Every finding on record at Mystic Park Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure that each resident had the right to secure and confidential personal and clinical records for 1 of 1 resident (Resident #1) reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #1's clinical information was not sent to other facilities without the resident's and responsible party's permission. This failure could result in residents' personal information being exposed to unauthorized individuals. Based on interview and record review, the facility failed to ensure that each resident had the right to secure and confidential personal and clinical records for 1 resident (Resident #1) reviewed for Privacy and Confidentiality. The facility failed to ensure resident #1's clinical information was not sent to other facilities without the resident's and responsible party's permission. This failure could result in residents' personal information being exposed to unauthorized individuals. Findings included: Record review of the Face Sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included altered mental status, (a sudden or significant change in a person's baseline awareness, cognition, or consciousness), hallucinations (sensory experiences that seem entirely real but are created by your mind without an actual external stimulus), and Type 2 diabetes mellitus without complications (indicates the body doesn't use insulin properly but hasn't sustained damage to the kidneys, nerves or eyes). Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. Record review of Resident #1's initial Care Plan dated 6/29/26 indicated she used anti-anxiety medication for anxiety and had impaired cognitive function or impaired thought processes related to a new environment. Record review of Resident #1's Elopement Assessment revealed she had a cognitive impairment or diagnosis associated with impaired judgment or wayfinding (for example dementia, Alzheimer's disease, delirium, psychosis, severe mood disorder); she has a history of elopement or an attempted elopement while at home; the family or responsible party expressed concern that the resident may attempt to leave the facility unsafely, and the resident has verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Record review of the hospital discharge notes dated 06/27/26 revealed Suspect some dementia with psychosis, Neurology consulted, continue with low-dose Seroquel and as needed antipsychotics, possibly has Lewy body dementia (a progressive brain disorder caused by abnormal protein deposits, called Lewy bodies, in the brain). Will need outpatient neuro for further evaluation. There was also a note that reflected [NAME] dependence - counseling done - continue to wean off. Record review of Resident #1's Progress Notes dated 06/30/26 by the Social Worker indicated SWr sent transfer referrals for [Resident #1] to [area nursing facilities] as per [Resident #1's] wishes. Interview on 07/02/26 at 10:18 a.m. with FM A, revealed that Resident #1 entered the facility on 06/27/26 from the hospital. Resident #1 had taken the medication, temazepam, for over 2 years and was asking for it. Resident #1 and the family were told that it had not been prescribed but they could give her something else to help her sleep. FM A stated they thought the nurse had told them they could bring her medication from home so that was what they did, and they put it in Resident #1's purse in her bedside table. FM A stated she did not read the list of prohibited items when she signed the admission paperwork since a nurse did the paperwork with her and just told her where to sign. FM A stated when they told the nurse they had brought it, she said it could not be in the resident's room and had to be prescribed by the doctor. FM A stated the nurse then proceeded to take the medication out of the room which then upset the resident. FM A then stated that a couple of days after the incident, the family was told the resident could not stay there and needed to find alternate placement. FM A stated no discharge notice was given. FM A stated they had already discussed placement with a memory care facility and were just waiting for the facility to complete remodeling of the room which would take at least a week. FM A stated the insurance had told them Resident #1 could receive rehab at the current facility until July 16, 2026. During an interview on 07/02/2026 at 1:05 pm, FM A stated she felt things were going better now but FM B was receiving calls from other facilities about admission which neither family member had requested. FM A was afraid the facility was going to force them to leave due to the medication issue and they really wanted Resident #1 to just make one move to the memory care unit. During an interview with the Adm Dir on 7/2/26 at 2:15 pm, the admissions and discharge processes were discussed. The Adm Dir stated they started doing discharge plans at admission. The Adm Dir stated they did have a list of items that could not be brought into the facility, such as medication, which was in the admission Packet, and she went over that with the family during the admission process. During an interview with the ADON on 7/2/26 at 2:35 pm, the ADON stated the facility started the discharge process at admission. The ADON stated We have weekly meetings and make sure the resident had a safe place to discharge. The ADON stated therapy and the doctor had input into the discharge process. The ADON stated they conducted a 72-hour care plan meeting and discussed discharge plans at that time. She stated the facility could provide the family options for facilities, and they gave them a list of facilities that may be able to take the resident. During an interview with the Social Worker on 07/02/26 at 3:10 pm, he stated the team had a 72-hour care plan meeting to discuss discharge plans. He stated they normally asked the family if they had a preference to see if they had a certain facility or part of town, they wanted resident to be in. The Social Worker was asked how he knew that Resident #1 wanted to move. The Social Worker stated that Resident #1 had asked to move and told me she didn't want to stay but the family didn't want to move her. Since the resident only spoke Spanish, the Social Worker was asked if he was able to speak with Resident #1 in Spanish. The Social Worker stated that he had some nurses translate for him and through the nurses notes I did confirm with her that she wanted to move. The Social Worker then stated that Resident #1 has a BIMS score of 13, so he doubted that she had dementia and said, with that score, I'm not sure she has a diagnosis of dementia. The Social Worker further stated that he knew the family wanted her to go to a local memory care unit, but he didn't know if she would qualify. The Social Worker stated he sent out referrals based on the request of Resident #1. During an interview with the Ops Manager on 07/02/26 at 5:07 pm, the issues regarding the family's concerns of not giving permission to send clinical information to other facilities was discussed as well as the issue with medication concerns. The Ops Manager stated the facility usually assisted families in finding alternate placement and was not aware Resident #1's family had already made other arrangements. He felt the discussion about alternate placement was held during the initial care plan meeting. During an interview with the MDS Coordinator on 07/02/26 at 5:15 pm, she stated the team met on 06/29/26 for the 72-hour care plan meeting. The MDS Coordinator stated the POA, FM B, was on the phone for the meeting. She said they discussed the fact the facility did not have a Medicaid Pending bed so she would need to find alternate placement. During an interview on 07/02/26 at 5:20 pm, the Ops Manager pointed out the documentation from the care plan meeting that reflected IDT team called [POA] to have the initial care plan because Resident #1 was asleep (and sometimes confused). The team confirmed that she wanted LTC and SWr is to assist in finding her LTC as [facility] doesn't have a Medicaid pending bed. During a phone interview on 07/02/26 at 5:30 pm, FM B/POA was asked about the discussion at the meeting. FM B stated Resident #1 liked the facility and wanted to stay but the facility told her they didn't have a Medicaid pending bed. FM B/POA stated she told them she would find placement for Resident #1 and did not ask for referrals to be sent to other facilities. FM B/POA further stated she and FM A were told the day after the meeting by the Social Worker and his assistant Resident #1 could no longer stay at the facility. The FM B/POA stated she didn't know what had changed, except for the issue with medication which had been resolved, since the initial agreement was that Resident #1 was going to get therapy in the facility until July 16th and would then either discharge to their preferred memory care unit or they would have to pay $218 per day which the family agreed to do if needed. FM B/POA stated she did not believe it was right that Resident #1's information had been shared with other facilities without her permission. She further stated she just wanted to stop receiving calls and emails from those facilities. Record review of the undated Policy/Procedure for Discharge Planning Process:The Facility's discharge planning process shall:Provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the Facility.d. Involve the interdisciplinary team (IDT) in the ongoing process of developing the discharge plan. The IDT shall include: the resident's attending physician, a registered nurse and nurse's aide with responsibility for the resident, a staff member from food and nutrition services, the resident and the resident's representative (to the extent possible). h. Document that a resident has been asked about their interest in receiving information regarding returning to the community. i. If the resident indicates an interest in returning to the community, the Facility shall document any referrals to local contact agencies or other appropriate entities made for this purpose. 4. The Facility shall document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

Based on observation, interview and record review, the facility failed to 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 for 1 of 5 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1 had pink neon tape on her wheelchair brakes as stated in her comprehensive care plan. This deficient practice could place residents at risk of receiving improper care and services. The findings included: Record review of Resident #1's face sheet dated 06/30/2026 revealed an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, unspecified (progressive memory loss and cognitive decline) and unsteadiness on feet. Record review of Resident #1's MDS assessment, dated 06/06/2026, revealed a BIMS score of 0 out of 15 indicating the resident's cognition was severely impaired. Further review of the MDS under Section J - Health Conditions indicated Resident #1 had 2 or more falls' in section J1800. Any falls since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS), whichever is more recent. Record review of Resident #1's care plan, dated 5/28/2024, revealed a focus area for the following: At risk for falls r/t poor mobility, muscle wasting and atrophy- multiple sites, weakness revised on 11/21/2024, with interventions that included 11/5/24: Pink neon tape applied to WC brakes initiated on 07/19/2025. Observation on 06/30/2026 at 10:45 a.m., revealed Resident #1 was asleep in her room with a wheelchair by her bedside with no pink neon tape on the brakes. During an interview on 06/30/2026 at 1:01 p.m., CNA A stated they had access to Resident #1's care plan through their Kardex. CNA A stated Resident #1 was a fall risk, and CNA A was unsure of the fall interventions in place for Resident #1, they could access the Kardex which would show the interventions. CNA A stated they could not remember seeing pink neon brakes on Resident #1's wheelchair brakes. CNA A stated the risk of not following interventions on a comprehensive care plan could be falls occurring. Observation on 06/30/2026 at 1:13 p.m., revealed Resident #1 being pushed by staff in a wheelchair, with no neon pink tape on the brakes, to the common area. During an interview on 06/30/2026 at 1:14 p.m., LVN B stated Resident #1 has had falls in the past. LVN B stated they had access to Resident #1's care plan with their fall interventions listed. LVN B stated on the morning of 06/30/2026 LVN B had switched Resident #1's wheelchair to a smaller wheelchair which LVN B stated they felt was safer for Resident #1. LVN B stated Resident #1's original wheelchair had pink neon tape on their wheelchair brakes, but the one Resident #1 was currently in did not. LVN B stated the pink neon tape to Resident #1's wheelchair was used to help Resident #1 use the wheelchair breaks. LVN B stated the risk of not following interventions on a comprehensive care plan could lead to consequences for the residents. During an interview on 06/30/2026 at 1:36 p.m., the DON stated nurses had access to resident's care plans and CNAs had access to residents Kardex's, and that both the care plan and Kardex showed interventions in place for residents. The DON stated nursing staff should be ensuring the interventions on resident's care plans were put in place. The DON stated LVN B should have contacted the ADON if LVN B felt the current wheelchair for Resident #1 was no longer safe for Resident #1. The DON stated the risk of not following interventions on a comprehensive care plan could lead to the potential for falls. Record review of the facility's policy titled, Fall Management System, dated 10/25, revealed: Policy: It is policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 8 residents (Residents #79, #5 and #25) reviewed for infection control:1. During the medication pass, the facility failed to ensure LVN H used appropriate hand hygiene between glove changes and when moving from a clean area to a dirty area when administering medication to Resident #79.2. During the medication pass, the facility failed to ensure Med Aide G used appropriate hand hygiene between glove changes and when moving from a clean area to a dirty area when administering medication to Resident #5.3. During the medication pass, the facility failed to ensure LVN F wiped the rubber seal to Resident #25's insulin pen with an alcohol swab prior to administering insulin.These failures could place residents at-risk for infection due to improper care practices.The findings included:1. Record review of Resident #79's face sheet dated 4/2/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included seizures, dementia, and gastrostomy status (medical procedure in which an opening is created through the abdominal wall directly into the stomach).Record review of Resident #79's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitive impaired for daily decision-making skills and was treated with an anti-convulsant.Record review of Resident #79's Order Summary Report dated 4/2/26 reflected the following:- Levetiracetam oral solution 100 mg/ml, give 15 ml via PEG-tube (gastrostomy tube) every 12 hours for seizures with order date 1/9/25 and no end date.Record review of Resident #79's comprehensive care plan with revision date 12/12/25 reflected that the resident had an alteration in neurological status related to epilepsy (seizures) with interventions that included to give medications as ordered.During an observation of the medication pass on 4/2/26 at 8:04 a.m., LVN H, after preparing Resident #79's Levetiracetam for administration, locked and moved the medication cart aside, LVN H returned to the resident's bedside, drew the resident's privacy curtain, then put on a pair of gloves without washing or sanitizing her hands. LVN H, while wearing the gloves, took the resident's bed remote to raise the bed, moved the bedside table and removed her gloves. LVN H then put on a pair of gloves, did not wash or sanitize her hands, and administered the resident's Levetiracetam medication through the gastrostomy tube. During an interview on 4/2/26 at 8:16 a.m., LVN H stated she had forgotten to sanitize her hands between changing gloves and when touching Resident #79's bed remote and bedside table. LVN H stated, it was important to perform proper hand hygiene between glove changes and when moving from a clean area to a dirty area to prevent cross contamination.2. Record review of Resident #5's face sheet dated 4/2/26 reflected a [AGE] year-old male admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included diabetes, infection following a procedure, superficial incisional surgical site, need for assistance with personal care, and infection of amputation stump, left lower extremity and osteoarthritis.Record review of Resident #5's most recent comprehensive MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills and was treated for pain.Record review of Resident #5's Order Summary Report dated 4/2/26 reflected the following:- Lidocaine External Patch 4%, apply to left shoulder topically one time a day for pain and remove per schedule with order dated 3/20/26 and no end date.Record review of Resident #5's comprehensive care plan with revision date 1/13/26 reflected the resident had primary osteoarthritis to the left shoulder with interventions that included to give analgesics as ordered by the physician.During an observation of the medication pass on 4/2/26 at 8:56 a.m., Med Aide G administered oral medications to Resident #5, then obtained the Lidocaine patch and a pair of gloves and placed them on the resident's bedside table. Med Aide G then drew Resident #5's privacy curtain, did not wash or sanitize her hands, and put on a pair of gloves. Med Aide G then pulled back Resident #5's shirt and placed the lidocaine patch on the resident's left shoulder.During an interview on 4/2/26 at 9:13 a.m., Med Aide G stated she forgot to sanitize her hands after preparing Resident #5's medications, and after drawing the resident's privacy curtain. Med Aide G stated she should have washed or sanitized her hands before putting on gloves because it was cross contamination and an infection could be passed to the resident or to other residents if not utilizing proper hand hygiene.During an interview on 4/3/26 at 8:20 a.m., the DON stated, it was her expectation, when moving from a clean area to a dirty area that the staff should perform proper hand hygiene to prevent or minimize infection.3. Record review of Resident #25's face sheet dated 4/2/26 reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included type 1 diabetes with hyperglycemia (the body's inability to produce insulin to regulate sugars), long term use of insulin, heart failure, end stage renal disease (the kidney's inability to filter waste and toxins from the blood) and dependence on renal dialysis (a medical treatment that replaces some of the functions of the kidneys).Record review of Resident #25's most recent MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills and was treated with insulin.Record review of Resident #25's Order Summary Report dated 4/2/26 reflected the following:- Humalog insulin 100 units/ml, inject 7 units subcutaneously before meals related to diabetes with order date 4/26/25 and no end date.- Humalog insulin 100 units/ml, inject as per sliding scale subcutaneously before meals and bedtime related to diabetes with order date 4/26/25 and no end date.Record review of Resident #25's comprehensive care plan with revision date 5/23/24 reflected the resident had diabetes with interventions that included to administer diabetes medication as ordered by the doctor.During an observation on 4/2/26 at 3:57 p.m., LVN F retrieved Resident #25's insulin pen from the medication cart and inserted a needle into the insulin pen without sanitizing the rubber seal with an alcohol swab.During an interview on 4/2/26 at 4:02 p.m., LVN F stated she had forgotten to sanitize the rubber seal to Resident #25's insulin pen before inserting a needle into the rubber seal and before injecting Resident #25 with insulin. LVN F stated, cleaning the rubber seal of the insulin pen with an alcohol swab was an important step because it prevented contamination and because you are puncturing the rubber seal with a needle used on the resident. During an interview on 4/3/26 at 8:15 a.m., the DON stated, the rubber seal of an insulin pen was supposed to be cleaned with an alcohol swab prior to inserting the rubber seal with a needle to prevent cross contamination. The DON stated that if cross contamination occurred the resident could get an infection.Record review of LVN F's Insulin Administration Competency Training dated 1/20/26 reflected LVN F had satisfied the requirements for administering insulin. LVN F's Insulin Administration competency training reflected in part, .Remove insulin from drawer and wipe the top of bottle with alcohol.Record review of the facility document titled Infection Prevention and Control Program, undated reflected in part, .The objective of the Infection Prevention and Control Program is to establish written standards, policies and procedures for a system of preventing, identifying, reporting, investigating, and controlling infections following accepted national standards for all residents, staff, volunteers, visitors, and other individuals providing services.The hand hygiene procedures will be followed by staff involved in direct resident contact.Record review of the facility document titled Prevention of Infection, IPCP - Hand Hygiene, undated reflected in part, .This facility considers hand hygiene the primary means to prevent spread of infection.Wash hands with soap.and water for the following situations.When hands are visibly soiled.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap.and water for the following situations.Before and after direct contact with residents.Before moving from a contaminated body site to a clean body site during resident care.After contact with objects.in the immediate vicinity of the resident.After removing gloves.The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 6 residents (Resident #88) reviewed for PASRR assessments. The facility did not refer Resident #88 to the appropriate state-designated mental health authority for review with the diagnoses of MDD and PTSD. This failure could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized services.The findings included: Record review of Resident #88's admission sheet dated 5/05/2023, with an original admission date of 01/18/2022 documented a [AGE] year-old male resident with diagnoses including cerebral infarction (stroke), type 2 diabetes mellitus, MDD, spinal stenosis (the narrowing of one or more spaces within the spinal canal), PTSD, anxiety, and hypertension (high blood pressure). Record review of Resident #88's quarterly MDS assessment, dated 01/05/2026 documented a BIMS score of 15 indicating intact cognition. Further review of the resident's assessment recorded in Section I - Active Diagnoses, Psychiatric/Mood Disorder, the diagnoses of I5900. Depression and I6100. Post Traumatic Stress Disorder. Record review of Resident #88's order summary included an active order for the antidepressant medication Celexa, with an order date of 5/05/2023. Celexa was ordered as Celexa 10 mg, Give 1 tablet by mouth one time a day for depression. Record review of Resident #88s January 2026 MAR documented the resident was receiving Celexa as prescribed. Record review of Resident #88's care plan with an initiation date of 11/17/2024 noted the resident is At Risk for Re-traumatization r/t history of trauma/ Post-Traumatic Stress Disorder (PTSD) He reports Post Traumatic Stress Disorder after episode of being trapped in a manhole of some sort and history of being assaulted. Further review of Resident #88's care plan with an initiation date of 01/11/2023 note the resident HAS A MOOD PROBLEM R/T MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE ANXIETY DISORDER, UNSPECIFIED OTHER PSYCHOACTIVE SUBSTANCE ABUSE HOMELESSNESS. Record review of physician progress note dated 11/18/2022 documented EXAM: Increased yelling out, Impulsive, Mood changes, Delusions, Increased anxiety, Wheelchair, Easily angers, Disoriented, Withdrawn, and diagnoses including Major depressive disorder, recurrent, severe with psychotic symptoms, and Generalized anxiety disorder. Record review of Resident #88's behavioral health services note dated 11/02/2023 documented in Past History: 2. Treatment goal: Psychiatric History: Patient has extensive history of psychiatric treatment and hospitalizations, he is unable to state medications that have been trialed in the past. He reports Post Traumatic Stress Disorder after episode of being trapped in a manhole of some sort and history of being assaulted, and Treatment Schedule: weekly due to recent variability of mood and behaviors. Record review of psychiatry follow up dated 4/30/2025 documented under Active Medical Problems diagnoses including MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE and POST-TRAUMATIC STRESS DISORDER, CHRONIC. During an interview with MDS LVN C on 4/02/2026 at 9:58 AM, MDS LVN C stated, there should not have been another PL1 done for the MDD, because we do not usually do a PL1 for MDD. MDS LVN C stated ID, MS, Cerebral palsy, are the diagnoses they do a PL1 for, and we do audits with qualifying diagnoses from CMS. MDS LVN C stated, we do not do a PL1 for MDD, and Resident #88's diagnosis of PTSD could have been after the audit, but it should not matter if the diagnosis occurred after the audit. MDS LVN C stated, if a diagnosis comes in, I'm the one who is responsible for redoing the PASSR. MDS LVN C stated he and MDS LVN B have the job to find out what the new diagnoses are, and they go through the clinicals, put in the new diagnoses. MDS LVN C stated, it is important to conduct the PL1, because if it is positive they can provide services. MDS LVN C stated yes, MDD and bipolar are both mood disorders, and they affect mood, some are more considered than others. During an interview with the Administrator on 4/02/2026 at 11:50 AM, the Administrator stated they took over the company on October 1, 2022, and Resident #88 was here prior to that. The Administrator further stated, based off of our policy we run a PL1 if there is a significant change, and since we have taken over, Resident #88 has had no behaviors or anything. The Administrator stated we follow the policy and procedures on that, and they did not have anything significant change on Resident #88 since they took over. During a second interview with MDS LVN C on 4/02/2026 at 11:53 AM, LVN MDS C stated he could not find a policy on how soon you can put in a PL1 or how far along, and he could not find anything that said that or on HHSC. MDS LVN C stated, the policy is based off HHSC. MDS LVN C further stated for the PTSD it is a case-by-case basis. MDS LVN C stated, Resident #88 was not exhibiting any type of red flags or behaviors indicating that he had PTSD, and we would not do a PL1 if he is not having behaviors. Record review of the facility policy titled PASARR Screening, undated, noted It is the policy of this facility to complete an accurate PASARR screening for individuals with a mental disorder and individuals with intellectual disability. and 7. A new PASRR evaluation is required if a residents condition changes significantly.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 Dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure Dumpster #1 had a rubber plug at the bottom, there were no stains on the ground outside the dumpster, and trash/food was not on the ground outside the dumpster. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.The findings were: During an observation on 03/31/26 at 9:26 a.m., the exterior dumpster area contained visible dried food debris and spilled waste on the ground next to the dumpster. The surrounding concrete surface had multiple darkened stains and residue. Several pest control traps were observed stored directly on the ground adjacent to the dumpster. The drain opening at the bottom of the dumpster was not sealed with a plug. During an interview on 03/31/26 at 9:26 a.m. the DS stated he was unaware of the food spilled by the dumpster. He stated it may have just happened. This surveyor pointed out that the food appeared dried up and contained rice and a fry. The DS stated they had not served any of that food at breakfast that day. The DS stated he was unsure why the pest traps were stored outside the dumpster. The DS stated he was unaware the drain plug was missing. The DS stated maintenance was responsible for power washing the area around the dumpster. The DS stated the dumpster area should be free of debris and food on the ground because it could attract pest. The DS stated the dumpster needed a plug to prevent any pest from getting into the dumpster and any drainage from leaking out. During an interview on 04/02/2026 at 9:59 a.m. the MS stated he cleaned, and pressure washed the dumpster area every 6 months, and he cleaned it again that week. The MS stated some of the stains were oil from the dumpster trucks. The MS stated the traps were supposed to be picked up by the pest control company, but they never came to get them. The MS stated they went ahead and discarded them now. The MS stated the drain plug was supplied by waste management and they were responsible for placing it on the dumpster. The MS stated he reached out to them to request one be put on the dumpster. The MS stated the drain plug prevented leakage and insects from getting inside the dumpster. The MS stated he would have cleaned the food spilled outside the dumpster, but the survey team saw it before he had that morning. Record review of the facility policy titled Waste Management and Cleaning, no date, revealed .Observation of dumpster area is completed daily by plant team between breakfast and lunch. report maintenance/housekeeping concerns to appropriate department.Check the perimeter area daily for any odors and excess waste

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 6 residents (Resident #88) who were reviewed for resident assessments. The facility failed to document Resident #88's use of pain medication on the quarterly MDS assessment. This failure could place residents at risk of improper or incorrect care or of not receiving services necessary for their physical, mental, and psychosocial well-being.The findings included: Record review of Resident #88's admission sheet dated 5/05/2023, with an original admission date of 01/18/2022 documented a [AGE] year-old male resident with diagnoses including cerebral infarction (stroke), type 2 diabetes mellitus, MDD, spinal stenosis (the narrowing of one or more spaces within the spinal canal), PTSD, anxiety, and hypertension (high blood pressure). Record review of Resident #88's quarterly MDS assessment, dated 01/05/2026 documented a BIMS score of 15 indicating intact cognition. Further review of the resident's MDS revealed the assessment recorded an answer of 0 in section J0100: Pain Management. At any time in the last 5 days has the resident A. Received scheduled pain medication regimen? 0. No. Record review of Resident #88's order summary documented an order for Tramadol (an opioid analgesic for pain) with an order date of 9/07/2025. Tramadol was ordered as Tramadol 50mg, Give 1 tablet by mouth three times a day for SPINAL STENOSIS. Record review of Resident #88's January 2026 MAR documented the resident received Tramadol as prescribed during the lookback period from 01/01/2026 through 01/05/2026. Record review of Resident #88s care plan with an initiation date of 12/26/2025 documented the resident Is on Pain medication Therapy .SPINAL STENOSIS, HEMIPLEGIA AND HEMIPARESIS, with a goal of Will be free of any discomfort or adverse side effects from pain medication through the review date. During an interview with MDS LVN B on 4/02/2026 at 1:40 PM, MDS LVN B stated for MDS assessments the accuracy is ensured by me and MDS LVN C. MDS LVN B stated, it is important for the MDS to be accurate, because it depicts everything at that ARD date, everything for that resident. MDS LVN B stated, you want it to be accurate and show an accurate picture of the resident. MDS LVN B stated, I don't think an inaccurate MDS would affect the resident in any way. MDS LVN B stated yes, Resident #88's Tramadol should have been coded on the MDS because he was receiving scheduled pain medication. During a second interview with MDS LVN B, on 4/02/2026 at 2:15 PM, MDS LVN B stated they follow the RAI manual from CMS as the policy for MDS assessmentsDuring an interview the DON on 4/02/2026 at 2:58 PM, the DON stated yes the MDS assessments should be accurate, because we want to make sure we are painting a clear picture of the resident. The DON stated her expectation was for staff to complete accurate MDS assessments, because that is the resident assessment. The DON stated MDS inaccuracies could not have an effect on the resident themself.Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025, noted Coding Instructions for J0100A, Been on a Scheduled Pain Medication Regimen Code 1, yes: if the medical record contains documentation that a scheduled pain medication was received.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #7) reviewed for incontinent care:The facility failed to ensure CNA D provided proper incontinent care to Resident #7. CNA D made several passes with one disposable wipe to clean the resident's penis. This failure could place residents at-risk for infection and skin break down due to improper care practices.The findings included:Record review of Resident #7's face sheet dated 4/1/26 reflected an [AGE] year old male admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included obstructive and reflux uropathy (a condition in which the normal flow of urine is blocked somewhere along the urinary tract), need for assistance with personal care, benign prostatic hyperplasia (a condition in which the prostate gland becomes enlarged, but not cancerous, which makes it harder to urinate) with lower urinary tract symptoms, and history of urinary tract infections.Record review of Resident #7's most recent quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills, required substantial/maximal assistance with toileting hygiene, and was frequently incontinent of bowel and bladder.Record review of Resident #7's comprehensive care plan with initiated date 3/30/26 reflected the resident was treated with antibiotic therapy related to a urinary tract infection with interventions that included to check for incontinence, wash, rinse, and dry soiled areas, and provide antibiotic therapy as ordered. During an observation of incontinent care to Resident #7 on 4/1/26 at 4:04 p.m., CNA D made several passes with one disposable wipe in a back-and-forth motion when cleaning the resident's penis. During a joint interview with CNA D and CNA E on 4/1/26 at 4:15 p.m., CNA D stated he did not recall using only one wipe to clean Resident #7's penis. CNA E, who assisted CNA D stated she observed CNA D make more than one pass with one disposable wipe to clean Resident #7's penis. Both CNA D and CNA E stated, when using a disposable wipe during incontinent care, it was best practice to use the wipe once and then toss it in the trash instead of making several passes with one disposable wipe. Both CNA D and CNA E stated using the disposable wipe more than once was a break in infection control, or cross contamination and could result in the resident getting a rash, a skin issue, or develop an infection. During an interview on 4/1/26 at 4:26 p.m., the DON stated, when a disposable wipe was used during incontinent care, you should only use the wipe once and then toss it out. The DON stated, using a disposable wipe for more than one pass was an infection control issue and could result in the resident getting an infection. The DON stated it would take more than one disposable wipe to clean the resident's penis.Record review of the facility document titled Policy/Procedure Incontinence Care, undated, reflected in part, .It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining the dignity of the resident and providing care in a respectful manner.Wash peri area using front to back strokes.Record review of CNA D's competency training document titled Perineal Care, dated 1/19/26 reflected CNA D had satisfied the requirement for providing incontinent care. Review of CNA D's competency training document reflected the following: Male: Pull back foreskin if male is uncircumcised. Wipe the tip of penis using circular motion beginning at urethra. Continue wiping down the penis to the scrotum and inner thighs. Use different wipe for each stroke.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 1 (200 hall nurse cart) of 4 medication carts observed for medication storage. A blue pill was lying on the ground by the 200 hall nurse cart. This failure could place residents who receive medications at risk of not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others. The findings included: On 3/31/26 at 10:24 AM a blue pill was observed on the floor of the 200 hall by the 200 hall nurse cart. In an interview with NA A on 3/31/2026 at 10:24 AM, NA A stated, it looks like a medication was lying on the ground. In an interview with MDS LVN B on 3/31/26 at 10:25 AM, MDS LVN B stated, it looks like a blue pill was lying on the floor. MDS LVN B stated the pill, should not be on the floor for patient safety, we don't want anyone to come by and pick it up. MDS LVN B stated they are supposed to pick it up, and if a resident picked it up there could be an issue with patient safety if someone took a pill and they didn't know what it was, it could be harmful. During an interview with RN J on 3/31/26 at 10:40 AM, RN J stated she was responsible for the 200-hall nurse cart. When shown the picture of the pill on the floor, RN J stated, it looks like a pill. RN J stated a pill should not be lying on the floor because, anyone can pick it up, it is not safe and it should be discarded, it can affect the body in a negative way if they take it and it is not theirs's; it could be mistaken for something else. During an interview with the DON on 3/31/26 at 2:27 PM, the DON stated, there should not pill be pills on the floor, if a pill is on the floor, it should be discarded in the proper way. The DON further stated we don't want pills on floor because anyone can pick it up, and that is bad because they could consume it or put it somewhere it shouldn't be and other people can get to it. Review of facility policy titled Medication Access and Storage, undated, noted It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: and 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers.

Based on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 (Cook I) of 11 dietary staff reviewed for qualified dietary staff. The facility failed to ensure [NAME] I had a current Food Handler Certificate. This failure could place residents who ate food from the facility's kitchen at risk of not having their nutritional needs met and place them at risk for food born illnesses.Findings included: Record review of a certificate titled Texas Food Manager Certification Program, dated 03/03/2021 and stated, expires 5 years from the effective date, The certificate belonged to [NAME] I. A handwritten date of 03/03/2026 was written on the certificate. The bottom of the document also contained a handwritten word Keyed with a check mark next to it. Record review of the facility's staff list, no date, revealed [NAME] I was hired on 06/18/25. During an observation on 3/31/26 at 9:15 a.m. [NAME] I was in the kitchen cleaning a microwave. He stated he would be preparing pure diets around 11 a.m. that morning if this surveyor wanted to observe. During an interview on 04/02/26 at 4:40 p.m. the DS stated the only food handler certificate he had for [NAME] I was the one hanging on the wall dated 03/03/2021. The DS stated all staff was expected to have current food handlers certificates if they were working in the kitchen. The DS stated he would check to see if the cook had a current certificate. During an interview on 04/02/26 at 5:00 p.m. the Administrator stated he would check with HR because [NAME] I should have a current food handlers' certificate. During an interview on 04/03/26 at 9:50 a.m. the Administrator stated HR had provided him with a copy of [NAME] I's current food handler's certificate. During an attempt on 04/03/26 at 10:07 a.m. [NAME] I did not respond to an attempted interview. Record review of a certificate titled Texas Food Manager Certification Program, dated 03/04/26, revealed [NAME] I had completed the Texas Food Safety Manger Certification Examination, stated, expires 5 years from the effective date. The same handwritten word keyed with a check mark was in the same spot on the new document. Record review of [NAME] I's food handler's certificate through online database verification, dated 03/04/26, revealed the certificate number was for [NAME] I. The name of the course was Texas Food Manager Exam English. The date the certificate was issued was 03/02/2021 and the date of expiration was 03/01/2026. During a follow-up interview, on 04/03/26, at 11:08 a.m. the Administrator stated HR must have given him the wrong certificate and she was unavailable to talk to due to a private matter. The Administrator stated he expected staff to have current food handlers' certificates because they were in the kitchen handling food. Record review of the facility's policy titled Dietary Services, Meals and Food, no date, revealed It is the policy of this facility to ensure dietary services are provided to our residents operating within the confines of Texas state regulations. Procedure: 1. The dietary manager is responsible for the total food service of this facility and responsible for ensuring food handler certifications are current for dietary staff.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to keep dish racks off the floor 2. The facility failed to discard dirty oil. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.The findings included: 1. During an observation on 03/31/26 at 9:23 a.m. one dish rack with two other dish racks on top of it was directly on the floor next to the sink in the kitchen. During an interview on 03/31/26 at 9:23 a.m. the DS stated the dish racks should not be on the floor they should be on top of a pallet when not in use because the floor was dirty. 2. During an observation on 3/31/26 at 9:31 a.m., the deep fryer located in the kitchen contained oil that was dark brown in color with visible food particles and sediment throughout. The oil was not transparent, and visibility through the oil to the bottom of the fryer was obscured. Residue buildup was noted along the interior surfaces of the fryer. During an interview on 3/31/26 at 9:31 a.m. the DS stated he cleaned the fryer every weekend. The DS stated he last cleaned it on 3/29/26 two days before. The DS stated it was normal for the oil to get that dark because he used it to fry a lot of food for the residents. During a subsequent observation and interview on 04/02/26 at approximately 10:48 a.m., the fryer oil appeared light in color and transparent, with very little visible debris, and the bottom of the fryer was clearly visible. The DS stated they had cleaned the fryer and changed the oil on 3/31/26. During an interview on 4/2/26 at 5:00 p.m. the Administrator stated the dish racks had been removed from the floor and were stored on a pallet. The Administrator stated the oil in the fryer was normal because they used it to fry food and that's how it looks after it was used. He stated they could provide cleaning schedules, and the fryer was last cleaned over the weekend. Record review of a document titled Weekly Deep Cleaning Schedule, dated March 2026, revealed the fryer oil was changed, sides and inside cleaned as needed, boiled out (every 3 months) on:03/04/2603/11/2603/17/2603/28/3103/31/26 Record review of the facility policy titled Dish Handling, no date, revealed, After dish racks have been emptied. Racks must be stored off of the floor. Record review of the facility policy titled Deep Fryer Cleaning Policy & Procedure, no date, revealed, Deep fryer will be cleaned on a regular basis as recommended by the manufacturer.Clean the element whenever the oil is filtered or changed.Clean the fry baskets at the end of the day.

