/16/19 at 11:50 AM, Certified Occupational Therapy Assistant (COTA) D stated Resident #1 received services from (MONTH) 27, 2019 to (MONTH) 25, 2019. Reason for referral was of Resident #1's [MEDICAL CONDITION], weakness to left side and she was a fall risk. He stated Resident #1's having this history should not be left unattended while toileting because she can fall. In an interview on 10/16/19 at 12:30 PM, CNA [NAME] stated she had assisted Resident #1 to the restroom. She stated Resident #1 was a high fall risk. She stated when she would toilet Resident #1 she would never leave her alone due to her history of left side weakness [MEDICAL CONDITION] high fall risk. She stated if she would run out of wipes or briefs while toileting she used call light for assistance but would not leave residents alone. CNA [NAME] stated the day of Resident #1 fall she was on break and was seated in front of the computer inputting her completed task. She stated she saw CNA A in hallway and CNA A told CNA [NAME] she needed wipes and a brief. CNA A proceed to go to linen closet to retrieve a brief and wipes. CNA [NAME] said that is when she heard a loud noise and went into Resident #1's restroom and she was laying on the floor with noted injuries to her head. CNA [NAME] stated she left the room, so the charge nurse could assess her and other staff were there assisting Resident #1. In an interview on 10/16/19 at 1:00 PM, CNA A stated the day of the incident with Resident #1 she was working 300 Hall. She stated she answered the call light to Resident #1 and Resident #1 told her she needed to be toileted. CNA A stated she sat Resident #1 on the toilet and stood right outside the door to give her privacy. She stated when Resident #1 finished she noticed there was no wipes or brief, so she told her to wait and not move from the toilet. She stated she left Resident #1 alone in the restroom to retrieve a brief and wipes. Once outside she heard a loud noise and ran to Resident #1 restroom and found resident on the floor with injuries. She stated the charge nurse immediately assessed her. CNA A stated she was unaware Resident #1 was a high fall risk and did not know her history of left side weakness. She stated it was her first time giving care for Resident #1 but she did not look in the computer to find out what her needs were. She stated she left Resident #1 unattended on the toilet and did not realize she had a history of [REDACTED]. She stated she did not think of using the call light to call for assistance for another staff member to bring her the supplies she needed. CNA A stated she should not have left Resident #1 unattended. In an interview on 10/16/19 at 1:35 PM, Assistant Director of Nursing (ADON) F stated any resident that has been identified as high fall risk are not to be left alone. All CNA's receive training on hire about not leaving a resident alone when they are fall risk residents. In an interview on 10/17/19 at 1:38 PM, Resident #8 stated Resident #1 was left unattended in the restroom on several occassions while being toileted. Resident #8 stated staff would take a long time to come back and attend to her sometimes. In an interview on 10/17/19 at 1:45 PM, Director of Nursing (DON) stated a resident that is high fall risk should not be left alone when toileting. She stated all CNA's get training on the computer for how to retrieve infromation on the care for the resident. She stated Resident #1 was a high fall risk and had weakness to left side. DON stated Resident #1 should not have been left unattended and received an injury to her head. Resident #1 was diagnosed with [REDACTED]. In an interview on 10/17/19 at 1:58 PM, Administrator stated the staff had access to the computer to retrieve information about a resident. He stated Resident #1 had a fall in the restroom on 09/29/19 and as a result had a Subdural Hematoma. He stated staff can't leave residents unattended when toileting when they are fall risk residents. Review of facility's policy on Falls/Ambulation Difficulty dated 2003 documented in part; Reducing Environment Hazards- storage of necessary items should be within easy reach.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for two (Resident #52 and #60) of 26 residents reviewed for accidents. Certified Nursing Assistant (CNA) J failed to ensure the safety of Resident #52 during a transfer from bed to wheelchair which resulted in Resident #52 falling and sustaining fractures. Four days after the fall and fractures Resident #52 died in the hospital. Resident #60 had unwitnessed falls which resulted in multiple bruises and lacerations above her right eyebrow and under her chin. This failure injured two residents and could have placed all residents who require assistance with transfers at risk for injury. Findings included: Resident #52 (closed records) Review of closed record for Resident #52's face sheet dated [DATE] documented in part, Resident #52 was an [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #52's history and physical examination [REDACTED]. The Physical Examination also documented she is improved, alert and oriented. Review of Resident #52's Minimum Data Set (MDS) assessment dated [DATE] as the Assessment Reference Date, documented transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) required extensive assistance of one-person physical assist. The Brief Interview for Mental Status (BIMS) summary score was 6 which indicated at the time of the MDS the resident was severely impaired. Review of Resident #52's Care Plan dated as last review/revised [DATE] documented in part: At risk for falls related to gait/balance issues. Resident #52 will be free of falls with major injury, ensure the resident is wearing appropriate footwear, keep furniture in locked position. Review of Fall Risk assessment dated [DATE] documented in part; Resident #52 was a high risk of falls. Review of the facility generated Event Nurses Note dated [DATE] at 7:00 AM documented in part; Resident was on the floor. CNA J stated resident was sitting on bed. CNA J was attempting to transfer resident from bed to chair, CNA J asked resident to hold on to wheelchair, instead resident held on to siderails, resident was wearing foot splint, fell . It also documented, the resident verbalized she was in severe pain, 6 out of 10, when moving her right arm and hip. The physician ordered X-Ray to right shoulder and right femur. It also documented the resident said, CNA J threw me on the floor. Review of X-Rays reports dated [DATE] documented in part; acute comminuted and slightly displaced fracture in the right Humerus neck, there is an acute slightly impacted [MEDICAL CONDITION] femoral neck. Review of Nurses Notes documented in part; [DATE] 11:00 AM Transfer Notification: Resident #52 was transferred to the hospital related resident fell , had pain to right arm and right hip. X-R showed fracture to right humurous. Doctor stated send to hospital emergency room (ER). [DATE] 5:30 PM Transfer Notification: Resident #52 was transferred to the hospital related doctor said to have resident return to the ER for re-evaluation of the right hip. In an interview on [DATE] at 2:00 PM Licensed Vocational Nurse (LVN) K said on [DATE] she was in the hallway just a couple of doors down when CNA J came and told her Resident #52 fell and was on the floor, LVN K said she went to room and found Resident #52 on the floor with her head toward the bottom of bed and her feet toward the head of the bed. Resident #52's glasses were in the chair at the head of the bed. LVN K said Resident #52's wheelchair was against the wall between the two resident's TV's, the breaks were off. LVN K said CNA J said the resident held onto the siderail and not the wheelchair like instructed. LVN K said CNA J said Resident #52 had a splint on her foot and when she stood up her foot splint slipped, and resident fell and hit the other bed in the room and then fell to the floor. LVN K said the resident, who was still on the floor, said that's not true she (CNA J) threw me on the floor. The CNA denied it. LVN K said she had no idea why the wheelchair was against the wall if CNA J was getting the resident up into the wheelchair. LVN K said when she went into the room the resident did not have a gait belt on. In an interview on [DATE] at 9:14 AM Assistant Director of Nursing (ADON) I said on the morning of [DATE] the Director of Nursing (DON) was out of the building and she was the on-call ADON. ADON I said as soon as she was notified she went to Resident #52's room. ADON I said Resident #52 was on the floor with her head toward the foot of the bed and her feet toward the head of the bed, she did not have a gait belt on. ADON I said when Resident #52 accused CNA J of throwing her on the floor she immediately suspended CNA J. Review of hospital medical records documented in part: History and Physical dated [DATE]; impacted right femoral neck fracture due to a fall. Consultation Report dated [DATE]; the femoral neck fracture will need to be treated with a percutaneous pinning Surgical Report dated [DATE]; Impacted right femoral neck fracture, procedure performed - open reduction internal fixation percutaneous pinning right femoral neck fracture, Implants - 6.5 cannulated screws X 2 with 1 washer. Post Anesthesia Care Unit assessment dated [DATE] at 4:23 PM documented Resident #52 was awake and oriented to person, place and time Clinical Documentation dated [DATE] at 4;12 am documented, in part, Code Blue initiated, Code ended at 4:21 AM with time of death. Review of incidents for past year revealed Resident #52 only had the fall on [DATE]. In a telephone interview on [DATE] at 1:36 PM CNA J said she would prefer an interpreter. Interpreter # 5 telephoned CNA J at 1:37 PM and CNA J did not answer her phone a message was left but she did not return the call. Review of Provider Investigation Report documented an in-service dated [DATE] was provided and all staff were instructed to complete computer training Preventing, Recognizing and Reporting Resident Abuse. Review of computer record of training completion documented only 11 out of 53 CNA's had completed the training as of [DATE]. The Provider Investigation Report also documented CNA J was terminated due to failing to ensure the safety/security of a resident in her care during a patient transfer from bed to wheelchair. It also documented CNA J failed to ensure proper transfer procedure was followed during the transfer which resulted in physical injury to the resident. Review of the Medical Examiners Report dated [DATE] documented in part, the Medical Examiner confirmed the immediate cause of death to be hypertensive [MEDICAL CONDITION] cardiovascular disease. Other significant conditions that contributed to the death but did not result in the underlying cause multiple [MEDICATION NAME] force injuries. The cause of death is Accident. Review of Policy and Procedure titled Moving a Resident, Bed to Chair/Chair to Bed dated 2003 documented in part; The purposes of this procedure are to provide for safe transferring of the resident. If moving a resident from bed to chair: place the chair so that it touches the side of the bed and faces the foot of the bed. Be sure the wheels are locked, assist the resident to a sitting position, position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient. Resident #60 Review of face sheet dated [DATE] documented in part Resident #60 was a [AGE] year-old female admitted on [DATE]. Review of Resident #60's History and Physical dated [DATE] documented in part, the following diagnoses, [MEDICAL CONDITION] of the liver, ascites, paranoid [MEDICAL CONDITION], hepatic failure, pancytopenia, diabetes, and high blood pressure. Review of comprehensive Minimum Data Set ((MDS) dated [DATE] documented Resident #60: Had delusions but no other behaviors Limited assistance of one staff for bed mobility Supervision of one staff for transfer Supervision of one staff for incontinent care Extensive assistance of one staff for personal hygiene such as shaving, brushing teeth, washing and drying hands and face Physical assistance of one staff for bathing (bath, shower, and sponge bath). Supervision of one staff for eating Walk in Room with supervision of one staff physical assist Review of Care Plan dated as initialed/revised [DATE] documented in part: At risk for falls related to balance problems during transition. Resident #60 will be free of falls with injury, anticipate and meet the resident's needs, the resident needs a safe environment Review of Fall Event Reports documented Resident #60 had unwitnessed falls on: [DATE] at 12:40 AM. The resident was found sitting on the floor, resident said she was sitting on her bed and she was trying to get up and her legs were stiff, so she sat down on the floor. [DATE] at 11:15 PM. The resident was found lying on her left side on the floor, the resident said she was walking to her chair and she fell down because her legs are stiff. [DATE] at 6:10 AM. The resident was found on the floor by the nurse's station, the resident had a laceration to her right eyebrow [DATE] at 3:47 PM. The resident was found lying on the floor after hearing her yelling, the resident had a laceration on her lower lip and chin Observation on [DATE] at 9:50 AM resident was in her room screaming very, very loudly with door closed. Upon entering room resident was noted to have a laceration with steri-strips over her right eyebrow and a large purple, red and green bruise to her right eye. In an interview on [DATE] at 10:00 AM LVN S said Resident #60 had a fall over the weekend that cut her eyebrow and gave her a black eye. She said during the week the units have three CNA's on day shift but on the evening shift and all shifts on the weekend they only have two CNA's, with less staff the CNA's cannot supervise the resident. In an interview on [DATE] at 10:30 AM CNA T said on weekends and evenings with less staff you cannot monitor the residents frequently so more accidents and incidents happen. In an interview on [DATE] at 9:00 AM CNA U said it was impossible to monitor all the residents on the weekends and evenings when there is less staff. Observation on [DATE] at 9:36 AM with CNA T revealed Resident #60 on the floor mattress, naked. Resident #60 had large dark purple bruises on her left hip and side and her entire back, her chin as well as her right eye. Continued observation revealed it took four nurses and CNA's to lift Resident #60 from the floor mattress to the wheelchair and from the wheelchair to the toilet. Observation on [DATE] at 9:59 AM Resident #60 was is her room, alone, screaming very loudly. Resident #60's room was at the end of the hall away from the nurse's station. In an interview on [DATE] at 10:05 AM LVN S said Resident #60 received [MEDICATION NAME] 30 milliliters twice a day but it did not help her confusion. LVN S said Resident #60 had not had an ammonia level lab done. Review of Policy and Procedure titled Preventive Strategies to Reduce Fall Risk dated as revised (MONTH) 5, (YEAR) documented in part: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Nursing Care: Maintain regular toileting schedules. Place confused residents close to nurses' station for close observation. Establish frequent nursing rounds on high risk residents. Increase nursing staff. In an interview on [DATE] at 11:51 AM the Nursing Home Administrator (NHA) said the facility does not offer gait belt training, He said gait belt training should be a part of the CNA certification. The NHA also said the facility does not do transfer training and it is not part of their computer-based learning.

Based on observation, interview and record review the facility failed to treat each resident in a manner that promoted maintenance or enhancement of quality of life for 1 (Resident #1) of 9 residents reviewed for quality of life. Resident #1 was required to take phosphorus-binding medication due to his [MEDICAL TREATMENT]. The medication was to decrease the absorption of phosphorus into the blood stream when the resident ate. It needed to be given while he was eating, otherwise it was not effective. Increased phosphorus in the body could lead to calcification of internal organs (heart, lungs, liver) which could lead to complications from organ failure. Licensed Vocational Nurse (LVN) A would not give the medication as intended at the request of Resident #1 and his [MEDICAL TREATMENT] Center. LVN A called the resident a liar, and resident #1 was afraid LVN A was going to physically harm him. This failure could have affected 28 residents who resided on the 2500 hallway by decreasing their quality of life. The findings included: Review of the electronic face sheet documented Resident #1 was a [AGE] year old male admitted in 2015. Review of the History and Physical dated 12/27/16 documented Resident #1 had [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #1 had a BIMS (Basic Interview for Mental Status) score of 9 out of 15 (moderately impaired cognitive ability for daily decision -making), had no behaviors and received [MEDICAL TREATMENT] services. Review of Physician order [REDACTED]. Review of the Provider Investigation Report dated 5/09/17 revealed on 5/09/17 Resident #1 complained to his Guardian Angel (facility program where department heads are assigned residnets to check on every day), LVN A did not give him his morning medications and then later claimed that LVN A scared him and he was afraid LVN A would hurt him. LVN A did enter Resident #1's room and demanded in a stern voice, Why are you lying? as witnessed by another LVN. Resident #1 was in a wheelchair while LVN A was standing about 4 feet away asking why he was lying. Review of a written statement by LVN A, undated, stated Resident was given his medications this morning (5/09/17) after breakfast meal in the dining room with no complaints. After resident informed his guardian angel that he received his medications 45 minutes late. Nurse with a witness (LVN G) went into the room and requested that he not lie to the guardian angel stating he does not receive his medication. This was the fourth time resident has made allegations and retracted his complaint after being confronted. Review of a statement from Resident #1 during an interview on 5/09/17, and written by the Interim DON, stated the resident stated he was afraid the nurse would try to hurt him. Observation on 5/30/17 at 9:17 AM, Resident #1 was seated in a wheelchair in his room. He was awake, alert and oriented. Resident #1 was clean, groomed and had a thin frame. In an interview on 5/30/17 at 9:17 AM, Resident #1 said it was very important he had his phosphorus binding medication with his meals, but LVN A would administer it to him 1 hour after he ate. By that time Resident #1 said the medication would not work. Resident #1 said he is fearful of the complications that can come from not taking his medications as he is supposed to. Resident #1 said the staff at the [MEDICAL TREATMENT] Center have spoken to the facility staff several times regarding the importance of receiving his phosphorus-binding medication while he is eating. Resident #1 said when he got his food he would send someone to LVN A for his medications. When LVN A would bring his medications, the LVN would say to him, Don't ask anyone to have me bring meds. Resident #1 mentioned the lateness of his medications to a lady who comes in every day and soon LVN A came to his room very angry. Resident #1 said he was physically afraid LVN A was going to harm him. Resident #1 said he was sexually abused as a child and was beaten by his father. Resident #1 said he spoke to his psychologist at his April appointment of his fear of LVN A and of not getting his medications right. The Psychologist called the facility but Resident #1 did not know who he spoke to. The Psychologist sent a note back to the facility with the resident requesting a different nurse. In an interview on 5/30/17 at 3:16 PM, LVN G said LVN A asked her to go into Resident #1's room with him. LVN G said LVN A asked Resident #1 if he got his medications this morning and Resident #1 answered they were given late. LVN A then asked him why he was lying and the resident made no reply. LVN G said when she had cared for Resident #1 she had worked out with him to let her know when he started eating and she would bring his phosphorus binder, but she added this did not seem to be working with LVN A. In a telephone interview on 5/30/17 at 5:26 PM, LVN F said Resident #1 went to the Psychologist's office, he thought around 4/20/17, and must have expressed concerns over his care because the psychologist wrote on a progress note recommending LVN A not take care of Resident #1 because he was treated rough. LVN F said he looked for the Director of Nurses (DON - previous) and the Administrator but they were in a meeting so he handed the note to the Assistant Director of Nurses (ADON, currently the Interim DON) on the 1st floor. When he checked the next day, the paper was on the desk of ADON B (the 2nd floor ADON). LVN G said he did not know what happened to the note after that, but there were no changes in Resident #1's nurse. LVN G said he did not think the note was taken seriously. In an interview on 5/31/17 at 8:30 AM, ADON B said she gave the note, which recommended LVN A and Resident #1 not work together, to the previous DON and was told they would handle it. ADON B said the Administrator did not know about the note until 5/09/17. ADON B said she thought changes were made to staffing by having LVN A have a witness every time he went into Resident #1's room. In an interview on 5/31/17 at 8:43 AM, the Interim DON said the note written by the psychologist recommended LVN A not care for Resident #1 because it caused trauma-related anxiety. When the incident occurred on 5/09/17, LVN A was taken off of the floor. When LVN G came on that afternoon, he asked about the note written by the psychologist. She and ADON B went to the Administrator asking about the note and she said, What note? The psychologist's note was never given to her and was missing. It had not been found in the resident's chart or the DON office. The Interim DON said they called the psychologist to find out was was in the note. The doctor said there was no allegation of physical or verbal abuse but Resident #1 becomes very anxious when he sees LVN A. The Interim DON said she assumed the previous DON had instructed LVN A to take a witness with him when he spoke with Resident #1. In an interview on 5/31/17 at 9:19 AM, the Administrator said she was not aware of Resident #1's history of assault and that he was afraid of LVN A. She was not made aware of the psychologist's suggestion until 5/09/17 as the previous DON kept it away from her. She said having LVN A go into Resident #1's room with a witness would not have been her solution. In a telephone interview on 5/31/17 at 2:26 PM, LVN A said the guardian angel approached him on 5/09/17 and told her Resident #1 had said he did not get his morning medications. LVN A said this was an ongoing thing with Resident #1 and when LVN A would confront Resident #1 about the allegations he would say, yea, I did get it. LVN A said he took another nurse as a witness and asked Resident #1 why he was lying. LVN A said he offered Resident #1 his medications, including his phosphorus binder, before his meals, but he refused to take them before he ate. Resident #1 always took his medications after he ate and would not leave the dining room until his medications were administered. The minute he finishes his meal the resident has the CNAs come tell him he's ready for his medications. LVN A said if he is with another resident he may have to wait at the most 5 minutes. LVN A said Resident #1 thinks he's the only resident. LVN A said it was his decision to take witnesses with him when he spoke with Resident #1. If the previous DON had said to do that, he didn't remember as he was already doing that. In an interview on 6/01/17 at 9:18 AM, Certified Nurse Aide (CNA) C said Resident #1 would request, when his breakfast and lunch meals were served, for the CNA to let LVN A know that he needed his pills. When she would go to LVN A he would wave his hands at her and say, I know, I know. When asked how long it was after that LVN A would take Resident #1 his pills - a couple of minutes, 10 minutes, 30 minutes - she said it was usually more than 30 minutes. Resident #1 would stay in the dining room until he received his medicine. In a telephone interview on 6/01/17 at 11:52 AM, [MEDICAL TREATMENT] Dietician H said on 4/13/17 Resident #1 told her he was not getting his phosphorus binders as he was supposed to. His phosphorus levels were increasing. The Dietician spoke with the facility's previous Director of Nurses (DON) and explained LVN A was not administering the phosphorus binders as needed. The binders needed to be given while the resident was still eating or they would be ineffective. One week later, Resident #1 said he was going out to lunch with his brother and asked for his binders so he could take them when he ate. Resident #1 said LVN A refused to give them to him, saying he could have a snack at the facility and take them prior to going out to lunch. Phosphorus binders have to be taken whenever a patient eats any food. Resident #1's phosphorus level was 6.8 at that time. When Resident #1 complained this 2nd time, he refused to let the dietician call the facility as LVN A was treating him differently and seemed to be annoyed with him. Resident #1 said he did not want LVN A to be more mad at him. The list of 23 residents who received [MEDICAL TREATMENT] services was obtained from the Resident Roster dated 5/10/17.

Based on observation, interview and record review the facility failed to consult with the physician when there was a change in condition for 1 of 3 residents (Resident # 3) reviewed for physician consultation. The facility failed to consult the physician when Resident # 3 was noted with increased somnolence and noted coughing when drinking liquids on the 6-2 shift on 02/15/17. This failure placed 144 resident at the facility at risk of not promptly receiving the necessary medical care by not consulting with the physicians were there was a change in condition. Findings include: Closed record review of the Resident Face Sheet dated 01/09/17 documented resident #3 was an [AGE] year old male initially admitted to the facility on [DATE] and readmitted back to the facility on [DATE]. Review History & Physical dated 01/10/17 documented resident #3 had [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 02/15/17 written by Licensed Vocation Nurse (LVN) I documented in part: At 9:00 AM, while administering morning medications noted resident with increased somnolence, noted resident coughing while drinking thin liquids. Oxygen saturation 84% on room air. Patient put on bedrest. Administered oxygen via nasal cannula. Oxygen saturation went up to 92%. Downgrade patient's liquid consistency to nectar. Call placed to physician, pending call back for further orders. Will note on 24 hours report and continue to monitor. Review of the facility's 24-Hour Report form dated 02/15/17 document in part on the day shift: Resident #3 noted with increased somnolence, coughing with thin liquids. Oxygen saturation at 84% on room air. Administered oxygen at 2 L/min. Pending return call from physician. Down grade liquids to nectar consistency. In an interview on 03/08/17 at 1:52 PM, LVN I, reported that after breakfast on 02/15/17 he had noted that the resident was coughing and looked weak. The night nurse reported that the resident was not sleeping well at night at the change of shift. I checked his oxygen saturation and was at 84% on room air. I decided to give him 2 L/min of oxygen via nasal cannula and downgrade his fluid consistency to nectar thick consistency. One of the CNAs reported to me that she had noted that the resident was coughing when he was drinking thin liquids. He was very impulsive and had to be reminded to take small sips. I placed a telephone call to the attending physician but he never called back. I did not think of calling his nurse practitioner. LVN I reported that he had never gotten a physician's orders [REDACTED]. LVN I said, I wrote the telephone order even though I never got the order from the attending physician. We used to have standing orders for this, but since there has been so many changes in DONs and Administrator everything has changed. We are very limited with time, because I have to pass medications to 30 resident and do admissions. I did not place another call to the physician. LVN I reported that they had been trained to notify their immediate supervisor, Director of Nurses (DON), Assistant Director of Nurses (ADON) or the Quality Manager if they are having problems with the physicians not promptly returning calls to report changes in condition. LVN I reported that they had been trained to write the telephone orders only after receiving orders from the attending physician or the nurse practitioner. LVN I reported that the attending physician had not returned his call at the end of his shift. Review of the Nurses Notes dated 02/15/17 written by Registered Nurse (RN) J documented in part: Given report by off-going nurse. Reported resident #3 was kept in bed all day because he was short of breath and inability to ambulate, oxygen saturation below 90% even with 2 L/min of oxygen. Pending return call from physician. Head to toe assessment at 2:45 PM, revealed resident was in respiratory distress, responsive to verbal stimuli, oxygen saturation at 90%, weakness of upper & lower extremities, Ronchi and rales in upper lobes with diminished breath sounds to lower lobes. Resident reported he ate breakfast but did not eat lunch. Patient with some difficulty breathing at night. Certified Nurse Aide (CNA) K reported that she had cared for resident #3 yesterday and stated that the resident had vomited x 4 and had reported this to LVN D. At 4:25 PM, resident oxygen saturation at 70-68% on 3 L/min of oxygen. Placed on non-rebreather mask, still sating at 70%. Noted increased ronchi and rales. Called 911 to send resident to the hospital. Call placed to physician, return call pending. Review of the facility's 24-Hour Report form dated 02/14/17 did not document resident #3 had vomited x 4 on the evening shift. In an interview on 03/08/17 at 3:19 PM, Registered Nurse (RN) J stated that LVN I had reported at the change of shift that resident #3 had been kept in bed because his oxygen saturation levels were low and that the resident was on oxygen. LVN I reported that he had placed a telephone call to the physician in the morning and was still pending a return call at the end of his shift. RN J said, The resident did not look too hot. He did not want to drink fluids and looked weak. He is usually very hyperactive and was not his usual self on that day. At 2:45 PM, I did a head to toe assessment and noted the resident had ronchi and rales to the lower lobes. I was also concerned because at that time CNA K reported to me that resident #3 had emesis x 4 on 02/14/17 and she had reported this to LVN D 02/14/17 who had been assigned to resident #3 on the evening shift. I reassessed the resident at 4:04 PM, the oxygen saturation levels dropped to 68-70 % so I put a non-rebreather mask on the resident. I called the physician and left a message with his secretary. The resident was getting worse so I called 911 at 4:45 PM. EMS arrived and the resident was sent to the emergency room for evaluation. The physician never called back so I placed another call to the physician's office and was informed by the secretary that the physician was aware that the resident had been sent out to the hospital. I guess the hospital called him because he never returned my calls. RN J reported that the nurses had been trained to immediately report changes of condition to the attending physician, if the physician does not return calls then we need to notify our direct supervisor so they can help us contact the physician. Telephone interview on 03/09/17 at 9:32 AM, (CNA) K reported that she had reported to LVN D on 02/14/17 that resident #3 had vomited four times on the evening shift. The first time that the resident vomited he was in the dining room. I immediately went to report this to LVN D who was assigned to the resident on that day. LVD wheeled the resident back to his room. Later during the shift, I was in the room with the resident and LVN D, when the resident vomited x 3. CNA K reported that they had been trained to immediately report to the nurses when a resident has a change in condition. Telephone interview on 03/09/17 at 9:39 AM, LVN D confirmed that he had worked on 02/14/17 on the evening shift and had been assigned to resident #3. LVN D denied that CNA K had reported to him that the resident had vomited x 4 on that day. The resident was not sick. No one reported to me on that day that the resident was vomiting. LVN D reported that they had been trained to immediately report changes of condition to the attending physician. Review of Hospital emergency room report dated 02/15/17 at 5:32 PM, documented in part: Resident #3 was sent from nursing home for [MEDICAL CONDITION], oxygen saturation at 90% in the morning on 3 L (liters)/min (minute) by nasal cannula. Patient was at 60% when nurse when to check and 74% on non-rebreather. Patient lost pulse upon arrival to Emergency Department. Diagnosis: [REDACTED]. None re-breather mask on oxygen 15 L/min; History of Present Illness: The patient presents in [MEDICAL CONDITION]. The onset was just prior to arrival. Preceding symptoms shortness of breath. Risk factors consist of diabetes mellitus and [MEDICAL CONDITION]. Patient was brought in by EMS (Emergency Medical Services) for being [MEDICAL CONDITION]. Diagnoses: [REDACTED]. Review of Hospital History & Physical dated 02/16/17 documented in part: The patient apparently was diagnosed with [REDACTED]. The patient is a resident in a nursing home. The patient started feeling short of breath this morning and he was taken via ambulance to the hospital. Upon arrival, the patient actually coded and was started on cardiac resuscitation, immediately the process started about a minute. Diagnoses: [REDACTED]. Review of Hospital Discharge Summary dated 02/18/17 documented in part: date of death : 02/18/17. Cause of Death: Cardiopulmonary arrest, Diabetes type 2, and Dementia. In an interview on 03/09/17 at 8:41 AM, the Quality Manager reported that on 02/15/17 resident #3 was sent to the hospital. I was covering for the ADON on the first floor because she was off on that day. I came down to get report and LVN I reported that the resident #3 was tired and they had left him in bed for breakfast. After lunch, I went to talk to resident #3 and he told me that he felt very weak and did not eat lunch. LVN I told me that he had called a telephone call to the physician and was pending a return call. The Quality Manager reported that the nurses had been trained to notify the Nursing Administration if they are unable to contact the physician when a resident has a change in condition so they could assist them in contacting the physician. Based on our nursing judgement depending on the condition of the resident we can put a resident on oxygen. The nurse has to keep calling the physician to report the change in condition and get a telephone order for the oxygen. LVN I did not report to me before the end of his shift on 02/15/17 that the physician had not returned his call at the end of the morning shift. We do need to get physician's orders [REDACTED]. In an interview and record with the Speech Therapist L reported that she had not downgrade resident #3 to Nectar thick liquids. The nurses need to get a physician's orders [REDACTED]. This is usually done after a speech therapy evaluation and recommendations. It was reported that resident #3 received Speech Therapy (ST) for Dysphagia and was discharged from ST on 12/22/16. Review of the Speech Therapy Discharge Summary documented in part: Continue Puree Consistencies and Thin liquids. Provide occasional supervision to remind the resident to alternate liquid/solids, rate modification, bolus size and general swallow technique/precautions. In an interview on 03/08/17 at 4:21 PM, the DON reported that the nurses had been trained to immediately notify the physician when a resident has a change in condition. It is not permissible for the nurses to write telephone orders without calling the physician. Our medical director just did an in-service training on reporting changes in condition to the physician. He said that according to his medical standards the nurses have up to 4 hours to get in contact with the attending physician. If the resident is not stable and the doctor has not returned his calls then the resident can be sent to the hospital. I had been trained in my other place of employment to downgrade a diet/fluid consistency pending a return telephone call from the physician for the resident's safety. In an interview on 03/08/17 at 4:38 PM, interim administrator reported that the nurses must immediately report changes in condition to the resident's attending physician. The nurses either can call or fax the necessary information to the physician. The nurses have been trained to immediately report to their immediate supervisor, DON, or the ADON if they are not able to contact the physician and the resident's condition continuous to deteriorate. If we cannot get a whole of the physician then we will send the resident to the hospital and will continue to get a whole of the physician. The administrator confirmed that the nurses are not allowed to write physician's orders [REDACTED]. The administrator stated, I have a morning meeting with the Nursing Administration every morning to follow up on changes in condition and I was not made aware that the nurses were having issues with contacting the physicians when residents had a change in condition or that the nurses were writing telephone orders without calling the physician. I will address these concerns right away. Review of the facility's policy on Change of Condition - Observing, Reporting and recording revised 1/2016 documented in part: Policy - It is the policy of this facility to inform the residents physician of the following: A significant change in the resident's physical, mental, or psychological status, in life-threating conditions or clinical complications. A need to alter treatment significantly. A decision to transfer or discharge the resident from the facility. Procedure - After resident changes in health status conduct a thorough assessment and compare against baseline. Do not leave the resident alone when a change in condition is identified until the licensed nurse had determined that the resident is not in danger in any way related to their medical condition. The physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable. If you are unable to reach the attending physician, call the alternate physician. If you are unable to reach this physician, call the medical director (if not the attending or alternate physician), or the emergency room physician. Documentation - Date, time condition change was identified. Pertinent assessment findings. Who was notified and when. Communication - The change in condition and interventions related to the change will be documented on the 24-Hour Report form on the shift that the change occurred. The DON/designee will report the change in condition and interventions to the appropriate Q & A (Quality Assurance) Committee. The resident census dated 03/01/17 provided by the Administrator documented 27 residents resided in the 200 Hall.