Based on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 10 residents (Residents #6 and Resident #8) reviewed for medical records. 1. The facility failed to ensure Resident #6's Mental Illness/Dementia Resident Review, form 1012 was completed and accurate. 2. The facility failed to ensure Resident #8's Mental Illness/Dementia Resident Review, form 1012 was completed and accurate.This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records. 1. Record review of Resident #6's admission record, dated 02/26/26, revealed a [AGE] year-old female resident was admitted to the facility on [DATE], with an initial admission date of 01/11/22, her diagnoses included of schizophrenia, unspecified (a chronic mental disorder characterized by disturbances in thought, perception, and behavior), with an onset date of 01/11/22, major depressive disorder, recurrent, moderate (a mood disorder characterized by repeated episodes of depressed mood, loss of interest, and impaired functioning), with an onset date of 01/11/22, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in cognitive function affecting memory, thinking, and the ability to perform daily activities), with an onset date of 01/31/22, unspecified dementia, unspecified severity, with agitation (a decline in cognitive function accompanied by restlessness or emotional distress), with an onset date of 08/18/24. Record review of Resident #6's significant change MDS assessment, dated 3/2/26, revealed she had moderate cognitive impairment for daily decision making. The MDS revealed she had depression, schizophrenia, and non-Alzheimer's dementia. The MDS also revealed she was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Record review of Resident #6's care plan, initiated 1/24/23, revealed she had mood problems related to schizophrenia, major depressive disorder, and dementia with behavioral disturbances. Interventions included administering medications and assist to identify strengths, positive coping skill and reinforce these. Record review of Resident #6's Mental Illness/Dementia Resident Review (Form 1012), revealed:Section A (Resident and Nursing Facility Identifying Information):Section A was completed with resident identifying information, including name, date of birth , facility name, and PASRR Level 1 was completed on 01/11/22.Section B (Dementia Review):Section B indicated Yes, the individual has a primary diagnosis of dementia. Section B.1 included physician attestation with physician name, license number, license state, and date of onset documented. A physician signature and date of 01/31/22 were present.Section C (Mental Illness Indication):Section C indicated Yes for schizophrenia; however, other listed diagnoses did not have corresponding Yes or No selections completed, and dates of onset were not documented for the applicable diagnoses. The physician signature and date in Section C were not completed. The directions in section C stated If all the responses are No, physician signs and dates the form. A new PL 1 is not needed at this time. Complete Sections D and E.If any of the responses are YES, the nursing facility needs to complete a new PL 1 and Sections D and E of the form. A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL 1.Section D (Nursing Facility Action):Section D did not have a selected response to indicate whether the PASRR Level 1 remained negative or if a new PASRR Level 1 screening was submitted. 2. Record review of Resident #8's admission record, dated 04/04/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE], with an initial admission date of 10/23/20, His diagnoses included schizoaffective disorder, bipolar type (a mental health disorder characterized by symptoms of schizophrenia such as hallucinations or delusions along with mood disorder symptoms such as mania or depression), with an onset date of 07/20/23, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a decline in cognitive function affecting memory, thinking, and the ability to perform daily activities), with an onset date of 10/23/20, unspecified psychosis not due to a substance or known physiological condition (a condition involving impaired thoughts and perceptions, including hallucinations or delusions, not attributed to substances or a medical condition), with an onset date of 10/23/20, bipolar disorder, unspecified (a mood disorder characterized by alternating periods of elevated mood and depression), with an onset date of 10/23/20, other specified depressive episodes (a mood disorder involving periods of depressed mood that do not meet full criteria for major depressive disorder), with an onset date of 10/23/20, unspecified mood [affective] disorder (a disorder affecting emotional state that does not meet criteria for a specific mood disorder), with an onset date of 10/23/20, and generalized anxiety disorder (a condition characterized by excessive and persistent worry), with an onset date of 10/23/20. Record review of Resident #8's quarterly MDS assessment, dated 12/26/25, revealed he had moderate cognitive impairment for daily decision making. The MDS revealed he had anxiety, depression, bipolar disorder, psychotic disorder, and non-Alzheimer's dementia. Record review of Resident #8's care plan, initiated 10/31/23, revealed he had psychosocial well-being problem related to schizoaffective disorder, bipolar type, dementia, and resident will frequently hide items, such as his wallet, gloves, or watch. He then forgets where he placed it, will become upset but finds it again after a while. Interventions included allow time to answer questions and to verbalize feelings, perceptions, and fears, encourage participation from resident who depended on others to make own decisions, and when conflict arose, remove residents to a calm safe environment and allow him to vent/share feelings. Record review of Resident #8's Texas Health and Human Services Mental Illness/Dementia Resident Review (Form 1012) revealed:Section A (Resident and Nursing Facility Identifying Information):Section A was completed with resident identifying information, including name, date of birth , facility name, and PASRR Level 1 was completed on 10/23/20.Section B (Dementia Review):Section B indicated Yes, the individual has a primary diagnosis of dementia. Section B.1 revealed the dementia diagnosis date of onset was documented as 10/23/20; however, the (Physician Attestation) physician signature date was not completed on the signature line, and the Physician's printed name was missing. Section C indicated Yes for schizoaffective disorder with a documented onset date of 07/20/23. Further review revealed bipolar disorder was handwritten under Any Other Disorder with a documented onset date of 10/23/20. Additional mental health diagnoses identified in the resident's medical record, including unspecified psychosis not due to a substance or known physiological condition, unspecified mood (affective) disorder, other specified depressive episodes, and generalized anxiety disorder, were not indicated on the form. The directions in section C stated If all the responses are No, physician signs and dates the form. A new PL 1 is not needed at this time. Complete Sections D and E. If any of the responses are YES, the nursing facility needs to complete a new PL 1 and Sections D and E of the form. A full PASRR Evaluation will be conducted after the nursing facility submits the new positive PL 1. Section D (Nursing Facility Action):Section D did not have a selected response to indicate whether the PASRR Level 1 remained negative or if a new PASRR Level 1 screening was submitted. During an interview on 4/2/26 at 2:15 p.m. MDS LVN C stated both Resident #6 had #8 had dementia as a primary diagnosis in the past. MDS LVN C stated 1012 forms were completed by another staff member who was no longer working for the facility. MDS LVN C stated he was unsure why the other staff added information to the 1012 form for Resident #8 3 years after it was signed by the doctor. MDS LVN C stated he understood the form was valid if a doctor signed it. MDS LVN C stated Resident #6 and Resident #8 would not qualify for PASRR services because they both had dementia diagnosis so both of their PASRR level 1 were answered no for mental illness and a 1012 form was completed instead. MDS LVN C stated he was one of the staff responsible for assuring residents PASRR paperwork was accurate. During an interview on 4/2/26 at 3:02 p.m. the DON stated she was unsure if the 1012 forms were completed correctly and she needed to ask her resource because she did not know. The DON never returned for a follow up interview. During a joint interview on 4/2/26 at 3:16 p.m. the Administrator, MDS LVN C, returned with a PASRR assessor on the phone. The PASRR assessor stated when a resident had a primary diagnosis a new 1012 form did not need to be completed if a new mental illness diagnosis was added. The PASRR assessor stated it would not matter how much time had passed by as long as the physician signed the 1012 nothing needed to be changed. The PASRR assessor stated the facility should not add information to the 1012 forms 3 years after it was completed. The PASRR assessor stated the facility should not have touched the forms at all and left them as was. A policy for accuracy of medical records was requested from the Administrator on 04/03/26 and not provided. Record review of the facility policy titled PASARR Screening,, no date, revealed It is the policy of this facility to complete an accurate PASARR screening for individuals with a mental disorder and individuals with intellectual disability.Purpose: To ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs.Procedures: 1. The initial screening referred to as a Level I and is completed prior to admission to a nursing facility. 2. A negative Level I screen permits admission to proceed and ends the prescreening process unless possible serious mental disorder or intellectual disability arises later. 3. A positive Level I screen necessitates an in-depth evaluation of the individual, by the state, known as a level II PASARR.7. A new PASARR evaluation is required if a resident's condition changes significantly.

47622 Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 (Resident #33) of 4 residents personal refrigerators reviewed, in that: 1. DA B touched dessert dishes on the inside of the dish to place them on the tray, DA A touched the rim on the inside of the plate while serving food, and DA C placed her thumb on rim and on the inside of the plate when she placed the plate on the tray. 2. There was one sandwich covered in a plastic bag, provided by the facility, in the refrigerator inside Resident #33's room, and the sandwich was unlabeled and undated. These failures could place residents who received meals and/or snacks from the kitchen and their personal refrigerators at risk for food borne illnesses. Findings included: During observation on [DATE] at 12:06PM Dietary Aide B grabbed a dessert dish, touching the inside rim of the dish and then grabbed two at the same time and repeated the action. Dietary Aide A touched the top of the rim of the plate while he placed food on the plates to be served to the residents. The DS (Dietary Supervisor) redirected and corrected the server. DA C was observed when she placed her thumb on the inside of the plate of food from DA A and placed the plate on the tray to be served to the residents. During an interview on [DATE] at 12:15PM the DS said DA A was recently promoted to the position to serve the food on the plates and it was his second day. The DS said he was trained on how to place the food on the plate and for infection control, but he was nervous because of the state surveyor. The DS said touching the rim of the plates could cause contamination and food borne illnesses to the residents. DA D asked the state surveyor about wearing gloves in the kitchen. The DS responded that she would not use gloves because someone could get comfortable and walk away from their workstation with the gloves, return to their station, and not remove the gloves (after touching non-food items), wash their hands, and put on new gloves. She said that was a very big way of cross contamination and infection control issue. The DS said there would be an in-service for food service and infection control immediately. In an interview on [DATE] at 10:04 AM Dietary Aide A said it was important not to touch the rim of the plate while handling food to avoid contamination of the residents' food that could make them sick. He said he had the in-service on how to handle the food yesterday. DA A said he learned not to touch the plates and to stay mindful of not to contaminate the residents' food. In an interview on [DATE] at 10:15 AM Dietary Aide C said it was important not to touch the surfaces where food will be on plates, cups, or utensils or any place food can be served because it could cause contamination. DA C said food contamination could make the residents sick. She said she had the training yesterday on how to handle food correctly. In an interview on [DATE] at 10:22 AM Dietary Aide B said she had the in-service yesterday on how to handle food. She said she learned not to touch the inside of the plates or cups because it could cause illnesses for the residents. In an interview on [DATE] at 11:26 AM the RD said she was contracted by the facility. The RD said it was important not to touch the plates because it was an infection control issue and could cause food borne illnesses. She said she did not allow gloves to be used on the line of serving food because they only protect the person wearing them and not the food. The RD said that when people where gloves, they had a false sense of security that they could touch everything because they wore gloves, don't change them, and then go back to touching food. During an interview on [DATE] at 10:30 a.m., the DS said all employees that work in Dietary Services received the training on food handling and infection control. Facility policy, not dated, titled Preparing and Serving Food policy statement read: It is the policy of this facility to prepare and serve food safely. Procedure #7 stated: Serving food- No bare hand contact with food items, food area of serving utensils, eating area of plates or utensils, and rim or inside of glasses. 2. Record review of Resident #33's face sheet, dated [DATE], revealed the resident was a [AGE] year old male and an admitted [DATE] with diagnoses that included: injury of head, cerebral infarction (disrupted blood flow to the brain), chronic obstructive pulmonary disease (block airflow and make it difficult to breathe), Alzheimer's disease (destroy memories and other important mental function), and dysphagia (swallowing difficulties). Record review of Resident #33's quarterly MDS assessment, dated [DATE], indicated his BIMS score was 3 reflecting he had severe cognitive impairment. Further record review indicated the resident required setup or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating in Section GG (Functional abilities). Record review of Resident #33's comprehensive care plan, dated [DATE], reflected [Resident #33] has potential nutritional problem related to possible dislike, and the intervention was Refrigerator temperatures to be recorded for both fridge and freezer every night and provide, serve diet as ordered and monitor and record every meal. Observation on [DATE] at 12:32 p.m. revealed Resident #33's refrigerator was in his room, and inside the refrigerator there was one sandwich covered in a plastic bag, and the sandwich had no label and no date. Interview on [DATE] at 1:04 p.m. with LVN-I acknowledged Resident #33's refrigerator was in his room, and inside the refrigerator there was one sandwich covered in a plastic bag, and the sandwich had no label and no date. The LVN-I stated the sandwich was peanut butter sandwich, and the facility kitchen provided the sandwich. Further interview with the LVN-I said she did not know what reason the sandwich had no label and date. The facility staff who provided the sandwich as a snack had a responsibility to write date and label. Interview on [DATE] at 10:33 a.m. with DON stated the staff who provide a sandwich to Resident #33 should have written the label and date. Without label and date, the resident might receive incorrect diet texture and expired sandwich, and it might cause food illness. Record review on [DATE] of in-service dated [DATE] titled How to Serve revealed 8 out of 8 employees in Dietary Services received the in-service. Record review of the facility policy, titled Dietary Services, undated, revealed It is the policy of this facility that food brought to the resident by family/visitors must be inspected before being provided to the resident.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #148) of 21 residents reviewed for infection control. CNA-J entered Resident #148's room, who was on EBP, on 01/23/2025 at 11:02 a.m. and failed to put on a gown when the CNA-J was providing suprapubic catheter care to the resident. These deficient practices affect residents who require assistance treatments and could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #148's face sheet, dated 01/24/2025, revealed the resident was a [AGE] year old male and an admitted [DATE] with diagnoses that included: anoxic brain damage (complete lack of oxygen to the brain), quadriplegia (paralysis of all four limbs), epilepsy (seizure), acute respiratory failure (inadequate gas exchange by the lung), and acute kidney failure (Kidney lose the ability to remove waste and balance fluids). Record review of Resident #148's admission MDS assessment, dated 01/15/2025, indicated his BIMS score was 0 reflecting he had severe cognitive impairment. Further record review indicated the resident had indwelling bladder catheter. Record review of Resident #148's comprehensive care plan, dated 01/09/2025, reflected [Resident #148] has suprapubic catheter, and the intervention was suprapubic catheter care every shift - monitor insertion site for skin breakdown and secure the catheter with a leg strap or anchor to minimize catheter related injury. Observation on 01/23/2025 at 10:55 a.m. revealed there was a sign posted on Resident #148's door, and the sign was Enhanced Barrier Precaution - EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs and assisting with toileting .Wound Care: Any skin opening requiring a dressing. Observation on 01/23/2025 at 11: 02 a.m. revealed CNA-J sanitized her hands outside Resident #148's room and put on gloves. The CNA-J entered to Resident #148's room and provided suprapubic catheter care to the resident without putting on a gown, then the CNA-J went out the resident's room and took off the dirty gloves and sanitizing her hands. Interview on 01/23/2025 at 11:10 a.m. with CNA-J confirmed she did not wear a gown when she was providing suprapubic catheter care to Resident #148. The resident had Enhanced Barrier Precaution, so CNA-J should have put on a gown when providing the catheter care to the resident to prevent possible contamination. CNA-J stated she was nervous and forgot to wear a gown, and the potential harm was Resident #148 might have infection. Interview on 01/24/2025 at 10:33 a.m. with the DON confirmed CNA-J should have put on a gown when entering Resident #148's room to provide the catheter care to the resident. The resident had Enhanced Barrier Precaution, which was Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs and assisting with toileting .Wound Care: Any skin opening requiring a dressing. The resident might get infection. Record review of the facility policy, titled Infection Prevention and Control Program, revised 01/2024, revealed Enhanced Barrier Precautions - during high-contact resident care activities: dressing, bathing/showering/transferring, changing linens, changing briefs, device care or use, and wound care: any skin opening requiring a dressing. Gloves and gown prior to the high contact care activity.

Based on interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 3 of 21 residents (Residents #61, #148, and #95) whose assessments were reviewed. 1. Resident #61's MDS assessment inaccurately reflected the resident received insulin injections when he did not. 2. The facility failed to ensure Resident #148's admission MDS, dated [DATE], correctly assessed the resident's hospice status as evidenced by coding No hospice receive in Section O-Special treatment, procedures, and program. However, Resident #148 was receiving hospice services. 3. Resident #95's discharge MDS assessment inaccurately reflected the resident was discharged to the hospital when he was discharged home. These failures could place residents at-risk for inadequate care and services. The findings included: 1. Record review of Resident #61's face sheet dated 1/22/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes with hyperglycemia (blood sugar levels that are higher than normal due to insulin resistance or insufficient insulin production). Record review of Resident #61's most recent annual MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and was incorrectly identified on the MDS, Section N-Medications, Insulin, as having been treated with insulin. Record review of Resident #61's comprehensive care plan, with revision date 7/2/24 revealed the resident had type 2 diabetes with hyperglycemia with interventions that included to adhere to medication parameters as directed by physician. Record review of Resident #61's Order Summary Report, dated 1/22/25 revealed the following: - Metformin tablet 1000 mg, give 1 tablet by mouth one time a day related to type 2 diabetes with hyperglycemia, with order date 8/8/23 and no stop date. - Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 ml (Dulaglutide), inject 0.5 ml subcutaneously in the morning every Monday related to type 2 diabetes with hyperglycemia with order date 8/8/23 and no stop date. Further review of Resident #61's Order Summary Report did not indicate the resident was treated with insulin. During an interview on 1/21/25 at 2:14 p.m., Resident #61 stated he did not take insulin. Resident #61 further stated that he received an injection weekly but was not sure what it was for. During an interview on 1/24/25 at 10:36 a.m., LVN L stated she was familiar with Resident #61 and after reviewing the resident's electronic medical record revealed Resident #61 received a Trulicity injection every Monday. LVN L stated Trulicity was an insulin but was not sure if the medication was a long acting or fast acting insulin. During an interview on 1/24/25 at 11:00 a.m., the DON revealed Resident #61 was treated with Metformin, and Trulicity was administered via injection once a week. The DON stated, Trulicity was a diabetic medication but was not an insulin. The DON stated Resident #61's MDS inaccurately indicated the resident was receiving insulin when he was not. The DON stated the MDS was important as it should accurately describe the resident assessment and services received. During an interview on 1/24/25 at 11:10 a.m., the MDS Nurse revealed Resident #61 received Metformin and Trulicity injections for the treatment of diabetes. The MDS Nurse stated he was not sure if Trulicity was an insulin and further revealed, the MDS had an RAI manual that listed medications to refer to but didn't really look at the list. During a follow-up interview on 1/24/25 at 11:18 a.m., the MDS Nurse stated, the (MDS) assessments are assessments, there is a modification button, if it was coded differently, and if Trulicity was coded incorrectly it can be corrected. It's not definite. The MDS Nurse revealed, the purpose of having the MDS was for clinical reasons and for financial purposes. 2. Record review of Resident #148's face sheet, dated 01/24/2025, revealed the resident was a [AGE] years old male and an admitted [DATE] with diagnoses that included: anoxic brain damage (complete lack of oxygen to the brain), quadriplegia (paralysis of all four limbs), epilepsy (seizure), acute respiratory failure (inadequate gas exchange by the lung), and acute kidney failure (Kidney lose the ability to remove waste and balance fluids). Record review of Resident #148's admission MDS assessment, dated 01/15/2025, indicated his BIMS score was 0 reflecting he had severe cognitive impairment. Further record review indicated K1. Hospice care in the Section O (Special treatment, procedures, and program) was answered No. Record review of Resident #148's comprehensive care plan, dated 01/09/2025, reflected [Resident #148] admitted to facility on hospice services, and the intervention was Hospice nurse will visit weekly, hospice to provide shower with visits, no x-ray and labs without hospice approval, and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Record review of Resident #148's physician order, dated 01/08/2025, reflected Resident #148 was admitted to the hospice for diagnosis of anoxic brain damage (complete lack of oxygen to the brain) on 01/08/2025. Interview on 01/24/2025 at 11:17 a.m. the DON stated Resident #148 was receiving hospice services since the resident was admitted to the facility on [DATE], and it was very important the MDS was accurate, so the facility might provide accurate care to Resident #148. Interview on 01/24/2025 at 2:00 p.m. the MDS nurse stated Resident #148's admission MDS, dated [DATE], was inaccurate because Resident #148 was receiving hospice services since the resident was admitted to the facility on [DATE]. It should have been answered Yes in the Section O (Special treatment, procedures, and program). The MDS nurse said he did not know what reason he coded No, and it was mistake. 3. Record review of Resident #95's face sheet dated 1/24/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Further review of Resident #95's face sheet, under Miscellaneous Information revealed the resident discharged home. Record review of Resident #95's most recent MDS discharge assessment dated [DATE] inaccurately indicated the resident was discharged to a short-term general hospital. Record review of Resident #95's Discharge Summary Report dated 11/18/24 revealed the resident was admitted to the facility on [DATE] for respite care and discharged on [DATE] to a foster home. During an interview on 1/24/25 at 3:31 p.m. the DON revealed Resident #95 was admitted to the facility for respite care and discharged to a foster home. The DON revealed, Resident #95 was not discharged to a hospital and the discharge MDS was coded incorrectly. During an interview on 1/24/25 at 3:38 p.m., the MDS Nurse revealed he had incorrectly indicated on Resident #95's discharge MDS the resident discharged to a hospital when he should have indicated the resident discharged to a home. The MDS Nurse stated the MDS was important because it determined the status of the resident and was determined how the facility got paid. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, . The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . Record review of the facility policy and procedure titled Resident Assessment, Comprehensive Assessment, undated, revealed in part, .It is the policy of this facility to complete a comprehensive assessment of the resident's needs which are based on the State's specific Resident Assessment Instrument (RAI) and the facility's interdepartmental assessment forms .Completion of the Resident Assessment Instrument (MDS and RAP's) will be completed as directed by the State . 39075

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #27 and #82) reviewed for incontinence care. 1. When CNA-E and CNA-F were providing incontinent care to Resident #27 on 01/23/2025, CNA-E did not clean the resident's right buttock area. 2. The facility failed to ensure Resident #82's indwelling urinary catheter drainage bag and tubing were not touching the floor. These failures could place residents with indwelling urinary catheter devices and who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #27's face sheet, dated 01/24/2025, revealed a [AGE] year-old male, originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included hereditary spastic paraplegia (inherited disorders that involves weakness and spasticity, which is stiffness of the legs), contracture-right knee (permanent tightening of the muscle), reduced mobility, muscle weakness, and seizures. Record review of Resident #27's most recent quarterly MDS assessment, dated 12/01/2024, revealed the resident's BIMS was 0 which indicated he had severe cognitive impairment and was always incontinent of bowel and bladder. Record review of Resident #27's comprehensive care plan, dated 10/12/2022, revealed [Resident #27] has bowel and bladder incontinence related to immobility, and For intervention - check as required for incontinence. Wash, rinse, and dry perineum. Change clothing as need after incontinence episodes. Observation on 01/23/2025 at 3:25 p.m., revealed during incontinent care to Resident #27, CNA-E cleaned Resident #27's right and left groin area, and CNA-E and CNA-F turned Resident #27 to right side. CNA-E cleaned the resident's left buttock area and middle area, including anus. When CNA-E cleaned the middle area, including anus, the resident had small bowel movement. CNA-E cleaned the resident's bowel movement and changed gloves after sanitizing her hands. CNA-E put a new brief to the resident and closed it without turning the resident to his left side and without cleaning the resident's right buttock area. Interview on 01/23/2025 at 3:36 p.m. with CNA-E stated she did not turn Resident #27 to his left side and did not clean the resident's right buttock area. Further interview with the CNA-E said that when she cleaned the resident's middle area, including anus, CNA-E wiped the resident's right buttock with only one time to clean the resident's bowel movement without turning the resident to left side. The CNA-E stated she though wiping the resident's right buttock with only one time was enough, and that was why the CNA-E did not turn the resident to left side and not clean the resident's entire right buttock area. CNA-E stated she should have turned Resident #27 to left side and cleaned the resident's entire right buttock area because the resident had bowel movement when CNA-E cleaned the resident. Interview on 01/24/2025 at 10:33 a.m. with DON stated CNA-E should have turned Resident #27 to his left side and cleaned the resident's entire right buttock area because the resident had bowel movement when CNA-E cleaned the resident to prevent possible unclean status of the resident. Record review of the facility policy and procedure, titled Incontinence Care, undated, revealed in part, . Staff will assemble equipment necessary to provide care. 7. Assist resident to turn and cleanse buttocks. 2. Record review of Resident #82's face sheet dated 1/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (condition where urine flow is blocked due to obstruction in the urinary tract and reflux uropathy refers to kidney damage where urine flows backward from the bladder into the ureters and kidney), disorders of kidney and ureter, and disorders of bladder. Record review of Resident #82's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and utilized an indwelling urinary catheter. Record review of Resident #82's Order Summary Report dated 1/22/25 revealed the following: - Catheter care every shift. Monitor urethral site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristic or secretions, catheter pulling causing tension every shift, with order date 3/16/24 and no stop date. Record review of Resident #82's comprehensive care plan with revision date 7/9/24 revealed the resident had an indwelling catheter related to obstructive and reflux uropathy. Interventions included to provide catheter care every shift and as needed and secure the catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow, check placement. Observation and interview on 1/21/25 at 12:03 p.m. revealed Resident #82 sitting up in the wheelchair at the doorway to her room with the indwelling urinary catheter bag and tubing touching the floor from underneath the wheelchair. Resident #82 asked for help and LVN M entered the resident's room. LVN M was made aware by the State Surveyor that Resident #82's indwelling urinary catheter and tubing were touching the floor. LVN M then moved Resident #82's wheelchair back while dragging the indwelling urinary catheter bag and tubing on the floor. LVN M revealed Resident #82's indwelling urinary catheter bag and tubing should not be touching the floor because it was considered an infection control issue and it could get kinked and trapped on the floor. During an interview on 1/23/25 at 3:54 p.m., the DON stated Resident #82's indwelling urinary catheter and tubing should not be touching the floor because it was a break in infection control and the resident could run over it with the wheelchair. The DON stated the tubing could kink and prevent urine flow and it that should occur, the resident could retain urine. Record review of the facility policy and procedure titled Quality of Care, Catheter Care, Indwelling, undated, revealed in part, .It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling. Monitoring of leg strap and level of drainage bag as indicated .PURPOSE: To promote hygiene, comfort and decrease risk of infection for catheterized residents .May secure the tubing with securement device PRN to prevent migration of catheter/friction/tension . Record review of the facility policy and procedure titled Quality of Care, Catheter Drainage Bag, undated, revealed in part, .It is the policy of the facility to maintain continuously closed urinary drainage system whenever possible .Position the drainage bag below the level of the resident's bladder .Drainage bag, nor tubing should be directly on the floor . 39075

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 medication and nursing carts (300-hall nursing cart and 200-hall nursing cart) reviewed for pharmacy services. 1. There was one medication (Dakin's solution half strength for skin irrigation) expired on 11/2024 found inside the 300-hall nursing cart on 01/22/2025. 2. There was Resident #54's medication (Urea 20 intensive Hydrating cream for dry skin) expired on 11/13/2024 found inside the 200-hall nursing cart on 01/22/2025. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Observation on 01/22/2025 at 2:52 p.m. revealed one bottle of Dakin's solution half strength for skin irrigation was found inside the 300-hall nursing cart, and it was expired 11/2024. Interview on 01/22/2025 at 3:01 p.m. with nurse RN-G acknowledged one bottle of Dakin's solution half strength for skin irrigation was found inside the 300-hall nursing cart, and it was expired 11/2024. The RN-G said the nurse did not know what reason the expired medication was inside the 300-hall nursing cart, and nurses should discard all expired medications from the nursing carts as per the facility policy. Potential harm was nurses might use the expired medication, and the expired medication might not have therapeutic effects. 2. Record review of Resident #54's face sheet, dated 01/24/2025, revealed a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), type 2 diabetes mellitus (body not control blood sugar), hypertension (high blood pressure), cerebral infarction (disrupted blood flow to the brain), and need for assistance with personal care. Record review of Resident #54's most recent quarterly MDS assessment, dated 10/22/2024, revealed the resident's BIMS score was 9 which indicated he had moderate cognitive impairment, and the resident did not have any skin breakdown but was at risk of developing pressure ulcers/injuries in Section M - skin condition. Record review of Resident #54's comprehensive care plan, dated 11/13/2024, revealed [Resident #54] has potential impairment to skin integrity related to fragile skin, and For intervention - encourage good nutrition and hydration in order to promote healthier skin and educate resident and caregivers of causative factor and measures to prevent skin injury. Observation on 01/22/2025 at 3:09 p.m. revealed one cream of Urea 20 intensive Hydrating cream for dry skin was found inside the 200-hall nursing cart, and it was expired 11/13/2024, and the label said, Discard after 11/13/2024. Interview on 01/22/2025 at 3:20 p.m. with nurse LVN-H acknowledged one cream of Urea 20 intensive Hydrating cream for dry skin was found inside the 200-hall nursing cart, and it was expired 11/13/2024, and the label said, Discard after 11/13/2024. The LVN-H said the nurse did not know what reason the expired medication was inside the 200-hall nursing cart, and nurses should discard all expired medications from the nursing carts as per the facility policy. Potential harm was nurses might use the expired medication, and the expired medication might not have therapeutic effects. Interview on 01/22/2025 at 3:42 p.m., the DON said facility nurses should discard all expired medications from the medication carts. Nurses had responsibility to make sure all expired medications should have been removed from carts. Record review of the facility policy, titled Pharmaceutical Services, undated, revealed All over-the-counter medications will be discarded as per manufacturer expiration dates and do not require an open date.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 4 resident units (200 unit) reviewed for dignity. CNA K and the MDS Nurse walked into several resident rooms in the 200 unit without knocking. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: Record review of Resident #25's face sheet dated 1/24/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included abnormalities of gait and mobility and presence of right artificial knee joint. Record review of Resident #25's most recent admission MDS assessment, dated 12/5/24 revealed the resident was cognitively intact for daily decision-making skills and had a functional limitation in range of motion to the lower extremity. Observation on 1/21/25 beginning at 12:33 p.m., revealed CNA K entered the following resident rooms on the 200 unit without knocking: - room [ROOM NUMBER] at 12:33 p.m., CNA K was observed moving a chair from the A side (nearest the bedroom door) of the room to the B side (farthest from the bedroom door) of the room. - room [ROOM NUMBER] at 12:33 p.m. - room [ROOM NUMBER] at 12:33 p.m., CNA K was observed straightening up the room During an interview on 1/21/25 at 12:37 p.m., CNA K stated she had entered the above-mentioned rooms to make sure the residents were doing ok. CNA K stated, normally I knock, some of the residents weren't in the room, but I'm sure I should have been knocking. CNA K revealed she should have been knocking on resident bedroom doors because it was a matter of privacy. Observation on 1/21/25 beginning at 12:41 p.m., revealed the MDS Nurse entered the following resident rooms on the 200 unit without knocking: - room [ROOM NUMBER] at 12:41 p.m. During an interview on 1/21/25 at 12:42 p.m., the MDS Nurse stated he had often worked the floor and was working the 200 unit. The MDS Nurse denied he did not knock on the bedroom door to room [ROOM NUMBER]. During an interview on 1/23/25 at 1:59 p.m., the DON revealed it was her expectation for staff to knock on resident bedroom doors, but if the resident were not in the room, and the main CNA knows where the resident is, if they are not in their room, it's ok for them to enter without knocking. The DON stated, if the CNA was aware a resident was in the room, then staff should knock on the bedroom door before entering. During an interview on 1/24/25 at 1:51 p.m., Resident #25 stated he had only been in the facility for about a month and stated staff sometimes knocked on his bedroom door and sometimes they didn't. Resident #25 stated there were times he would be sleeping and then realize staff were in his room without knowing. Resident #25 stated, I don't like it, but what can I do, they work here. Record review of the facility policy and procedure titled Resident Rights, Dignity and Respect, undated revealed in part, .It is the policy of this facility that all residents be treated with kindness, dignity, and respect .Staff members shall knock before entering the Resident's room .