Based on observation, interview, and record review the facility failed to promptly notify the Resident's legal representative or interested family member and physician for 1 of 5 residents reviewed for notifications (Resident #15). Resident #15's physician and family were not promptly notified on 7/23/16 at midnight when she said that she wanted to kill herself. Resident #15 was found in the shower room attempting to hang herself with a belt wrapped around her neck tied to the corner of the shower rod at approximately 6:00 a.m. on 7/23/16. This failure resulted in an Immediate Jeopardy (IJ) identified on 10/11/16. While the IJ was lowered on 10/13/16, the facility remained out of compliance at Actual Harm isolated due to the facility ' s need to monitor their plan for effectiveness. This failure could have affected the facility's other 9 residents identified as having referrals for psychological services or those that were sent out of the facility due to expressing intent to harm themselves by placing them at risk for not having their psychological and psychiatric needs being met. The findings were: Closed record review of Resident #15's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #15's Behavioral Health Hospital A document located in the facility ' s closed record, with the date of service 5/26/16 and date of admission 5/25/16, Psychiatric Evaluation revealed the following: CHIEF COMPLAINT: I was suicidal after I got angry with my daughter. History of Present Illness: Resident #15 is a [AGE] year-old female who has a history of [MEDICAL CONDITION] .The patient has been referred to us due to suicidal thoughts after she claims she got upset with her daughter .who happens to be her caretaker . Mental Status Exam: The patient is alert and cooperative. The patient is oriented to place and person, but disoriented to time. The patient reports no death wishes at the time of this assessment. She denies thoughts of suicide or of harming anyone, but admits that she was suicidal before being admitted here .The patient ' s insight is limited, judgment is impaired. She shows some anger toward her daughter and apparently, she is not happy with her daughter being her caretaker. The patient claims she does not have any other options. She is able to ambulate with a walker and she smiles and she also has a sense of humor . Record review of Behavioral Health Hospital A's Resident #15's Suicide Reassessment located in the facility ' s closed record, dated 5/29/16, 5/30/16, and 5/31/16 revealed Resident #15 was on suicide precautions and was also meeting criteria for precautions or observations for suicide or self-injurious behavior. Record review of Resident #15's Behavioral Health Hospital A's After Care Discharge Plan with the Date of Discharge 6/6/16 located in the facility ' s closed record revealed problems addressed was danger to self. Problems that need additional follow-up .4. Depression It also indicated that Resident #15 would have a follow-up appointment with Physician A, and the reason of referral would be med management. Record review of Resident #15's facility Physician Telephone Orders, dated 6/6/16, revealed Admit resident to SNF under the care of Physician A . signed by LVN C. Record review of Resident #15's Admission MDS 3.0 (Minimum Data Set 3.0), dated 6/13/16, revealed the following: she scored 10 out of 15 on the BIMS (Brief Interview for Mental Status) indicating moderate cognitive impairment, a 0 in Section D-Mood indicating no symptoms of depression, in Section G Functional Status she needed supervision and one person physical assist to walk in corridor (she used a walker and wheelchair, in Section N-Medications she received an anti-depressant for 7 days, in Section O- Special Treatments, Procedures, and Programs she did not receive psychological services, and Section Q- she did not have a legal guardian or legal authorized representative. Record review of Resident #15's individual resident care plan (Initiate within 24 hours of admission), dated 6/6/16, revealed Behavior/Mood Issues: [MEDICAL CONDITION]. There was no mention of depression or [MEDICAL CONDITION] on the initial care plan. Record review of Resident #15's care plan, dated 6/13/16, revealed the following: Resident at risk for Psychosocial well being problems .History of [MEDICAL CONDITIONS], Mood Disorder .Monitor need for psychological or psychiatric services; discuss with resident ' s MD .Administer meds as ordered by MD. Resident at risk for side effects from [MEDICAL CONDITION] Medication use as evidenced by: Resident receives Antidepressant .Administer resident's meds as ordered by MD .(care plan does not specifically list medications) Record review of Resident #15's Resident Incident report dated 7/25/16 revealed she was discharged from the facility on 7/23/16. The date and time of the incident was 7/23/16 was 6:00 a.m. The narrative of incident and description of injuries: Writer notified by CNA that resident was in shower room with clothing belt around resident's neck, double wrapped and tied to right shower stall. Resident was observed with eyes bulging out, redness in face, and tongue hanging outside of mouth. Resident was very anxious and stated in Spanish that she wanted to kill herself. Redness around neck due to tightness of belt .Immediate Actions Taken: Head to toe assessment (assessment), 1: 1 with resident, 911 activated, unit manager, Physician A answering service contacted. The incident report indicates on 7/23/16 Physician A was notified at 6:16 a.m. (initial contact), and responded on 7/25/16 at 12:30 p.m. The incident report indicates Resident #15 ' s daughter was contacted at 6:30 a.m. and her son was contacted at 1:00 p.m. Resident #15 was transported by EMS to Hospital B on 7/23/16 at 6:50 a.m. The incident report indicated it was prepared by LVN A, and Resident #15 was assessed by LVN A. LVN A reported to her supervisor on 7/23/16 at 6:00 a.m. Record review of Resident #15's Nursing Notes signed by LVN A, dated 7/23/16 at 9:12 a.m. revealed the following: Notified by CNA at 1200 midnight that resident was expressing desire to die. CNA stated that resident was wandering around in shower room on the first round and she redirected resident back to room. CNA first round was 2315 (11:15 p.m.). Once writer was notified of resident expressing desire to want to die, writer and CNA sat with resident at nursing rotunda for about 1 hour or so. Resident stated she was ready to go to bed. Resident went to bed and remained asleep. Last round was made at 0530 (5:30 a.m.) and resident was in bed resting. During resident care in room [ROOM NUMBER] and was called into shower room on 2200 at 0600 by oncoming CNA B that resident had clothing belt hanging from right shower stall and belt tied around neck twice and resident was leaning forward. Writer observed redness after belt was removed from around resident ' s neck. Resident ' s eyes were bulging out and moth was open with and tongue outside mouth. Resident was immediately brought to nurses (nurses ' ) station. VS (Vital Signs) 77/57, 131, Spo2 90, 97.3, 24. Resident was very anxious and crying. Immediately contacted RN A regarding matter, was ordered to activate 911. 911 activated at 0617. EMS arrived at 0628 and assessed resident. Physician A answering service phoned, and RP daughter .contacted. Left message with resident ' s RP twice and still awaiting call back. Resident was taken by EMS (911) at 0650 via stretcher. Contacted by Police Department A regarding matter and was told that a officer would be in to take a statement. Reported to oncoming staff. Record review of Resident #15's Nursing Notes signed by RN A, dated 7/23/16 at 3:43 p.m. revealed the following: Writer received a return call from residents R/P around 1230, informed her that her mother had tried to strangle herself this am. Daughter stated that her mother was mad at her and did not want anything to do with her. She stated that we had to call her brother who is going to be responsible for her mother. Writer received a retun (return) call at around 1430 (2:30 p.m.) from son and explained to him that his mother had tried to strangle herself this am and that she was very distraught and wanted to talk to her son and not the daughter .Writer informed son that mother was taken to Hospital B and he stated he would call over there to see how his mother was doing . In interviews on 10/6/16 at 4:16 p.m. and on 10/10/16 at 5:13 p.m. and review of written statement on 7/23/16 signed by CNA A, CNA A said that at midnight Resident #15 came out of her room and was going into the shower room. CNA said Resident #15 was very alert and oriented. CNA A said that it was her first time back in 3 weeks and she did not know Resident #15. CNA A said that Resident #15 said to her me quiero matar which translates to I want to kill myself in Spanish. She said Resident #15 was upset about her daughter. She said Resident #15 was sad .depressed .you could see it in her face. CNA A said that she brought the resident to the nurse ' s station and told LVN A what the resident said. CNA A said Resident #15 was kept up front for about 1 to 1 ½ hours. She said that Resident #15 was falling asleep in the chair. She said then she took Resident #15 back to bed. CNA A said Resident #15 was in her room. She said no action was taken .no one told me to do anything different. She said the nurse did not tell me to check on her every 15 minutes. She said that I did not do anything different. CNA A said that she checked on the resident every 1-2 hours. She said that she started her last round at 4:00 a.m. and she was gone for about 7 minutes to take her barrels out. CNA A said she came back and sat at the nurse ' s station where she could see the hallway. CNA A said she would have noticed Resident #15 going into the shower room. She said the nurse did not tell her to watch Resident #15. She said one of the other CNAs found Resident #15 in the shower room at shift change around 6:00 a.m. She said Resident #15 was a very tall woman, and she had the tie looped around her neck twice. She said the facility did not in-service her on anything. She said that she now is PRN, and works full-time at the hospital. She said it could have been handled better. She said nobody knew what to do .the nurse should not be at fault. She said it was also the first time it had happened at the facility. In interviews on 10/6/16 at 5:54 p.m. and on 10/10/16 at 2:45 p.m. and review of written statement on 7/23/16, LVN A said that she had been working at the facility for two years. She said that Resident #15 was found attempting to hang herself, but not hanging at around 6:00 a.m. She said if the shower rod was not that tall she would have got it right .she probably would have succeeded, referring to Resident #15 hanging herself by the shower rod. She said around 11:30 p.m.-11:45 p.m. CNA A told her that Resident #15 told CNA A that she wanted to kill herself in Spanish. LVN A said that CNA A was translating for Resident #15 as LVN A did not speak Spanish. LVN A said that Resident #15 was up at the nurse ' s station upset about her daughter. LVN A said at that time she did not feel like Resident #15 was showing signs and symptoms of distress LVN A said Resident #15 was looking kind of blue. When asked if she knew the facility policy regarding suicide prevention or when a resident says they want to harm themselves she said No, not really. LVN A said she monitored Resident #15 based on her nursing judgment Q (every) 15 minutes. She said sometimes it ' s Q15 minutes .it ' s one on one now. She said I dropped the ball I should have contacted the supervisor right away. She said that she called the doctor, but not right away (did not give a specific time). She said she never spoke to Physician A, and did not receive a call back. LVN A said I did the best I knew how to do .I should have initiated one-on-one at night. She said that she checked on her every 15 minutes, and at 5:45 a.m. the last time she saw Resident #15 she was in her room alone sleeping. She said that she was at the nurse ' s station for about an hour, and Resident #15 said she felt better and wanted to go back to her room and lay down. LVN A said Resident #15 went back to her room, and LVN A checked on her every 15 minutes. LVN A did not indicate that she checked Resident #15 ' s room. LVN A said I was not really knowledgeable regarding [MEDICAL CONDITION]. She said that she there was not a previous in-service regarding [MEDICAL CONDITION] at the facility. LVN A said she knew the resident had a [DIAGNOSES REDACTED]. LVN A said when she was admitted from Behavioral Health Hospital A .we are not equipped to have people like that in our facility. LVN A said she was alerted by CNA B that Resident #15 had tried to hang herself in the shower room. LVN A said she was on another hall at that time. She said when she saw Resident #15 in the shower room that Resident #15 appeared to be in a psychotic state .her eyes were bugging out .she had it wrapped .pretty tight, referring to the belt around her neck. LVN A said she must have attempted it before .it ' s like she knew what to do. LVN A said Resident #15 was found in the shower room a little after 6:00 a.m. and that she called her supervisor right away. She said that no one saw Resident #15 go in to the shower room. She said her supervisor asked why she had not called at midnight, and LVN A said she was suspended. She said that she spoke to CNA A, and asked how Resident #15 could have gotten out of bed without CNA knowing. LVN A said CNA A went to take out her barrels. LVN A said that she did not think during that time to look at the book on policies and procedures. LVN A said it also depends on what the doctor says. LVN A said that she learned from the incident and that one-on-one would have been much better. She said I will never let that happen again. LVN A said I was disappointed in myself .I felt like it was my fault. She said I am not aware of the policy, regarding [MEDICAL CONDITION] but also indicated that it ' s one on one now. She said that the protocol is one-on-one right away instead of Q15. LVN A said she feels like it would be a good idea if they received additional training. LVN A said that a few days ago that Resident #15 and her daughter had a fight. LVN A said when she finally got in touch with Daughter A, Daughter A asked her to call her brother, Resident #15 ' s son. Record review of Resident #15's 15 Minute Surveillance Program, dated 7/23/16, revealed the following: Every 15 minutes from 12:00 a.m. until 6:00 a.m. LVN A initialed she had checked Resident #15' s location. The resident was documented at the nursing station from 12:00 a.m.-2:45 a.m., in her bedroom from 3:00 a.m.-5:45 a.m., and in the shower room at 6:00 a.m. In an interview on 10/11/16 at 9:35 a.m. CNA B said she had been working at the facility for 3 years on the 6:00 a.m. to 2:00 p.m. shift. She said that she found Resident #15 in the shower room at approximately 5:50 a.m. She said she just happened to walk in the shower room. She said that she and CNA A helped remove the cord from Resident #15's neck. She said that Resident #15 ' s room was about two doors down from the shower room, and Resident #15 used a walker. She said that Resident #15 had used a cord from her dress and had it wrapped around her neck and it was tied to the shower rod. She said the walker was next to her. She said her feet were still on the ground. She said that they helped her sit down in her wheelchair. She said that in her previous shifts during the day that week Resident #15 had not been acting sad. Record review of a written statement by RN A dated 7/23/16 revealed I received a telephone call around 0610 from 10-6 LVN. LVN stated that Resident #15 was found in 2200 Hall Shower with a nylon belt wrapped around her neck. I told LVN to call 911, DR., and place resident on 1:1 observation. I arrived at the facility around 6:15 a.m. and went to 2nd floor rotunda, where I found resident sitting in chair crying and stating that she hated her daughter and wanted to see her son. Resident #15 had redness to the posterior aspect of her neck. EMS arrived and began to assess her. I explained to EMS that she had dementia and other medical conditions. They insisted on asking her if she wanted to go to hospital. Her vitals were 97.6, 132, 22, 80/70. She was very distraught and continued to cry. EMS finally agreed to take her to hospital and stated that an emergency detention order would be acquired through policy. She was taken to Hospital B on stretcher around 650-700 am. I notified DON, Administrator at 0700. Record review of Resident #15's Resident/Patient Discharge Summary, signed by Social Worker A on 8/22/16, revealed she was admitted on [DATE] and discharged on [DATE]. He discharge [DIAGNOSES REDACTED]. In interviews on 10/10/16 at 4:25 p.m. and at 5:11 p.m. the Director of Education said that she was in charge of training. She said they did not discuss suicide prevention during orientation. She said that they were in the process of updating the policies. She said also when there is a suicide attempt, the staff are supposed to do one-to-one, contact the physician, and intervene when the residents are depressed. She said the policy dated 2/14/14 is the previous company ' s policy. The Director of Education said that she had conducted a lot of training on Change in Condition and Behaviors, but the last in-service done on suicide prevention before the one after the incident with Resident #15 was in 2014 when they were introducing the policy dated 2/14/14. In an interview on 10/11/16 at 10:44 a.m. the Administrator said that when the resident stated she wanted to harm herself she should have been put on one on one and the nurse should have notified the doctor and the family. In an interview on 10/11/16 at 3:12 p.m. Physician A, the facility's Medical Director, said regarding the incident with Resident #15 that LVN A ended up getting his answering service when she called later. He said for that resident for that moment in time when she said she wanted to kill herself she should have been placed immediately on suicidal precautions. He said that means to observe the person at all times until transferred, or one on one. He said usually the nurses would call the DON, and the pt. would be put on suicide precautions. He said that is what you have to do .immediate measures. He said in the middle of the night one may not be able to send a person out so they need to be under direct observation. Physician A said in other words .if I said ok let me call the doctor .you have to do direct observation. Physician A said that a person cannot be left 6-7 hours by himself or herself after voicing that the person wanted to kill himself or herself. Physician A said that Resident #15 should have been on one-to-one not just 15 minute checks, he said that is standard procedure. He said that they also should have removed sharp objects from her room as she could have used them on her wrists or on her eyes. He also said sometimes suicidal are also homicidal. Record review of the facility's Clinical Management: Suicide Prevention Policy, dated 2/14/14, found in the book of policies and procedures at the nurses ' station on the first and second floor of the facility on 10/10/16 at 4:09 p.m. revealed the following: It is the facility ' s policy to ensure that residents/patients who voice and/or display suicidal ideation actions receive services and interventions to help them manage feelings and maintain their psychosocial well being Procedure 1. Report any of the following warning signs immediately to your immediate supervisor: Resident/patient expresses feelings of worthlessness, hopelessness, or helplessness Outbursts of anger, mood swings, drastic changes in behavior . Experienced a recent significant loss Direct and indirect statements such as, I wish I were dead, I'm going to kill myself, I'm useless, and I can't go on living like this. Changes in eating or sleeping habits Withdrawal from friends, family, or social activities Preoccupation with death .Making final arrangements - will, funeral plans, insurance changes . Previous suicide attempts 4. Assess resident/patient ' s environment for safety and remove and store objects which could be used for self-harm 5. Assess resident/patient for physical problems or drug reactions Check for new medication orders which occurred prior to noted changes in resident/patient 6. Notify Physician and/or Medical Director of the initial assessment including mood, mental status and safety issues, to obtain an order for [REDACTED]. 7. Notify and involve family/significant other. Request a family member to sit with resident/patient if possible . 9. Monitor resident/patient closely. Enlist assistance of other staff members to look in on resident/patient. Record review of the policy titled Change of Condition- Observing, Reporting, and Recording, with an effective date 9/2015 and Revised Date 1/2016 received on 10/13/16 from the ADON from the Policy and Procedure book, revealed the following: It is the policy of this facility to inform the resident, the resident ' s physician and if indicted (indicated) the resident ' s responsible part of the following: .2. A significant change in the resident ' s physical, mental or psychosocial status, such as deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications . Procedure: Observing, Reporting and Documenting a Change in Condition: 1. After a resident changes in condition including . changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable .If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director, or the emergency room physician .5. Notify resident ' s responsible party. The facility Administrator and DON were notified on 10/11/16 at 5:00 p.m. of an Immediate Jeopardy for the above failures. In an interview with the Administrator and DON on 10/11/16 at 5:15 p.m. when asked why the IJ occurred they said that the one to one was their new policy. They said the policy dated, 2/14/14, was in effect at that time. When asked why the nurse was written up for not doing the one to ones the DON said that she wrote up the nurse as the 15 minute checks was not enough to keep Resident #15 safe. The DON also said that LVN A should have notified her supervisor. They believed the IJ should be for the time period of when the resident was alone in her room from 1:00 a.m. to 6:00 a.m. as she was at the nurse ' s station for an hour. The DON said that she felt like they followed the policies they had in place, but more could have been done at the time. The DON said she feels like they have everything in place now to prevent the incident from occurring again. When the surveyor asked when the new policy went into place, they said after they talked to corporate about this incident (7/23/16). The DON and Administrator said the new company took over on 3/1/16. The DON said that she felt like more could have been done for the Resident #15 ' s safety. They said they felt like one-to-one should have been done on 7/23/16, if not the Administrator said the DON would not have written up LVN A. The Plan of Removal Revision #4 was accepted by the investigator on 10/13/16 at 4:45 p.m. and included the following steps: Facility Action: 07/23/16 Resident was sent to the emergency room and Behavioral Hospital A for treatment and is no longer in the facility. Failure that led to past IJ: Resident was not under direct supervision at the time if the incident. Incident occurred in between 15 minute checks. Facility Actions to remove threat: Resident was sent to the emergency room and Behavioral Hospital A. Staff member was suspended pending investigation. Specific Resident: Resident #15 was only resident affected at the time. Other residents that could be affected: Any resident expressing or with a history of a desire to harm self could be affected. On 7/25/2016 In-services were begun with all facility staff on abuse and neglect prevention to include changes in resident condition and residents that express a desire to harm themselves. Since incident on 7/23/2016 any resident that expressed a desire to harm self will be placed on one to one observation by any staff or family member until cleared by a physician, psychologist or until sent out of the facility for evaluation. Facility has an ongoing practice that changes in a resident ' s condition are be (will be) brought to the floor nurse, unit manager, DON, Social Worker or administration at any time. Asking residents if they have a desire to harm themselves is part of the MDS process. Changes in condition are monitored and reviewed by nurse management in their daily clinical meetings held during the work week. A stand down meeting is held by the DON, and ADONS to review any additional follow-up needed. Policy review/update to address situation: As of 7/23/2016 any resident that expressed a desire to harm self will be placed on one to one observation by any staff or family member until cleared by a physician, psychologist or sent out of the facility for evaluation. One to one observation means having someone with the resident at all times. Previous policy has been replaced to include closer monitoring of resident until cleared. On 10/10/2016 in-services were conducted by the DON with nursing staff on updated policies on suicide prevention, abuse and neglect. Additional in-services were on Incident Reporting, Witness Statements, 24-hour checks and reporting process. Don (DON) or Quality Manager will continue until all facility staff has been in-serviced. Since 9/15/2016 referrals to our facility with potential psychological or behavioral [DIAGNOSES REDACTED]. Starting 10/10/2016 current practice includes using a Medication Reconciliation Worksheet of Post-Hospital Care by the RN Quality Manager to review medications from referring entity and physician to ensure all ordered medications are available and administered per physicians ' orders. History and physical and physician progress notes [REDACTED]. Starting on 10/13/2016, prior to admission, DON or Nursing Administration will review all admissions and readmissions History and Physical. If resident has a history of suicidal tendencies, this will be highlighted and placed on the 24-hour report as well as reported to nurse receiving admission. In addition to this information in the History and Physical in the chart, a care plan on suicidal ideation will be in place. All nursing staff will be in serviced on this immediately and during new hire. DON or designee will also review History and Physical so that medications mentioned in the History and Physical are included when using the Hospital to facility reconciliation for the physician ' s review on what medications to continue at the facility. Attached Document: Medication Reconciliation Worksheet for Post-Hospital Care, dated 2014, revealed a sheet in order for Part 1: Hospital Recommended Medications Needing Clarification, and Part 2: Medications Prior to hospitalization Needing Clarification. VERIFICATION: Record review of the facility In-service titled Behavior Management, Suicide Prevention, dated 7/25/16 presented by the Director of Education, revealed the following: It is the facility ' s policy to ensure any resident that voices and or displays suicidal ideation actions receive services and interventions to help them manage feelings and maintain their psychosocial well being. All staff must remain vigilant to this type of behavior and intervene immediately. Resident will be placed on one to one observation, physician & (and) RP (Responsible Party) notified, staff member will be assigned to remain with the resident at all times until inpatient tx (treatment) is arranged in the event of an actual suicide attempt. Nursing staff and additional staff signed this in-service. Record review of the facility In-service titled Incident Reporting, Witness Statements, 24 hour chart checks, 24 hour Reporting process, dated 10/11/16 and presented by the DON, revealed objectives: 1. Incident Reports must be completed as per facility policy 2. 2. CNAs must complete witness statements with information about last round, safety, etc . 3. NOC shift nurses will complete chart checks daily and addressed missed orders, labs, etc . 4. 24 hour reporting process will be completed as per facility policy The in-service was signed by nursing staff. Record review of the facility In-service titled Abuse/Neglect, Suicide Prevention and Policies dated 10/11/16 and presented by the DON, revealed objectives: 1. Any type of abuse or neglect will not be tolerated 2. Please review policy and procedure manual for current policy 3. New suicide prevention policy is located in P&P (Policy and Procedure) book located at nurses rotunda. Patient safety is the number one goal. Patient must be on one on one until seen by psychiatry/psychology. The in-service was signed by nursing staff. The policy referred the facility policy titled, Suicide Precautions, with an effective date 9/2015 and Revised Date 1/2016 In interviews conducted on 10/11/16 through 10/13/16 on all three shifts (6:00 a.m.-2:00 p.m., 2:00 p.m.-10:00 p.m., 10:00 p.m.-6:00 a.m.) revealed the nursing staff and CNAs were aware of the policy and procedures for suicide prevention. They all reported that when a resident expresses that he or she wants to harm himself or herself the resident needs to be placed on one-on-one supervision. The doctor, family, and supervisor need to be notified immediately. They were also aware of admission procedures. 9 LVNS (LVN A, C, D, E, F, G, H, I, and J) were interviewed as well as 4 CNAs (C, D, E, and F). In an interview on 10/13/16 between 5:02 p.m. and 5:10 p.m. the DON said that she had started the in-services on the new policies regarding suicide prevention on the night shift on 10/10/16 to make sure they know what the policies are if they have a question. On 10/13/16 a new Policy and Procedure book was located at the nursing stations and contained the new policy that addressed suicide prevention. Record Review of the facility policy titled, Su