44020 Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with State law through established procedures for 2 of 6 residents (Residents #1 and #2), reviewed for abuse and neglect. 1. Resident #1 was found to have a 9X3 abrasion to the back of her right shoulder and an abrasion to her right elbow on 8/15/24 that was not witnessed and not reported to HHSC. 2. The facility failed to report an unobserved fall where Resident #2 was sent for a hospital evaluation. This failure could place residents at risk of abuse and or neglect. The findings were: 1. Record review of Resident #1's face sheet dated 12/19/24 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included Alzheimer's disease unspecified (general term for memory loss and other cognitive abilities serious enough to interfere with daily life), restlessness and agitation, and muscle wasting and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue). Record review of Resident #1's discharge return anticipated MDS assessment dated [DATE] revealed the resident's BIMS was blank and her cognitive assessment indicated the resident was severely impaired cognitively. The resident had inattention and disorganized thinking. The resident was frequently incontinent of urine and always incontinent of bowel and was receiving hospice services. Record review of Resident #1's undated care plan revealed a focus for high fall risk due to Alzheimer's disease, weakness, and lack of coordination revised on 3/15/24 with interventions that included toileting the resident, sensory bracelet, among others. Another focus for actual falls due to poor balance and safety awareness. Interventions included a bolster mattress, encourage activities, and wear a soft helmet. Record review of Resident #1's provider investigation report from a facility self-report dated 8/27/24 revealed a skin evaluation dated 8/26/24 by RN F Rugburn scrape to right posterior shoulder and right elbow are resolving and remain closed. Record review of Resident #1's progress notes revealed a late entry with an effective date of 8/23/24 at 7:21 p.m. by RN F Late Entry for 8/23/2024. Resident continues with resolving rugburn scrapes to right elbow and right posterior back. Right elbow has a light reddish/brown discoloration. Right posterior shoulder is mostly pink skin with a small amount of reddish/brown discoloration. Skin prep is being applied to right elbow daily. Right posterior shoulder is being treated with a dry dressing 2 times per week and PRN. Resident has severe EPS (Extrapyramidal side effects - drug induced involuntary movements that one cannot control) and has constant movement of her extremities and severe pelvic thrusting. Record review of Resident #1's progress notes revealed a note by RN F dated 8/15/24 with no time the resident was found to have a 9x3 abrasion (medical record did not specify cm or in) to the back of her right shoulder and an abrasion to her right elbow that were likely from the resident's EPS movements. In an observation on 12/16/24 at 3:16 p.m. Resident #1 was seated in a wheelchair in the secure unit dining room at a table with a sensory board in front of her. The resident would periodically move her hands to the soft helmet or push the wheelchair to roll backwards using her feet. The resident was not able to answer questions appropriately. A staff member was standing near the resident and redirecting her attention to the sensory board and the resident would lean forward and touch the activity board but was unable to stay focused on any tasks. No EPS movements of pelvic thrusting or shoulder movements were observed, no tremors, or repetitive movements were observed. In an interview on 12/19/24 at 10:25 a.m. the Administrator stated RN F was no longer at the facility and had transferred to a sister facility. The contact number for RN F was requested and never received. In an interview on 12/19/24 at 2:40 p.m. the ADON stated, Resident #1's EPS movements have decreased significantly. The ADON stated the abrasion to the back and elbow on 8/15/24 were likely from the resident's EPS movements. The ADON stated it was important to investigate injuries to determine the cause and to make sure it was not abuse. The ADON stated she felt it was the resident's EPS movements at the time that caused the abrasions. In an interview on 12/19/24 3:31pm the DON stated Resident #1's constant movements were the cause of the abrasion to her back/shoulder and elbow. The DON stated she thought the EPS movements were care planned but stated she was unable to find them on the care plan. The DON stated these injuries were not reported to HHSC because she felt they did not fall under the categories for reporting according to the Provider letter . The DON stated it was important to report injuries to ensure the proper investigation was being completed. In an interview on 12/19/24 at 3:52 p.m. the Administrator stated he did not recall at that time why the abrasions for Resident #1 on 8/15/24 were not reported to HHSC. The Administrator stated it was important for injuries to be reported so an investigation took place and to find out the source of the injury. The Administrator stated the health and safety of the residents would be the risks for not reporting. The Administrator stated some incidents were not reported to HHSC due to following the guidance of the Provider Letter PL-2024-14. 2. Record review of Resident #2's face sheet, dated 12/18/2024, revealed Resident #2 was admitted on [DATE] with diagnoses which included: Alzheimer's disease, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified osteoarthritis, unspecified site, need for assistance with personal care, muscle weakness (generalized), difficulty in walking, not elsewhere classified, and other abnormalities of gait and mobility. Record review of Resident #2's Quarterly MDS assessment, dated 11/01/2024, revealed Resident #2's BIMS score was 00 indicating severe cognitive impairment and she was dependent of staff for sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfers (helper does all of the effort). Record review of Resident #2's care plan date initiated 08/16/2024 had a focus of Has had an actual fall r/t Poor Balance .08/15/24: Fall from WC; No injury, 10/25/24 Fall from WC; Abrasion to L side of face. revealing a revision date of 10/28/2024. Care plan interventions/tasks read 08/15/24: staff to assist resident to bed after dinner services date initiated 08/16/2024, 10/25/2024: Nonskid socks provided when OOB Date initiated: 10/28/2024. Record review of Resident #2's nursing progress note dated 10/25/2024, time 07:30 a.m. read Resident had a fall resulting to a discoloration to left side of forehead and bridge of nose. Remained alert c/o pain was given 650 mg of Tylenol. Notified PA and family. Resident was sent to [hospital name] to be evaluated Record review of Resident #2's Fall Risk Evaluation effective date 08/15/2024 read Category: High Risk. During an interview on 12/18/2024 at 11:11 a.m. LVN D stated she believed Resident #2 had leaned forward in her wheelchair and fallen from the wheelchair in the television area. Stating resident was face down when she was found and unable to communicate or describe what had happened. LVN D stated assessed resident and resident was sent out to the emergency room for an evaluation due to her having discoloration to her face. During an interview on 12/18/2024 at 5:39 p.m. the DON stated Resident #2 was sent out to the ER because she was on an anti-coagulant (blood thinner). The DON further stated the facility will usually send residents to the ER for evaluation when they suffer a fall and are taking an anti-coagulant to rule out a bleed. The DON stated she had been reporting falls with injury until the updated provider letter. The DON provided a copy of the provider letter PL 2024-14 (Replaces PL 2019-17) Title: Abuse, Neglect, exploitation, misappropriation of Resident Property and other incidents that a nursing facility (NF), Must Report to the Health and Human Services Commission (HHSC). The DON referred to Page 4 of 13 pages section titled Do Not Report * an injury that is not suspicious or of unknown source. as the reason for not reporting the incident. The DON stated a root cause analysis was done and interviews were performed by the ADON. The DON stated the fall occurred at 6:15 a.m. and this was typically when they were getting residents up for the dining room and would have been getting residents ready for the breakfast. The DON further stated residents were placed near the nursing station and in the common area before going into the dining room. The DON stated the incident was not reported because it was not suspicious, she was following the provider letter from August 2024, resident tended to attempt to stand up at times which could potentially cause a fall when leaning forward to get up, resident received an anti-coagulant and resident was sent to the ER as per the facility policy and procedures. During an interview on 12/18/2024 at 5:43 p.m. the ADON stated when a resident was found on the floor, they considered it a fall due to the change in plane. The ADON stated there were no witnesses and Resident #2 was not able to tell her what happened. The ADON stated the investigation process of the incident involved interviewing staff when the resident was found, how they found the resident. The ADON stated Resident #2 would try to get up at times on her own and in her attempts to get up, she would lean forward. The ADON stated Resident #2 was sent to the ER to ensure there were no other injuries. During an interview on 12/19/2024 at 2:13 p.m. with CNA E, she stated the day Resident #2 fell , she was already up in the common area when CNA E arrived at 6:00 a.m. for her shift. CNA E further stated she heard staff call for assistance because Resident #2 had fallen. CNA E stated Resident #2, at times, would lean forward in her wheelchair and fidget with her leg rest of the wheelchair. During an interview on 12/19/2024 at 3:52 p.m. the ADM stated when incidents occurred, they followed the guidance of the provider letter that had been updated in August of 2024. The ADM stated it was important for unobserved incidents to be reported to the authorities to ensure investigations take place. He further stated reporting helped in finding out the source and helped to ensure the resident were safe. Record review of facility's Incident/Accidents policy, no date, read, Policy: It is the policy of this facility to ensure all incidents/accidents occurring on our premises are investigated and reported to the administrator and/or DON. Procedure: 3. Investigation and follow up. B. Should the incident/accident meet the requirements of reporting to the State Department of Health, the Administrator of Director of Nursing will follow regulations. Record review of facility's undated Anticoagulants related to Falls policy read, Policy: It is the policy of the facility to ensure proper treatment is conducted for residents who are on anticoagulants that sustain falls. Procedures: 1. If resident sustains an unwitnessed fall and unable to give description, med profile must be checked for anticoagulant use. If resident takes anticoagulants, notify physician, and send out to ER for a CT of the head to rule out head [NAME]. Review of the facility policy undated for incidents and accidents . 3. B. Should incident/accident meet the requirements of reporting to the State Department of Health, the Administrator or Director of Nursing will follow regulations.

Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment with housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 6 residents (Residents #3 and #4) reviewed for resident rights: Residents #3 and #4 shared a room with a strong odor of urine. This failure could place residents at risk of embarrassment, humiliation, low self-esteem, and not residing in a sanitary and comfortable, homelike environment. The findings were: Record review of Resident #3's face sheet dated 12/18/24 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to damage or abnormalities inside the developing brain that disrupt the brain's ability to control movement and maintain posture and balance.), Epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures), and unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed the resident's speech was unclear, and no BIMS interview was completed. The resident was dependent on staff for toileting, bathing, and personal hygiene. The resident was frequently incontinent of urine and bowel. The resident usually understands and was sometimes able to be understood. Record review of Resident #3's care plan revised on 3/22/24 revealed a focus for ADL self-care with a goal to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. Interventions were for staff assistance. Another focus for incontinence revised on 3/22/24 and interventions included checking the resident's brief and cleaning the resident. Another focus for a potential behavior problem revised 8/12/24 included the resident urinating in common areas or in his bed after being taken to the toilet by staff. Interventions included to anticipate and meet needs, psych evaluation and treatment, and praise. Record review of Resident #4's face sheet dated 12/19/24 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. The resident's diagnoses included unspecified dementia, mild with other behavioral disturbance (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), aphasia following cerebral infarction (disorder that impairs the expression and understanding of language as well as reading and writing following a stroke), and muscle wasting and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed the resident's speech was unclear, and no BIMS interview was completed. Assessment for daily decision making indicated the resident was severely cognitively impaired. The resident was totally dependent on staff for toileting, bathing, and personal hygiene. The resident was frequently incontinent of urine and bowel. The resident usually understands and was sometimes able to be understood. Record review of Resident #4's care plan revised on 11/24/24 revealed a focus for the resident refusing to participate in activities and refusing to come out of his room for daily activities with a goal for the resident to be satisfied. Interventions included to invite and encourage to participate in activities. Record review of the housekeeping employee schedule for November 2024 and December 2024 revealed a starred note at the bottom of the schedules *note clean (Resident #3 and #4's rm #) twice per day AM and PM. In an observation and interview on 12/16/24 at 3:00 p.m. upon entering Residents #3 and #4's shared room, a strong odor of urine was noted. Resident #3 was on a low bed on the floor with no sheets, had two blankets balled up, 1 sock on and 1 sock off. Resident #3 was dressed in sweatpants and a t-shirt. Resident #3's mattress was slid slightly away from the wall and the frame of the bed. Resident #3 smiled at me when calling his name but was unable to answer questions. The resident was observed moving around in the bed at will. A fall mat with a gray zipped covering was on the floor next to his bed. The source of the urine odor was unknown. CNA A was passing by in the hallway and stated she and another CNA were assigned to Resident #3. CNA A did not enter the room, but when asked if the room always smelled like that, CNA A stated yes, due to Resident #3 urinating on the floor at night. During attempts to interview Resident #4, he made eye contact, but did not reply to my questions. In an observation and interview on 12/16/24 at 3:08 p.m. in Residents #3 and #4's shared room, the strong odor of urine remained, and the DON stated, she could smell the urine and stated the room was on a twice daily cleaning schedule and they used special cleaning solution in the room due to Resident #3 urinating on the floor and other places at will. The DON stated she would check with housekeeping on cleaning the room and what specific solution they used. In an observation on 12/16/24 at 3:39 p.m. Residents #3 and #4's shared room continued with the strong urine smell, and Resident #3's fall mat remained in place next to his bed. Residents #3 and #4 did not appear to be wet and had no wet areas to their clothing. In an observation and interview on 12/16/24 at 3:50 p.m. of Residents #3 and #4's shared room and the strong urine odor remained present in the room but stronger on Resident #3's side of the room. The fall mat next to Resident #3's bed remained and the resident was in the bed. Upon lifting the corner of the fall mat the underside of the mat and the floor were both wet with standing liquid on the fall mat and floor. The DON arrived to the room at 3:58 p.m. and after donning gloves lifted the fall mat and the entire underside of the fall mat and under mat on the floor was wet with standing liquid with whitish bubble looking lines scattered in different areas. After putting on a glove, this surveyor observed a corner where the foam was viewable by the zipper to the fall mat cover and the foam inside the zipped cover was observed to leave wetness on the glove and was wet. The odor of the liquid on the floor, the underside of the mat, and the foam had the same strong urine odor. The Administrator came to the room at 4:00 p.m. and stated the room was cleaned twice daily due to the resident urinating on the floor. The fall mat would be thrown in the trash and replaced with a new one but was switched out when wet to be cleaned. In an observation on 12/18/24 at 11:45 a.m. in Residents #3 and #4's shared room, Resident #4 was in bed watching TV, Resident #3 was not in the room. The fall mat on the floor was a blue one and appeared to be new or in like new condition and was clean and dry. A slight urine odor was detected but no excessive or strong urine odors were noted in the room. In an interview on 12/18/24 at 2:07 p.m. the DON stated Resident #3's fall mat was a new mat and they threw the old fall mat in the trash because the actual foam inside the fall mat was wet. The DON stated the room was cleaned twice daily and if the fall mat had been urinated on it was sent to the laundry for cleaning and switched out with another fall mat. In an interview on 12/19/24 at 3:31 p.m. the DON stated during the observation on 12/16/24 at 3:58 p.m. in Residents #3 and #4's shared room, the standing liquid looked like a combination of cleaning solution and urine. The DON stated it smelled like a combination to her as well. The DON stated she only smelled urine in the room when Resident #3 urinated on the floor and they would get housekeeping to clean. The DON stated Resident #4 had never complained of it being an issue. The DON stated it was important the room did not smell like urine to ensure a sanitary, homelike environment. When asked if she would want to sleep in that room with that smell, the DON stated she would not. In an interview on 12/19/24 at 3:52 p.m. the Administrator stated during the observation on 12/16/24 at 4:00 p.m. he could only smell the urine a little bit. The Administrator stated the room was cleaned twice daily and as needed. The Administrator stated the old fall mat was thrown away and replaced with a new one and the room was cleaned as well. The Administrator stated it was important for the room to not smell like urine to ensure a sanitary homelike environment and respect for the residents. In an interview on 12/19/24 at 4:02pm with HK B and HK C they stated they were both familiar with Residents #3 and #4's shared room. HK B stated it was cleaned twice daily. HK C stated it was cleaned twice daily around 8:00 a.m. and again after 1:00 p.m. and when requested by staff due to Resident #3 urinating. HK C further stated they did clean the fall mats especially in that room due to the resident urinating on the floor and him moving the mat. HK B stated they clean every nook and cranny in that room due to the resident urinating on stuff and they moved the bed as well to clean. HK C stated they did a deep cleaning twice daily. HK B and HK C both stated the room was cleaned with the same cleaning solutions that other rooms were cleaned with. Review of the facility's undated policy on resident rights indicated . Residents have the right to 1. Be treated with respect and dignity as well as . Have a clean and safe environment .

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for one (Resident #1) of one resident reviewed for hospice services. The facility failed to contact the hospice service medical physician or nurse to clarify physician orders for Digoxin to be given with parameters and if lab should be done for Resident #1 . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/26/2024 at 6:05 pm. The IJ template was provided to the facility on [DATE] at 6:05 p.m. While the IJ was removed on 4/28/2024, the facility remained out of compliance at level of potential with a scope identified as isolated harm because of the facility's need to evaluate the effectiveness of their corrective actions. This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers. The findings were: Record review of Resident #1's face sheet, dated 4/25/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and a readmission on 4/19/2024 with diagnoses which included coronary artery disease(Coronary artery disease (CAD) limits blood flow in your coronary arteries, which deliver blood to your heart muscle.) hypertension(High blood pressure, also known as hypertension, is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high.), unspecified atrial fibrillation (an irregular and often rapid heart rhythm), vascular dementia(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Diabetes Mellitus 2(A metabolic disorder in which the body has high sugar levels for prolonged periods of time.), and history of stroke. Record review of Resident #1's physician orders, dated 2/19/2024, revealed there was no order to monitor the parameters of the Digoxin or to have any labs done for checking the Digoxin level for toxicity. Physician order read: Digoxin 0.25 mg tab po daily. During an interview on 4/25/2024 at 11:57 am DON of Hospice stated the admitting hospice nurse do medication reconciliation when a resident is admitted to hospice services. The nurses go over each medication to make sure the order is correct. He stated he did not know if the two nurses (the hospice nurse and the facility nurse) questioned the digoxin order not having a parameter or to have lab ordered for a digoxin level. He stated when a resident is on hospice, labs are not typically done as this is part of the palliative care. During an interview on 4/25/2024 at 12:41 pm LVN I stated he was the admitting nurse for Resident #1 when he was admitted to facility under hospice care. He stated the hospice nurse and himself went over the medications ordered by the hospice MD including digoxin. He further stated neither he nor the hospice nurse questioned the digoxin not having parameters and labs for potential toxicity. He stated normally digoxin when ordered has parameters and labs ordered. Record review of Resident #1's EMR progress notes dated 4/13/2024 reflected a change in condition/transfer form requesting Resident #1's family requesting resident be sent to hospital. Record review of Resident #1 required hospitalization on [DATE] for complaints of nausea during the period of 2/23/2024- 4/13/2024(7 different dates), resulting in h hospital discharge diagnosis of nausea and vomiting due to digoxin toxicity. Lab values at the hospital revealed an elevated digoxin level of 3.7 with 2 being normal indicating digoxin toxicity. During an interview on 4/25/2024 at 12:41 pm LVN I stated he was the admitting nurse for Resident #1 when he was admitted to facility under hospice care. He stated the hospice nurse and himself went over the medications ordered by the hospice MD including digoxin. He further stated neither he nor the hospice nurse questioned the digoxin not having parameters and labs for potential toxicity. He stated normally digoxin when ordered has parameters and labs ordered. LVN I further revealed Resident #1 complained of nausea multiple times during the period of 2/29/2024-4/13/2024. LVN I said Resident #1 received nausea medication when he complained of nausea and it wass effecctive. During an interview on 4/25/2024 at 1:22 pm facility DON stated if a resident is on hospice services the facility nursing staff follow the physician orders that are provided by hospice. She stated Resident #1 had a physician order for digoxin 0.25 mg tab po daily and there were no parameters or labs ordered. She further stated if the hospice physician did not order any then we would not have parameters or do lab. DON said, I expect the nurses to follow physician orders. During a telephone interview on 4/28/2024 at 2:22 pm hospice medical physician stated he did not order parameters or lab for toxicity regarding Resident #1's Digoxin. He stated he does not typically have residents on digoxin and did not order parameters or labs. Resident #1 was already on digoxin when we admitted him to hospice services in January 2024 and I do not know who originally ordered it. He further revealed digoxin when taken can be toxic if other underlying diagnoses exist with a resident. He stated we all learned from this. The Administrator and DON were notified of an IJ on 4/26/2024 at 6:02 pm and was given a copy of the IJ Template and a POR (plan of removal) was requested. The Plan of Removal was accepted on 4/28/2024 at 2:20 pm and included the following: The Mystic Park Plan of Removal 4-26-2024: IJ called per IJ template Quality of Care 684 Immediate Action o Medical Director notified of Immediate Jeopardy on 4/26/24 at 7:30PM o Resident# 1 is no longer on Digoxin. Resident #1 returned to the facility on [DATE] with digoxin discontinued. o Resident #1 now has an order that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. o Primary Care Physician was called on 4/26/24 at 7:45PM o Resident #1 medications were reviewed on 4/26/2024 by the pharmacist to ensure no other medication that require parameters or routine labs are missing. No other Medications that may require parameters or lab monitoring were found. o An audit was completed on all Hospice residents and all residents to ensure no other medication that require parameters, routine labs or orders that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice are in place Audit was started on 4/26/2024 at 6:05 pm and will be completed by 9:00AM 4/27/24. Audit was completed by Nurse managers. o Care plans were reviewed for all hospice residents by MDS nurses to ensure any hospice resident who requires Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications Audit started at on 4/26/24 and will be completed by 4/27/24 9:00AM. o The following in services were started on 4/26/24 and will be completed on 4/27/24 by 9AM -Abuse and Neglect all staff, Documentation of conversation with MD if MD does not want to order parameters or monitor labs for medications requiring monitoring -all licensed staff. Monitoring for signs and symptoms of digoxin toxicity for all licensed staff and Care plans for hospice residents to reflect monitoring or interventions for medications. All staff will receive in services prior to working a shift, any staff that has not received in servicing will not be allowed to work a shift until they have received in servicing. o An audit was started to ensure all residents in the facility have had a review done by the pharmacist for the month of April this audit was started on 4/26/24 and will be completed by 4/27/24. Identification of Others Affected. All Hospice residents have the potential to be affected by this alleged deficient practice. Currently there are 19 residents on Hospice. Systemic Change to Prevent Re-occurrence. 1. All new admissions will be reviewed to identify to ensure all medications that require parameters or lab monitoring are in place and orders. This process will start 4/26/2024 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 2. All new Hospice residents and new admissions care plans will be reviewed to ensure Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications. This process will start 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 3. All new hospice residents and new admissions will be reviewed to ensure medications that require parameters, routine labs or invasive procedures have an order that reads not to be done unless ordered by Hospice. This Process will start on 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekend. 4. All new hired employees will receive in servicing on the topics listed in this plan of removal before working the floor, this process will start 4/26/2024. 5. Staffing coordinator will be in serviced on the process of new hire in servicing and will not schedule new staff on floor until in servicing has been received. Staffing Coordinator will be in serviced on 4/26/2024. 6. The pharmacist will exit with DON and review the list of residents to ensure all received a review and interventions are in place. This will start on 4/26/24. Monitoring 1.DON / DESIGN EE will review new admissions this includes Hospice admissions in the clinical meeting Monday thru Friday for appropriate orders and intervention. The weekend supervisor will review new Hospice admissions and notify the DON of any issues noted. This process will start on 4/26/2024. 2. An off cycle QAPI will be completed on 4/26/2024 to review the IJ template and plan of removal this will be completed by 4/27/2024 10:00AM. 3.Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor verification of the Plan of Removal on 4/28/2024 was as follows: Record review of Nurse Noted dated 4/26/24 at 7:30 PM authored by the Administrator revealed the MD was notified (medical director). During an observation and interview on 4/27/24 at 3:15 Pm, Resident #1 was in the activity hall playing Bingo; alert and oriented X2. No injuries, bruises, or skin tears present. The resident mood was neutral, no signs of distress. Resident was sitting in a W/C. The resident stated that medications help, and he was aware of having taken in the past Digoxin. The resident was not sure whether he still had the Digoxin prescribed. The Resident stated he had no current side effects from any medications. Record review of Resident #1's clinical note dated 4/18/24, revealed that the medication Digoxin was discontinued. Record review of Resident #1's MD orders dated 4/26/24 at 5:00 PM authored by Hospice Medical Physician, revealed: no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. During an interview on 4/27/24 at 3:24 PM, the DON stated the facility could not perform clinical interventions to include x-ray, labs, or invasive procedures unless ordered by the hospice physician or facility physician. The DON stated, if there was a misunderstanding in orders the facility would check with both physicians. Record review of Resident #1's Nurse Note dated 4/26/24 at 7:45 PM authored by RN L revealed Primary Care Physician was called on 4/26/24 at 7:45PM. During an interview on 4/27/24 at 3:44 PM, the Pharmacist stated the Medication Regimen Review for Resident #1 (see above) was correct and accurate. Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 3:57 PM, LVN I MDS Nurse stated he pulled reports of medications that needed parameters with a focus on the 19 hospice residents and updated any care plans that needed revisions; but there were no major revisions. LVN I stated that MDS will check and put in parameters required for new admissions LVN stated that residents that might require parameters included: BP monitoring, insulin, and cardiac. LVN, I attended training (6A-2P) and the highlight of the training was that all medications that need parameters determined by the physician are captured in the orders and CP. In interviews on 04/27/24 from 4:00 PM. to 5:35 PM with 5 day shift (6 a.m. to 2 p.m.) nursing staff (4 LVNs, 1 RN,), 4 evening shift (2P-10P) , 3 LVN and 1 RN and 2 night shift (6 p.m. to 6 a.m.) nursing staff (1 LVNs, 1 RN) revealed they had been in-serviced on parameters, following MD orders, checking on hospice dioxygen monitoring, CP involving parameters, medication review of new admissions to include hospice and abuse and neglect. In interviews on 4/28/2024 from 11:01- 4 med aide (6-2/2-10pm shift- (4VM and 2 not set up), 3 LVN's( 6a-2pm) 7(cna's (work 6-2 and 2-10), 2- CMA, Housekeeping 3,dept heads(main, admit, ad, med rec),laundry(1 ) dietary(3) Abuse and neglect and medications if pertains to license. Record review Med aide 4/26/2024- in service 100% signature or via phone. Record review of in-service training signatures revealed: o Abuse and neglect 129 signatures (100%) completed 4/26/24. o Digoxin monitoring revealed 27 signatures (100% licensed nursing staff) o Medications with parameters revealed 27 signatures (100% licensed nursing staff) o CP for MDS Nurses: revealed 2 signatures (100%) o New Admissions -Weekend RN supervisor: revealed 1 signature (100%). Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 4:08 PM, the DON stated a log was created which included medications that required parameters and CP; and a separate tab for hospice stating to ask about orders for no labs, x-rays or invasive procedures. Record review of facility' admission sheet for 4/27/24 revealed no hospice admissions as of 4:19 PM. During an interview on 4/27/24 at 4:10 PM Admissions Coordinator stated no new hospice admissions as of 4:10 Pm on 4/27/24; the DON would verify the status of the resident before the residents. Record review of facility log titled New Log in-services revealed a section on training on Digoxin, abuse and neglect, and MD notification involving parameters and documentation, if applicable. During an interview on 4/27/24 at 4:35 PM, the Staffing Coordinator stated he was in-serviced on not allowing new staff on the floor unless they completed the in-service on parameters. Record review of in-service sheet dated 4/26/24 revealed Staffing Coordinator signed the in-service training sheet on parameters. Record review of Resident Medication Review List dated 4/26/24 revealed that 102 residents were reviewed, and interventions were in place. During telephone interview on 4/27/24 at 4:40 PM, the Pharmacist stated that she exited with DON and reviewed the list of residents to ensure all received a review and interventions were in place. This would start on 4/26/24 around 10:00 AM and ended the review at 4/27/24 around 10:30 AM. Record review of QAPI out of cycle meeting revealed meeting held on 4/27/24 at 8:40 AM; signatories included: MD, Administrator, DON, two department heads, and IP. During an interview on 4/27/24 at 4:48 PM, the Administrator stated: the meeting discussed the IJ template and the POR and to follow MD orders. The Administrator stated that QAPI for the next 90 days will continue to review compliance with the POR. On 4/28/2024 at 2:20 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated because the facility's need to monitor the implementation and effectivness of their plan of removal.

Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving ,dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to clarify orders for Digoxin regarding the need for parameters and labs. The facility failed to ensure the pharmacist performed a medication review every 30 days. The facility failed to monitor Digoxin levels of Resident #1 because he did not have an order. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/26/2024 at 6:05 pm. The IJ template was provided to the facility on [DATE] at 6:05 p.m. While the IJ was removed on 4/28/2024, the facility remained out of compliance at level of potential harm with a scope identified as isolated harm because of the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of a critically low pulse, toxic digoxin blood levels, missed signs and symptoms of illness, hospitalization , and death. Findings included: Record review of Resident #1's face sheet, dated 4/25/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and a readmission on 4/19/2024 with diagnoses which included coronary artery disease(Coronary artery disease (CAD) limits blood flow in your coronary arteries, which deliver blood to your heart muscle.) hypertension(High blood pressure, also known as hypertension, is when your blood pressure, the force of your blood pushing against the walls of your blood vessels, is consistently too high.), unspecified atrial fibrillation (an irregular and often rapid heart rhythm), vascular dementia(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.), Diabetes Mellitus 2(A metabolic disorder in which the body has high sugar levels for prolonged periods of time.), and history of stroke. Record review of Resident #1's physician orders, dated 2/19/2024, revealed there was no order to monitor the parameters of the Digoxin or to have any labs done for checking the Digoxin level for toxicity. Physician order read: Digoxin 0.25 mg tab po daily. Record reveiw of Residnet #1's progress notes dated 2/29/2024 @17:43 revealed Note Text: Resident(#1) c/o feeling very slightly nauseous and asked if he could have something to help. Order written per standing orders from Medical Doctor for Zofran prn for each nausea episode, 3/2/24 @23:54 c/o nausea, 3/18/2024 c/o nausea,3/20/24 c/o nausea, 4/12/2024 c/o nausea. Record review of the facility's pharmacy review dated 2/23/2024 by facility pharmacist indicated a review was completed on 2/23/2024 and the pharmacy review indicated no documentation or concerns with medication digoxin. Record review of the facility's pharmacy review dated 3/1/2024- 3/31/2024 did not include Resident #1 on the list being reviewed for March 2024. Record review of Resident #1's EMR progress notes dated 4/13/2024 reflected a change in condition/transfer form requesting Resident #1's family requesting resident be sent to hospital. Record review of Resident #1 required hospitalization on [DATE] for complaints of nausea during the period of 2/23/2024- 4/13/2024(7 different dates), resulting in h hospital discharge diagnosis of nausea and vomiting due to digoxin toxicity. Lab values at the hospital revealed an elevated digoxin level of 3.7 with 2 being normal indicating digoxin toxicity. During an interview on 4/25/2024 at 12:41 pm LVN H stated he was the admitting nurse for Resident #1 when he was admitted to facility under hospice care. He stated the hospice nurse and himself went over the medications ordered by the hospice MD including digoxin. He further stated neither he nor the hospice nurse questioned the digoxin not having parameters and labs for potential toxicity. He stated normally digoxin when ordered has parameters and labs ordered. LVN H further revealed Resident #1 complained of nausea multiple times during the period of 2/29/2024-4/13/2024. LVN H said Resident #1 received nausea medication when he complained of nausea and it wass effecctive. During an interview on 4/25/2024 at 2:08 pm with the facility's Pharmacist revealed she had done a pharmacy review on 2/23/2024 and had not advised any changes to digoxin or need for labs or parameters because Resident #1 was on hospice services and hospice typically did not do labs . She stated digoxin usually had a parameter set for holding medication if heart rate was less than 60 and labs to be done every 6 months to check for toxicity. She further revealed there was no pharmacy review done in March 2024 as she stated resident was in and out of the hospital. Record review of the facility's policy entitled: Nursing Administration, Section: Care and Treatment, Subject: Pharmaceutical Services; Policy: It is the policy of the facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. Procedures: The pharmacist, in collaboration with the facility and physician helps develop and evaluate the implementation of pharmaceutical services procedures that address the needs of the residents and reflect current standards of practice. Pharmacist schedules with the facility to review and audit charts. Admission drug regimen reviews will be conducted within the first 7 days of admission and monthly thereafter. The Administrator and DON were notified of an IJ on 4/26/2024 at 6:02 pm and was given a copy of the IJ Template and a POR (plan of removal) was requested. The Plan of Removal was accepted on 4/28/2024 at 2:20 pm and included the following: The Mystic Park Plan of Removal 4-26-2024: IJ called per IJ template Quality of Care 684 Immediate Action o Medical Director notified of Immediate Jeopardy on 4/26/24 at 7:30PM o Resident# 1 is no longer on Digoxin. Resident #1 returned to the facility on [DATE] with digoxin discontinued. o Resident #1 now has an order that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. o Primary Care Physician was called on 4/26/24 at 7:45PM o Resident #1 medications were reviewed on 4/26/2024 by the pharmacist to ensure no other medication that require parameters or routine labs are missing. No other Medications that may require parameters or lab monitoring were found. o An audit was completed on all Hospice residents and all residents to ensure no other medication that require parameters, routine labs or orders that reads no labs, x-rays, or invasive procedures to be done unless ordered by Hospice are in place Audit was started on 4/26/2024 at 6:05 pm and will be completed by 9:00AM 4/27/24. Audit was completed by Nurse managers. o Care plans were reviewed for all hospice residents by MDS nurses to ensure any hospice resident who requires Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications Audit started at on 4/26/24 and will be completed by 4/27/24 9:00AM. o The following in services were started on 4/26/24 and will be completed on 4/27/24 by 9AM -Abuse and Neglect all staff, Documentation of conversation with MD if MD does not want to order parameters or monitor labs for medications requiring monitoring -all licensed staff. Monitoring for signs and symptoms of digoxin toxicity for all licensed staff and Care plans for hospice residents to reflect monitoring or interventions for medications. All staff will receive in services prior to working a shift, any staff that has not received in servicing will not be allowed to work a shift until they have received in servicing. o An audit was started to ensure all residents in the facility have had a review done by the pharmacist for the month of April this audit was started on 4/26/24 and will be completed by 4/27/24. Identification of Others Affected. All Hospice residents have the potential to be affected by this alleged deficient practice. Currently there are 19 residents on Hospice. Systemic Change to Prevent Re-occurrence. 1. All new admissions will be reviewed to identify to ensure all medications that require parameters or lab monitoring are in place and orders. This process will start 4/26/2024 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 2. All new Hospice residents and new admissions care plans will be reviewed to ensure Medications that may require parameters or lab monitoring have care plan in place to indicate monitoring or interventions for medications. This process will start 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekends. 3. All new hospice residents and new admissions will be reviewed to ensure medications that require parameters, routine labs or invasive procedures have an order that reads not to be done unless ordered by Hospice. This Process will start on 4/26/24 and will be monitored by the DON /DESIGNEE daily and will be monitored by the weekend supervisor on the weekend. 4. All new hired employees will receive in servicing on the topics listed in this plan of removal before working the floor, this process will start 4/26/2024. 5. Staffing coordinator will be in serviced on the process of new hire in servicing and will not schedule new staff on floor until in servicing has been received. Staffing Coordinator will be in serviced on 4/26/2024. 6. The pharmacist will exit with DON and review the list of residents to ensure all received a review and interventions are in place. This will start on 4/26/24. Monitoring 1.DON / DESIGN EE will review new admissions this includes Hospice admissions in the clinical meeting Monday thru Friday for appropriate orders and intervention. The weekend supervisor will review new Hospice admissions and notify the DON of any issues noted. This process will start on 4/26/2024. 2. An off cycle QAPI will be completed on 4/26/2024 to review the IJ template and plan of removal this will be completed by 4/27/2024 10:00AM. 3.Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The surveyor verification of the Plan of Removal on 4/28/2024 was as follows: Record review of Nurse Noted dated 4/26/24 at 7:30 PM authored by the Administrator revealed the MD was notified (medical director). During an observation and interview on 4/27/24 at 3:15 Pm, Resident #1 was in the activity hall playing Bingo; alert and oriented X2. No injuries, bruises, or skin tears present. The resident mood was neutral, no signs of distress. Resident was sitting in a W/C. The resident stated that medications help, and he was aware of having taken in the past Digoxin. The resident was not sure whether he still had the Digoxin prescribed. The Resident stated he had no current side effects from any medications. Record review of Resident #1's clinical note dated 4/18/24, revealed that the medication Digoxin was discontinued. Record review of Resident #1's MD orders dated 4/26/24 at 5:00 PM authored by Hospice Medical Physician, revealed: no labs, x-rays, or invasive procedures to be done unless ordered by Hospice order is dated 4/26/24. During an interview on 4/27/24 at 3:24 PM, the DON stated the facility could not perform clinical interventions to include x-ray, labs, or invasive procedures unless ordered by the hospice physician or facility physician. The DON stated, if there was a misunderstanding in orders the facility would check with both physicians. Record review of Resident #1's Nurse Note dated 4/26/24 at 7:45 PM authored by RN L revealed Primary Care Physician was called on 4/26/24 at 7:45PM. During an interview on 4/27/24 at 3:44 PM, the Pharmacist stated the Medication Regimen Review for Resident #1 (see above) was correct and accurate. Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 3:57 PM, LVN I MDS Nurse stated he pulled reports of medications that needed parameters with a focus on the 19 hospice residents and updated any care plans that needed revisions; but there were no major revisions. LVN I stated that MDS will check and put in parameters required for new admissions LVN stated that residents that might require parameters included: BP monitoring, insulin, and cardiac. LVN, I attended training (6A-2P) and the highlight of the training was that all medications that need parameters determined by the physician are captured in the orders and CP. In interviews on 04/27/24 from 4:00 PM. to 5:35 PM with 5 day shift (6 a.m. to 2 p.m.) nursing staff (4 LVNs, 1 RN,), 4 evening shift (2P-10P) , 3 LVN and 1 RN and 2 night shift (6 p.m. to 6 a.m.) nursing staff (1 LVNs, 1 RN) revealed they had been in-serviced on parameters, following MD orders, checking on hospice dioxygen monitoring, CP involving parameters, medication review of new admissions to include hospice and abuse and neglect. In interviews on 4/28/2024 from 11:01- 4 med aide (6-2/2-10pm shift- (4VM and 2 not set up), 3 LVN's( 6a-2pm) 7(cna's (work 6-2 and 2-10), 2- CMA, Housekeeping 3,dept heads(main, admit, ad, med rec),laundry(1 ) dietary(3) Abuse and neglect and medications if pertains to license. Record review Med aide 4/26/2024- in service 100% signature or via phone. Record review of in-service training signatures revealed: o Abuse and neglect 129 signatures (100%) completed 4/26/24. o Digoxin monitoring revealed 27 signatures (100% licensed nursing staff) o Medications with parameters revealed 27 signatures (100% licensed nursing staff) o CP for MDS Nurses: revealed 2 signatures (100%) o New Admissions -Weekend RN supervisor: revealed 1 signature (100%). Record review of facility's 19 audits of Hospice residents revealed: no issues with parameters involving labs, x-rays, and invasive procedures. During an interview on 4/27/24 at 3:50 PM, the DON stated the report was pulled of residents requiring parameters and checked that every one of the residents had the parameters as ordered by the physician. No resident had a parameter as an outlier. During an interview on 4/27/24 at 4:08 PM, the DON stated a log was created which included medications that required parameters and CP; and a separate tab for hospice stating to ask about orders for no labs, x-rays or invasive procedures. Record review of facility' admission sheet for 4/27/24 revealed no hospice admissions as of 4:19 PM. During an interview on 4/27/24 at 4:10 PM Admissions Coordinator stated no new hospice admissions as of 4:10 Pm on 4/27/24; the DON would verify the status of the resident before the residents. Record review of facility log titled New Log in-services revealed a section on training on Digoxin, abuse and neglect, and MD notification involving parameters and documentation, if applicable. During an interview on 4/27/24 at 4:35 PM, the Staffing Coordinator stated he was in-serviced on not allowing new staff on the floor unless they completed the in-service on parameters. Record review of in-service sheet dated 4/26/24 revealed Staffing Coordinator signed the in-service training sheet on parameters. Record review of Resident Medication Review List dated 4/26/24 revealed that 102 residents were reviewed, and interventions were in place. During telephone interview on 4/27/24 at 4:40 PM, the Pharmacist stated that she exited with DON and reviewed the list of residents to ensure all received a review and interventions were in place. This would start on 4/26/24 around 10:00 AM and ended the review at 4/27/24 around 10:30 AM. Record review of QAPI out of cycle meeting revealed meeting held on 4/27/24 at 8:40 AM; signatories included: MD, Administrator, DON, two department heads, and IP. During an interview on 4/27/24 at 4:48 PM, the Administrator stated: the meeting discussed the IJ template and the POR and to follow MD orders. The Administrator stated that QAPI for the next 90 days will continue to review compliance with the POR. On 4/28/2024 at 2:20 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated because the facility's need to monitor the implementation and effectivness of their plan of removal.

Based on the comprehensive assessment of a resident, the facility must ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 4 of 5 residents (Resident #'s 1, 2, 3, and 4) reviewed for pressure sores, in that: 1. The facility failed to ensure Resident #1 received: -weekly skin assessments as ordered by a physician -weekly pressure wound assessments, including wound size and description -wound care and dressing changes one time a day as ordered by a physician instead of 3 times a week. 2. The facility failed to ensure Resident #2 received wound care and treatment as ordered by a physician. -Resident #2 did not receive daily wound care to both the right and left heel, instead it was received on Monday, Wednesday, and Friday and did not receive wound care on 8/03/2022 as ordered. -Resident #2 did not receive consistent assessment of pressure injuries including stage, description and measurements to indicate healing or worsening of pressure injuries. -Resident #2 did not receive [MEDICATION(S)] treatment to his right or left heel wound in July as ordered by a physician. -The facility did not immediately obtain orders when Resident #2 was identified has having a pressure injury on her coccyx. -The Treatment Nurse (same as Wound Care Nurse) failed to utilize appropriate infection control practices during wound care to Resident #2. 3. The facility failed to ensure Resident #3 received weekly skin assessments as ordered by the physician. -Resident #3 did not consistently receive assessment of pressure injuries including stage, description and measurements used to indicate healing or worsening of pressure injuries. -Resident #3 did not receive wound care to pressure injuries as ordered by the physician. -Resident #3 did not receive identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . -The Treatment Nurse failed to utilize appropriate hand hygiene and infection control practices during wound care to Resident #3. 4. The facility failed to ensure Resident #4 received: -consistent weekly skin assessments as ordered by the physician -assessments of pressure injuries including stage, description and measurements to indicate healing or worsening of pressure injuries -identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in the identification of Immediate Jeopardy (IJ) on 8/06/2022 at 7:22 p.m. While the immediacy was removed on 8/11/2022, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its POR. These failures affected residents with skin injures and wounds and resulted in a wound infection, hospitalization and amputation and could place additional residents at risk for a delay in treatment, a decline in health, hospitalization , loss of limb and/or a significant decline in health. The findings included: 1. Record review of a face sheet dated 8/4/2022 for Resident #1 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's annual MDS dated [DATE] revealed a BIMs score of 13 (scale of 0-15) which indicated the resident was cognitively intact. Record review of Resident #1's Care Plan dated 12/08/2017 and last revised on 3/10/2022 revealed Resident #1 had diabetes mellitus with interventions which included: monitor/document/report to physician as needed for signs and symptoms of infection to any open area. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to the ADON and Treatment Nurse your finding, one time a day every Thursday. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's medical record revealed there were no weekly skin assessments documented under forms since 6/11/2022. Record review of Resident #1's electronic medical record between 8/04/2022-08/08/2022 revealed there was no documentation uploaded of any of the wound care physician notes in the medical record for review by any other physician or medical practitioners. Record review of a Wound Evaluation and Management Summary dated 7/25/2022 documented by the wound care physician revealed: full thickness wound to buttock, stage 4 measuring 26 cm x 15 cm x 0.3 cm with 100% granulation tissue. The dressing treatment plan included: zinc ointment, apply once daily for 11 days, collagen power, apply once daily for 11 days. Record review of Resident #1's progress notes revealed no documentation of wounds, wound progress, wound size, or wound description. Record review of Resident #1's hospital medical record dated 7/31/2022 revealed: Resident #1 arrived at the emergency department on 7/31/2022 at 5:34 p.m. for a wound check. He had a diabetic foot ulcer which was infected and pressure injury to sacrum. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 complained of generalized pain. Patient sleeping most of the time. Stage 3 pressure wound to left inner buttock and right inner buttocks. During an interview on 8/05/2022 at 12:46 p.m. Resident #1 stated he received wound care three times a week on Monday, Wednesday, and Friday from the Treatment Nurse. He stated sometimes the Treatment Nurse would miss a dressing change. Resident #1 stated he did not receive wound care to any of his wounds on Friday 7/29/2022 because the Treatment Nurse had a day off. Resident #1 stated he did not ask another nurse at the facility to provide wound care because he figured since the Treatment Nurse was not at the facility it wasn't getting done. He stated occasionally a Charge Nurse had provided wound care to him in the past, but they did not like to do it. Resident #1 stated he sensed a power struggle between the Treatment Nurse and the Charge Nurses. During an interview on 8/05/2022 at approximately 3:20 p.m. the Wound Care Physician stated a short amount of time of 4-5 days was a sufficient amount of time, without a dressing change, for a wound to go from not infected to infected especially since Resident #1 had diabetes which put him at additional risk for infection. During an interview on 8/05/2022 at 3:51 p.m. RN T stated had not received reports from staff that Resident #1's wounds did not have a dressing and if they did it was after a bath/shower and the dressings were changed. During an interview on 8/05/2022 at 2:47 p.m., NA Z stated he had concerns about multiple residents not receiving wound care. He stated he has seen different residents (Resident #1, Resident #3 and unknown name) without dressings for days on end. NA Z stated he tried talking to the Treatment Nurse about providing wound care and it ended in an argument. NA Z stated there were several residents complaining about wound care (undisclosed names). NA Z stated the Treatment Nurse told him he should not tell him how to do his job. NA Z stated he told the former ADON (LVN BB) about his concerns and he told the DON approximately 1 month ago who said she would talk to the Treatment Nurse. During an observation/interview on 8/05/2022 at 7:01 p.m., Resident #1 stated he felt like his wounds were not taken care of like they were supposed to have been at the nursing facility. He said, despite that the nursing home was his home and he liked his room, his roommate and most of the staff and he wanted to return. 2. Record review of Resident #2's face sheet dated 8/05/2022 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's MDS (marked other) dated 7/24/2022 revealed the resident had a BIMs score of 4 (scale of 0-15) which indicated a severe cognitive impairment. Record review of Resident #2's MDS (marked other) dated 7/24/2022 revealed the resident had moisture associated skin damage (MASD) (site unspecified) and two pressure injuries. Record review of Resident #2's Care Plan dated 2/09/2022 revealed the resident had type 2 diabetes mellitus with interventions which included: check all of body for breaks in skin and treat promptly as ordered by a doctor. Record review of Resident #2's Care Plan dated 2/09/2022 and last revised 4/14/2022 revealed a wound a stage 3 to the coccyx and unstageable wounds to right and left heel with interventions which included: weekly treatment documentation to include measurement of each area of skin breakdown; width, length, depth, type of tissue and exudate. Interventions included no related infection control interventions. Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation on the TAR for updated wound care orders based on the Wound Care Physicians orders dated 7/19/2022. Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Wound Evaluation and Management Summary dated 7/19/2022 revealed right heel full thickness unstageable wound due to necrosis that measured 2.5 cm x 2 cm x 0.2 cm which was surgically debrided with orders to add [MEDICATION(S)] application one time daily for 30 days and continue with the collagen power one time daily to open area for 30 days, continue with sterile sponge gauze and kerlix wrap for 30 days. Record review of Resident #2's weekly pressure ulcer evaluation dated 7/27/2022 revealed the right heel pressure wound measured 2.5 cm x 2 cm x 0.2 cm and was documented an unstageable pressure wound. Record review of Resident #2's TARs for August 2022 revealed the wounds to right heel were not documented as completed and were only scheduled for wound care on Monday, Wednesday and Friday instead of everyday as ordered by the Wound Care Physician. Record review of Resident #2's Wound Evaluation and Management Summary dated 7/19/2022 revealed: left heel wound was described as unstageable due to necrosis with wound care orders to add [MEDICATION(S)] to wound one time daily for 30 days. Record review of Resident #2's weekly pressure ulcer evaluation dated 7/27/2022 revealed the left heel pressure wound measured 3 cm x 2 cm and was documented an unstageable pressure wound. Record review of Resident #2's July TAR revealed the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's TARs for August 2022 revealed the wounds to left heel were not documented as completed on 8/03/2022 and were only scheduled for wound care on Monday, Wednesday and Friday instead of everyday as ordered by the Wound Care Physician. Record review of Resident #2's Wound Evaluation and Management Summary dated 7/19/2022 the wound to the coccyx was not noted in the Wound Care Physician's notes. Record review of Resident #2's weekly pressure ulcer evaluation dated 7/27/2022 revealed the coccyx measured 3 cm x 3 cm x 0.1 cm and was documented as a stage 3 pressure wound. Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of wound care on Resident #2 on 8/04/2022 at 1:51 p.m., the Treatment Nurse prepared wound care supplies at a medication cart in the hallway on wax paper. The Treatment Nurse then entered the resident room and placed the wax paper with wound care supplies on the resident's bed beside the resident's legs. The Treatment Nurse then left the supplies on the bed and went to wash his hands. The wax paper and wound supplies remained on Resident #2's bed while the Treatment Nurse provided wound care to Resident #2's buttocks. During continued observation of wound care for Resident #2 on 8/04/2022 at 1:51 p.m. with CNA S and the Treatment Nurse revealed two nickel sized wounds to the Resident left buttocks and coccyx area which were open but without signs and symptoms of infection. The Treatment Nurse provided wound care to Resident #2's buttocks/coccyx but did not look at or observe the wounds or wound dressings to Resident #2's heels. After performing wound care to Resident #2's buttocks/coccyx the Treatment Nurse exited the room and did not return. CNA S remained in the room and Resident #2's heels were observed with intact boarder dressings that were dated 8/02/2022 (instead of 8/03/2022 as ordered). During an interview on 8/04/2022 at 1:58 p.m. Resident #2 was unable to answer interview questions due to cognitive status but was able to answer basic yes or no questions. During an interview on 8/04/2022 at 2:00 p.m., CNA S stated the dressings to Residents heels (both right and left) were dated 8/02/2022. During an interview on 8/04/2022 at 2:58 p.m. the Treatment Nurse declined to look at a photo of the 8/02/2022 dated wounds to Resident #2's feet. When asked why the wound dressing were dated 8/02/2022 instead of 8/3/2022 he stated, I did not have any staff to help me hold. It is really strange. It is really odd. I thought I did wound care that is why I did not look at his feet. When asked why [MEDICATION(S)] was not applied to the left heel in July, he stated he could apply [MEDICATION(S)], but it did not do anything when applied to eschar (dead tissue that is black or brown and can resemble a scab or a scab. He stated wound care was ordered every Monday, Wednesday, and Friday. 3. Record review of Resident #3's face sheet dated 8/04/2022 revealed an admitted [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's significant change MDS dated [DATE] revealed the resident had one or more unhealed pressure wounds). The MDS revealed Resident #3 had an unstageable pressure wound (location not stated) and a stage 3 pressure wound (location not stated) and MASD (moisture associated skin damage site unspecified). Record review of Resident #3's Care Plan dated 5/12/2022 revealed a suspected deep tissue injury with interventions which included: administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to the ADON and TX Nurse your findings, one time a day every Wednesday. Record review of Resident #3's Weekly Skin Evaluation dated 7/06/2022 revealed Resident #3 had no abnormal skin area. (Unknown staff) Record review of Resident #3's Weekly Skin Evaluation dated 7/21/2022 revealed Resident #3 had no abnormal skin area. (Unknown staff) Record review of Resident #3's Weekly Skin Evaluation dated 7/27/2022 revealed Resident #3 had no abnormal skin area. (Unknown staff) Record review of Resident #3's Weekly Skin Evaluation dated 8/03/2022 revealed Resident #3 had abnormal skin areas including pressure ulcers that were not new wounds. There was no documentation of wound location or description of wounds. (Unknown staff) Record review of Resident #3's weekly pressure ulcer assessment dated [DATE] revealed a pressure wound to the right ankle that measured 3 cm x 3 cm and listed as unstageable. There was no documentation of the left heel wound or the sacral wound in the weekly assessment. Record review of Resident #'3 weekly non pressure wound assessments revealed there were no assessments of any non-pressure wounds since 5/12/2022. Record review of Resident #3's weekly pressure ulcer assessments revealed there was no assessment of the pressure wounds since 6/14/2022. Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's TARs for August 2022 revealed there was no documentation that the wound to the resident's right 5th toe was treated. Record review of Resident #3's medical record revealed no documentation of the wound to the resident's right 5th toe. Record review of Resident #3's progress notes revealed no documentation of wound assessment for any of the wounds. Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] ointment with collagen sprinkles and leave open to air, one time daily for wound healing. Record review of Resident #3's TARs for July 2022 revealed there was no documentation that wound care was provided for Resident #3's coccyx wound on: -Monday, July 11. 2022 -Wednesday, July 20, 2022 -Thursday, July 21, 2022 -Sunday, July 24, 2022 -Monday, July 25, 2022 -Tuesday, July 26, 2022, -Thursday, July 28, 2022 -Friday, July 29, 2022 -Sunday, July 31, 2022 Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser, pat dry with 4 x 4 gauze, apply collagen sheet to wound bed, apply calcium alginate, cover with dry absorbent dressing one time a day every Monday, Wednesday, and Friday. Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's July TAR revealed there was no documentation wound care was provided to the left heel on: -Monday, July 11, 2022 -Wednesday, July 20, 2022 -Monday, July 25, 2022 -Friday, July 29, 2022 Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's July TAR revealed there was no documentation wound care was provided to the right malleolus (ankle) on: -Monday, July 11, 2022 -Wednesday, July 20, 2022 -Monday, July 25, 2022 -Friday, July 29, 2022 Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a skin observation/interview for on 8/04/2022 at 1:15 p.m. with NA I revealed Resident #3 was unable to be interviewed due to cognitive status. During the observation the coccyx/buttocks had a thick layer of [MEDICATION(S)] and was not able to be visualized for extent of skin injury. There was a dressing to the left heel which had come loose on 3 of the 4 sides and was dated 8/03/2022. The heel wound had a small open area without redness or drainage. The right ankle had a dressing intact dated 8/03/2022. A small wound to the right foot 5th toe had a raised border, depression in the center and a small opening in the center of the wound. The hospice CNA entered Resident #3's room to give the resident a bath at the end of this observation. During an observation of wound care to Resident #3 on 08/04/2022 at 2:20 p.m., the Treatment Nurse prepared wound care supplies on wax paper and then placed the wax paper with the wound care supplies on Resident #3's bed near her feet. The Treatment Nurse then left the supplies on the bed, washed his hands and donned gloves. The Treatment Nurse provided wound care to Resident #1's left heel by cleansing the wound and did not change gloves or utilized hand hygiene before applying wound care medication and treatment. After applying the treatment to the wound the Treatment nurse still did not change his gloves or utilize hand hygiene and using the same gloves put a clean dressing on wound without changing his gloves or utilizing hand hygiene. The Treatment Nurse doffed his gloves but without using hand hygiene provided wound care to Resident #3's right ankle without changing gloves and utilizing hand hygiene by cleansing the wound and then without doffing gloves, applied medication and treatment to the wound and then without doffing his gloves he applied a clean dressing to the wound. During an interview on 8/04/2022 at 2:58 p.m. the Treatment Nurse stated he did not wash or sanitize his hands when providing wound care to Resident #3 because he did not have hand sanitizer and had to go into the hallway to use it. He stated as long as he did not touch anything dirty, he did not need to change his gloves or use hand hygiene. The Treatment Nurse stated when he removed the old dressings, he did not touch the wound or drainage from the wound, so his hands were not dirty, when he cleansed the wounds, he touched the gauze to clean the wound but again did not touch the drainage from the wound. The Treatment Nurse stated he just touched cleansing supplies, so he did not need to utilize hand hygiene or change his gloves. The Treatment Nurse stated he provided wound care the way he was trained. The Treatment Nurse stated he was trained to place the wound supplies on wax paper and then on a bedside tray (table). He stated he was not trained to place it on the resident's bed but did so because the surveyor would not tell him which residents were to be observed in advance so he could properly set up the room for an observation. The Treatment Nurse stated the wax paper provided a barrier between the supplies and the bed. During continued observation of wound care for Resident #3 on 8/04/2022 at 2:20 p.m. the Treatment removed provided wound care to the left heel and ankle. The right ankle dressing was removed prior to wound care which revealed a quarter size open wound area with a large amount of dark red skin discoloration surrounded the entire wound. The Treatment Nurse did not provide wound care to the right 5th toe. He stated he was not aware of the wound until brought to his attention by the surveyor. The Treatment Nurse stated those types of areas are left open to air and the facility does not do anything for the wounds, they just leave them alone. He stated he would call the doctor and get orders for skin prep and an order to leave open to air. During continued interview on 8/04/2022 at 2:58 p.m. the Treatment Nurse stated the wound to Resident #3's 5th toe was new and must have occurred during a bath provided by hospice immediately prior to wound care which was provided. He stated he was not aware of the wound until the surveyor's intervention. During an interview on 8/05/2022 at 2:47 p.m., NA Z stated Resident #3 had dressings left off her wounds for a couple of days at a time and had notified both the Treatment Nurse and RN T. He stated the Treatment Nurse said okay and RN T stated he would tell the treatment nurse. During an interview on 8/05/2022 at 12:22 p.m. Resident #3's hospice nurse stated Resident #3 had a really bad wound to the coccyx, which was not healing, a left heel pressure injury that was not getting better, and a right lateral ankle wound that was staying the same but not getting better and not getting worst. The hospice nurse stated she last saw the wound while making rounds with the Wound Care Nurse approximately two weeks ago. She stated Resident #3 was not eating, had poor nutrition, and poor skin turgor. She stated the wounds may not heal because of the resident's current nutritional state. She stated she had not noticed any wound care concerns 4. Record review of Resident #4's face sheet dated 8/05/2022 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIM's score of 3 (scale of 0-15) which indicated a severe cognitive impairment. Record review of Resident #4's MDS revealed the resident was at risk for pressure ulcers and MASD (moisture associated skin damage to unspecified site). Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's August 2022 TARS revealed no record or documentation of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to the ADON and Treatment nurse your findings, one time a day every Tuesday. Record review of Resident #4's weekly skin evaluation dated 7/26/2022 revealed Resident #4 had non-blanching redness to the coccyx. (Sign of early pressure ulcer). There was no documentation of the right or left foot wound. Record review of Resident #4's weekly skin evaluation dated 8/02/2022 revealed the resident did not have any abnormal skin areas and had wrinkling associated with aging skin. (Unknown staff). Record review of Resident #4's weekly pressure ulcer evaluations revealed there was no documentation of pressure wound assessments since 2/17/2022. Record review of Resident #4's weekly non-pressure evaluations revealed there was no documentation of non-pressure wound assessments since 6/21/2022. Record review of Resident #4's progress notes revealed no documentation of the wounds to Resident #4's feet or coccyx. Record review of the Treatment Nurses Wound Care Logs dated 6/1/2022 thru July 25, 2022, revealed Resident #4's coccyx wound was on the log but did not have any measurements of skin injury and the wounds to Resident #4's right and left foot were not documented. During a skin observation to Resident #4 on 8/04/2022 at 1:05 p.m. with CNA V revealed Resident #4 had a small area of redness to the coccyx area approximately a quarter in size with a layer of [MEDICATION(S)] to the wound. Resident #4 had an oval shaped pressure wound to the left ball of the foot approximately the size of an elongated quarter that with eschar with areas that were brown and black, and a small eraser head sized wound to the right ball of the foot with a small open center and discoloration including small amounts of redness around the foot. Neither one of the two-foot wounds had dressings. Resident #4 had contractures of all 4 extremities and was lying in the fetal position. During an interview on 8/04/2022 at 1:05 p.m. Resident #4 was unable to answer any interview questions or make her needs known due to cognitive status. During an interview on 8/04/2022 at 1:08 p.m., CNA V stated there were no dressings to the wounds on either foot and there were no loose dressings in the socks that were on the resident's foot or in the bed. During an interview on 8/04/2022 at 2:58 p.m. the Treatment Nurse stated he was aware of the wounds to Resident #4's feet because they did not need treatment and did not provide wound care because it was the bottom of the foot although he could put skin prep. He stated it just depended on the resident and the wound. He stated he did not need to document and treat every little skin area. During an interview on 8/04/2022 at 3:27 p.m. the Treatment Nurse stated Resident #4's coccyx wound was MASD and not a pressure wound. He stated the left foot wound had eschar and the right foot wound looked like an abrasion. He stated neither foot wound looked like a pressure wound to him because they kept coming back. During an interview on 8/06/2022 at 1:56 p.m., Resident #4's RP stated she had taken photos of the foot wounds and sent them to the Social Worker and the hospice nurse a couple of weeks ago on July 11, 2022. She stated she told the Social Worker she was concerned about the care her family member received. The RP stated the Social Worker stated the wounds were not infected, the wounds come and go, and the resident gets ointment. The RP stated the Hospice Nurse told her she would follow up with the facility nurse (unknown name). During an interview on 8/09/2022 at 12:29 p.m. the former Social Worker stated she no longer worked at the facility as of 8/05/2022. She stated she had no complaints of wound ca

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 5 residents (Resident #s 1 and 5) reviewed for treatment and services, in that: 1. The facility failed to ensure Resident #1 received: -weekly skin assessments as ordered by a physician -weekly pressure and non-pressure wound assessments, including wound size and description -wound care and dressing changes one time a day as ordered by a physician instead of 3 times a week -wound care on 7/28/2022 through 7/29/2022 which resulted in an infection to the diabetic foot, hospitalization for [CONDITION(S)], [CONDITION(S)] and amputation of the right foot 5th toe, metatarsal bone, muscle and surrounding soft tissue. 2. The facility failed to ensure Resident #5 received: -accurate weekly skin assessments as ordered by a physician -wound care and treatment as ordered to a right chest (axilla) wound and right breast wound in July and August. -The Treatment Nurse failed to utilize appropriate hand hygiene and infection control practices during wound care to Resident #5. These failures resulted in the identification of Immediate Jeopardy (IJ) on 8/06/2022 at 7:22 p.m. While the immediacy was removed on 8/11/2022, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its POR. These failures affected residents with skin injures and wounds and resulted in a wound infection, hospitalization and amputation and could place additional residents at risk for a delay in treatment, a decline in health, hospitalization , loss of limb and/or a significant decline in health. The findings included: 1. Record review of a face sheet dated 8/4/2022 for Resident #1 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's annual MDS dated [DATE] revealed a BIMs score of 13 (scale of 0-15) which indicated the resident was cognitively intact. Record review of Resident #1's annual MDS dated [DATE] revealed the resident had a diabetic foot ulcer and received applications of nonsurgical dressings to feet and ointment/medications. Record review of Resident #1's Care Plan dated 12/08/2017 and last revised on 3/10/2022 revealed Resident #1 had diabetes mellitus with interventions which included: monitor/document/report to physician as needed for signs and symptoms of infection to any open area. Record review of Resident #1's Care Plan dated 4/27/2022 revealed the resident had a diabetic foot ulcer to the right distal lateral foot with interventions which included: monitor/document wound size, depth, margins, peri wound skin, sinuses, undermining, exudates, [CONDITION(S)], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to the ADON and Treatment Nurse your finding, one time a day every Thursday. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser, gently pat dry with 4 x 4 gauze, apply collagen sprinkles to wound bed, cover with calcium alginate one time a day every Monday, Wednesday, and Friday for wound healing. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] (redness) to right lateral aspect of right foot with an associated ulcer. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's medical record revealed there were no weekly skin assessments documented under forms since 6/11/2022. Record review of Resident #1's weekly non-pressure ulcer evaluations revealed there were no assessments on non-pressure wound injuries since 6/21/2022. Record review of Resident #1's electronic medical record between 8/04/2022-08/08/2022 revealed there was no documentation uploaded of any of the wound care physician notes in the medical record for review by any other physician or medical practitioners. Record review of Resident #1's Wound Evaluation and Management Summary dated 7/25/2022 documented by the wound care physician revealed: the diabetic foot ulcer to the right distal later foot was a full thickness wound measuring 2 cm x 2 cm x 0.2 cm. The wound was surgically debrided to remove necrotic tissue and establish the margins of viable tissue. Wound treatment orders for this wound included: collagen power and calcium alginate with gauze island dressing with boarder one time a day for 30 days. Record review of a Wound Evaluation and Management Summary dated 7/25/2022 documented by the wound care physician revealed: a lymphademic wound of the right, proximal medial (beginning top of knee down midline) knee full thickness measuring 0.5 cm x 0.5 cm x 0.1 cm and right lateral (inside of leg) shin full thickness measuring 0.5 cm x 0.5 cm x 0.1 cm and right distal leg full thickness measuring 0.5 cm x 0.5 cm x 0.1 cm with dressing treatment plan which included: calcium alginate with gauze sponge dressing, covered with Kerlix one time a day for 30 days. Record review of a Wound Evaluation and Management Summary dated 7/25/2022 documented by the wound care physician revealed: Lymphedemic wound of the left shin full thickness measuring 11 cm x 4 cm x 0.1 cm. The wound was surgically debrided to remove necrotic tissue and establish the margins of viable tissue. The dressing treatment plan was collagen sheet one time daily for 11 days, calcium alginate, apply one time daily for 24 days with Kerlix dressing applied one time daily for 24 days and ACE bandage apply once daily for 17 days. Record review of a Wound Evaluation and Management Summary dated 7/25/2022 documented by the wound care physician revealed: full thickness wound to buttock, stage 4 measuring 26 cm x 15 cm x 0.3 cm with 100% granulation tissue. The dressing treatment plan included: zinc ointment, apply once daily for 11 days, collagen power, apply once daily for 11 days. Record review of Resident #1's progress notes revealed no documentation of wounds, wound progress, wound size, or wound description. Record review of Resident #1's TAR (Treatment Administration Record) for July 2022 revealed the wound care to Resident #1's left lower extremity, right distal diabetic foot ulcer and right lower extremity had no documentation of wound care of 7/29/2022. The last documented wound care was on 7/27/2022. Record review of Resident #1's Change of Condition Form dated 7/31/2022 at 4:07 p.m. revealed Resident #1 wound to right foot 5th digit appears infected. The document indicated this symptom had occurred before and was treated with antibiotics. The form indicated Resident #1 was sent to a local hospital for evaluation. Record review of Resident #1's hospital medical record dated 7/31/2022 revealed: Resident #1 arrived at the emergency department on 7/31/2022 at 5:34 p.m. for a wound check. He had a diabetic foot ulcer which was infected and pressure injury to sacrum. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 complained of generalized pain. Patient sleeping most of the time. Stage 3 pressure wound to left inner buttock and right inner buttocks. Record review of Resident #1's MRI results from a local hospital dated 8/04/2022 revealed Findings consistent with [CONDITION(S)] (infection in the bone) in the fifth metatarsal (head, neck and shaft/diaphysis and base of the fifth toe. During an interview on 8/04/2022 at 3:27 p.m., the Treatment Nurse stated Resident #1 was in the hospital due to a diabetic foot ulcer. The Treatment Nurse stated Resident #1 had just come off antibiotics and 3 days later, while he was performing rounds on 7/31/2022, he opened up Resident #1's right foot dressing. The Treatment Nurse stated the foot and wound did not look good to me. He stated he called MD CC and the NP (unknown name) who said to send the resident out (to the hospital). The Treatment Nurse stated Resident #1 had [CONDITION(S)] wounds from the knee down which were almost healed. The Treatment Nurse stated diabetic foot ulcer did not want to heal. He described the diabetic foot ulcer as having redness around the wound, but no streaks or [CONDITION(S)]. The Treatment Nurse stated the wound was deep red and had lots of exudate (drainage) and blood drainage. He stated there was no foul smell. The Treatment Nurse stated Resident #1 had paralysis and could not feel pain. He stated Resident #1 did not complain about the wound at all. The Treatment Nurse stated the Wound Care Physician had treated the wound on 7/25/2022 and the wound looked fine at that time. He stated nobody told him the wound looked infected. He stated Resident #1 only received wound care on Monday, Wednesday, and Fridays. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/05/2022 at 12:46 p.m. Resident #1 stated he was admitted to a local hospital on Sunday, 7/31/2022 after the Treatment Nurse looked at the wound on his right foot/5th toe area and stated the wound looked bad and was infected. Resident #1 stated he was now scheduled for an amputation of the toe in the next couple of days because he had a sever bone infection. Resident #1 stated the wound started off as a small blister and he took antibiotics for several days over a month ago in May or June 2022. Resident #1 stated he had paralysis of his lower extremities and did not have sensation to the right foot. He stated the right foot was completely numb and he did not feel pain to the area. Resident #1 stated he received wound care three times a week on Monday, Wednesday, and Friday from the Treatment Nurse. He stated sometimes the Treatment Nurse would miss a dressing change. Resident #1 stated he did not receive wound care to any of his wounds on Friday 7/29/2022 because the Treatment Nurse had a day off. Resident #1 stated he did not ask another nurse at the facility to provide wound care because he figured since the Treatment Nurse was not at the facility it wasn't getting done. He stated occasionally a Charge Nurse had provided wound care to him in the past, but they did not like to do it. Resident #1 stated he sensed a power struggle between the Treatment Nurse and the Charge Nurses. During an interview on 8/05/2022 at 2:47 p.m., NA Z stated he had noticed Resident #1's pinky toe was swollen and red with discoloration (date unknown). He stated he did not think the wound looked infected. NA Z stated he thought the bandages to Resident #1's foot and leg were on too tight. NA Z stated he always asked Resident #1 if he was in pain or discomfort and the resident told him he was fine. NA Z stated on July 25 th-27th Resident #1 did not have any dressings on the wounds either one of his legs or feet for any of those days. He stated he told the Treatment Nurse the resident was waiting for his leg wraps and he said okay. NA Z stated he told RN T the legs didn't have wraps or dressings and he said he would tell the Treatment Nurse. NA Z stated the dressings were never done on those days. He stated he had off and when he came back from being off for a day Resident #1 had dressing on the wounds. During an interview on 8/05/2022 at approximately 3:20 p.m. the Wound Care Physician stated Resident #1 had several wounds. She stated the wound to his right lateral foot near the 5th digit (toe) was approximately 2 cm in size and it was chronic as the resident had the wound for greater than 84 days. She stated she last saw the wound on 7/25/2022 and at that time it did not look significantly different than the time before other than it had a lot more slough. The Wound Care physician stated she had classified the wound to the right lateral foot as a diabetic foot ulcer because the resident had diabetes, but it could be a pressure ulcer. She stated she had not noticed the resident lying on the right lateral foot as much, so she classified it as a diabetic ulcer. The Wound Care Physician stated she did not see an infection of the wound and does not remember anything alarming. The Wound Care Physician was notified the wound was only being treated 3 times a week by the Treatment Nurse instead of 5. She stated sometimes 3 days a week is sufficient by the Treatment Nurse because there were other nurses available if needed to provide wound care. The Wound Care Physician stated a short amount of time of 4-5 days was a sufficient amount of time, without a dressing change, for a wound to go from not infected to infected especially since Resident #1 had diabetes which put him at additional risk for infection. During an interview on 8/05/2022 at 3:51 p.m. RN T stated Resident #1 had several wounds, particularly of the legs. He stated Resident #1 had a diabetic foot ulcer to the foot. RN T stated he last saw the area around the wound 2 days before he went to the hospital. He stated he did not remove the wound dressing to assess the wound, instead he just looked casually at the skin he could see around the wound. RN T stated the wound did not look infected because there was no drainage and no foul odor. RN T stated there was redness around the wound, but it was something the wound always had. RN T stated he had not received reports from staff that Resident #1's wounds did not have a dressing and if they did it was after a bath/shower and the dressings were changed. During an interview on 8/05/2022 at 2:47 p.m., NA Z stated he had concerns about multiple residents not receiving wound care. He stated he has seen different residents (Resident #1, Resident #3 and unknown name) without dressings for days on end. NA Z stated he tried talking to the Treatment Nurse about providing wound care and it ended in an argument. NA Z stated there were several residents complaining about wound care (undisclosed names). NA Z stated the Treatment Nurse told him he should not tell him how to do his job. NA Z stated he told the former ADON (LVN BB) about his concerns and he told the DON approximately 1 month ago who said she would talk to the Treatment Nurse. During an observation/interview on 8/05/2022 at 7:01 p.m., Resident #1 was observed in a hospital bed. He was awake, alert, oriented and conversational. Resident #1 was observed with multiple bandages to both right and left lower legs and heavy bandages including ACE wrap to the right foot. Resident #1's wounds had multiple pinpoint bleeding areas to both the right and left shin area of each leg and multiple observed cracks to the skin. Not all the area was able to be observed due to application of dressings to the legs. The wounds to the right foot were not able to be observed. Resident #1 stated he was scheduled for an amputation to his right 5th toe and part of the tissues around the toe and the bone where the wound was on the side of his foot. Resident #1 stated due to paralysis he had no feeling in the foot. Resident #1 stated he felt sad to be losing part of his foot and toe. He stated he was resigned to it because the hospital doctor described the infection and stated it was the best thing for him. Resident #1 stated he was not presented with options but told the amputation was necessary. Resident #1 stated on 8/01/2022 the Treatment Nurse came to the hospital to see him. He stated he was very surprised to see him and felt unsure and uncertain about his intentions. Resident #1 stated the Treatment Nurse was polite and stated, Good thing we caught the infection just in time. Resident #1 stated he felt like his wounds were not taken care of like they were supposed to have been at the nursing facility. He said, despite that the nursing home was his home and he liked his room, his roommate and most of the staff and he wanted to return. During an interview on 8/05/2022 at 7:23 p.m., a local hospital RN stated Resident #1 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated Resident #1 noticed redness and felt pressure to the wound but no pain due to his paralysis. She stated upon Resident #1's admission to theER on [DATE] he met [CONDITION(S)] criteria from the right foot infection and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated his plan of care included the OR on 8/06/2022 for [CONDITION(S)]. The RN stated Resident #1 had an MRI of the foot on 8/03/2022 and had signed surgical consent for an amputation of the right metatarsal (long foot bone directly under 5th toe extending into the foot). During an observation/interview on 8/06/2022 at 12:06 p.m. of Resident #1 at a local hospital revealed the resident had his right foot wrapped in a surgical dressing. The foot was unable to be directly observed. Resident #1 stated his right 5th toe, bone underneath and tissue surrounding the wound was amputated this morning. He stated he was glad it was over. During an interview on 8/06/2022 at 12:31 p.m., a local hospital RN stated Resident #1 right 5th toe and metatarsal bone and surrounding muscle and soft tissue were amputated this morning. She stated the foot was infected with [CONDITION(S)] ([CONDITION(S)]-resistant staphylococcus aureus, a bacterium which is resistant to commonly used antibiotics). The local hospital RN read the surgical report which stated, Right Foot Ray amputation (a type of amputation which included removal of the toe and the bone connection to the appendage) involving right tarsal due to right foot infection. Amputation involved 5th toe and metatarsal bone, muscle and soft tissue involvement. 2. Record review of Resident #5's face sheet dated 8/05/2022 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed the resident had a BIMs score of 6 (scale of 0-15) which indicated a severe cognitive impairment. Record review of Resident #5's quarterly MDS dated [DATE] revealed the resident had a skin abrasion (location not specified). Record review of Resident #5's Care Plan dated 06/09/2022 revealed the resident had skin [CONDITION(S)] to the right lateral chest wall and right nipple area with interventions which included: apply treatment per medical practitioner's orders and monitor for effectiveness of currently treatment. Weekly assessment and evaluation of injury, refer to skin forms for weekly wound assessment, measurements and description of ulcer. Record review of Resident #5's Care Plan dated 11/16/2020, last revised on 5/13/2022 revealed the resident had impairment to skin integrity with interventions which included report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #5's weekly non-pressure ulcer skin assessment dated [DATE] revealed a new wound as of 6/10/2022 to the right lateral chest measuring 3 cm x 3 cm x 0.2 cm. Record review of Resident #5's weekly non-pressure ulcer evaluations revealed the wound to the nipple and the wound to the right axilla had not been assessed since 6/21/2022. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Report to the ADON and Treatment Nurse with your findings. Record review of Resident #5's weekly skin assessment dated [DATE] revealed the resident had abnormal non-pressure ulcer skin areas that were not new. The skin assessment did not document location or size of the abnormal skin areas. Record review of Resident #5's weekly skin assessment dated [DATE] revealed Resident #5 was marked as having no abnormal skin areas. The assessment did not accurately identify or note the wounds to her right axilla or right breast nipple area. (Unknown staff) Record review of Resident #5's weekly skin assessment dated [DATE] revealed Resident #5 was marked as having no abnormal skin areas. The assessment did not accurately identify or note the wounds to her right axilla or right breast nipple area. (Unknown staff) Record review of Resident #5's weekly skin assessment dated [DATE] revealed Resident #5 had abnormal skin areas that were non-pressure ulcers that were not new with a note: Resident continues with the fungating mass (skin lesion with breaks in the skin and tissue death that occur with cancer) to right axilla area. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with Dakin's, pat dry with 4 x 4 gauze, apply skin prep to peri-wound, apply collagen, sprinkle with [MEDICATION(S)] to wound bed, apply calcium alginate, cover with dry absorbent dressing one time a day for wound healing. Record review of Resident #5's TAR for July 2022 revealed there was no documentation of wound care to the right lateral chest (axilla) on: -Monday, July 11, 2022 -Friday, July 15, 2022 -Thursday, July 21, 2022 -Monday, July 25, 2022 -Tuesday, July 26, 2022 -Thursday, July 28, 2022 -Friday, July 29, 2022 -Saturday, July 30, 2022 -Sunday, July 31, 2022 Record review of Resident #5's TAR for July 2022 revealed there was no documentation of wound care to the right nipple area on: -Monday, July 11, 2022 -Friday, July 15, 2022 -Thursday, July 21, 2022 -Monday, July 25, 2022 -Tuesday, July 26, 2022 -Thursday, July 28, 2022 -Friday, July 29, 2022 -Saturday, July 30, 2022 -Sunday, July 31, 2022 Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's TAR for August 2022 revealed there was no documentation of wound care to the right lateral chest (axilla) on: -Wednesday, August 3. 2022. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's TAR for August 2022 revealed there was no documentation of wound care to the right lateral chest (axilla) on: -Wednesday, August 3. 2022. During an interview on 8/04/2022 at 2:07 p.m. Resident #5 stated the Treatment Nurse provided wound care of her right chest/axilla and right breast but not too often. Due to cognitive status Resident #5 was unable to provide further detail. During an observation of wound care to Resident #5 on 8/04/2022 at 2:07 p.m. the Treatment Nurse entered the resident room and placed the supplies for wound care prepared on wax paper directly on Resident #5's bed. The Treatment Nurse then washed his hands prior to wound care, donned gloved and then removed an old dressing to Resident #5's right breast. Without changing his gloves or washing his hands, the Treatment nurse then cleaned the wound, and applied a new dressing without changing his gloves or utilizing hand hygiene. After applying the new dressing, the Treatment Nurse changed his gloves and left the room briefly before resuming wound care. The Treatment Nurse then changed dressing #2 to a wound on Resident #5's right axilla without changing his gloves or utilizing hand hygiene when he removed the old dressing, cleansed the wound and put on a clean dressings all without changing gloves. During continued observation on 8/04/2022 at 2:07 p.m. Resident #5 was observed with wounds to her right breast and right chest/axilla area demonstrated dressings which were old and dated 8/02/2022 (instead of 8/03/2022). The Treatment Nurse removed the dressings which revealed a quarter size open wound to the right breast wall and absence of the nipple and a penetrating wound to the right chest wall/axilla area in the folds of skin with redness surrounding the wound. Wound care was provided by the Treatment Nurse to the wounds on Resident #5's right breast and chest wall/axilla area. During an interview on 8/04/2022 at 2:58 p.m. the Treatment Nurse stated he did not wash or sanitize his hands when providing wound care to Resident #5 during wound because he did not have hand sanitizer and had to go into the hallway to use it. He stated as long as he did not touch anything dirty, he did not need to change his gloves or use hand hygiene. The Treatment Nurse stated when he removed the old dressings, he did not touch the wound or drainage from the wound, so his hands were not dirty, when he cleansed the wounds, he touched the gauze to clean the wound but again did not touch the drainage from the wound. The Treatment Nurse stated he just touched cleansing supplies, so he did not need to utilize hand hygiene or change his gloves. The Treatment Nurse stated he provided wound care the way he was trained. The Treatment Nurse stated he was trained to place the wound supplies on wax paper and then on a bedside tray (table). He stated he was not trained to place it on the resident's bed but did so because the surveyor would not tell him which residents were to be observed in advance so he could properly set up the room for an observation. The Treatment Nurse stated the wax paper provided a barrier between the supplies and the bed. During continued interview on 8/04/2022 at 2:58 p.m., the Treatment Nurse stated he did not change the dressing to Resident #5's right breast or right chest/axilla as ordered by a physician because the nursing staff was supposed to change her wounds. He stated he left the building at 3 p.m. on 8/03/2022 and he told a male nurse to perform wound care. The Treatment Nurse stated I am hoping I did not contact him (male nurse) at the wrong time. I think this may be on me. I do not know if I communicated correctly. During an interview on 8/05/2022 at 12:22 p.m. Resident #5's hospice nurse stated Resident #5 had [CONDITION(S)] on breast since 5/2021 and she had been told it was cancerous [CONDITION(S)] that kept opening and closing. She stated Resident #5 tends to pick at the wounds when they are uncovered. The Hospice Nurse stated wound care for Resident #5 was provided by the Treatment Nurse at the facility. She stated hospice was not providing any wound care and it was up to the facility to provide actual wound care. The Hospice Nurse stated the hospice worked side-by side with the facility to obtain orders. She stated since the facility Treatment Nurse was wound care certified she relied on his judgement, and his assessment to get orders for the wounds. The Hospice Nurse stated if Resident #5 picked off the dressing it should be replaced but otherwise should receive wound care at least once every 2-3 days. During an observation on 8/04/2022 between 10:40 a.m.-12:34 p.m. the Treatment Nurse was observed moving between the computer at the nurses' station to the computer on the treatment cart. He was observed occasionally walking down a hallway and entering a resident room briefly without wound care supplies. The Treatment nurse was observed moving the Treatment cart to various locations but was not observed performing any wound care. During an interview on 8/04/2022 at 12:34 p.m. the Treatment Nurse became angry when approached. He stated he had 13 residents who he provided wound care for during the week. He stated as of this interview he had not performed any wound care for any resident yet for the day. The Treatment Nurse stated he did not want to be observed unless this surveyor told him what resident the surveyor had come to the facility to see. He stated he wanted to go make sure the room of that resident was set up before providing care. The Treatment Nurse ended the interview and was observed entering the office of the Administrator. During an interview on 8/04/2022 at 2:58 p.m., the Treatment Nurse stated he was trained at another facility with advanced clinicians, including a Nurse Practitioner for wound care. He stated he had made rounds with the NP (unknown) for a year. He stated he received wound care certification through the physician group that provided wound care services. He declined to answer the question if he had received any training at the current facility. During an interview on 8/04/2022 at 3:27 p.m. the Treatment Nurse stated Resident #5 was a hospice resident and the Wound Care Physician did not assess or treat hospice residents because they did not get paid. He was not tracking referrals made by the Wound Care Physician. During an interview on 8/05/2022 at approximately 3:20 p.m., the Wound Care Physician stated she comes to the facility on ce a week, although she recently missed a week. She stated the Treatment Nurse lets her know which residents he wants her to see. She stated she mostly sees residents with pressure wounds but will see all wounds if asked. The Wound Care Physician stated she does not typically see hospice residents unless asked. She stated Resident #5 was last seen in 2019. The Wound Care Physician stated she had worked with the Treatment Nurse for approximately 2 months. She stated they talk on rounds and discuss patients. She stated they talked about wound management, and he seemed eager to learn and do better. The Wound Care Physician stated she thinks the Treatment Nurses cared deeply about the patients. During an interview on 8