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being for 1 (Resident #2) of 7 residents who were reviewed for care and services. Resident #2 had a circumcision on 3/28/16 and the facility failed to follow the physician's orders for care of the surgical site. The pressure dressing remained on Resident #2's penis until he was seen by his physician on 4/15/16. During this time Resident #2 developed open wounds at the base of the penis (at the edge of the dressing) and a rash on both groin areas. Antibiotic ointment ordered to begin twice a day on the day after surgery was never administered. This failure could place 29 residents who resided on the 200 hallway at risk of not receiving physician ordered care and services. The findings included: Record review of the face sheet dated 1/08/16 documented Resident #2 was an [AGE] year old man readmitted on [DATE]. Record review of the facility History and Physical dated 12/22/15 documented Resident #2 had [DIAGNOSES REDACTED]. Record review of DC (discharge) Order for Resident #2's circumcision on 3/28/16, from Surgeon C, stated to remove dressing in am (morning of 3/29/2016), Apply Abx (antibiotic) ointment twice per day, Do not pull on strings. Call your doctor if you have: fever greater than 101, continued vomiting, severe pain not relieved by pain medications, or if you are unable to void in 8 hours. Follow up time frame: 3 weeks. Record review of Resident #2's Medication Administration Record [REDACTED]. Record review of Departmental Notes dated 3/28/16, 10:14 AM, by Licensed Vocational Nurse (LVN) A, documented Resident #2 went out to (a local facility) for circumcision procedure. The note timed for 1:51 PM documented Resident #2 returned with instructions not to remove bandage until tomorrow morning. A follow-up appointment to be made three weeks from now. There were no further nurse's notes on paper or electronic charting until 4/14/16. Record review of Physicians Order Sheet for April 2016 documented an order for [REDACTED].>Record review of CNA (certified nurses assistant) Bath Sheet dated 6/06/16 and 4/07/16 documented Resident #2 did not refuse his bath and there were no skin issues. Record review of electronic Skin Inspection Report and paper Weekly Skin Assessment there were no documented weekly skin assessments for Resident #2 from 3/28/16 until 4/16/16. Interview on 5/26/16 at 3:08 PM, Certified Nurse Aides (CNA) I and J said Resident #2 did not like much help in the shower or going to the bathroom. They said the aides let him shower without assistance They denied seeing a dressing on his penis. Record review of the 24 Hour Report/Change of Condition Report (a communication tool used by the nurses) from 3/27/16 through 3/31/16 documented Resident #2 was going for surgery, but there was no communication that Resident #2 had the circumcision, needed to have the dressing removed the next morning or required antibiotic ointment be applied twice per day. Record review of the annual Minimum Data Set (MDS - a comprehensive assessment of the resident) dated 4/01/16 revealed Resident #2 was cognitively intact, had no behaviors, required 1 person extensive assistance to use the toilet, required 1 person total dependence for showers, was frequently incontinent of bladder and bowel, had no surgical wounds, required no surgical wound care or applications of ointments/medications other than to the feet. Record review of Resident #2's comprehensive Care Plan dated 4/01/16, interventions were given to have weekly skin assessments by a licensed nurse and daily skin observations by caregivers. The care plan identified a problem of refusal to shower/bathe but the MDS did not document any behaviors and there was no documentation of refusals from 3/25/16 through 4/14/16. There was no care plan addressing the care of the circumcision. In an interview on 5/26/16 at 3:55 PM, LVN H said the MDS did not document the surgical wound as there was no documentation found on the circumcision. He said the nurse should have started an acute care plan to address Resident #2's circumcision and the care to be provided. The care plan would have been on the resident's chart. Record review of the Provider Investigation Report dated 4/20/16 revealed Resident #2 had a circumcision on 3/28/16 and had orders to remove the pressure dressing in the A.M., apply antibiotic ointment twice per day and do not pull on strings. Wound care orders received by (LVN A). Attending nurse failed to transcribe orders as per protocol. Pressure dressing was left in place and not removed. There was severe breakdown, no necrosis, [DIAGNOSES REDACTED] and bleeding. The Description of the assessment dated [DATE] stated Resident #2 presented with the dressing in place. Foul odor. Patient in pain. He has incisional drainage. He has pain in his incision. Record review of Office Visit Report dated 4/15/16 by Surgeon C stated the Pt (patient) presents today with dressing in place. Foul odor. Pt in pain. Order post op were very specific to remove dressing POD (post op day) 1. The report continues with the patient having incisional drainage, pain in his incision, swelling around his incision and redness at his incision site. The GU ([MEDICAL CONDITION]) Examination stated Severe skin breakdown, no necrosis. [DIAGNOSES REDACTED] (redness)and bleeding. Surgeon C wrote, I called both the charge nurse and nurse administrator to discuss my concerns. I discussed the risks of further ramifications to penile tissue. I was reassured that the order to remove the dressing was in place and that the nurse failed to comply. I also expressed my deep dissatisfaction and disgust with the care of this patient post operatively. He will start wound care with wet to dry dressing changes, f/u (follow-up) in one week, start PO (oral) antibiotics. In an interview on 5/25/16 at 2:13 PM, LVN D (worked the 2 PM - 10 PM shift) said he received report from LVN A on 3/28/16 that Resident #2 had returned from a circumcision and the doctor wanted to remove the dressing himself. LVN D said he saw Resident #2's penis that night (3/28/16) and it looked fine. After that, it totally slipped my mind and he said he did not assess Resident #2's surgical site after that. In a telephone interview on 5/25/16 at 3:30 PM, LVN A said when Resident #2 returned from having the circumcision on 3/28/16 he had orders with him, but she said the orders that said to remove the dressing the next day were never put into her hands. They must have come later somehow. LVN A said she scheduled the follow-up appointment with the urologist as ordered on one of the papers she received. (Note: this was the paper that had the order to remove the dressing the next day and to begin antibiotic ointment twice a day). When asked what gave her the impression the doctor wanted to remove the dressing himself, LVN A said she remembered seeing an order to remove the dressing and to follow-up to remove it. LVN A said Resident #2 did not like to have staff provide his hygiene so she was unable to assess him and when she did see the circumcision site (4/14/16) she requested the follow-up appointment be pushed up (from 4/21/16 to 4/15/16). LVN A said when a resident comes back to the facility and has a surgical wound/dressing she always notifies the Wound Care Nurse (WCN) and said she told WCN G about the dressing. Once the WCN is notified, she will then take over care of the wound/dressing. LVN A said if a resident comes back to the facility without orders, she would tell her supervisor so he can get the orders that day. LVN A said she did not remember if she told her supervisor (Unit Manager F) but everyone knew he had that (circumcision) done. In a telephone interview on 5/25/16 at 3:44 PM, LVN E (worked the 10 PM - 6 AM shift) said the night shift was responsible to check the orders received during the day to see if they had been implemented. LVN E said there were no post-operative care orders for Resident #2's circumcision. He had been told on 3/28/16 the WCN had seen the resident and everything was fine. In an interview on 5/26/16 at 10:12 AM, LVN B said he did not perform a skin assessment on Sunday 4/10/16 (Resident #2 had weekly skin assessments on Sundays) because the skin assessment was not scheduled on Resident #2's MAR, there was no list of scheduled skin assessments available and he had not been told Resident #2 had a circumcision. The antibiotic ointment was not applied because he did not know there was an order for [REDACTED]. In an interview on 5/26/16 at 2:55 PM, WCN G said if a resident had a dressing and he was a new admit, she would assess the site. She may not see the first day but she does the assessments on day 2 and day 3. If a resident goes out and comes back, she gets a copy of the orders and if there was a skin issue she gets a referral to see him. WCN G said she was first contacted about Resident #2 on 4/14/16. When she saw Resident #2 on 4/14/16, he had a rash on both groins and had a partially unwrapped pressure dressing (Coban) around his penis. The area had a foul odor. He had a light yellow slough at the base of the penis where the skin had broken down on either side where the dressing had cut into the skin. When she asked him what was around his penis he told her he had a circumcision. WCN G said LVN A told her Resident #2 had a follow-up appointment next week (4/21/16) but the WCN told her to call the doctor and have him seen earlier. WCN G said if she had known about the circumcision, she would have removed the dressing the next day. In an interview on 5/26/16 at 3:33 PM, the Director of Education said when a resident comes back to the facility after a procedure, orders are transcribed, any special needs are placed on the 24 hour report and a 72 hour alert paper is filled out by the Unit Manager and put in the Medication Administration Record [REDACTED]. The Director of Education said surgery would be an event that should have been followed for 72 hours. In an interview on 5/26/16 at 4:16 PM, the Director of Nurses (DON) said she did not know about the circumcision (done on 3/28/16) until after the dressing was discovered on 4/14/16. The DON said LVN A received the order. Due to problems with the nurses saying the transport drivers were not bringing orders to them, the nurses now sign for the orders, which the DON said LVN A had done. The nurse is supposed to go see the resident and assess him, document (for 3 days), transcribe orders, pass on in report any assessments or treatment to be done and put information on the 24 hour report. The DON said the nurse following LVN A on 3/28/16 (LVN D) was told to not touch the dressing . The DON said Resident #2 should have had 2 weekly skin assessments performed between 3/28/16 and 4/14/16 by the weekend nurses but they were not done. Observation on 5/27/16 at 8:55 PM, Resident #2 was ambulating in the hallway by pushing his wheelchair. He said everything with the circumcision turned out fine. He said he did have pain when the dressing was on and he went to the doctor, but when it was taken off he did not have any more pain. In a telephone interview on 6/01/16 at 8:18 AM, in response to phone calls from 5/25/16 and 5/26/16, Surgeon C said the condition of Resident #2's penis was very bad, but salvageable. He said you can check the hospital records, but I'm very specific with my orders to remove the dressing the next day. Surgeon C said by the time he saw Resident #2 it was about 3 weeks out and the pressure dressing was still on and there was a rancid odor. Something was NOT normal. It was mind boggling that no one noticed. Surgeon C said the penis was macerated (to make soft by soaking or steeping in a liquid) and had a least a superficial infection. Surgeon C said the pressure dressing was Coban and it can get tighter the longer it stays on and can affect blood flow. In an interview on 5/26/16 at 9:32 AM, the Director of Education said the new owners of the facility (since 4/01/16) had not provided any policies and procedures (P&P), so the facility was using some P&Ps from the past owners. There were no P&Ps on resident assessment/reassessments or skin assessments. Review of the facility policy 24 Hour Reporting dated 1/28/14 stated the use of the 24 hour report sheet is for staff to document and communicate any resident concern or event which occurs during the shift. These events include but are not limited to move in or move out, ER transfer or 911 call out, resident fall or other event, hospitalization , acute skin condition or other out of the ordinary event. The staff will document the resident concern on the 24 hour report sheet and in the resident record any out of the ordinary resident information. Transfer unresolved issues to the next day's report sheet for continued monitoring. Continue to document and follow up for at least 72 hours on out of the ordinary resident events. The census of 29 residents on the 200 hallway was obtained from the Resident Roster dated 5/24/16.

Based on interview and record review, the Nursing Facility Administrator (NFA) and Director of Nurses (DON) failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. A. The NFA and the DON did not have a system in place to supervise nursing staff to ensure interventions were implemented to prevent development and worsening of pressure sores and to prevent discontinuation of a necessary medication. Resident #1was admitted [DATE] without pressure sores. Resident #1 developed 3 pressure sores just 10 days after admission and had a total of 5 pressure sores within 9 weeks of admission. She was discharged to the hospital 11/30/15 for treatment of [REDACTED]. B. The NFA did not ensure that Resident #11 received appropriate antibiotic treatment for [REDACTED]. Resident #11 was admitted to the facility 12/11/15 with osteo[DIAGNOSES REDACTED] requiring 4 weeks of IV [MEDICATION NAME] treatment. Resident #11 never received IV [MEDICATION NAME] at the facility due to the cost of the medication. Six days after admission he was returned to the hospital with increased pain and the physician order which documented Patient needs QD (every day) wound care, pain management and IV antibiotics for osteo[DIAGNOSES REDACTED], continue IV [MEDICATION NAME] until 1/21/16. This failure could place 155 residents at risk of negative outcomes. The findings included: In an interview on 12/15/15 at 8:12 AM, Assistant Director of Nursing (ADON) said she and the DON only know about resident conditions if the nurse and Unit Manager cannot handle the condition then they tell the ADON and DON. In an interview on 1/8/16 at 1:36 PM, the DON said she does not know resident conditions she only gets involved when the nurse and Unit Manager cannot handle a condition or situation and they ask her to get involved. In an interview on 12/30/15 at 8:30 AM the NFA said if medication is expensive we tell the hospital to change to a less expensive medication before they send the resident. NFA said we cannot afford to provide expensive medications. NFA said they did not have a system to make sure the requests were done before the hospital sent the residents. A. Resident #1 Closed record review of Resident #1's Physician orders dated September 2015 documented Resident #1 was a [AGE] year old female admitted [DATE], with [DIAGNOSES REDACTED]. Closed record review of Resident #1's Nursing Comprehensive Admission Eval dated 9/23/15 documented skin assessment completed, excoriation to sacral area with noted bruising and bilateral heels soft and dry. During an interview on 12/10/15 at 3:30 PM, Licensed Vocational Nurse (LVN) A said she admitted Resident #1 to the facility on [DATE], on admission when she inspected Resident # 1's skin she noted a circular excoriation on the sacrum but no breakdown anywhere. Review of Resident #1's Admission Physician's Orders dated 9/23/15 indicated no evidence the physician was notified of the sacrum excoriation. Review of Resident #1's Admission Physician's Orders dated 9/23/15 indicated no order for barrier cream, a pressure relieving device to the bed or wheelchair or any type of order for sacrum excoriation. Record review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 required 2 staff to provide extensive assistance for bed mobility, transfer and toilet use. Resident #1 had no pressure ulcers at the time of this assessment. Resident #1's cognitive Skills for daily decision making was modified independence. Resident #1 had a urinary catheter and was incontinent of bowel. Closed record review revealed Resident #1's pressure ulcer care plan dated 10/3/15 indicated staff were to provide Resident #1 pressure relieving devices for the bed and wheelchair. Staff were to assist the resident with turning/repositioning every two hours and as needed. Closed record review of Resident #1's 14 day MDS assessment dated [DATE] indicated Resident # 1 had 3 pressure ulcers at Stage II. The date of the first acquired Stage II was 10/3/15. Closed record review of Resident #1's Wound Assessment Report, completed by wound care nurse, dated 10/3/15, indicated the following: Assessment Occasion: New Wounds, Received verbal and written referral to assess skin impairment to sacrum. Resident evaluated and noted to have one large area of breakdown measuring 9cm X 9cm Sacrum: unstageable due to slough/eschar smaller ulcerative areas within smaller ulcerative areas within Left buttock 3cm X 1 cm, upper Right buttock 2cm X 3cm X 0.1cm right buttock 1cm X 1cm X 0.1cm. Surrounding tissue dark in coloration and macerated Physician called treatment directives pending. Review of Physician telephone order dated 10/4/15 documented to decubitus ulceration of left buttock, sacrum and right buttock clean with normal saline, pat dry, apply Santyl and calcium algenate foam boarder dressing change daily and as needed Review of Physician telephone order dated 10/5/15 documented discontinue treatment order dated 10/4/15. New Order - cleanse with normal saline, pat dry, apply hydrogel and collegen, cover with foam dressing daily (left buttock, sacrum, right buttock) Review of Physician telephone order dated 10/6/15 documented discontinue foley catheter. (Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.) The National Pressure Ulcer Advisory Panel - NPUAP <http://www.npuap.org> » Resources <http://www.npuap.org/resources/> » Educational and Clinical Resources <http://www.npuap.org/resources/educational-and-clinical-resources/> » NPUAP Pressure Ulcer Stages/Categories (accessed 1/13/16) Closed record review of Resident #1's Skin assessment sheets, completed by wound care nurse, indicated on 11/19/15 - New wounds (deep tissue injury) left heel measuring 1.5cm X 1.5cm right heel measuring 2.5cm X 1.5cm. both heels closed, purple and red, boggy, no drainage, treatment per physicians orders. Review of Physician telephone order dated 11/19/15 documented Left and Right heel Deep Tissue Injury clean with normal saline, pat dry, apply protective heeler and secure with Kerlix every 3 days (Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. ) The National Pressure Ulcer Advisory Panel - NPUAP <http://www.npuap.org> » Resources <http://www.npuap.org/resources/> » Educational and Clinical Resources <http://www.npuap.org/resources/educational-and-clinical-resources/> » NPUAP Pressure Ulcer Stages/Categories (accessed 1/13/16) No skin assessment sheets were completed between 11/20/15 and 11/30/15 when the wound care nurse was on vacation. Closed record review of Resident #1's Physician Order dated 11/22/15 documented turn resident side to side while in bed, do not leave more than 2 hours in the same position. In an interview on 12/23/15 at 8:15 AM, Resident #1 who was at another facility said she was not turned or repositioned, she was always on her back (at Facility A). Closed record review of Resident #1's Skin assessment sheets, completed by wound care nurse, indicated on 11/30/15 - Deteriorated wound on the sacrum, Unstageable due to slough/eschar measuring 13.50cm X 9.5cm X 3.0cm. Resident has unstageable to sacrum, 100% eschar to wound; wound has a foul smell and is warm to touch. Primary care physician came in to assess resident and ordered to send resident to hospital emergency room for wound infection. Closed record review of Resident #1's Physician Order dated 11/30/15 documented send Resident #1 to the hospital emergency room due to suspected wound infection to coccyx. During an interview on 12/10/15 at 1:10 PM, LVN B said she was the nurse for Resident #1 when she lived at the facility. LVN B said Resident #1 was a heavy woman and could only assist a little so she required 2 staff to turn and reposition her. LVN B said she tried to go into rooms to check if residents have been repositioned. LVN B said she did not do treatments for Resident #1's wound. LVN B said Wound Care Nurse (WCN) C does all of the treatments on the first floor. LVN B said when Wound Care Nurse C was on vacation, a nurse trained in wound care covered for her. During an interview on 12/10/15 at 1:27 PM, Wound Care Nurse C said she was the wound nurse for the first floor. Wound Care Nurse C said the wound care nurse assessed new admission's skin within 24 hours of admission and then daily for 3 days. Wound Care Nurse C said Resident #1 was admitted on [DATE] and she started to work at the facility on 9/24/15, so she was in training at the time. Wound Care Nurse C said Resident #1 was admitted with excoriation that progressed into wounds. She said she changed the treatments several times with no improvement. Wound Care Nurse C said she went on vacation for 10 days (November 19 - 29) and when she returned the wound looked very bad; it was black and had a bad odor. She said she called the physician and he came in to look at the wounds and gave the order to send Resident #1 to the hospital due to possible wound infection. In an interview on 12/15/15 at 8:12 AM, Assistant Director of Nursing (ADON) said the nurse on duty evaluated a new admissions skin and within 24 hours of admission the Wound Care Nurse assessed the new admission's skin and then every day for 3 days on all new admissions. ADON said she and the Director of Nursing (DON) only know about resident conditions if the nurse and Unit Manager (UM) cannot handle the condition then they tell the ADON and DON. In an interview on 12/15/15 at 1:00 PM, the ADON said the Central Supply Clerk provided an air mattress for her bed on 10/12/15 (Nine days after the care plan documented the need for a pressure relieving device for her bed) In an interview on 12/15/15 at 4:00 PM, Director of Nursing (DON) said for excoriation, barrier cream should have been ordered, she did not know why it was not ordered for Resident #1. The DON said the Wound Care Nurse assesses the skin of new admissions for 3 days after admission, she did not know why Resident #1 did not have documentation of skin assessments by the Wound Care Nurse for 3 days after admission. DON said she knew the Wound Care Nurse had changed the treatment several times for Resident #1 but that was all she knew. DON said she was not involved in resident conditions, the nurses and Unit Managers handle that. DON said she has 2 wound care nurses, Wound Care Nurse C for the first floor and Wound Care Nurse D for the second floor. The DON said Wound Care Nurse D has many years of experience and if anyone has a question about a wound she (WCN D) can guide them. In an interview on 12/16/15 at 10:00 AM, DON said the skin assessment sheet containing the measurements and description of Resident #1's wounds was not done while the Wound Care Nurse (WCN C) was on vacation. The DON said it (the skin assessment) should have been done on 11/23/15, but it was not done by the nurse assigned to cover for the Wound Care Nurse on that day. The DON said she had nurses that have been trained in wound care to fill in if a wound care nurse was off or on vacation. In an interview on 12/29/15 at 10:50 AM, Wound Care Nurse C said she was trained by Wound Care Nurse D. WCN C said Wound Care Nurse D is a veteran wound care nurse and has many years of experience. In an interview on 12/15/15 at 3:20 PM, LVN E said he covered for WCN C and did the wound treatment for [REDACTED]. LVN E said he should have measured the wound but he was very busy and didn't realize it was the day for the measurement. In an interview on 12/31/15 at 10:52 AM LVN F said he covered for WCN C Tuesday through Friday (11/24/15 - 11/27/15) while she was on vacation. LVN F said Resident #1's wounds had escar and slough but had increased in odor so he requested the veteran Wound Care Nurse (WCN D) look at the wound and tell him what to do. He said that WCN D looked at the wound and told him the odor was just from the [MEDICATION NAME] agent being used and not to worry about it, it was normal. LVN F said WCN D had many years of experience and because she told him it was normal, he did not telephone the physician. In an interview on 12/31/15 at 11:00 AM, WCN D said LVN F told her Resident #1 had a smell and asked if she would look at her wounds. WCN D said she worked upstairs, she didn't have anything to do with the wounds downstairs and she was not in charge. WCN D said she went downstairs to see Resident #1 and it (the wound) did have an odor. WCN D said that she told LVN F to call the doctor or show it to him when he came in. In an interview on 12/31/15 at 11:20 AM, LVN B said she was in the room with Resident #1 when LVN F was showing the wound to WCN D. LVN B said WCN D said the bad odor was just from the [MEDICATION NAME] agent, it was normal. Review of Resident #1's hospital admission History and Physical dated 11/30/15 documented Resident #1 was a patient who comes into the hospital hypotensive, [MEDICAL CONDITION] with blood pressure of 96/50, pulse 114 [MEDICAL CONDITION] and pending septic shock. I (physician) was call(ed) by the nursing facility Wound Care Nurse today for a worsening wound. When I walked into her nursing facility room the whole room was purulent smell, chronic sacral wound infection, yellow discoloration, very foul smell, ulceration, purulent drainage over the coccyx area. This is with ulceration, weakness, fatigue, foul smell. Plan: bring to hospital, ICU admission, IV hydration, broad spectrum antibiotics and surgical consult. Prognosis is guarded in a critically ill patient. (If a person with a weak immune system has a pressure ulcer that becomes infected, there is a risk that the infection will spread into their blood and other organs. This is known as blood poisoning or septicaemia. In the most serious cases of blood poisoning, damage to multiple organs can lead to a large drop in blood pressure, known as septic shock <http://www.nhs.uk/conditions/septic-shock/Pages/Introduction.aspx?url=Pages/What-is-it.aspx>, which can be fatal. Symptoms include cold skin and an increased heart beat. http://www.nhs.uk/Conditions/Pressure-ulcers/Pages/Complications.aspx) (accessed 1/13/16). Review of Resident #1's emergency room report dated 11/30/15 documented, Necrotic Infected Sacral Ulcer. (necrotic -adjective Dead; referring to death of cells or tissues. Segen's Medical Dictionary. © 2012 Farlex, Inc. All rights reserved.)(accessed 1/13/16) Review of photographs taken by the hospital on [DATE] revealed a very large pressure sore covering the sacrum, coccyx and extending up the lower back, over onto her left buttock and extending on her right buttock almost to her hip. The photograph revealed the wound had a large dark black middle, surrounded by a large dark green area surounded by yellow with dark red surrounding the wound The left buttock also had multiple open areas visable. Review of photographs taken by the hospital on [DATE] documented Left Heel Unstageable and revealed Resident #1's left heel on the outer side extending from the heel to mid-ankle was a dark black/purple. Review of photographs taken by the hospital on [DATE] documented Right Heel deep tissue injury and revealed the bottom of the right heel was dry and scaly, the outer side was dark red/purple. Review of Resident #1's hospital plastic surgery physician consult dated 12/1/15 documented; reason for consult: Stage 4 sacral ulcer, general appearance: sacral decubitus bed ulcer with evidence of necrotic tissue and foul smell, measurements 15 cm X 13 cm necrotic base with surrounding [DIAGNOSES REDACTED], Plan: operating room debridement. (Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. The National Pressure Ulcer Advisory Panel - NPUAP <http://www.npuap.org> » Resources <http://www.npuap.org/resources/> » Educational and Clinical Resources <http://www.npuap.org/resources/educational-and-clinical-resources/> » NPUAP Pressure Ulcer Stages/Categories ) (accessed 1/13/16) Review of Resident #1's hospital infectious disease physician consult dated 12/1/15 documented; reason for consultant: infected sacral decubitus ulcer, admitted to the hospital because of a large ulcer to the back with purulent drainage and was found to be septic at the time of admission to the hospital, she was started on antibiotic yesterday and admitted to ICU, assessment: Stage 4 decubitus ulcer, gram-negative urinary tract infection [MEDICAL CONDITION] syndrome. Review of Resident #1's hospital operative note dated 12/2/15 documented; Stage IV sacral decubitus with necrosis and abscess, removed skin, subcutaneous tissue, muscle, fascia, all necrotic areas. Abscess was also drained, bone cultures were taken. Review of Resident #1's hospital physician progress notes [REDACTED].#1 was a [AGE] year old lady who came in with a large sacral decubitus ulcer. She underwent an incision and drainage by plastic surgeon and was on a ventilator for period of time, as of 12/7/15 she had been extubated. Review of the facility policy and procedure Prevention and Management of Wounds dated July 1, 2013 indicated the following: Purpose: To ensure that a resident admitted does not develop pressure sores To promote healing, prevent infections and prevent new pressure ulcers from developing Policy Statement: Residents will receive appropriate treatment for [REDACTED]. A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. B. Resident #11 Closed record review of Resident #11's face sheet dated 1/8/16 documented he was a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is an infection in a bone. <http://www.mayoclinic.org/diseases-conditions/osteo[DIAGNOSES REDACTED]/basics/definition/con- 518>) Closed record review of Resident #11's hospital status report dated 12/11/15 by Infectious Disease physician documented: There is residual osteo[DIAGNOSES REDACTED] involving the ankle. The patient will be continued with the same medical treatment, wound care and will continue with [MEDICATION NAME], all previous cultures grew gram positive organisms. He needs to continue with IV Antibiotic therapy for the osteo until January 14, 2016. Closed record review of Resident #11's Physician admission orders [REDACTED]. ([MEDICATION NAME] is indicated for the treatment of [REDACTED]. Complicated Skin And Skin Structure Infections Complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of the following Gram-positive <http://www.rxlist.com/script/main/art.asp?articlekey=9585> bacteria: Staphylococcus aureus (including [MEDICAL CONDITION] <http://www.rxlist.com/script/main/art.asp?articlekey= >-resistant isolates), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae subsp. equisimilis, and [MEDICATION NAME] faecalis ([MEDICATION NAME]-susceptible isolates only). http://www.rxlist.com/[MEDICATION NAME]-drug/indications-dosage.htm) Closed record review of Resident #11's Admission Report Sheet dated 12/11/15 documented; [DIAGNOSES REDACTED]. Antibiotics: IV [MEDICATION NAME] Stop Date 1/14/16. Closed record reviews of Resident #11's Telephone Orders dated 12/12/15 documented discontinue [MEDICATION NAME] IV give [MEDICATION NAME] IV once a day regarding osteo[DIAGNOSES REDACTED]. Closed record review of Resident #11's Telephone Orders dated 12/12/15 documented clarification of [MEDICATION NAME] IV stop date 12/14/15. Closed record review of Resident #11's Medication Administration Record [REDACTED]. In a telephone interview on 12/31/15 Licensed Vocational Nurse (LVN) G said he was working on 12/12/15 and the pharmacy called and told him Resident 11's medicine was expensive and the insurance company would not pay for it. LVN G said if the pharmacy calls with an issue with a medication the nurse tells the supervisor about it and the supervisor takes care of it. LVN G said Unit Manager (UM) H was working as the supervisor that Saturday so he told her and she took care of it. In an interview on 1/7/16 at 4:00 PM UM H said the pharmacy called and said the IV [MEDICATION NAME] was expensive. UM H said the Nursing Facility Administrator (NFA) and the Director of Nursing (DON) had instructed if a medication was expensive to call the physician to request another medication. UM H said she called the physician to change the medication due to cost and she talked to the on-call Nurse Practitioner (NP) covering for the physician and she did change it to [MEDICATION NAME]. UM H said the pharmacy wanted a stop date so she telephoned the on-call NP again and the NP gave the stop date of 12/14/15 which she told the pharmacy. UM H said she did not know Resident #11 was supposed to get the IV [MEDICATION NAME] until 1/14/16. UM H said when you are acting as weekend supervisor you do not have time to review the new admissions charts you are very busy. UM H said she doesn't know what happened after the weekend. UM H said the Unit Manager checks charts each day Monday - Friday for new admissions and especially on Monday morning. The Unit Manager of that floor UM I should have gone over the chart and medications and called the physician for orders. In a telephone interview on 1/7/16 at 3:52 PM the Pharmacy Supervisor (PS) reviewed Resident #11 in their computer and said Resident #11 was documented as all-inclusive. Resident #11 was admitted on [DATE] with an order for [REDACTED].>In an interview on 12/30/15 at 3:55 PM RN L said he checks telephone orders but he is not responsible for checking new admission orders [REDACTED] In an interview on 1/8/16 at 10:25 AM UM I said a new admission should have a 24 hour care plan in the chart. UM I verified Resident #11 did not have a 24 hour care plan in his chart. UM I said the Unit Managers have a New Admission Check Quality Manager (QM) list that is completed within 24 hours or on Monday if the resident is admitted on a Friday or weekend. UM I said the Monday after Resident #11's admission was 12/14/15 which was his first day back from vacation and he did not check Resident #11's chart. UM I said Resident #11's chart, orders, care plan were not checked by anyone. UM I said one day during that week Resident #11 asked to speak to him and questioned why he was not getting his IV antibiotics. UM I said he asked the nurse and the nurse told him Resident #11 was getting his IV antibiotic so he went back and told Resident #11 he was getting his IV antibiotic there was a stop date and he got 2 doses as ordered. UM I said Resident #11 insisted he was not getting his IV antibiotics as ordered so he told the DON that Resident #11 was concerned about his IV antibiotic and the DON handled it. In an interview on 1/8/16 at 1:36 PM the DON said Resident #11 was admitted with an order for [REDACTED]. DON said the facility follows physician orders, she did not think anything about Resident #11 being admitted for 1 month of IV antibiotic treatment for [REDACTED]. DON said she did not know about IV's and orders in the facility. DON said she only got involved when the nurse and Unit Manager cannot handle a condition or situation and they ask her to get involved. DON said she was told about Resident #11 on 12/17/15, she got involved, called his Infectious Disease physician and transferred Resident #11 out to the hospital for admission so he could get his IV [MEDICATION NAME]. DON said we do not give expensive drugs. DON said they are not resident advocates they just follow physician orders and do not question them. In an interview on 12/22/15 at 1:35 PM Attending Physician (AP) said the weekend oncall NP doesn't have any information about new admissions. The AP said the oncall NP and physician rely on the facility to give them all of the information on a resident. The AP said if the oncall NP wasn't told the hospital Infectious Disease physician ordered [MEDICATION NAME] until 1/14/16 she would have no way to know that information. In an interview on 12/30/15 at 8:30 AM the NFA said prior to admission he reviewed the record and told the hospital the facility would only take the resident if the [MEDICATION NAME] was discontinued because it was too expensive. NFA said he did not know the Infectious Disease physician documented the resident required [MEDICATION NAME]. NFA said Resident #11 payor source was private insurance with an all inclusive contract so the facility was responsible for paying for everything the resident required. In an interview on 1/6/16 at 4:00 PM at another nursing facility Resident #11 said he went to the first nursing facility because he had osteo[DIAGNOSES REDACTED] and needed IV [MEDICATION NAME] until 1/14/16. Resident #11 said he was at the first facility for 6 days and only got 2 little bags of IV antibiotic. Resident #11 said everyday he questioned the nurses and the wound care nurse about his IV and told them he was not getting his medication like he should. The nurses and UM I kept telling him he was getting it, Resident #11 said he is a [AGE] year old man who is alert and oriented and he knew he was not getting his medication. Resident #11 said he was having more and more pain in his left foot and by Thursday 12/17/15 the pain was all the way up to his thigh. He said at that point he insisted someone had to do something and call his Infectious Disease physician because he was not getting his IV antibiotic medication as ordered . Resident #11 said NP J came into his room and looked at his foot and said he needed to get out of there right away because his foot looked bad. Resident #11 said when he got to the hospital a doctor told him his foot got worse because he did not have his IV [MEDICATION NAME] and Resident #11 would need surgery. Resident #11 said the surgeon told him his foot was much worse and they would have to drain the infection and remove a small amount of his left foot because he did not get his IV antibiotics. Resident #11 said his surgeon said the facility should have followed the orders from the hospital. Record review of hospital Infectious Disease Consultation Report dated 12/18/15 documented Resident #11 was transferred to the hospital because of swelling, pain and tenderness to the site where he had surgery on 12/3/15. Infected left foot. He will need to be taken back to surgery for [REDACTED]. Record review of hospital Progress Note dated 12/21/15 documented infected left foot. Awaiting incision, drainage and washout of the foot following which he will need to go on IV antibiotics for at least 3-4 weeks because of the infection and underlying osteo[DIAGNOSES REDACTED]. Review of the census report provided by the NFA on 12/10/15 documented 155 residents residing in the facility. No other evidence was presented.

Based on interview, and record review, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individuals clinical condition demonstrated that they were unavoidable for 1 (Resident #1) of 9 residents reviewed for pressure sores. Resident #1 was admitted [DATE] without pressure sores. On 10/03/15 Resident #1 was identified to have a new unstageable, due to slough/eschar, pressure sore on her sacrum. She was admitted to the hospital 11/30/15 for treatment of [REDACTED]. A. the facility failed to complete skin assessments between 11/19/2015- 11/30/2015 while the wound care nurse was on vacation. B. the facility failed to notify the physician of the decline in the wound condition. An Immediate Jeopardy (IJ) was identified on 12/30/15. While the IJ was removed on 12/31/15, the facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at pattern because the facility had not monitored their plan for effectiveness. These failures could place 17 other residents with pressure sores at risk for developing new or worsening pressure sores and developing [MEDICAL CONDITION] (skin infection),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings included: Closed record review of Resident #1's Physician orders dated September 2015 documented Resident #1 was a [AGE] year old female admitted [DATE], with [DIAGNOSES REDACTED]. Closed record review of Resident #1's Nursing Comprehensive Admission Eval dated 9/23/15 documented skin assessment completed, excoriation to sacral area with noted bruising and bilateral heels soft and dry. During an interview on 12/10/15 at 3:30 PM, Licensed Vocational Nurse (LVN) A said she admitted Resident #1 to the facility on [DATE], on admission when she inspected Resident # 1's skin she noted a circular excoriation on the sacrum but no breakdown anywhere. Review of Resident #1's Admission Physician's Orders dated 9/23/15 indicated no evidence the physician was notified of the sacrum excoriation. Record review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 required 2 staff to provide extensive assistance for bed mobility, transfer and toilet use. Resident #1 had no pressure ulcers at the time of this assessment. Resident #1's cognitive Skills for daily decision making was modified independence. Resident #1 had a urinary catheter and was incontinent of bowel. Closed record review revealed Resident #1's pressure ulcer care plan dated 10/3/15 indicated staff were to provide Resident #1 pressure relieving devices for the bed and wheelchair. Staff were to assist the resident with turning/repositioning every two hours and as needed. Closed record review of Resident #1's 14 day MDS assessment dated [DATE] indicated Resident # 1 had 3 pressure ulcers at Stage II. The date of the first acquired Stage II was 10/3/15. Closed record review of Resident #1's Wound Assessment Report, completed by wound care nurse, dated 10/3/15, indicated the following: Assessment Occasion: New Wounds, Received verbal and written referral to assess skin impairment to sacrum. Resident evaluated and noted to have one large area of breakdown measuring 9cm X 9cm Sacrum: unstageable due to slough/eschar smaller ulcerative areas within Left buttock 3cm X 1 cm, upper Right buttock 2cm X 3cm X 0.1cm right buttock 1cm X 1cm X 0.1cm. Surrounding tissue dark in coloration and macerated Physician called treatment directives pending. Review of Physician telephone order dated 10/4/15 documented to decubitus ulceration of left buttock, sacrum and right buttock clean with normal saline, pat dry, apply Santyl and calcium algenate foam boarder dressing change daily and as needed Review of Physician telephone order dated 10/5/15 documented discontinue treatment order dated 10/4/15. New Order - cleanse with normal saline, pat dry, apply hydrogel and collegen, cover with foam dressing daily (left buttock, sacrum, right buttock) Review of Physician telephone order dated 10/6/15 documented discontinue foley catheter. (Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.) The National Pressure Ulcer Advisory Panel - NPUAP <http://www.npuap.org> » Resources <http://www.npuap.org/resources/> » Educational and Clinical Resources <http://www.npuap.org/resources/educational-and-clinical-resources/> » NPUAP Pressure Ulcer Stages/Categories (accessed 1/13/16) Closed record review of Resident #1's Skin assessment sheets, completed by wound care nurse, indicated on 11/19/15 - New wounds (deep tissue injury) left heel measuring 1.5cm X 1.5cm right heel measuring 2.5cm X 1.5cm. both heels closed, purple and red, boggy, no drainage, treatment per physicians orders. Review of Physician telephone order dated 11/19/15 documented Left and Right heel Deep Tissue Injury clean with normal saline, pat dry, apply protective heeler and secure with Kerlix every 3 days (Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. ) The National Pressure Ulcer Advisory Panel - NPUAP <http://www.npuap.org> » Resources <http://www.npuap.org/resources/> » Educational and Clinical Resources <http://www.npuap.org/resources/educational-and-clinical-resources/> » NPUAP Pressure Ulcer Stages/Categories (accessed 1/13/16) No skin assessment sheets were completed between 11/20/15 and 11/30/15 when the wound care nurse was on vacation. Closed record review of Resident #1's Physician Order dated 11/22/15 documented turn resident side to side while in bed, do not leave more than 2 hours in the same position. In an interview on 12/23/15 at 8:15 AM, Resident #1, who was now at another facility, said she was not turned or repositioned, she was always on her back (at Facility A). Closed record review of Resident #1's Skin assessment sheets, completed by wound care nurse, indicated on 11/30/15 - Deteriorated wound on the sacrum, Unstageable due to slough/eschar measuring 13.50cm X 9.5cm X 3.0cm. Resident has unstageable to sacrum, 100% eschar to wound; wound has a foul smell and is warm to touch. Primary care physician came in to assess resident and ordered to send resident to hospital emergency room for wound infection. Closed record review of Resident #1's Physician Order dated 11/30/15 documented send Resident #1 to the hospital emergency room due to suspected wound infection to coccyx. During an interview on 12/10/15 at 1:10 PM, LVN B said she was the nurse for Resident #1 when she lived at the facility. LVN B said Resident #1 was a heavy woman and could only assist a little so she required 2 staff to turn and reposition her. LVN B said she tried to go into rooms to check if residents have been repositioned. LVN B said she did not do treatments for Resident #1's wound. LVN B said Wound Care Nurse (WCN) C does all of the treatments on the first floor. LVN B said when Wound Care Nurse C was on vacation, a nurse trained in wound care covered for her. During an interview on 12/10/15 at 1:27 PM, Wound Care Nurse C said she was the wound nurse for the first floor. Wound Care Nurse C said the wound care nurse assessed new admission's skin within 24 hours of admission and then daily for 3 days. Wound Care Nurse C said Resident #1 was admitted on [DATE] and she started to work at the facility on 9/24/15, so she was in training at the time. Wound Care Nurse C said Resident #1 was admitted with excoriation that progressed into wounds. She said she changed the treatments several times with no improvement. Wound Care Nurse C said she went on vacation for 10 days (November 19 - 29) and when she returned the wound looked very bad; it was black and had a bad odor. She said she called the physician and he came in to look at the wounds and gave the order to send Resident #1 to the hospital due to possible wound infection. In an interview on 12/15/15 at 8:12 AM, Assistant Director of Nursing (ADON) said the nurse on duty evaluated a new admissions skin and within 24 hours of admission the Wound Care Nurse assessed the new admission's skin and then every day for 3 days on all new admissions. ADON said she and the Director of Nursing (DON) only know about resident conditions if the nurse and Unit Manager (UM) cannot handle the condition then they tell the ADON and DON. In an interview on 12/15/15 at 1:00 PM, the ADON said the Central Supply Clerk provided an air mattress for her bed on 10/12/15 (Nine days after the care plan documented the need for a pressure relieving device for her bed) In an interview on 12/15/15 at 4:00 PM, Director of Nursing (DON) said for excoriation, barrier cream should have been ordered, she did not know why it was not ordered for Resident #1. The DON said the Wound Care Nurse assesses the skin of new admissions for 3 days after admission, she did not know why Resident #1 did not have documentation of skin assessments by the Wound Care Nurse for 3 days after admission. DON said she knew the Wound Care Nurse had changed the treatment several times for Resident #1 but that was all she knew. DON said she was not involved in resident conditions, the nurses and Unit Managers handle that. DON said she has 2 wound care nurses, Wound Care Nurse C for the first floor and Wound Care Nurse D for the second floor. The DON said Wound Care Nurse D has many years of experience and if anyone has a question about a wound she (WCN D) can guide them. In an interview on 12/16/15 at 10:00 AM, DON said the skin assessment sheet containing the measurements and description of Resident #1's wounds was not done while the Wound Care Nurse (WCN C) was on vacation. The DON said it (the skin assessment) should have been done on 11/23/15, but it was not done by the nurse assigned to cover for the Wound Care Nurse on that day. The DON said she had nurses that have been trained in wound care to fill in if a wound care nurse was off or on vacation. In an interview on 12/29/15 at 10:50 AM, Wound Care Nurse C said she was trained by Wound Care Nurse D. WCN C said Wound Care Nurse D is a veteran wound care nurse and has many years of experience. In an interview on 12/15/15 at 3:20 PM, LVN E said he covered for WCN C and did the wound treatment for [REDACTED]. LVN E said he should have measured the wound but he was very busy and didn't realize it was the day for the measurement. In an interview on 12/31/15 at 10:52 AM LVN F said he covered for WCN C Tuesday through Friday (11/24/15 - 11/27/15) while she was on vacation. LVN F said Resident #1's wounds had escar and slough but had increased in odor so he requested the veteran Wound Care Nurse (WCN D) look at the wound and tell him what to do. He said that WCN D looked at the wound and told him the odor was just from the [MEDICATION NAME] agent being used and not to worry about it, it was normal. LVN F said WCN D had many years of experience and because she told him it was normal, he did not telephone the physician. In an interview on 12/31/15 at 11:00 AM, WCN D said LVN F told her Resident #1 had a smell and asked if she would look at her wounds. WCN D said she worked upstairs, she didn't have anything to do with the wounds downstairs and she was not in charge. WCN D said she went downstairs to see Resident #1 and it (the wound) did have an odor. WCN D said that she told LVN F to call the doctor or show it to him when he came in. In an interview on 12/31/15 at 11:20 AM, LVN B said she was in the room with Resident #1 when LVN F was showing the wound to WCN D. LVN B said WCN D said the bad odor was just from the [MEDICATION NAME] agent, it was normal. Review of Resident #1's hospital admission History and Physical dated 11/30/15 documented Resident #1 was a patient who comes into the hospital hypotensive, [MEDICAL CONDITION] with blood pressure of 96/50, pulse 114 [MEDICAL CONDITION] and pending septic shock. I (physician) was call(ed) by the nursing facility Wound Care Nurse today for a worsening wound. When I walked into her nursing facility room the whole room was purulent smell, chronic sacral wound infection, yellow discoloration, very foul smell, ulceration, purulent drainage over the coccyx area. This is with ulceration, weakness, fatigue, foul smell. Plan: bring to hospital, ICU admission, IV hydration, broad spectrum antibiotics and surgical consult. Prognosis is guarded in a critically ill patient. (If a person with a weak immune system has a pressure ulcer that becomes infected, there is a risk that the infection will spread into their blood and other organs. This is known as blood poisoning or septicaemia. In the most serious cases of blood poisoning, damage to multiple organs can lead to a large drop in blood pressure, known as septic shock <http://www.nhs.uk/conditions/septic-shock/Pages/Introduction.aspx?url=Pages/What-is-it.aspx>, which can be fatal. Symptoms include cold skin and an increased heart beat. http://www.nhs.uk/Conditions/Pressure-ulcers/Pages/Complications.aspx) (accessed 1/13/16). Review of Resident #1's emergency room report dated 11/30/15 documented, Necrotic Infected Sacral Ulcer. (necrotic -adjective Dead; referring to death of cells or tissues. Segen's Medical Dictionary. © 2012 Farlex, Inc. All rights reserved.)(accessed 1/13/16) Review of photographs taken by the hospital on [DATE] revealed a very large pressure sore covering the sacrum, coccyx and extending up the lower back, over onto her left buttock and extending on her right buttock almost to her hip. The photograph revealed the wound had a large dark black middle, surrounded by a large dark green area surounded by yellow with dark red surrounding the wound The left buttock also had multiple open areas visable. Review of photographs taken by the hospital on [DATE] documented Left Heel Unstageable and revealed Resident #1's left heel on the outer side extending from the heel to mid-ankle was a dark black/purple. Review of photographs taken by the hospital on [DATE] documented Right Heel deep tissue injury and revealed the bottom of the right heel was dry and scaly, the outer side was dark red/purple. Review of Resident #1's hospital plastic surgery physician consult dated 12/1/15 documented; reason for consult: Stage 4 sacral ulcer, general appearance: sacral decubitus bed ulcer with evidence of necrotic tissue and foul smell, measurements 15 cm X 13 cm necrotic base with surrounding [DIAGNOSES REDACTED], Plan: operating room debridement. (Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. The National Pressure Ulcer Advisory Panel - NPUAP <http://www.npuap.org> » Resources <http://www.npuap.org/resources/> » Educational and Clinical Resources <http://www.npuap.org/resources/educational-and-clinical-resources/> » NPUAP Pressure Ulcer Stages/Categories ) (accessed 1/13/16) Review of Resident #1's hospital infectious disease physician consult dated 12/1/15 documented; reason for consultant: infected sacral decubitus ulcer, admitted to the hospital because of a large ulcer to the back with purulent drainage and was found to be septic at the time of admission to the hospital, she was started on antibiotic yesterday and admitted to ICU, assessment: Stage 4 decubitus ulcer, gram-negative urinary tract infection [MEDICAL CONDITION] syndrome. Review of Resident #1's hospital operative note dated 12/2/15 documented; Stage IV sacral decubitus with necrosis and abscess, removed skin, subcutaneous tissue, muscle, fascia, all necrotic areas. Abscess was also drained, bone cultures were taken. Review of Resident #1's hospital physician progress notes [REDACTED].#1 was a [AGE] year old lady who came in with a large sacral decubitus ulcer. She underwent an incision and drainage by plastic surgeon and was on a ventilator for period of time, as of 12/7/15 she had been extubated. Review of the facility policy and procedure Prevention and Management of Wounds dated July 1, 2013 indicated the following: Purpose: To ensure that a resident admitted does not develop pressure sores To promote healing, prevent infections and prevent new pressure ulcers from developing Policy Statement: Residents will receive appropriate treatment for [REDACTED]. A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. An IJ was identified on 12/30/15 at 9:10 AM and the Administrator was informed. The Plan of Removal was accepted on 12/31/15 at 10:24 AM and it included the following: Upon notification of the immediate jeopardy, the administrator summoned the Clinical Nursing staff to his office. Clinical Nursing teams were assigned to complete an assessment or evaluation on current residents to ensure each resident who had a pressure ulcer, excoriation or reddness of skin had appropriate documentation, accurate measurements and current treatments based upon a physician order. Assessments and or evaluations will be completed by 5:00 PM on 12/30/15. The attending physician will be notified fo an discrepancies and new orders will be obtained if necessary. Based upon the evaluation of current resident on 12/30/15 no other resident was found to have a pressure ulcer. Two residents were found to have a skin excoriation. The attending physician was contacted and treatment orders were obtained. To ensure that every resident who is admitted does not develop a pressure ulcer, unless the clinical condition demonstrates they were unavoidable every residents at admission will have a visual skin inspection, paying particular attention to bony prominences. Additionally, the clinical nurse will conduct risk assessments; initiate the Braden scale at admission and weekly for three weeks and then quarterly or with any change in condition. The results of the risk factor analysis are entered into AHT. The initial care plans are developed by facility staff. The facility will establish preliminary positioning as needed, including transfers and repositioning in bed or wheel chairs, with appropriate mattresses and cushions. The facility clinical nurses complete weekly skin assessment (non-wounds). The wound care coordinators complete a weekly skin assessment only on wounds. Residents will be assessed or evaluated for potential pressure ulcer development, excoriations or redness of skin on admission and weekly for three weeks by a licensed nurse. Assessments and or evaluations will be conducted prior to each interdisciplinary care conference, and with any significant change of condition. Nursing assistants are required to report any suspicious skin alterations to their licensed nurse during any shift, when ADL care is provided. Upon securing a new treatment order the facility has a treatment nurse 7 days per week, including holidays. The facility has a stock amount of wound care products which are based upon their formulary. Should a physician order a particular product that is not on our formulary, the wound care coordinator or a licensed nurse will contact the attending physician to secure an alternative treatment until the product can be obtained. The facility will follow physician orders for any new admission. Any resident who is found with a new wound will be treated following facility protocol. During the morning stand up meeting new admissions are discussed. Any resident who required special equipment, i.e. speciality mattress the facility central supply supervisor immediately calls the DME dealer to deliver the air mattress. The time for delivery is around 2 to 4 hours. The stand up meeting starts at 9:15 AM and last for approximately 20 minutes. 98% of admissions arrive after 2 PM. Any resident who is expected to be admitted over the weekend and requires an air mattress is ordered the day before admission. The central supply supervisor is on call 24 hours a day 7 days per week to assist with DME equipment. The facility has one speciality mattress on site at all times. Additionally, the facility wound care coordinators will assess or evaluate each resident's skin and wound at admission and at least quarterly therafter to determine appropriate steps to prevent development of pressure ulcers or skin impairments. Additionally, areas of excoriation and redness will be discussed with the attending physician and appropriate treatment orders will be obtained. Appropriate interventions are implemented, monitored and revised as needed based upon physician order. In the event one of the wound care nurses are sick or on vacation, the facility has either Registered Nurses (Unit Managers or an Audit Nurse) who have training and experience to provide wound care. The facility additionally have a PRN nurse who by training and experience can provide wound care to our resident population. The facility wound care coordinators measure residents weekly who have a wound. Residents are reviewed during the weekly skin meeting. If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the resident's overall clinical condition will be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions will be discussed with the attending physician. A discussion will be held with the attending physician regarding any new treatment orders. The resident's care plan will be updated based upon any new orders. Additionally, surgical wounds, diabetic, arterial and venous ulcers, lacerations, excoriations, shearing,[MEDICAL CONDITION] any changes in skin condition are discussed with the DON or ADON, Unit Manager, MDS coordinators, and Wound Care Coordinators during the meeting. Treatment plans are either resolved or revised based upon current clinical information. The Director of Quality and Education began conducting additional training on 12/30/15 for clinical staff on the facility guidelines for the recognition and prevention of wounds and skin impairments. Nursing assistant receiving additional training on recognition and reporting of skin impairments, skin prevention practices, turning and positioning, ADL, incontinence care, hydration and feeding to assist in reducing skin care issues on 12/30/15. The training for the nurses and assistant who are scheduled for work today, is expected to be completed by 11:00 PM on 12/30/15. Any staff member who did not receive training will not be allowed to return to work until they have completed the required training. Clinical nurses and nursing assistants will receive additionally training monthly for 90 days or until compliance is met. Trends and audits results will be presented by the Director of Nursing or designee at the monthly Quality Assurance/Performance Improvement committee meeting. Audit results and system components will be reviewed by the performance improvement committee with subsequent plans of correction developed and implemented as deemed necessary to ensure compliance is maintained. On 12/31/15 the surveyor confirmed by interviews with 6 LVN's and 10 CNA's and by record reviews that nursing staff were in-serviced on the above and were knowledgeable about the changes in procedures. The surveyor reviewed charts of the 2 residents identified with excoriation and of 4 new admissions. On 12/31/15 at 10:24 AM, the ADON was informed the IJ was removed. The facility remained out of compliance at a scope and severity of actual harm that is not immediate jeopardy at pattern because the facility had not monitored their plan for effectiveness. The CMS Form 672 dated 12/10/15 indicated 17 residents had pressure sores. No other evidence was presented.

Based on interview and record review, the facility failed to ensure 1 (Resident #11) of 4 residents reviewed for Intravenous (IV) medications was free of significant medication errors. Six days after admission Resident #11 was returned to the hospital with increased pain and the physician order [REDACTED]. Resident # 11 was admitted to the facility 12/11/15 with [DIAGNOSES REDACTED]. Resident #11 requiring 4 weeks of IV [MEDICATION NAME] treatment. Resident #11 did not receive IV [MEDICATION NAME] at the facility, the day after admission IV [MEDICATION NAME] was changed to [MEDICATION NAME], a less expensive drug, and for only 2 days. This facility failure resulted in harm for Resident #11 and could affect 3 other residents admitted to the facility for IV medications and place them at risk for exacerbation of current health issues, development of new health issues, and the possibility of hospitalization . Findings included: Closed record review of Resident #11's face sheet dated 1/8/16 documented he was a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is an infection in a bone. <http://www.mayoclinic.org/diseases-conditions/osteo[DIAGNOSES REDACTED]/basics/definition/con- 518>) Closed record review of Resident #11's hospital status report dated 12/11/15 by Infectious Disease physician documented: There is residual osteo[DIAGNOSES REDACTED] involving the ankle. The patient will be continued with the same medical treatment, wound care and will continue with [MEDICATION NAME], all previous cultures grew gram positive organisms. He needs to continue with IV Antibiotic therapy for the osteo until January 14, 2016. Closed record review of Resident #11's Physician admission orders [REDACTED]. ([MEDICATION NAME] is indicated for the treatment of [REDACTED]. Complicated Skin And Skin Structure Infections Complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of the following Gram-positive <http://www.rxlist.com/script/main/art.asp?articlekey=9585> bacteria: Staphylococcus aureus (including [MEDICAL CONDITION] <http://www.rxlist.com/script/main/art.asp?articlekey= >-resistant isolates), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae subsp. equisimilis, and [MEDICATION NAME] faecalis ([MEDICATION NAME]-susceptible isolates only). http://www.rxlist.com/[MEDICATION NAME]-drug/indications-dosage.htm) Closed record review of Resident #11's Admission Report Sheet dated 12/11/15 documented; [DIAGNOSES REDACTED]. Antibiotics: IV [MEDICATION NAME] Stop Date 1/14/16. Closed record reviews of Resident #11's Telephone Orders dated 12/12/15 documented discontinue [MEDICATION NAME] IV give [MEDICATION NAME] IV once a day regarding osteo[DIAGNOSES REDACTED]. Closed record review of Resident #11's Telephone Orders dated 12/12/15 documented clarification of [MEDICATION NAME] IV stop date 12/14/15. Closed record review of Resident #11's Medication Administration Record [REDACTED]. In a telephone interview on 12/31/15 Licensed Vocational Nurse (LVN) G said he was working on 12/12/15 and the pharmacy called and told him Resident 11's medicine was expensive and the insurance company would not pay for it. LVN G said if the pharmacy calls with an issue with a medication the nurse tells the supervisor about it and the supervisor takes care of it. LVN G said Unit Manager (UM) H was working as the supervisor that Saturday so he told her and she took care of it. In an interview on 1/7/16 at 4:00 PM UM H said the pharmacy called and said the IV [MEDICATION NAME] was expensive. UM H said the Nursing Facility Administrator (NFA) and the Director of Nursing (DON) had instructed if a medication was expensive to call the physician to request another medication. UM H said she called the physician to change the medication due to cost and she talked to the on-call Nurse Practitioner (NP) covering for the physician and she did change it to [MEDICATION NAME]. UM H said the pharmacy wanted a stop date so she telephoned the on-call NP again and the NP gave the stop date of 12/14/15 which she told the pharmacy. UM H said she did not know Resident #11 was supposed to get the IV [MEDICATION NAME] until 1/14/16. UM H said when you are acting as weekend supervisor you do not have time to review the new admissions charts you are very busy. UM H said she doesn't know what happened after the weekend. UM H said the Unit Manager checks charts each day Monday - Friday for new admissions and especially on Monday morning. The Unit Manager of that floor UM I should have gone over the chart and medications and called the physician for orders. In a telephone interview on 1/7/16 at 3:52 PM the Pharmacy Supervisor (PS) reviewed Resident #11 in their computer and said Resident #11 was documented as all-inclusive. Resident #11 was admitted on [DATE] with an order for [REDACTED].>In an interview on 12/30/15 at 3:55 PM RN L said he checks telephone orders but he is not responsible for checking new admission orders [REDACTED] In an interview on 1/8/16 at 10:25 AM UM I said a new admission should have a 24 hour care plan in the chart. UM I verified Resident #11 did not have a 24 hour care plan in his chart. UM I said the Unit Managers have a New Admission Check Quality Manager (QM) list that is completed within 24 hours or on Monday if the resident is admitted on a Friday or weekend. UM I said the Monday after Resident #11's admission was 12/14/15 which was his first day back from vacation and he did not check Resident #11's chart. UM I said Resident #11's chart, orders, care plan were not checked by anyone. UM I said one day during that week Resident #11 asked to speak to him and questioned why he was not getting his IV antibiotics. UM I said he asked the nurse and the nurse told him Resident #11 was getting his IV antibiotic so he went back and told Resident #11 he was getting his IV antibiotic there was a stop date and he got 2 doses as ordered. UM I said Resident #11 insisted he was not getting his IV antibiotics as ordered so he told the DON that Resident #11 was concerned about his IV antibiotic and the DON handled it. In an interview on 1/8/16 at 1:36 PM the DON said Resident #11 was admitted with an order for [REDACTED]. DON said the facility follows physician orders, she did not think anything about Resident #11 being admitted for 1 month of IV antibiotic treatment for [REDACTED]. DON said she did not know about IV's and orders in the facility. DON said she only got involved when the nurse and Unit Manager cannot handle a condition or situation and they ask her to get involved. DON said she was told about Resident #11 on 12/17/15, she got involved, called his Infectious Disease physician and transferred Resident #11 out to the hospital for admission so he could get his IV [MEDICATION NAME]. DON said we do not give expensive drugs. DON said they are not resident advocates they just follow physician orders [REDACTED]. In an interview on 12/22/15 at 1:35 PM Attending Physician (AP) said the weekend oncall NP doesn't have any information about new admissions. The AP said the oncall NP and physician rely on the facility to give them all of the information on a resident. The AP said if the oncall NP wasn't told the hospital Infectious Disease physician ordered [MEDICATION NAME] until 1/14/16 she would have no way to know that information. In an interview on 12/30/15 at 8:30 AM the NFA said prior to admission he reviewed the record and told the hospital the facility would only take the resident if the [MEDICATION NAME] was discontinued because it was too expensive. NFA said he did not know the Infectious Disease physician documented the resident required [MEDICATION NAME]. NFA said Resident #11 payor source was private insurance with an all inclusive contract so the facility was responsible for paying for everything the resident required. In an interview on 1/6/16 at 4:00 PM at another nursing facility Resident #11 said he went to the first nursing facility because he had osteo[DIAGNOSES REDACTED] and needed IV [MEDICATION NAME] until 1/14/16. Resident #11 said he was at the first facility for 6 days and only got 2 little bags of IV antibiotic. Resident #11 said everyday he questioned the nurses and the wound care nurse about his IV and told them he was not getting his medication like he should. The nurses and UM I kept telling him he was getting it, Resident #11 said he is a [AGE] year old man who is alert and oriented and he knew he was not getting his medication. Resident #11 said he was having more and more pain in his left foot and by Thursday 12/17/15 the pain was all the way up to his thigh. He said at that point he insisted someone had to do something and call his Infectious Disease physician because he was not getting his IV antibiotic medication as ordered . Resident #11 said NP J came into his room and looked at his foot and said he needed to get out of there right away because his foot looked bad. Resident #11 said when he got to the hospital a doctor told him his foot got worse because he did not have his IV [MEDICATION NAME] and Resident #11 would need surgery. Resident #11 said the surgeon told him his foot was much worse and they would have to drain the infection and remove a small amount of his left foot because he did not get his IV antibiotics. Resident #11 said his surgeon said the facility should have followed the orders from the hospital. Record review of hospital Infectious Disease Consultation Report dated 12/18/15 documented Resident #11 was transferred to the hospital because of swelling, pain and tenderness to the site where he had surgery on 12/3/15. Infected left foot. He will need to be taken back to surgery for [REDACTED]. Record review of hospital Progress Note dated 12/21/15 documented infected left foot. Awaiting incision, drainage and washout of the foot following which he will need to go on IV antibiotics for at least 3-4 weeks because of the infection and underlying osteo[DIAGNOSES REDACTED]. Interviews with floor nurses on 1/7/16 revealed 3 residents were currently receiving IV antibiotics. No other evidence was presented.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent an accident with injury for one (Resident # 15) of 5 reviewed for supervision and accidents. The facility failed to properly supervise Student Nurse B as she was doing an assessment on Resident #15. Resident #15 was being transferred by Student Nurse B when she was dropped and fractured her right femur on 5-25-14. This deficient practice affected 1 resident and could effect 5 residents by placing them at risk for falls with injury. The findings include: Review of Resident #15 ' s face sheet dated 5-26-14 documented she was a [AGE] year old female admitted to the facility on [DATE]. Resident #15 was her own responsible party, weighed 118 pounds and had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) dated 5-28-14 documented Resident 15 was able to make herseld understood and was able to understand others. Resident #15 did not trigger for any behavior problems, needed 2 people extensive assistance with bed mobility and transfers. Resident #15 was coded as not being stable when moving from a seated to standing position and was only able to stabalize after staff assistance. Review of the provider investigation report dated 5-26-14 documented Student Nurse B was performing an assessment on Resident #15's left stump where her lower leg had been amputated when Resident #15 grabbed the student by the neck, the resident slipped and fell on her right knee. Resident #15 fractured her right medial femur. Review of the same report under the Provider Response section the facility: Educated facility staff to supervise resident transfers being performed by student nurses. Review of the Radiology Report dated 5-25-14 revealed a fracture involving right medial distal femur with no displacement. In a telephone interview on 6-20-14 at 1:19pm with Resident #15 ' s son he stated his mother is currently at another nursing home and aware of everything that happened concerning the fall at the facility. Resident #15 did not want to return to the facility because of the incident. According to the son, Resident #15 told him that Student Nurse B told her to hold on to her neck while she made the transfer from the wheelchair to the bed and that is when Student Nurse B dropped her. According to the son, Resident #15 had surgery and is recovering at another nursing home. In a telephone interview on 6-20-14 at 1:11pm,CNA C stated on the day of the incident she was in another patients room when she heard someone scream for help. CNA C found where the scream was coming from and saw Resident #15 in between the footrest and her chair, Resident #15 was holding on to Student Nurse B. CNA C stated Student Nurse B wanted to place Resident #15 back in her wheelchair but Resident #15 ' s foot was stuck and the resident was placed on the floor and a call was made to Nurse D. CNA C and Nurse D asked Resident #15 and Student Nurse B what happened. Student Nurse B reported Resident #15 leaned forward and lost her balance while she was performing an assessment on her. CNA C stated Resident #15 stated that is not what happened. Resident #15 reported Student Nurse B was taking her to bed but the wheelchair was too far from the bed. CNA C reported Resident #15 was alert and oriented to person and place. Resident #15 was able to assist with transfers and has never been forceful with staff about getting put back to bed. CNA C denied being informed by Student Nurse B that she was taking the resident to her room to perform and assessment. In a telephone interview on 6-20-14 at 8:18am, Nurse D stated prior to the incident Student Nurse B and Resident #15 were sitting by the nurse ' s station talking. Nurse D said they were speaking Spanish and he was not able to understand the conversation. They were laughing and talking and Student Nurse B had visited with the resident multiple times before that day. Nurse D said he left the nurses station to check on one of his residents and when he returned back to the nurses station Resident #15 and Student Nurse B were no longer there. Nurse D stated he assumed a CNA came to check and change the resident ' s brief. Nurse D was then called to Resident #15 ' s room where the incident occurred. Student Nurse B reported she was doing a head to toe assessment when the resident grabbed her neck. Student Nurse B said the resident complained of pain to her butt and wanted to go to bed but denied trying to transfer the resident and stated she knew the rules. Nurse B stated anytime a student wants to do an assessment on the residents they must inform the nurse so they can be present. Nurse D stated he was not informed that Student Nurse B was taking Resident #15 to her room or to do an assessment on the resident. In a telephone interview on 6-23-14 at 2:27pm, Student Nurse B requested to be interviewed on conference along with the Director of Education at the school she was attending. Student Nurse B stated on the day of the incident (5-25-14) she was talking to Resident #15 by the nursing station when she asked the resident if she could perform an assessment on her. Student Nurse B stated she informed Nurse D. The Resident agreed and she took her to her room. According to Student Nurse B , Resident #15 was wearing a gown and she lifted it up in order to see the amputated knee. Initially, Student Nurse B stated her assessment would involve touching the resident but later denied touching the resident during the assessment. Student Nurse B was in Resident #15 ' s room assessing her left stump where her left lower leg had been amputated and the resident kept asking to be placed in bed. As Student Nurse B was assessing the knee, Resident #15 grabbed Student Nurse B on both shoulders and interlocked her hands around Student Nurse B ' s neck. The resident then lifted all of her weight out of the wheelchair and onto Student Nurse B ' s neck. Student Nurse B was unable to hold Resident #15 ' s weight or put her back in the wheelchair. Resident #15 hit her right knee on the floor. Student Nurse B stated she called for help and then CNA C came to the room to help. Both Student Nurse B and CNA C lowered Resident #15 to the floor and called for Nurse D. Student Nurse B stated she had not received any training from the facility in regards to what she could and could not do with the residents. Student Nurse B stated she was told by her instructor that she could not transfer resident to the bed, wheelchair, or bathroom. Student Nurse B denies attempting to transfer the resident to her bed. Student Nurse B stated she only was performing her assessment on the resident. In the same interview (conference call) when asked about facility training for the students the Director of Education stated the student do a ' scavenger hunt ' in the nursing home to review facility policies and procedures. This is how they become aware of facility practices. There is no formal training giving to the students before they begin their clinical rotations. In an interview on 6-20-14 at 10:40am, with the DON, when asked who was responsible to supervise the student nurses she stated the student ' s instructor. When asked who was responsible to supervise the instructor the DON stated the instructor has a license and is responsible to supervise herself. The DON stated her responsibility was to the residents in the facility. The DON stated the facility is not responsible for checking off skills for the students. Student Nurse B had the responsibility to tell the nurse or her instructor that she was going to perform an assessment on Resident #15. The DON stated sometimes there are 20 students in the building and there is no way the facility staff can supervise all of them and is the reason the students have an instructor present. In an interview on 6-20-14 at 10:17am, the Administrator stated there was no policy for students that attended the Vocational Nursing program that come to use the facility as a clinical site but provided a contract between the facility and the school. It read in part: Externship Site Affiliation Agreement Responsibilities of Provider: 4. To ensure that participating Students receive adequate supervision from Providers staff during the externship. Participating Students cannot replace Regular Staff Members at Providers location or site. 5 residents were identified by CNA G on 6-11-14 that needed assistance with a two person transfer on the 2200 hall.