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 5 of 5 residents (Resident #'s 1, 2, 3, 4, and 5) reviewed for abuse, in that: 1. The facility failed to ensure processes were in place to ensure Residents received wound care services as ordered by a physician to Resident #1, #2, #3, and #5. The failure to provide wound care services as ordered by the wound care physician on a daily basis resulted in an infection to Resident #1's right foot and 5th toe which resulted in an infection, [CONDITION(S)] (infection of the bone), hospitalization and amputation of a portion of the right foot and 5th toe. 2. The facility failed to ensure identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The facility failed to develop policies and procedures for wound care treatment and services 4. The facility failed to monitor and supervise the Treatment Nurse after repeated complaints of missing wound care which resulted in the Treatment Nurse operating outside of nursing scope of practice. This failure resulted in the identification of Immediate Jeopardy (IJ) on 8/08/2022 at 4:42 p.m. While the immediacy was removed on 8/11/2022, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of pattern due to the facility's need to monitor the implementation and effectiveness of its POR. These failures placed residents at risk for unidentified and untreated wounds, inadequate wound care treatment and services and could result in infection, illness, a decline in health, loss of limb or a decline in health. The findings included: 1a. Record review of a face sheet dated 8/4/2022 for Resident #1 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's annual MDS dated [DATE] revealed a BIMs score of 13 (scale of 0-15) which indicated the resident was cognitively intact. Record review of Resident #1's annual MDS dated [DATE] revealed the resident had a diabetic foot ulcer and MASD (moisture associated skin damage) and received applications of nonsurgical dressings to feet and ointment/medications. Record review of Resident #1's Care Plan dated 12/08/2017 and last revised on 3/10/2022 revealed Resident #1 had diabetes mellitus with interventions which included: monitor/document/report to physician as needed for signs and symptoms of infection to any open area. Record review of Resident #1's Care Plan dated 4/27/2022 revealed the resident had a diabetic foot ulcer to the right distal lateral foot with interventions which included: monitor/document wound size, depth, margins, peri wound skin, sinuses, undermining, exudates, [CONDITION(S)], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser, gently pat dry with 4 x 4 gauze, apply collagen sprinkles to wound bed, cover with calcium alginate one time a day every Monday, Wednesday, and Friday for wound healing. Record review of Resident #1's Wound Evaluation and Management Summary dated 7/25/2022 documented by the wound care physician revealed: the diabetic foot ulcer to the right distal lateral foot was a full thickness wound measuring 2 cm x 2 cm x 0.2 cm. The wound was surgically debrided to remove necrotic tissue and establish the margins of viable tissue. Wound treatment orders for this wound included: collagen power and calcium alginate with gauze island dressing with boarder one time a day for 30 days. Record review of Resident #1's TAR for July 2022 revealed wound care to Resident #1's right distal diabetic foot ulcer was scheduled 3 days a week on Monday, Wednesday and Friday instead of every day. Record review of Resident #1's TAR (Treatment Administration Record) for July 2022 revealed the wound care to Resident #1's left lower extremity, right distal diabetic foot ulcer and right lower extremity had no documentation of wound care of 7/29/2022. The last documented wound care was on 7/27/2022. Record review of Resident #1's Charge of Condition Form dated 7/31/2022 at 4:07 p.m. revealed Resident #1 wound to right foot 5th digit appears infected. The document indicated this symptom had occurred before and was treated with antibiotics. The form indicated Resident #1 was sent to a local hospital for evaluation. Record review of Resident #1's hospital medical record dated 7/31/2022 revealed: Resident #1 arrived at the emergency department on 7/31/2022 at 5:34 p.m. for a wound check. He had a diabetic foot ulcer which was infected and a pressure injury to sacrum. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 complained of generalized pain. Patient sleeping most of the time. Stage 3 pressure wound to left inner buttock and right inner buttocks. Record review of Resident #1's MRI results from a local hospital dated 8/04/2022 revealed Findings consistent with [CONDITION(S)] (infection in the bone) in the fifth metatarsal (head, neck and shaft/diaphysis and base of the fifth proximal phalanx. During an interview on 8/04/2022 at 3:27 p.m., the Treatment Nurse stated Resident #1 was in the hospital due to a diabetic foot ulcer. The Treatment Nurse stated while he was performing rounds on 7/31/2022, he opened up Resident #1's right foot dressing. The Treatment Nurse stated the foot and wound did not look good to him. He stated he called MD CC and the NP (unknown name) who said to send the resident out (to the hospital) The Treatment Nurse stated diabetic foot ulcer did not want to heal. He described the diabetic foot ulcer as having redness around the wound, but no streaks or [CONDITION(S)]. The Treatment Nurse stated the wound was deep red and had lots of exudate (drainage) and blood drainage. He stated there was no foul smell. The Treatment Nurse stated Resident #1 had paralysis and could not feel pain. He stated Resident #1 did not complain about the wound at all. The Treatment Nurse stated the Wound Care Physician had treated the wound on 7/25/2022 and the wound looked fine at that time. He stated nobody told him the wound looked infected. He stated Resident #1 only received wound care on Monday, Wednesday, and Fridays. During an interview on 8/05/2022 at 12:46 p.m. Resident #1 stated he was admitted to a local hospital on Sunday, 7/31/2022 after the Treatment Nurse looked at the wound on his right foot/5th toe area and stated the wound looked bad and was infected. Resident #1 stated he was now scheduled for an amputation of the toe in the next couple of days because he had a severe bone infection. Resident #1 stated the wound started off as a small blister and he took antibiotics for several days over a month ago in May or June 2022. Resident #1 stated he had paralysis of his lower extremities and did not have sensation to the right foot. He stated the right foot was completely numb and he did not feel pain to the area. Resident #1 stated he received wound care three times a week on Monday, Wednesday, and Friday from the Treatment Nurse. He stated sometimes the Treatment Nurse would miss a dressing change. Resident #1 stated he did not receive wound care to any of his wounds on Friday 7/29/2022 because the Treatment Nurse had a day off. Resident #1 stated he did not ask another nurse at the facility to provide wound care because he figured since the Treatment Nurse was not at the facility it wasn't getting done. He stated occasionally a Charge Nurse had provided wound care to him in the past, but they did not like to do it. Resident #1 stated he sensed a power struggle between the Treatment Nurse and the Charge Nurses. During an interview on 8/05/2022 at 2:47 p.m., NA Z stated he had noticed Resident #1's pinky toe was swollen and red with discoloration (date unknown). He stated he did not think the wound looked infected. NA Z stated he thought the bandages to Resident #1's foot and leg were on too tight. NA Z stated he always asked Resident #1 if he was in pain or discomfort and the resident told him he was fine. NA Z stated on July 25 th-27th Resident #1 did not have any dressings on the wounds either one of his legs or feet for any of those days. He stated he told the Treatment Nurse the resident was waiting for his leg wraps and he said okay. NA Z stated he told RN T the legs didn't have wraps or dressings and he said he would tell the Treatment Nurse. NA Z stated the dressings were never done on those days. He stated he had off and when he came back from being off for a day Resident #1 had dressing on the wounds. During an interview on 8/05/2022 at approximately 3:20 p.m. the Wound Care Physician stated Resident #1 had several wounds. She stated the wound to his right lateral foot near the 5th digit was approximately 2 cm in size and it was chronic as the resident had the wound for greater than 84 days. She stated she last saw the wound on 7/25/2022 and at that time it did not look significantly different than the time before other than it had a lot more slough (dead skin tissue). The Wound Care physician stated she had classified the wound to the right lateral foot as a diabetic foot ulcer because the resident had diabetes, but it could be a pressure ulcer. She stated she had not noticed the resident lying on the right lateral foot as much, so she classified it as a diabetic ulcer. The Wound Care Physician stated she did not see an infection of the wound and does not remember anything alarming. The Wound Care Physician was notified the wound was only being treated 3 times a week by the Treatment Nurse instead of 5. She stated sometimes 3 days a week is sufficient by the Treatment Nurse because there were other nurses available if needed to provide wound care every day. The Wound Care Physician stated a short amount of time of 4-5 days was a sufficient amount of time, without a dressing change, for a wound to go from not infected to infected especially since Resident #1 had diabetes which put him at additional risk for infection. During an interview on 8/05/2022 at 3:51 p.m. RN T stated Resident #1 had several wounds, particularly of the legs. He stated Resident #1 had a diabetic foot ulcer to the foot. RN T stated he last saw the area around the wound 2 days before he went to the hospital. He stated he did not remove the wound dressing to assess the wound, instead he just looked casually at the skin he could see around the wound. RN T stated the wound did not look infected because there was no drainage and no foul odor. RN T stated there was redness around the wound, but it was something the wound always had. RN T stated he had not received reports from staff that Resident #1's wounds did not have a dressing and if they did it was after a bath/shower and the dressings were changed. He stated the Treatment Nurse was responsible for wound care. During an observation/interview on 8/05/2022 at 7:01 p.m., Resident #1 was observed in a hospital bed. He was awake, alert, oriented and conversational. Resident #1 was observed with multiple bandages to both right and left lower legs and heavy bandages including ACE wrap to the right foot. The wounds to the right foot were not able to be observed. Resident #1 stated he was scheduled for an amputation to his right 5th toe and part of the tissues around the toe and the bone where the wound was on the side of his foot. Resident #1 stated due to paralysis he had not feeling in the foot. Resident #1 stated he felt sad to be losing part of his foot and toe. He stated he was resigned to it because the hospital doctor described the infection and stated it was the best thing for him. Resident #1 stated he was not presented with options but told the amputation was necessary. Resident #1 stated on 8/01/2022 the Treatment Nurse came to the hospital to see him. He stated he was very surprised to see hi and felt unsure and uncertain about his intentions. Resident #1 stated the Treatment Nurse was polite and stated, Good thing we caught the infection just in time. Resident #1 stated he felt like his wounds were not taken care of like they were supposed to have been at the nursing facility. He said, despite that the nursing home was his home and he liked his room, his roommate and most of the staff and he wanted to return. During an interview on 8/05/2022 at 7:23 p.m., a local hospital RN stated Resident #1 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated Resident #1 noticed redness and felt pressure to the wound but no pain due to his paralysis. She stated upon Resident #1's admission to theER on [DATE] he met [CONDITION(S)] criteria from the right foot infection and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated his plan of care included the OR on 8/06/2022 for [CONDITION(S)]. The RN stated Resident #1 had an MRI of the foot on 8/03/2022 and had signed surgical consent for an amputation of the right metatarsal (long foot bone directly under 5th toe extending into the foot). During an observation/interview on 8/06/2022 at 12:06 p.m. of Resident #1 at a local hospital revealed the resident had his right foot wrapped in a surgical dressing. The foot was unable to be directly observed. Resident #1 stated his right 5th toe, bone underneath and tissue surrounding the wound was amputated this morning. He stated he was glad it was over. During an interview on 8/06/2022 at 12:31 p.m., a local hospital RN stated Resident #1 right 5th toe and metatarsal bone and surrounding muscle and soft tissue were amputated this morning (8/06/2022). She stated the foot was infected with [CONDITION(S)] ([CONDITION(S)]-resistant staphylococcus aureus, a bacterium which is resistant to commonly used antibiotics). During an interview on 8/05/2022 at 2:47 p.m., NA Z stated he had concerns about multiple residents not receiving wound care. He stated he has seen different residents (Resident #1, Resident #3 and unknown name) without dressings for days on end. NA Z stated he tried talking to the Treatment Nurse about proving wound care and it ended in an argument. NA Z stated there were several residents complaining about wound care (undisclosed names). NA Z stated the Treatment Nurse told him he should not tell him how to do his job. NA Z stated he told the former ADON (LVN BB) about his concerns and he told the DON approximately 1 month ago who said she would talk to the Treatment Nurse. 1b. Record review of Resident #2's face sheet dated 8/05/2022 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's MDS (marked other) dated 7/24/2022 revealed the resident had a BIMs score of 4 (scale of 0-15) which indicated a severe cognitive impairment. Record review of Resident #2's MDS (marked other) dated 7/24/2022 revealed the resident had moisture associated skin damage (MASD) (site unspecified) and two pressure injuries. Record review of Resident #2's Care Plan dated 2/09/2022 revealed the resident had type 2 diabetes mellitus with interventions which included: check all of body for breaks in skin and treat promptly as ordered by a doctor. Record review of Resident #2's Care Plan dated 2/09/2022 and last revised 4/14/2022 revealed an unstageable wounds to right and left heel with interventions which included: weekly treatment documentation to include measurement of each area of skin breakdown; width, length, depth, type of tissue and exudate. Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation on the TAR for updated wound care orders based on the Wound Care Physicians orders dated 7/19/2022. Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Wound Evaluation and Management Summary dated 7/19/2022 revealed right heel full thickness unstageable wound due to necrosis that measured 2.5 cm x 2 cm x 0.2 cm which was surgically debrided with orders to add [MEDICATION(S)] application one time daily for 30 days and continue with the collagen power one time daily to open area for 30 days, continue with sterile sponge gauze and kerlix wrap for 30 days. Record review of Resident #2's Wound Evaluation and Management Summary dated 7/19/2022 revealed: left heel wound was described as unstageable due to necrosis with wound care orders to add [MEDICATION(S)] to wound one time daily for 30 days. Record review of Resident #2's TARs for August 2022 revealed the wounds to right heel were not documented as completed and were only scheduled for wound care on Monday, Wednesday and Friday instead of everyday as ordered by the Wound Care Physician. Record review of Resident #2's July TAR revealed the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's TARs for August 2022 revealed the wounds to left heel were not documented as completed on 8/03/2022 and were only scheduled for wound care on Monday, Wednesday and Friday instead of everyday as ordered by the Wound Care Physician. During an observation of wound care to Resident #2 on 8/04/2022 at 1:51 p.m. with CNA S and the Treatment Nurse revealed two nickel sized wounds to the Resident left buttocks and coccyx area which were open but without signs and symptoms of infection. The Treatment Nurse provided wound care to Resident #2's buttocks/coccyx but did not look at or observe the wounds or wound dressings to Resident #2's heels. After performing wound care to Resident #2's buttocks/coccyx the Treatment Nurse exited the room and did not return. CNA S remained in the room and Resident #2's heels were observed with intact boarder dressings that were dated 8/02/2022 (instead of 8/03/2022 as ordered). During an interview on 8/04/2022 at 1:58 p.m. Resident #2 was unable to answer interview questions due to cognitive status but was able to answer basic yes or no questions. During an interview on 8/04/2022 at 2:00 p.m., CNA stated the dressings to Residents heels (both right and left) were dated 8/02/2022. During an interview on 8/04/2022 at 2:58 p.m. the Treatment Nurse declined to look at a photo of the 8/02/2022 dated wounds to Resident #2's feet. When asked why the wound dressing were dated 8/02/2022 instead of 8/3/2022 he stated, I did not have any staff to help me hold. It is really strange. It is really odd. I thought I did wound care that is why I did not look at his feet. When asked why [MEDICATION(S)] was not applied to the left heel in July, he stated he could apply [MEDICATION(S)], but it did not do anything when applied to eschar (dead tissue that is black or brown and can resemble a scab or a scab. He stated wound care was ordered every Monday, Wednesday, and Friday. 1c. Record review of Resident #3's face sheet dated 8/04/2022 revealed an admitted [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's significant change MDS dated [DATE] revealed the resident had one or more unhealed pressure wounds). The MDS revealed Resident #3 had an unstageable pressure wound (location not stated) and a stage 3 pressure wound (location not stated) and MASD (moisture associated skin damage site unspecified). Record review of Resident #3's Care Plan dated 5/12/2022 revealed a suspected deep tissue injury with interventions which included: administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] ointment with collagen sprinkles and leave open to air, one time daily for wound healing. Record review of Resident #3's TARs for July 2022 revealed there was no documentation that wound care was provided for Resident #3's coccyx wound on: -Monday, July 11. 2022 -Wednesday, July 20, 2022 -Thursday, July 21, 2022 -Sunday, July 24, 2022 -Monday, July 25, 2022 -Tuesday, July 26, 2022, -Thursday, July 28, 2022 -Friday, July 29, 2022 -Sunday, July 31, 2022 Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with wound cleanser, pat dry with 4 x 4 gauze, apply collagen sheet to wound bed, apply calcium alginate, cover with dry absorbent dressing one time a day every Monday, Wednesday, and Friday. Record review of Resident #3's July TAR revealed there was no documentation wound care was provided to the left heel on: -Monday, July 11, 2022 -Wednesday, July 20, 2022 -Monday, July 25, 2022 -Friday, July 29, 2022 Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's July TAR revealed there was no documentation wound care was provided to the right malleolus (ankle) on: -Monday, July 11, 2022 -Wednesday, July 20, 2022 -Monday, July 25, 2022 -Friday, July 29, 2022 Record review of Resident #3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a /interview for Resident #3 on 8/04/2022 at 1:15 p.m. revealed Resident #3 was unable to be interviewed due to cognitive status. During an observation of wound care to Resident #3 on 8/04/2022 at 2:20 p.m. the Treatment removed provided wound care to the left heel and ankle. The right ankle dressing was removed prior to wound care which revealed a quarter size open wound area with a large amount of dark red skin discoloration surround the entire wound. During an interview on 8/05/2022 at 2:47 p.m., NA Z stated Resident #3 had dressings left off her wounds for a couple of days at a time and had notified both the Treatment Nurse and RN T. He stated the Treatment Nurse said okay and RN T stated he would tell the treatment nurse. 1d. Record review of Resident #5's face sheet dated 8/05/2022 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's quarterly MDS dated [DATE] revealed the resident had a BIMs score of 6 (scale of 0-15) which indicated a severe cognitive impairment. Record review of Resident #5's quarterly MDS dated [DATE] revealed the resident had a skin abrasion (location not specified. Record review of Resident #5's Care Plan dated 06/09/2022 revealed the resident had skin [CONDITION(S)] to the right lateral chest wall and right nipple area with interventions which included: apply treatment per medical practitioner's orders and monitor for effectiveness of currently treatment. Weekly assessment and evaluation of injury, refer to skin forms for weekly wound assessment, measurements and description of ulcer. Record review of Resident #5's Care Plan dated 11/16/2020, last revised on 5/13/2022 revealed the resident had impairment to skin integrity with interventions which included report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. to MD. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with Dakin's, pat dry with 4 x 4 gauze, apply skin prep to peri-wound, apply collagen, sprinkle with [MEDICATION(S)] to wound bed, apply calcium alginate, cover with dry absorbent dressing one time a day for wound healing. Record review of Resident #5's TAR for July 2022 revealed there was no documentation of wound care to the right lateral chest (axilla) on: -Monday, July 11, 2022 -Friday, July 15, 2022 -Thursday, July 21, 2022 -Monday, July 25, 2022 -Tuesday, July 26, 2022 -Thursday, July 28, 2022 -Friday, July 29, 2022 -Saturday, July 30, 2022 -Sunday, July 31, 2022 Record review of Resident #5's TAR for July 2022 revealed there was no documentation of wound care to the right nipple area on: -Monday, July 11, 2022 -Friday, July 15, 2022 -Thursday, July 21, 2022 -Monday, July 25, 2022 -Tuesday, July 26, 2022 -Thursday, July 28, 2022 -Friday, July 29, 2022 -Saturday, July 30, 2022 -Sunday, July 31, 2022 Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's TAR for August 2022 revealed there was no documentation of wound care to the right lateral chest (axilla) on: -Wednesday, August 3. 2022. Record review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's TAR for August 2022 revealed there was no documentation of wound care to the right lateral chest (axilla) on: -Wednesday, August 3. 2022. During an interview on 8/04/2022 at 2:07 p.m. Resident #5 stated the Treatment Nurse provided wound care of her right chest/axilla and right breast but not too often. Due to cognitive status Resident #5 was unable to provide further detail. During an observation on 8/04/2022 at 2:07 p.m. Resident #5 was observed with wounds to her right breast and right chest/axilla area demonstrated dressings which were old and dated 8/02/2022 (instead of 8/03/2022). The Treatment Nurse removed the dressings which revealed a quarter size open wound to the right breast wall and absence of the nipple and a penetrating wound to the right chest wall/axilla area in the folds of skin with redness surrounding the wound. Wound care was provided by the Treatment Nurse to the wounds on Resident #5's right breast and chest wall/axilla area. During an interview on 8/04/2022 at 2:58 p.m., the Treatment Nurse stated he did not change the dressing to Resident #5's right breast or right chest/axilla as ordered by a physician because the nursing staff was supposed to change her wounds. He stated he left the building at 3 p.m. on 8/03/2022 and he told a male nurse to perform wound care. The Treatment Nurse stated I am hoping I did not contact him (male nurse) at the wrong time. I think this may be on me. I do not know if I communicated correctly. During an interview on 8/05/2022 at 12:22 p.m. Resident #5's hospice nurse stated Resident #5 had [CONDITION(S)] on breast since 5/2021 and she had been told it was cancerous [CONDITION(S)] that kept opening and closing. She stated Resident #5 tends to pick at the wounds when they are uncovered. The Hospice Nurse stated wound care for Resident #5 was provided by the Treatment Nurse at the facility. She stated hospice was not providing any wound care and it was up to the facility to provide actual wound care. The Hospice Nurse stated the hospice worked side-by side with the facility to obtain orders. She stated since the facility Treatment Nurse was wound care certified she relied on his judgement, and his assessment to get orders for the wounds. The Hospice Nurse stated if Resident #5 picked off the dressing it should be replaced but otherwise should receive wound care at least once every 2-3 days. During an interview on 8/05/2022 at approximately 3:20 p.m., the Wound Care Physician stated she comes to the facility on e time a week, although she recently missed a week. She stated the Treatment Nurse lets her know which residents he wants her to see. She stated she mostly sees residents with pressure wounds but will see all wounds if asked. The Wound Care Physician stated she does not typically see hospice residents unless asked. She stated she had not assessed or treated wound to Resident #3. She stated she last saw Resident #4 in December of 2020 and Resident #5 was last seen in 2019. The Wound Care Physician stated she had worked with the Treatment Nurse for approximately 2 months. She stated they talk on rounds and discuss patients. She stated they talk about wound management, and he seemed eager to learn and do bett