Based on record review and interview the facility failed to follow policies regarding the implementation of residents rights to formulate Advance Directives by not having six Residents, (ID #s 3, 9,10,13,16, and 21) correct CPR status identified as evidenced by: A. Resident #21 had an OOH-DNR, did not have a Code Sheet, had conflicting physician's orders, and the facility incorrectly identified her as a Full Code. B. Resident #9 had an OOH-DNR, and was incorrectly identified as a Full Code. C. Resident #13 had an OOH-DNR and was incorrectly identified as a Full Code on the Face Sheet. D. Resident #3 had an Out of Hospital DNR Order (OOH-DNR) and was incorrectly identified as a Full Code by the facility and physician's orders. E. Resident #10 had an OOH-DNR, was incorrectly identified as Full Code on the Face Sheet, and no physician's orders addressing code status. F. Resident #16 was identified as a Full Code; however, her consolidated orders listed her as a DNR. G. 3 of 4 nurses did not know how to correctly identify the code status of the residents before the IJ was called. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a Level of Potential for More than Minimal Harm at a Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. This failure could affect any of the 150 residents who reside in the facility by not honoring the residents' rights, and could delay emergency treatment as well as unnecessarily prolonging of life. The findings included: Resident #21 Review of Resident #21's face sheet, dated [DATE], revealed a [AGE] year old female with the following Diagnoses: [REDACTED]. She was originally admitted on [DATE] and readmitted [DATE]. Her Code Status on the face sheet was listed as DNR. Review of Resident #21's chart on [DATE] revealed an OOH-DNR signed by her guardian and physician on [DATE]. Review of Resident #21's telephone orders revealed an unsigned telephone order stating Full Code on [DATE]. Review of Resident #21's care plan revealed a DNR status on [DATE]. Review of Resident #21's telephone orders revealed a signed telephone order stating DNR on [DATE]. Review of Resident #21's History and Physical revealed her code status as Full Code signed by the physician on the encounter date of [DATE]. Review of Resident #21's consolidated orders revealed she was checked as a Full Code, signed by the physician on [DATE]. Review of a list of residents and their code status received from the DON on [DATE] at 11:07 a.m. listed Resident #21 as a Full Code. Review of Resident #21's chart revealed that the colored code sheet was missing; there was no red DNR sheet or green Full Code sheet. During an interview LVN A on [DATE] at 10:00 a.m., stated that Resident #21's chart was "not put together yet" and because there was no red or green sheet, the nurse would assume she was a Full Code. The nurse was then shown the DNR status on face sheet and OOH-DNR in chart, and LVN said because there is no red or green sheet, the resident is Full Code. During an interview on [DATE] at 10:35 a.m., Resident #21 reported in Spanish that she would like to be resuscitated; however, her guardian had requested OOH-DNR. During an interview on [DATE] at 2:10 p.m., the ADON reported that Resident #21 was DNR because of the OOH-DNR. The ADON was shown the unsigned telephone order on [DATE] stating Full Code, and the consolidated orders stating full code signed [DATE]. She stated that they needed to clarify the order. The ADON said she did not know what the resident ' s code status was. Resident #21 had an OOH-DNR, did not have a Code Sheet, had conflicting physician's orders, and the facility incorrectly identified her as a Full Code. Resident #21 ' s Code Status was corrected to a DNR on [DATE] at 9:40 a.m. Resident #9 Review of Resident #9's Face Sheet, dated [DATE], revealed a [AGE] year old female whose [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE], and her status was listed as Full Code. Review of Resident #9's chart revealed a green Full Code sheet in the front with a CPR consent signed with no date to initiate CPR and an OOH-DNR signed by the physician [DATE]. Review of Resident #9's current consolidated orders signed by the physician [DATE] listed her as a DNR code. Review of Resident #9's current Face Sheet, dated [DATE], listed her as a Full Code. Review of Resident #9's care plan code status was not addressed. Review of a list of residents and their Code Status received from the DON on [DATE] at 11:07 a.m. listed Resident #9 as a DNR. Resident #9 had an OOH-DNR, and was incorrectly identified as a Full Code. Resident #9 ' s Code Status was corrected to a DNR on [DATE] at 9:40 a.m. Resident #13 Review of Resident #13's face sheet, dated [DATE], revealed a [AGE] year old female with the following Diagnoses: [REDACTED]. She was originally admitted on [DATE]. Her Code Status on her Face Sheet was Full Code. Review of Resident #13's physician's orders revealed a DNR status signed [DATE]. Review of Resident #13's chart revealed a red DNR sheet and an OOH-DNR signed by the resident and her physician on [DATE]. Review of Resident #13's care plan revealed a DNR status on [DATE]. During an interview on [DATE] at 12:02 p.m., Resident #13 reported she did not want CPR, and had discussed Advanced Directives with the staff. Review of a list of residents and their code status received from the Director of Nurses on [DATE] at 11:07 a.m. listed Resident #13 as a DNR. Resident #13 had an OOH-DNR and was incorrectly identified as a Full Code on the Face Sheet. Resident #13 ' s Code Status was corrected to a DNR on all documents on [DATE] at 9:40 a.m. Resident #3 Review of Resident #3's Face Sheet revealed an [AGE] year old female whose [DIAGNOSES REDACTED]. She was originally admitted to the facility on [DATE] and readmitted [DATE]. Her code status was listed as DNR. Review of Resident #3's chart revealed a red DNR sheet in the front with an OOH-DNR signed by the physician [DATE]. Resident #3's Care Plan dated [DATE] has Resident Full Code marked out, with a hand written note "Not any more resident DNR " dated [DATE]. Review of Resident #3's current consolidated orders signed by the physician [DATE] listed her as a Full Code. Review of a list of residents and their code status received from the DON on [DATE] at 11:07 a.m. listed Resident #3 as a Full Code. Resident #3 had an Out of Hospital DNR Order (OOH-DNR) and was incorrectly identified as a Full Code by the facility and physician's orders. Resident #3's Code Status was corrected to a DNR status on [DATE] at 9:40 a.m. on the facility list and physician ' s order. Resident #10 Review of Resident #10's face sheet, dated [DATE], revealed a [AGE] year old male whose [DIAGNOSES REDACTED]. His Code Status was listed as a Full Code. Review of Resident #10's chart revealed a red DNR sheet in the front with an OOH-DNR signed by the physician [DATE]. Review of Resident #10's current consolidated orders signed by the physician [DATE] revealed no orders for his code status. Review of Resident #10's care plan dated [DATE], updated [DATE], revealed Resident #10 having a code status of DNR. Review of a list of residents and their Code Status received from the DON on [DATE] at 11:07 a.m. listed Resident #10 as a DNR. Resident #10 had an OOH-DNR, was incorrectly identified as Full Code on the Face Sheet, and the Face Sheet was corrected to DNR status on [DATE] at 9:40 a.m. Resident #16 Review of Resident #16's Face Sheet, dated [DATE], revealed an [AGE] year old female whose [DIAGNOSES REDACTED]. Her Code Status was listed as a Full Code. Review of Resident #16's chart revealed a green Full Code CPR sheet in the front with a CPR Consent signed by Resident #16's Authorized Representative on [DATE]. Review of Resident #16's current consolidated orders signed by the physician on [DATE] listed her as a DNR. Review of Resident #16's care plan dated [DATE], updated [DATE], revealed Resident #16 having a Full Code Status. Review of a list of residents and their code status received from the DON on [DATE] at 11:07 a.m. listed Resident #16 as a Full Code. Resident #16 was identified as a Full Code; however, her consolidated orders listed her as a DNR. Resident #16 ' s consolidated orders were corrected to Full Code on [DATE] at 9:40 a.m. During an interview on [DATE] at 10:05 a.m., the Social Services Director stated that determining the code status is a team effort. She stated she verifies the code status at the 72-hour care plan meeting. She said the nurses find out from her or admissions if the resident is a Full Code or DNR. The nurses put in the green Full Code sheet or the red DNR sheet. Social Services Director said the green and red is what she has been abiding by to determine Code Status. She said that she and the Social Services Assistant change the code status in the care plan. During an interview on [DATE] at 10:40 a.m., the DON stated there was no way to pull up a list of residents with their Code Status in the computer system. She stated it would take a while to get a list of the residents and their code status, as she would have to go through each chart of every resident. An Immediate Jeopardy (IJ) was identified on [DATE] at 11:45 a.m., and the Administrator and DON were notified. In an interview on [DATE] at approximately 3:05 p.m. the DONand Administrator stated that the facility did not count the face sheet for the code status because it could not be updated. In an interview on [DATE] at approximately 3:20 p.m. the DON stated that the staff are trained to look at the physician order concerning code status. The staff do not consider the face sheet or the red/green sheet, they do not mean anything. During a telephone interview on [DATE] at 4:44 p.m., LVN D stated that the admissions person puts a red DNR sheet or green Full Code to show code status. She said that she checks to see if another paper is signed by the physician to let her know Code Status, and she also looks at the Face Sheet. In an interview on [DATE] at 5:15 a.m., LVN E stated she had been working with the Facility for two weeks. LVN E said if someone was to code, she would run to the chart and first thing she would do is to look at the sheet in front of the chart. If the front sheet was green, then she would start CPR. LVN E stated the front sheets in front of the charts are tripled checked throughout the chart. LVN E stated the code status are on the face sheets, admission notes, and advanced directives. LVN E said if the code status did not match throughout the chart, she would have to go with the advanced directive everyone signed, but the first thing she would do is to go by the code sheet in front of the chart. LVN E said if for some reason a resident coded, and this resident had a green code sheet, then she would start CPR. If after starting CPR it was discovered by another nurse that the resident was a DNR, then she would stop doing CPR. During an interview on [DATE] at 5:20 a.m., LVN D stated she had not had an in-service on code status. She reported she would look for the red DNR sheet or green Full Code sheet, and look for a paper signed by the doctor for code status. She reported if the papers on code status did not match, she would determine the code status by the document with the doctor's signature. Review of Clinical Management Policy: Cardiopulmonary Resuscitation (CPR)-Basic Life Support marked "new", dated [DATE], indicated "the facility will provide or withold cardiopulmonary resuscitation based on resident/patient wishes and preferences and physician orders. Unless a decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient who experiences a cardiopulmonary arrest while in the facility. If a decision (code status) has not been established and documented, CPR will be initiated. CPR will not be initiated if the resident has a Do Not Resuscitate (DNR) order. DNR orders will be obtained following state specific guidelines/regulations". Also, under Procedure for this policy the following was found: "4. Instruct responders(s) to obtain resident's chart to determine code status and bring emergency cart to site of code." "5. If certified in CPR and resident is a full code (green sheet in front of chart), initiate CPR. If resident is a DNR (Red sheet in front of chart), do not initiate CPR." The facility's Plan of Removal of Immediate Jeopardy was accepted [DATE] at 8:00 a.m., and included: 1) On [DATE] at 12:30 p.m., the Nurse Management staff validated that physician orders, care plans, face sheets, and code status alert sheet (green/red) on current facility residents are consistent with each other. 2) On [DATE] at 12:00 p.m., the Nursing Management staff in-serviced licensed nursing staff on facility policy of honoring resident choice of Full Code/DNR status. If a decision (Code Status) has not been established and documented, CPR will be initiated (Green sheet in front of chart). CPR will not be initiated if resident has a DNR order (Red sheet in front of chart). Care Plan and face sheet will be updated to reflect resident wishes. 3) At time of admission/readmission, Nurse Management staff will review resident clinical record to verify code status has been established and documented. Care Plan and face sheet will be updated to reflect resident wishes and physician orders. 4) With any new Physician order, changes regarding code status, Nurse Management will review resident clinical records to verify code status, expressed by resident/responsible party, has been established, documented, physician orders received and present in the medical record. Care Plan and face sheet will be updated to reflect resident/responsible party wishes. During Standards of Care, Interdisciplinary Team (IDT) will validate physician orders, Advanced Directives, Care Plans, and Face Sheets of each resident are consistent with each other. 5) Advanced Directive Policy has been added to the new employee orientation agenda. Nursing staff will be re-educated on Advanced Directive policy on a quarterly basis. An observation on [DATE] at 2:15 p.m. revealed the MDS coordinator pulling face sheets out of the chart, and replacing new ones in the chart. During an interview on [DATE] at 2:15 p.m. the MDS coordinator stated she was just told to update face sheets in the charts. Review of Resident #21's chart revealed a telephone order dated [DATE] at 2:20 p.m. indicating resident to continue to be a DNR. During an interview on [DATE] at 3:40 p.m., the MDS coordinator said that she can update the Code Status on the Face Sheets, and that she changed out the Face Sheets. She also said that all of the nurses have access to the computer system, and can update the status on the face sheet and print them out. Review of an updated list of residents and their Code Status received from the DON on [DATE] at 9:40 a.m. correctly lists Resident #3, #10, and #21 as a DNR. The list identified Resident #16 as a Full Code. Comparison from list received [DATE] at 11:07 a.m. and list received [DATE] at 9:40 a.m. a total of 12 Residents Code Status had been changed upon review by facility. Interviews with facility staff on [DATE] revealed staff had been in-serviced on Advanced Directive status. Record review on [DATE] revealed correct Advanced Directive status on 10 random resident records. In an interview on [DATE] at 4:00 p.m. LVN C stated that on the charts there is a green sheet if residents in a full code and a red sheet if the resident is a DNR. She stated that the code status is on the physician orders. She stated that the information is updated by the social worker. In an interview on [DATE] at 4:10 p.m. LVN B stated that on the charts there is a green sheet or red sheet for code status. He stated that the resident's Code Status is on the physician orders. Stated it is updated by the social worker. In an interview on [DATE] at 5:30 a.m. LVN G stated that on the front of the resident's chart is a green sheet for Full Code and red sheet for DNR. He stated that the Code Status in on the physician orders. He stated that it is in the care plan. He stated that if updates are made the DON and social worker take care of it. During an interview on [DATE] at 9:05 a.m., LVN O stated that she had been trained at 5:45 a.m. that morning. She said that when a resident first comes from the hospital they need to check on the code status and notify the doctor. She stated everything has to match. In an emergency, she would go to the chart and look for the red DNR sheet or the green Full Code sheet. During an interview on [DATE] at 9:08 a.m., LVN A stated she had training yesterday and in order to determine code status she said she would look at the red DNR sheet or the green Full Code sheet, the face sheet, and also check the doctor's orders to see if they matched. In an interview on [DATE] at 9:08 a.m., RN A said the facility had taught her to look at orders for DNR, update care plans, and make sure the face sheet matched Code Status. RN A said the nursing department was also told to check OOH-DNR and to give a copy to the Social Worker and inform everyone on the floor of resident's code status. While the IJ was removed on [DATE] at 9:00 a.m., the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not an IJ with a scope of Pattern because the facility had not had time to monitor their Plan of Removal for effectiveness. CMS Form 672, dated [DATE], identified a census of 150.

Based on interview and record review, the facility failed to effectively train 20 of 20 employees in emergency procedures related to fire in that: a. Licensed and direct care staff did not know the procedure for evacuation of residents from the second floor. b. Staff had not been in-serviced on the evacuation plan. c. No evidence of evacuation drill. 6 of 6 non-ambulatory residents reviewed (ID # 1, 3, 10, 13, 17 and 21 ) that reside on the second floor and require staff physical assistance would experience a delay in being safely evacuated. An Immediate Jeopardy (IJ) was identified on 03/27/14. While the IJ was removed on 03/28/14, the facility remained out of compliance at a level of potential for more than minimal harm at a pattern because the facility had not had time to monitor their plan of Removal for effectiveness. These findings could affect 72 residents who resided on the second floor, placing them at risk for harm in the event of an emergency or disaster at the facility. The findings included: Review of CMS-672 form dated 03/25/14 revealed 67 residents on the second floor required assistance for transfers and 5 were totally dependent for transfers. In an interview on 3/26/14 at 3:10 p.m. LVN A said that she was unaware of a plan on how to get residents in wheelchairs down the stairs. In an interview on 03/27/14 at approximately 11:00 a.m., The MDS Director stated that only four residents on the second floor were independent in ambulation, 67 needed assistance of one or two, and five were totally dependent for transfers. During an interview on 03/27/14 at 9:54 a.m. with the Emergency Preparedness Coordinator (EPC) stated that the facility had not practiced an evacuation since he had been employed. (1 year). He stated that the facility had Paraslydes (corrugated [MEDICATION NAME] stretcher device used for patient transport and for transporting medical equipment attached to patients, for use in evacuation, it is designed to transport one resident at a time) for the stairwell and that he was sure the nurse's know how to use them. He again stated that the facility had not practiced using the Paraslydes since he had been at the facility. During an observation 03/27/14 at 11:21 a.m. with the EPC revealed one duffle bag located on the first floor 200 Hall stairwell closet. The duffle bag had a ParaSlyde flyer displayed on the front. Interview on 03/27/14 at 11:21 a.m. the EPC said there was only one ParaSlyde and this was it. He said that the facility had not had training on the use of the ParaSlyde, but that he was sure that the nurses knew how to use them. During an observation on 03/27/14 at 11:22 a.m. the duffle bag was opened and found to contain a total of five ParaSlydes for the entire building (72 residents located on second floor). During an interview on 03/27/14 at 11:53 a.m. the Administrator stated that the staff would evacuate the second floor using the ParaSlydes. She was shocked that the EPC was the only staff member besides herself that knew about the ParaSlydes in the building. In an interview on 03/27/14 at 10:09 a.m. LVN H when questioned about the emergency evacuation plan stated that she was trained in the disaster plan last year. She said she would get the ambulatory residents down the stairs. She stated that you can ' t use the elevators. She was not sure about the other residents. She was unaware of a ParaSlyde. She said she had been employed one & half years at the facility. In an interview on 03/27/14 at 10:15 a.m. LVN A when questioned about the disaster plan, she stated that she had not been trained. She stated that she would assist the ambulatory residents down the stairs. She stated that for Residents in wheelchairs and bed fast that there was nothing she could do. She would put them in their rooms and close the doors. She said she had been employed three years at the facility. She worked mainly on the second floor. In an interview on 03/27/14 at 10:31 a.m. LVN I when questioned about the disaster plan stated that she had not been trained in the disaster plan. She stated nurses are responsible if a fire occurs, they are to do a head count of the residents, and instruct others to move the residents away from the fire, until an all clear is sounded. She stated that it has never been explained how to evacuate the second floor. When asked how she thought the evacuation would happen LVN I stated that the nurse management would give instructions, but she was not sure who that would be. When questioned about what she thought would happen, LVN I stated " They are going to burn " . When questioned what she meant she clarified, " the residents are going to burn " . She said she had been employed nine years at the facility and mainly worked on the second floor. In an interview on 3/27/14 at 10:40 a.m., when questioned about the disaster plan LVN J stated that she knew the codes, but that she had not been trained in this facility. She stated that she had worked in a sister facility and was trained there. When asked how you evacuate she replied " I ' m going to have to get back to you on that. " She then stated that she knew to get the ambulatory residents out the stairs and then non-ambulatory she said that she didn't know, but that she would get back to me on that. She said she had been employed 3 months and worked on the ground floor. During an interview on 03/27/14 at 11:21 a.m., LVN K (second floor manager) stated that he had been trained on the disaster plan 6 months before in a staff meeting. He said that he was unaware of the facility having Paraslydes. During an interview on 03/27/14 at 11:25 a.m., the DON stated that the staff had been trained on the disaster plan 6 months before in a staff meeting. She said she was unaware of the facility having Paraslydes. She said they would use sheets and mattresses. In an interview on 3/27/14 at 10:07 a.m., Laundry Aide A stated if she discovered a fire in a resident's room while walking down the hall, she would get the resident out. Then Laundry Aide A stated she really would not know what to do because she had not been trained on the disaster plan. She said she had been employed for two years. She said she delivered linens to both floors. In an interview on 3/27/14 at 10:30 a.m. CNA J stated that she would take the wheelchair residents down the ramp. She stated no we do not have a ramp, she stated "guess the one in the wheelchair would take to their room and close the door and stay in there with them " . She stated the bedfast resident she would close door and place a wet towel at the bottom of the door. She said she had worked for the facility three years and worked both floors. In an interview on 3/27/14 at 10:35 a.m., CNA B said that she was not sure about evacuating residents out of the building and said she would use the elevator to get residents downstairs. She left the interview area and came back at approximately 10:50 a.m. and said that she had misunderstood the question and would take residents downstairs using a sheet. She said she had worked at the facility for six months and worked both floors. In an interview on 03/27/14 at 10:45 a.m. Central Supply clerk stated that she did not know how to evacuate the facility. She has been employed for two months and works both floors of the building. An Immediate Jeopardy (IJ) was identified on 03/27/14 at 11:45 a.m. , and the Administrator and DON were notified. Review of sampled non-amubulatory resident records who resided on the second floor revealed the following: Resident #1 Review of Resident #1's Face Sheet revealed that she is a [AGE] year old female admitted to the facility on 10/6/10 and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. [MEDICAL CONDITION], senile dementia, dysphagia, muscle weakness, diabetes, debility, End Stage [MEDICAL CONDITION], convulsions and high blood pressure. Review of Resident #1's MDSs dated 12/30/13 and 3/24/14 Section G #s 0110F1 and 0110F2 indicated that the resident required extensive physical assistance of one person for locomotion off the unit. Section G 0600C showed Resident #1 ' s mobility device to be a wheelchair. Observations on 3/25/14 at 12:25 p.m. and 3/26/14 at 10:10 a.m. and 12:30 a.m. showed Resident #1 to be in a wheelchair. Resident #3 Review of Resident #3's face sheet revealed a [AGE] year old female with [DIAGNOSES REDACTED]. Include: [MEDICAL CONDITION], high blood pressure, dementia, diabetes type II, [MEDICAL CONDITION] and weakness, difficulty walking, depression and [MEDICAL CONDITION] of the foot. According to MDSs dated 1/25/14 and 2/24/14 Section G 0110F1 and F2, Resident #3 is totally dependent on one person physical assistance for locomotion off the unit. She has wheelchair listed as her mobility device in G 0600C. Resident #3, on 3/25/14 at 12:05 p.m. and 3/26/14 at 9:45 a.m., was observed in a wheelchair. Resident #10 Review of Resident #10 ' s face sheet, dated 2/12/14, revealed a [AGE] year old male who [DIAGNOSES REDACTED]. Review of Resident #10 ' s Annual Minimum Data Set (MDS) 3.0, dated 2/07/14, Section G: Functional Status, G0110F1 and G0110F2, assessed Resident #10 as requiring extensive physical assistance of one staff with locomotion off unit. Section G 0600C listed Resident #10 ' s mobility device as a wheelchair. Resident #13 Review of Resident #13 ' s face sheet dated 1/06/14 revealed a [AGE] year old female with the following Diagnoses: [REDACTED]. Insufficiency and [DIAGNOSES REDACTED], [MEDICAL CONDITION], Muscular Disuse Atrophy Not Elsewhere Classified, Lack of Coordination, Abnormality of Gait, Muscle Weakness General, and Diabetes Mellitus without mention of complication, type II or unspecified type, uncontrolled. Review of Resident #13 ' s Annual Minimum Data Set (MDS) 3.0 dated 3/24/14, Section G0110B1 and G0110B2 assessed the resident as needing extensive assistance with one person to transfer. G0600C listed Resident #13 ' s mobility device as a wheelchair. Resident #17 Review of Resident #17's face sheet revealed a [AGE] year old male admitted to the facility on 11/24/11 and readmitted on [DATE]. Resident #4 ' s [DIAGNOSES REDACTED]. fecal impaction, atrophy, End Stage [MEDICAL CONDITION], diabetic retinopathy, [MEDICAL CONDITION], depression, [MEDICAL CONDITION] and Diabetes Type II. Review of Resident #17's MDS dated [DATE], Section G 0110F1 and 0110F2 assessed the resident as being total dependent on one staff person for physical assistance off the unit. G 0600C listed Resident #4's mobility device as a wheelchair. Review of Resident #17's MDS dated [DATE], Section G 0110F1 and 0110F2 assessed the resident as needing extensive assistance of one staff person for physical assistance off the unit. G 0600C listed the resident's mobility device as a wheelchair. Resident #21 Review of Resident #21 ' s face sheet dated 3/10/14 revealed a [AGE] year old female with the following Diagnoses: [REDACTED]. Review of Resident #21 ' s Annual Minimum Data Set (MDS) 3.0 dated 3/14/14, Section G0110F1 and G0110F2 assessed the resident as needing extensive assistance, and completely dependent on staff for assistance off the unit. G 0600C listed Resident #21 ' s mobility device as a wheelchair. In an interview on 3/27/14 at 4:00 p.m. LVN C stated that she would move the residents to their room and place a wet blanket at the bottom of the door and stay with resident until all clear was announced. She stated the residents upstairs not sure. She stated that she would have to move the wheelchair residents down the stairs using the wheelchair. She said had worked for two months, mostly downstairs. During a telephone interview on 3/27/14 at 4:02pm, CNA G reported during a fire, she would keep the residents in the room with the door closed. She reported she did not know how to get the residents down to the first floor. She said she would use the elevator. She then stated she would carry the residents down the stairs, and she would need help. She said she had worked one and a half years at the facility on the second floor. In an interview on 3/27/14 at 4:24 p.m., CNA M stated she had been working for the facility for 6 months. She said she did not work the second floor and did not know how to evacuate residents in a wheelchair out of the second floor. CNA M stated she had never been trained on how to evacuate residents in case of an emergency. During a telephone interview on 3/27/14 at 4:44pm, LVN D stated taking the residents downstairs to the first floor in an emergency is a problem , because they are not supposed to use the elevator. She reported getting downstairs is a problem, and she would try to get people downstairs with two people. She reported in the five years she has worked at this facility, she has not had training on how to evacuate people from the second floor. In an interview on 3/28/14 at 5:15 a.m., LVN E, who worked on the second floor, stated she had been working for the facility for 2 weeks. She said she had not been officially trained on the evacuation disaster plan. But that if she had to evacuate the residents she would use the stairwells and she would have either carry the residents or put them in a boat (ParaSlyde) and take them out of the building. In an interview on 3/28/14 at 5:15 a.m., LVN E, who worked on the second floor, stated she had been working for the facility for 2 weeks. She said she had not been officially trained on the evacuation disaster plan. But that if she had to evacuate the residents she would use the stairwells and she would have either carry the residents or put them in a boat (ParaSlyde) and take them out of the building. In an interview on 3/28/14 at 5:30 a.m., CNA H, who worked on the second floor, stated he had been working for the facility for 4 years. CNA H said he was in-serviced on the evacuation plan sometime the year before, but not recently. CNA H stated if he had to evacuate bed bound or residents in a wheelchair, he would have to have a ramp to bring them down the stairs if the elevator was not working. He said he did not know where he would get the ramp because he did not know where it was located. In an interview on 3/28/14 at 5:30 a.m. CNA K, who worked on both floors, stated she would close the doors. She stated that she would take the wheelchair residents out first. She stated that she would use the elevators to get the wheelchair residents out. She stated that she would use the service elevators and stated that the elevator in the lobby is always breaking down. She stated the bedfast residents would stay in rooms stated " We have to have two people for the Hoyer lift. " During an interview on 3/28/14 at 5:32am, CNA G stated that in order to evacuate the residents from the second floor, she would carry them downstairs, and ask the nurse for the procedure with those in the bed. She reported she has not had any new training on evacuating the residents. In an interview on 3/28/14 at 9:08 a.m., RN A stated she had not been in-serviced on the evacuation plan in case of an emergency. Review of the inservice training records revealed an " Active Shooter/Emergency preparedness " inservice was conducted on 11/8/13 Review of the inservice training records revealed an inservice was held on 5/24/13 which addressed " Disaster Planning " was attended by 46 employees. Thirteen of the twenty staff interviewed above did not attend (MDS Director, RN A, LVN C,D,H,I, J, K, Laundry Aide A, CNA J,K,M, Central Supply Clerk). A paper (undated) entitled " Evacuation " accompanied this inservice paperwork, and described the " Order of Evacuation " . " The Priority of Movement shall be in the following order: 1. Injured 2. Independed Ambulatory Residents 3. Wheelchairs and Walkers 4. Bed-ridden Residents (with a blanket carry for fire and wheeled in bed for windstorms). " Review of the facility ' s undated emergency preparedness polices provided by the facility as the current policy, revealed the following under the Disaster Plan: 1. Fire Safety, Disaster and Security Policy Step X Evacuation Procedure: A. General Procedures, 1. The elevators are never to be used in a fire emergency. Step XII Evacuation Carriers, A. Non-ambulatory residents: 2. To evacuate non-ambulatory residents down stairs with one person ... a. Drag person face up to top of stairs c. Back slowly down the step and maintain close contact at all times with one of your legs against the residents back. The policy did not address use of ParaSlydes. The policy did not address the order of evacuation of residents. The facility's Plan of Removal of Immediate Jeopardy was accepted 03/28/14 at 8:00 a.m., and included: 1). Total of 73 staff members in-serviced on evacuation of the 71 residents located on the second floor at 12(noon) p.m. 3/27/14. Instructions of Evacuation Carries- A. Non-Ambulatory Residents, 1. Universal Transport, 2. To Evacuate Residents down steps, 3. Use of ParaSlyde evacuation equipment. B. Ambulatory Residents, 1. The Side Assists C. Combative Residents, 1. The Bear Hug 2) Evacuation of Second floor to be part of Orientation with new staff members. 3) Maintenance Supervisor/designee will include in-service on evacuation of residents located on second floor as part of the Fire Drill conducted Monthly. Observations on 3/27/14 at noon and 1:30 p.m. and on 03/28/14 at 6:00 a.m. of in-service training revealed employees being trained on the evacuation procedure and included the use of the ParaSlyde system. On 03/28/14, Interviews with LVNs, CNAs, Housekeeping, and Central Supply Staff indicated they had been trained on the evacuation procedure including the use of the Paraslyde system and understood the processes. In an interview with the Administer on 04/02/14 at 4:40 p.m. said that the current number of employees was 173. She also said that the facility had the ParaSlydes since 2008. While the IJ was removed on 03/28/14 at 9:00 a.m., the facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not IJ with a scope of Pattern because the facility had not had time to monitor their plan of Removal for effectiveness. Review of CMS-672 form dated 03/25/14 revealed 67 residents on the second floor required assistance for transfers and 5 were totally dependent for transfers.

Purpose of visit: (X ) complaint ( ) incident ( ) other ________________________ Complainant was contacted: Yes Prior to the investigation: __Yes____ After the investigation: Date/Time _5/25/12 at 3 pm F/U Letter sent Date/Time:_5/25/12_ Complaint was anonymous: __N____ Surveyor entered the facility (date/time): 05/25/12 Was Form Center for Medicaid Services (CMS) 801 Completed? Yes Were any trends identified since the last full book survey? Yes Did the state agency enter the facility at a time relative to the allegation? N/A Did the allegation state what time the event took place took place? No Census was: _156__. A sample size of _5__ was chosen, which represented residents at risk for outcome(s) related to allegation of: Pressure Sores. Protocols Reviewed (Please check all that apply, and note concerns if Y, cite concern in relevant summary for record review) __X___ Nursing Service, Sufficient Staffing Issues /Concerns: Y N ___X__ Investigative Protocol for Infection Control Issues /Concerns: Y N ___X__ Investigative Protocol for Pain Management Issues /Concerns: Y N __X___ Unintended Weight Loss Issues /Concerns: Y N __X___ Hydration Protocol Issues /Concerns: Y N __X___ Urinary Incontinence and Catheters Investigative Protocol Issues /Concerns: Y N ___X__Pressure Ulcer Investigative Protocol Issues /Concerns: Y N ___X__ Nutritional Status Investigative Protocol Issues /Concerns: Y N __X___ Abuse Prohibition Investigative Protocol Issues /Concerns: Y N __X___ Activities Investigative Protocol Issues /Concerns: Y N __X___ Accidents and Supervision Investigative Protocol Issues /Concerns: Y N __X__ Quality Assessment and Assurance Investigative Protocol Issues /Concerns: Y N Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure sores for 2 (ID #8 and #2) of 5 residents sampled for pressure sores. The facility's failure could have affected any of the 5 residents identified as having pressure sores and the 13 residents identified by the facility as receiving preventative skin care or current treatment for [REDACTED]. The findings include: Review of Resident #8's clinical record revealed he is [AGE] year old male who was admitted from another area facility with a history of falls. He has a diagonosis of Rib fracture, Alzhiemers, Dysphagia, [MEDICAL CONDITIONS], and Celiac Disease. Resident is a Hospice patient and is currently being treated for [REDACTED]. Record Review of the "Weekly Skin Assessment" revealed that resident #8 was assessed April 18, 2012 by Wound Care LVN B (WCL B) and documented "No New". Record Review of the "Skin Grid/Pressure/Stasis/Diabetic only" dated April 23, 2012 record revealed a Stage III Pressure Ulcer measuring 2.0cm in Length and 1.5cm in Width and 0.1cm in depth. In an Interview with WCL B on 5/24/12 at 10:20 am he stated that resident #8 has been receiving wound care since he arrived. WCL B stated he had assess resident #8 on April 23, 2012 and discovered a Stage III Pressure ulcer to the buttocks . WCL B confirmed he had not received a referral or had been notified by CNAs or Nursing regarding a new wound to the buttocks developing. Review of Resident #8's Comprehensive Plan of Care dated 4/25/12 revealed a Problem "Pressure Area Stage III (R) Ischium" approach 4- assist with turn/repositioning every two hours and prn. Observation on 5/24/12 at 1:30 pm revealed Resident #8 sitting outside of his room in his wheelchair. Observation on 5/24/12 at 2:30 pm revealed Resident #8 sitting outside of his room in his wheelchair with his head bowed and eyes closed. Wife was sitting next to him seated in the seat of her walker. Observation on 5/24/12 at 3:40 pm revealed resident #8 sitting outside of his room in his wheelchair with his head bowed and eyes closed. Observation on 5/24/12 at 4:10 pm revealed resident #8 sitting outside of his room awake looking at activity in hallway outside of his room. Wife is sitting next to him seated in the seat of her walker. In an Interview with Resident #8's and his wife on 5/24/12 at 4:10 his wife stated she and her husband where tired of sitting there. Resident #8's wife was sitting on the seat of her walker next to resident #8 wheelchair. Wife states she does not like her husband sitting in the hallway for such a long period of time. When asked if they had requested the staff to put him back to bed resident #8's responded "it wouldn't matter" residents wife also stated "they tell me he need to sit up so he does not try to get out of bed." Review of Resident #2's closed clinical record revealed he is an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A History of Diverticulitis, [MEDICAL CONDITION] Fibrillation, Depression, [MEDICAL CONDITION], Diabetes, Hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of Resident #2's Nursing Comprehensive admitted d 5/14/12 revealed the following: Neurological - Alert, Orientation to time, place, person, Impaired cognition-no, Oral/Dental - Tongue, Gums, Cheeks, Lips noted as pink. Mouth Sores - No. [MEDICAL CONDITION] - Incontinent Integumentary - Skin-normal, Skin Risk - Braden Scale-17, Mild Risk for skin breakdown. ADL's - Independent for Eating and Locomotion Review of Weekly Skin Report dated 5/15/12 to 5/21/12 revealed there was no documentation of Resident #2's irritation to bilateral inner thighs and the buttocks. Interview with wound care nurse A (WCN A) on 5/24/12 at 8:43 am stated she was not aware of a policy for wound care. She stated she had never been trained in wound care but does rely on the monthly rounds the wound care specialist makes which she is involved in. Review of " Protocol: Wound Prevention and Treatment " given by WCNA which states that every resident with skin breakdown will be placed on the weekly skin report if it is excoriation, she will monitor that the barrier cream is placed according to orders. WCN A stated she monitors existing wounds and /or new wounds on her weekly rounds to monitor for improvement or progression. No assessment or documentation appeared in the Weekly Skin Report for the week of 5/15/12 thru 5/21/12 for Resident #2. Review of Resident #2"s comprehensive Plan of Care dated 5/15/12 noted assist x1 for all "ADL Functions" such as Bed Mobility, Transfers, Dressing, Eating, toileting, Personal Hygiene, and Bathing. Review of Comprehensive Plan of care dated 5/15/12 with problems listed as: Resident has current Skin Concerns irritated bilateral inner thighs/buttocks. Approach - 2. Monitor areas for increase breakdown, s/s of infection--report to M.D. 4. Encourage p.o. and fluid intake with in dietary limits. Review of Comprehensive Plan of Care dated 5/15/12 Risk for Skin Breakdown related to: Incontinence, Impaired bed mobility, Obesity, Diabetes Approach 2. monitor areas for increased breakdown, s/s of infection report to M.D. 4. Encourage P.O. and fluid intake with in dietary limits. 5. Keep M.D. and R.P. (responsible party) informed of residents progress. Review of Comprehensive Plan of Care dated 5/15/12 documented problem - Resident is a Diabetic and is at Risk for: Frequent infections, Pressure/Venous/Stasis Ulcers, Vision Impairment, Hyper/Hypo-glycemia, [MEDICAL CONDITION], cognitive impairment, physical impairment. Approach - 2) Monitor for thirst, excessive appetite or voiding, change in level of consciousness or mood, perspiring --report to M.D. 3)Monitor skin for changes--redness, circulatory problems breakdown, report to M.D., RP (Responsible Party) 4) Encourage p.o, and fluid intake with in dietary limits. Intake and Output was not being monitored. Skin changes were not being monitored and/or reported. Review of Bathing Roster for Resident #2 revealed Shower was given on 5/16 and 5/17 with 1 person assist, on 5/18 a Shower was given as Total dependence. There is no documentation of the CNAs reporting any skin abnormalities to the nurse. Record review revealed dietary did not completed an assessment on resident #2 during his stay from 5/14/12 to 5/19/12. As stated in facility admission process, resident assessments should be completed within 24 hours. The dietician failed to initiate a weight record for this resident with a [DIAGNOSES REDACTED]. Interview on 5/24/12 at 2:15 pm with CNA C stated that showers are scheduled per hallway. If she gives a resident a bath during her shift, she will document it in the computer either given or refused. CNA A stated she does not always tell the nurse when a resident refuses a shower/bath since she already put it in the computer. Interview on 5/24/12 at 3:50 pm with LVN D said that she verify's that the CNA's have completed their assigned duties as she walks up and down the hallway to see if the resident and their rooms are clean. LVN stated she sometime also "goes into their rooms and asked the residents if they showered today and they will tell me." Interview on 5/25/12 at 9:27 am with LVN E said she monitors that the residents are being turned every 2 hours, LVN D stated that all residents should be up in the chair if they are able to. She stated they do not have a turning schedule but the nurses make their rounds and even if a resident is up in a wheelchair, they will stand them up and shift their weight. There is not any documentation to confirm this action takes place. Interview on 5/24/12 at 4:25 pm with Wound Care Tech states it is standard turning procedure to turn or reposition every resident regardless if they have a wound or not every 2 hours. Resident #8 was observed sitting in a wheelchair in the same position from 1:30 pm to 4:45 pm . Resident #2 was sent to ER upon family request on 5/19/12 via EMS ambulance. Review of ER notes dated 5/19/12 revealed resident was admitted with a [DIAGNOSES REDACTED]. On admission to the hospital on [DATE] at 1939 ( 7:39 pm) nursing staff in the emergency room notes reveal Assessment in part,mucosa is dry, skin is dry, oral mucosa is dry, with poor turgor, Stage II Decubitus ulcers on Buttocks measuring 2.6 cm to 7.5 cm has [DIAGNOSES REDACTED]tous and macerated edges. Urine is amber and scant. (Decubitus ulcers were not identified at Mountain View). Record review of emergency room Notes dated 05/129/12 revealed that the emergency room Physician had consulted a specialist due to patient has severe collection of cream around penis, with [MEDICAL CONDITION]. Review of the "Clinical Management" Admission Process last revised 5/01/2011 revealed in part Procedure 1. residents assessments completed within 24 hours to include nutrition services. Procedure 6. initiate resident patient weight record and vital signs - individual resident flow sheet Review of Wound Prevention and Treatment Protocol dated 2/2010 revealed in part --Procedure 1. Assess all resident/patients to determine risk for pressure ulcer development to include Nutrition Risk Data collection and Assessment. Procedure 6 on page 5 -- Identify and/or revise interventions including, but not limited to: Monitor Weight., Monitor hydration and food intake. Review of Wound Prevention and Treatment dated 2/2012 under "Pressure Ulcer Prevention - Mild Risk" revealed in part 1. Skin Hygiene and inspection . d. Inspect the skin daily for signs and symptoms of breakdown. part 4 Nutrition a. Monitor nutrition and hydration status. b. Monitor weight as applicable Resident #2 continued with his hosptial stay at the end of this investigation. The facility identified 13 Residents receiving Wound Care report dated 5/15/12 - 5/21/12.

Based on interview and record review, the facility failed to provide adequate supervision and a safe environment free of accident hazards for one (resident #1) reviewed for incidents. A) Resident # 1 was transferred by one certified nurse (CNA) when resident #1 was a two + person transfer. Resident # 1 sustained a fall resulting in a spiral fracture to left distal femur, while being transferred from the shower bed to his regular bed. This failure could affect all 24 residents that require assistance with hoyer lift transfers. Findings included: 1) Record review of the face sheet documented resident #1 was a [AGE] year old male who was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] and 02/21/12 revealed resident #1 is interviewable, not able to ambulate, he was total care and is a 2+ person transfer with a hoyer lift. Record review of the comprehensive plan of care dated 12/14/11 and on 3/2/12 resident #1 is nonweight bearing, must be lifted mechanically with a hoyer lift and required 2 staff members at all times when using the hoyer lift. Record review of the facility's resident incident report dated 2/21/12 documented in part: When (CNA) #F was transferring resident #1 from shower stretcher to bed the hoyer net seat tore. The (CNA) #F broke fall by holding the resident #1 with her body and placing him on floor safely. He had an abrasion to the right inner great toe and left outer elbow. He had an abrasion to right toe, approximately 1x1 centimeters (cm). He had an abrasion to left outer elbow 1x1(cm). The abrasions were treated. 2) Review of Providers' Investigation Report dated 2/28/12 documented in part: As resident #1 was being transferred from the shower gurny into the bed with the hoyer lift the net tore and resident #1 fell to the floor. CNA #F was lifting the net and the net tore. Head to toe assessment was done at time of injury. No obvious deformity seen. Two superficial abrasions found to right inner great toe and left outer elbow. On 2/27/12 swelling was noticed and X-rays were ordered of the hip, tibia and femur. Results on 2/28/12 indicated spiral fracture the distal femur. Resident was sent to the hospital for further evaluation.,CNA #F was given a written warning and suspended for not following company's policy and procedures on hoyer lift management. Documentation of written statement attached to the Providers Investigation Report written by the facility's director of nurses (ADON) #M revealed resident is a 2 person hoyer lift and one CNA was taking care of the resident #1. Record review of the facility's Disciplinary Action Report: Verbal or Written dated 2/22/12 revealed CNA #F was given a written report warning for not following and failed to comply with the Company's policy on transferring residents in a hoyer lift. 3) Review of nurses notes written by LVN #G dated 2/21/12 at 3:56 PM documented in part: when CNA #F was transferring resident #1 from shower stretcher to bed, hoyer seat tore. 4) Review of nurses notes written by LVN #G dated 2/27/12 at 9:24 PM, documented in part: a CNA #K reported to nurse was doing ADL's she noted resident #1 to have edema of the left leg. Called was placed to Nurse Practitioner. Review review of nurses notes revealed that on 2/28/12 resident was transferred to the hospital. Review of nurses notes written by LVN #G dated 2/28/12 at 6:44 PM, documented in part: residents #1 X- Rays of left hip,femur and order. Left leg is still edematous. Review of nurses notes written by LVN #I dated 2/28/12 at 6:44 AM documented in part: resident left to hospital via ambulance for treatment of [REDACTED]. Record of nurses notes written by director of nurses #E dated 2/28/12 at 9:52 AM documented in part: resident #1 was being transferred from shower stretcher to bed via hoyer lift. Resident is a quadriplegic. At the time of fall on 2/21/12 no injury was noted except abrasions to the left toe and left outer elbow. On 02/28/12 resident #1 was noted with swelling to the entire left leg. X-rays were ordered and the x-ray showed that he had a spiral fracture to the distal femur with modest displacement. Resident #1 was transferred to the hospital. 5) Record review of Mobilex X- rays dated 2/28/12 reveals results the femur shows osteoporosis. There was a spiral fracture involving the distal femur with modest displacement. 6) Observation on 3/15/12 at 9:30 AM revealed resident #1 was in his room lying in his bed watching television. 7) Record review of the Braden Fall Risk assessment dated [DATE] revealed that resident #1 Fall Risk was 15 (12-16) being Moderate Risk. 8) Record review of the Hospital History and Physical dated 02/28/12 documents in part: resident #1 admitting [DIAGNOSES REDACTED]. 9) In an interview on 3/15/12 at 9:30 AM with resident #1 he stated he was feeling okay. Resident alert and oriented to person and time. He stated that as a result of the fall he had several days ago when he was transferred by CNA #F he had to have surgery. He reported the day of the incident the CNA #F had showered him and he was left on the shower bed in his room for about 45 minutes. He asked CNA #F to put him to bed because he was very uncomfortable. The CNA #F decided to transfer him by herself it was then when the hoyer lift net tore and he fell to the floor. He stated CNA #F held his head so he did not hurt his head. He stated he had no feelings to his body because he was quadriplegic. He did not know that he had a fracture. 10) In an interview on 3/15/12 at 1:15 PM with CNA #F she stated she was the one person on the second floor when she had showered resident #1 and she needed to put him to bed because he stated to her that he was very uncomfortable. When the surveyor asked her if she was the only person on the second floor she stated two nurses were on the floor on the hall giving report but she did not ask them for help. She stated she decided to transfer resident #1 by herself because the resident told her they do it all the time. " I did not want him to report me for not listening to him". She stated she knew that he was a 2 person transfer, but that she did not know the hoyer lift net was going to break. She stated she been trained and inserviced on how to use to the hoyer lift. She stated she knew that residents that are hoyer lift transfers are to be transferred by 2 persons. 11) In an interview on 3/15/12 at 3:35 PM with CNA #K stated she works the 2:00 PM to 10:00 PM shift, she identified resident #1 as being oriented x 3, a little demanding, and stated that resident is a 2 person transferred with hoyer lift. She reported she was the CNA that noticed the swelling of the leg and reported to the nurse. She reported this was after the fall he had several days ago. 12) In an interview on 3/16/12 at 1:30 PM, both licensed vocational nurses (LVN) #G and LVN #H reported they were the nurses giving report when CNA #F yelled for help on 2/21/12. They both stated that CNA #F did not ask for help to transfer him. The nurses were sitting about 15 feet away from the resident's room. LVN #H stated CNA #F had just showered resident and had transferred him to his room. It must had been about 10 to 15 minutes that resident was in the shower bed. I just don't know why she didn't ask us for help". Incoming LVN # G, 2:00 PM to 10:00 PM reported she did a head to toe assessment on day on 2/21/12. She reported was no form in the chart of the head to toe assessment. When she did the assessment there was no indication of fractures. He had some abrasions its notes on the nurses notes. The resident was noticed on 2/28/12 with swelling to the left leg, he was sent to the emergency room for evaluation and admitted to hospital for surgery. Resident returned to the facility on [DATE]. 13) In an interview on 3/16/12 at 1:10 PM with the facility administrator reported there is no policy for hoyer lift transfers. Record review of the facility Direct Supply order form revealed hoyer sling/nets were removed and replaced with new ones. Record review of the facility's Maintenance- Supplies Equipment dated 05/01/11 documents in part: Equipment: - must be ready for use at all times to serve the residents' needs - Care should should be exercised in the handing and the use of our equipment to prevent damage or injury The census of 161 residents was provided by the facility's Administrator on 3/15/12.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents (Resident #17) reviewed for elopement, and provide an environment as free of accident hazards as is possible for 86 residents who lived on the second floor. The facility failed to: (A) Provide adequate supervision to prevent the elopement of Resident #17. Resident #17 was admitted to the facility on [DATE] at 1:00 p.m. with dementia, poor judgment, and a known history of wandering. At 5:30 p.m. he was discovered to be missing from the facility. Five-and-one-half hours later, at 11:00 p.m., police located the resident and returned him to the facility. The facility had not implemented changes in his plan of care to address elopement risk. Resident #17 exhibited exit-seeking behaviors. This failure could affect any of the 24 residents identified by the facility as having an increased elopement risk. These residents could be placed at risk of serious injury or death. (B) Provide an environment as free of accident hazards as is possible. Four of four exit stairwells leading from the second floor to the first floor had metal chains secured across the top from handrail to handrail. If a resident attempted to go down the stairs and did not see the chain, or in an emergency evacuation, serious injuries could result. This could affect any of the 86 residents who reside on the second floor. Immediate Jeopardy (IJ) was identified on 12/16/11. While the IJ was removed on 12/17/11, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility had not yet monitored their plan for effectiveness or completed alarm modifications. The findings included: A. Supervision to prevent elopement. Review of the facility "Face Sheet" dated 12/13/11 at 1:00 p.m. revealed Resident #17 was a [AGE] year old Hispanic male admitted to the facility from the local behavioral hospital with the [DIAGNOSES REDACTED]. Review of the local behavioral hospital "Progress Notes" dated 12/03/11 revealed Resident #17 was admitted to the behavioral hospital for management of dementia with psychotic features and hallucinations. The progress notes revealed the plan for Resident #17 was for him to be in an environment that attends his needs 24 hours a day, 7 days a week. Review of the local behavioral hospital "Progress Notes" dated 12/05/11 revealed Resident #17 "wanders, but can be redirected easily, memory is severely impaired, and insight and judgment were limited." Review of the local behavioral hospital "Progress Notes" dated 12/06/11 revealed Resident #17 had "poor cognition and poor judgment, decreased coordination and balance." Review of the facility "Pre-admission Inquiry" dated 12/07/11 for Resident #17 revealed [DIAGNOSES REDACTED]. Resident#17's physician orders [REDACTED]." Review of the facility "Elopement Risk Data Collection and Assessment" dated 12/13/11 at 4:22 p.m. revealed the potential risk factors included: elopement history, impaired cognition, independently mobile, adjustment difficulties, exit seeking behavior, psychiatric history and wandering behavior." The facility "Comprehensive Plan of Care" for Resident #17 dated 12/13/11 documented Resident Assessment Protocol (RAP): Resident deemed at risk for wandering as evidenced by: new admission to the facility, is ambulatory, resistant to being placed in long term care facility, Dementia/Alzheimer's and elopement. No interventions were documentd. During an interview in Spanish with a Spanish speaking surveyor on 12/15/11 at 3:23 p.m. with Resident #17, he stated that he had left the facility two days ago and he was going home to Chihuahua, Mexico. Resident #17 stated he did not know who brought him back to the facility. Resident #17 stated that he left the facility through the front door. Resident #17 stated that he is independent; he dresses himself, feeds himself, toilets himself, bathes himself and is independently ambulatory. During an interview on 12/16/11 at 10:20 a.m. with the DON, the DON stated that she was notified that Resident #17 was missing approximately 5:30 p.m. on 12/13/11 and she and staff made rounds inside the facility, outside on facility grounds looking for Resident #17. She stated that when it was determined that Resident #17 was not on facility grounds, then staff left in their personal vehicles to search the surrounding area for Resident #17. She stated that the family was contacted and the facility requested a photograph of Resident #17 for identification purposes and the local police department was notified that Resident #17 was missing from the facility. The DON went on to state that the facility gives themselves 24 hours to complete the admission paperwork, including photographing the resident. During an observation on 12/15/11 at 4:18 p.m. Resident #17 appeared to present himself as a visitor; he was dressed in a button up shirt, jeans, cowboy boots, and cowboy hat and was carrying his toothbrush while ambulating around the facility. During an interview in Spanish with a Spanish speaking surveyor on 12/17/11 at 2:30 p.m. Resident #17 showed the surveyor the exit door on Hall 2400 and stated that he went down the stairs and exited through the front door. "Nurses Notes" dated 12/13/11 at 4:37 p.m. for Resident #17 documented "Resident admitted to facility 1300 (1:00 p.m.) - accompany (sic) by sister, resident in wheelchair, however able to ambulate ... wander guard placed to left lower extremity due to Dementia and increased risk for elopement." "Nurses Notes" dated 12/14/11 at 12:02 a.m. for Resident #17 documented "resident found wandering around facility around 5:30 - later resident was nowhere to be seen - search party in effect throughout facility - resident was not found - Director of Nurses(DON), family member notified - Police was contacted - Police later returned Resident #17 to the facility around 2300 - Resident was reoriented to facility - head to toe assessment initiated - no apparent injuries noted - resident was hydrated, medication was administered - DON and family notified of resident's return - resident's sister in facility - 10 p.m. to 6 a.m. nurse shift notified." The care plan had not been updated since 12/13/11. In an interview on 12/16/11 a 10:20 a.m. the DON stated that no additional provisions were made for Resident #17 following his elopement on 12/13/11. During an interview with Licensed Vocational Nurse (LVN) #Y on 12/16/11 at 2:15 p.m. stated Resident #17 had just been admitted on [DATE]. She went on to state that the previous shift nurse had informed her on 12/13/11 that Resident #17 did have a history of wandering and Resident #17's sister was here until approximately 4:30 p.m. She stated that the staff had begun serving dinner and she saw Resident #17 walking in the hallways and walking in and out of residents rooms. LVN #Y stated that Resident #17 seemed okay to her, that Resident #17 was looking for his home and he thinks he is in Chihuahua, Mexico. She stated that she was at the medication cart and was talking with another LVN and they noticed Resident #17 not being there and they started looking for Resident #17 around 5:00 to 5:30 p.m. LVN #Y stated that Resident #17 was new at that time and that Resident #17 did not look like a resident. LVN #Y stated that the facility did not have a photograph of Resident #17 and the family brought a photograph with them for the police department for identification purposes. LVN #Y stated that approximately 11:00 p.m. on 12/13/11 she was called downstairs to identify Resident #17 for the local police department. Review of local police department "Incident/Investigation Report" dated 12/13/11 revealed the facility notified the local police department at 6:00 p.m. that Resident #17 was missing. A police officer was dispatched to the facility at that time, and a search was conducted. The report also revealed that a police officer was dispatched to a downtown location for a subject matching the description of Resident #17 was located walking east on a local street. The officer conducted a follow up at the facility. The officer observed that Resident #17 did not sustain any injuries during his absence and subsequently turned Resident #17 over to the nursing staff at the facility. There was no time noted on the police report as to what time Resident #17 was located or returned to the facility. During an interview on 12/16/11 at 1:45 p.m. the Administrator stated that when a resident with a wander guard on gets close to an exit door, the alarm will not sound until the resident attempts to open the door. She stated that the inside doors are not armed with wander guard, but the outside exit doors are. During an interview on 12/16/11 at 8:45 a.m. with the Administrator, the Administrator stated that the staff made rounds inside the facility, around the building and then began searching in their private vehicles in the area surrounding the facility looking for Resident #17 about 5:40 p.m. on 12/13/11. She stated that the family was contacted and the facility requested a photograph of Resident #17 for identification purposes and the local police department was notified that Resident #17 was missing from the facility. She stated that Resident's #17 sister had told the facility that Resident #17 had eloped from his home several times in the past. "Nurses Notes" dated 12/14/11 at 2:59 p.m. for Resident #17 entered by the DON documented "Resident admitted from {local behavioral hospital} related to increased dementia with behavioral disturbance. Resident is ambulatory and at risk for falls related to generalized weakness. Resident is oriented to person and is able to follow simple commands. Resident does have a history of elopement from his home. Wander guard in place. Resident did elope from facility at approximately 1730. Was found uninjured by police and brought back to facility. He remains calm and cooperative. Resident is on frequent watch .....Will continue to monitor for adjustment to new environment." "Nurses Notes" dated 12/15/11 at 6:43 a.m. for Resident #17 documented "at beginning of shift resident was sitting in dining room - started to wander down hall - assisted to his room .....resident checked every hour ....." Interview on 12/16/11 at 10:20 a.m. with the DON revealed there was no evidence of documentation available of hourly checks being conducted. "Nurses Notes" dated 12/15/11 at 9:47 p.m. for Resident #17 documented "resident continues to wander around facility - attempted twice to exit the building through Hall 2300 and later in the evening through Hall 2500 - resident was able to get to the stairs through the emergency exit -went to return resident into the building - resident redirected and escorted to room - resident continues to wander around rotunda ...." During an observation on 12/16/11 at 2:00 p.m. Resident #17's room was located two doors away from an exit on Hall 2200. The exit door closest to Resident #17's room had signs on the inside of the door that stated this was an emergency exit only and the door did not alarm and did not open when this surveyor attempted to open this fire exit door. During an observation on 12/16/11 at 4:03 p.m. a surveyor stood at the nurse's station while two other surveyors opened the emergency exit on Hall 2400 (where resident #17 stated he had exited). The surveyor noted a faint alarm at the nurse's station when the door was opened, and the alarm stopped when the door was closed. The faint alarm would not be audible if staff was not present at the nurse's station. The surveyor noted that the staff did not pay any attention to this alarm. On 12/16/11 at 2:30 p.m. a wander guard was obtained from the Environmental Services Director (ESD) in order to test the doors. - The exit door on Hall 2200 did not open and did not alarm; - The exit door on Hall 2300 alarmed when the door was opened and it took staff 20 seconds to respond. - The exit door on Hall 2500 sounded alarms of one short beep and stopped when the door closed. - The exit door on Hall 2400 emitted a soft sounding alarm that is only heard at the nurses' station and shuts off when the door is closed. - When this surveyor attempted to leave the facility by the front door, the lobby doors did alarm as well as the front door alarmed. This surveyor noted that staff did not pay any attention to the alarming doors. This surveyor was able to exit the building without any difficulty or without being stopped by staff. The IJ was called and facility administration was notified on 12/16/11 at 5:15 p.m. Observation on 12/16/11 at 6:35 p.m. of the 2300 hall exit revealed when surveyors opened the door without entering a code, the alarm did not sound. When surveyors went out the doors to the landing and top of the stairs the door closed. Upon attempt to open the door from the stairwell the door would not open. A resident from close proximity attempted to let surveyors into the hall but was unable to. A CNA saw the surveyors knocking on the exit door and came to open the door. The CNA entered a code "123" and the door beeped. When surveyor opened the door the alarm sounded. On the metal alarm box was written 123 off - 123 on. At 6:42 p.m. LVN "OO" came to the door and said "you have to put the code in twice, if you only put the code in once, it deactivates the alarm. Maintenance Staff "K" said he did not know when the last staff in-service was concerning the alarms on the exit doors. During an interview on 12/16/11 at 7:30 p.m. with the DON, the DON stated that the facility has initiated one-to-one status for Resident #17. During an observation on 12/16/11 at 7:35 p.m. the ESD was giving an in-service to the staff on duty at that time on all doors and door codes on the upstairs fire exit doors. During an interview on 12/16/11 at 7:37 p.m. with the Business Office Manager (BOM), the BOM stated he had worked at the facility for the past [AGE] years and he stated "four to five" years ago is when he noted the chains across the upstairs stairwells. During an interview on 12/17/11 at 10:15 a.m. LVN MM stated that when the door on Hall 300 alarms, it is very loud and annoying and that the alarm sounds off when the exit door on Hall 300 is opened. During an observation on 12/17/11 at 11:20 a.m. on Hall 2200, CNA KK was in Resident #17's room, Resident #17 was sitting on his bed, fully dressed with hat and boots on. During an interview on 12/17/11 at 11:22 a.m. on Hall 2200, CNA KK stated that his responsibility was to be one-to-one for Resident #17 and he had been with Resident #17 since 11:00 a.m. and to keep Resident #17 in visual sight at all times. Record review of Resident #17's "Social Services" notes dated 12/17/11 at 3:32 p.m. revealed " resident admitted from {local behavioral hospital} 12/13/2011 - resident alert and oriented X1 - resident wanders and at risk for elopement - upon admission elopement event occurred - resident found and appears to be in no emotional distress - resident with wander guard and one to one staff for safety due to elopement risk - resident Spanish speaking and answers with predominately closed ended answers (yes and no). Resident has blank affect, and states he is going home, however is unable to provide a physical address when asked - resident states he worked but cannot provide information on type of occupation, resident's sisters called to gather psychosocial history - and sister stated she would talk to this social service person face to face - resident is unable to complete Brief interview for Mental Status (BIMS) - will continue to monitor." Review of facility policy and procedure titled "Elopement Prevention and Management" dated 05/01/11 revealed "Elopement - when a cognitively impaired resident leaves the physical structure of the facility unattended and without staff knowledge." "The Elopement Prevention and Management Protocol is an interdisciplinary process designed to reduce the risks for elopement while maximizing independence. The interdisciplinary team, which includes the resident and family, designs and develops the least restrictive interventions to meet the individualized needs and goals of our residents: ... .... - Assess the security of potential internal environmental risk factors including, but not limited to: elevators, exit doors, screens, stairwells, windows; maintain door alarms and wander control systems in proper working order; ...... - Review and correct deficiencies in practices as they relate to the following: cueing devices/monitors, resident identification systems, response to alarms, testing of alarms; ..... - Maintain a current protected list of names and photographs of residents identified at risk for elopement. Assure picture contains the following information: name, description, height, weight, age, and pertinent medical information; ....... - Monitor the whereabouts of the "at risk resident" during rounds; validate through observation, the resident is wearing electronic device every shift as indicated; record residents at risk for elopement on assignment sheets; ..... - The interdisciplinary team will re-evaluate cognitively impaired resident who have attempted, unsuccessfully or successfully, to leave the facility without staff knowledge. With the assistance of the resident and family, individualized interventions will be developed and initiated to manage the elopement behavior. " ....... B. Accident hazards During an observation on 12/16/11 at 3:00 p.m. the fire exit door on Hall 2400 had a sign on the door that stated this was an emergency exit and that this door was alarmed. When this surveyor attempted to open the door, this surveyor did not hear an alarm and there was a chain across the stairwell about waist high. The chain was attached to each hand rail with eye bolts. The left hand side of the hand rail, the chain was attached to the eye bolt with a solid piece of chain that was not removable. The right hand side of the hand rail, the chain was attached with a chain clip to the eye bolt. In the event of an emergency, the chain would prevent or delay egress or present an accidental trip hazard. During an interview on 12/16/11 at 6:19 p.m. with the Administrator, stated that it was her understanding that the chains across the upstairs fire exit stairwell exit on Halls 2200, 2300, 2400 and 2500 have been there "for years." During an interview on 12/16/11 at 6:52 p.m. Maintenance Staff "K" said he had worked at the facility for one year. Staff "K" verified he had already removed the chains across the top of the stairwells on Halls 2300, 2200, and 2500. Staff "K" said they have all had chains "since I have been here." Plan of Removal for Immediate Jeopardy at Mountain View Healthcare Center December 17, 2011 - The chains across the stairwells have been removed. - Hall 300 outer exit door has had an audible alarm installed on Saturday, December 17, 2011, that now alarms in the hallway in addition to alarming at the nurses' station. The alarm can only be silenced by someone entering the code. Once the code is entered and alarm silenced then the alarm is in activated mode. - Hall 200 and 500 exit doors have the same type of alarm as stated above. The additional hallway alarm for these exit doors will be installed on Monday, December 19, 2011. - 2400 Hall exit door will continue to be monitored 24-hours/day until an alarm exit device that is key-operated can be installed, which will be completed by Thursday, December 22, 2011. This device will be in activated mode at all times except for when it is alarming. - Hall 2200, 2300, and 2500 will have a magnetic exit door alarm installed that is key-operated and will be activated mode at all times except for when it is alarming. This will be completed by Thursday, December 22, 2011. - Until these alarms are installed, each nurse assigned to these halls at shift-change will do a manual check that the door is de-activated and then re-activated. This will be documented on a checklist-type spreadsheet. - Signs will be placed on these exit doors that they are not to be used except in emergency situations. - A wander guard alarm will be installed at elevators to alert facility that someone with a wander guard has been on the elevator. - A staff assignment schedule for monitoring the 2400 Hall exit door has been implemented effective 12/16/11. This monitoring will be discontinued once the new alarm exit device has been installed. - Instructions for the staff on what to do during their monitoring time of the door have been implemented effective 12/17/11. Each staff member involved in this door monitoring will sign and date the instructions acknowledging their understanding. - An Elopement Risk Assessment was completed for Resident {#17} on 12/13/11. Wander guard was placed to left lower extremity at this same time. - A staff assignment schedule for 1:1 for {Resident #17} has been implemented effective 12/16/11. This will continue until 12/22/11 at which time {Resident #17} will be reassessed for the need to continue 1:1. - Instructions for the staff on what to do during their 1:1 time with resident have been implemented effective 12/17/11. Each staff member involved in this 1:1 care will sign and date the instructions acknowledging their understanding. - On 12/16/11 the Family Nurse Practitioner (FNP) reassessed {Resident #17}. At this time she changed {Resident #17's} medications and wrote an order for [REDACTED]. - The Wandering Care Plan for {Resident #17} was updated on 12/17/11 to add 1:1 visual at all times. Interviews with facility staff from various shifts were completed on 12/17/11 to confirm the facility had conducted in-services regarding activation of door alarms, manual checks and documentation of door alarms at each shift change, continous 1:1 visual contact with Resident #17, and continous monitoring of hall 2400 emergency exit door. Installation of an audible alarm on the hall 300 outer exit door was confirmed on 12/17/11 at 5:00 p.m. Frequent observations of Resident #17 from 12/16/11 - 12/17/11 revealed a staff member monitoring him 1:1. Frequent observations of the hall 2400 exit door from 12/16/11 - 12/17/11 revealed a staff member constantly stationed at the door. The immediacy was removed on 12/17/11 at 5:20 p.m., but the noncompliance continued at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern because the facility had not yet monitored their plan for effectiveness or completed alarm modifications. Review of the resident census list provided by the facility on 12/16/11 revealed 24 residents had Wander Guards. Review of the Resident Roster list dated 12/12/11 revealed 86 residents lived on the second floor.