Based on interview and record review, the facility failed to provide or arrnage services that meet professional standards for 1 of 27 residents (resident #21) whose care was reviewed for Code Status in that: LVN C, LVN E and RN D failed to assess, document interventions and initiate Cardiopulmonary Resuscitation (CPR) for Resident #21 who was unresponsive, pulseless and a full code status. This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This deficient practice could affect 56 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and resulted in death. The findings were: According to the Texas Board of Nursing, Rules and Regulations, Published [DATE],and accessed on [DATE], the Texas Administrative Code, Part 11, Chapter 2 17, §217.12. Unprofessional Conduct (1) Unsafe Practice - actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11; (6) Misconduct - actions or conduct that include, but are not limited to: (C) . or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority and/or licensing board; The provisions of this 271.12 adopted to be effective [DATE], 29 TexReg 9192. Record review of resident #21's face sheet ([DATE]) revealed she was admitted to the facility on [DATE] with an original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's consolidated orders for [DATE] revealed resident #21 was a Full Code. Record review of Resident's #21's Admission MDS dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) was 14, indicating the resident's cognition was intact. Review of Resident #21's care plan dated [DATE] did not address the resident's full code status. Record review of Resident #21's nurses progress note dated [DATE] at 5:40 a.m. revealed resident up in wheelchair down 300 hall waiting, by nurses cart when this nurse in another patients room stating she needed Tylenol. Resident stated to have general pain ,[DATE] (5 out of 10) Tylenol administered and approximately ,[DATE] minutes resident started yelling for help in room. See nurse note for further details. Record review of Resident#21's nurse's progress note dated [DATE] at 6:05 a.m. revealed This nurse was called into resident's room by another nurse for emergency with severe respiratory distress. Resident required help to sit up then stated I can't breathe. Oxygen on at 2 liters per nasal cannula with oxygen saturations at ,[DATE]%. Heart rate 80. Oxygen started at 10 liters per minute non rebreather mask and laid on pillow. 911 called for transport. Resident continues to make respiratory effort. 0630 EMS arrived CPR initiated by EMS shortly after. EMS continued CPR and transported resident via stretcher to hospital at 7:10 a.m. with CPR in progress. Record review of Resident #21's facility's SBAR (Situation Background Assessment Recommendation) dated [DATE] (no time) under Situation revealed severe respiratory distress stayed the same. Background-pulse 86 respirations 20 temp 98.2 oxygen sats 69%. Under section 4. Respiratory evaluation: shortness of breath is marked under describe symptoms or signs reveals respiratory distress oxygen sats at 69%. Further review of record reveals under 5. Cardiac: no changes observed was checked off. Section on pulse is left blank. 6. Skin evaluation was checked off as other no description. Advance Care Planning Full Code. Sent to hospital with CPR in progress by EMS. Appearance severe respiratory distress had difficulty breathing. Primary care physician notified at 9:00 AM. Family notified at 6:30 a.m. Record review of Resident #21's EMS run report dated [DATE] revealed dispatch was notified at 6:21 a.m. EMS at patient's bedside at 6:30 a.m. Further review of run report revealed dispatched for an unconscious patient and found [AGE] year old female laying supine on the floor of a nursing home. Staff on scene stated the patient was just fine at 6:00 a.m. and then complained of shortness of breath and then fell to the ground. Glass coma scale 3, pulseless, apneic. CPR started. Record review of Resident #21's hospital records dated [DATE] at 7:26 am HPI (History Present Illness) revealed Patient is a [AGE] year old female with history of [MEDICAL CONDITIONS] ([MEDICAL CONDITION] Infarction x5), [DIAGNOSES REDACTED] A-fib, Ischemic Cardiovascular Accident ([MEDICAL CONDITION]) who presents to the ED via EMS from rehab facility in [MEDICAL CONDITION] with CPR in progress. Per rehab the patient fell out of bed at 6:00 a.m. and was complaining of shortness of breath. She became unresponsive and EMS was called at 6:20 a.m. No pulse or heart rate noted, unresponsive, Abrasion to left knee. Time of death 7:33 a.m. Clinical impression [MEDICAL CONDITION]. Record review of Resident #21's emergency department record dated [DATE] 7:26 a.m. under subjective assessment revealed According to EMS patient is from nursing home at 6:00 a.m. the patient had a fall and was complaining of shortness of breath. She then went unresponsive. EMS arrived at 6:30 a.m. to find the patient pulseless. She was on oxygen but no compressions were being done. Interview on [DATE] at 11:46 a.m. with LVN E revealed Resident #21 was up in her wheelchair in the hallway asking for Tylenol after being medicated Resident # 21 went back to her room. Further interview with LVN E revealed she heard Resident # 21 yelling to get her up. When she walked in the room Resident #21 was laying on her back by the bed complaining of shortness of breath. LVN E further revealed she completed a quick assessment to see if she was hurt, when she and CNA (unknown) tried to get resident #21 up, Resident # 21 became unresponsive. LVN E further revealed she checked Resident #21's oxygen saturation, she then went to get the crash cart and check the resident's code status. LVN C came in to assist her and they placed the resident on oxygen and called EMS. Further interview with LVN E revealed they did not check vital signs nor initiate CPR. Interview on [DATE] at 10:45 a.m. with the DON revealed she was informed by LVN C that resident was calling for help and that the resident was in respiratory distress and that LVN C had called other nurses for help. DON further revealed the nurses had asked her about documenting the incident. DON further revealed she began an investigation and had staff write statements on the incident. Interview on [DATE] at 9:25 am with RN D revealed when she entered the resident's room she found resident # 21 lying on the floor gasping for air. RN D further revealed she was informed by LVN C resident had fallen. She was on oxygen concentrate at 2 liters via nasal cannula. We changed to tank oxygen non-rebreather mask 10 liters, called 911, heart rate was faint oxygen 56% started CPR as we waited for the 911 team. When they arrived we handed over to them. Interview on [DATE] at 9:42 a.m. with LVN C revealed she heard a certified nurse's aide in 300 hall (could not recall who it was) saying she needs a nurse LVN C further revealed when she went to answer the call, noted resident # 21 was on floor. LVN C further revealed resident complained of not being able to breathe and was placed on oxygen at 2 liters per minute (lpm) per nasal cannula. Another nurse checked the oxygen saturation it was low (did not specify how low) so we started resident on non-rebreather at 10 lpm and somebody called 911. During further interview LVN C revealed Resident #21 was alert the whole time she was in the room. She left the room after EMS arrived. Interview on [DATE] at 11:25 a.m. RN D recanted statement made on [DATE] at 9:25 a.m., which stated they had started CPR. RN D revealed they did not initiate CPR they changed the oxygen to non-rebreather mask. RN D further revealed they checked the oxygen saturation periodically and it would not read a pulse or oxygen saturation level. RN D further revealed 911 was called who came in and started CPR. Interview on [DATE] at 1:55 p.m. with the DON revealed the facility's process for ensuring staff know the residents' code status is by using the colored system in the chart a green sheet is placed in the medical record if resident is a full code and a red sheet if the resident is a DNR. The DON further revealed that all nurses were certified on the use of AED and CPR. The DON further revealed she monitored that staff know what to do in the event of respiratory or cardiac distress through competencies or check offs done on new hires then annually. The DON further revealed mock codes are conducted on each shift once per quarter. The DON further revealed an investigation was not conducted regarding resident # 21 being found on the floor in respiratory distress and transferred to the hospital. Record review revealed no sign in sheets for in-service training of mock codes being completed for past 6 months. Record review of documentation received on Mock Code Blue revealed The Director of Nursing will complete a Mock Code each shift once per quarter. Record review of nurses initial and annual competencies did not reveal competency or check off training on what to do in the event of respiaratory or [MEDICAL CONDITION]. Interview on [DATE] at 12:32 p.m. with Paramedic #1 revealed upon entering Resident #21's room, resident #21 was found lying in supine position next to her bed with an oxygen non-rebreather on her. The resident did not have a pulse nor was breathing. Staff did not initiate CPR. Interview on [DATE] at 12:36 p.m. with Paramedic #2 revealed they were informed that resident had fallen, was breathing and unresponsive. Paramedic # 2 further revealed resident was pulseless and not breathing upon arrival to resident's room. Record review of the American Heart Association (AHA) site: HTTPS://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ revealed BLS is the foundation for saving lives after [MEDICAL CONDITION]. Fundamental aspects of adult BLS include immediate recognition of sudden [MEDICAL CONDITION] and activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator (AED). Further review revealed Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The facility's Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Policy (no date) revealed Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect, psychological harm. Training: Each employee of the facility is required to be trained in issues related to abuse prohibition practices. These include orientation and/or on-going training sessions that deal with appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Identification: Staff are knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries; sudden changes in resident's behavior or personality; and resident fear and anxiety. Investigation- All employees who suspect abuse at any time are to report it to their immediate supervisor. The administrator or his/her designee will report the allegation of abuse immediately to the state (IHS) and to the proper local authorities. Record review of facility's policy on Change in a Resident's Condition or Status (2001) revealed 2). A significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3). Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication form. 8).The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. 9). If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations. Record review of facility's policy on Emergency Procedure- Cardiopulmonary Resuscitation (2001) revealed Personnel have completed training on the initiation of CPR and basic life support, including defibrillation for victims of sudden [MEDICAL CONDITION]. General Guidelines: 3). Victims of [MEDICAL CONDITION] may initially have gasping respirations. Training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION]. 6). If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. Preparation for CPR; 3). Provide periodic Mock Codes (simulations of an actual [MEDICAL CONDITION]) for training purposes. The Administrator and DON were notified on [DATE] at 5:05 p.m. that an Immediate Jeopardy situation was identified. The facility submitted a plan of removal dated [DATE] which was accepted on [DATE]outlining immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: 1. The Don and ADON initiated education regarding Change in Condition Policy and Procedure and Acute/Emergent Change in Condition with licensed and non-licensed staff on [DATE]. Education was completed on [DATE]-[DATE] with 100% completion of education for all shifts. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education for non-licensed staff included how facility immediately call for help and immediately notify the charge nurse when a change in condition is noted. Education on completion of the stop & watch tool as a notification system to charge nurses. Stop & watch tools include early warning of different behavior, talking less, need for more help, decreased participation in activities, eating/drinking less, weight changes, agitated more than usual, tired/weak/confused/drowsy and change in skin color. This tool assists the staff in identifying early signs of possible acute change in condition. Education for licensed staff include immediate assessments for any acute/emergent change in condition. Assessment will include vital signs, neurological status, current level of pain, and recent changes in pain level, level of consciousness, cognitive and emotional status. Licensed staff will assess the acute change onset, duration and severity, active diagnoses, medications, oxygen administration, and notification of MD. Emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education implemented on [DATE] by DON and ADON completed [DATE] all with licensed staff regarding pain management policy that included proper assessment of pain, types of pain including acute and chronic pain. Education also included how to identify moderate to severe pain, pain interventions including short and long-acting medications, non-pharmaceutical interventions and notifications to MD regarding unrelieved pain. Licensed staff completed written test regarding pain management. Staff had a passing score of 100% on the written test. 100% completion of education will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education with licensed and non-licensed staff was verified by a written test with passing score (100% score). Written test on identification and notification of changes in conditions included roles staff members have in identifying change in condition (all staff), physical signs of change in conditions, how to identify emergent/acute changes in condition including non-responsive residents, respiratory distress and complaints of pain and who to notify the change in condition. 2. The Don and ADON completed education with licensed staff on [DATE] regarding initiating CPR and AED and according to SCC policy and procedure, which states emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. DON and ADON completed mock code blue with licensed facility staff on [DATE] to [DATE]. Mock code blue includes scenario based training on how to intervene when a resident is unresponsive, has abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents, AED applied and 911 notified. Also included timeline documentation of timeline of interventions. 3. The DON and ADON completed education with licensed staff on [DATE] regarding Education on initiating, completing an incident report, notifications, investigation, documentation and interventions. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 4. Administrator, DON and ADON were educated by Director of Clinical Operations on [DATE] on incident and accident investigations and provide training to staff as indicated post incident. 5. Charge nurse will initiate report, investigation, and interventions following an incident. DON, ADON, Medical Records Director completed education on [DATE]. 100% completion of education and participation in mock code blue for all shifts were completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 6. Facility will complete an ad hoc QA meeting with medical director, administrator, DON, and two other quality assurance staff members on [DATE] to review the alleged deficiencies and the plan to remove. Facility will complete debriefing meeting with administrator, DON and staff involved in any change in condition resulting in a transfer from the facility, DON will review documentation after any change in condition resulting in a transfer from the facility, Debriefing meetings will be presented to facility to facility QAPI committee for review and recommendation. DON will monitor direct care staff competency and proficiency regarding assessment and interventions for residents experiencing acute/emergent change in condition by conducting random mock code evaluations. DON and Medical Director will complete chart audits and utilization of interact QI analysis tool. Evaluations, chart audits and analysis will be presented to QAPI committee for review and recommendation. Interview on [DATE] at 11:15 a.m. with the Facility Administrator revealed the process for ensuring the needs of residents are being met is by reviewing incident reports in morning clinical meetings. Administrator further revealed she conducts spot checks to see if competencies are being completed by physically verifying the competencies. The administrator further revealed she reviews information obtained from the quality of life rounds completed by the management team, grievances, resident council or other sources of information to determine what competencies need to be audited. Further interview revealed she was not sure if there was a documentation issue or a concern on the nurses' actuals steps. Verification of Plan of Removal: Record review of Residents # 2, 23, 24 and 25 consolidated orders and medical records reviewed for code status coincided with colored code status sheet in medical record. Record review of in-service training on initiating CPR and AED, Incident/Accident Investigation, Stop and Watch Tool, Change in Resident Condition, and Charting and Documentation revealed 60% of the staff was in-serviced. Record review of mock code in-service training reveled a mock code blue evaluation was conducted on [DATE] at 1:40 p.m. Record review of in-service on pain reminders-moderate-severe pain/ Types of pain revealed 60% of nurses were in-serviced. Record review of in-service titled Completing Investigations revealed Administrator, DON, ADON and Food Service Manager were trained on [DATE]. Interview with LVN W on [DATE] at 4:04 PM revealed LVN W was able to explain what she had learned in the in-services. LVN W described how to use the Stop and Watch sheets and how to assess a resident that had a significant change in status. LVN W further revealed that she was educated on when she was supposed to initiate CPR. Interview with RN X on [DATE] at 4:17 PM revealed RN X was able to explain how the Stop and Watch tool worked and she revealed that she had received in-services on what to do if a resident had a change in condition and she explained how to assess a resident and when she would initiate CPR on a resident. Interview with CNA Y on [DATE] at 4:21 PM revealed CNA Y had received an in-service on how to use the Stop and Watch tool. CNA Y was able to explain when and how she would use the tool and she explained that she would pass on the information from the Stop and Watch sheet to the charge nurse. Interview with CNA Z on [DATE] at 4:25 PM revealed CNA Z had received an in-service on how to use the Stop and Watch tool. CNA Z was able to explain when and how he would use the tool and he explained that he would pass on the information from the Stop and Watch sheet to the ADON. Interview with CNA AA on [DATE] at 4:50 PM revealed CNA AA was able to explain how to look for a resident change in condition and how to use the Stop and Watch tool and to report the change in condition to the charge nurse. Interview with LVN BB on [DATE] at 4:55 PM revealed LVN BB was able to explain how and what to assess with resident who was in distress or had fallen. LVN BB was able to list the different vitals to be taken and explained that if the resident was not breathing and did not have a pulse, CPR would be initiated and 911 would be called right away. Interview with Medication Aide CC on [DATE] at 5:03 PM revealed that she had been trained on how to use the Stop and Watch tool. Medication Aide CC revealed that if she noticed a change in condition with any resident she would tell nurse immediately by filling out and giving nurse the Stop and Watch tool. Interview with RN DD on [DATE] at 5:05 PM revealed that if a resident had a change in condition, RN DD would assess the resident for oxygen and vitals and fill out an SBAR. She further revealed that in an emergency situation she would call for help and get the crash cart and AED and initiate CPR if the resident had no pulse. Interview with the ADON on [DATE] at 4:40 PM revealed that she would immediately follow up any incident by determining the cause and who, what, when, and why of the incident. She revealed that she would review the resident's clinical record and change care if needed and provide education to staff. She revealed that more serious incidents should be investigated within one hour after notification and other less severe incidents should be investigated by the next working day. The ADON also confirmed that an Ad Hoc QA meeting was completed on [DATE] and that the monthly QAPI meeting will include the issues related to the IJ, including assessment, monitoring, CPR and training of staff. While the IJ was removed on [DATE] at 5:55 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR). According to the Resident Code Status roster (no date) provided on [DATE] revealed there was 57 resident coded as a full code.

Based on observation, record review and interview, the facility failed to develop and implement written policies and procedures that prohibit the neglect of 1 of 27 (residents # 21) whose care was reviewed for Code Status in that: LVN C, LVN E and RN D failed to assess, document interventions and initiate Cardiopulmonary Resuscitation (CPR) for Resident #21 who was unresponsive, pulseless and a full code status. The Facility failed to investigate the incident and provide corrective action. This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff were in-serviced on assessing the residents for change in condition, proper documentation, code identification and provision of CPR and AED (Automated External Defibrillators). This deficient practice could affect 56 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and resulted in death. The findings were: Record review of resident #21's face sheet ([DATE]) revealed she was admitted to the facility on [DATE] with an original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's consolidated orders for [DATE] revealed resident #21 was a Full Code. Record review of Resident's #21's Admission MDS dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) was 14, indicating the resident's cognition was intact. Review of Resident #21's care plan dated [DATE] did not address the resident's full code status. Record review of Resident #21's nurses progress note dated [DATE] at 5:40 a.m. revealed resident up in wheelchair down 300 hall waiting, by nurses cart when this nurse in another patients room stating she needed Tylenol. Resident stated to have general pain ,[DATE] (5 out of 10) Tylenol administered and approximately ,[DATE] minutes resident started yelling for help in room. See nurse note for further details. Record review of Resident#21's nurse's progress note dated [DATE] at 6:05 a.m. revealed This nurse was called into resident's room by another nurse for emergency with severe respiratory distress. Resident required help to sit up then stated I can't breathe. Oxygen on at 2 liters per nasal cannula with oxygen saturations at ,[DATE]%. Heart rate 80. Oxygen started at 10 liters per minute non rebreather mask and laid on pillow. 911 called for transport. Resident continues to make respiratory effort. 0630 EMS arrived CPR initiated by EMS shortly after. EMS continued CPR and transported resident via stretcher to hospital at 7:10 a.m. with CPR in progress. Record review of Resident #21's facility's SBAR (Situation Background Assessment Recommendation) dated [DATE] (no time) under Situation revealed severe respiratory distress stayed the same. Background-pulse 86 respirations 20 temp 98.2 oxygen sats 69%. Under section 4. Respiratory evaluation: shortness of breath is marked under describe symptoms or signs reveals respiratory distress oxygen sats at 69%. Further review of record reveals under 5. Cardiac: no changes observed was checked off. Section on pulse is left blank. 6. Skin evaluation was checked off as other no description. Advance Care Planning Full Code. Sent to hospital with CPR in progress by EMS. Appearance severe respiratory distress had difficulty breathing. Primary care physician notified at 9:00 AM. Family notified at 6:30 a.m. Record review of Resident #21's EMS run report dated [DATE] revealed dispatch was notified at 6:21 a.m. EMS at patient's bedside at 6:30 a.m. Further review of run report revealed dispatched for an unconscious patient and found [AGE] year old female laying supine on the floor of a nursing home. Staff on scene stated the patient was just fine at 6:00 a.m. and then complained of shortness of breath and then fell to the ground. Glass coma scale 3, pulseless, apneic. CPR started. Record review of Resident #21's hospital records dated [DATE] at 7:26 am HPI (History Present Illness) revealed Patient is a [AGE] year old female with history of [MEDICAL CONDITIONS] ([MEDICAL CONDITION] Infarction x5), [DIAGNOSES REDACTED] A-fib, Ischemic Cardiovascular Accident ([MEDICAL CONDITION]) who presents to the ED via EMS from rehab facility in [MEDICAL CONDITION] with CPR in progress. Per rehab the patient fell out of bed at 6:00 a.m. and was complaining of shortness of breath. She became unresponsive and EMS was called at 6:20 a.m. No pulse or heart rate noted, unresponsive, Abrasion to left knee. Time of death 7:33 a.m. Clinical impression [MEDICAL CONDITION]. Record review of Resident #21's emergency department record dated [DATE] 7:26 a.m. under subjective assessment revealed According to EMS patient is from nursing home at 6:00 a.m. the patient had a fall and was complaining of shortness of breath. She then went unresponsive. EMS arrived at 6:30 a.m. to find the patient pulseless. She was on oxygen but no compressions were being done. Interview on [DATE] at 11:46 a.m. with LVN E revealed Resident #21 was up in her wheelchair in the hallway asking for Tylenol after being medicated Resident # 21 went back to her room. Further interview with LVN E revealed she heard Resident # 21 yelling to get her up. When she walked in the room Resident #21 was laying on her back by the bed complaining of shortness of breath. LVN E further revealed she completed a quick assessment to see if she was hurt, when she and CNA (unknown) tried to get resident #21 up, Resident # 21 became unresponsive. LVN E further revealed she checked Resident #21's oxygen saturation, she then went to get the crash cart and check the resident's code status. LVN C came in to assist her and they placed the resident on oxygen and called EMS. Further interview with LVN E revealed they did not check vital signs nor initiate CPR. Interview on [DATE] at 10:45 a.m. with the DON revealed she was informed by LVN C that resident was calling for help and that the resident was in respiratory distress and that LVN C had called other nurses for help. DON further revealed the nurses had asked her about documenting the incident. DON further revealed she began an investigation and had staff write statements on the incident. Interview on [DATE] at 9:25 am with RN D revealed when she entered the resident's room she found resident # 21 lying on the floor gasping for air. RN D further revealed she was informed by LVN C resident had fallen. She was on oxygen concentrate at 2 liters via nasal cannula. We changed to tank oxygen non-rebreather mask 10 liters, called 911, heart rate was faint oxygen 56% started CPR as we waited for the 911 team. When they arrived we handed over to them. Interview on [DATE] at 9:42 a.m. with LVN C revealed she heard a certified nurse's aide in 300 hall (could not recall who it was) saying she needs a nurse LVN C further revealed when she went to answer the call, noted resident # 21 was on floor. LVN C further revealed resident complained of not being able to breathe and was placed on oxygen at 2 liters per minute (lpm) per nasal cannula. Another nurse checked the oxygen saturation it was low (did not specify how low) so we started resident on non-rebreather at 10 lpm and somebody called 911. During further interview LVN C revealed Resident #21 was alert the whole time she was in the room. She left the room after EMS arrived. Interview on [DATE] at 11:25 a.m. RN D recanted statement made on [DATE] at 9:25 a.m., which stated they had started CPR. RN D revealed they did not initiate CPR they changed the oxygen to non-rebreather mask. RN D further revealed they checked the oxygen saturation periodically and it would not read a pulse or oxygen saturation level. RN D further revealed 911 was called who came in and started CPR. Interview on [DATE] at 1:55 p.m. with the DON revealed the facility's process for ensuring staff know the residents' code status is by using the colored system in the chart a green sheet is placed in the medical record if resident is a full code and a red sheet if the resident is a DNR. The DON further revealed that all nurses were certified on the use of AED and CPR. The DON further revealed she monitored that staff know what to do in the event of respiratory or cardiac distress through competencies or check offs done on new hires then annually. The DON further revealed mock codes are conducted on each shift once per quarter. The DON further revealed an investigation was not conducted regarding resident # 21 being found on the floor in respiratory distress and transferred to the hospital. Record review revealed no sign in sheets for in-service training of mock codes being completed for past 6 months. Record review of documentation received on Mock Code Blue revealed The Director of Nursing will complete a Mock Code each shift once per quarter. Record review of nurses initial and annual competencies did not reveal competency or check off training on what to do in the event of respiaratory or [MEDICAL CONDITION]. Interview on [DATE] at 12:32 p.m. with Paramedic #1 revealed upon entering Resident #21's room, resident #21 was found lying in supine position next to her bed with an oxygen non-rebreather on her. The resident did not have a pulse nor was breathing. Staff did not initiate CPR. Interview on [DATE] at 12:36 p.m. with Paramedic #2 revealed they were informed that resident had fallen, was breathing and unresponsive. Paramedic # 2 further revealed resident was pulseless and not breathing upon arrival to resident's room. Record review of the American Heart Association (AHA) site: HTTPS://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ revealed BLS is the foundation for saving lives after [MEDICAL CONDITION]. Fundamental aspects of adult BLS include immediate recognition of sudden [MEDICAL CONDITION] and activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator (AED). Further review revealed Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The facility's Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Policy (no date) revealed Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect, psychological harm. Training: Each employee of the facility is required to be trained in issues related to abuse prohibition practices. These include orientation and/or on-going training sessions that deal with appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Identification: Staff are knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries; sudden changes in resident's behavior or personality; and resident fear and anxiety. Investigation- All employees who suspect abuse at any time are to report it to their immediate supervisor. The administrator or his/her designee will report the allegation of abuse immediately to the state (IHS) and to the proper local authorities. Record review of facility's policy on Change in a Resident's Condition or Status (2001) revealed 2). A significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3). Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication form. 8).The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. 9). If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations. Record review of facility's policy on Emergency Procedure- Cardiopulmonary Resuscitation (2001) revealed Personnel have completed training on the initiation of CPR and basic life support, including defibrillation for victims of sudden [MEDICAL CONDITION]. General Guidelines: 3). Victims of [MEDICAL CONDITION] may initially have gasping respirations. Training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION]. 6). If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. Preparation for CPR; 3). Provide periodic Mock Codes (simulations of an actual [MEDICAL CONDITION]) for training purposes. The Administrator and DON were notified on [DATE] at 5:05 p.m. that an Immediate Jeopardy situation was identified. The facility submitted a plan of removal dated [DATE] which was accepted on [DATE]outlining immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: 1. The Don and ADON initiated education regarding Change in Condition Policy and Procedure and Acute/Emergent Change in Condition with licensed and non-licensed staff on [DATE]. Education was completed on [DATE]-[DATE] with 100% completion of education for all shifts. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education for non-licensed staff included how facility immediately call for help and immediately notify the charge nurse when a change in condition is noted. Education on completion of the stop & watch tool as a notification system to charge nurses. Stop & watch tools include early warning of different behavior, talking less, need for more help, decreased participation in activities, eating/drinking less, weight changes, agitated more than usual, tired/weak/confused/drowsy and change in skin color. This tool assists the staff in identifying early signs of possible acute change in condition. Education for licensed staff include immediate assessments for any acute/emergent change in condition. Assessment will include vital signs, neurological status, current level of pain, and recent changes in pain level, level of consciousness, cognitive and emotional status. Licensed staff will assess the acute change onset, duration and severity, active diagnoses, medications, oxygen administration, and notification of MD. Emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education implemented on [DATE] by DON and ADON completed [DATE] all with licensed staff regarding pain management policy that included proper assessment of pain, types of pain including acute and chronic pain. Education also included how to identify moderate to severe pain, pain interventions including short and long-acting medications, non-pharmaceutical interventions and notifications to MD regarding unrelieved pain. Licensed staff completed written test regarding pain management. Staff had a passing score of 100% on the written test. 100% completion of education will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education with licensed and non-licensed staff was verified by a written test with passing score (100% score). Written test on identification and notification of changes in conditions included roles staff members have in identifying change in condition (all staff), physical signs of change in conditions, how to identify emergent/acute changes in condition including non-responsive residents, respiratory distress and complaints of pain and who to notify the change in condition. 2. The Don and ADON completed education with licensed staff on [DATE] regarding initiating CPR and AED and according to SCC policy and procedure, which states emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. DON and ADON completed mock code blue with licensed facility staff on [DATE] to [DATE]. Mock code blue includes scenario based training on how to intervene when a resident is unresponsive, has abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents, AED applied and 911 notified. Also included timeline documentation of timeline of interventions. 3. The DON and ADON completed education with licensed staff on [DATE] regarding Education on initiating, completing an incident report, notifications, investigation, documentation and interventions. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 4. Administrator, DON and ADON were educated by Director of Clinical Operations on [DATE] on incident and accident investigations and provide training to staff as indicated post incident. 5. Charge nurse will initiate report, investigation, and interventions following an incident. DON, ADON, Medical Records Director completed education on [DATE]. 100% completion of education and participation in mock code blue for all shifts were completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 6. Facility will complete an ad hoc QA meeting with medical director, administrator, DON, and two other quality assurance staff members on [DATE] to review the alleged deficiencies and the plan to remove. Facility will complete debriefing meeting with administrator, DON and staff involved in any change in condition resulting in a transfer from the facility, DON will review documentation after any change in condition resulting in a transfer from the facility, Debriefing meetings will be presented to facility to facility QAPI committee for review and recommendation. DON will monitor direct care staff competency and proficiency regarding assessment and interventions for residents experiencing acute/emergent change in condition by conducting random mock code evaluations. DON and Medical Director will complete chart audits and utilization of interact QI analysis tool. Evaluations, chart audits and analysis will be presented to QAPI committee for review and recommendation. Interview on [DATE] at 11:15 a.m. with the Facility Administrator revealed the process for ensuring the needs of residents are being met is by reviewing incident reports in morning clinical meetings. Administrator further revealed she conducts spot checks to see if competencies are being completed by physically verifying the competencies. The administrator further revealed she reviews information obtained from the quality of life rounds completed by the management team, grievances, resident council or other sources of information to determine what competencies need to be audited. Further interview revealed she was not sure if there was a documentation issue or a concern on the nurses' actuals steps. Verification of Plan of Removal: Record review of Residents # 2, 23, 24 and 25 consolidated orders and medical records reviewed for code status coincided with colored code status sheet in medical record. Record review of in-service training on initiating CPR and AED, Incident/Accident Investigation, Stop and Watch Tool, Change in Resident Condition, and Charting and Documentation revealed 60% of the staff was in-serviced. Record review of mock code in-service training reveled a mock code blue evaluation was conducted on [DATE] at 1:40 p.m. Record review of in-service on pain reminders-moderate-severe pain/ Types of pain revealed 60% of nurses were in-serviced. Record review of in-service titled Completing Investigations revealed Administrator, DON, ADON and Food Service Manager were trained on [DATE]. Interview with LVN W on [DATE] at 4:04 PM revealed LVN W was able to explain what she had learned in the in-services. LVN W described how to use the Stop and Watch sheets and how to assess a resident that had a significant change in status. LVN W further revealed that she was educated on when she was supposed to initiate CPR. Interview with RN X on [DATE] at 4:17 PM revealed RN X was able to explain how the Stop and Watch tool worked and she revealed that she had received in-services on what to do if a resident had a change in condition and she explained how to assess a resident and when she would initiate CPR on a resident. Interview with CNA Y on [DATE] at 4:21 PM revealed CNA Y had received an in-service on how to use the Stop and Watch tool. CNA Y was able to explain when and how she would use the tool and she explained that she would pass on the information from the Stop and Watch sheet to the charge nurse. Interview with CNA Z on [DATE] at 4:25 PM revealed CNA Z had received an in-service on how to use the Stop and Watch tool. CNA Z was able to explain when and how he would use the tool and he explained that he would pass on the information from the Stop and Watch sheet to the ADON. Interview with CNA AA on [DATE] at 4:50 PM revealed CNA AA was able to explain how to look for a resident change in condition and how to use the Stop and Watch tool and to report the change in condition to the charge nurse. Interview with LVN BB on [DATE] at 4:55 PM revealed LVN BB was able to explain how and what to assess with resident who was in distress or had fallen. LVN BB was able to list the different vitals to be taken and explained that if the resident was not breathing and did not have a pulse, CPR would be initiated and 911 would be called right away. Interview with Medication Aide CC on [DATE] at 5:03 PM revealed that she had been trained on how to use the Stop and Watch tool. Medication Aide CC revealed that if she noticed a change in condition with any resident she would tell nurse immediately by filling out and giving nurse the Stop and Watch tool. Interview with RN DD on [DATE] at 5:05 PM revealed that if a resident had a change in condition, RN DD would assess the resident for oxygen and vitals and fill out an SBAR. She further revealed that in an emergency situation she would call for help and get the crash cart and AED and initiate CPR if the resident had no pulse. Interview with the ADON on [DATE] at 4:40 PM revealed that she would immediately follow up any incident by determining the cause and who, what, when, and why of the incident. She revealed that she would review the resident's clinical record and change care if needed and provide education to staff. She revealed that more serious incidents should be investigated within one hour after notification and other less severe incidents should be investigated by the next working day. The ADON also confirmed that an Ad Hoc QA meeting was completed on [DATE] and that the monthly QAPI meeting will include the issues related to the IJ, including assessment, monitoring, CPR and training of staff. While the IJ was removed on [DATE] at 5:55 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR). According to the Resident Code Status roster (no date) provided on [DATE] revealed there was 57 resident coded as a full code.

Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being in accordance with the physician orders [REDACTED].#21) whose care was reviewed for Code Status in that: LVN C, LVN E and RN D failed to assess Resident # 21's after change in condition declined, no vital signs were taken, and Cardiopulmonary Resuscitation (CPR) was not initiated for Resident #21 who was unresponsive, pulseless and a full code status contributing to Resident #21's death. This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern because facility needed to continue monitoring implementation of plan of removal. This deficient practice could affect 56 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and result in death. The findings were: Record review of resident #21's face sheet ([DATE]) revealed she was admitted to the facility on [DATE] with an original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's consolidated orders for [DATE] revealed resident #21 was a Full Code. Record review of Resident's #21's Admission MDS dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) was 14, indicating the resident's cognition was intact. Review of Resident #21's care plan dated [DATE] did not address the resident's full code status. Record review of Resident #21's nurses progress note dated [DATE] at 5:40 a.m. revealed resident up in wheelchair down 300 hall waiting, by nurses cart when this nurse in another patients room stating she needed Tylenol. Resident stated to have general pain ,[DATE] (5 out of 10) Tylenol administered and approximately ,[DATE] minutes resident started yelling for help in room. See nurse note for further details. Record review of Resident#21's nurse's progress note dated [DATE] at 6:05 a.m. revealed This nurse was called into resident's room by another nurse for emergency with severe respiratory distress. Resident required help to sit up then stated I can't breathe. Oxygen on at 2 liters per nasal cannula with oxygen saturations at ,[DATE]%. Heart rate 80. Oxygen started at 10 liters per minute non rebreather mask and laid on pillow. 911 called for transport. Resident continues to make respiratory effort. 0630 EMS arrived CPR initiated by EMS shortly after. EMS continued CPR and transported resident via stretcher to hospital at 7:10 a.m. with CPR in progress. Record review of Resident #21's facility's SBAR (Situation Background Assessment Recommendation) dated [DATE] (no time) under Situation revealed severe respiratory distress stayed the same. Background-pulse 86 respirations 20 temp 98.2 oxygen sats 69%. Under section 4. Respiratory evaluation: shortness of breath is marked under describe symptoms or signs reveals respiratory distress oxygen sats at 69%. Further review of record reveals under 5. Cardiac: no changes observed was checked off. Section on pulse is left blank. 6. Skin evaluation was checked off as other no description. Advance Care Planning Full Code. Sent to hospital with CPR in progress by EMS. Appearance severe respiratory distress had difficulty breathing. Primary care physician notified at 9:00 AM. Family notified at 6:30 a.m. Record review of Resident #21's EMS run report dated [DATE] revealed dispatch was notified at 6:21 a.m. EMS at patient's bedside at 6:30 a.m. Further review of run report revealed dispatched for an unconscious patient and found [AGE] year old female laying supine on the floor of a nursing home. Staff on scene stated the patient was just fine at 6:00 a.m. and then complained of shortness of breath and then fell to the ground. Glass coma scale 3, pulseless, apneic. CPR started. Record review of Resident #21's hospital records dated [DATE] at 7:26 am HPI (History Present Illness) revealed Patient is a [AGE] year old female with history of [MEDICAL CONDITIONS] ([MEDICAL CONDITION] Infarction x5), [DIAGNOSES REDACTED] A-fib, Ischemic Cardiovascular Accident ([MEDICAL CONDITION]) who presents to the ED via EMS from rehab facility in [MEDICAL CONDITION] with CPR in progress. Per rehab the patient fell out of bed at 6:00 a.m. and was complaining of shortness of breath. She became unresponsive and EMS was called at 6:20 a.m. No pulse or heart rate noted, unresponsive, Abrasion to left knee. Time of death 7:33 a.m. Clinical impression [MEDICAL CONDITION]. Record review of Resident #21's emergency department record dated [DATE] 7:26 a.m. under subjective assessment revealed According to EMS patient is from nursing home at 6:00 a.m. the patient had a fall and was complaining of shortness of breath. She then went unresponsive. EMS arrived at 6:30 a.m. to find the patient pulseless. She was on oxygen but no compressions were being done. Interview on [DATE] at 11:46 a.m. with LVN E revealed Resident #21 was up in her wheelchair in the hallway asking for Tylenol after being medicated Resident # 21 went back to her room. Further interview with LVN E revealed she heard Resident # 21 yelling to get her up. When she walked in the room Resident #21 was laying on her back by the bed complaining of shortness of breath. LVN E further revealed she completed a quick assessment to see if she was hurt, when she and CNA (unknown) tried to get resident #21 up, Resident # 21 became unresponsive. LVN E further revealed she checked Resident #21's oxygen saturation, she then went to get the crash cart and check the resident's code status. LVN C came in to assist her and they placed the resident on oxygen and called EMS. Further interview with LVN E revealed they did not check vital signs nor initiate CPR. Interview on [DATE] at 10:45 a.m. with the DON revealed she was informed by LVN C that resident was calling for help and that the resident was in respiratory distress and that LVN C had called other nurses for help. DON further revealed the nurses had asked her about documenting the incident. DON further revealed she began an investigation and had staff write statements on the incident. Interview on [DATE] at 9:25 am with RN D revealed when she entered the resident's room she found resident # 21 lying on the floor gasping for air. RN D further revealed she was informed by LVN C resident had fallen. She was on oxygen concentrate at 2 liters via nasal cannula. We changed to tank oxygen non-rebreather mask 10 liters, called 911, heart rate was faint oxygen 56% started CPR as we waited for the 911 team. When they arrived we handed over to them. Interview on [DATE] at 9:42 a.m. with LVN C revealed she heard a certified nurse's aide in 300 hall (could not recall who it was) saying she needs a nurse LVN C further revealed when she went to answer the call, noted resident # 21 was on floor. LVN C further revealed resident complained of not being able to breathe and was placed on oxygen at 2 liters per minute (lpm) per nasal cannula. Another nurse checked the oxygen saturation it was low (did not specify how low) so we started resident on non-rebreather at 10 lpm and somebody called 911. During further interview LVN C revealed Resident #21 was alert the whole time she was in the room. She left the room after EMS arrived. Interview on [DATE] at 11:25 a.m. RN D recanted statement made on [DATE] at 9:25 a.m., which stated they had started CPR. RN D revealed they did not initiate CPR they changed the oxygen to non-rebreather mask. RN D further revealed they checked the oxygen saturation periodically and it would not read a pulse or oxygen saturation level. RN D further revealed 911 was called who came in and started CPR. Interview on [DATE] at 1:55 p.m. with the DON revealed the facility's process for ensuring staff know the residents' code status is by using the colored system in the chart a green sheet is placed in the medical record if resident is a full code and a red sheet if the resident is a DNR. The DON further revealed that all nurses were certified on the use of AED and CPR. The DON further revealed she monitored that staff know what to do in the event of respiratory or cardiac distress through competencies or check offs done on new hires then annually. The DON further revealed mock codes are conducted on each shift once per quarter. The DON further revealed an investigation was not conducted regarding resident # 21 being found on the floor in respiratory distress and transferred to the hospital. Record review revealed no sign in sheets for in-service training of mock codes being completed for past 6 months. Record review of documentation received on Mock Code Blue revealed The Director of Nursing will complete a Mock Code each shift once per quarter. Record review of nurses initial and annual competencies did not reveal competency or check off training on what to do in the event of respiaratory or [MEDICAL CONDITION]. Interview on [DATE] at 12:32 p.m. with Paramedic #1 revealed upon entering Resident #21's room, resident #21 was found lying in supine position next to her bed with an oxygen non-rebreather on her. The resident did not have a pulse nor was breathing. Staff did not initiate CPR. Interview on [DATE] at 12:36 p.m. with Paramedic #2 revealed they were informed that resident had fallen, was breathing and unresponsive. Paramedic # 2 further revealed resident was pulseless and not breathing upon arrival to resident's room. Record review of the American Heart Association (AHA) site: HTTPS://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ revealed BLS is the foundation for saving lives after [MEDICAL CONDITION]. Fundamental aspects of adult BLS include immediate recognition of sudden [MEDICAL CONDITION] and activation of the emergency response system, early CPR, and rapid defibrillation with an automated external defibrillator (AED). Further review revealed Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. Record review of facility's policy on Change in a Resident's Condition or Status (2001) revealed 2). A significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. d. Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3). Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication form. 8).The nurse will record in the resident's medical record information relative to change in the resident's medical/mental condition or status. 9). If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations. Record review of facility's policy on Emergency Procedure- Cardiopulmonary Resuscitation (2001) revealed Personnel have completed training on the initiation of CPR and basic life support, including defibrillation for victims of sudden [MEDICAL CONDITION]. General Guidelines: 3). Victims of [MEDICAL CONDITION] may initially have gasping respirations. Training in BLS includes recognizing presentations of sudden [MEDICAL CONDITION]. 6). If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. Preparation for CPR; 3). Provide periodic Mock Codes (simulations of an actual [MEDICAL CONDITION]) for training purposes. The Administrator and DON were notified on [DATE] at 5:05 p.m. that an Immediate Jeopardy situation was identified. The facility submitted a plan of removal dated [DATE] which was accepted on [DATE]outlining immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: 1. The Don and ADON initiated education regarding Change in Condition Policy and Procedure and Acute/Emergent Change in Condition with licensed and non-licensed staff on [DATE]. Education was completed on [DATE]-[DATE] with 100% completion of education for all shifts. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education for non-licensed staff included how facility immediately call for help and immediately notify the charge nurse when a change in condition is noted. Education on completion of the stop & watch tool as a notification system to charge nurses. Stop & watch tools include early warning of different behavior, talking less, need for more help, decreased participation in activities, eating/drinking less, weight changes, agitated more than usual, tired/weak/confused/drowsy and change in skin color. This tool assists the staff in identifying early signs of possible acute change in condition. Education for licensed staff include immediate assessments for any acute/emergent change in condition. Assessment will include vital signs, neurological status, current level of pain, and recent changes in pain level, level of consciousness, cognitive and emotional status. Licensed staff will assess the acute change onset, duration and severity, active diagnoses, medications, oxygen administration, and notification of MD. Emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education implemented on [DATE] by DON and ADON completed [DATE] all with licensed staff regarding pain management policy that included proper assessment of pain, types of pain including acute and chronic pain. Education also included how to identify moderate to severe pain, pain interventions including short and long-acting medications, non-pharmaceutical interventions and notifications to MD regarding unrelieved pain. Licensed staff completed written test regarding pain management. Staff had a passing score of 100% on the written test. 100% completion of education will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education with licensed and non-licensed staff was verified by a written test with passing score (100% score). Written test on identification and notification of changes in conditions included roles staff members have in identifying change in condition (all staff), physical signs of change in conditions, how to identify emergent/acute changes in condition including non-responsive residents, respiratory distress and complaints of pain and who to notify the change in condition. 2. The Don and ADON completed education with licensed staff on [DATE] regarding initiating CPR and AED and according to SCC policy and procedure, which states emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. DON and ADON completed mock code blue with licensed facility staff on [DATE] to [DATE]. Mock code blue includes scenario based training on how to intervene when a resident is unresponsive, has abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents, AED applied and 911 notified. Also included timeline documentation of timeline of interventions. 3. The DON and ADON completed education with licensed staff on [DATE] regarding Education on initiating, completing an incident report, notifications, investigation, documentation and interventions. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 4. Administrator, DON and ADON were educated by Director of Clinical Operations on [DATE] on incident and accident investigations and provide training to staff as indicated post incident. 5. Charge nurse will initiate report, investigation, and interventions following an incident. DON, ADON, Medical Records Director completed education on [DATE]. 100% completion of education and participation in mock code blue for all shifts were completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 6. Facility will complete an ad hoc QA meeting with medical director, administrator, DON, and two other quality assurance staff members on [DATE] to review the alleged deficiencies and the plan to remove. Facility will complete debriefing meeting with administrator, DON and staff involved in any change in condition resulting in a transfer from the facility, DON will review documentation after any change in condition resulting in a transfer from the facility, Debriefing meetings will be presented to facility to facility QAPI committee for review and recommendation. DON will monitor direct care staff competency and proficiency regarding assessment and interventions for residents experiencing acute/emergent change in condition by conducting random mock code evaluations. DON and Medical Director will complete chart audits and utilization of interact QI analysis tool. Evaluations, chart audits and analysis will be presented to QAPI committee for review and recommendation. Interview on [DATE] at 11:15 a.m. with the Facility Administrator revealed the process for ensuring the needs of residents are being met is by reviewing incident reports in morning clinical meetings. Administrator further revealed she conducts spot checks to see if competencies are being completed by physically verifying the competencies. The administrator further revealed she reviews information obtained from the quality of life rounds completed by the management team, grievances, resident council or other sources of information to determine what competencies need to be audited. Further interview revealed she was not sure if there was a documentation issue or a concern on the nurses' actuals steps. Verification of Plan of Removal: Record review of Residents # 2, 23, 24 and 25 consolidated orders and medical records reviewed for code status coincided with colored code status sheet in medical record. Record review of in-service training on initiating CPR and AED, Incident/Accident Investigation, Stop and Watch Tool, Change in Resident Condition, and Charting and Documentation revealed 60% of the staff was in-serviced. Record review of mock code in-service training reveled a mock code blue evaluation was conducted on [DATE] at 1:40 p.m. Record review of in-service on pain reminders-moderate-severe pain/ Types of pain revealed 60% of nurses were in-serviced. Record review of in-service titled Completing Investigations revealed Administrator, DON, ADON and Food Service Manager were trained on [DATE]. Interview with LVN W on [DATE] at 4:04 PM revealed LVN W was able to explain what she had learned in the in-services. LVN W described how to use the Stop and Watch sheets and how to assess a resident that had a significant change in status. LVN W further revealed that she was educated on when she was supposed to initiate CPR. Interview with RN X on [DATE] at 4:17 PM revealed RN X was able to explain how the Stop and Watch tool worked and she revealed that she had received in-services on what to do if a resident had a change in condition and she explained how to assess a resident and when she would initiate CPR on a resident. Interview with CNA Y on [DATE] at 4:21 PM revealed CNA Y had received an in-service on how to use the Stop and Watch tool. CNA Y was able to explain when and how she would use the tool and she explained that she would pass on the information from the Stop and Watch sheet to the charge nurse. Interview with CNA Z on [DATE] at 4:25 PM revealed CNA Z had received an in-service on how to use the Stop and Watch tool. CNA Z was able to explain when and how he would use the tool and he explained that he would pass on the information from the Stop and Watch sheet to the ADON. Interview with CNA AA on [DATE] at 4:50 PM revealed CNA AA was able to explain how to look for a resident change in condition and how to use the Stop and Watch tool and to report the change in condition to the charge nurse. Interview with LVN BB on [DATE] at 4:55 PM revealed LVN BB was able to explain how and what to assess with resident who was in distress or had fallen. LVN BB was able to list the different vitals to be taken and explained that if the resident was not breathing and did not have a pulse, CPR would be initiated and 911 would be called right away. Interview with Medication Aide CC on [DATE] at 5:03 PM revealed that she had been trained on how to use the Stop and Watch tool. Medication Aide CC revealed that if she noticed a change in condition with any resident she would tell nurse immediately by filling out and giving nurse the Stop and Watch tool. Interview with RN DD on [DATE] at 5:05 PM revealed that if a resident had a change in condition, RN DD would assess the resident for oxygen and vitals and fill out an SBAR. She further revealed that in an emergency situation she would call for help and get the crash cart and AED and initiate CPR if the resident had no pulse. Interview with the ADON on [DATE] at 4:40 PM revealed that she would immediately follow up any incident by determining the cause and who, what, when, and why of the incident. She revealed that she would review the resident's clinical record and change care if needed and provide education to staff. She revealed that more serious incidents should be investigated within one hour after notification and other less severe incidents should be investigated by the next working day. The ADON also confirmed that an Ad Hoc QA meeting was completed on [DATE] and that the monthly QAPI meeting will include the issues related to the IJ, including assessment, monitoring, CPR and training of staff. While the IJ was removed on [DATE] at 5:55 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR). According to the Resident Code Status roster (no date) provided on [DATE] revealed there was 57 resident coded as a full code.

Based on interviews and record reviews the administrator failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for 1 of 27 (Resident #21) in that: The DON failed to: 1. Ensure nurses received training assessing change in resident's condition, documenting interventions, and initiating CPR for Resident # 21 who was a full code and experienced harm (death). 2. Failed to conduct an investigation following Resident #21's who was found on the floor in respiratory distress and became unresponsive, pulseless and died . Resident #21 was a Full Code status. 3. Failed to provide training or corrective measures following incident. The Administrator failed to: 1. Supervise the DON's training and monitoring of direct care staff in assessing change of condition, document interventions, and initiating CPR for Resident # 21 who was a full code and experienced harm and contributed to Resident #21's death. 2. Failed to conduct an investigation following Resident #21's who was found on the floor in respiratory distress and became unresponsive, pulseless and died . Resident #21 was a Full Code status. 3. Failed to provide training or corrective measures following the incident. This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff were in-serviced on assessing the residents for change in condition, proper documentation, code identification and provision of CPR and AED (Automated External Defibrillators). This deficient practice could affect 56 residents in the facility who were Full Code and could result in their request for full code not being honored and not receiving CPR immediately if their heart stopped and resulted in death. The findings were: Interview on [DATE] at 10:45 a.m. with the DON she revealed she was informed by LVN C that resident was calling for help and that the resident was in respiratory distress and that LVN C had called other nurses for help. DON further revealed the nurses had asked her about documenting the incident. DON further revealed she began an investigation and had staff write statements on the incident. Interview on [DATE] at 1:55 p.m. with the DON revealed the facility's process for ensuring staff know the residents' code status is by using the colored system in the chart a green sheet is placed in the medical record if resident is a full code and a red sheet if the resident is a DNR. The DON further revealed that all nurses are certified on the use of AED and CPR. The DON further revealed she monitors that staff know what to do in the event of respiratory or cardiac distress through competencies or check offs done on new hire then annually. The DON further revealed mock codes are conducted on each shift once per quarter. The DON further revealed an investigation was not conducted regarding resident # 21 being found on floor in respiratory distress and transferred to the hospital. Record review revealed no sign in sheets for in-service training of mock codes being completed for past 6 months. Record review of documentation received on Mock Code Blue revealed The Director of Nursing will complete a Mock Code each shift once per quarter. Record review of nurses' initial and annual competencies did not reveal competency or check off training on what to do in the event of respiratory or [MEDICAL CONDITION]. Interview on [DATE] at 11:15 a.m. with the Facility Administrator revealed the process for ensuring the needs of residents are being met is by reviewing incident reports in morning clinical meetings. Administrator further revealed she conducts spot checks to see if competencies are being completed by physically verifying the competencies. The administrator further revealed she monitors that the DON is completing in-service trainings and competencies by conducting audit reviews based on the information obtained from the quality of life rounds completed by the management team, grievances, resident council or other sources of information. Further interview revealed she was not sure if there was a documentation issue or a concern on the nurses' actual steps. Record review of resident #21's face sheet ([DATE]) revealed she was admitted to the facility on [DATE] with an original admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #21's consolidated orders for [DATE] revealed resident #21 was a Full Code. Record review of Resident's #21's Admission MDS dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) was 14, indicating the resident's cognition was intact. Review of Resident #21's care plan dated [DATE] did not address the resident's full code status. Record review of Resident #21's nurses progress note dated [DATE] at 5:40 a.m. revealed resident up in wheelchair down 300 hall waiting, by nurses cart when this nurse in another patients room stating she needed Tylenol. Resident stated to have general pain ,[DATE] (5 out of 10) Tylenol administered and approximately ,[DATE] minutes resident started yelling for help in room. See nurse note for further details. Record review of Resident#21's nurse's progress note dated [DATE] at 6:05 a.m. revealed This nurse was called into resident's room by another nurse for emergency with severe respiratory distress. Resident required help to sit up then stated I can't breathe. Oxygen on at 2 liters per nasal cannula with oxygen saturations at ,[DATE]%. Heart rate 80. Oxygen started at 10 liters per minute non rebreather mask and laid on pillow. 911 called for transport. Resident continues to make respiratory effort. 0630 EMS arrived CPR initiated by EMS shortly after. EMS continued CPR and transported resident via stretcher to hospital at 7:10 a.m. with CPR in progress. Record review of Resident #21's facility's SBAR (Situation Background Assessment Recommendation) dated [DATE] (no time) under Situation revealed severe respiratory distress stayed the same. Background-pulse 86 respirations 20 temp 98.2 oxygen sats 69%. Under section 4. Respiratory evaluation: shortness of breath is marked under describe symptoms or signs reveals respiratory distress oxygen sats at 69%. Further review of record reveals under 5. Cardiac: no changes observed was checked off. Section on pulse is left blank. 6. Skin evaluation was checked off as other no description. Advance Care Planning Full Code. Sent to hospital with CPR in progress by EMS. Appearance severe respiratory distress had difficulty breathing. Primary care physician notified at 9:00 AM. Family notified at 6:30 a.m. Record review of Resident #21's EMS run report dated [DATE] revealed dispatch was notified at 6:21 a.m. EMS at patient's bedside at 6:30 a.m. Further review of run report revealed dispatched for an unconscious patient and found [AGE] year old female laying supine on the floor of a nursing home. Staff on scene stated the patient was just fine at 6:00 a.m. and then complained of shortness of breath and then fell to the ground. Glass coma scale 3, pulseless, apneic. CPR started. Record review of Resident #21's hospital records dated [DATE] at 7:26 am HPI (History Present Illness) revealed Patient is a [AGE] year old female with history of [MEDICAL CONDITIONS] ([MEDICAL CONDITION] Infarction x5), [DIAGNOSES REDACTED] A-fib, Ischemic Cardiovascular Accident ([MEDICAL CONDITION]) who presents to the ED via EMS from rehab facility in [MEDICAL CONDITION] with CPR in progress. Per rehab the patient fell out of bed at 6:00 a.m. and was complaining of shortness of breath. She became unresponsive and EMS was called at 6:20 a.m. No pulse or heart rate noted, unresponsive, Abrasion to left knee. Time of death 7:33 a.m. Clinical impression [MEDICAL CONDITION]. Record review of Resident #21's emergency department record dated [DATE] 7:26 a.m. under subjective assessment revealed According to EMS patient is from nursing home at 6:00 a.m. the patient had a fall and was complaining of shortness of breath. She then went unresponsive. EMS arrived at 6:30 a.m. to find the patient pulseless. She was on oxygen but no compressions were being done. The facility submitted a plan of removal dated [DATE] which was accepted on [DATE] outlining immediate interventions employed by the Facility to abate any further concerns surrounding the above issue: 1.The Don and ADON initiated education regarding Change in Condition Policy and Procedure and Acute/Emergent Change in Condition with licensed and non-licensed staff on [DATE]. Education was completed on [DATE]-[DATE] with 100% completion of education for all shifts. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education for non-licensed staff included how facility immediately call for help and immediately notify the charge nurse when a change in condition is noted. Education on completion of the stop & watch tool as a notification system to charge nurses. Stop & watch tools include early warning of different behavior, talking less, need for more help, decreased participation in activities, eating/drinking less, weight changes, agitated more than usual, tired/weak/confused/drowsy and change in skin color. This tool assists the staff in identifying early signs of possible acute change in condition. Education for licensed staff include immediate assessments for any acute/emergent change in condition. Assessment will include vital signs, neurological status, current level of pain, and recent changes in pain level, level of consciousness, cognitive and emotional status. Licensed staff will assess the acute change onset, duration and severity, active diagnoses, medications, oxygen administration, and notification of MD. Emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education implemented on [DATE] by DON and ADON completed [DATE] all with licensed staff regarding pain management policy that included proper assessment of pain, types of pain including acute and chronic pain. Education also included how to identify moderate to severe pain, pain interventions including short and long-acting medications, non-pharmaceutical interventions and notifications to MD regarding unrelieved pain. Licensed staff completed written test regarding pain management. Staff had a passing score of 100% on the written test. 100% completion of education will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. Education with licensed and non-licensed staff was verified by a written test with passing score (100% score). Written test on identification and notification of changes in conditions included roles staff members have in identifying change in condition (all staff), physical signs of change in conditions, how to identify emergent/acute changes in condition including non-responsive residents, respiratory distress and complaints of pain and who to notify the change in condition. 2. The Don and ADON completed education with licensed staff on [DATE] regarding initiating CPR and AED and according to SCC policy and procedure, which states emergent/acute change in condition with unresponsiveness, abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents and 911 notified. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. DON and ADON completed mock code blue with licensed facility staff on [DATE] to [DATE]. Mock code blue includes scenario based training on how to intervene when a resident is unresponsive, has abnormal respirations, respiratory/cardiac distress or arrest; CPR will be initiated immediately on full code residents, AED applied and 911 notified. Also included timeline documentation of timeline of interventions. 3. The DON and ADON completed education with licensed staff on [DATE] regarding Education on initiating, completing an incident report, notifications, investigation, documentation and interventions. Education was completed on [DATE]. 100% completion of education and participation in mock code blue for all shifts will be completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 4. Administrator, DON and ADON were educated by Director of Clinical Operations on [DATE] on incident and accident investigations and provide training to staff as indicated post incident. 5. Charge nurse will initiate report, investigation, and interventions following an incident. DON, ADON, Medical Records Director completed education on [DATE]. 100% completion of education and participation in mock code blue for all shifts were completed by [DATE]. Those employees on leave/FMLA will have their education completed upon arrival for the start of the next scheduled shift to work. 6. Facility will complete an ad hoc QA meeting with medical director, administrator, DON, and two other quality assurance staff members on [DATE] to review the alleged deficiencies and the plan to remove. Facility will complete debriefing meeting with administrator, DON and staff involved in any change in condition resulting in a transfer from the facility, DON will review documentation after any change in condition resulting in a transfer from the facility, Debriefing meetings will be presented to facility to facility QAPI committee for review and recommendation. DON will monitor direct care staff competency and proficiency regarding assessment and interventions for residents experiencing acute/emergent change in condition by conducting random mock code evaluations. DON and Medical Director will complete chart audits and utilization of interact QI analysis tool. Evaluations, chart audits and analysis will be presented to QAPI committee for review and recommendation. Verification of Plan of Removal: Record review of Residents # 2, 23, 24 and 25 consolidated orders and medical records reviewed for code status coincided with colored code status sheet in medical record. Record review of in-service training on initiating CPR and AED, Incident/Accident Investigation, Stop and Watch Tool, Change in Resident Condition, and Charting and Documentation revealed 60% of the staff was in-serviced. Record review of mock code in-service training reveled a mock code blue evaluation was conducted on [DATE] at 1:40 p.m. Record review of in-service on pain reminders-moderate-severe pain/ Types of pain revealed 60% of nurses were in-serviced. Record review of in-service titled Completing Investigations revealed Administrator, DON, ADON and Food Service Manager were trained on [DATE]. Interview with LVN W on [DATE] at 4:04 PM revealed LVN W was able to explain what she had learned in the in-services. LVN W described how to use the Stop and Watch sheets and how to assess a resident that had a significant change in status. LVN W further revealed that she was educated on when she was supposed to initiate CPR. Interview with RN X on [DATE] at 4:17 PM revealed RN X was able to explain how the Stop and Watch tool worked and she revealed that she had received in-services on what to do if a resident had a change in condition and she explained how to assess a resident and when she would initiate CPR on a resident. Interview with CNA Y on [DATE] at 4:21 PM revealed CNA Y had received an in-service on how to use the Stop and Watch tool. CNA Y was able to explain when and how she would use the tool and she explained that she would pass on the information from the Stop and Watch sheet to the charge nurse. Interview with CNA Z on [DATE] at 4:25 PM revealed CNA Z had received an in-service on how to use the Stop and Watch tool. CNA Z was able to explain when and how he would use the tool and he explained that he would pass on the information from the Stop and Watch sheet to the ADON. Interview with CNA AA on [DATE] at 4:50 PM revealed CNA AA was able to explain how to look for a resident change in condition and how to use the Stop and Watch tool and to report the change in condition to the charge nurse. Interview with LVN BB on [DATE] at 4:55 PM revealed LVN BB was able to explain how and what to assess with resident who was in distress or had fallen. LVN BB was able to list the different vitals to be taken and explained that if the resident was not breathing and did not have a pulse, CPR would be initiated and 911 would be called right away. Interview with Medication Aide CC on [DATE] at 5:03 PM revealed that she had been trained on how to use the Stop and Watch tool. Medication Aide CC revealed that if she noticed a change in condition with any resident she would tell nurse immediately by filling out and giving nurse the Stop and Watch tool. Interview with RN DD on [DATE] at 5:05 PM revealed that if a resident had a change in condition, RN DD would assess the resident for oxygen and vitals and fill out an SBAR. She further revealed that in an emergency situation she would call for help and get the crash cart and AED and initiate CPR if the resident had no pulse. Interview with the ADON on [DATE] at 4:40 PM revealed that she would immediately follow up any incident by determining the cause and who, what, when, and why of the incident. She revealed that she would review the resident's clinical record and change care if needed and provide education to staff. She revealed that more serious incidents should be investigated within one hour after notification and other less severe incidents should be investigated by the next working day. The ADON also confirmed that an Ad Hoc QA meeting was completed on [DATE] and that the monthly QAPI meeting will include the issues related to the IJ, including assessment, monitoring, CPR and training of staff. While the IJ was removed on [DATE] at 5:55 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR). According to the Resident Code Status roster (no date) provided on [DATE] revealed there was 57 resident coded as a full code.

Based on observation, record review and interview the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (# 2) whose care was reviewed for accidents in that: Resident #2 was not pevented from leaving the building and fell in the driveway resulting in a fractured femur, surgical intervention and decline of physical function. This failure could affect 1 resident assessed at risk for falls and elopement. The findings were: Review of an admission record dated 7/20/15 documented the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medication regime revealed the resident was treated for [REDACTED]. An initial care plan dated 6/4/15 assessed that the resident was at risk for elopement and wandering due to dementia and impaired safety awareness. The facility's interventions included redirection from doors and offering of alternative activities; distracting the resident by offering pleasant diversions, food, conversation and/or television; and stipulated that if I attempt to elope or am wandering it is usually because I'm agitated about something. A psychiatric progress note dated 8/14/15 documented that the resident had occasional episodes of anxiety and impulsivity which occurred mostly towards the afternoon hours. Review of an MDS dated [DATE] revealed that the resident's cognitive ability was assessed a BIMS score of 4 indicating severe impairment with intermittent focus and disorganized thinking. The MDS also assessed the resident required 1-2 person assistance with ambulation and used a wheelchair and/or walker. Review of a physician's progress note dated 9/10/15 revealed the resident had DAT (dementia Alzheimer's type) with behaviors and that a nurse practitioner (NP) had discussed with Resident #2's family the possibility of moving the resident to a safer environment (dementia unit) that was secure and locked for the resident's safety. The NP also documented that the facility could no longer provide a safe environment for the resident. Review of a physician's progress report dated 9/17/15 revealed that Resident #2 had exhibited a change in behavior requiring the staff to increase supervision and monitoring when the staff attempted to provide incontinent care just before dinner. The behavior included combativeness, punching and kicking the staff when attempting to change the resident's clothing which was wet with urine. The physician documented attempting to examine the resident also on 9/17/15 and the resident threatened to punch the physician. The physician ordered 2.5 mg of Haldol (antipsychotic) IM to be administered. Review of a progress note by a NP dated 9/24/15 revealed that within the week of behavioral change, Resident #2's aggression continued and he again attempted to elope on 9/19/15. Haldol 5 mg IM was administered and the NP instructed the staff to continue supportive care and elopement precautions. Review of incident reports from 6/11/15 to 10/30/15 revealed multiple attempts by Resident #2 to leave the building and found by the staff: a. On 6/11/15 at 7:14 p.m., Resident #2 attempted to leave through 2 different locations within the building and the staff redirected the resident from the doors and offered alternate activities; b. On 6/18/15 at 6:30 p.m., Resident #2 slipped out of his wheelchair without any injuries. c. On 6/22/15 at 6:00 p.m., Resident #2 was found wandering in the parking lot and the resident was brought back into the facility. Interventions were to distract the resident from wandering by offering pleasant diversions, food, conversation and television. d. On 6/27/15 at 6:30 p.m., Resident #2 fell on the front porch outside the building and was redirected back into the building. There were no further interventions to address the elopment tendency. e. On 6/28/15 at 5:30 p.m., Resident #2 eloped from the building and was redirected back into the building. There were no further interventions to address the elopment tendency. f. On 8/11/15 at 5:30 p.m., Resident #2 fell in the hallway attempting to open an exit door at the end of a hallway. There were no further interventions to address the elopment tendency. g. On 9/10/15 at 1:30 p.m., Resident #2 was found walking in the parking lot and brought back into the building. There were no further interventions to address the elopment tendency. h. On 10/30/15 at approximately 6:00 p.m., Resident #2 was sitting in his wheelchair in the dining room and got up from the wheelchair (not equipped with an alarm system) and walked out of the main dining room, passing the nurses' station and receptionist desk and walked out the front door. He fell on the ground and fractured his right femur. There were no further interventions to address the elopment tendency. Review of the incident report dated 10/30/15 revealed that Resident #2 was found on the found by a visiting hospice nurse. The facility became aware of the resident's fall when the hospice nurse entered the facility and called for help. During a head to toe assessment in which the resident's limbs were tested for full range of motion, the resident expressed a grimace when the right leg was moved. An x-ray dated 10/30/15 confirmed a proximal femoral neck acute fracture. The assessing staff member documented that the resident had reported looking for his car as the reason for walking out the door. Review of the facility's policy for Wandering/Missing Residents (undated and listed under Operational/Resident Care Policies) revealed the following guidelines: a. All instances of wandering or attempted elopement will be recorded in the medical record. b. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. c. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. d. All staff is responsible for knowing whose name is on the list and be able to recognize the resident and be able to intervene as necessary. e. A monitoring device will be placed on the resident according to the manufacturer's directions. The policy did any include systems to alert the staff when the residents were getting out of their wheelchairs and/or or applying electronic alarms to wheelchairs to alert the staff of the resident standing up from and walking away from their wheelchair. Interview with the Administrator on 11/13/15 during the entrance conference revealed that the facility did not have a monitoring device system such as a wander guard. When the policy was reviewed, the Administrator stated that the policy needed to be changed. During initial observation rounds at 10:20 a.m. on 11/13/15, Resident #2 was observed sitting up in bed being interviewed by 2 staff members from the rehabilitation department. Both feet were inserted into foam pressure relieving boots and the resident was fully dressed. An ADL reminder sheet was located above the bed and indicated the resident required anti-tippers attached to the wheelchair. The wheelchair next to the bed did not have the anti-tipper devices and was not labeled as belonging to the resident according to the facility's policy. The resident was alert, but unable to answer questions related to the fall. During interview on 11/17/15 at 10:55 a.m., LVN A, ADON, reported that Resident #2 was observed by the staff in the main dining room sitting in a wheelchair waiting for his meal. When the resident ' s meal tray was brought to the table, the staff realized that the resident was not in his wheelchair and was not in the dining room. The staff in the dining room was alerted to the resident's location when the visiting hospice nurse entered the facility and began shouting for help at the entrance of the facility. The resident was not observed leaving the dining room or exiting the building. During further interview with LVN A, on 11/17/15 at 10:55 a.m., the elopement policy was discussed and LVN A stated that she was not sure of the existence and location of the wander book. Accompanying LVN A, the book was found in the unlocked drawer of receptionist's desk near the entrance of the front door. The receptionist was seated the desk and stated that at 6:00 p.m. on 10/30/15, there would not have been anyone at the desk to monitor the entrances and exits of residents. Review of the wander book at approximately 11:15 a.m. on 11/17/15 revealed that there was only 1 person's picture and profile in the book: Resident #2. At approximately 1:00 p.m. on 11/17/15, Resident #2 was observed in bed fully dressed and alert and oriented to self. The resident's daughter was visiting with him. LVN B, Treatment Nurse, assisted in removing the resident's pants to assess the incision to the right upper leg. A long closed incision line was noted containing approximately 20 plus staples. The resident was asked to lift the leg and upon doing so expressed pain to the upper leg by grimacing and squinting his face. The resident was asked in Spanish if there was pain and he responded with yes. During interview at approximately 1:10 p.m., Resident #2's daughter stated that the facility had reported the falls and elopements to the family and had considered alternate placement. She stated that she and her sister visited the resident daily and each alternated their visits. She stated that the facility's location was convenient for their visits, but was now concerned whether Resident #2 would be able to walk again and whether the resident would attempt to elope again. The interim Director of Nurses reported on 11/17/15 that there was only 1 resident (#2) in the facility at risk for elopement.