Based on observation, interview, and record review the facility failed to ensure 1 of 27 residents reviewed for pressure ulcers (Resident # 18) did not develop an avoidable pressure ulcer, and failed to ensure necessary treatment and services to promote healing. The facility failed to prevent the development of an avoidable stage III pressure ulcer on Resident #18's left heel by failing to: a) obtain a pressure reducing mattress when the resident had multiple stage II pressure ulcers identified on 09/12/11. A pressure relief mattress was not ordered until 12/02/11; b) follow-up on a low [MEDICATION NAME] level identified on 09/28/11; c) provide preventative measures after a DTI (Deep Tissue Injury) of the left heel was declared healed on 10/03/11. On 11/29/11 a stage III pressure ulcer of the left heel was identified; d) ensure treatment orders for the left heel pressure ulcer were initiated timely. A telephone order dated 12/08/11 to change the wound care product being used and to change the dressing daily was not implemented until 12/11/11; and e) ensure care plan interventions included pressure relief measures, monitoring nutritional status, nutritional supplements to increase protein for wound healing, and other interventions as appropriate. The facility's failure could affect any of the 9 residents identified by the facility as having pressure ulcers by placing them at risk for further development and/or worsening of pressure ulcers. Findings included: Review of Resident #18's Face Sheet in the current clinical record revealed she was [AGE] years old when admitted to the facility on [DATE]. The Face Sheet revealed she was readmitted to the facility following a hospitalization on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's History and Physical from a local hospital admitted d 08/04/11 revealed she was admitted to the hospital "because of her persistent fever and redness, swelling and severe pain and tenderness in her right lower extremity as well as somewhat to her left lower extremity, also multiple decubiti. Admittng [DIAGNOSES REDACTED]. Physical examination findings included : "Extremities: Patient has severe cellulitic changes, right lower extremity, and mild [MEDICAL CONDITION] , left lower extremity. Multiple decubiti and broken skinsof different stages in ber both lower extremities..." Review of MDS assessments dated 02/11/11 and 10/31/11 revealed Resident #18 was not ambulatory, required extensive to total assistance for transfers, dressing and bathing, and was incontinent of bowel and bladder. The MDS dated [DATE] listed three stage II pressure ulcers. The MDS dated [DATE] listed the resident at high risk for pressure ulcers with no current ulcers. Review of Resident #18's facility readmission orders no wound care at this time." Review of laboratory report dated 08/10/11 revealed a [MEDICATION NAME] level (a short-term measure of protein stores) of 11 (normal range 18 - 45). Review of the clinical record did not reveal any orders for follow-up lab studies. Review of the Weekly Skin Assessment form dated 08/09/11 to 08/30/11 revealed the following: 08/09/11 - Skin impairment site left buttock (marked with and x on body diagram). 08/16/11 - 08/30/11 - No new areas of skin impairment were documented. Review of a telephone order dated 08/18/11 revealed an order for [REDACTED]. Review of a Nutritional Risk Screen dated 08/20/11 revealed Resident #18 was at high nutritional risk with a total of 17 points. (8 points or greater equals high risk). Interventions dated 08/23/11 included regular diet with the addition of Prostat 101, 1 ounce twice daily for 30 days "to help ameliorate low protein stores". Review of a telephone order dated 08/31/11 revealed an order to clean open abrasion on left heel with normal saline, apply [MEDICATION NAME] (antibiotic ointment) and small dry dressing daily and as needed until healed. No other documentation was found in the clinical record related to an abrasion on the left heel. Review of the form Skin Grid/Pressure/Stasis/Diabetic Only, dated 08/18 - 09/20/11, revealed the following entries: 08/18/11 - Site: left heel; Present on admission - no; Type of wound - pressure; Stage DTI; Dimensions - length 1.0 cm, width 1.5 cm. no depth recorded; no drainage; color pink; no tunneling/undermining. 08/23/11 - All information the same as 08/18 except: length1.0 cm, width 1.0 cm, depth recorded as none; Type of wound marked as a zero; Appearance dry purple, No odor. 08/30/11 - All information the same as 08/23 except: width 1.3 cm. 09/06/11 - All information the same as 08/30 except: length 0.4 cm, width0.7 cm; Appearance dry brownish. 09/12/11 - All information the same as 09/06 except: length 0.6 cm, width 0.3 cm; Type of wound marked as ' S ' for stasis; Appearance marked as ' R ' for red. 09/20/11 - All information the same as 09/12 except: length 0.7 cm, width 0.7 cm; Type of wound marked as a zero; Appearance brown. Review of the form Skin Grid/Pressure/Stasis/Diabetic Only, dated 08/30 - 09/20/11, revealed entries on 09/12/11 describing three stage II areas on the right posterior thigh: #1 - 7.5 cm long x 9.5 cm wide x 0 cm deep; #2 - 7.0 cm long x 9.0 cm wide x 0 cm deep; and #3 - 3.0 cm long x 3.0 cm wide x 0 cm deep. Review of the form Skin Grid/Pressure/Stasis/Diabetic Only, dated 09/27/11, revealed documentation of a stage II pressure area on the right buttock 1.5 cm long x 1.5 cm wide x 0 cm deep. Review of the form Skin Grid/Pressure/Stasis/Diabetic Only, dated 09/30/11, revealed documentation of a stage II pressure area on the left buttock 1.0 cm long x 1.0 cm wide x 0 cm deep. Review of a telephone order dated 09/27/11 revealed an order stating patient needs pressure relief pad - not eggcrate. No evidence was found in the clinical record regarding the pressure relief pad. Review of laboratory report dated 09/28/11 revealed an [MEDICATION NAME] level (a long-term measure of protein stores) of 2.6 (normal 3.5 - 5.7). Review of the clinical record did not reveal any orders for follow-up lab studies or any follow up for the administration of Prostat 101 that was ordered on [DATE] for 30 days "to help ameliorate low protein stores". Review of the Weekly Skin Assessment form dated 09/30 - 10/25/11 revealed the following: 09/30/11 and 10/25/11 - skin tear left heel. Review of the Weekly Skin Report dated 10/04 - 10/10/11 revealed the following entry: Description: DTI left heel 1.3 cm x 0.3 cm; D/Br (dry/brown?) closed; Treatment: padded dressing every 3 - 5 days and as needed; Date Identified: 09/26/11 Date Healed: 10/03/11 Review of the Weekly Skin Report dated 11/29 - 12/05/11 revealed the following entry: Description: Stage III left heel 1.2 cm x 1.2 cm x 0.1 cm. Y/R/M (yellow/red/moderate? Wound bed, drainage?) Treatment: Normal saline, pat dry. Apply [MEDICATION NAME] AG every Monday, Wednesday, Friday and as needed. Date Identified: 12/03/11 Review of a computer generated treatment sheet dated 10/01 - 10/31/11 revealed the following: Padded dressing to bilateral heels. Change every 3 - 5 days and as needed until healed (Started 08/18/11). In the Hour column was printed 10 - 6 and prn (10 pm - 6 am and as needed). The form was initialed (indicating treatment done) on 10/01, 10/05, 10/08, 10/12, 10/17, 10/22, and 10/27/11. Further review of a handwritten treatment sheet dated for October 2011 revealed an entry for: Padded dressing left heel, DTI (Deep Tissue Injury), Change every 3 - 5 days and as needed until healed. There was no entry in the Hour column. The form was initialed (indicating treatment done) on 10/20, 10/22, 10/27 and 10/29/11. Written in underneath the initials on 10/27 and 10/29 was "Resolved ..." . Review of another handwritten treatment sheet dated October 2011 revealed an entry for Prevalon boots (helps minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals). In the Hour column was written Info (Information). There were no initials on the document indicating the treatment was done. Review of the current clinical record revealed no order for Prevalon boots. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed documentation in Section M - Skin Conditions as follows: M0150 - Risk of Pressure Ulcers - Yes M0210 - Unhealed Pressure Ulcer(s) - No M0300 - Current Number of Unhealed ...Pressure Ulcers at Each Stage - No entries including G. - Unstageable - Deep Tissue. Review of the significant Change MDS dated [DATE] revealed the same information as described above in the 10/21/11 MDS. Review of a computer generated treatment sheet dated 11/01 - 11/30/11 revealed the following: Padded dressing to bilateral heels. Change every 3 - 5 days and as needed until healed (Started 08/18/11). In the Hour column was printed 10 - 6 (marked out) and prn (as needed). The form was initialed (indicating treatment done) on 11/02/11 and every three days through 11/30/11. Review of the Weekly Skin Assessment form dated 11/08 - 12/06/11 revealed entries for 11/08, 11/22, 11/29, and 12/06/11, each documented, "No {new} areas of skin impairment". Review of Nurse's Notes, on a double sided single sheet, dated 08/20 through 11/02/11 revealed no documentation related to the resident's left heel. The other side of the document, dated 11/10 through 12/09/11, revealed the following: "12/02/11...Stage III noted to left heel, recently changed by wound care (illegible) ..." Review of a Skin Grid/Pressure/Stasis/Diabetic Only form dated 12/02 - 12/08/11 revealed the following entries: 12/02/11 - Site: Left heel; Present on Admission - no; Type of wound: Pressure; Stage - III; length - 1.2 cm, width - 1.2 cm, depth 0.1 cm; drainage - moderate, slight amount; odor - none. 12/08/11 - Stage III; length 1.0 cm, width 0.9 cm, depth 0.1 cm; 40% slough, 60% granulation tissue, slight drainage. Review of a telephone order dated 12/02/11 revealed the following: Left heel Stage III - Cleanse with normal saline, pat dry, apply [MEDICATION NAME] AG (contains silver to reduce/prevent infection), cover with dry dressings every 2 days and as needed ...Air mattress per Hospice to relieve pressure. Review of a telephone order dated 12/08/11 revealed the following: left heel Stage III - cleanse with normal saline, pat dry, apply Santyl (used to break up and remove dead skin and tissue), and cover with dry padded dressing daily and as needed. Review of the handwritten treatment sheet dated 12/2011 revealed the above order was not started until 12/11/11. Review of the Comprehensive Plan of Care revealed a care plan dated 12/02/11 with the problem of Stage III left heal listed. General approaches listed included performing treatments as ordered ..., monitor for increased breakdown/signs of infection, monitor for pain, encourage fluids, assess skin weekly and record findings. The care plan did not list any approaches regarding pressure relief, monitoring nutritional status, nutritional supplements to increase protein for wound healing, etc. Observation of wound care on 12/16/11 at 1:43 p.m. by RN "N" revealed a healing ulcer on the left heel. RN "N" performed the wound care following the order dated 12/08/11 as described above. In an interview during this observation RN "N" said the ulcer was likely caused by the resident rubbing her heal on the mattress. She said Resident #18 did not like being in bed and would become anxious and rub her heels on the mattress. She said the resident also has ill-fitting shoes. RN "N" also said she (RN) does not attend the quarterly interdisciplinary care plan meetings, she does her own care plans for wound care. Review of a telephone order dated 12/16/11 revealed the following: Patient needs new larger shoes ...Do not put current black shoes on patient. On 12/17/11 at 5:30 p.m. Resident #18 was observed in the rotunda in her wheelchair wearing the above mentioned black shoes. During an interview with the DON on 12/17/11 at 6:25 p.m. she said Resident #18 should have had a follow-up consultation with the Registered Dietician, follow-up lab studies, and possibly continuation of the Prostat 101 if indicated by lab studies. She said the facility protocol for ordering equipment such as an alternating pressure matress is the presence of multiple stage II pressure ulcers or a stage III - IV pressure ulcer. When asked what kinds of interventions could have prevented the DTI on Resident #18's left heel, and could have prevented the breakdown to a stage III ulcer, she said offloading pressure and the use of heel protectors. No additional evidence was provided by the facility during the Exit Conference on 12/17/11. Review of CMS form 672 dated 12/17/11 revealed 9 residents identified by the facility as having pressure ulcers.

Based on interview and record review the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 (ID #2) of 5 sampled residents. Resident #2 was not administered his nebulizer treatments according to physician's orders [REDACTED]. This failure could affect 167 residents at the facility by not receiving their medications according to physician's orders [REDACTED]. The findings include: 1. Record review of the Face Sheet documented resident # 2 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. The Annual History & Physical dated 2/12/10 documented [DIAGNOSES REDACTED]. Observation on 05/16/11 at 1:00 PM, with Registered Nurse (RN) #A revealed that there was no Albuterol and Ipratropium in the medication cart for resident #2. Albuterol and Ipratropium are bronchodilators in reversible airway obstruction due to Asthma or COPD. RN #A stated, "I tried to give resident #2 his nebulizer treatment this morning, but he refused so I documented the refusal on the Medication Administration Record (MAR). I know that I had the Albuterol and Ipratropium in the medication cart for resident #2 this morning when I passed my morning meds. I guess that we ran out of the Albuterol and Ipratropium. I do not remember if I, reordered the medications from the pharmacy. Let me go check to see if we have any Albuterol and Ipratropium for resident #2 in the medication room." RN #A informed the surveyor that he had found a new box of Albuterol in the medication room for resident #2. It was observed that the pharmacy label documented the Albuterol had been refilled on 10/25/10. The pharmacy label documented, "Albuterol 0.083 % INHAL SOL use 1 vial with 1 vial of Ipratropium via nebulizer four times a day. Quantity sent 150 vials. Order after 11/03/10." RN #A stated, " I will reorder the breathing medications from the pharmacy right away. Anyway, I just wanted you to know that resident #2 always refuses his nebulizer treatments when I offered it to him every morning. " Record review of the physician's orders [REDACTED]. Record review of the MAR dated April 2011 for resident #2 documented resident had refused the Albuterol and Ipratropium Nebulizer treatment at 9:00 AM on May 2-6, 2011, May 9-13, 2011, May 15, 2011 and May 16, 2011. The MAR did not have any documentation for May 3-5, 2011 and May 15, 2011 at 4:00 PM, that documented if the Albuterol and Ipratropium Nebulizer treatment had been administered according to physician's orders [REDACTED]. Record review of the Department Notes for resident #2 revealed that the facility did not have any written documentation in the resident's Nurses Notes that documented resident had refused the Albuterol and Ipratropium Nebulizer treatment at 9:00 AM on May 2-6, 2011, May 9-13, 2011, May 15, 2011 and May 16, 2011 or that the physician had been notified of the refusals according to facility policy. The MAR had blanks on May 3-5, 2011 and May 15, 2011 at 4:00 PM, for the Albuterol and Ipratropium Nebulizer treatment. The facility did not have any written documentation on the MAR or the Nurses Notes that documented if resident #2 had refused his breathing treatments on those days. Telephone interview on 5/17/11 at 11:13 AM, Pharmacist #B revealed that the last time that the Albuterol was reordered for resident #2 was 10/25/10. The Pharmacist stated, "prior to that reorder, the Albuterol was reordered 9/21/10. Today, we received a fax on 5/16/11 from the nursing home requesting a reorder for the Albuterol and Ipratropium for resident #2. According to our records, the Ipratropium was last reordered on [DATE] and 11/16/10." The Pharmacist reported that she was not aware that the resident's order, had been changed on 1/29/11 from 4 times a day, to twice a day and PRN (as needed). In an interview on 5/17/11 at 11:20 AM, Licensed Vocational Nurse (LVN) #C reported that she had worked on 5/12/11 on the 2-10 shift and was assigned to resident #2. LVN #C stated, "I remember giving resident #2 his breathing treatment on that day. I also remember that resident #2 had his own supply of the Albuterol and Ipratropium in the medication cart on that day. I do not borrow medications from other residents." In an interview on 5/17/11 at 11:25 AM, resident #2 reported that he has been having problems with getting his breathing treatments as ordered by the physician for a very long time. Resident #2 stated, "I only get my breathing treatments every now and than. The few times, that I do get my treatments the nurses forget to come and take off the breathing mask. I get very angry and frustrated because they do not do things the way they should. That is why I will take off the breathing mask and throw it on the floor. I do not have any family or anyone that can help me with this problem. I cannot talk to anyone here, or report to the nurses, that I'm not getting my breathing treatments as ordered because they all cover up for one another." It was observed that resident #2 was coughing and spitting out copious amounts of phlegm while he was talking to the surveyor. In an interview on 5/17/11 at 3:00 PM, the Administrator reported that RN #A had been terminated 5/17/11 for not administering medications according to physician's orders [REDACTED]. The Administrator stated, "we conducted an investigation and resident #2 reported that RN #A had not offered him his breathing treatments. The resident also denied that he had refused his breathing treatments as RN #A had documented on the MAR." Record review revealed Disciplinary Action Report: Termination Notice dated 5/17/11 documented in part: "RN#A did not do nebulizer treatments to a resident for 2 weeks, documentating that the resident refused. During investigation it was determined that the resident did not refuse the treatments, but was not offered the treatments by this nurse." Record review of the facility's policy and procedure on Medication Administration dated 05-01-2011 provided by facility Administrator documented in part: Purpose-To administer the following: Right Medication, Right dose, Right dosage form, Right route, Right resident/patient, Right time. Document the following as applicable: Omitted dose by circling in the Nursing Progress Notes or on the back of the MAR. Notify physician of changes in resident/patient or with refusal of medication. The universe of 167 residents was obtained from a census sheet provided by Business Office Manager on 5/16/11.

Based on observation, interview and record review the facility failed to provide the necessary care and services to 2 (residents #2 and #3) of 3 sampled residents as evidenced by: A. Resident #3 was diagnosed with [REDACTED].#N ordered Fleets enemas everyday. On 1/24/11, resident #3 had an appointment with the [MEDICATION NAME] because of increasing abdominal distention and x-ray documentation of moderate colonic ileus. The GI doctor ordered medications and treatments for resident #3. On 1/28/11, FNP #N discovered resident #3 never received the ordered medications because they were never transcribed to the MAR. Resident #3 was sent to the emergency roiagnom on [DATE] for worsening abdominal obstruction, not eating and pain. B. Resident #2 had a [DIAGNOSES REDACTED]. Resident #2 received a blood thinner ([MEDICATION NAME] 8 milligrams everyday) to prevent formation of the blood clots. On 12/15/10, FNP #N increased the dose of [MEDICATION NAME] to 9 milligrams (mg) everyday because the resident's blood levels were not at a therapeutic level to prevent blood clots. The [MEDICATION NAME] dosage was not increased until FNP #N discovered this and wrote another order on 1/07/11 for resident #2 to get the increased dosage. Resident #2 was not administered [MEDICATION NAME] according to physician order for [REDACTED]. This failure could have placed 61 residents on the 500 and 2500 hallways at risk to not receive the necessary care and services to attain or maintain their hightest practicable physical, mental and psychological well-being. The findings are: Resident #3 Record review of the face sheet documented resident #3 was a [AGE] year old woman and was admitted to the facility on [DATE] and readmitted on [DATE]. The hospital History and Physical dated 1/28/11 documented [DIAGNOSES REDACTED]. Record review of the Provider Investigation Report dated 1/29/11 documented a "failure to transcribe order" with an occurrence date on 1/28/11 for resident #3. The resident's functional ability was assessed to require extensive assistance, was interviewable and had the capacity to make informed decisions. The Description of the Allegation stated "Resident with history of constipation, refusal of treatment, refusal of medication to prevent obstruction. Order noted/written for Fleets enema and KUB (x-ray of the abdomen) for bowel obstruction. KUB 1/17 and 1/28. FNP (Family Nurse Practitioner) notified of results KUB when rounding." Description of Injury - "Patient developed small bowel obstruction and transferred to hospital; where she received treatment, stabilized then returned." Investigation Summary documented "Upon review noted resident has long history of SBO (small bowel obstruction) and refusal of treatment. Resident monitored by various departments for SBO. X-rays (KUB) reveal monitoring 1/15, 1/17 and 1/28 when KUB show colonic obstruction. Orders note transcribed to MAR by agency LVN. Full time employee notified provider upon reviewing chart and orders obtained for transfer. Resident transferred and treated; then returned to facility." The Report included a copy of a handwritten note signed by Director of Nurses (DON) #J that stated at 9:10 PM on 1/28/11, "received call from FNP in regards to orders that were not transcribed nine days ago from [MEDICATION NAME]. Now resident #3 has an obstruction (bowel) as noted by x-ray and is being sent out to hospital." The Report included a handwritten note signed by Licensed Vocational Nurse (LVN) #R stated, in part, resident #3 had a very firm and distended abdomen with hyperactive bowel sounds. Resident did not want to go to the hospital. FNP #N was notified, a KUB was obtained and reported to FNP #N. Resident #3 took her evening medications, refused supper and was transferred to the emergency room at 9 PM on 1/28/11. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented resident #3 had moderately impaired cognition for daily decision making, did not reject care and required 2 person assist total dependence for transfer and toilet use. Record review of IOC (Interdisciplinary Plan of Care) Summary - Part 2 dated 1/13/11 documented "Behaviors none" for resident #3. Record review of electronic Departmental Notes dated 8/04/10 through 2/08/11 documented 1 refusal of an in and out catheterization on 12/19/10. There was no other written documentation that resident #3 refused treatments or medications. Observation on 2/09/11 at 1:47 PM, revealed resident #3 in a wheelchair in her room. Three CNAs (Certified Nurse Aide) came in and transferred resident #3 into her chair to be weighed. Resident #3 had a markedly distended abdomen. Resident #3 denied pain. CNA #T stated resident #3's abdomen was usually big, but it was larger today. CNA #T stated resident #3 does not refuse cares. The resident was observed to be cooperative and followed the CNA's directions with the transfer and weight. With CNA #T translating, resident #3 stated she does not have difficulty passing stool and she does not refuse her medications. Record review of Telephone Orders dated 1/14/11 for resident #3 documented orders for Fleets enema now and everyday, KUB tonight or in the morning and to discontinue [MEDICATION NAME] suppositories (soften stool) every morning. In a telephone interview on 2/10/11 at 1:49 PM, FNP #N stated she was not as upset about resident #3 not getting the Fleets enemas as she was that the resident did not get the GI doctor's ([MEDICATION NAME] - doctor who specializes in disorders of the stomach and intestines) orders. When asked what orders, FNP #N stated, "they aren't on the chart are they? Resident #3 saw the GI doctor on 1/24/11. He sent a prescription for [MEDICATION NAME] tabs (laxative) everyday and increased the [MEDICATION NAME] (increases fluid in intestines to help stool pass) to three times a day. I saw the resident on 1/28/11 because of worsening pain, abdominal obstruction and constipation. I saw the prescription on the chart and asked why it had never been done. The prescription was never transcribed onto an order sheet. I sent her to the emergency room that day. I don't know, and we'll never know, if the treatment the GI doctor ordered would have kept her out of the hospital." Record review of a copy of the orders from the GI doctor's office faxed to the State office on 2/11/11 documented the following: a. Prescription dated 1/24/11 for Sitz Mark x-ray. (This prescription was found in resident #3's medical record.) b. Telephone Orders - no date on orders, but by interview with GI doctor's medical assistant were written on resident #3's office visit on 1/24/11 - 1. (Arrow pointing up) Increase [MEDICATION NAME] 24 mcg to AC (before meals) 2. [MEDICATION NAME] tablets 1 po (by mouth) BID (two times a day) 3. Soap suds enema X 1 (once). 4. [MEDICATION NAME] supp nightly PRN (as needed) These last 4 orders were on the same sheet of Telephone Orders. Record review of resident #3's Medication Administration Record (MAR) for January 2011, confirmed with LVN #Q and/or DON #J, documented the following: a. Fleets enema QD (everyday), order date 1/14/11, is not written on the MAR b. [MEDICATION NAME] 24 mcg (micrograms) take 1 capsule by mouth twice daily. The medication was given from 1/01/11 through 1/28/11 when resident #3 was transferred to the hospital. There is no documentation that the [MEDICATION NAME] was increased to 3 times a day and no documentation of refusal of the medication. c. [MEDICATION NAME] 10 mg (increase movement through the intestines) po bid was circled as not given at 4:00 PM on 1/21/11 through 1/24/11 and 1/28/11. There is no written documentation as to why this medication was not given. d. Soap suds enema administered on 1/24/11 (This was one of the orders from the visit to the GI doctor on 1/24/11. This order was not found documented on any other Telephone Order or prescription sheet anywhere else in resident #3's medical record.) e. [MEDICATION NAME] suppository nightly prn with a beginning date of 1/24/11. (This was one of the orders from the visit to the GI doctor on 1/24/11. This order was not found documented on any other Telephone Order or prescription sheet anywhere else in resident #3's medical record.) f. No written documentation on the MAR for [MEDICATION NAME] tablets 1 BID. Record review of portable KUB (abdominal) x-ray Radiology Report dated 1/28/11 documented in the conclusion "Marked colonic ileus (a condition that is marked by a painfully distended abdomen, among other things, that cause a back-up but not a complete blockage of the intestines) or obstruction. Follow-up is advised. The findings are worse than 01/17/2011." Record review of portable KUB Radiology Report dated 1/17/11 documented in the conclusion "Moderate colonic ileus. Follow-up is advised to monitor for potential colonic obstruction. The findings are improved from 01/15/2011." Record review of Progress Note dated 1/14/11 by FNP #N documented a follow-up secondary to increased (1 arrow pointing upward) size of abdomen. Patient denies pain but admits increase in size. Patient getting Physical Therapy but needs Hoyer lift transfers. Only goes to bedside chair in morning - needs to go after each meal. Impression stated resident #3 is not being toileted as instructed. Record review of Physicians Order Sheet for January documented an order originally dated 5/17/10 to toilet resident #3 on bedside commode after every meal and at bedtime and prn (as needed). Record review of Progress Note dated 1/18/11, FNP #N documented resident #3 had continued ileus with minimal improvement. Trial rectal tube - send back to [MEDICATION NAME]. Record review of Progress Note dated 1/28/11, FNP #N documented follow-up secondary to increased (2 arrows pointing upward) abdominal distention, not eating. [MEDICATION NAME] meds not carried out. KUB shows markedly worse obstruction. Abdomen markedly distended, hard with no bowel sounds only the most random pings. The impression stated worsening abdominal obstruction - unable to eat, in pain, upset tearful doesn't want to go to hospital. Very painful rectum - fearful of rectal exam at hospital but she needs to go out - risk of keeping her here and trying to manage too great. In a telephone interview on 2/11/11 at 9:30 AM, Medical Assistant (MA) #S, from the GI doctor's office, stated resident #3 was seen by the doctor on 1/24/11. At the end of the visit, orders for [MEDICATION NAME] tablets (laxative), soap suds enema and [MEDICATION NAME] suppositories were written on Telephone Order sheet and sent back to the facility with the other paperwork the facility sends to the appointment. A prescription for a Sitz Marker exam was also included in the paperwork packet. In a telephone interview on 2/11/11 at 9:10 AM, Pharmacy Tech #P stated the pharmacy did not receive any orders for [MEDICATION NAME] tabs or to increase [MEDICATION NAME] during the week of 1/24/11. In an interview on 2/11/11 at 10:20 AM, Licensed Vocational Nurse (LVN) #Q confirmed he received the order for the Fleets enema now and QD. '"I put the now order on the MAR and administered the enema, but the QD order was not put on the MAR because when I went in to give resident #3 the Fleets enema, she said she would take it today but she would not take it tomorrow because it was irritating." LVN #Q stated he told FNP #N what resident #3 had said. LVN #3 stated he should have written the QD order for the Fleets enema on the MAR and should have given her the opportunity to refuse the medication on the following days. In an interview on 2/11/11 at 1:35 PM, LVN #R stated on 1/14/11 she saw the physician orders for a Sitz Marker (x-ray study that determines how fast food travels through the bowel) but did not see the page of orders for the medications and treatments. In an interview on 2/11/11 at 10:20 AM, DON #J confirmed she investigated the order for the Fleets enema. There was no response, just a shrug of the shoulders, when asked why the investigation did not include the orders from the GI doctor. DON #J stated the orders from the GI doctor were in resident #3's medical records and did not know why they were not there now. When pointed out there was no documentation that resident #3 refused treatments and medications on the MDS, nurse's notes, MAR and by interview, DON #J stated she and Quality Manager #C are providing education classes on transcribing of orders and documentation. B. Resident #2 Record review of face sheet documented resident #2 was an [AGE] year old woman who was admitted to the facility on [DATE] and re-admitted on [DATE]. The History and Physical documented [DIAGNOSES REDACTED]. Record review on Telephone Orders dated 12/15/10 documented an order for [REDACTED]. Draw PT, INR weekly (Blood tests that check clotting of the blood). Record review of resident #2's recapitulated Physician Order Sheet for January 2011 (printed on 12/22/10) documented an order for [REDACTED]. Take 2 tablets (8 mg) by Mouth Once Daily at 6 PM. At the bottom of the sheet is documented orders reviewed by LVN #L. The order for [MEDICATION NAME] 8 mg was discontinued on 12/15/10 and was not changed to [MEDICATION NAME] 9 mg on the recapitulated orders when the orders were reviewed for accuracy at the end of December. Record review of resident #2's Telephone Orders dated 1/07/11, FNP #N documented "Pt should be on [MEDICATION NAME] 9 mg po qd (ordered 12/15/10). Repeat PT INR in 2 weeks please." Record review of resident #2's MAR for December 2010 documented the following: a. [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg take 2 tablets (8 mg) by mouth once daily at 6 PM was discontinued on 12/15/10. b. [MEDICATION NAME] Sodium ([MEDICATION NAME]) 8 mg po qd, 6 PM, was handwritten onto the MAR. The "8 mg" appeared to have been initially written as a "9" that was changed to an "8" . c. There was no documentation of administration of [MEDICATION NAME] from12/15/10 through 12/24/10, 12/26/10 - 12/27/10 and 12/29/10 - 12/31/10 (15 days) d. All other medications for those dates, except for the [MEDICATION NAME] after 12/14/10, were documented as administered. Record review of the resident #2's MAR for January 2011 (printed on 12/22/10) documented the following: a. [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg tablet, take 2 tablets by mouth once daily at 6 PM. The MAR did not indicate the [MEDICATION NAME] 8 mg was discontinued on 12/15/10 and the MAR was not corrected to reflect the new dose of [MEDICATION NAME] 9 mg when it was reviewed for accuracy at the end of December. [MEDICATION NAME] 8 mg was documented as administered 1/01/11 through 1/06/11, then was marked as discontinued on 1/07/11. b. [MEDICATION NAME] 9 mg po at 6 PM was documented as administered on 1/08/11 through 1/09/11 and 1/12/11 through 1/31/11. There was no written documentation the [MEDICATION NAME] was administered on 1/07/11, 1/10/11 and 1/11/11. Record review of Refill Order Sheet provided by Pharmacy Tech #P, dated 12/21/10, documented a handwritten order for [MEDICATION NAME] Sodium ([MEDICATION NAME]) 9 mg PO QD. The sheet documented it was received by the pharmacy on 12/21/10 at 8:40 PM (during the 2P-10P shift) Record review of copy of Telephone Order faxed on 1/07/11, provided by Pharmacy Tech #P, documented an order for [REDACTED]." In a telephone interview on 2/11/11 at 9:10 AM, Pharmacy Tech (PT) #P stated, "The first documented order for [MEDICATION NAME] 9 mg for resident #2 was received on 1/07/11. A fax of a refill order sheet was received at the pharmacy on 12/21/10 and there was a handwritten request to refill [MEDICATION NAME] 9 mg po qd. There was not an order previously faxed and filled for [MEDICATION NAME] 9 mg. If we weren't too busy we may have faxed it back to the facility telling them to send the order. But if we were busy, it was ignored. The nurses know they cannot fill a new order by writing it on a refill order sheet. We have to have the written physician order." In an telephone interview om 2/10/11 at 1:49 PM, FNP #N stated, "We have a difficult time getting the INR up to 2.0. (International Normalized Ratio to standardize the clotting test [MEDICATION NAME] Time. Normal levels are 1-2, but therapeutic levels to prevent blood clots are 2-3.5). Since the [MEDICATION NAME] 9 mg has been started, the INR has come up to 1.4 which is encouraging. We are fortunate the resident did not suffer a worsening of her condition." During a interview on 2/11/11 at 9:45 AM, LVN #L reviewed the 2P-10P schedule for the 2500 hallway, resident #2's December 2010 MAR and the Telephone Order dated 12/15/10. LVN #L confirmed she worked on the 2500 hallway from 2P-10P on 12/15/10 through 12/17/10 and 12/20/10 through 12/23/10. LVN #L confirmed she noted the order to increase the [MEDICATION NAME] to 9 mg by mouth everyday. LVN #L stated the copy of the order was faxed to the pharmacy. LVN #L stated the [MEDICATION NAME] 8 mg was discontinued on the MAR and the new order for [MEDICATION NAME] 9 mg by mouth everyday was transcribed onto resident #2's MAR. "I then would have removed the discontinued medication from the medication cart and put it in the drug destruction box. But I don ' t remember if I did that with resident #2's discontinued [MEDICATION NAME]." In review of the MAR, the new [MEDICATION NAME] order appeared to be written as an 8 and not a 9. LVN #L stated she wrote 9 mg and did not know who changed the 9 to an 8. LVN #L confirmed there was no written documentation on resident #2 ' s MAR that anyone administered [MEDICATION NAME] 9 mg 12/15/10 through 12/24/10, 12/26-27/10 and 12/29/10 through 12/31/10. LVN #L stated she did not remember if she gave or did not give the [MEDICATION NAME] 9 mg to resident #2. "I forgot to initial some medications." LVN #L confirmed that all other medications she administered to resident #2 on the days she worked were initialed on the MAR. When asked what is done when there is no medication in the drawer, LVN #L stated, "If the medication is not there, I order a refill for the medication on the pharmacy refill form." In an interview on 2/09/10 at 5:10 PM, LVN #O stated, "When new medication orders are received I clarify the patient, that the dosage is correct, the time it is to be given, the diagnosis, notify the family, fax the order to the pharmacy and transcribe the order to the MAR. I pass the information on to the oncoming nurse and also write it on the 24 Hour Report sheet. At the end of the month, each nurse is assigned 10 residents' charts to review for accurate transcription of orders on the monthly recap and the new MAR. If there is anything missing or wrong, I correct it after verifying with the written orders." In record review of the 24 Hour Report and Incident Reporting Review for December 2010 for the 2500 hallway, there were no 24 hour reports for 12/15/10 through 12/17/10. In an interview on 2/11/11 at 9:38 AM, Assistant Director of Nurses (ADON) #M stated if the 24 hour reports are not there then they were not done. "The 24 hour reports are not always used to communicate new orders but I would have expected an increase in resident #2's [MEDICATION NAME] to be there." Assistant Director of Nurses (ADON) #M stated nurses are assigned towards the end of each month resident charts to review for accuracy of the recapitulated orders and the MAR. If there are differences, the orders are reviewed and corrections are made. Record review of INR results for resident #2 and the associated [MEDICATION NAME] dosages are as follows: 12/01/10 - 1.0 (8 mg) 12/16/10 - 1.0 (no [MEDICATION NAME]) 1/03/11 - 1.0 (8 mg) 1/21/11 - 1.1 (9 mg) 1/24/11 - 1.1 (9 mg) 1/31/11 - 1.3 (9 mg) 2/07/11 - 1.4 (9 mg) The dose of the [MEDICATION NAME] was increased and the INR began to increase towards the therapeutic level of 2.0. Record review of Protocol: Physician Orders revised May 2010, provided by Quality Manager #C on 2/10/10, documented in part the following: "10. Discontinue the original physician's order when the physician changes an order that is currently in place. Assure the new order reflects the change. 11. Fax all orders immediately to the pharmacy. 12. Note physician's orders (recaps/renewals, telephone/verbal, or fax orders, etc.) by writing "noted" , dating, and signing with name and title. 13. Confirm accuracy of orders when the new monthly orders arrive from pharmacy. a. Transcription errors b. Errors of omission The universe of 61 residents was from the Resident Roster provided by Nursing Facility Administrator #U on 2/09/11.

Based on observation, interview and record review the facility failed to provide adequate supervision for 1 (resident #1) of 5 residents reviewed who were identified as fall risks. The facility staff failed to supervise resident #1 who had a history of [REDACTED]. On 1/21/11 resident #1 was left unsupervised in the dining room during the night shift, released the self-release belt on the wheelchair he was seated in, and was found seated on his buttocks on the floor. X-rays obtained on 1/26/11 documented a fractured right hip. This failure is likely to have caused resident #1 to sustain a fractured right hip and presents a risk of potential harm to 41 other residents identified by the facility to be at risk for falls. The findings are: Record review of the face sheet documented resident #1 was an [AGE] year old man who was admitted to the facility on [DATE] and re-admitted on [DATE]. The History and Physical dated 9/01/10 documented [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented resident #1 had severe cognitive impairment, had verbal behavioral symptoms directed towards others, behavioral symptoms not directed at others, 1-person total dependence for bed mobility/transfer/locomotion in unit/dressing/eating/toilet use/ personal hygiene/bathing, needed human assist for balance during transitions and walking, had functional limitation in range of motion for both lower extremities and received restorative therapy for active range of motion. Record review of Fall Risk assessment dated [DATE] documented resident #1's Morse Fall Risk Score was 50. 45 or Higher = High Risk for Falls. The Fall Risk Assessment documented resident #1 had impaired gait/transferring and his mental status was forgets or does not know limitations. Factors to Consider documented resident #1 had an unsteady gait, loses balance, poor standing balance, muscle weakness, confusion and motor restlessness. There was no other documented Fall Risk Assessment on resident #1 until he was re-admitted to the facility on [DATE]. Requests were made of the Director of Nurses (DON) #J and Quality Manager (QM) #C on 2/10/11 and 2/11/11 for the policy and procedure on frequency of resident assessments; however, one was not provided. Record review of the Interdisciplinary Plan Of Care Summary - Part 2 dated 11/18/10 documented resident #1 used a wheelchair belt alarm and constantly attempted to remove the belt alarm. Record review of the Care Plan, last review date of 11/19/10, documented Problem: Potential for Injury: falls related to cognitive deficits with poor safety awareness, attempts to stand unassisted, history of previous falls, loses balance easily and unsteady gait. The Interventions included reminders and encouragement to use the call light, to have a wheelchair alarm and to have a bed alarm. There is no written documentation on the care plan that resident #1 removes his wheelchair seat belt alarm, unclips his bed alarm and requires supervision. Record review of Resident Incident Report dated 1/21/11 documented resident #1, at 4:45 AM, "was anxious and wandering around in w/c (wheelchair). He went to dining room and fell . Pt. (patient) has a bruise below outer aspect of Rt (right) elbow. Head to toe assessment done Tylenol given for pain." Resident Condition at Time of Incident documented resident #1 was administered Tranquilizers/Sedatives in the past 8 hours, had a history of [REDACTED]. Record review of the Provider Investigation Report dated 1/29/11 documented resident #1 "was found to have Fx (fracture) R (right) hip from an x-ray on 1/27/11." The incident date was documented as 1/26/11 and the location was the Physical Therapy Room. The Provider Response stated "on 1/21/11 resident had fall with (no) apparent injuries. Resident was assessed and denied pain. On 1/26/11 resident was in Physical Therapy c/o (complained of) severe pain to (right) hip. (Physician) was notified. X-ray to (right) hip was done. Resident found to have Fx R femoral neck. Res was sent to (hospital). Provider Action Taken Post-Investigation stated resident "will be monitored more closely. Fall precautions in place i.e. chair alarm, bed alarm. Call light, adapt as needed." Record review of portable Radiology Report dated 1/22/11 documented resident #1 had mild osteoarthritis of the right hip but no fracture or dislocation was seen. Record review of Progress Note dated 1/26/11, resident #1's primary physician documented "pt had a fall a few days ago. R hip x-ray showed no fracture or dislocation only joint narrowing from OA (osteoarthritis). Pt c/o right thigh pain - able to do PT (physical therapy). Right leg contusion (bruise) - will get x-ray of femoral area." Record review of portable Radiology Report dated 1/26/11 of right femur documented the femur showed osteoporosis and there was an impacted femoral neck fracture new since 1/22/11. Record review of the hospital Final Report of the right femur x-ray documented resident #1 had a suspected right femoral neck fracture. There was no documentation of osteoporosis. Record review of Nursing Rehab/Restorative Program, PT, dated January 2011 documented on 1/24/11 that resident #1 complained of pain to groin area and the nurse was notified. On 1/26/11, there was documentation that resident #1 complained of groin pain and the nurse was notified. Observation on 2/09/11 at 8:12 AM, revealed resident #1 lying in bed, awake, alert but confused. He refused to eat breakfast and wanted a health shake. Restorative Nurse Aide (RNA) #A encouraged him to drink his milk. A landing mat is folded up and is at the foot of the bed which is in the low position. RNA #A stated resident #1 is supposed to have a bed alarm, but confirmed it is not on him nor is there a bed pad alarm on the mattress. RNA #A stated resident #1 sometimes tries to get up without assistance and is sometimes combative with care. RNA #A stated resident #1 also has a wheelchair with a self-release belt that has an alarm. In an interview on 2/09/11 at 8:27 AM, Licensed Vocational Nurse (LVN) #B stated resident #1 has a low bed, bed and wheelchair alarms and a mat on the floor to try to prevent injuries and falls. When LVN #B accompanied surveyor to resident #1's room, there was a clip alarm attached to the resident. LVN #B stated when RNA #A informed LVN #B there was no alarm on resident #1's bed, LVN #B gave a clip alarm to RNA #A to place on resident #1. Observation on 2/09/11 at 4:52 PM, with Certified Nurse Aide (CNA) #H, revealed resident #1 lying in bed. The clip portion of the alarm that clips to the resident's clothing was attached to his gown, but the alarm box laid on the bed and not attached to anything. (Tab/Clip alarms clip on the back of the resident's clothing and if they move too far the pull cord will release the magnet or tab and the alarm will sound.) CNA #H stated she attached the alarm box to the sheet underneath resident #1's pillow, but he removed it. Observation on 2/09/11 at 10:40 PM, revealed resident #1 lying in bed, agitated. The clip alarm is attached to his clothing but the body of the alarm laid on the bed and was not attached to anything. In an interview on 2/09/11 at 4:40 PM, CNA #G stated resident #1 will remove his seatbelt and stand up without calling for assistance. CNA #G stated resident #1 will also remove the clip alarm and will not use the call light. CNA #G stated the CNAs will try to chart at the computer closest to wherever he is so they can watch him and catch him before he tries to get out of his bed or wheelchair. In an interview on 2/09/11 at 10:27 PM, LVN #I stated resident #1 was up a lot at night due to sleep disturbance. LVN #I stated the staff tried to put him in bed that night but he refused so he was up in his wheelchair with the self-release belt in place. Resident #1 wandered around the nurse's station where they could keep an eye on him because he tried to pull the alarm off and stand up. LVN #I stated resident #1 was still in the wheelchair in the dining room (next to the nurse's station) and it was the busy time of the morning. Everyone (2 LVNs and 4 CNAs) were busy and no one was watching resident #1. " At 4:45 AM, I heard his seat belt alarm sound and the CNAs came and told me resident #1 was on the floor. I assessed him and he could move his arms and legs and did not complain of pain. We got him up and took him back to his room so I could further assess him. He did not complain of pain until the night of 1/22/11. I called the doctor and we got an x-ray that was negative for a fracture of his right hip. In an interview on 2/10/11 at 2:40 PM, LVN #B stated resident #1 "complained of right leg pain during therapy on 1/26/11. That was the first time I was notified that he was having pain. Resident #1's Primary Care Physician (PCP) was in the facility and I notified her. The PCP examined resident #1 and ordered an x-ray of the right hip. The x-ray revealed a fracture of the right hip. There was no report that he had fallen after the fall on 1/21/11." Record review of Protocol: Falls Management revised November 2010, provided by Quality Manager (QM) #C on 2/10/11, documented in part the following: a. Implement Plan of Care-Fall Risk Reduction based on individual resident/patient needs. b. Implement interventions to reduce risk in residents/patients with irregular gait balance and weakness. c. Implement interventions to reduce risk in residents/patients with confusion. d. Review and revise Interdisciplinary Plan of Care, individualize to resident. The universe of 42 residents at risk for falls was provided by Nursing Facility Administrator #U on 2/09/11.

Based on interview and record review, it was determined that the facility failed to ensure that 1 (ID#1) of 27 sampled residents was free from verbal abuse as evidenced by: A) Licensed Vocational Nurse (LVN) #F verbally abused and yelled at resident #1 when resident had asked her for pain medication for her knee and was given the wrong medication. LVN #F kept raising her voice at resident #1 and repeating herself that she understood, causing resident to cry. This failure placed residents who resided in one of two floors (second floor) of the facility where LVN #F worked, at risk of being abused. The findings include: 1) Review of closed medical record face sheet for resident #1 revealed resident was a [AGE] year-old female who was admitted to the nursing facility on 10/01/10 with [DIAGNOSES REDACTED]. Review of the Hospital Operative Report revealed that on 09/28/10 resident #1 underwent a Total Knee Arthroplasty with Navigation (Total Knee Replacement). Review of Minimum Data Set (MDS) Admission assessment dated [DATE] revealed resident #1 was able to determine attention, orientation and ability to register and recall new information under cognitive patterns and had no behavior symptoms. In a telephone interview on 10/27/10 at 5:10 PM, resident #1 stated that she had been admitted to the nursing facility on 10/01/10 for therapy due to having a total right knee replacement. Resident #1 stated that on 10/09/10 (Saturday) at 4:00 PM, she had told Certified Nurse Aide (CNA) #O to ask LVN #F for pain medication for her knee. CNA #O returned and informed her that LVN #F would be bringing her medication. At 4:40 PM, resident #1 was still waiting for her pain medication, got up and as she was leaving her room, LVN #F was at the entrance of her room out on the hall with her medication cart. She told LVN #F in Spanish that she needed her pain pill as she pointed at her right knee. LVN #F gave her a round pill and resident told her that was not her pain pill and placed the cup with the round pill on the medication cart. She went to the nurse's station and asked another nurse, LVN #D, who was Hispanic, that her right knee was hurting, that she had asked the nurse for pain medication and the nurse had given her the wrong medication. LVN #D went with her to inform LVN #F that she needed her pain medication and LVN #D returned back to the nurse's station. Resident stated that LVN #F was very mad and started yelling at her. Resident #1 started crying as she explained what had happened to her on that day. The resident continued by saying that when LVN #D was going back to the nurse's station, she heard LVN #F yelling at her, turned back and told LVN #F that she had no right to yell at the resident. Resident #1 received her pain medication from LVN #F and stated that she felt very bad after the incident and wanted to cry at that point. She returned to her room and sat on her bed, was very sad and felt bad and helpless because she was not able to defend herself. LVN #D then followed her to her room, hugged her and told her that everything was going to be okay. The following day on Sunday, Social Services Employee #J spoke with her and gave her a plain sheet of paper for her to write a statement of what had occurred the previous day. Resident stated that she hesitated in writing and turning in a statement because she was afraid LVN #F might hurt her or get someone else to hurt her. Resident mentioned that she knows that LVN #F has the keys to the medication cart for other residents and was afraid she might want to hurt her by giving her medications belonging to other residents. She said that after the incident, she was worried and was not able to sleep at night. Resident stated that during the time she was at the nursing facility for rehabilitation, she did very good with her therapy. She was discharged home on[DATE] and has been coming to the nursing facility for outpatient therapy. Resident stated that she needs surgery to her left knee and had plans to return to the nursing home but was afraid LVN #F might be there and retaliate against her. She stated that for the past 3 days at home, she has been taking her sleeping pill because she has not been able to sleep. 2) In a telephone interview on 10/25/10 at 3:17 PM, LVN #D stated that on the day of the incident on 10/09/10 around 4:00 PM, she was at the nurse's station and LVN #F was out in the hall in front of resident #1's room. Resident #1 approached her and told her that she had asked LVN #F for her pain medication because she had knee pain. LVN #D identified resident #1 to be very oriented and with it, knew her medications, knew what was going on and was a very humble and sweet lady. The resident speaks only Spanish. LVN #F, who is Nigerian, understands a little bit of Spanish and misinterprets what you are saying. Resident #1 told her that LVN #F was trying to give her two Tylenols for pain and she told the nurse that she wanted her pain medication which was stronger than Tylenol. The resident told her that LVN #F was not listening to what she was telling her. They both went to LVN #F and she explained to the nurse that resident #1 had knee pain and wanted her pain medication. She told her that she did not want Tylenol but the stronger pain medication that was oval shaped. LVN #F stated that she was not trying to give resident Tylenol but her 4:00 PM medications as she demonstrated to LVN #D. LVN #F told her that if resident #1 wanted her pain medications she could always ask her in Spanish "medicina para dolor" (medication for pain) saying that she understood very well. LVN #F kept repeating the same statement over and over to resident #1, "Medicina para dolor! Medicina para dolor! Why doesn't she tell me!" LVN #F was rude and getting very upset, was excited as her tone of voice was getting louder and louder out in the hall to the point that she looked like she wanted to explode! It made resident #1 uncomfortable causing resident to cross her arms and lower her head down. LVN #D stated that she had to intervene by physically getting in between resident #1 and LVN #F and assuring resident that she was going to get her medication. She took resident #1 to her room to see if LVN #F would calm down, but LVN #F kept talking and talking repeating over and over the same subject and would not stop. She tried to get LVN #F to be quiet by telling her that it was okay because she and resident #1 had understood her message. LVN #D stated that she immediately notified the weekend supervisor Registered Nurse (RN) #E. RN #E later told her that she had gone to speak to resident #1 and resident started crying as she was telling her about the incident. 3) In a telephone interview on 10/27/10 at 9:00 AM, RN #E stated she was the weekend supervisor and had been informed by LVN #D around 7:30 PM that resident #1 needed to talk to her regarding an incident that occurred on 10/09/10. During the interview with resident #1, she complained that around 4:20 PM, she had asked LVN #F for a pain pill, the nurse had given her [MEDICATION NAME], so she refused it. The resident then went to ask another nurse, LVN #D, for a pain pill so both the nurse and resident #1 went to LVN #F and asked for resident's pain medication. LVN #F told LVN #D that she had already given resident #1 her pain pill which wasn't true. LVN #F then got upset and started yelling at the resident and telling her that she only had to ask her for her medications and not any other nurse. LVN #D interrupted LVN #F by telling her that if she needed someone to translate for her in Spanish, just to ask her. Resident #1 told her that LVN #F had treated her really bad and started crying as she explained what had occurred on that day. RN #E identified resident #1 as being alert and oriented to person, place and time. She stated that resident #1 knew all of her medications, the shape and the color. Resident #1 had surgery on her right knee and was at the nursing facility for therapy. She was on scheduled pain medication which she was receiving every 6 hours due to having a lot of pain to her right knee. The resident would get her pain medication at 6:00 AM and would then go to therapy at 10:00 AM every day. She said that LVN #F was not fluent in Spanish and only knew a few words in Spanish like pain, hungry and sleepy. She gave a blank sheet of paper to resident #1 so that she could write a statement regarding the incident. RN # E stated that she had not informed Director of Nurses (DON) #G immediately about the incident but had documented it in the weekend report. 4) In an interview on 10/27/10 at 2:50 PM, Social Services Employee (SSE) #H identified resident #1 as being a Spanish speaker, spoke a few words in English, as being alert and oriented to person, place, time and was aware of her surroundings. She stated that on Sunday the following day after the incident, she had spoken to resident #1 right before dinner time. Resident #1 told her that around 4:00 PM she had asked for her pain pill and LVN #F had said that she would be right there. She went to her room and waited until 4:40 PM. At that time resident had gone out again to ask LVN #F for her pain pill. The nurse gave her a pill, resident stated she looked at it and told LVN #F that it was not the right pill. LVN #F said "yes it is". Resident #1 told LVN #F that her pain pill was oval and she had given her a different pill. Resident went to ask LVN #D for her pain medication. LVN #D was trying to explain to LVN #F what resident #1 needed, but LVN #F kept saying in Spanish that she knew what pain was. Resident told her that LVN #F was getting upset because LVN #D was trying to explain what she needed. Resident #1 stated that LVN #F started yelling at resident #1 in her face. LVN #D then got in front of LVN #F because she was getting very upset. The resident said that she felt very bad after the incident and could not understand why the nurse got mad if that was her job. SSE #H stated that resident #1 told her that she did not want LVN #F caring for her anymore. SSE #H stated that after she had spoken with resident #1, she was okay and noted no negative effects or emotional distress. 5) In an interview on 10/26/10 at 3:45 PM LVN #F, alleged perpetrator, stated that she works the 2:00 PM to 10:00 PM from Monday through Friday and does not work on weekends only when needed. LVN #F denied yelling and being verbally abusive with resident #1. She stated that she knew a few words in Spanish enough to deal with the patients. LVN #F stated that on the day of the incident it was approximately 7:00 PM when she was passing the evening medications and as she arrived to resident #1's room, resident was already standing up at the door with her walker. She handed resident her [MEDICATION NAME] with a cup of water. Resident #1 looked at it and mumbled something in Spanish which she did not understand. Resident #1 then went to talk to LVN #D at which time LVN #D went and rudely told her that the resident knew what she gets. She went on by saying if she had a problem with that, then she should call her. She told her that if she did not understand Spanish, then there was no need for her to work in a Spanish Community. LVN #D told her that resident needed her pain pill and that she had given her Tylenol. LVN #F stated that she had given resident #1 her [MEDICATION NAME]. She stated that she had apologized to resident #1 for the delay and misunderstanding. LVN #F stated that she had never been accused before and had been suspended for one week. She was in-serviced on Abuse Prohibition and Resident Rights. LVN #F stated that when she returned back to the nursing facility, DON #G had informed her that there was a miscommunication. 6) In an interview on 10/28/10 at 8:20 AM, DON #G stated that she was a little disappointed with LVN #D, LVN #F and RN #E the weekend supervisor. She stated that RN #E did not talk to resident #1 after the incident. LVN #D did not report the incident to RN #E right away until the following day. RN #E did not talk to LVN #F. DON #G reported that the Social Services Director (SSD) #I had texted her on Sunday and had informed her about the incident regarding LVN #F causing resident #1 to cry. She texted the weekend supervisor RN #E telling her that SSD #I said that LVN #F had made resident #1 cry when she had asked for a pain pill. DON #G texted SSD #I asking if resident was okay. DON #G stated that a couple days later on Tuesday 10/12/10 she had spoken with resident #1 and had asked her in Spanish how she felt after the conversation she had with LVN #F. Resident #1 was quiet for a minute and responded "okay" in Spanish. DON #G stated that she had interviewed LVN #F who denied being verbally abusive with resident #1. DON #G stated that LVN #F did not understand resident #1 wanted a pill. During interview with LVN #F she had told her that she knew enough words to communicate to residents. LVN #F said a phrase in Spanish . . ."Tengo dolor mi" (Have pain me) and stated that it meant "If they have pain they can come to me". DON #G said that as the interview progressed LVN #F's voice kept getting louder. DON #G stated that the incident investigation was unconfirmed. She did believe LVN #F raised her voice, it did happen. She did not think her intention was to hurt her. 7) In a telephone interview on 10/28/10 at 3:06 PM, SSD #I stated that he was a Licensed Social Worker in Texas and works at the nursing facility 15 to 20 hours a week during the evening and at times on weekends. He stated that he had worked on Sunday 10/10/10 and the weekend supervisor RN #E had mentioned the incident involving resident #1 to him before dinner that day. RN #E mentioned that the incident had occurred the night before. He asked the nurse if she had informed DON #G, written a report because this was a serious incident because resident #1 was crying. He told DON #G that she had to inform either the Nursing Facility Administrator (NFA) #C or DON #G immediately. He stated that he did not call the State but had informed DON #G and she told him that the weekend supervisor RN #E would call it in and she would tell her what to do. SSD #I said that the following day DON #G had asked him to do a follow-up on the incident. He visited resident #1 and she stated that she was fine, laughing and said she felt the nurse was not understanding her. Resident #1 told him that she was in pain so she went with another nurse to ask her for pain medication. 8) Review of facility policy provided by the NFA #C on 10/25/10 entitled Abuse Prevention, revised 05/2010 revealed, in part: The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Verbal Abuse -- Oral, written or gestured language that includes disparaging and derogatory terms to the resident/patient or their families or within their hearing distance, to describe resident/patient, regardless of their age, ability to comprehend or disability. The universe of 176 was obtained from the CMS-672 dated 10/26/10 provided by Director of Nurses #G.