Based on observation, record review and interview the facility failed to develop and implement policies and procedures that prohibit the neglect of 1 of 2 residents (# 2) whose care was reviewed for elopement in that: Resident #2 was not monitored and eloped from the building and fell in the driveway resulting in a fractured femur, surgical intervention and decline of physical function. This failure could affect 1 resident assessed at risk for elopement. The findings were: Review of the facility's policy for Wandering/Missing Residents (undated and listed under Operational/Resident Care Policies) revealed the following guidelines: a. All instances of wandering or attempted elopement will be recorded in the medical record. b. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. c. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. d. All staff is responsible for knowing whose name is on the list and be able to recognize the resident and be able to intervene as necessary. e. A monitoring device will be placed on the resident according to the manufacturer's directions. The policy did any include systems to alert the staff when the residents were getting out of their wheelchairs and/or or applying electronic alarms to wheelchairs to alert the staff of the resident standing up from and walking away from their wheelchair. Interview with the Administrator on 11/13/15 during the entrance conference at approximately 8:30 a.m. revealed that the facility did not have a monitoring device system such as a wander guard. When the policy was reviewed, the Administrator stated that the policy needed to be changed. Review of Resident #2's admission record dated 7/20/15 documented the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medication regime revealed the resident was treated for [REDACTED]. An initial care plan dated 6/4/15 assessed that the resident was at risk for elopement and wandering due to dementia and impaired safety awareness. The facility's interventions included redirection from doors and offering of alternative activities; distracting the resident by offering pleasant diversions, food, conversation and/or television; and stipulated that if I attempt to elope or am wandering it is usually because I'm agitated about something. A psychiatric progress note dated 8/14/15 documented that the resident had occasional episodes of anxiety and impulsivity which occurred mostly towards the afternoon hours. Review of an MDS dated [DATE] revealed that the resident's cognitive ability was assessed a BIMS score of 4 indicating severe impairment with intermittent focus and disorganized thinking. The MDS also assessed the resident required 1-2 person assistance with ambulation and used a wheelchair and/or walker. Review of a physician's progress note dated 9/10/15 revealed the resident had DAT (dementia Alzheimer's type) with behaviors and that a nurse practitioner (NP) had discussed with Resident #2's family the possibility of moving the resident to a safer environment (dementia unit) that was secure and locked for the resident's safety. The NP also documented that the facility could no longer provide a safe environment for the resident. Review of a physician's progress report dated 9/17/15 revealed that Resident #2 had exhibited a change in behavior requiring the staff to increase supervision and monitoring when the staff attempted to provide incontinent care just before dinner. The behavior included combativeness, punching and kicking the staff when attempting to change the resident's clothing which was wet with urine. The physician documented attempting to examine the resident also on 9/17/15 and the resident threatened to punch the physician. The physician ordered 2.5 mg of [MEDICATION NAME] (antipsychotic) IM to be administered. Review of a progress note by a NP dated 9/24/15 revealed that within the week of behavioral change, Resident #2's aggression continued and he again attempted to elope on 9/19/15. [MEDICATION NAME] 5 mg IM was administered and the NP instructed the staff to continue supportive care and elopement precautions. Review of incident reports from 6/11/15 to 10/30/15 revealed multiple attempts by Resident #2 to leave the building and found by the staff: a. On 6/11/15 at 7:14 p.m., Resident #2 attempted to leave through 2 different locations within the building and the staff redirected the resident from the doors and offered alternate activities. b. On 6/18/15 at 6:30 p.m., Resident #2 slipped out of his wheelchair without any injuries. c. On 6/22/15 at 6:00 p.m., Resident #2 was found wandering in the parking lot and the resident was brought back into the facility. Interventions were to distract the resident from wandering by offering pleasant diversions, food, conversation and television. d. On 6/27/15 at 6:30 p.m., Resident #2 fell on the front porch outside the building and was redirected back into the building. There were no further interventions to address the elopment tendency. e. On 6/28/15 at 5:30 p.m., Resident #2 eloped from the building and was redirected back into the building. There were no further interventions to address the elopment tendency. f. On 8/11/15 at 5:30 p.m., Resident #2 fell in the hallway attempting to open an exit door at the end of a hallway. There were no further interventions to address the elopment tendency. g. On 9/10/15 at 1:30 p.m., Resident #2 was found walking in the parking lot and brought back into the building. There were no further interventions to address the elopment tendency. h. On 10/30/15 at approximately 6:00 p.m., Resident #2 was sitting in his wheelchair in the dining room and got up from the wheelchair (not equipped with an alarm system) and walked out of the main dining room, passing the nurses' station and receptionist desk and walked out the front door. He fell on the ground and fractured his right femur. There were no further interventions to address the elopment tendency. Review of the incident report dated 10/30/15 revealed that Resident #2 was found on the found by a visiting hospice nurse. The facility became aware of the resident's fall when the hospice nurse entered the facility and called for help. During a head to toe assessment in which the resident's limbs were tested for full range of motion, the resident expressed a grimace when the right leg was moved. An x-ray dated 10/30/15 confirmed a proximal femoral neck acute fracture. The assessing staff member documented that the resident had reported looking for his car as the reason for walking out the door. During initial observation rounds at 10:20 a.m. on 11/13/15, Resident #2 was observed sitting up in bed being interviewed by 2 staff members from the rehabilitation department. Both feet were inserted into foam pressure relieving boots and the resident was fully dressed. An ADL reminder sheet was located above the bed and indicated the resident required anti-tippers attached to the wheelchair. The wheelchair next to the bed did not have the anti-tipper devices and was not labeled as belonging to the resident according to the facility's policy. The resident was alert, but unable to answer questions related to the fall. During interview on 11/17/15 at 10:55 a.m., LVN A, ADON, reported that Resident #2 was observed by the staff in the main dining room sitting in a wheelchair waiting for his meal. When the resident ' s meal tray was brought to the table, the staff realized that the resident was not in his wheelchair and was not in the dining room. The staff in the dining room was alerted to the resident's location when the visiting hospice nurse entered the facility and began shouting for help at the entrance of the facility. The resident was not observed leaving the dining room or exiting the building. During further interview with LVN A, on 11/17/15 at 10:55 a.m., the elopement policy was discussed and LVN A stated that she was not sure of the existence and location of the wander book. Accompanying LVN A, the book was found in the unlocked drawer of receptionist's desk near the entrance of the front door. The receptionist was seated the desk and stated that at 6:00 p.m. on 10/30/15, there would not have been anyone at the desk to monitor the entrances and exits of residents. Review of the wander book at approximately 11:15 a.m. on 11/17/15 revealed that there was only 1 person's picture and profile in the book: Resident #2. At approximately 1:00 p.m. on 11/17/15, Resident #2 was observed in bed fully dressed and alert and oriented to self. The resident's daughter was visiting with him. LVN B, Treatment Nurse, assisted in removing the resident's pants to assess the incision to the right upper leg. A long closed incision line was noted containing approximately 20 plus staples. The resident was asked to lift the leg and upon doing so expressed pain to the upper leg by grimacing and squinting his face. The resident was asked in Spanish if there was pain and he responded with yes. During interview at approximately 1:10 p.m., Resident #2's daughter stated that the facility had reported the falls and elopements to the family and had considered alternate placement. She stated that she and her sister visited the resident daily and each alternated their visits. She stated that the facility's location was convenient for their visits, but was now concerned whether Resident #2 would be able to walk again and whether the resident would attempt to elope again. The interim Director of Nurses reported on 11/17/15 that there was only 1 resident (#2) in the facility at risk for elopement.

Based on observations, interviews and record review the facility failed to implement the facility's written policy and procedures to prevent neglect for 1 of 21 residents (#1): Resident #1 was not placed in a wheelchair with anti-tipper devices as assessed and care planned and fell backwards striking his head on the leg of a table and sustaining a laceration and subdural hematoma (collection of blood outside of a blood vessel). The resident died 6 days later in the hospital from a subdural hematoma. This failure resulted in an Immediate Jeopardy which was identified on [DATE] at 2:50 p.m.but the facility remained out of compliance at a severity level of actual harm and pattern due to all staff not being in-serviced and all resdients not being assessed for the need for anti-tipper devices. The deficient practice could affect 21 residents who were identified by the facility as requiring wheelchairs with anti-tipper devices to prevent residents from tipping backwards and being injured. The finding were: Review of Resident #1's admission face sheet dated [DATE] documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated [DATE] documented that Resident #1 was a fall risk due to being a double [MEDICAL CONDITION] and because the resident was unaware of safety needs. The most current care plan dated [DATE] documented a fall and that the appropriate intervention was to keep the resident in the correct wc. Review of a Rehabilitation Screen form dated [DATE] documented that Resident #1 was on caseload to obtain new splints for right hand and elbow contractures. A referral to rehab services dated [DATE] due to a recent fall documented that the resident's wc was to be checked for anti-tippers properly working. The Director of the Rehabilitation department documented that the anti-tipper devices were in place and working correctly and that the CNA (J) on shift was educated in the presence of the ADON about checking for tippers prior to putting the resident in the chair. Review of a multidisciplinary therapy screen form dated [DATE] documented that Resident #1 had fallen on [DATE] from the wheelchair and that the DME (durable medical equipment) company would be called to get a specialty wheelchair for the resident. Review of incident reports for April, May and [DATE] revealed that Resident #1 had several falls: On [DATE] Resident #1 was sitting in a wheelchair in the dining room waiting for breakfast and fell backwards in the wheelchair striking the back of his head on the floor. He sustained a hematoma and was treated with ice to reduce the swelling. The after-fall assessment recommended the resident be kept in the correct wheelchair. The resident was referred to Rehab Services who assessed the resident and recommended that the resident's wheelchair be checked for anti-tippers properly working. The Referral to Rehab Services dated [DATE] documented that Resident #1's wheelchair had been checked and that the anti-tippers were in place and working correctly. The referral also documented that a CNA (J) who was on shift was educated about checking for tippers prior to putting the resident in the chair and the ADON was present. The referral was conducted by Staff N, Director of Rehab Services. An incident report dated [DATE] documented that Resident #1 was found at 2:15 p.m. with a discoloration to the left eye that had turned black. The incident was unwitnessed. An incident report dated [DATE] at 1:00 pm documented that Resident #1 had slid out of the wheelchair to the floor in the dining room. (There was no documentation of the anti-tippers in place.) The writer of the incident report recommended to prevent recurrence that the resident was not to be in the common area without 2 or more staff if the pt. was out of bed. An incident report dated [DATE] documented that Resident #1 had been placed in a wheelchair without anti-tippers and pushed into the main dining room. While waiting for breakfast to be served, Resident #1 fell backward in the main dining room while waiting for breakfast. The resident struck his head on the leg of a table and sustained a laceration and a hematoma. The resident was immediately transferred by ambulance to the ER. Review of the hospital's admission notes for [DATE] at 9:44 a.m. revealed that Resident #1 had not had a [MEDICAL CONDITION] prior to the fall at the nursing facility, but while in route by ambulance to the ER, the resident had deterioration of AMS and became unresponsive and had a [MEDICAL CONDITION]. The ER physician documented that the laceration was 3 cm long and required 6 staples to close it. A CT scan taken at the hospital on [DATE] documented the presence of a large right subdural hematoma (collection of blood below the inner layer of the Dura but external to the brain and arachnoid membrane; most common type of traumatic intracranial mass lesion) with an 11 millimeter midline shift (shift past its center line considered ominous because it is commonly associated with a distortion of the [DIAGNOSES REDACTED] and associated with high intracranial pressure). In the ER, the resident became unresponsive and had a 20 second tonic/clonic [MEDICAL CONDITION] (grand mal [MEDICAL CONDITION] that affects the entire brain) which was controlled by an injection of [MEDICATION NAME]. An IV of [MEDICATION NAME] 1500 mg was started to control further [MEDICAL CONDITION] and the resident was moved to the intensive care unit on a palliative status and expired on [DATE] under inpatient hospice care. Review of the facility provider's investigation report dated [DATE] revealed that Resident #1 was placed in a wheelchair without anti-tippers by CNA J and taken into the main dining room for breakfast. LVN/CN H observed Resident #1 falling backwards from the nurses' station and attempted to stop the resident from hitting the floor. The resident struck the back of his head on the leg of a table. The resident was sent to the ER for treatment. An interview documented by the facility on [DATE] with CNA J documented that the CNA stated that the resident's wheelchair was broken and unable to be used safely. CNA J used the wheelchair that was in the room, which did not have anti-tipper devices. The resident was taken to the dining room for breakfast. During the initial entrance conference on [DATE] at 1:20 p.m., the DON reported that Resident #1 had been provided a wheelchair with anti-tipper devices, but on [DATE] the resident was placed in a different wheelchair without anti-tippers, because the wheelchair was broken and was being fixed. During interview on [DATE] at 9:43 a.m., LVN/CN H stated that on [DATE] at approximately 8:00 a.m. she was standing by the nurses' station and was about to cross to the main dining room (approximately 40 to 50 feet) to check on the residents when she observed Resident #1 tipping backwards and fall. She stated that the resident did not have a [MEDICAL CONDITION] and that she was not aware that Resident #1 required anti-tipping devices on the wheelchair. During interview on [DATE] at 9:52 a.m., the Maintenance Director B stated that he could not remember what wheelchair belonged to Resident #1. He stated that a high back wheelchair with anti-tipping devices was brought to him because the securing knob to the cross bar at the back was missing. He stated that the missing knob would not render the chair unsafe. He stated that since the fall on [DATE], all the wheelchairs had green tags with the name of the resident using the wheelchair and he was not able to log repairs, etc., by the name of the resident. During observation at approximately 10:00 a.m.on [DATE], the Maintenance Director pointed out the wheelchair he had replaced the knob located in the back of the building. Although the wheelchair had anti-tipping devices, the Maintenance Director would not state that the wheelchair belonged to Resident #1. During interview on [DATE] at 10:18 a.m., the Rehab Service Director N stated that she received a copy of incident reports related to falls and that she had assessed Resident #1 after the fall backwards in the wheelchair that occurred on [DATE]. She stated that she had educated CNA J, who was on shift, about checking for anti-tippers prior to putting the resident in the chair and that the ADON was present during the session. Rehab Service Director N stated that she had not seen the wheelchair Resident #1 was in on [DATE]. She stated that the reason she had recommended a specialty wheelchair on [DATE] was because the resident was nonverbal and that his trunk balance was declining (bilateral above knee [MEDICAL CONDITION]). The resident was scheduled to be measured for a specialty wheelchair on Monday, [DATE]. During interview on [DATE] at 11:15 a.m., CNA J stated that he was assisted by CNA K in transferring Resident #1 from bed to the wheelchair on the morning of [DATE]. He stated that there was no other wheelchair in the room and this wheelchair did not have anti-tipper devices. He stated that the resident did not have a wheelchair with anti-tipper devices for the last 35 days. He stated that he was not aware of any unsafe discrepancies on the previous chair with the anti-tipper devices. He stated that he was not in the dining room when Resident #1 fell on [DATE]. During observation on [DATE] at 11:30 a.m., CNA J looked at the wheelchair with anti-tippers located in the back of the building and stated that he couldn't tell if this wheelchair had been used by Resident #1. During interview on [DATE] at 11:42 a.m., CNA K confirmed that she had assisted CNA J in transferring Resident #1 from the bed to the wheelchair by Hoyer lift. She stated that there was only 1 wheelchair in the room and it did not have anti-tipper devices. She stated that she was not in the dining room when Resident #1 fell on [DATE]. As prescribed in the facility's policy dated 2001: Equipment: General Use For All Residents: General Guidelines specify that: (1) assessment by nursing or Therapy will determine the need for assistive devices on wheelchairs as needed; (2) therapy screens as needed for wheelchair positioning and assistive; (3) wheelchairs, walkers, crutches, canes, etc., will be inspected for safety and appropriateness; (4) assistive devices (cushions, leg rests, etc.) will be provided to the resident for wheelchair use as needed. On [DATE] at 3:15 p.m. an IJ was identified and the Administrator was notified at 3:55 p.m. The following steps were contained in the POR: 1. The facility staff audited every resident in a wheelchair audited by Rehabilitation Services and DON. Twenty-one residents in wheelchairs were observed to have anti-tipper devices and green name tags identifying the resident using the wheelchair. 2. The ADL sheets above each resident's bed had tippers written on the ADL sheets above the residents' bed. 3. All staff on duty on the evening shift (,[DATE]) on [DATE] were in-serviced again regarding anti-tippers, ADL signs and the green wheelchair labels (tags) attached to the wheelchairs. 4. The nursing and rehabilitation staff began to update the care plans of the 21 residents in with anti-tippers and the assessments of those residents who had been assessed prior to the IJ were reviewed. 5. Included in the in-services were instructions regarding a procedure that was to be followed when wheelchairs were in need of repair, i.e. ensuring the name tag identified the resident using the wheelchair and the maintenance department returning the wheelchair to that resident. 6. Nursing service developed an audit sheet with the names and room numbers of residents with wheelchairs equipped with anti-tipper devices, with which to document visualization of the wheelchair and devices once a day. On [DATE] at approximately 6:30 p.m. and 7:15 p.m., the POR was verified by interview, record review and observations: Interviews on [DATE] at 7:15 p.m. with LVN's A, I, and M confirmed that they had been in-serviced again and were aware of the protocol outlined in the POR. Interview with the DON on [DATE] at 7:25 p.m. revealed that the night shif staff would be in-serviced at 5:00 a.m. on [DATE] and that both the day shift and weekend shifts would be in-serviced. After verifying the implementation of the POR, the Administrator was informed that the IJ was removed on [DATE] at 7:30 p.m. While the IJ was removed, the facility remained out of compliance at a scope of pattern at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents at risk for falls were provided appropriate equipment and devices to reduce the chances of falls and injuries. Information provided by the facility staff indicated that there were 21 residents in the facility with wheelchairs with anti-tipper devices and that the devices were to be checked periodically to ensure the devices were in place.

Based on observations, interviews and record review the facility failed to ensure that resident environment remained free of accident hazard and received adequate supervison and assistance devices to prevent accidents for 1 of 21 residents (#1) reviewed for accidents. Resident #1 was not placed in a wheelchair with anti-tipper devices as assessed and care planned and fell backwards striking his head on the leg of a table and sustained a laceration and subdural hematoma. The resident later died in the hospital. This failure resulted in an Immediate Jeopardy which was identified on [DATE] at 2:50 p.m.but the facility remained out of compliance at a severity level of actual harm and isolated due to all staff not being in-serviced and all resdients not being assessed for the need for anti-tipper devices. The deficient practice could affect 21 residents who were identified by the facility as requiring wheelchairs with anti-tipper devices to prevent residents from tipping backwards and being injured. The finding were: Review of Resident #1's admission face sheet dated [DATE] documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated [DATE] documented that Resident #1 was a fall risk due to being a double amputee and because the resident was unaware of safety needs. The most current care plan dated [DATE] documented a fall and that the appropriate intervention was to keep the resident in the correct wc. Review of a Rehabilitation Screen form dated [DATE] documented that Resident #1 was on caseload to obtain new splints for right hand and elbow contractures. A referral to rehab services dated [DATE] due to a recent fall documented that the resident's wc was to be checked for anti-tippers properly working. The Director of the Rehabilitation department documented that the anti-tipper devices were in place and working correctly and that the CNA (J) on shift was educated in the presence of the ADON about checking for tippers prior to putting the resident in the chair. Review of a multidisciplinary therapy screen form dated [DATE] documented that Resident #1 had fallen on [DATE] from the wheelchair and that the DME (durable medical equipment) company would be called to get a specialty wheelchair for the resident. Review of incident reports for April, May and [DATE] revealed that Resident #1 had several falls: On [DATE] Resident #1 was sitting in a wheelchair in the dining room waiting for breakfast and fell backwards in the wheelchair striking the back of his head on the floor. He sustained a hematoma and was treated with ice to reduce the swelling. The after-fall assessment recommended the resident be kept in the correct wheelchair. The resident was referred to Rehab Services who assessed the resident and recommended that the resident's wheelchair be checked for anti-tippers properly working. The Referral to Rehab Services dated [DATE] documented that Resident #1's wheelchair had been checked and that the anti-tippers were in place and working correctly. The referral also documented that a CNA (J) who was on shift was educated about checking for tippers prior to putting the resident in the chair and the ADON was present. The referral was conducted by Staff N, Director of Rehab Services. An incident report dated [DATE] documented that Resident #1 was found at 2:15 p.m. with a discoloration to the left eye that had turned black. The incident was unwitnessed. An incident report dated [DATE] at 1:00 pm documented that Resident #1 had slid out of the wheelchair to the floor in the dining room. (There was no documentation of the anti-tippers in place.) The writer of the incident report recommended to prevent recurrence that the resident was not to be in the common area without 2 or more staff if the pt. was out of bed. An incident report dated [DATE] documented that Resident #1 had been placed in a wheelchair without anti-tippers and pushed into the main dining room. While waiting for breakfast to be served, Resident #1 fell backward in the main dining room while waiting for breakfast. The resident struck his head on the leg of a table and sustained a laceration and a hematoma. The resident was immediately transferred by ambulance to the ER. Review of the hospital's admission notes for [DATE] at 9:44 a.m. revealed that Resident #1 had not had a seizure prior to the fall at the nursing facility, but while in route by ambulance to the ER, the resident had deterioration of AMS and became unresponsive and had a seizure. The ER physician documented that the laceration was 3 cm long and required 6 staples to close it. A CT scan taken at the hospital on [DATE] documented the presence of a large right subdural hematoma (collection of blood below the inner layer of the Dura but external to the brain and arachnoid membrane; most common type of traumatic intracranial mass lesion) with an 11 millimeter midline shift (shift past its center line considered ominous because it is commonly associated with a distortion of the [DIAGNOSES REDACTED] and associated with high intracranial pressure). In the ER, the resident became unresponsive and had a 20 second tonic/clonic seizure (grand mal seizures that affects the entire brain) which was controlled by an injection of Ativan. An IV of Keppra 1500 mg was started to control further seizures and the resident was moved to the intensive care unit on a palliative status and expired on [DATE] under inpatient hospice care. Review of the facility provider's investigation report dated [DATE] revealed that Resident #1 was placed in a wheelchair without anti-tippers by CNA J and taken into the main dining room for breakfast. LVN/CN H observed Resident #1 falling backwards from the nurses' station and attempted to stop the resident from hitting the floor. The resident struck the back of his head on the leg of a table. The resident was sent to the ER for treatment. An interview documented by the facility on [DATE] with CNA J documented that the CNA stated that the resident's wheelchair was broken and unable to be used safely. CNA J used the wheelchair that was in the room, which did not have anti-tipper devices. The resident was taken to the dining room for breakfast. During the initial entrance conference on [DATE] at 1:20 p.m., the DON reported that Resident #1 had been provided a wheelchair with anti-tipper devices, but on [DATE] the resident was placed in a different wheelchair without anti-tippers, because the wheelchair was broken and was being fixed. During interview on [DATE] at 9:43 a.m., LVN/CN H stated that on [DATE] at approximately 8:00 a.m. she was standing by the nurses' station and was about to cross to the main dining room (approximately 40 to 50 feet) to check on the residents when she observed Resident #1 tipping backwards and fall. She stated that the resident did not have a seizure and that she was not aware that Resident #1 required anti-tipping devices on the wheelchair. During interview on [DATE] at 9:52 a.m., the Maintenance Director B stated that he could not remember what wheelchair belonged to Resident #1. He stated that a high back wheelchair with anti-tipping devices was brought to him because the securing knob to the cross bar at the back was missing. He stated that the missing knob would not render the chair unsafe. He stated that since the fall on [DATE], all the wheelchairs had green tags with the name of the resident using the wheelchair and he was not able to log repairs, etc., by the name of the resident. During observation at approximately 10:00 a.m.on [DATE], the Maintenance Director pointed out the wheelchair he had replaced the knob located in the back of the building. Although the wheelchair had anti-tipping devices, the Maintenance Director would not state that the wheelchair belonged to Resident #1. During interview on [DATE] at 10:18 a.m., the Rehab Service Director N stated that she received a copy of incident reports related to falls and that she had assessed Resident #1 after the fall backwards in the wheelchair that occurred on [DATE]. She stated that she had educated CNA J, who was on shift, about checking for anti-tippers prior to putting the resident in the chair and that the ADON was present during the session. Rehab Service Director N stated that she had not seen the wheelchair Resident #1 was in on [DATE]. She stated that the reason she had recommended a specialty wheelchair on [DATE] was because the resident was nonverbal and that his trunk balance was declining (bilateral above knee amputee). The resident was scheduled to be measured for a specialty wheelchair on Monday, [DATE]. During interview on [DATE] at 11:15 a.m., CNA J stated that he was assisted by CNA K in transferring Resident #1 from bed to the wheelchair on the morning of [DATE]. He stated that there was no other wheelchair in the room and this wheelchair did not have anti-tipper devices. He stated that the resident did not have a wheelchair with anti-tipper devices for the last 35 days. He stated that he was not aware of any unsafe discrepancies on the previous chair with the anti-tipper devices. He stated that he was not in the dining room when Resident #1 fell on [DATE]. During observation on [DATE] at 11:30 a.m., CNA J looked at the wheelchair with anti-tippers located in the back of the building and stated that he couldn't tell if this wheelchair had been used by Resident #1. During interview on [DATE] at 11:42 a.m., CNA K confirmed that she had assisted CNA J in transferring Resident #1 from the bed to the wheelchair by Hoyer lift. She stated that there was only 1 wheelchair in the room and it did not have anti-tipper devices. She stated that she was not in the dining room when Resident #1 fell on [DATE]. On [DATE] at 3:15 p.m. an IJ was identified and the Administrator was notified at 3:55 p.m. The following steps were contained in the POR: 1. The facility staff audited every resident in a wheelchair audited by Rehabilitation Services and DON. Twenty-one residents in wheelchairs were observed to have anti-tipper devices and green name tags identifying the resident using the wheelchair. 2. The ADL sheets above each resident's bed had tippers written on the ADL sheets above the residents' bed. 3. All staff on duty on the evening shift (,[DATE]) on [DATE] were in-serviced again regarding anti-tippers, ADL signs and the green wheelchair labels (tags) attached to the wheelchairs. 4. The nursing and rehabilitation staff began to update the care plans of the 21 residents in with anti-tippers and the assessments of those residents who had been assessed prior to the IJ were reviewed. 5. Included in the in-services were instructions regarding a procedure that was to be followed when wheelchairs were in need of repair, i.e. ensuring the name tag identified the resident using the wheelchair and the maintenance department returning the wheelchair to that resident. 6. Nursing service developed an audit sheet with the names and room numbers of residents with wheelchairs equipped with anti-tipper devices, with which to document visualization of the wheelchair and devices once a day. On [DATE] at approximately 6:30 p.m. and 7:15 p.m., the POR was verified by interview, record review and observations: Interviews on [DATE] at 7:15 p.m. with LVN's A, I, and M confirmed that they had been in-serviced again and were aware of the protocol outlined in the POR. Interview with the DON on [DATE] at 7:25 p.m. revealed that the night shif staff would be in-serviced at 5:00 a.m. on [DATE] and that both the day shift and weekend shifts would be in-serviced. After verifying the implementation of the POR, the Administrator was informed that the IJ was removed on [DATE] at 7:30 p.m. While the IJ was removed, the facility remained out of compliance at a scope of pattern at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents at risk for falls were provided appropriate equipment and devices to reduce the chances of falls and injuries. Information provided by the facility staff indicated that there were 21 residents in the facility with wheelchairs with anti-tipper devices and that the devices were to be checked periodically to ensure the devices were in place.

Based on observations, interviews and record review the facility failed to implement the facility's written policy and procedures for prevention of neglect for 1 of 21 residents (#1) reviewed for falls and the use of anti-tipping devices on wheelchairs: . Resident #1 was not placed in a wheelchair with anti-tipper devices as assessed and care planned and fell backwards striking his head on the leg of a table and sustaining a laceration and subdural hematoma (collection of blood outside of a blood vessel). The resident died 6 days later in the hospital from a subdural hematoma. This failure resulted in an Immediate Jeopardy which was identified on [DATE] at 2:50 p.m.but the facility remained out of compliance at a severity level of actual harm and pattern due to all staff not being in-serviced and all resdients not being assessed for the need for anti-tipper devices. The deficient practice could affect 21 residents who were identified by the facility as requiring wheelchairs with anti-tipper devices to prevent residents from tipping backwards and being injured. The finding were: As prescribed in the facility's policy dated 2001: Equipment: General Use For All Residents: General Guidelines specify that: (1) assessment by nursing or Therapy will determine the need for assistive devices on wheelchairs as needed; (2) therapy screens as needed for wheelchair positioning and assistive; (3) wheelchairs, walkers, crutches, canes, etc., will be inspected for safety and appropriateness; (4) assistive devices (cushions, leg rests, etc.) will be provided to the resident for wheelchair use as needed. Review of Resident #1's admission face sheet dated [DATE] documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated [DATE] documented that Resident #1 was a fall risk due to being a double [MEDICAL CONDITION] and because the resident was unaware of safety needs. The most current care plan dated [DATE] documented a fall and that the appropriate intervention was to keep the resident in the correct wc. Review of a Rehabilitation Screen form dated [DATE] documented that Resident #1 was on caseload to obtain new splints for right hand and elbow contractures. A referral to rehab services dated [DATE] due to a recent fall documented that the resident's wc was to be checked for anti-tippers properly working. The Director of the Rehabilitation department documented that the anti-tipper devices were in place and working correctly and that the CNA (J) on shift was educated in the presence of the ADON about checking for tippers prior to putting the resident in the chair. Review of a multidisciplinary therapy screen form dated [DATE] documented that Resident #1 had fallen on [DATE] from the wheelchair and that the DME (durable medical equipment) company would be called to get a specialty wheelchair for the resident. Review of incident reports for April, May and [DATE] revealed that Resident #1 had several falls: On [DATE] Resident #1 was sitting in a wheelchair in the dining room waiting for breakfast and fell backwards in the wheelchair striking the back of his head on the floor. He sustained a hematoma and was treated with ice to reduce the swelling. The after-fall assessment recommended the resident be kept in the correct wheelchair. The resident was referred to Rehab Services who assessed the resident and recommended that the resident's wheelchair be checked for anti-tippers properly working. The Referral to Rehab Services dated [DATE] documented that Resident #1's wheelchair had been checked and that the anti-tippers were in place and working correctly. The referral also documented that a CNA (J) who was on shift was educated about checking for tippers prior to putting the resident in the chair and the ADON was present. The referral was conducted by Staff N, Director of Rehab Services. An incident report dated [DATE] documented that Resident #1 was found at 2:15 p.m. with a discoloration to the left eye that had turned black. The incident was unwitnessed. An incident report dated [DATE] at 1:00 pm documented that Resident #1 had slid out of the wheelchair to the floor in the dining room. (There was no documentation of the anti-tippers in place.) The writer of the incident report recommended to prevent recurrence that the resident was not to be in the common area without 2 or more staff if the pt. was out of bed. An incident report dated [DATE] documented that Resident #1 had been placed in a wheelchair without anti-tippers and pushed into the main dining room. While waiting for breakfast to be served, Resident #1 fell backward in the main dining room while waiting for breakfast. The resident struck his head on the leg of a table and sustained a laceration and a hematoma. The resident was immediately transferred by ambulance to the ER. Review of the hospital's admission notes for [DATE] at 9:44 a.m. revealed that Resident #1 had not had a [MEDICAL CONDITION] prior to the fall at the nursing facility, but while in route by ambulance to the ER, the resident had deterioration of AMS and became unresponsive and had a [MEDICAL CONDITION]. The ER physician documented that the laceration was 3 cm long and required 6 staples to close it. A CT scan taken at the hospital on [DATE] documented the presence of a large right subdural hematoma (collection of blood below the inner layer of the Dura but external to the brain and arachnoid membrane; most common type of traumatic intracranial mass lesion) with an 11 millimeter midline shift (shift past its center line considered ominous because it is commonly associated with a distortion of the [DIAGNOSES REDACTED] and associated with high intracranial pressure). In the ER, the resident became unresponsive and had a 20 second tonic/clonic [MEDICAL CONDITION] (grand mal [MEDICAL CONDITION] that affects the entire brain) which was controlled by an injection of [MEDICATION NAME]. An IV of [MEDICATION NAME] 1500 mg was started to control further [MEDICAL CONDITION] and the resident was moved to the intensive care unit on a palliative status and expired on [DATE] under inpatient hospice care. Review of the facility provider's investigation report dated [DATE] revealed that Resident #1 was placed in a wheelchair without anti-tippers by CNA J and taken into the main dining room for breakfast. LVN/CN H observed Resident #1 falling backwards from the nurses' station and attempted to stop the resident from hitting the floor. The resident struck the back of his head on the leg of a table. The resident was sent to the ER for treatment. An interview documented by the facility on [DATE] with CNA J documented that the CNA stated that the resident's wheelchair was broken and unable to be used safely. CNA J used the wheelchair that was in the room, which did not have anti-tipper devices. The resident was taken to the dining room for breakfast. During the initial entrance conference on [DATE] at 1:20 p.m., the DON reported that Resident #1 had been provided a wheelchair with anti-tipper devices, but on [DATE] the resident was placed in a different wheelchair without anti-tippers, because the wheelchair was broken and was being fixed. During interview on [DATE] at 9:43 a.m., LVN/CN H stated that on [DATE] at approximately 8:00 a.m. she was standing by the nurses' station and was about to cross to the main dining room (approximately 40 to 50 feet) to check on the residents when she observed Resident #1 tipping backwards and fall. She stated that the resident did not have a [MEDICAL CONDITION] and that she was not aware that Resident #1 required anti-tipping devices on the wheelchair. During interview on [DATE] at 9:52 a.m., the Maintenance Director B stated that he could not remember what wheelchair belonged to Resident #1. He stated that a high back wheelchair with anti-tipping devices was brought to him because the securing knob to the cross bar at the back was missing. He stated that the missing knob would not render the chair unsafe. He stated that since the fall on [DATE], all the wheelchairs had green tags with the name of the resident using the wheelchair and he was not able to log repairs, etc., by the name of the resident. During observation at approximately 10:00 a.m.on [DATE], the Maintenance Director pointed out the wheelchair he had replaced the knob located in the back of the building. Although the wheelchair had anti-tipping devices, the Maintenance Director would not state that the wheelchair belonged to Resident #1. During interview on [DATE] at 10:18 a.m., the Rehab Service Director N stated that she received a copy of incident reports related to falls and that she had assessed Resident #1 after the fall backwards in the wheelchair that occurred on [DATE]. She stated that she had educated CNA J, who was on shift, about checking for anti-tippers prior to putting the resident in the chair and that the ADON was present during the session. Rehab Service Director N stated that she had not seen the wheelchair Resident #1 was in on [DATE]. She stated that the reason she had recommended a specialty wheelchair on [DATE] was because the resident was nonverbal and that his trunk balance was declining (bilateral above knee [MEDICAL CONDITION]). The resident was scheduled to be measured for a specialty wheelchair on Monday, [DATE]. During interview on [DATE] at 11:15 a.m., CNA J stated that he was assisted by CNA K in transferring Resident #1 from bed to the wheelchair on the morning of [DATE]. He stated that there was no other wheelchair in the room and this wheelchair did not have anti-tipper devices. He stated that the resident did not have a wheelchair with anti-tipper devices for the last 35 days. He stated that he was not aware of any unsafe discrepancies on the previous chair with the anti-tipper devices. He stated that he was not in the dining room when Resident #1 fell on [DATE]. During observation on [DATE] at 11:30 a.m., CNA J looked at the wheelchair with anti-tippers located in the back of the building and stated that he couldn't tell if this wheelchair had been used by Resident #1. During interview on [DATE] at 11:42 a.m., CNA K confirmed that she had assisted CNA J in transferring Resident #1 from the bed to the wheelchair by Hoyer lift. She stated that there was only 1 wheelchair in the room and it did not have anti-tipper devices. She stated that she was not in the dining room when Resident #1 fell on [DATE]. On [DATE] at 3:15 p.m. an IJ was identified and the Administrator was notified at 3:55 p.m. The following steps were contained in the POR: 1. The facility staff audited every resident in a wheelchair audited by Rehabilitation Services and DON. Twenty-one residents in wheelchairs were observed to have anti-tipper devices and green name tags identifying the resident using the wheelchair. 2. The ADL sheets above each resident's bed had tippers written on the ADL sheets above the residents' bed. 3. All staff on duty on the evening shift (,[DATE]) on [DATE] were in-serviced again regarding anti-tippers, ADL signs and the green wheelchair labels (tags) attached to the wheelchairs. 4. The nursing and rehabilitation staff began to update the care plans of the 21 residents in with anti-tippers and the assessments of those residents who had been assessed prior to the IJ were reviewed. 5. Included in the in-services were instructions regarding a procedure that was to be followed when wheelchairs were in need of repair, i.e. ensuring the name tag identified the resident using the wheelchair and the maintenance department returning the wheelchair to that resident. 6. Nursing service developed an audit sheet with the names and room numbers of residents with wheelchairs equipped with anti-tipper devices, with which to document visualization of the wheelchair and devices once a day. On [DATE] at approximately 6:30 p.m. and 7:15 p.m., the POR was verified by interview, record review and observations: Interviews on [DATE] at 7:15 p.m. with LVN's A, I, and M confirmed that they had been in-serviced again and were aware of the protocol outlined in the POR. Interview with the DON on [DATE] at 7:25 p.m. revealed that the night shif staff would be in-serviced at 5:00 a.m. on [DATE] and that both the day shift and weekend shifts would be in-serviced. After verifying the implementation of the POR, the Administrator was informed that the IJ was removed on [DATE] at 7:30 p.m. While the IJ was removed, the facility remained out of compliance at a scope of pattern at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor to ensure residents at risk for falls were provided appropriate equipment and devices to reduce the chances of falls and injuries. Information provided by the facility staff indicated that there were 21 residents in the facility with wheelchairs with anti-tipper devices and that the devices were to be checked periodically to ensure the devices were in place.